Citation analysis is one of the most commonly used methods in academic assessments. Up to now, most of academic assessments are based on English literature, ignoring the fact that the role of Chinese papers in academic assessments has become increasingly indispensable. Therefore, to give full play to the role of Chinese literature in academic assessments is an urgent task of current academic circle. Based on Chinese academic data from ScholarSpace, i.e., 82826 Chinese computer science journal papers, we conduct a comprehensive assessment of academic influence from the perspectives of fields, journals and institutions, in order to achieve a better understanding of the development of Chinese computer literature in the past 60 years. We find that Chinese scholars tend to cite papers in English, discover evolution trend of fields, journals and institutions, and call on journals, institutions, and scholars to strengthen their cooperation. The progress of scientific research is closely related to academic inheritance. Only by standing on the shoulders of predecessors can the younger generation see further. Citation is a form of academic inheritance. Through citation analysis, scholars can understand the development of academic fields and draw lessons from classical research ideas, thus gaining new academic achievements. Therefore, citation analysis is one of the most commonly used methods in academic assessments.Up to now, most of academic assessments are based on databases that mainly consist of English literature, such as DBLPHowever, this assessment method is not entirely suitable for Chinese scholars, since a considerable number of them writes in their native language, and there are many excellent works in Chinese papers [According to  papers have fewer than h citations each  literature.ScholarSpaceChinese Journal of Computers(CJC), Journal of Computer Research and Development(JCRD), Scientia Sinica (Informationis)(SS-I), Journal of Software(JS), Journal of Computer-Aided Design & Computer Graphics(JCAD&CG), Acta Electronica Sinica(AES), Journal of Chinese Information Processing(JCIP), Journal of Frontiers of Computer Science and Technology(JFCST), Journal of Chinese Computer Systems(JCCS), Journal of Image and Graphics(JIG), as well as Computer Science(CS), including the 10 sub-fields of computer science defined by CCF (China Computer Federation), i.e., Computer Network and Communication(Network), Information Security and Privacy Protection(Security), Chinese Information Processing and Information Retrieval(Info), Computer Theory(Theory), Graphics and Human-Computer Interaction(Graphics & HCI), Software Engineering/System Software/Program Designing(Software), Database System and Data Mining(Database), Architecture and High Performance Computing(Architecture), Artificial Intelligence and Robotics(AI), as well as Intersection and Synthesis(Intersection).As a subsystem of ScholarSpace, our dataset, ScholarCitation has obtained 71,221 citation relationships of 82,826 journal papers from top 11 Chinese computer science journals, i.e., The ontology of our dataset is shown in target papers in the following analysis. We define a series of evaluation indicators for three types of entities: fields, journals, and academic institutions, including the number of papers, the number of self-citations, the number of other-citations, the number of other-references, the number of citations, the number of references, self-citation rate, citation rate, and reference rate. The definitions of these indicators are shown in For ease of explanation, the 82,826 journal papers collected by ScholarCitation will be referred to as Further explanation of these indicators is provided below.P means the total number of target papers published by entity E in a period T. For example, assuming that Chinese Academy of Sciences(CAS) published 1000 papers between 2009 and 2018, then P is 1000.First, the number of papers CS−S means the total number of times that entity E cited its own published target papers in a period T, and the meaning of self-citation rate CRS−S is the number of self-citations of entity E per paper in a period T. For example, assuming that CAS published 4000 papers and cited itself 2000 times between 2009 and 2018, then CS−S is 2000, and CRS−S is the ratio of 2000 to 4000, i.e., 0.5.Second, the number of self-citations CO−S means the total number of times that the target papers published by entity E were cited by other entities in a period T. For example, assuming that CAS was cited by other institutions 3000 times between 2009 and 2018, then CO−S is 3000.Third, the number of other-citations Ced means the total number of times that the target papers published by entity E were cited by all entities (itself and other entities) in a period T, and the meaning of citation rate CedR is the number of citations of entity E per paper in a period T. For example, if CS−S is 2,000 and CO−S is 3,000, then Ced is the sum of 2,000 and 3,000, i.e., 5,000. At the same time, if P is 1,000, then CedR is the ratio of 5,000 to 1,000, i.e., 5.Fourth, the number of citations CS−O means the total number of times that the entity E cited target papers published by other entities in a period T. For example, assuming that CAS cited other institutions 4,000 times between 2009 and 2018, then CS−O is 4,000.Fifth, the number of other-references C means the total number of times that the entity E cited target papers published by all entities (itself and other entities) in a period T, and the meaning of reference rate CR is the number of references of entity E per paper in time T. For example, if CS−O is 4,000 and CS−S is 2,000, then C is the sum of 4,000 and 2,000, i.e., 6,000. At the same time, if P is 1,000, then CR is the ratio of 6,000 to 1,000, i.e., 6.Sixth, the number of references CS for entities of institutions. The meaning of CS is the sum of citation scores of entity E in a period T. The calculation method of this indicator is based on the CSRankingsIn addition, we define citation score This section will first give an overview of our citation analysis in section overview of citation analysis, then conduct the citation analysis based on fields, journals and institutions in section fields-based citation analysis, section journals-based citation analysis, and section journals-based citation analysis respectively. In section cross citation analysis, we will finish cross citation analysis.By 2018, ScholarCitation has collected 71,221 self-citation relationships of 82,826 target papers. Therefore, the self-citation rate of ScholarCitation is 0.86. However, from the official website of Scimagojrmerely considering self-citation, Chinese scholars prefer to cite English papers.By comparison, in the field of computer science, the self-citation rate of Chinese and English journal papers published by Chinese scholars is much higher than that of Chinese journal papers. Therefore, P, C and CR, and found out the temporal changes of the three indicators. The publication and citation of target papers in the last 10 years are shown in Horizontally speaking, Chinese scholars prefer to cite English papers. What about the longitudinal situation? We sampled target papers from ScholarCitation from 2009 to 2018, calculated Chinese papers in the field of computer science show a development trend of “high quality in small amount.” However, although citation rate is on the rise, there is still a gap between it and self-citation rate (2.60) of the above-mentioned Chinese and English journal papers. This situation is not only aroused by the quality of target papers, but also by Chinese scholars' preference to cite English papers.In terms of the number of papers, it increased first and then decreased from 2009 to 2018. However, the overall fluctuation is modest in that the gap between the maximum and the minimum is within 1,000. In terms of the number of citations, it shows an overall growing trend and reached the maximum in 2015. However, similar to the number of papers, the fluctuation of the number of citations, which remains at around 5,000, is slight. As the result of the calculation of the number of papers and citations, citation rate is a more comprehensive indicator. As is seen in the figure, citation rate shows an overall upward trend and reached a maximum of 1.56 in 2015. This is because the number of papers in each year differs little, but in 2015 the number of citations reached a maximum. Therefore, as a whole, P), the number of self-citations ), the number of other-citations ), the number of other-references , and citation rate ). The publication and citation of papers in 10 sub-fields of computer are shown in In order to understand the development of different sub-fields of computers, we extracted citation data collected by ScholarCitation from 1960 to 2018 to calculate 5 indicators for each field: the number of papers published , so the rate of citation in each field, that is, the ratio of the number of citations to the number of papers, fluctuates little (standard deviation is 0.17).Second, there are differences in the composition of citations among different fields. In terms of the composition of citations, the fields where the number of self-citations is significantly higher than that of other-citations are Info, Graphics & HCI, as well as Network. On the other hand, the fields where the number of other-citations is significantly higher than that of self-citations are Architecture, Theory, and Intersection. Therefore, the degree of interdependence among different fields differs.Third, there are differences in citation preference among different fields. In terms of citation preference, the fields of Graphics & HCI, and Network prefer to cite papers in their own fields, while the fields of Theory, Architecture, and Security prefer to cite papers in other fields. This conclusion and the second point above can mutually confirm, indicating that the degree of interdependence among different fields is different.Cumulative citation of the target field in a period T is the sum of citations of target papers in this field in T, which is denoted as Ced. In order to compare the differences of citations in different fields, we introduce the concept of proportion. The proportion of cumulative citation in a target field refers to the ratio of cumulative citation of the target field to that of all fields. Next, we will further analyze the historical development of fields according to the proportion of cumulative citation in different fields. First, the development of Architecture is slowing down. The field of Architecture (HPC) has been the hotspot from 1982 to 2000. But since the twenty-first century, its ranking has been gradually declining: In 2001, it was surpassed by Network, as well as Graphics & HCI, falling to the third place. In 2003, the fields of Theory, Software developed rapidly, rendering a decline in the ranking of HPC to the 5th place. In 2006, 2008 and 2012, the fields of AI, Info, and database and data mining surpassed HPC, respectively, so it ended at the 8th place.Second, Graphics & HCI, as well as Network have become hot fields. The fields of Graphics & HCI, and Network ranked the same for the first time in 1982. After they reached their peaks in 1983 and 1986, respectively, their rankings began to decline slowly. And they got the same rankings again in the 1990s, when they were in their troughs. However, since 1995, the two have grown rapidly and succeeded in occupying the top two places in the twenty-first century.Third, Software and Theory are neck and neck. Although their starting points are sharply different, since 1983, the proportion of cumulative number of citations in Software and Theory has been very close to each other. The former performed slightly worse than the latter from 1983 to 1989, while from 1989 to 2003, the latter was overtaken by the former, but the gap was not huge. The field of Theory gained a weak leading edge again from 2003 to 2006. And from 2006 to 2018, the field of Software was slightly better.P), the number of self-citations ), the number of other-citations ), the number of other-references ), and citation rate ). The publication and citation of papers in eleven most representative journals of computer are shown in In order to understand the development of different computer journals, we extracted the citation data of ScholarCitation from 1960 to 2018 to calculate 5 indicators for each journal: the number of published papers , CJC (founded in 1978) and JCIP (founded in 1986). The lowest are SS-I (founded in 1950), JCCS (founded in 1980), CS (founded in 1974) and JFCST (founded in 2007). It can be seen that the citation rate of a journal has little relation with its starting time.Second, there are differences in the composition of citations among different journals. In terms of the composition of citations, the journals with more self-citations than other-citations include JCAD&CG, AES, JCIP, JCCS, and CS. On the contrary, the journals with more other-citations than self-citations include CJC, JCRD, and JS. From the analysis above, the significance of the three most representative Chinese journals  of computer science can be inferred.Third, there are differences in citation preference among different journals. In terms of citation preference, JCAD&CG, AES, and JCIP prefer to cite their own papers, while JFCST, JCCS, and CS prefer to cite papers from other journals.Cumulative citation of a target journal J in a period T is the sum of citations of target papers published by J in T, which is denoted as Ced. In order to compare the differences of citations of different journals, we introduce the concept of proportion. Proportion of cumulative citation of a target journal refers to the ratio of cumulative citation of the target journal to that of all journals. In order to further analyze the historical development of each journal, we use the indicator of the proportion of cumulative citation of different journals. Chinese Journal of Computers, AES, JS, JCRD, and JCAD&CG. These five outstanding journals fall into two categories: stably developing veterans and rapidly rising stars.As is shown in The first is the stably developing veterans. From the perspective of rankings, the performance of journals established for a long time are relatively stable. Except being overtaken by JS in 2009-2012 and 2016-2017, CJC (founded in 1978) and AES (founded in 1962), have consistently ranked in the top two. As for JCRD, founded in 1982, it held the third place till it was overtaken by JS in 2006, and has ranked the fourth since then. However, it is worthy to mention that according to the numeric value of proportion of cumulative citation, CJC and AES show a downward trend.Then there are the rapidly rising stars. After 10 years' hard work, JCAD&CG (founded in 1989) and JS (founded in 1990), both developed rapidly in the twenty-first century. The former has been in the top five since 2003, and the latter has been in the top three since 2006. JS even surpassed AES, obtaining the second place.Cumulative citation score of a target institution I in a period T is the sum of the citation scores of target papers published by the corresponding institution in T, which is denoted as CS. To compare differences between cumulative citation scores of various institutions, we introduce cumulative citation score proportion, which refers to the ratio of cumulative citation scores of the target institution to that of all institutions. + or A on Computer Science and Technology in the 4th round of subject evaluation conducted by Ministry of Education of China.As is the case in citation analysis based on fields and journals, in order to analyze the historical development of each institution, the proportion of the cumulative citation score of each institution will be analyzed below. CAS tops the list. From 1979 to 2018, cumulative citation score of CAS has always been the highest one, leaving institutions in the second place far behind. However, in terms of numerical value, cumulative citation score proportion of CAS fluctuated, descending from 1979 to 2002, increasing from 2002 and 2008 and achieving stability at around 36% from 2008 to 2018. High ranks of CAS mainly attributes to its sheer size. As a whole, ranks of institutions have remained stable since the twenty-first century, especially in the last decade.It can be inferred from +, A, A−, B+, B, C+ are 4, 7, 12, 24, 24, 26, respectively. An institution is accurate-evaluated if it receives an A+ in the assessment conducted by Ministry of Education, and ranks No.1~No.4 after our calculation. We calculated the accuracy of each rating according to the definition above.For each institution, we calculated its ranking of average citation score in the last 10 years and compared the rankings with the assessment in the 4th round of subject evaluation conducted by Ministry of Education of China on Computer Science and Technologyare consistent with the evaluation results of Ministry of Education of China.SS-I, target journals are all included in Cross citation analysis is based on journal-field. Generally speaking, in terms of the subject of computer science, papers collected by English journals are focused on a certain field, while Chinese journals tend to be more comprehensive. That is to say, a journal may include target papers from multiple fields simultaneously. Similarly, target papers in a particular field may be distributed among different journals. most representative Chinese journals of computer science present a situation of tripartite confrontation and are typical comprehensive journals. As a consensus, three most representative Chinese journals of computer science are CJC, JS, and JCRD. They show strong performance, occupying at least two of the top three positions in all fields except Graphics & HCI. Secondly, journals oriented to specific fields to some extent represent the authority of their own fields and are typical characteristic journals. For instance, JIG and JCAD&CG win the top two in the field of Graphics & HCI, while JCIP is the leader in the field of Info.From the analysis of Based on citation relationships collected in ScholarCitation system, we conduct a citation analysis of Chinese journals in the field of computer science with a time span of 60 years. As a whole, Chinese papers in the field of computer science shows a trend of “high quality in small amount.” The number of papers increased and then decreased in the last decade. However, the number of citations showed an overall growing trend. Merely considering self-citation, Chinese scholars tend to cite papers in English.Three most representative Chinese journals of computer science present a situation of tripartite confrontation and are typical comprehensive journals. They show high coincidence of cooperative institutions and cooperate closely with multi-cooperation institutions. As for characteristic journals, they to some extent represent the authority of their own fields and pay more attention to the dominant institutions in their own fields.Development trends of different fields and institutions differ. The development of Architecture slowed, while Graphics & HCI, and Network developed into hot fields. In terms of institutions, ranks of institutions have remained stable since the twenty-first century, especially in the last decade.Journals, institutions and scholars should strengthen their cooperation, working to improve the quality of papers together. More analysis should also be conducted on literature in non-English languages to boost diversity.The datasets generated for this study are available on request to the corresponding author.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Replication and cross-validation of research findings across independent longitudinal studies is essential for a cumulative science. However, the interplay between harmonization, replication, and generalizability of results across interdisciplinary longitudinal studies can present remarkable challenges. Careful interpretation of multistudy results must include consideration of the age, birth cohort, health, and education of individuals in the sample, measurements, the number and spacing of assessments, and rates of response and attrition. Placed in a broader historical (or future) context, we must consider the representativeness of population sampling, historical period, and analytic method in understanding the replicability and generalizability of findings. In a multistudy context, harmonization can be considered at levels of research question, statistical models, and measurements and can minimize some sources of cross-study variability. I will discuss the challenges and benefits of harmonization and the coordinated analysis approach used by the IALSA research network to achieve results from multi-study integrative research.


