C++ wrapper ‘BGSLibrary’ v3.0.0 developed by Andrews Sobral. The comparison is based on segmentation accuracy of the algorithms on a series of indoor color-depth video clips of a single person's head and upper body, each highlighting a common factor that can influence the accuracy of foreground-background segmentation. The algorithms are run on the color image data, while the ‘ground truth’ is semi-automatically extracted from the depth data. The camera chosen for capturing the videos features paired color-depth image sensors, with the color sensor having specifications typical of mobile devices and webcams, which cover most of the use cases for these algorithms. The factors chosen for testing are derived from a literature review accompanying the dataset as being able to influence the efficacy of background segmentation. The assessment criteria for the results were set based on the requirements of common use cases such as gamecasting and mobile communications to allow the readers to make their own judgements on the merits of each algorithm for their own purposes.This dataset consists of video files that were created to test the accuracy of background segmentation algorithms contained in the  Little is known about their performance under some of the factors which affect segmentation efficacy.•This data will be useful to researchers who are developing and testing algorithms for portrait segmentation.•Color and ‘ground truth’ video clips are available for each of the factors described. A new algorithm can be tested by applying it to the color video clip and generating the segmented video. This can then be compared against the ‘ground truth’ to obtain any of the metrices of segmentation efficacy.•https://github.com/scloke/SegTest can be adapted to run the efficacy test automatically, capture new clips, and generate corresponding ‘ground truth’ clips.Alternatively, the custom software available at •C++ headers which can be used to directly interface OpenCV image structures with the algorithms in BGSLibrary’.The custom software also contains 1Background segmentation is the process whereby an object of interest in the foreground of an image, often a person, is separated from the background. Typical applications are news and weather casting, game livestreaming, video conferencing and chat software, photo augmentation (Snapchat filters and beauty apps), and technical help desks Accurate segmentation is quite difficult to achieve, and the method of choice depends on the application and the factors governing the process. In this article, the term ‘factor’ is defined as a characteristic of a particular use case that will influence the efficacy of foreground-background segmentation of an algorithm.C++ wrapper ‘BGSLibrary’ v3.0.0 developed by Andrews Sobral [The data consists of a comparison of background segmentation algorithms contained in the s Sobral , 3. The 1.1The video clips in the Mendeley Data repository are organized into folders with names according to the labels in The ‘ground truth’ video clips were saved to AVI files encoded with the lossless FFV1 codec so that the individual frames can be extracted for analysis. These files can be viewed using VLC media player (cross-platform), Media Player Classic (Windows 10), or any player which can use the FFV1 video codec.22.1There are several common factors which affect indoor segmentation efficacy: 1) image noise, 2) camera jitter and movement, 3) automatic camera settings, 4) illumination and shadows, 5) background initialization, 6) color camouflage, and 7) ghost images, sleeping foregrounds, and dynamic backgrounds 2.2C++ wrapper ‘BGSLibrary’ v3.0.0 developed by Andrews Sobral for head segmentation, given that it is a mature library that has been continually updated over the past eight years and now includes over 40 routines [This experiment was carried out to assess the suitability of the algorithms in the routines , 3.The camera chosen for this features paired color-depth image sensors, with the color sensor having specifications typical of mobile devices and webcams, which cover most of the use cases for these algorithms. The factors chosen for testing are derived from the literature review as being able to influence the efficacy of background segmentation. The assessment criteria for the results were set based on the requirements of common use cases such as gamecasting and mobile communications to allow the readers to make their own judgements on the merits of each algorithm for their own purposes.2.3A series of video clips was captured with an Intel RealSense Depth Camera D435 featuring a global shutter, large color pixels of 3 um square, and a depth sensor using disparity mapping from stereo infra-red cameras. The following camera settings were used: structured light projector on, autofocus enabled, autoexposure disabled, automatic white balancing disabled, backlight compensation disabled, and powerline frequency compensation disabled.Capture resolution was 640 × 480 pixels at 30 frames per second (fps) for color data and 90 fps for depth data, with the depth data processed using temporal and spatial smoothing with hole-filling to reduce artefacts. Synthetic paired color and depth frames were motion interpolated from the source frames to generate video clips without any inter-frames. The clips were then saved to Audio Video Interleave (AVI) files using FFMPEG, with dimensions of 640 ×480 pixels at 30 fps. Color clips were encoded using the lossy MPEG-4 Part 2 codec at a bit rate of 4 megabit per second (Mbps) except for the noise clips which were encoded at 12 Mbps to preserve the noise artefacts.The clips were captured at night under controlled bidirectional diagonal and side lighting with Philips Hue White & Color Ambiance bulbs set to the ‘Energize’ preset with a color temperature of 6410 K, calculated from the Mired Color Temperature supplied by the Philips Hue Software Development Kit. The camera was placed 120 cm in front of either a plain green screen (standard), a cream-colored screen (camouflage), or with the screen removed (complex), having the subject standing 60 cm in front of the screen, with no intervening objects. This resulted in a foreground area that was consistently about half the total background size, which is sufficiently balanced to not distort the measures of segmentation efficacy, and yet not too big which would prevent the face detection routine from working properly. The factors listed in All clips were 40 s long with the first 10 s showing just the background. The subject entered the scene at the 10 s mark and stood in the center of the frame while keeping a neutral expression, with the face and upper body fully visible. The comparison period was set to all frames between the 20 and 40 s mark inclusive. The brightness for all clips was normalized by applying the appropriate constant gamma correction to keep the average pixel brightness throughout the clip at 50% of the maximum brightness.For lighting change factors, the lighting conditions were altered mid-way through the comparison period. For the ‘Ghost Images’ clip, the comparison period was set to one second after the transition. This is because most algorithms for detection and removal of moving objects, ghosts, and shadows operate in less than a second. The comparison period for the ‘Sleeping Foreground’ clip was set to 10 s after the transition to allow enough time for the object to be incorporated into the background model.In clips where a subject was present, the face location was determined using libfacedetection by Shiqi Yu, and a seed point and depth obtained from the center of the bounding rectangle The segmentation foreground was obtained by processing the color data using the appropriate ‘BGSLibrary’ algorithm with default settings, except for the ‘GMG’ and ‘GMM KaewTraKulPong’ routines which require an earlier version of OpenCV see . To speeC++ 2019 in a 64-bit address space with 32 GB RAM allocated and an NVIDIA GeForce GTX 1060 6GB graphics card installed. Image processing was done using the libraries in EmguCV 3.2.0 and Accord.Net 3.8.0. The system speed was rated at 475 million floating points per second (MFLOPS) using the Intel processor diagnostic tool 2.10, 64-bit version.Testing was performed on a system using Microsoft Windows 10 with a four-core Intel Xeon E3 processor running at 3.5 GHz using Visual Basic and Visual Processing time was calculated as the average time taken to process each frame over the comparison period.Accuracy was defined as follows:TP (true positives) represent correctly classified foreground pixels, TN (true negatives) represent correctly classified background pixels, FP  represent incorrectly classified foreground pixels, FN  represent incorrectly classified background pixels, N represents the total number of frames, and t represents the frame time. The ‘ground truth’ is used as the reference for both TP and TN pixels, while the comparison was the segmentation result from the ‘BGSLibrary’ algorithm. A lower result for the accuracy indicates greater deviation from the ‘ground truth’.In Precision and recall were defined as follows:In In The F1 score  was then calculated as the harmonic mean of both precision and recall:The F1 score can range between 0 – 1 and a lower result indicates greater deviation from the ‘ground truth’.The False Positive Rate (FPR) was defined as:In In general, accuracy is used when the proportion of true results is the key issue, while the F1 score