Recognizing Human Activity of Daily Living Using a Flexible Wearable for 3D Spine Pose Tracking.

The World Health Organization recognizes physical activity as an influencing domain on quality of life. Monitoring, evaluating, and supervising it by wearable devices can contribute to the early detection and progress assessment of diseases such as Alzheimer's, rehabilitation, and exercises in telehealth, as well as abrupt events such as a fall. In this work, we use a non-invasive and non-intrusive flexible wearable device for 3D spine pose measurement to monitor and classify physical activity. We develop a comprehensive protocol that consists of 10 indoor, 4 outdoor, and 8 transition states activities in three categories of static, dynamic, and transition in order to evaluate the applicability of the flexible wearable device in human activity recognition. We implement and compare the performance of three neural networks: long short-term memory (LSTM), convolutional neural network (CNN), and a hybrid model (CNN-LSTM). For ground truth, we use an accelerometer and strips data. LSTM reached an overall classification accuracy of 98% for all activities. The CNN model with accelerometer data delivered better performance in lying down (100%), static (standing = 82%, sitting = 75%), and dynamic (walking = 100%, running = 100%) positions. Data fusion improved the outputs in standing (92%) and sitting (94%), while LSTM with the strips data yielded a better performance in bending-related activities (bending forward = 49%, bending backward = 88%, bending right = 92%, and bending left = 100%), the combination of data fusion and principle components analysis further strengthened the output (bending forward = 100%, bending backward = 89%, bending right = 100%, and bending left = 100%). Moreover, the LSTM model detected the first transition state that is similar to fall with the accuracy of 84%. The results show that the wearable device can be used in a daily routine for activity monitoring, recognition, and exercise supervision, but still needs further improvement for fall detection.

Printed and Flexible ECG Electrodes Attached to the Steering Wheel for Continuous Health Monitoring during Driving.

Continuous health monitoring in a vehicle enables the earlier detection of symptoms of cardiovascular diseases. In this work, we designed flexible and thin electrodes made of polyurethane for long-term electrocardiogram (ECG) monitoring while driving. We determined the time for reliable ECG recording to evaluate the effectiveness of the electrodes. We recorded data from 19 subjects under four scenarios: rest, city, highway, and rural. The recording time was five min for rest and 15 min for the other scenarios. The total recording (950 min) is publicly available under a CC BY-ND 4.0 license. We used the simultaneous truth and performance level estimation (STAPLE) algorithm to detect the position of R-waves. Then, we derived the RR intervals to compare the estimated heart rate with the ground truth, which we obtained from ECG electrodes on the chest. We calculated the signal-to-noise ratio (SNR) and averaged it for the different scenarios. Highway had the lowest SNR (-6.69 dB) and rural had the highest (-6.80 dB). The usable time of the steering wheel was 42.46% (city), 46.67% (highway), and 47.72% (rural). This indicates that steering-wheel-based ECG recording is feasible and delivers reliable recordings from about 45.62% of the driving time. In summary, the developed electrodes allow continuous in-vehicle heart rate monitoring, and our publicly available recordings provide the opportunity to apply more sophisticated data analytics.

Continuous Monitoring of Vital Signs Using Cameras: A Systematic Review.

In recent years, noncontact measurements of vital signs using cameras received a great amount of interest. However, some questions are unanswered: (i) Which vital sign is monitored using what type of camera? (ii) What is the performance and which factors affect it? (iii) Which health issues are addressed by camera-based techniques? Following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement, we conduct a systematic review of continuous camera-based vital sign monitoring using Scopus, PubMed, and the Association for Computing Machinery (ACM) databases. We consider articles that were published between January 2018 and April 2021 in the English language. We include five vital signs: heart rate (HR), respiratory rate (RR), blood pressure (BP), body skin temperature (BST), and oxygen saturation (SpO2). In total, we retrieve 905 articles and screened them regarding title, abstract, and full text. One hundred and four articles remained: 60, 20, 6, 2, and 1 of the articles focus on HR, RR, BP, BST, and SpO2, respectively, and 15 on multiple vital signs. HR and RR can be measured using red, green, and blue (RGB) and near-infrared (NIR) as well as far-infrared (FIR) cameras. So far, BP and SpO2 are monitored with RGB cameras only, whereas BST is derived from FIR cameras only. Under ideal conditions, the root mean squared error is around 2.60 bpm, 2.22 cpm, 6.91 mm Hg, 4.88 mm Hg, and 0.86 °C for HR, RR, systolic BP, diastolic BP, and BST, respectively. The estimated error for SpO2 is less than 1%, but it increases with movements of the subject and the camera-subject distance. Camera-based remote monitoring mainly explores intensive care, post-anaesthesia care, and sleep monitoring, but also explores special diseases such as heart failure. The monitored targets are newborn and pediatric patients, geriatric patients, athletes (e.g., exercising, cycling), and vehicle drivers. Camera-based techniques monitor HR, RR, and BST in static conditions within acceptable ranges for certain applications. The research gaps are large and heterogeneous populations, real-time scenarios, moving subjects, and accuracy of BP and SpO2 monitoring.