The involvement of psychological factors in the etiology of chronic diseases is rousing the interest of the scientific community (Conversano, Psychodynamic research has highlighted the role of personality in the development and progression of psychopathological and organic diseases (Price et al., One aspect of personality commonly studied in patients with chronic diseases is alexithymia, which is defined as the inability to distinguish between emotions, thoughts, and physiological responses to stimuli. Alexithymia has been found to be associated with several medical conditions (Lumley et al., per se and its influence on individual psychological well-being has been widely documented (Alonzo, Among other factors which contribute both to the onset and to the course of chronic illness, stressful life events are involved in the pathogenesis of both psychological and organic diseases (McFarlane,  Alonzo, . Researc Alonzo, . Accordi Alonzo, , confirm Alonzo,  as well  Alonzo, .the opportunities provided by bioscience and computational psychiatry to creatively explore and assess the value of protocol-directed combinations of specific treatment components to address the key problems of individual patients” (Fonagy, Taking these findings together, we assume that psychological and organic issues are intercorrelated and a comprehensive understanding of chronic medical conditions should consider all aspects of the illness (Yoo and Ryff,  Fonagy, .CC and MD contributed in equal part to the development, conceptualization, literature review, and writing of the manuscript. 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.


Dear Editor,The presence of recurrent skin lesion outbreaks in intertriginous areas and lower extremities, during years of evolution, may be a presenting form of necrolytic migratory erythema (NME), which is a paraneoplastic skin disease that is associated with malignant glucagonoma in 90% of cases.This report presents the case of a 59-year-old woman with a history of keratoconjunctivitis, asthenia, and constipation. She was referred to evaluate recurrent skin lesions with four years of evolution. She was affected by erythematous, scaly plaques and hyperpigmentation in the legs, gluteal area, groin area, thighs, and elbows, with no associated systemic symptoms . She proWith the suspicion of NME and high levels of glucagon, an abdominal CT scan was made showing a 4 cm mass in the pancreas, and the presence of a malignant glucagonoma was confirmed by pathological anatomy. The skin lesions completely resolved after tumor resection. However, one year later she developed liver metastasis with no recurrence of skin lesions.etc., NME may be the first and only glucagonoma symptom.Although malignant glucagonoma may be accompanied by systemic symptoms such as diarrhea, weight loss, newly developed diabetes, normocytic anemia, zinc deficiency, or fatty acid or amino acid deficiency, None declared.Inés Gracia Darder: Approval of the final version of the manuscript; conception and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; participation in study design; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.Daniel Ramos: Approval of the final version of the manuscript; conception and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; participation in study design; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.Julián Boix Vilanova: Approval of the final version of the manuscript; conception and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; participation in study design; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.Ana Francisca Bauzá Alonso: Approval of the final version of the manuscript; conception and planning of the study; drafting and editing of the manuscript; collection, analysis, and interpretation of data; participation in study design; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.None declared.