is employed when negative results are more important since it magnifies the effect of incorrect classification. While accuracy is an easy measure to understand, it has the drawback of giving a distorted representation of efficacy when there is a big imbalance in the number of negatives and positives. For face and head segmentation, missing portions of the face or addition of background features to the face are both undesirable, so the F1 score should be the preferred measure of segmentation efficacy.For the three factors where no subject was present and the ‘ground truth’ consists of complete background, the preferred measure would be the FPR since all errors consist of false positives. For the ‘Ghost Images’ and ‘Dynamic Background’ factors, a low FPR indicates the algorithm has the ability to rapidly remove ghost images and cope with dynamic background objects respectively. However, for the ‘Sleeping Foreground’ factor, a low FPR indicates that the stationary foreground object has been absorbed into the background model and no longer shows up.Segmentation efficacy should be calculated on a per-image basis to distinguish algorithms that vary in performance depending on image content, and ought to include a measure of spread in addition to centrality. This is especially important when evaluating algorithms that have a temporal component, as the segmentation result can change even though the images in the clip may be broadly similar.2.4Gaussian and Uniform noise was added to the standard clip according to the method used by López-Rubio, with four levels of each type The two types of sudden illumination changes which are common in indoor settings come from switching overhead lights or drawing curtains , and from opening and closing room doors which lead to an external light source . This was simulated by dimming and brightening all lights at once , or by doing so with the lights from one direction only . In contrast, the effect of shadows from uneven illumination was simulated by keeping the lights from one direction turned off throughout the clip duration. There was no temporal variance in the illumination, compared to the local change where the lighting was altered partway through the clip.The requirement for background initialization was simulated by trimming the standard clip to show the subject in a stable stance , or with two seconds of clear background  at the start. In both cases, the comparison period was shifted to 10 s after the clip start to align with standard clip processing.Simple color camouflage was simulated by using a cream-colored background screen, which was similar in color to the subject's skin. The subject also changed clothing to match the background color. This color was not exactly matched as it would be an unfair test since even humans would have difficulty differentiating the subject's outline under such conditions. For complex color camouflage, this was simulated by removing the background screen to show a typical indoor scene under daylight. The lighting for the subject was still controlled using the same bidirectional studio lights, and portions of the background were of similar color to the subject's clothing, skin, and hair.For the final three factors, no subject was present and the ‘ground truth’ was set to complete background. Simulation of ‘Ghost Images’ was achieved by draping a complex patterned cloth over part of the background screen and dropping it at the 10 s mark. The comparison period was adjusted to start one second after the cloth completely left the image frame to test whether the algorithm could rapidly remove ‘Ghosts’.Simulation of ‘Sleeping Foreground’ was done by lowering the same patterned cloth over part of the background screen at the 10 s mark. The comparison period was set to start 10 s after the cloth was completely lowered and had achieved a stable position. This was to assess the algorithm's tendency to absorb stationary foreground objects into the background. A ‘Dynamic Background’ was simulated using a running stand fan placed in the same position where the subject would normally stand. This was to test the algorithm's ability to cope with background objects that display regular repetitive motion.2.5The results for comparison testing of efficacy and processing speed for the algorithms in the ‘BGSLibrary’ were summarized in 2.6The results were assessed according to the following criteria: 1) high efficacy to properly segment the head and upper body, 2) consistency, 3) processing speed short enough for real-time segmentation, and 4) tolerance to the factors tested . Good seTo satisfy the criteria for high efficacy, the median F1 score should be 0.95 and above under standard processing conditions, while the segmentation should be consistent enough that the 10th centile F1 score does not go below 0.80. For full real-time processing with a frame rate of 30 fps, each frame should require a maximum of 33 ms. With a more relaxed constraint of 10 fps if the intervening frames can be motion interpolated, the segmentation time for each frame should be a maximum of 100 ms. An algorithm is considered to tolerant to the factor tested if it can still segment adequately with a median F1 score above 0.80.To establish a cutoff for the ‘Ghost Images’ and ‘Sleeping Foreground’ factors, we need to refer to For the ‘Dynamic Background’ factor, the highest median FPR is for the ‘Simple Gaussian’ and ‘Fuzzy Gaussian’ algorithms. On viewing both, the ‘Fuzzy Gaussian’ clip has less noise and the maximum FPR representing the area of the moving fan blades can be derived from integrating the segmented foreground over the comparison period of the clip and removing pixel noise with a small kernel median filter. This value was found to be 0.0563, and we can similarly assume that a median FPR less than 5% of this value (FPR = 0.003) indicates that the algorithm can adequately deal with dynamic backgrounds by removing the spinning fan blades.2.7There are several limitations to the methodology of the comparison testing. The first is that the ‘ground truth’ could not be consistently derived from the depth data since the disparity maps were coarse and unstable, even after extensive pre-processing with temporal and spatial smoothing with hole-filling. While the use of automated GrabCut improved this significantly, there was still a need to manually inspect each frame for quality. Areas which were prone to incorrect segmentation had to be marked out and corrected manually . This imThe next limitation is that the camera was static and true motion was not tested. This is important since many use cases require a mobile camera. However, this was unavoidable since the quality of the disparity maps would deteriorate even further with movement.Another limitation is that while the ‘memory effect’ was demonstrated for several of the routines, it is possible that extending the test period may have detected it in more of them. Examination of the full clips for the routines which satisfied the stability criterion did indicate that towards the end of the clips there was deterioration in segmentation efficacy for some of them.One more limitation is that there is only a single subject in all the video clips. While this does make the testing conditions consistent and improves the comparability of the results between factors, having more subjects with different combinations of hair and skin color will make the results more generalizable.The final limitation is that only temporal segmentation routines were tested formally. It is possible that the non-temporal routines may eventually prove to be more suited to head and upper body segmentation. There is however no equivalent to the ‘BGSLibrary’ for non-temporal algorithms, and this is a gap in the current body of research.2.8The first step would be to use a better depth camera to retake the test video clips, and the upcoming Intel RealSense L515 which uses solid state light detection and ranging (LiDAR) technology seems to be a big improvement on the D435 model used in this study. It has a depth error standard deviation of only 2.5 mm at 1 m distance from the target, gives cleaner contour outlines, has a higher resolution, and scans fast enough to cope with motion. This would remove the need for manual intervention when determining the ‘ground truth’ and would allow testing of both subject and camera motion.Another step would be to gather and test non-temporal segmentation algorithms in a new library using the same methodology. Although it will require a lot of effort, this is necessary if we wish to identify suitable routines for head and upper body segmentation, since the routines from the ‘BGSLibrary’ are poorly suited for this.The third step would be to expand the series of clips to cover background segmentation of the face only, since some use cases do not require the whole head and upper body. Examples of this would be face expression analysis and computation of facial action units.The only human subject was the first author for which informed consent was sought and obtained. The study has ethics approval from the University of Auckland Human Participants Ethics Committee (Ref. 021497).10.13039/501100001537University of Auckland (ID 663710048).This study was paid for using PRESS account funding from the The authors declare that they have no known competing financial interests or personal relationships which have, or could be perceived to have, influenced the work reported in this article.