Automatic Detection of Atrial Fibrillation in ECG Using Co-Occurrence Patterns of Dynamic Symbol Assignment and Machine Learning.

Early detection of atrial fibrillation from electrocardiography (ECG) plays a vital role in the timely prevention and diagnosis of cardiovascular diseases. Various algorithms have been proposed; however, they are lacking in considering varied-length signals, morphological transitions, and abnormalities over long-term recordings. We propose dynamic symbolic assignment (DSA) to differentiate a normal sinus rhythm (SR) from paroxysmal atrial fibrillation (PAF). We use ECG signals and their interbeat (RR) intervals from two public databases namely, AF Prediction Challenge Database (AFPDB) and AF Termination Challenge Database (AFTDB). We transform RR intervals into a symbolic representation and compute co-occurrence matrices. The DSA feature is extracted using varied symbol-length V, word-size W, and applied to five machine learning algorithms for classification. We test five hypotheses: (i) DSA captures the dynamics of the series, (ii) DSA is a reliable technique for various databases, (iii) optimal parameters improve DSA's performance, (iv) DSA is consistent for variable signal lengths, and (v) DSA supports cross-data analysis. Our method captures the transition patterns of the RR intervals. The DSA feature exhibit a statistically significant difference in SR and PAF conditions (p < 0.005). The DSA feature with W=3 and V=3 yield maximum performance. In terms of F-measure (F), rotation forest and ensemble learning classifier are the most accurate for AFPDB (F = 94.6%) and AFTDB (F = 99.8%). Our method is effective for short-length signals and supports cross-data analysis. The DSA is capable of capturing the dynamics of varied-lengths ECG signals. Particularly, the optimal parameters-based DSA feature and ensemble learning could help to detect PAF in long-term ECG signals. Our method maps time series into a symbolic representation and identifies abnormalities in noisy, varied-length, and pathological ECG signals.

Wearable Devices in Health Monitoring from the Environmental towards Multiple Domains: A Survey.

The World Health Organization (WHO) recognizes the environmental, behavioral, physiological, and psychological domains that impact adversely human health, well-being, and quality of life (QoL) in general. The environmental domain has significant interaction with the others. With respect to proactive and personalized medicine and the Internet of medical things (IoMT), wearables are most important for continuous health monitoring. In this work, we analyze wearables in healthcare from a perspective of innovation by categorizing them according to the four domains. Furthermore, we consider the mode of wearability, costs, and prolonged monitoring. We identify features and investigate the wearable devices in the terms of sampling rate, resolution, data usage (propagation), and data transmission. We also investigate applications of wearable devices. Web of Science, Scopus, PubMed, IEEE Xplore, and ACM Library delivered wearables that we require to monitor at least one environmental parameter, e.g., a pollutant. According to the number of domains, from which the wearables record data, we identify groups: G1, environmental parameters only; G2, environmental and behavioral parameters; G3, environmental, behavioral, and physiological parameters; and G4 parameters from all domains. In total, we included 53 devices of which 35, 9, 9, and 0 belong to G1, G2, G3, and G4, respectively. Furthermore, 32, 11, 7, and 5 wearables are applied in general health and well-being monitoring, specific diagnostics, disease management, and non-medical. We further propose customized and quantified output for future wearables from both, the perspectives of users, as well as physicians. Our study shows a shift of wearable devices towards disease management and particular applications. It also indicates the significant role of wearables in proactive healthcare, having capability of creating big data and linking to external healthcare systems for real-time monitoring and care delivery at the point of perception.