The article presents, in a clear, concise manner, the main concepts, such as digital imaging, segmentation, extraction/selection of relevant features, artificial intelligence (AI), machine learning, deep learning, neural network, computer-aided diagnosis, content-based image retrieval, radiomics, and radiogenomics, introducing the reader to these new “-omics” that we will have to deal with on a daily basis in the near future.The article “Artificial intelligence, machine learning, computer-aided diagnosis, and radiomics: advances in imaging towards to precision medicine” by Koenigkam-Santos et al.In recent decades, the field of radiology and diagnostic imaging has been influenced by new technologies that have led to changes in the way radiologists practice their specialty. Notable among such technologies are digital imaging and picture archiving and communication systems (PACS), which have completely modified the reporting of imaging examinations and have allowed large numbers of images to be stored. This large amount of qualitative (imaging) and quantitative data is what constitutes the “Big Data” of medical imaging.,3. In addition, online database sharing and competitions such as those organized by Kaggle have facilitated the development and testing of new algorithms, accelerating their enhancement.In recent years, the development of AI, the increased access to powerful computers, and the large accumulation of data have resulted in great advances in the field of radiology and diagnostic imaging. Many of those advances, such as cell phone use, have enabled social progress and changes in quality of life. In AI, the advance of machine learning algorithms, especially deep learning and neural networks, has allowed the development of powerful computer science tools. Some emblematic examples were victories by the “machines” over champions in games like chess and Go-10. In the field of dermatology, a cell phone application has been developed to differentiate melanomas from other skin lesions and has been shown to have the same accuracy as that of a group of dermatologists. In the field of pathology, algorithms such as those developed by Liu et al. have been shown to have greater sensitivity for detecting tumor cells in histopathological specimens than do human pathologists. In the field of ophthalmology, studies on the detection and classification of diabetic retinopathy have demonstrated the clinical application of AI in the diagnosis of retinal lesions.The evolution of deep learning involving neural networks has been followed with great interest, and deep learning has changed many aspects of our daily lives; it is sure to revolutionize health care as well. The idea that its impact will be pronounced, likely transforming daily clinical practice in fields such as radiology, pathology, ophthalmology, and diagnostic ophthalmology, has been supported by the results of a number of scientific articles, demonstrate the desire on the part of radiology societies to participate in the development of AI instruments for imaging diagnosis. In the field of imaging, there are several potential applications for AI, such as in patient flow algorithms, in the definition of image protocols, in the generation of synthetic images, in quality control, in radiation dose control, in computer-aided diagnosis, in automated lesion detection, in automated interpretation of findings, in radiomics, and in radiogenomics, which could result in great changes in radiology practice.In the field of radiology, competitions involving the use of AI at annual meetings of the Radiological Society of North America-for bone age definition in 2017 and for the diagnosis of pneumonia in 2018-as well as the launch of a journal focusing specifically on AI in radiology introduce concepts that promote a deeper understanding of this new era.Change is coming, and we radiologists, who have always had our activities closely linked to evolving technologies, should all be aware of AI, which could allow us to put into practice the concepts of precision medicine and personalized medicine. Review articles like the one authored by Koenigkam-Santos et al.


With the incidence and prevalence of COVID-19 disease, health, social, and economic considerations need to be reviewed and redefined. Since this pandemic, even more severe and pervasive than the First and Second World Wars, has disrupted the world’s social systems and economic structures, many well-known concepts and disciplines in the social health sciences need to be adapted. Changes in many professions, industries and economic resources have undoubtedly made new demands on social health.Adherence to the principles of individual ethics, professional ethics, and social ethics, attention to social media , sustainable development, social justice, prevention of violence , vigilance and active management of international institutions  in preventing wars between governments, equitable distribution of food resources, preventing the increase of non-communicable diseases  are among the urgencies of government and global management.Here it is necessary to mention a group of disciplines discussed in social health .


Walter Everaerd, former President of the International Academy of Sex Research, World Association for Sexual Health (WAS) gold medalist, and internationally acclaimed sex researcher, died on October 4, 2019, at the age of 82. Walter had been suffering from bladder cancer for several years. He is survived by his wife Bets, his three children, and eight grandchildren.Walter was a pioneer in experimental sexology in the Netherlands. At the age of 21, after two years of military service, Walter began his studies at Utrecht University, where he specialized in the new and promising fields of experimental clinical psychology and psychotherapy. In an academic environment that was at the time mainly oriented toward psychoanalysis and introspection as scientific methods, Walter approached clinical problems as an experimental psychologist and behavioral therapist. He became a full professor in Psychology at the age of 37 at Utrecht University, and he moved to the University of Amsterdam 12 years later. Over the years, with his students and collaborators, he received numerous grants in fields as diverse as symptom perception, interoception, vaginismus, sexual arousal, stress and health, cancer, asthma, and traumatic memory. Walter’s contributions to the field of sexology, both theoretically and experimentally, have significantly changed and advanced how we define sexuality and treat sexual problems. Influenced by Walter’s work, the field of sexuality has now moved away from drive and libido as the main explanatory constructs for sexual response and sexual expression toward information processing models of sexual response. Walter was the first scholar to propose that sexual arousal should be considered an emotion. Also, current views and knowledge of sexual desire and sexual arousal problems, as reflected by the DSM-5, have, in more direct and indirect ways, been informed and inspired by Walter’s theoretical and experimental work.Walter was a modest and kind man who took his task as an academic mentor as seriously as his scientific endeavors. He mentored almost 60 Ph.D. students, many of whom became full professors. It is probably no exaggeration to say that he raised several generations of Dutch sexologists. His former Ph.D. students include Stephanie Both, Peggy Cohen-Kettenis, Joost Dekker, Jos Frenken, Luk Gijs, Erick Janssen, Bram Kuiper, Ellen Laan, Anne Oldenhave, Theo Sandfort, Mark Spiering, Arno Toorians, Adriaan Tuiten, Daan van Beek, Janneke van der Velde, and Jacques van Lankveld. Walter was honorary member, scientific program chair, and host and president of several national and international psychological and sexological societies, including the International Academy of Sex Research. He also served as department chair and as a board member and chair of various university bodies and national organizations, such as the Dutch Association for Gay and Lesbian Studies and the Dutch Health Council. He was the recipient of many awards, including the Heymans Award of the Dutch Psychological Association, the Sexologist of the Year Award of the Polish Academy of Sexology, the van Emde Boas–van Ussel Award of the Dutch Society of Sexology, and the WAS Gold Medal.We are grateful for Walter’s many contributions, and we will miss him dearly.


Safe community is based on four principles: safety belief, knowledge of the proper use of safety devices, access to safety requirements and respect for the rules, and safe driving is one of its axes. According to the World Health Organization s annual report for 2015, more than 1.25 million People die because of traffic accidents worldwide, and the eighth cause of death in the world is the leading cause of death in the age group of 15-15 years. This study was carried out to promote the safe community based on traffic accident analysis in the age group under 19 years old in Iran.This study was conducted through document review, reassessment of documents, data from the World Health Organization, Death and Immortality of Iran, and the Forensic Medicine Organization.According to the statistics, in 2016, there was a change in the pattern of injuries in adolescence, and the first three priorities were changed to traffic accidents (32%), fall (16%), poisoning and violence (5%). Is. The study of the 10-year trend of traffic accidents in three types of pedestrians, motorcyclists and motorcycles shows that the age group of 15-19 years old males in all three levels is in the number of injuries. In the traffic accident cases, the pattern of injuries has changed. Despite the fact that 34.5% of the victims of the incident belonged to the age group of 19 to 15 years old, it was ranked second in the age group of 19-15 years old. The major causes of driving accidents in the age group of 19-15 years were not having a driving license, mental and emotional state, non-use of seat-belts, imagine the ability to control a car or engine, dramatic movements during driving and Lack of attention to driving directions which could be prevented.All organizations involved in traffic safety and the safe community should focus on providing cultural, educational, and empowering age groups with the explanation of the areas of technical, scientific, educational and research services and the design of safety promotion interventions. Preventive strategies should be employed at three primary, secondary and tertiary levels.Safe community, Traffic Accidents, Prevention, Child and Adolescent


Drs Kahleova, Alwarith, and Rembert, as employees of Physicians Committee for Responsible Medicine, were involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The research team of the Physicians Committee for Responsible Medicine had full autonomy in all aspects of the study.” This article has been corrected.In the Original Investigation titled “Effect of a Low-Fat Vegan Diet on Body Weight, Insulin Sensitivity, Postprandial Metabolism, and Intramyocellular and Hepatocellular Lipid Levels in Overweight Adults: A Randomized Clinical Trial,”


The levels of obesity in the general population are reaching epidemic proportions. Over the last 40 years, the prevalence of obesity in the United States has tripled, and the World Health Organization estimates that 650 million individuals worldwide older than 18 years are obese. Although it has long been recognized that obesity is a key risk factor in the etiology of type 2 diabetes and cardiovascular disease, emerging evidence indicates that obesity is an adverse factor in the development and severity of many human cancers, including those of the breast and colon  was associated with reduced risk of obesity-related cancers, particularly endometrial cancer . LikewisThe current study by Meyerhardt and colleagues is a rare example of a trial that has examined the combination of metformin with an exercise intervention in the context of cancer. Although limited by the small sample size and relatively low compliance to metformin, the results conclusively demonstrate that the combination was most effective at reducing insulin, body weight, HOMA, and leptin in breast and colorectal cancer survivors, highlighting the potential utility of metformin and exercise in patient management and care in oncology. Of particular interest, in exploratory analyses there were greater effects of metformin, exercise, and especially the combination of the two on insulin, glucose, HOMA, and body mass index (BMI) in patients with higher baseline values for each of these variables. This implies that patients with the highest BMI, or those with the most severe metabolic dysfunction, may experience the greatest benefit of metformin and exercise and raises the possibility that stratification strategies based on those parameters may become instrumental in predicting response in future cancer trials of metabolic medications, weight loss, or exercise regimens. These findings emphasize the importance of incorporating standard patient characteristics, such as body weight, BMI, and blood insulin, in the design and execution of future clinical trials.It is estimated that by the year 2030, 50% of Americans will be considered formally obese . Given tAffiliations of authors: Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada ; Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada .The authors have no conflicts of interest to disclose.