Background: In Germany, non-pharmacists  are permitted to advise on and sell medications in addition to pharmacists. The aim of this study was to determine if pharmacists and non-pharmacists referred patients to a medical consultation for a scenario in which consulting a doctor was mandatory (‘appropriate outcome’) and what the quality of questioning and – if a medication was dispensed – the quality of information provided were in this context. The study also aimed to determine which factors predicted a necessary referral to a doctor.Methods: A cross-sectional, covert simulated patient study was conducted in a random sample of community pharmacies stratified by location in the German state of Mecklenburg-Vorpommern. Each pharmacy was visited once by one of four trained investigators. They simulated a symptom-based request involving a grandmother with acute diarrhoea. A multivariate binary logistic regression analysis using potential variables from bivariate analysis was carried out to determine the predictors for a referral to a doctor.Results: All 199 planned visits were conducted. A necessary referral to a doctor was recommended in 59.8% (n=119) of all visits. The most commonly asked question was ‘for whom is the medication?’ , while ‘clarification by a doctor’ was asked the least . In 87.9% (n=175) of all visits a medication was dispensed. Multivariate analysis revealed that, unlike pharmacists, non-pharmacists have a 2.446 times higher likelihood of recommending a referral to a doctor .Conclusions: In almost half of the visits a necessary referral to a doctor was not recommended. Furthermore, the quality of questioning and the quality of information were below expectations. Moreover, involvement of non‑pharmacists was surprisingly identified as a relevant factor influencing the appropriate outcome. Worldwide about 1 billion people develop acute diarrhoea each year2, causing about 2 billion cases of acute diarrhoea3, and about 30% of the German population suffer from acute diarrhoea episodes each year2. Because those affected report becoming ill on average 1.7 times per year2, this means that about 42 million cases of acute diarrhoea can therefore be expected in Germany.Acute diarrhoea is one of the most common diseases worldwide4.According to the guidelines of the German Society of General Medicine and Family Medicine, acute diarrhoea is an imbalance between secretion and absorption in the bowels, whereby the symptoms last fewer than 14 days and are associated with an increased frequency (≥ three loose stools in a day) or an increased water content (≥ 75%) or an increased stool weight (≥ 250 g)Salmonella or diarrheagenicEscherichia coli) or parasites 5. More than 90% of cases result from infections, with viral infections being the most common cause6. Bacterial infections, on the other hand, are more often associated with travel, food poisoning and comorbidities. Medications , gastrointestinal disorders , endocrine disorders  or other medical conditions (e.g. amyloidosis) can also trigger acute diarrhoea5.Acute diarrhoea may be a result of infections with viruses , bacteria , not least because of the wide range of possible causes, when the diarrhoea is self-medicated with over-the-counter (OTC) medications that are only available from CPs in Germany. As part of a high quality consultation, pharmacy staff should also identify when it is necessary to refer a patient to a medical consultation based on symptoms8. In Germany, non-pharmacists  are permitted to advise on and sell medications in addition to pharmacists.In Germany there is no medical consultation in about two-thirds of cases of acute diarrhoea12, indications other than acute diarrhoea in adults have been investigated in scientific14 and non-scientific studies19. Because of this lack of studies specifically for acute diarrhoea, the quality of advice provided for acute diarrhoea in adults was analysed for Germany for the first time in 2014 and also identified clear deficiencies20. Despite performance feedback used in the process to improve the quality of advice, a follow-up study in 2017 identical to that conducted in 2014 again showed poor quality of advice22. All the above-mentioned studies have in common that they are based on the simulated patient method (SPM) to determine the quality of advice provided. The SPM is a covert participatory observation by a person who, in an ideal situation, is indistinguishable from a real customer  and visits a CP to simulate a real-life consulting situation based on a previously defined scenario. The data are then collected on the basis of previously defined criteria using an assessment form and the CP is provided with performance feedback, if applicable23.Although studies available from Germany regarding the quality of advice provided in CPs reveal significant deficits, analogous to the international literatureDespite the two studies from 2014 and 2017 mentioned above, there remains a lack of information about the quality of advice for the indication acute diarrhoea in Germany. The reason is that the four scenarios investigated in these two studies were designed as ‘moderate’, in that referral to a medical consultation by the pharmacy staff was not mandatory in any of the scenarios. Both studies also investigated only the quality of advice provided in 21 CPs in a medium-sized northern German city .27.The aim of this current study was, therefore, to determine, on the basis of a considerably larger number of CPs, whether pharmacy staff referred patients to a medical consultation for a scenario in which consulting a doctor was mandatory (‘appropriate outcome’) and what the quality of questioning and – if a medication was dispensed – the quality of information provided were in this context. Factors influencing the ‘appropriate outcome’ were also determined analogous to other national and international studies28 and, to determine the quality of advice provided in the CPs investigated, based on the highly recommended29 SP method that is often used internationally33 as a form of participatory observation34. It must once more be explicitly emphasized that this study shares no similarities with the previous studies conducted in 2014 and 2017 apart from the indication investigated (acute diarrhoea).A cross-sectional study design was chosen in accordance with the ‘STROBE Statement – Checklist of items that should be included in reports of cross-sectional studies’2 area; low population density of 68.9 residents/km2)35. The Pharmacy Association of Mecklenburg-Vorpommern declined to provide a list of all registered CPs in the state when requested by phone. Consequently, CPs were identified using the pharmacy finder available on the websiteApotheken-Umschau.de36. All CPs that had a postcode in the state of Mecklenburg-Vorpommern on the reference date of 1 October 2018 using the postcode search of the pharmacy finder were included in the study. These hits were validated with a corresponding Google search. As a result, a basic population ofN=396 CPs was determined. A comparison with the last available information from the German Federal Chamber of Pharmacies (ABDA) for the end of 2018 regarding the total number of CPs in Mecklenburg-Vorpommern37 showed a 99% agreement. The minimum necessary sample size (n) was determined for a population size (N) of 396 and an error margin (e) of 0.05 using the following formula, which is based on a degree of variability of P=0.5 and a 95% confidence interval38:Because of time constraints associated with the SPs, the visits took place over winter between 1 November and 15 December 2018 in the German state of Mecklenburg-Vorpommern . Because the tool also considers ‘dispensing a medication in an appropriate quantity up to consulting a doctor’ within the discretionary powers of the pharmacy staff, items eight to eleven evaluate whether a medication was dispensed and whether in the process information about the dosage, duration and side effects was provided also for the case of the limits of self-medication being exceeded and the necessary referral to consult a doctor.41 and to ensure a realistic consultation situation, the visits took place without first informing the CPs included in the random sample in accordance with other national21 and international43 studies.Only objective items were used in order to avoid a subjective assessment and thus latitude in the evaluation by the SPs . Therefore, only dichotomous scales were used (closed yes/no questions) to complete the individual items. To avoid the Hawthorne effectAs part of their three-semester research project at the Neubrandenburg University of Applied Sciences, two female and two male Masters students in the Health Sciences faculty, that is, four SPs, were available for the visits. Each CP was visited once , whereby the CPs were distributed randomly across the four SPs .Before starting the data collection, each of the SPs familiarised themselves with the theoretical principles of the methodology and the contents of the evaluation form.A pilot study with four visits was then carried out by each of the SPs to train the SPs in the use of the methodology and to verify the functionality of the collection form and the scenario. The total 16 visits were carried out in CPs that were not part of the stratified random sample. No changes to the scenario and the collection form were required after testing the scenarios.The visits were carried out on different days of the week and at different times of the day. The SPs made their request to the pharmacy staff who first approached them. The SPs only provided additional information if they were then asked by the pharmacy staff to ensure