Unobtrusive Health Monitoring in Private Spaces: The Smart Home.

With the advances in sensor technology, big data, and artificial intelligence, unobtrusive in-home health monitoring has been a research focus for decades. Following up our research on smart vehicles, within the framework of unobtrusive health monitoring in private spaces, this work attempts to provide a guide to current sensor technology for unobtrusive in-home monitoring by a literature review of the state of the art and to answer, in particular, the questions: (1) What types of sensors can be used for unobtrusive in-home health data acquisition? (2) Where should the sensors be placed? (3) What data can be monitored in a smart home? (4) How can the obtained data support the monitoring functions? We conducted a retrospective literature review and summarized the state-of-the-art research on leveraging sensor technology for unobtrusive in-home health monitoring. For structured analysis, we developed a four-category terminology (location, unobtrusive sensor, data, and monitoring functions). We acquired 912 unique articles from four relevant databases (ACM Digital Lib, IEEE Xplore, PubMed, and Scopus) and screened them for relevance, resulting in n=55 papers analyzed in a structured manner using the terminology. The results delivered 25 types of sensors (motion sensor, contact sensor, pressure sensor, electrical current sensor, etc.) that can be deployed within rooms, static facilities, or electric appliances in an ambient way. While behavioral data (e.g., presence (n=38), time spent on activities (n=18)) can be acquired effortlessly, physiological parameters (e.g., heart rate, respiratory rate) are measurable on a limited scale (n=5). Behavioral data contribute to functional monitoring. Emergency monitoring can be built up on behavioral and environmental data. Acquired physiological parameters allow reasonable monitoring of physiological functions to a limited extent. Environmental data and behavioral data also detect safety and security abnormalities. Social interaction monitoring relies mainly on direct monitoring of tools of communication (smartphone; computer). In summary, convincing proof of a clear effect of these monitoring functions on clinical outcome with a large sample size and long-term monitoring is still lacking.

Unobtrusive Health Monitoring in Private Spaces: The Smart Vehicle.

Unobtrusive in-vehicle health monitoring has the potential to use the driving time to perform regular medical check-ups. This work intends to provide a guide to currently proposed sensor systems for in-vehicle monitoring and to answer, in particular, the questions: (1) Which sensors are suitable for in-vehicle data collection? (2) Where should the sensors be placed? (3) Which biosignals or vital signs can be monitored in the vehicle? (4) Which purposes can be supported with the health data? We reviewed retrospective literature systematically and summarized the up-to-date research on leveraging sensor technology for unobtrusive in-vehicle health monitoring. PubMed, IEEE Xplore, and Scopus delivered 959 articles. We firstly screened titles and abstracts for relevance. Thereafter, we assessed the entire articles. Finally, 46 papers were included and analyzed. A guide is provided to the currently proposed sensor systems. Through this guide, potential sensor information can be derived from the biomedical data needed for respective purposes. The suggested locations for the corresponding sensors are also linked. Fifteen types of sensors were found. Driver-centered locations, such as steering wheel, car seat, and windscreen, are frequently used for mounting unobtrusive sensors, through which some typical biosignals like heart rate and respiration rate are measured. To date, most research focuses on sensor technology development, and most application-driven research aims at driving safety. Health-oriented research on the medical use of sensor-derived physiological parameters is still of interest.

Removal of simulated biofilm at different implant crown designs with interproximal oral hygiene aids: An in vitro study.