To generate high-quality evidence, contextually relevant outcome measurement instruments are required. Quality of life evaluation among polio survivors typically involves the use of generic instruments, which are developed and validated among a different groups of people. There is no clear evidence whether these instruments are appropriate for the measurement of quality of life among polio survivors in northwest Nigeria. The purpose of this review is to identify and select a pre-existing instrument that is best suited for the measurement of quality of life among polio survivors in northwest Nigeria.Using the findings of a previous scoping review of the literature and qualitative descriptive study, we screened 11 quality of life instruments that are used in polio literature. We identified and selected the most appropriate instrument, which reflected the perspectives of polio survivors in northwest Nigeria and at the same time exhibited good measurement properties.The Quality of Life Index, World Health Organization Quality of Life Brief, and Comprehensive Quality of Life Scale are consistent with the perspectives of polio survivors in northwest Nigeria and have satisfactory measurement properties. Among these instruments, the Quality of Life Index satisfied most of the screening criteria we employed and is suitable for cross-cultural adaptation in northwest Nigeria.Most instruments that are employed to evaluate the quality of life of polio survivors were not primarily designed as a measure of quality of life. To select the appropriate instrument, there is a need to consider and reflect the perspectives of the individuals, to improve the validity of the measurement. Paralytic polio is a neuromuscular disorder, which is characterized by acute flaccid paralysis, especially in the upper and lower limb muscles, resulting from the destruction of motor neurons in the brainstem and spinal cord by poliovirus , 10. EviStudies have shown that in comparison with the general population, polio survivors frequently report poor health and quality of life (QoL) , 51, 64.QoL is an important outcome that can be employed to evaluate the unmet social and healthcare needs of individuals and also determine the success of various interventions , 48, 52.Development and validation of a new QoL instrument is exceptionally laborious. Hence, researchers suggest cross-cultural adaptation and validation of pre-existing instruments . One of In our previous review, we identified 11 instruments that have been employed to measure the QoL of polio survivors globally . Table 1We conducted this integrative review using the findings of our previous studies: a scoping review of QoL assessment instruments among polio survivors  and a quThe screening of the instruments was done by two authors (SS and BK) to minimize bias and improve validity. We evaluated the characteristics of the instruments using the guidelines proposed by Bentzen and colleagues , and wheThe intent of the instrument refers to the aim of the instrument, which addresses the question: for what purpose was the instrument developed? It reflects the appropriateness of the instrument and the construct that the instrument purports to measure , 24, 32.Content suitability denotes the extent to which the instrument reflects the perspectives of the target individuals. For this review, we looked for reflection of the perspectives of polio survivors. Content suitability mirrors some aspects of validity since it capitalizes on the representation of the construct based on the individuals’ perceptions , 24. We Psychometric analysis refers to the evaluation of the measurement properties of the instruments, based on evidence of reliability , validity , and responsiveness . We asseFeasibility refers to the burden, time, and resources required to administer, score, analyze, and interpret the instrument. It includes aspects such as comprehensibility, interpretability, cost of the instrument, completion time, mode of administration, etc. . We asseConsiderations in adapting the instrument for cross-cultural use deals with the core aspects of translation and adaptation of the instrument into other cultures . To admiTable Of the 11 instruments we screened, only 5 instruments were solely designed for measuring QoL. These include the Quality of Life Index (QLI), Kaasa’s Questionnaire (KQ), Quality of Life Profile (QP), World Health Organization Quality of Life Questionnaire- Brief (WHOQOLBREF), and Comprehensive Quality of Life Scale (CQS). For the remaining six instruments, five were designed to measure health status: Short-Form 36 (SF-36), Nottingham Health Profile (NHP), European Quality of Life Instrument-Five Dimensions (EQ5D), Swedish Health-related Quality of Life Questionnaire (SWED-QUAL), and the Short-Form 12 (SF-12). While the last instrument, the Satisfaction with Life Scale (SWLS), was designed to assess global satisfaction with life.In terms of content suitability, only the QLI has items that reflect all the perspectives of the polio survivors, satisfaction of needs , happiness, spirituality, and self-perception . This is followed by the QP, WHOQOLBREF, and CQS respectively. The QP has items reflecting most aspects of satisfaction of needs  and happiness, and two aspects of self-perception, self-value and feeling independent. The items of the WHOQOLBREF reflect happiness and most aspects of satisfaction of needs and self-perception. The CQS has items reflecting the satisfaction of needs and happiness; however, the scale has no item that represents self-perception. The remaining instruments have at least one item reflecting happiness and some aspects of satisfaction of needs and self-perception. Surprisingly, none of the 11 instruments has any item that reflects spirituality except the QLI. Thus, only the QLI satisfies all the requirements of this feature.In terms of psychometric properties, the SF-36 has good evidence of six measurement properties , followed by the QLI , EQ5D , and WHOQOLBREF  each with five measurement properties. The NHP  and SF-12  have four adequate psychometric properties. The remaining instruments have at least three good measurement properties, except the QP, which has only evidence of adequate content validity. None of the instruments has evidence of measurement error  or cross-cultural validity . Thus, with the exception of QP, all the instruments have satisfactory evidence of good measurement properties.All the instruments are user-comprehensive. However, in terms of interpretability, only the SF-36, NHP, QLI, and SF-12 have both meaningful profile and indices scores. While the remaining instruments have either profile score or indices score. Most of the instruments can be self-administered, except the CQS, which requires administration by an interviewer. Besides, most of the instruments are available in the public domain; however, users require written permission for non-commercial use of the instruments. Most of the instruments take approximately 10 min to complete, except CQS which takes about 45 min to complete. Thus, in terms of feasibility, all the instruments are feasible for application in northwest Nigeria.The QLI, KQ, QP, WHOQOLBREF, and CQS have more items that are relevant in the Hausa language compared to the remaining instruments because they are more consistent with the perspectives of polio survivors in northwest Nigeria. All the instruments have contents with semantic relevance in the Hausa language; however, some of the items of the instruments would require adaptation. Moreover, except for the WHOQOLBREF, none of the instruments have been adapted to the Hausa culture. However, the authors that translated the WHOQOLBREF did not provide information about how equivalence was established . Based oAs stated earlier, our goal was to identify and select the most appropriate QoL instrument for cross-cultural adaptation in northwest Nigeria. Specifically, we intended to select the instrument with the following features: primarily designed as a measure of QoL, consistent with the perspectives of polio survivors in northwest Nigeria, good measurement properties, feasible, and amenable to cross-cultural adaptation in northwest Nigeria. Subsequently, we identified and selected only instruments that have all or most of these characteristics. Based on the screening performance of the instruments Table , the QLIThe Quality of Life Index (QLI) was developed by Ferrans and Powers  to measuConversely, the World Health Organization Quality of Life Questionnaire-Brief (WHOQOLBREF) is an abbreviated version of the WHOQOL-100, which was developed cross-culturally by the World Health Organization Quality of life Group . The WHOOn the other hand, the Comprehensive Quality of life Scale (CQS) assesses QoL on both subjective and objective axes across seven domains, which include material well-being, health, productivity, intimacy, safety, place in the community, and emotional well-being . The CQSThis review aims to identify and select a pre-existing QoL instrument that is consistent with the perspectives of polio survivors in northwest Nigeria and at the same time exhibits good psychometric properties. The findings of this review show that the Quality of Life Index (QLI), World Health Organization Quality of Life Questionnaire- Brief (WHOQOLBREF), and Comprehensive Quality of Life Scale (CQS) are consistent with the perspectives of polio survivors in northwest Nigeria and have satisfactory measurement properties , 56. TheThe QLI, WHOQOLBREF, and CQS were primarily designed for the measurement of QoL and have well-established evidence of good psychometric properties . In contTo apply the QLI, WHOQOLBREF, and CQS in the measurement of QoL of polio survivors in northwest Nigeria, there is a need to cross-culturally adapt and validate the instruments in the northwestern Nigerian context . GeneralOn the other hand, the item equivalence refers to the acceptability of the items of the instruments in the target culture . Here, tCross-cultural adaptation of outcome measurement instruments has many advantages over the development of a new tool. Cross-cultural adaptation is economically cheaper, less time consuming, and can produce equivalent instruments in various cultures for comparison , 9, 18. Finally, when applying the QoL instrument for cross-cultural adaptation, psychometric validation, or routine QoL evaluation, users should take response shift into consideration, in order to avoid paradoxical scores of QoL measurement. As pointed out earlier in the introduction, response shift can occur as a result of redefinition of the construct, when the individual readjust their priorities as a result of a life-changing event, environmental influences, and newly acquired coping strategies. Moreover, response shift could also ensue when the individual reprioritizes their values or change their internal standards of measurement through recalibration . VariousWe could not identify any study in the literature that integrates individuals’ perspectives to select a QoL instrument that is similar to our process. Our approach to the selection of QoL instrument is based on rigorous recommendations and the perspectives of polio survivors (in northwest Nigeria), to select the most appropriate instrument available. Moreover, we considered critical aspects for cross-cultural adaptation and feasibility of the instrument in addition to psychometric properties. However, despite our effort to ensure rigor, this review has some limitations. For example, we did not assess client comprehensibility of the instruments, which could compromise possible self-administration of the instrument. Moreover, because our study was based on a previous scoping review, we may have not included other relevant QoL assessment instruments in our screening.Most instruments that are used to assess the QoL of polio survivors were not primarily designed for the measurement of QoL. Thus, it is pertinent to employ instruments that are specifically designed for QoL evaluation. To select a contextually relevant instrument, there is a need to consider and integrate the perspectives of the individuals. Our findings show that the QLI, WHOQOLBREF, and CQS are consistent with the perspectives of polio survivors in northwest Nigeria. Hence, these instruments could be used to evaluate the QoL of polio survivors in northwestern Nigeria and similar contexts. Although the instruments have demonstrated good measurement properties, we recommend the validation of the instruments among Nigerian polio survivors. Drawing upon the screening performance of the instruments, the QLI exhibits the following characteristic features: primarily designed as a measure of QoL, more consistent with the perspectives of polio survivors in northwest Nigeria, more evidence of good measurement properties, feasible, and amenable to cross-cultural adaptation in northwest Nigeria. Hence, we recommend the translation, cross-cultural adaptation, and psychometric validation of the QLI among polio survivors in northwest Nigeria. A rigorous protocol of cross-cultural adaptation such as the International Society for Pharmacoeconomics and Outcomes Research principles of good practice can be considered. Measurement of QoL among polio survivors in northwest Nigeria could provide the impetus needed to draw the attention of stakeholders toward addressing the unmet needs of the individuals. Therefore, to generate high-quality evidence about the QoL of the polio survivors, a culturally relevant and valid instrument is necessary; which researchers can produce using cross-cultural adaptation and psychometric validation techniques.