that the information provided is invariable.Along with the items on the evaluation form, the SPs planned, analogous to the international literature , to alsoThe corresponding evaluation form was completed immediately after the visits by the SPs to minimise any recall bias in the study results due to faulty memories. After termination of the study, each CP received general written performance feedback.45, a binary logistic regression model was developed to identify the influence of various independent variables  and adjusted odds ratios (AOR), 95% confidence intervals (CI) and P values were reported. A P value less than 0.05 was deemed significant in multivariate analysis.Data were entered in duplicate into and analysed with SPSS software , version 25 for Windows. As part of the descriptive statistics, frequencies and percentages were determined. Furthermore, 95% confidence intervals (CI) for categorical data using bootstrapping methods were also reported. Because the rule of thumb for sample size assumptions (minimum of 10 events per predictor variable) is given for a logistical regressionriables  on the a47, the data collected were anonymised and recorded in such a way that the CPs involved could not be identified. CPs were not asked for consent prior to the study being conducted because obtaining written consent would have significantly and negatively impacted the results. To resolve the issue of informed consent, the authors contacted the CPs by mail and email after the study informing them that an SP study had been conducted with the corresponding background information49. Recruited students provided their written informed consent to act as SPs.The study protocol was approved by the institutional ethics committee of the Neubrandenburg University of Applied Sciences (registration number: HSNB/GPM/139/18). According to the ‘Guideline for the use of mystery research in market and social research’All 199 planned visits were actually carried out, with a total of €784.70 used from the primary author’s own resources.This reveals that the CPs are mostly in locations with competing CPs nearby. In addition, only a minority of the CPs had a quality certificate. In most of the visits, the advising pharmacy staff were female, between 30 and 49 years of age and were non-pharmacists, i.e. pharmacy technicians and pharmaceutical technical assistants.The appropriate outcome was achieved in 59.8% (n=119) of all visits . The queThe binary logistic regression model is shown in2 value of 0.45.In this multivariate analysis, being a non-pharmacist  or pharmacy staff with an undetermined professional group  as opposed to a pharmacist and two  or three or more  questions being asked as opposed to no questioning were two factors that were significantly associated with referral to a doctor. The location of the CP, the presence of a quality certificate and a queue, the age and the gender of the pharmacy staff as well as the time of day of the visits did not have any significant effect on the appropriate outcome. The model returned a Nagelkerke R50. In another study a recommendation rate for a necessary medical consultation of 57% was determined for a medication-based query, likewise for acute diarrhoea in adults, in Australian CPs27. Considerably worse results for the recommendation of a necessary medical consultation are seen in the international literature for other indications such as pain (recommendation rate: approx. 27%43), vaginal thrush (recommendation rates: 10% and 22%51) and asthma (recommendation rates: 40% and 19%52), which were all medication-based queries. In contrast, the only study that has investigated the recommendation for a necessary medical consultation to date in Germany showed a very high recommendation rate of 90%, again for a medication-based query for an antacid13.Although the appropriate outcome, that is, the recommendation to consult a doctor, was achieved in approximately 60% of all visits, approximately 40% of all CPs did not recommend that the patient consult a doctor even though this would have been necessary. Due to the design of the scenario as a symptom-based query, the study results obtained would probably be worse in everyday consultations with its mix of symptom- and product-based queries. This is reflected in the international and national literature in which  scenarios showed a better quality of advice for a symptom-based query than for a medication-based query54. In regards to a lack of knowledge, pharmacists should receive greater training during their studies in patient consultations using examples44, especially as to date the teaching of such ‘soft skills’ in German universities has been below average compared to other European countries55. In addition, the systematic use of checklists could also help to ensure a better quality of advice in daily patient contact56.Possible reasons discussed in the international literature for the poor quality of advice provided include lack of time, manpower, interest and knowledge on behalf of the pharmacy staff59. In a German study, pharmacy staff suggested that this is due to the worry that the client may feel patronised13. In contrast to this, another German study determined that most patients would like to have a consultation in the CP; however, the study design meant that rather health-conscious and therefore not representative study participants were included60. In a very recent German study, it was stated by pharmacy staff that patients frequently did not want any advice in terms of drug handling, sometimes due to a lack of time61. In a somewhat older English study, 62.5% of the patients interviewed did not expect to be asked any questions by the pharmacy staff during their last purchase of a non-prescription medication62. Similar results were obtained in a more recent study in Qatar in which the pharmacist cited ‘no interest by the patients’ as the central reason for providing insufficient advice42. Another very recent qualitative study from Australia was also able to determine in this context that from the perspective of both the consumers and the pharmacy staff, the frequent lack of privacy is also an important reason for the poor exchange of information63. It would, therefore, be necessary to require CP owners in future to provide appropriate spaces that ensure privacy.On the other hand, the international literature reveals that pharmacy staff most definitely have the knowledge to provide good advice, but it is only inadequately applied in actual patient contact65, the number of questions asked had a significant effect on the appropriate outcome. This is based on the rationale that the right decision – in our case to recommend consulting a doctor – can only be made if appropriate questions are asked and thus information is obtained about the patient. In contrast to this, a Saudi Arabian study revealed that there was no relationship between the number of questions asked and the appropriate outcome – in this case, the dispensing of prescription medications without a medical prescription25. However, the outcome ‘dispensing prescription medications without a medical prescription’ is not comparable to the outcome ‘recommendation to consult a doctor’. While for the first a sensible decision can be made even without asking appropriate questions , for the latter a sensible decision is only possible on the basis of appropriately asked questions.Analogous to other international studies21. In a recent SP study, again for acute diarrhoea in adults, that was conducted in Iraq, this question was asked in almost 80% of all visits66. In contrast, the results are considerably worse for a comparable Turkish SP study which also investigated the quality of advice provided for acute diarrhoea in adults in which this question was only asked in 26% of all visits67. Because certain medications can cause diarrhoea, asking about any pre-existing medical conditions or the patient’s medical history is particularly important68. This question was asked in this study in approximately one-third of the visits and is thus more frequent than in the comparable national studies21. In the similar Turkish SP study, this question was not asked in a single visit67.In regards to individual questions, the question about the duration of the acute diarrhoea was asked more frequently compared to similar national studies21 and international literature69, information is often provided about the dosage of the medication but rarely about possible side effects. An active query by patients could help to greatly improve the frequency of advice provided for the criterion ‘side effects’, as was shown in a recent SP study from Tanzania70.Depending on the criteria being investigated, there are also clear differences in the information that is given to the patients when medication is dispensed. Analogous to the national21 or a significantly higher likelihood of pharmacists27 achieving the appropriate outcome. In the Turkish SP study pharmacists made significantly more recommendations to their patients than pharmaceutical technical assistants67. For indications other than acute diarrhoea in adults there was an analogous picture – either a significantly better quality of advice provided by pharmacists compared to non-pharmacists65 or no significant differences between the two professional groups71. Due to inconsistent national and international studies and given the surprising results obtained in this study, future studies should investigate in greater depth this influencing factor for the advice provided.Along with the number of questions asked, the professional group of the pharmacy staff providing the advice also had a significant