OBJECTIVES: To compare the removal of simulated biofilm at two different implant-supported restoration designs with various interproximal oral hygiene aids. METHODS: Mandibular models with a missing first molar were fabricated and provided with single implant analogues (centrally or distally placed) and two different crown designs (conventional [CCD] and alternative crown design [ACD]). Occlusion spray was applied to the crowns to simulate artificial biofilm. Thirty participants (dentists, dental hygienists, and laypersons) were equally divided and asked to clean the interproximal areas with five different cleaning devices to further evaluate if there were differences in their cleaning ability. The outcome was measured via standardized photos and the cleaning ratio, representing the cleaned surfaces in relation to the respective crown surface. Statistical analysis was performed by linear mixed-effects model with fixed effects for cleaning tools, surfaces, crown design and type of participant, and random effects for crowns. RESULTS: The mean cleaning ratio for the investigated tools and crown designs were (in%): Super floss: 76 ± 13/ACD and 57 ± 14/CCD (highest cleaning efficiency), followed by dental floss: 66 ± 13/ACD and 56 ± 15/CCD, interdental brush: 55 ± 10/ACD and 45 ± 9/CCD, electric interspace brush: 31 ± 10/ACD and 30 ± 1/CCD, microdroplet floss: 8 ± 9/ACD and 9 ± 8/CCD. There was evidence of an overall effect of each factor "cleaning tool," "surface," "crown design," and "participant" (p < 0.0001). CONCLUSIONS: ACD allowed more removal of the artificial biofilm than CCD with Super floss, dental floss, and interdental brush. Flossing and interproximal brushing were the most effective cleaning methods. A complete removal of the artificial biofilm could not be achieved in any group.

Mobile access to virtual randomization for investigator-initiated trials.

Background/aims Randomization is indispensable in clinical trials in order to provide unbiased treatment allocation and a valid statistical inference. Improper handling of allocation lists can be avoided using central systems, for example, human-based services. However, central systems are unaffordable for investigator-initiated trials and might be inaccessible from some places, where study subjects need allocations. We propose mobile access to virtual randomization, where the randomization lists are non-existent and the appropriate allocation is computed on demand. Methods The core of the system architecture is an electronic data capture system or a clinical trial management system, which is extended by an R interface connecting the R server using the Java R Interface. Mobile devices communicate via the representational state transfer web services. Furthermore, a simple web-based setup allows configuring the appropriate statistics by non-statisticians. Our comprehensive R script supports simple randomization, restricted randomization using a random allocation rule, block randomization, and stratified randomization for un-blinded, single-blinded, and double-blinded trials. For each trial, the electronic data capture system or the clinical trial management system stores the randomization parameters and the subject assignments. Results Apps are provided for iOS and Android and subjects are randomized using smartphones. After logging onto the system, the user selects the trial and the subject, and the allocation number and treatment arm are displayed instantaneously and stored in the core system. So far, 156 subjects have been allocated from mobile devices serving five investigator-initiated trials. Conclusion Transforming pre-printed allocation lists into virtual ones ensures the correct conduct of trials and guarantees a strictly sequential processing in all trial sites. Covering 88% of all randomization models that are used in recent trials, virtual randomization becomes available for investigator-initiated trials and potentially for large multi-center trials.

Survey of Non-Rigid Registration Tools in Medicine.

We catalogue available software solutions for non-rigid image registration to support scientists in selecting suitable tools for specific medical registration purposes. Registration tools were identified using non-systematic search in Pubmed, Web of Science, IEEE Xplore® Digital Library, Google Scholar, and through references in identified sources (n = 22). Exclusions are due to unavailability or inappropriateness. The remaining (n = 18) tools were classified by (i) access and technology, (ii) interfaces and application, (iii) living community, (iv) supported file formats, and (v) types of registration methodologies emphasizing the similarity measures implemented. Out of the 18 tools, (i) 12 are open source, 8 are released under a permissive free license, which imposes the least restrictions on the use and further development of the tool, 8 provide graphical processing unit (GPU) support; (ii) 7 are built on software platforms, 5 were developed for brain image registration; (iii) 6 are under active development but only 3 have had their last update in 2015 or 2016; (iv) 16 support the Analyze format, while 7 file formats can be read with only one of the tools; and (v) 6 provide multiple registration methods and 6 provide landmark-based registration methods. Based on open source, licensing, GPU support, active community, several file formats, algorithms, and similarity measures, the tools Elastics and Plastimatch are chosen for the platform ITK and without platform requirements, respectively. Researchers in medical image analysis already have a large choice of registration tools freely available. However, the most recently published algorithms may not be included in the tools, yet.

A Survey of DICOM Viewer Software to Integrate Clinical Research and Medical Imaging.