On the hundredth day since days since the WHO was notified of the first cases of “pneumonia with unknown cause” in China, the COVID-19 pandemic, caused by SARS-CoV-2, has spread throughout the world to 195 countries with over 1.5 million cases and more than 85 000 deaths [The Government of the Republic of Croatia has established the National Civil Defense Headquarters in order to raise the level of preparedness of all the competent authorities, protect the health of Croatian citizens and coordinate all the services in the battle against SARS-CoV-2 in Croatia. The Deputy Prime Minister and Minister of the Interior was chosen to lead the headquarters, whose members are the Director of the Croatian Institute of Public Health, the Director of the Croatian Institute of Emergency Medicine, and the Director of the Dr Fran Mihaljević University Hospital for Infectious Diseases (UHID), who is also the President of the Croatian Society for Biosafety and Biosecurity. After the daily meetings, the headquarters issues press releases.Together with other public services, all the health care institutions were quickly mobilized in preparation for the battle against the COVID-19 epidemic, with the UHID taking the leading role, from the establishment of quarantine to being declared the National Hospital for COVID-19. The Minister of Health issued the decision to proclaim the threat of a COVID-19 epidemic as an administrative measure, which does not indicate the degree of the threat but permits the Minister to mobilize all the resources in the health care system, redeploying ID physicians, other health care workers (HCWs) and equipment, in order to improve the administration of the health care system.Unfortunately, what few had thought possible has come to pass. An infectious disease has transformed social and economic relations, as well as humanity as a whole, entering and altering every pore of society. Colleges and schools have closed their doors, students are attending classes from home, via television and computers, the majority of the public sector employees are working from home, while some, regrettably, have lost their jobs. The churches have also closed their doors.am by an earthquake of 5.5 magnitude on the Richter scale, followed in the next 24 hours by 57 aftershocks. Due to extensive property damage, several hospitals had to be evacuated, including the UHID, where there were 86 patients at the moment, including 22 COVID-19 patients, 15 of whom were in the ICU. This additional misfortune has jeopardized the safety of us all, especially the most vulnerable members of our society: children, the elderly and the sick. A total of 27 persons were injured during the earthquake, of whom one, sadly a 15-year-old girl, died of her injuries.At the end of the fourth week of the epidemic in Croatia, a total of 206 cases had been confirmed, with 49 newly diagnosed on 21 March 2020. When we thought that nothing worse could happen, on 22 March 2020, the citizens of Zagreb, the capital of Croatia, home to a quarter of the total Croatian population, were awakened at 6:24 We as HCWs were expected to remain clear-headed, gather all our strength, knowledge and skills, and provide our patients with the best of what was possible, and sometimes even the impossible. But we also remember the scene around our hospital buildings, where the old and young, staff and patients, corona-positive and negative, were scattered on the grass and the parking lot, shivering from the cold and fear.Nevertheless, we survived that, too, and we will continue to survive, even when faced with greater challenges. We have demonstrated and proven that we cannot do without one another: physicians without nurses, patients without HCWs, HCWs without non-medical and support staff, parents without children, and children without parents.In addition to property damage, we were quite apprehensive that the earthquake would accelerate the spread of the COVID-19 epidemic in Croatia since the earthquake, which left many homeless and fearful of earthquakes to come, triggered migrations to other parts of the country. However, six weeks since the first COVID-19 case and three weeks after the earthquake, only 1650 cases have been registered in Croatia  are major threats to humanity. Nevertheless, no one expected that a second misfortune, the earthquake, would occur during this pandemic in our little country.The subtitle of the previously cited article by Čivljak et al. , What's All HCWs, including physicians, nurses, technicians, laboratory personnel, caregivers and other staff who come into contact with patients, are being directly or indirectly exposed to the infected and sick, which places them at risk. At the UHID, among 691 employees, only two have acquired SARC-CoV-2 infection in the post-earthquake period: one nurse and one ancillary worker. On the national level, no increase in the incidence of COVID-19 was experienced in the post-earthquake period, as shown in Moreover, owing to the chronic shortage of medical personnel throughout the entire health care system, particularly now when the demands are increasing, we are being expected to make great sacrifices in order to provide the best possible care to all citizens. An additional burden is that 216 HCWs in Croatia have COVID-19, while another 562 are in self-isolation at the moment. All of them are currently unable to perform their regular professional duties and the number may soon increase. The Minister of Health has stated that the health care system is not in jeopardy for now and the ministry is redeploying HCWs in order to fill the most crucial positions.Salmonella, chickenpox, or other infectious diseases in general [This third coronavirus epidemic underscores the need for the ongoing surveillance of infectious disease trends throughout the world. However, in combination with a natural disaster, such as earthquake, the risk for increasing the number of the infected, as well as outbreaks of other infectious diseases, is higher. As shown in the systematic review by Suk et al., cascading effects of post-disaster outbreaks are possible after earthquakes, such as outbreaks of  general .By now, due to a well-organized public health system and coordinated outbreak response, Croatia has overcome the current challenges, including extensive damage to hospitals, shortage of hospital personnel, and disruption of supply chains. We hope that everything done so far will provide the basis for stopping this epidemic in Croatia and mitigating the damage done from the COVID-19 epidemic and the recent earthquake.