influence on the appropriate outcome. Non pharmacists  have a significantly higher likelihood of achieving the appropriate outcome than pharmacists. On the other hand, two comparable SP studies from Germany and Australia – also for acute diarrhoea in adults – did not show any significant difference in the quality of advice provided by the two professional groups72. An SP study design also avoids social desirability, unlike a survey. By using 4 SPs, the study also satisfies the requirement of not having fewer than 2  but also not too many (standardisable) SPs72.This is the first German study that investigated to what degree CPs recommend a necessary medical consultation for acute diarrhoea in adults. The sample size used in the study (n=199) is also considerably larger than the international median sample size (n=112) for SP studies73, because the perspective of persons not involved in developing the study design would have been considered. On the other hand, carrying out the pilot study also aimed to train the SPs in the use of the methodology, which again would no longer have been possible. By way of qualification, it must be stated that the results only refer to one scenario. In addition, only one indication was investigated. Because the study results only refer to one German state, future studies should be expanded to include additional or all German states. The results also refer only to a quite specific time because the study is a cross-sectional study. There is further need for research to determine whether and, if yes, how the results change over time, which is only possible with a longitudinal study design. Carrying out the visits in winter only may have had a seasonal impact on the findings because the pharmacy staff may possibly have been more aware of this indication due to the increased occurrence of acute diarrhoea in the winter months and therefore the results of our study may have been better than at other times of the year74. The audio recordings recommended in the literature for quality assurance75 must be omitted for data privacy reasons because all CPs would have to be informed about this in advance, which would jeopardise the covert study design. Although the particular evaluation forms were filled out by the SPs immediately after visiting the CPs and only objective evaluation criteria were used, recall bias26 and the intra- and inter-observer variabilities typical for SP studies76 cannot be completely ruled out. For greater quality assurance, future SP studies could always carry out and evaluate visits in parallel using two persons (1 SP and 1 observer)77. Although in the literature it is recommended for reasons of effectiveness to provide performance feedback to initiate improvement measures immediately after the particular visit23, this was omitted because the student SPs would probably not be accepted by pharmacy staff as briefing partners14. The restrictions on time and resources and the very high number of CPs visited mean that it was also not possible to provide the CPs with individual written performance feedback including benchmarking after the visits.Conducting the pilot study with persons other than the researchers may have improved the approach79.The findings of this study recommend further research to identify why the advice provided is so often poor and particularly why the quality of advice provided by pharmacists is so inadequate. The results should make both the Mecklenburg Vorpommern pharmacy association and legislators aware of the need to significantly escalate their quality management efforts. In this context appropriate mandatory continuing education courses as well as regular independent reviews with an adequate sanction mechanism could provide a stimulus to sustainably improve the quality of adviceIn almost half of the visits a necessary referral to a doctor was not recommended. Furthermore, the quality of questioning and the quality of information were below expectations. Moreover, two or more questions and, surprisingly, the involvement of non pharmacists were identified as relevant factors influencing the appropriate outcome.https://doi.org/10.7910/DVN/5KVLW480Harvard Dataverse: Replication Data for: Do north-eastern German pharmacies recommend a necessary medical consultation for acute diarrhoea? Magnitude and determinants using a simulated patient approach,Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).Data are available under the terms of the Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?I cannot comment. A qualified statistician is required.Are all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?PartlyAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:NAI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. I have reviewed the responses and changes made in the revised manuscript. I am satisfied with the improvement.  With the present quality, I approve this manuscript for indexing.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?NoAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:NAI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. I enjoyed reading the manuscript. It is a well conducted study with robust methodology and focusing on ‘community pharmacist referral’ which is an important aspect of community pharmacy practice. I thank the F1000Research for providing me the opportunity in reviewing this manuscript. The ‘simulated client method’ used in this research is suitable in evaluating the real-life practice happening at the community pharmacies. I have few concerns associated with the manuscript and are as below:Abstract:The result section of the abstract mentions about ‘non-pharmacist’. It would be nice to elaborate more on those non-pharmacists somewhere in the Introduction section. Though it is mentioned in the Results, para 2, one would like to know whether non-pharmacists are allowed to dispense medications. This may be useful for international readers. Similarly, in the result part the statement ‘two or more questions as opposed to no questions were significantly associated with a referral to a doctor’ doesn’t appear to be novel. It is understood that someone who had not asked any question will be unable to refer. Authors might consider other observations to be mentioned at this section of the abstract.    Introduction: The paragraph 6, authors need to clearly mention which ‘baseline’ and ‘follow-up’ study are they mentioning. What is the relation between the current study and those previous studies. Are they the same sample?I also found some similarity with few of the previous publications by the author using the same 'acute diarrhea' scenario. Authors need to verify the contents and avoid any similarities. May be the Introduction section should elaborate more on the justification of this research.  Why did all these studies used only ‘acute diarrhea’ as the scenario? This needs further elaboration.    MethodologyUnder scenario and assessment, it is not clear how authors categorized ‘Diarrhoea being present for five days as well as a high fever (40°C) are both considered to exceed the limits of self-medication’. I suppose even if there is presence of mucus and/or blood in the stool may be considered referral. I suggest more explanation on development of the scenario and content validation and why ‘Dysentery’ was excluded from the scenario.    Results:In this research, 45.2% of the dispensers were ‘non-pharmacists’. If that is the case then how can we correlate the research findings to evaluate the Community Pharmacy practice? The term ‘non-pharmacist’ needs more elaboration. Probably in the Introduction section, as I mentioned elsewhere.Table 4, response 8. Dispensing of a medication 175 (87.9%). What were these medications. Were there any antibiotics? What happened to the rest 22.1%? Why they did not dispense medications? These are some missing information and needs to be incorporated in the Results section.    Discussion:The discussion can focus on reason for non-referral by the pharmacists. Are there skills related issues? Do the pharmacists possess adequate skills in assessing patients with diarrhea? These aspects may further enrich the discussion.    Limitations:Authors could explore any seasonal impact on the finding.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?I cannot comment. A qualified statistician is required.Are all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?PartlyAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Pharmacy Practice, Pharmacovigilance, PharmacoepidemiologyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. We would like to thank the reviewer for taking the time to review our manuscript and also for the very helpful and detailed comments, recommendations and questions. See our point-by-point response to the reviewer’s comments below.I enjoyed reading the manuscript. It is a well conducted study with robust methodology and focusing on ‘community pharmacist referral’ which is an important aspect of community pharmacy practice. I thank the F1000Research for providing me the opportunity in reviewing this manuscript. The ‘simulated client method’ used in this research is suitable in evaluating the real-life practice happening at the community pharmacies.I have few concerns associated with the manuscript and are as below:The result section of the abstract mentions about ‘non-pharmacist’. It would be nice to elaborate more on those non-pharmacists somewhere in the Introduction section. Though it is mentioned in the Results, para 2, one would like to know whether non-pharmacists are allowed to dispense medications. This may be useful for international readers.  