The digital imaging and communications in medicine (DICOM) protocol is the leading standard for image data management in healthcare. Imaging biomarkers and image-based surrogate endpoints in clinical trials and medical registries require DICOM viewer software with advanced functionality for visualization and interfaces for integration. In this paper, a comprehensive evaluation of 28 DICOM viewers is performed. The evaluation criteria are obtained from application scenarios in clinical research rather than patient care. They include (i) platform, (ii) interface, (iii) support, (iv) two-dimensional (2D), and (v) three-dimensional (3D) viewing. On the average, 4.48 and 1.43 of overall 8 2D and 5 3D image viewing criteria are satisfied, respectively. Suitable DICOM interfaces for central viewing in hospitals are provided by GingkoCADx, MIPAV, and OsiriX Lite. The viewers ImageJ, MicroView, MIPAV, and OsiriX Lite offer all included 3D-rendering features for advanced viewing. Interfaces needed for decentral viewing in web-based systems are offered by Oviyam, Weasis, and Xero. Focusing on open source components, MIPAV is the best candidate for 3D imaging as well as DICOM communication. Weasis is superior for workflow optimization in clinical trials. Our evaluation shows that advanced visualization and suitable interfaces can also be found in the open source field and not only in commercial products.

DICOM for Clinical Research: PACS-Integrated Electronic Data Capture in Multi-Center Trials.

Providing surrogate endpoints in clinical trials, medical imaging has become increasingly important in human-centered research. Nowadays, electronic data capture systems (EDCS) are used but binary image data is integrated insufficiently. There exists no structured way, neither to manage digital imaging and communications in medicine (DICOM) data in EDCS nor to interconnect EDCS with picture archiving and communication systems (PACS). Manual detours in the trial workflow yield errors, delays, and costs. In this paper, requirements for a DICOM-based system interconnection of EDCS and research PACS are analysed. Several workflow architectures are compared. Optimized for multi-center trials, we propose an entirely web-based solution integrating EDCS, PACS, and DICOM viewer, which has been implemented using the open source projects OpenClinica, DCM4CHEE, and Weasis, respectively. The EDCS forms the primary access point. EDCS to PACS interchange is integrated seamlessly on the data and the context levels. DICOM data is viewed directly from the electronic case report form (eCRF), while PACS-based management is hidden from the user. Data privacy is ensured by automatic de-identification and re-labelling with study identifiers. Our concept is evaluated on a variety of 13 DICOM modalities and transfer syntaxes. We have implemented the system in an ongoing investigator-initiated trial (IIT), where five centers have recruited 24 patients so far, performing decentralized computed tomography (CT) screening. Using our system, the chief radiologist is reading DICOM data directly from the eCRF. Errors and workflow processing time are reduced. Furthermore, an imaging database is built that may support future research.

Simplifying electronic data capture in clinical trials: workflow embedded image and biosignal file integration and analysis via web services.

To improve data quality and save cost, clinical trials are nowadays performed using electronic data capture systems (EDCS) providing electronic case report forms (eCRF) instead of paper-based CRFs. However, such EDCS are insufficiently integrated into the medical workflow and lack in interfacing with other study-related systems. In addition, most EDCS are unable to handle image and biosignal data, although electrocardiography (EGC, as example for one-dimensional (1D) data), ultrasound (2D data), or magnetic resonance imaging (3D data) have been established as surrogate endpoints in clinical trials. In this paper, an integrated workflow based on OpenClinica, one of the world's largest EDCS, is presented. Our approach consists of three components for (i) sharing of study metadata, (ii) integration of large volume data into eCRFs, and (iii) automatic image and biosignal analysis. In all components, metadata is transferred between systems using web services and JavaScript, and binary large objects (BLOBs) are sent via the secure file transfer protocol and hypertext transfer protocol. We applied the close-looped workflow in a multicenter study, where long term (7 days/24 h) Holter ECG monitoring is acquired on subjects with diabetes. Study metadata is automatically transferred into OpenClinica, the 4 GB BLOBs are seamlessly integrated into the eCRF, automatically processed, and the results of signal analysis are written back into the eCRF immediately.

Integrated image data and medical record management for rare disease registries. A general framework and its instantiation to theGerman Calciphylaxis Registry.