We focused on medical informatics journal publications rather than on conference proceedings by comparing and analyzing the data from journals and conferences from a broader perspective. The aim is to summarize the unique contributions of China to medical digitization and foster more multilevel international cooperation.  In February 2019, publications from 2008 to 2018 in three major English-language medical informatics journals were retrieved through Scopus, including the journals, namely, International Journal of Medical Informatics , JAMIA (United States), and Methods of Information in Medicine . Three major Chinese-language journals, namely, China Digital Medicine (CDM), Chinese Journal of Health Informatics and Management (CJHIM), and Chinese Journal of Medical Library and Information Science (CJMLIS), were searched within the major three Chinese literature databases. The datasets were preprocessed using the NLP package on Python, and a smart local moving algorithm was used as a clustering method for identifying the aforementioned journals.  Between 2008 and 2018, the total number of published papers and H-index of the three English-language journals was 1371 and 67 (IJMI), 1752 and 86 (JAMIA), and 637 and 35 (MIM), respectively. In the same period, the total number of published papers and H-index in the three Chinese-language journals was 6668 and 23 (CDM), 1668 and 22 (CJHIM), and 2557 and 25 (CJMLIS), respectively. IJMI, JAMIA, and MIM received submissions from 82, 59, and 62 countries/regions, respectively. By contrast, the three Chinese journals only received submissions from seven foreign countries. The proportions of authors from institutional affiliations were similar between the three English-language journals  and CJMLIS because the majority of the authors were from universities , followed by medical institutions  or research institutes . Furthermore, the proportions of the authors from enterprises were low  for all journals. However, the authors in CDM and CJHIM were mainly from medical institutions (50% and 40%), followed by universities (33% and 32%) and research institutes (3% and 4%). In addition, the proportions of enterprises were only 3% and 2%, respectively. Among the top five authors in three English-language journals (ranked in terms of the number of published papers), 100% had doctoral or master's degrees, compared with only 60% in the Chinese journals. Additionally, 28204 different keywords were extracted from the aforementioned papers, covering 275 specific high-frequency key terms. Based on these key terms, four clusters were found in the English literature—“Health and Clinical Information Systems,” “Internet and Telemedicine,” “Medical Data Statistical Analysis,” and “EHRs and Information Management”—and three clusters were found in the Chinese literature: “Hospital Information Systems and EMR,” “Library Science and Bibliometrics Analysis,” and “Medical Reform Policy and Health Digitization.” Only two clusters are similar, and Chinese-language journals focus more on health information in technology and industrial applications than in medical informatics basic research.  This study provides important insights into the development of medical informatics (MI) in China and Western countries showing that the medical informatics journals of China, the United States, and Europe have distinct characteristics. Specifically, first, compared with the Western journals, the number of papers published in the journals of professional associations in the field of MI in China is large and the application value is high, but the academic influence and academic value are relatively low; second, most of the authors of the Chinese papers are from hospitals, and most of the counterparts in the Western countries are from universities. The proportion of master's or doctoral degrees in the former is also lower than that of the latter; furthermore, regarding paper themes, on the one hand, China MI has no theoretical and basic research on medical data statistics and consumer health based on the Internet and telemedicine; on the other hand, after nearly 10 years of hospital digital development, China has fully used the latecomer and application advantages in hospitals and, through extensive international cooperation, has made significant advancements in and contributions to the development of medical information. Medical informatics (MI) can be defined as the acquiring, storing, retrieving, and using of healthcare information to foster better collaboration among a patient's various healthcare providers , which oJournal of the American Association (JAMIA), is also included in the SCI.The establishment and development of a discipline rely on the foundation and support of a system, including relevant institutions and associations, mainstream auxiliary journals, and publications , for whiDifferent from MI in Western countries that developed from computer applications to medicine, MI in China evolved from medical library information science in the early 1980s. Along with the development of hospital digitization in China, this discipline did not become independent until 2010. To date, only a few educational institutions in China have established an MI institute or graduate courses , and the majority of participants are undergraduates . FurtherTo efficiently, accurately, and timely understand the research hot spots and developing trends of medical informatics, researchers have adopted bibliometrics to study the frontiers of MI from three aspects: academies, conferences, and journals. As for academies, V. Maojo et al. in 2012 reviewed the members attending three mainstream academies of MI, including Medical Informatics Europe (MIE) 2005–2008, MedInfo 2004, 2007, and 2010, and AMIA 2005–2009, and thought that the influence of these academies outside this discipline was very low . As for Under the framework of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) , We seleFirst, the English-language papers were searched on Scopus, which provided comprehensive preprocessed data from academic publications and has been accepted as one of the best databases for literature analysis . The seaMetadata of journals, including the names of journals, organization of the sponsors, organization of the publication, time of publication, period of publication, place of publication, and database of inclusionMetadata and contents of periodical papers, including the title; keywords; abstract; year of publication; citations of papers; and authors' names and education level, affiliations, and countryBecause all the databases had standard functions for data analysis and abstraction, we selected and imported the following information:Next, to maximize the effectiveness and accuracy of co-word analysis and data visualization, we preprocessed the target datasets. First, the titles and keywords of the included articles were standardized into lowercase, and the morphology and abbreviations were reproduced in Python 2.7 + NLTK NLP . Second,The basic characteristics of the papers were analyzed with the built-in functions of Scopus, CQVIP, CNKI, and WanFang Data. The author affiliations were clustered using self-developed tool based on Python 2.7. The tool clusters the authors' affiliations into six categories: medical institutions, universities, manufacturers, research institutions, and others. The H-index was designed as a measure of scientific research impact , which iPapers published in MI journals between 2008 and 2018, including the three Chinese MI journals  and the three English MI journals , were analyzed both quantitatively and qualitatively. The basic information of each journal is listed in Supplementary Materials From the three mainstream Chinese-language databases, 6668, 1668, and 2557 articles between 2008 and 2018 were identified from CDM, CJHIM, and CJMLIS, respectively, with a total of 10893 and an annual rate of 990 articles. Using Scopus, 1371, 637, and 1752 articles were identified from IJMI, MIM, and JAMIA, respectively, with a total of 3760 and an annual rate of 341 articles. The number of Chinese-language papers was 2.89 times that of English-language papers, and the number of papers in CDM was 1.77 times that of the total number of English-language papers . The proThe academic influence of the professional MI journals is significantly different. JAMIA and IJMI are top-ranked journals, followed by MIM; however, the Chinese MI journals  are ranked much lower. JAMIA published 1752 papers between 2008 and 2018, which were cited 44051 times, with an average of 25.1 times per paper and an H-index of 86 . IJMI puWe compared similar statistics from the three Chinese MI journals, and the results suggest that the total citations of the three Chinese MI journals are slightly lower than that of IJMI (23184 vs. 26900) but far lower than that of JAMIA (44051), even though the total number of papers published by the three Chinese journals was 16.9 and 13.2 times those in IJMI and JAMIA, respectively.Similar to the country distribution of authors in the MI conference proceedings, the regional MI journals, including JAMIA  and MIM , and Chinese MI journals  were dominated by local authors, whereas the international journals such as IJMI  represented authors from various regions. Between 2008 and 2018, JAMIA published submissions from authors of 58 countries or regions, and the number of countries or regions with >10 manuscripts was 15; however, the majority of authors were from the United States (approximately 69%), followed by Europe (∼10%). By contrast, the proportion of the authors from China  was only 4%. MIM published submissions of the authors from 62 countries or regions, and the number of countries or regions with >10 manuscripts were 21. However, most authors were from Europe (approximately 63%), followed by the United States (about 16%), and the proportion of authors from China  was only 2.4%. IJMI published submissions from the authors of 81 countries or regions; the number of countries or regions with >10 manuscripts was 28; and approximately 27%, 40%, and 6% of authors were from the United States, Europe, and China , respectively. The Chinese MI journals  were less internationalized because publications by foreign authors were only from Japan, Canada, the United States, South Korea, the United Kingdom, Netherlands, and Germany. The affiliations and academic backgrounds of the authors were largely different among journals. The proportions of different affiliations were similar between the English-language journals  and the Chinese journal CJMLIS because the majority (>50%) of authors were from universities , followed by medical institutions  or research institutes . Furthermore, the proportions of enterprises were low  across all journals. However, the authors in CDM and CJHIM were mainly from medical institutions , followed by universities  and research institutes , and the proportions of enterprises were only 3% and 2%, respectively . These dWe further assessed the top five authors in each journal and analyzed their affiliations and academic and knowledge backgrounds  and Chinese MI academic journals  because the majority of authors had no background in clinical medicine. Of the top five authors in IJMI, one had an MD, four had doctoral degrees, and all were from universities. Among the top five authors in CDM, one had a master's and doctoral degree, three had doctoral degrees, and two had master's degrees. Furthermore, two were from medical institutions and three were from institutes.We also observed some differences because the top five authors from IJMI, MIM, and JAMIA all received professional academic training in MI; however, the top five authors in the Chinese MI academic journals mostly did not receive this training; usually were from the computer, public health, statistics, library science, or informatics fields; and only became involved in MI after employment.The purpose of the keyword selection and analysis is to identify the focal points of research that have been confirmed as a major step in monitoring the development and trend of a discipline . Here, tg-index [The frequency distributions of the keywords were largely different between the Chinese- and English-language MI journals, which led to differences in the high-frequency word selection methods. To simplify the selection and analytical process and to decrease unnecessary interference from low-frequency words, we selected high-frequency words. However, no unified method is available to determine the critical levels of high-frequency words, and the available methods include the subjective empirical method, 80/20 rule , Price'sg-index , and higN1 is the number of keywords with one word frequency and T is the frequency threshold of high-frequency words.To select the appropriate frequency threshold, we first observed the frequency distributions of keywords in the six MI journals and found that the repeated rates of keywords were low in papers from Chinese MI journals compared with those in the international high-quality and mainstream MI journals . Namely, many keywords occurred once, and the rate of these words was 20% higher than those in the English-language papers, which limited the applicability of the high/low-frequency word isolation method based on Zipf's law. Specifically, the threshold value was slightly larger, and too few high-frequency words were intercepted. After multiple trials, we adopted different high-frequency word threshold computation methods according to the characteristics of English-language and Chinese-language papers and used Donohue's method  based onFor the Chinese papers, according to the 80/20 rule , high-frAnalysis of keywords can indirectly reveal the hotspots and changing trends in research topics, which is critical for understanding the development of this field . Next, wThe results showed the keywords from the English-language MI journals were reorganized into four clusters, which we named (1) “Internet and Telemedicine” (yellow), (2) “Health and Clinical Information Systems” (blue), (3) “Medical Data Statistical Analysis” (green), and (4) “EHRs and Information Management” (red). Notably, our clustering results were supported by Kim et al., who mined the abstracts and texts from the articles published in 23 English-language MI journals within 12 years . Only thThe results of the clustering are presented in Figures We previously analyzed the MI conference proceedings in China, the United States, Europe, and IMIA and found that MI research in China was largely different and lagged behind other developed regions in terms of academic evaluation, multisource cooperation, talent pool and quality, focal points, trends, and research investment . In thisMI as an emerging interdisciplinary field has not been set within a specific category in the WOS but has a similar category—Medical Informatics—involving 25 journals. JAMIA (the 2017 impact factor: 4.27), IJMI (the 2017 impact factor: 2.95), and MIM (the 2017 impact factor: 1.53) rank as 3, 6, and 17, respectively. In particular, JAMIA has been highly approved by the Academic Committee of China Computer Society, listed by the China Computer Society as a key recommendation, is a well-known and highly reputed journal in the cross-disciplinary/comprehensive/emerging field, and encourages submissions from Chinese counterparts .However, China has no authorized MI journal or any MI journal included in SCI, EI, or Medline. We believe that this may be related to the academic levels of these journals. Of the three authorized MI professional journals, the H-indices of CDM, CJHIM, and CJMLIS are 23, 22, and 25, respectively, which are less than half that of IJMI and are 70% that of MIM. However, they are slightly higher than that of MEI and the MedInfo proceedings (H-index of both: 19) and lower than that of the AMIA Annual Symposium (H-index: 32) . FurtherIJMI, MIM, and JAMIA, as authorized academic journals in MI, have attracted submissions from academic researchers and industrial workers worldwide; however, the Chinese MI journals  have received submissions from only seven foreign countries. However, in the IJMI, MIM, and JAMIA journals, the proportion of Chinese authors  did not exceed 6%, which implies gaps in MI development in China.China has an insufficient talent pool for MI and has no continued support from existing educational institutions for the advancement of industrial development, which is stated as “cold in academic research, (and) incorporate(s) hot in industrial application” . The autSuch a difference in author characteristics between the Chinese journals and journals from other regions is because of the distinguished developmental environment for MI in China. In 2009 in China, HIT was considered one of the “ four beams and eight pillars” of the new healthcare reform , and MI EMR Function Grade Specification issued by the National Health Commission of China in 2015, telemedicine was already included in EMR [EN-Cluster 1 (“Internet and Telemedicine”): this cluster results from the introduction of the Internet into the medicine field and is based on extensive research on diabetes and family care through the Internet, telemedicine, and other techniques and through questionnaires. Surprisingly, telemedicine in Europe and the United States has formed an independent system, but in China telemedicine belongs to the cluster “Hospital Information Systems and EMR” and is an important part of hospital information systems (HIS) and a supplement to out-hospital continuity of medical services to patients. We posit that this situation may be related to the “digital hospital” policies in China. On the one hand, in the d in EMR ; on the d in EMR .EN-Cluster 2  and CN-Cluster 1 (“HIS and EMR”): clinical informatics , especiaEN-Cluster 3 : this cluster is exclusive to the English-language MI journals and involves abundant content related to theoretical models, including the topics associated with medical information methodology, artificial intelligence, natural semantic processing, and data mining software and systems.EN-Cluster 4 (EHRs and Information Management): this cluster is also exclusive to the English-language MI journals and describes an important aspect of MI. We posit that this also means that EHRs have gradually become a widely approved and accepted concept. The European and US researchers are focusing on technical issues of EHRs. Notably, EHRs are not present in the high-frequency keyword list in China; nevertheless, its in-hospital version—EMR —is the cCN-Cluster 2 : this cluster is exclusive to the Chinese-language MI journals, and its research and application are concentrated in medical information research; medical information resources construction, retrieval, and services; and other health information management and evaluations. We posit that this occurs because the development of MI in China originated from library science in the mid-1980s, and this narrow sense of MI continues to account for a large proportion in China.CN-Cluster 3 : this cluster is exclusive to China and involves the propaganda, interpretation, analysis, and comments of HIT policies issued by healthcare reforms and government functional departments.In Figures As an independent discipline, MI has been widely accepted in Europe and the United States. To date, greater than 80 US-based academic institutions offer on-site or distance MI training programs . AdditioThis study provides notable contributions to theory and practice.From the theoretical perspective, first, this study further enriches and improves the knowledge of global MI literature research; in particular, for the first time, this study adds the analysis of Chinese MI journal literature. On this basis, our comparison of bibliometrics between three representative official English journals of the international MI societies and three Chinese journals of the national MI societies overcomes the limitation that some bibliometrics research in the field of MI has mainly focused on English-language literature , 42, 48.Second, we explore the differences in authors between those in China and Western countries in their organizations and academic degrees. We find that on the one hand, most of the authors of Chinese papers are from medical institutions, and most of their counterparts in Western countries are from universities. The proportion of doctoral or master's degrees in the former is lower than that in the latter. By contrast, China's MI is mainly based on the traditional medical literature system, and the trainees are mainly undergraduates. Therefore, the education level and faculty's strength are far behind their counterparts in Europe and the United States. Thus, we suggest that China's MI field should establish and improve the education system of medical informatics, strengthen the training of faculty by sending teachers and researchers to study abroad, introduce advanced educational concepts of medical informatics, and employ teachers from different professional backgrounds to participate in the teaching, to improve the teaching environment and curriculum selection for students. Furthermore, for the first time, we explore the differences in the themes of the papers published in the mainstream Chinese and English MI journals during the past 11 years. On the one hand, China has fully used the latecomer advantage and application advantage in hospitals, especially the extensive implementation and application of EMR ; on the Third, this study has extended our previous research about the academic proceedings published by main academies of MI , 5, 8 anBecause discipline evaluation is a complicated task, we assess papers published in journals. Moreover, we use data from representative professional journals on MI in both China and Western countries but exclude all MI journals, use a limited number of searching tools to find other professional publications, and exclude achievements of patents or other forms. Furthermore, many achievements in MI may have been published in non-MI journals, but we have no perfect method or mechanism to include these papers; however, we intend to analyze these papers in subsequent studies.We used bibliometrics to analyze Chinese- and English-language MI papers published in six representative MI journals between 2008 and 2018 in China, the United States, and Europe. The results of this study provide important insights for the development of MI in China and Western countries. First, compared with the Western counterparts, the number of papers published in the journals of professional associations in the field of MI in China is large and the application value is high, but the academic influence and academic value are relatively low; second, most of the authors of the Chinese papers are from hospitals, and most of the counterparts in the Western countries are from universities. The proportion of master's or doctoral degrees in the former is also lower than that of the latter; further, regarding paper themes, on the one hand, China MI has no theoretical and basic research on medical data statistics and consumer health based on the Internet and telemedicine; on the other hand, after nearly 10 years of hospital digital development, China has fully used the latecomer and application advances in hospitals and, through extensive international cooperation, has made significant advancements in and contributions to the development of medical information.