Abstract:Thank you for this comment. The following sentence has been added to the background section of the abstract: ‘In Germany, non-pharmacists  are permitted to advise on and sell medications in addition to pharmacists.’ Similarly, in the result part the statement ‘two or more questions as opposed to no questions were significantly associated with a referral to a doctor’ doesn’t appear to be novel. It is understood that someone who had not asked any question will be unable to refer. Authors might consider other observations to be mentioned at this section of the abstract.  Thank you for this comment. We replaced the statement ‘two or more questions as opposed to no questions were significantly associated with a referral to a doctor’ with other observations.Introduction:The paragraph 6, authors need to clearly mention which ‘baseline’ and ‘follow-up’ study are they mentioning. What is the relation between the current study and those previous studies. Are they the same sample?   Thank you for this comment. We expressed ourselves misleadingly.To clarify, the sentence has been restructured as follows: ‘Despite the two studies from 2014 and 2017 mentioned above, there remains a lack of information about the quality of advice for the indication acute diarrhoea in Germany. The reason is that the four scenarios investigated in these two studies were designed as ‘moderate’, in that referral to a medical consultation by the pharmacy staff was not mandatory in any of the scenarios.’ Also to clarify, the word ‘current’ has been added to this sentence: ‘The aim of this current study was, therefore, to determine on the basis of a considerably larger number of pharmacies whether the pharmacy staff referred patients to a medical consultation for a scenario in which consulting a doctor was mandatory (‘appropriate outcome’) and what the quality of questioning and – if a medication was dispensed – the quality of information provided were in this context.’ The following sentence was also added to the design subsection in the methods section: ‘It must once more be explicitly emphasized that this study shares no similarities with the previous studies conducted in 2014 and 2017 apart from the indication investigated (acute diarrhoea).’ I also found some similarity with few of the previous publications by the author using the same 'acute diarrhea' scenario. Authors need to verify the contents and avoid any similarities.   Thank you for this comment. This study and the previous studies investigate the same indication (acute diarrhoea) but do not use the same scenario. As described in the introduction section, the scenarios used in previous studies from 2014 and 2017 were designed as ‘moderate’ in that in none of the scenarios was a referral for medical consultation by the pharmacy staff mandatory. In contrast, this study determines whether the pharmacy staff referred patients to a medical consultation in a scenario in which consulting a doctor was mandatory. Therefore, it is simulated – unlike the studies from 2014 and 2017 – that the grandmother has had diarrhoea for five days and fever (40°C) (see Table 1). To clarify, the following sentence has been added to the design subsection in the methods section: ‘It must once more be explicitly emphasized that this study shares no similarities with the previous studies conducted in 2014 and 2017 apart from the indication investigated (acute diarrhoea).’ May be the Introduction section should elaborate more on the justification of this research.  Why did all these studies used only ‘acute diarrhea’ as the scenario? This needs further elaboration.   Thank you for this comment. As mentioned in the introduction section, there are studies available from Germany regarding the quality of advice provided in pharmacies but none for this indication. To better clarify why three research studies for acute diarrhoea are necessary, the sentences have been restructured as follows: ‘Because of this lack of studies for acute diarrhoea, the quality of advice provided for acute diarrhoea in adults was analysed for Germany for the first time in 2014 and also identified clear deficiencies. Despite performance feedback used in the process to improve the quality of advice, a follow-up study in 2017 identical to that conducted in 2014 again showed poor quality of advice.’ And furthermore: ‘Despite the two studies from 2014 and 2017 mentioned above, there remains a lack of information about the quality of advice for the indication acute diarrhoea in Germany. The reason is that the four scenarios investigated in these two studies were designed as “moderate”, in that referral to a medical consultation by the pharmacy staff was not mandatory in any of the scenarios.’ MethodologyUnder scenario and assessment, it is not clear how authors categorized ‘Diarrhoea being present for five days as well as a high fever (40°C) are both considered to exceed the limits of self-medication’. I suppose even if there is presence of mucus and/or blood in the stool may be considered referral. I suggest more explanation on development of the scenario and content validation and why ‘Dysentery’ was excluded from the scenario.   Thank you for this comment. More explanation on development of the scenario and content validation has been given. Additionally, it has been explained why ‘Dysentery’ was excluded from the scenario. Therefore, the relevant sentences have been restructured as follows: ‘The tool provided by the Federal Chamber of Pharmacies indicates 10 possible reasons  each of which, if present, are considered to exceed the limits for self-medication and should result in the recommendation to consult a doctor. For this reason, a scenario was designed in which the grandmother’s diarrhoea had already been present for five days and she also had a fever of 40°C. Blood or mucus in the stool as another possible indication that the limits of self-medication had been exceeded was not considered in the scenario because it did not appear realistic for a grandmother to share this intimate information with her grandchildren. Therefore, if the pharmacy staff asked the SPs about the presence of blood in the grandmother’s stool, the SPs stated that it was not known whether there was blood in the stool.’ Results:In this research, 45.2% of the dispensers were ‘non-pharmacists’. If that is the case then how can we correlate the research findings to evaluate the Community Pharmacy practice? The term ‘non-pharmacist’ needs more elaboration. Probably in the Introduction section, as I mentioned elsewhere.   Thank you for this comment. The following sentence has been added to the introduction section to better explain the term ‘non-pharmacist’: “In Germany, non-pharmacists  are permitted to advise on and sell medications in addition to pharmacists.’Table 4, response 8. Dispensing of a medication 175 (87.9%). What were these medications. Were there any antibiotics? What happened to the rest 22.1%? Why they did not dispense medications? These are some missing information and needs to be incorporated in the Results section.   Thank you for this comment. The relevant sentences have been restructured as follows: ‘In 87.9% (n=175) of all visits a medication was dispensed, whereas in 22.1% (n=24) of all visits no medication was dispensed. Regarding the visits in which a medication was dispensed, in 77.2% (n=135) of visits loperamide was dispensed and in 11.4% (n=20) probiotics were dispensed, whereas, for example, antibiotics that require a prescription in Germany were not dispensed at all.’ As described previously in the methods section, the guidelines expect that for such a condition that pharmacists are free to determine whether they also dispense a medication in addition to a mandatory referral to a doctor. It is therefore no wonder that a medication was not dispensed in all test purchases.Discussion:The discussion can focus on reason for non-referral by the pharmacists. Are there skills related issues? Do the pharmacists possess adequate skills in assessing patients with diarrhea? These aspects may further enrich the discussion.   44 , especially as to date the teaching of such ‘soft skills’ in German universities has been below average compared to other European countries55 .’ Thank you for this comment. To further enrich the discussion, the following sentence and an additional reference has been added: ‘In regards to a lack of knowledge, pharmacists should receive greater training during their studies in patient consultations using examplesLimitations:Authors could explore any seasonal impact on the finding.   74 .’ Thanks a lot for this comment. The following sentence and an additional reference to the limitations have been added: ‘Carrying out the visits in winter only may have had a seasonal impact on the findings because the pharmacy staff may possibly have been more aware of this indication due to the increased occurrence of acute diarrhoea in the winter months and therefore the results of our study may have been better than at other times of the year Ethical approval: I appreciate that in this study obtaining a written consent from the staff of the pharmacies would have greatly and negatively impacted the results and any “appropriate outcome” obtained would have been a biased one.Pre-piloting the scenario with other than the researchers may have improved the approach.The SPs made their request to the pharmacy staff who first approached them. Were the SPs certain whether “the pharmacy staff who first approached them” a pharmacist or pharmacy technician? In table 3, about 72% were not pharmacist and not able to determine. Moreover, the authors stated in the results that “In most of the test purchases, the advising pharmacy staff were females, between 30 and 49 years of age and did not have a pharmacy degree (non-pharmacist)”. Since those they should practice under the supervision of a pharmacist, the authors need to elaborate on this in relation to their discussion where they state” Non-pharmacists  have a significantly higher likelihood of achieving the appropriate outcome than pharmacists”.Point 2 must be also discussed in relation to their conclusion where they state” Furthermore, more questioning and involvement by non-pharmacists was identified as relevant factors influencing the appropriate outcome. There is a further need for research to identify why the advice provided is so often poor and particularly why the quality of advice provided by pharmacists is so inadequate”.In table 5, under Queue and Number of questions asked the percentages do not total to 100%. Therefore, the authors need to check their original data, or declare “Missing data” in the table to total the percentage to 100%.I thank you for trusting me with the review of this article which presents a well-designed and executed study. I do approve of indexing the article after some answers and minor corrections to be provided by the authors.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?No source data requiredIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Drug Utilization Studies, Pharmacy education, Pharmacy Practice , NeuropharmacologyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. We would like to thank the reviewer for taking the time to review our manuscript and also for the very helpful and detailed comments, recommendations and questions. See our point-by-point response to the reviewer’s comments below.I thank you for trusting me with the review of this article which presents a well-designed and executed study. I do approve of indexing the article after some answers and minor corrections to be provided by the authors.Ethical approval: I appreciate that in this study obtaining a written consent from the staff of the pharmacies would have greatly and negatively impacted the results and any “appropriate outcome” obtained would have been a biased one.   48, 49 .’Thank you for this comment. Yes, that is why we did not ask for consent to participate in advance. To clarify, the relevant sentence has been restructured as follows: ‘CPs were not asked for consent to participate prior to the study being conducted because obtaining written consent would have significantly and negatively impacted the results.’ Additionally, the following sentence was added: ‘To resolve the issue of informed consent, the authors contacted the CPs by mail and email after the study informing them that an SP study had been conducted with the corresponding background informationPre-piloting the scenario with other than the researchers may have improved the approach. 73 , because the perspective of persons not involved in developing the study design would have been considered. On the other hand, carrying out the pilot study also aimed to train the SPs in the use of the methodology, which again would no longer have been possible.’Thank you for this comment. Therefore, the following sentences and an additional reference have been added to the limitations: ‘Conducting the pilot study with persons other than the researchers may have improved the approachThe SPs made their request to the pharmacy staff who first approached them. Were the SPs certain whether “the pharmacy staff who first approached them” a pharmacist or pharmacy technician? Thank you for this comment. This information was given in Table 2: ‘Exact measurement based on the name tag, the receipt and, if necessary, using a telephone query by the SP after completing the test purchase.’ Despite these efforts, the professional group of the pharmacy staff could not be determined in 55 of 199 test purchases. ‘Non-pharmacists  have a significantly higher likelihood of achieving the appropriate outcome than pharmacists.’In table 3, about 72% were not pharmacist and not able to determine. Moreover, the authors stated in the results that “In most of the test purchases, the advising pharmacy staff were females, between 30 and 49 years of age and did not have a pharmacy degree (non-pharmacist)”. Since those they should practice under the supervision of a pharmacist, the authors need to elaborate on this in relation to their discussion where they state   Thank you for this comment. We have expressed ourselves misleadingly. Therefore, we have deleted ‘but only under the supervision of pharmacists’ in the introduction. To better explain the word ‘non-pharmacist’, we have additionally restructured the sentence as follows: ‘In Germany, non-pharmacists  are permitted to advise on and sell medications in addition to pharmacists.’ Therefore, we believe that the sentence ‘Non-pharmacists  have a significantly higher likelihood of achieving the appropriate outcome than pharmacists.’ in the discussion section is now clearer.Point 2 must be also discussed in relation to their conclusion where they state “Furthermore, more questioning and involvement by non-pharmacists was identified as relevant factors influencing the appropriate outcome. There is a further need for research to identify why the advice provided is so often poor and particularly why the quality of advice provided by pharmacists is so inadequate”.   Thank you for this comment. Please see our remarks to your point 3. We have deleted ‘but only under the supervision of pharmacists’ and have restructured the relevant sentence in the introduction section as follows: ‘In Germany, non-pharmacists  are permitted to advise on and sell medications in addition to pharmacists.’ Therefore, we believe that the sentences ‘Moreover, two or more questions and, surprisingly, the involvement of non-pharmacists were identified as relevant factors influencing the appropriate outcome.’ in the conclusions and ‘The findings of this study recommend further research to identify why the advice provided is so often poor and particularly why the quality of advice provided by pharmacists is so inadequate.’ in the study recommendations is easier to understand.In table 5, under Queue and Number of questions asked the percentages do not total to 100%. Therefore, the authors need to check their original data, or declare “Missing data” in the table to total the percentage to 100%.   Thank you for this comment. We have checked all percentages reported in tables and made corrections if necessary. The conclusion in the abstract section must be consistent with the objective of the study and main findings.Percentages reported in tables must equal to 100% - kindly check all figures.Tables cited in the main text should in proper order.Even though due to the nature of the study, subjects selected were not asked for consent, did the authors contact them after the study informing that a study was conducted with reasons? This is one way that the researchers could resolve the issue of informed consent prior to the study.Create a paragraph on Study recommendations at the end of the Discussion section.  Consider to move some parts of the conclusion. Rewrite the conclusion section.Thank you for allowing me to review this article.  It is an interesting study using an interesting approach i.e. SP.  I have a few comments:Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?YesAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?NoAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Social-behavioral and Administrative aspects of health and pharmacyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. We would like to thank the reviewer for taking the time to review our manuscript and also for the very helpful and detailed comments, recommendations and questions. See our point-by-point response to the reviewer’s comments below.Thank you for allowing me to review this article. It is an interesting study using an interesting approach i.e. SP. I have a few comments:The conclusion in the abstract section must be consistent with the objective of the study and main findings.   Thank you for this comment. The conclusion has been restructured to be consistent with the objectives of the study and main findings.Percentages reported in tables must equal to 100% - kindly check all figures.   Thank you for this comment. We have checked all percentages reported in tables and made corrections if necessary.Tables cited in the main text should in proper order.   Thank you for this comment. We have ensured that the tables are cited in the correct order.Even though due to the nature of the study, subjects selected were not asked for consent, did the authors contact them after the study informing that a study was conducted with reasons? This is one way that the researchers could resolve the issue of informed consent prior to the study.    48, 49 .’Thank you for this comment. Yes, we contacted the subjects after the study informing them that an SP study was conducted with reasons. Therefore, the following sentence and two additional references have been added: ‘To resolve the issue of informed consent, the authors contacted the pharmacies by mail and email after the study informing them that an SP study had been conducted with the corresponding background informationCreate a paragraph on Study recommendations at the end of the Discussion section. Consider to move some parts of the conclusion. Rewrite the conclusion section.   Thank you for this comment. We have created a new paragraph on study recommendations at the end of the discussion section and have moved some parts of the conclusion to this new paragraph. Additionally, the conclusions section has been rewritten.