Real-time cell analysis (RTCA) is a technique based on impedance and microsensor electrodes. RTCA system allows label-free, real-time, and continuous monitoring of cell adhesion, morphology, and rate of cell proliferation. The system offers a wide range of applications, mainly in toxicological studies, new drug screening, and microbiology. Here, we describe the usefulness of the system in different applications and compare this technology with conventional endpoint assays based on tetrazolium salts. We present advantages and disadvantages of the system and endpoint methods and their limitations in cytotoxicity investigations. Thus, the CI is a reflection of overall cell number, adhesion quality, and cell morphology, which can change as a function of time .,94.42,94Determination of cell numbers is a crucial step in studies focused especially on cytokinetics and cell toxicity . The conThe application of RTCA system in cytotoxicity tests should also be considered when drugs containing additives such as: sorbitol, lactate, and sodium hydroxide are studied . These cDespite the disadvantages of the endpoint assays and RTCA system, both methods are reliable and suitable in cytotoxicity investigations, and they generate mostly comparable results. Braicu and Gherman investigated the effect of epigallocatechin gallate in triple-negative breast cancer cells (Hs578 T). The dynamic real-time monitoring of the cells treated with the compound confirmed the antiproliferative effects obtained by MTT test . VistejnIn spite of more and more use of the RTCA technology, the main limitation of this system is the cost of experiments. E-plates are expensive, single use, and disposable. However, some authors indicate that E-plates can be regenerated and reused several times without significantly affecting experimental results ,. Other The characteristics of the RTCA technology and endpoint assays are presented in 4in vitro studies, especially in the need to confirm the RTCA results.The real-time cell analysis system is a modern and useful technique applied in many areas of research. Despite high costs of experiments and some limitations, the system provides a high throughput and quantitative method for continuous and real-time monitoring of cell proliferation and cellular morphological changes. The system is used in pharmacological, toxicological, and microbiological studies, mainly to evaluate cytotoxicity of new drugs and improve the effects of different therapies. However, it is worth emphasizing that classical endpoint assays, due to low cost and simplicity, will still be widely applied as basic methods in many The authors declare that there is no conflict of interest regarding the publication of this paper.