Being able to recognize human activities is essential for several applications such as health monitoring, fall detection, context-aware mobile applications. In this work, we perform the recognition of the human activity based on the combined Weighted SVM and HMM by taking advantage of the relative strengths of these two classification paradigms. One significant advantage in WSVMs is that, they deal the problem of imbalanced data but his drawback is that, they are inherently static classifiers - they do not implicitly model temporal evolution of data. HMMs have the advantage of being able to handle dynamic data with certain assumptions about stationary and independence. The experiment results on real datasets show that the proposed method possess the better robustness and distinction. The advancement of technologies has facilitated the monitoring of human activities through the embedded sensors in a smartphone. Recently, smart phones, equipped with a rich set of sensors, are explored as alternative platforms for human activity recognition (HAR) , 2. HAR With smartphones becoming an integral part of daily human life , they arThe human sensor based activity recognition is a combination of sensor networks hand-in-hand with the data mining and machine learning techniques . The smaThe basic procedure for mobile activity recognition involves i) collection of labelled data, i.e., associated with a specific class or activity from users that perform sample activities to be recognized ii) classification model generation by using collected data to train and test classification algorithms iii) a model deployment stage where the learnt model is transferred to the mobile device for identifying new contiguous portions of sensor data streams that cover various activities of interest. Sensor data can be processed in real-time or logged for offline analysis and evaluation. The model generation is usually performed offline on a server system and later deployed to the phone to recognize the activity performed.Recently, several authors , 8 have In this work, we adopted a new method for physical activity recognition using mobile phones that uses labels outputting WSVM in HMM. WSVM investigated the effect of overweighting the minority class on SVM modeling between the performed activities. HMM is a natural solution to address the activity complexity by ― capturing and smoothing information during the transition between two activities . We also used the feature extraction approach that transforms the original high dimensional data to a lower dimensional feature space. The transformation can be linear or nonlinear. In this project, we employed the linear Principal Component Analysis (PCA)  to extraFigure The principal component features concatenated with the WSVM estimated label vector are employed as a new training data to train HMM classifier. The final classification is performed with the ‘Viterbi’ algorithm, by the use of a HMM model.An estimated label vector is generated by the ‘Viterbi’ algorithm and the system will output the recognized activity .S:PCA  is an orλ is the eigenvalue of S and V is the eigenvector corresponding to the λ:This problem leads to solve the eigenvalue equation with 1, v2, …, vi],  is the n × n matrix containing n eigenvectors and λ is an n × n diagonal matrix of eigenvalues of the covariance matrix. In Eq.  and majority classes (yi = +1), as followOsuna et al.  proposedgian Eq.  for the (resp.) the number of positive (resp. negative) instances in the initial database . Solving the formulation dual of WSVM  and {0.1, 1, 5, 10, 100}, respectively, to maximize the error rate of five fold- cross validation technique. The optimal parameters σopt = 0.9, 0.9, and 0.8 are found to be optimal the training dataset of HAR, HAPT, and WISDM, respectively. We show in the Table These algorithms are tested under MATLAB environment and the WSVM algorithm is tested with implementation LibSVM  using Gae 0.1, 0., 0.5, 1 In terms of reducing the datasets, the feature reduction identifies the most relevant features for the learning process. We notice that PCA features can improve the discrimination between different activities than the original features. For WISDM the performances of activity recognition are low than HAR and HAPT datasets with 561 features. This is explained by the number of features (6) for WISDM is not sufficient when using PCA algorithm. Another reason to the lowest accuracy in WISDM dataset is attributed to the use only the accelerometer sensor comparatively to the HAR and HAPT that use the both accelerometer and gyroscope sensors.To get a detailed knowledge of the performances on each class corresponding to current activity for the HAR dataset with six different activities. We calculate the confusion matrix of the proposed method in Table In the Table Experimental results of the hybrid model presented demonstrate how it can be effectively employed for activity recognition of static and dynamic activities. It obtains a significant performance. Specifically, we show how the hybrid system obtained by using the WSVM label output a new feature added to the reduced data for training and testing HMM outperforms other well known supervised pattern recognition approaches. We consider that WSVM approach has great potential to deal the imbalance class in this human activity recognition problem. However, it must be noticed that hybridizing these schemes implies a more complex system. Fortunately, the training phase in a deployed activity recognizer is usually done offline, so we do not consider such growth of complexity a real problem in our domain.


Plant growth hormone, gibberellic acid (GA3 for different concentrations 0, 40, and 100 μM. Application of 40 μM GA3 failed to show any differences in the OCT structural images. However, bOCT contrast image was clearly different. Changes were found to be statistically significant. Although the mechanism for the contrast difference is not clear, it can be said there is a large change across the temporal scale with the application of GA3. Demonstration of OCT utilizing the speckle contrast is believed to have the potential as a promising tool in plant physiology.Contrast across the temporal axis was calculated for each pixel of the structural images and biospeckle OCT contrast images were obtained under the conditions of before and after application of GA Optical coherence tomography (OCT) maps in three dimensions of a structure by utilizing the inherent reflectivity variations arising as a result of optical refractive index variations within a biological tissue , 8. OCT However, the potential of OCT in the field of plant biology and botany has still been under investigated. Most recently, OCT has been used in in vitro study of autumnal color change of maple leaves and their associated changes in optical properties . There hIt should be pointed out that the potential of OCT in monitoring structural changes of plants in relation to environmental variations has been very limited. Our group earlier reported the use of monitoring changes in the activity with respect to Ozone exposure of rice plants , 12 and In such monitoring, we proposed the use of laser speckles that have a granular appearance and are, in general, considered to be a noise degrading the structural images. The speckles invariably arise from the random interference of the scattered light when an optically rough surface or a scattering medium object is subject to the illumination of a coherent light source such as a laser source. If the object is stationary with no motion of the surface structure of the object, the intensity of the speckle patterns remain temporally stable. However, when the object is dynamic, i.e., there is a continuous movement of the scattering centers as in the case of biological samples, the speckle pattern varies, and there is a fluctuation in the intensity. This dynamic speckle pattern is a specific characteristic of the biological tissues and thus has been named as biospeckle and could be used to characterize the activity of the biological sample , 2, 16. 3), after an hour.In this study, the temporal variation of each pixel of the structural images or OCT reflectivity signals were characterized by a parameter called biospeckle contrast which is defined as the ratio of the standard deviation to the mean intensity of a pixel calculated over a few tens of seconds. The study was done before and following application of a phytohormone, gibberellic acid  by which the light beam is scanned laterally in the x and y directions to be focused through an imaging lens L3  across the sample to generate 3D OCT structural images. The light from the output port of the circulator is collimated by a lens L5 to pass through a custom-built spectrometer consisting of a grating, a lens L6  and a line-scan camera . The spectral interference signal was first converted from the wavelength space to a wavenumber space through rescaling and then Fourier transformed to obtain the depth resolved reflectivity profile of the sample. Lateral scanning was done by scanning the galvano-mirror acquiring x–z scan images. One z-scan was acquired in 250 μsec and x–z image frames were acquired at an acquisition rate of 10 frames per second. Image size was fixed to be 2048 × 512 pixels.Biospeckle contrast, C, was defined as the ratio of the standard deviation of the intensity at each pixel along time to the mean value of the pixel across the total time of scans. When speckle contrast is large, it could mean a large variation from mean across the frames and thus large temporal fluctuations. Presence of large temporal fluctuations in the intensity would indicate for stronger movements within the leaf. Therefore, the magnitude of changes in speckle contrast could be used to predict the dynamics within the leaf.3. OCT x–z image reflectivity signals can visualize different laminar structure of the internal structure of the leaf with the intensity scale given in log scale Our results suggest bOCT could be used to in in vivo real short time monitoring of Chinese chives leaf under growth hormone application GAAdditional file. Supplemetary details about the plant growing conditions, microtome observations and quantitative analysis along with Figures S1 to S4 are given.


In this paper analytical expressions are derived to describe the spin motion of a particle in magnetic and electric fields in the presence of an axion field causing an oscillating electric dipole moment (EDM). These equations are used to estimate statistical sensitivities for axion searches at storage rings. The estimates obtained from the analytic expressions are compared to numerical estimates from simulations in Chang et al. (Phys Rev D 99(8):083002, 2019). A good agreement is found. Axions and axion like particles (ALPs) are candidates for dark matter. There is thus a huge experimental effort for the search of these kind of particles. For a detailed review, we refer the reader to references , 3. AxioA and not to its square. To date, NMR based methods are being used to look at oscillating EDMs [For the second (and third) term in the list  this is ing EDMs .Another possibility is to search for axions/ALPs in storage rings. Storage ring experiments have been proposed to search for electric dipole moments of charge particles , 7. Thest the time in the laboratory system, G  and The spin motion relative to the momentum vector in electric and magnetic fields is governed by the Thomas-BMT equation –10:2\docFor the following discussion it is more convenient to write Eq. ested in , 11. TheThe solution to first order in eriments . At the t for The phase entclass1pt{minimaFor the special case mentclasspt{minimamentclasspt{minimaEquations N particles continuously on a target with the same rate over a time period T during which the beam polarization P is assumed to be constant and using a polarimeter with an average analyzing power A of the scattering process and a fraction f of the beam particles detected, the observed vertical polarization , assumiN, efficiency f, analyzing power A, polarization P and spin coherence time Table One year of beam time  Running at one fixed frequency, (2) covering a wide range in frequency.The results are in good agreement compared to reference  where a