The countries of Central Asia and the Caucasus are linked by travel and trade, which is promoted by visa-free mobility across borders. Unfortunately, this migrant mobility has given rise to the transmission of various infections within this region. Overlaps in culture, tradition, and behavior among these countries provide opportunities to share experiences that have proven effective in controlling transmission. Here we present a review of hepatitis B virus (HBV) prevalence, prevention and treatment across Central Asia and the Caucasus. Overall, owing to effective measures, while HBV prevalence has been steadily declining in the region, certain gaps still exist regarding the generation and availability of HBV infection data. Following the collapse of the Soviet Union in 1991, 15 countries gained independence: Armenia, Azerbaijan, Belarus, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Moldova, Russia, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan  Figure . CountriIn this article, we provide an overview of the prevalence, control, and treatment of hepatitis B virus (HBV) infection among the nine countries of Central Asia and the Caucasus. We review the policies implemented by the governments for the prevention and treatment of HBV, and highlight areas that have worked in certain countries and may be adapted by others.The prevalence of hepatitis B infection in Armenia significantly increased from <2% to 8% between 2000 and 2007 ,7. This As a bloodborne pathogen, HBV transmits readily through injection needles and blood transfusions. The safety of donated blood and its products is ensured by implementation of rigorous screening protocols by the blood banks . AccordiIn Armenia, the HBV vaccine was introduced in 1999, and the birth dose was instituted the same year . The vacWith the exception of Georgia and Turkmenistan, for all the countries of Central Asia and the Caucasus, clinical guidelines for the treatment of HBV infection are either available online or in the report of the Alliance for Public Health  Table 4Table 4. Overall, in Central Asia and the Caucasus, the prevalence of HBV and associated co-infections has been declining, owing to rigorous implementation of vaccination, treatment, and blood donor screening protocols. Thorough and large-scale surveys are key to recording evolving trends in the prevalence and transmission of infections. While regular surveys are being carried out by countries such as Armenia, Azerbaijan, Georgia, and Kazakhstan, certain exceptions still exist. Another area of focus is to enhance public accessibility of the information related to data, as well as policies regarding HBV infection and its control. For the prevalence of HBV single and co-infection, information was readily available from Azerbaijan, Georgia, and Kyrgyzstan, while from the rest of the countries this information was either partially available or unavailable. Additionally commendable is the full disclosure of information regarding blood-screening protocols by Kazakhstan, Kyrgyzstan, the Russian Federation, and Tajikistan. It appears, therefore, that in certain countries the information, while it may exist, is not readily available for review or scrutiny, compromising the transparency of the process.


Social isolation and loneliness have profound implications for quality of life and health and welfare budgets, but interventions to reduce loneliness are limited effective. The aim of this study is to examine the often-ignored impact of macro-level drivers of loneliness, in addition to micro-level drivers by adopting a cross-national perspective. We use longitudinal data from 2013 and 2015 from the Survey of Health, Aging, and Retirement in Europe (SHARE), combined with macro-level data from additional sources. Our study confirms that key micro-level drivers of loneliness are gender, health and partnership status, frequency of contact with children and changes therein. Macro level drivers are level of safety in the neighbourhood, and poverty and social deprivation of a society. In order to understand and reduce loneliness we require not just a focus on individual risk factors, behaviours and expectations, but also on macro-level factors that are associated with exclusion from social relations.


In the original published version of this article, the article listed the order of the authors in the incorrect order: Christian Ventura, Cody Gibson, George Donald Collier. This has now been corrected to: Cody Gibson, Christian Ventura, George Donald Collier. The publisher apologizes for this mistake. Both the HTML and PDF versions of the article have been updated to correct this error.


Coinciding with the 2020 presidential election, the 75th anniversary of the Gerontological Society of America arrives amid the contentious creation of a new future for politics and aging. Increasing inequality, spreading disinformation, and mounting despotism are escalating threats to constitutional democracy, but at the same time other social changes are promoting the development of a more thoroughly caring, intergenerationally just, and robustly democratic society. At the crux of this societal transformation, relentless political inertia on core aging issues, like the role of government in the care and support of older adults, continues to inhibit meaningful change in federal policy, dampening the potential for older Americans to achieve desired future states, like living well despite advanced age or disability. This session examines major contemporary trends at the intersection of politics and aging in the United States. Papers address the economics and demographics of aging, drawing attention to increasing federal spending on older adults, decreasing availability of caregivers, and geographic clustering of older people; changes in the age of the electorate, intergenerational political values, and the growing politically polarization of American society; the tendency for federal initiatives to fail to support caregivers, for reasons of policy history, policy traits, and mass public features, like the political isolation of informal caregivers; and the role of linguistic and metaphorical practices in shaping our experiences and views of aging. Discussion addresses opportunities for the country to become more age-friendly while also sustaining democratic institutions and national unity.


The recent Covid-19 pandemic has had significant psychological and social effects on the population. Research has highlighted the impact on psychological well-being of the most exposed groups, including children, college students, and health workers, who are more likely to develop post-traumatic stress disorder, anxiety, depression, and other symptoms of distress. The social distance and the security measures have affected the relationship among people and their perception of empathy toward others. From this perspective, telepsychology and technological devices assume important roles to decrease the negative effects of the pandemic. These tools present benefits that could improve psychological treatment of patients online, such as the possibility to meet from home or from the workplace, saving money and time and maintaining the relationship between therapists and patients. The aim of this paper is to show empirical data from recent studies on the effect of the pandemic and reflect on possible interventions based on technological tools. The Covid-19 pandemic led to a prolonged exposure to stress. As a consequence, researchers showed an increased interest in measuring social and community uneasiness in order to psychologically support the population. This increased attention might help in managing the current situation and other possible epidemics and pandemics. The security measures adopted in managing the pandemic had different consequences on individuals, according to the social role invested. Some segments of the population seem to be more exposed to the risk of anxious, depressive, and post-traumatic symptoms because they are more sensitive to stress.The following article has two focuses of interest: (1) the evaluation of the psychological and social effects of the pandemic on the population, mostly children, college students, and health professionals; and (2) the identification of new perspectives of intervention based on digital devices and in line with the social security measures and mental health promotion. Telepsychology, for instance, is a valid tool, effective in taking charge of the psychological suffering caused by the pandemic and in preventing the chronicity of the disease. The prolonged stress could involve anxiety, depression, and the inability to manage traumatic and negative emotions. Furthermore, the constant fear of contagion affects daily life and leads to social isolation, modifying human relations.Studies of pandemics faced over time, such as SARS, Ebola, H1N1, Equine Flu, and the current COVID-19, show that the psychological effects of contagion and quarantine is not limited on the fear of contracting the virus . There aAs reported in a recent survey administered during the Covid-19 pandemic, children and young adults are particularly at risk of developing anxious symptoms . The resHealth-care workers (HCWs) are another segment of population particularly affected by stress . HCWs arAs a consequence of the pandemic, the health professionals who were overworked suffered high level of psychophysical stress . Health As emerged by the recent literature, the promotion of psychological interventions on the specific population who is more likely to develop pathologies and suffering is needed. The Lancet Global Mental Health Commission’s observation  reportedIn order to reduce anxiety and depression symptoms widespread among the population, the At the same time, as a consequence of the emerging issues, psychotherapists provided psychological support online, addressing the technological challenge ; Liu et via webcam  in order to use them in relation to the specific purposes identified by the professional. For example, the Italian Service of Online Psychology conducted a study based on a service of helpdesk on Facebook. This service guided people in asking for psychological help, working on their personal motivation. At the same time, another helpdesk on Skype provided some psychological sessions a webcam . In thisa webcam .One of the future goals of public and private psychological organizations should be the promotion of specific training for psychologists and psychotherapists, with the following aims: (1) developing the basic skills in managing the effects of a pandemic and of emergency situations; and (2) sensitizing patients to online therapeutic relationship, providing the main rules and benefits of the process . On thisOnline psychological services provide several advantages, especially in the current situation of pandemic. First of all, online services help people in a short period of time, reducing the risk of contagion and the strong feeling of anxiety in both psychotherapists and patients, who feel uncomfortable in doing traditional psychotherapy due to the pandemic . Furtheronline disinhibition effect demonstrating how the web, unlike the real life, leads to the failure of the hierarchical relationship based on dominant-dominated among individuals; this aspect, according to the author, allows a greater sense of freedom in expressing oneself and less concern related to judgment (ibid.). Other researchers  social context and historical period of the individual, (b) neurological mechanisms, and (c) psychological and behavioral responses to feelings of others. The neuro-sociological perspective analyzes the mechanisms involved in the empathic process, focusing on human communication and interpersonal relationships . SpecifiAccording to the abovementioned considerations, our suggestion consists in:Primary prevention. Studying the impact of the pandemic toward an at-risk population to reduce symptoms related to stress and providing specific online psychological counseling based on the target .Secondary prevention. Overcoming the limitations of the human interaction based on digital devices: (1) developing new spaces of inter- and intrasocial communication and new tools of support and psychological treatment, reproducing the multisensory experienced during the face-to-face interaction ; (2) training the next generation of psychotherapists in managing online devices and in implementing their adaptive and personal skills; and (3) sensitizing the general population on telepsychology and its advantages.Research according to the neurosociological perspective. Studying human interaction mediated by new technologies and the role of empathy, associating neuroscience, sociology, and psychology.VS, DA, and VA conceptualized the contribution. VS wrote the paper, reviewed the manuscript, and provided the critical revision processes as PI. All authors approved the submission of the manuscript.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.