Especially for investigator-initiated research at universities and academic institutions, Internet-based rare disease registries (RDR) are required that integrate electronic data capture (EDC) with automatic image analysis or manual image annotation. We propose a modular framework merging alpha-numerical and binary data capture. In concordance with the Office of Rare Diseases Research recommendations, a requirement analysis was performed based on several RDR databases currently hosted at Uniklinik RWTH Aachen, Germany. With respect to the study management tool that is already successfully operating at the Clinical Trial Center Aachen, the Google Web Toolkit was chosen with Hibernate and Gilead connecting a MySQL database management system. Image and signal data integration and processing is supported by Apache Commons FileUpload-Library and ImageJ-based Java code, respectively. As a proof of concept, the framework is instantiated to the German Calciphylaxis Registry. The framework is composed of five mandatory core modules: (1) Data Core, (2) EDC, (3) Access Control, (4) Audit Trail, and (5) Terminology as well as six optional modules: (6) Binary Large Object (BLOB), (7) BLOB Analysis, (8) Standard Operation Procedure, (9) Communication, (10) Pseudonymization, and (11) Biorepository. Modules 1-7 are implemented in the German Calciphylaxis Registry. The proposed RDR framework is easily instantiated and directly integrates image management and analysis. As open source software, it may assist improved data collection and analysis of rare diseases in near future.

Crowdsourcing image segmentation for deep learning: integrated platform for citizen science, paid microtask, and gamification.

OBJECTIVES: Segmentation is crucial in medical imaging. Deep learning based on convolutional neural networks showed promising results. However, the absence of large-scale datasets and a high degree of inter- and intra-observer variations pose a bottleneck. Crowdsourcing might be an alternative, as many non-experts provide references. We aim to compare different types of crowdsourcing for medical image segmentation. METHODS: We develop a crowdsourcing platform that integrates citizen science (incentive: participating in the research), paid microtask (incentive: financial reward), and gamification (incentive: entertainment). For evaluation, we choose the use case of sclera segmentation in fundus images as a proof-of-concept and analyze the accuracy of crowdsourced masks and the generalization of learning models trained with crowdsourced masks. RESULTS: The developed platform is suited for the different types of crowdsourcing and offers an easy and intuitive way to implement crowdsourcing studies. Regarding the proof-of-concept study, citizen science, paid microtask, and gamification yield a median F-score of 82.2, 69.4, and 69.3 % compared to expert-labeled ground truth, respectively. Generating consensus masks improves the gamification masks (78.3 %). Despite the small training data (50 images), deep learning reaches median F-scores of 80.0, 73.5, and 76.5 % for citizen science, paid microtask, and gamification, respectively, indicating sufficient generalizability. CONCLUSIONS: As the platform has proven useful, we aim to make it available as open-source software for other researchers.

Unobtrusive Monitoring of Clinical Deterioration in Smart Homes.

Clinical deterioration (CD) is the physiological decompensation that incurs care escalation, protracted hospital stays, or even death. The early warning score (EWS) calculates the occurrence of CD based on five vital signs. However, there are limited reports regarding EWS monitoring in smart home settings. This study aims to design a CD detection system for health monitoring at home (HM@H) that automatically identifies unstable vital signs and alarms the medical emergency team. We conduct a requirement analysis by interviewing experts. We use unified modeling language (UML) diagrams to define the behavioral and structural aspects of HM@H. We developed a prototype using a SQL-based database and Python to calculate the EWS in the front end. A team of five experts assessed the accuracy and validity of the designed system. The requirement analysis for four main users yielded 30 data elements and 10 functions. Three main components of HM@H are the graphical user interface (GUI), the application programming interface (API), and the server. Results show the possibility of using unobtrusive sensors to collect smart home residents' vital signs and calculate their EWS scores in real-time. However, further implementation with real data, for frail elderly and hospital-discharged patients is required.

Creating Digital Rescue Sheets.

Rescue sheets enable rescue personnel to timely extricate trapped victims of road traffic accidents and increase their chance of survival. However, in the year 2024, these rescue sheets are still paper based DIN A4 documents. The digital transformation of the rescue process through new reporting technologies, such as eCall or the International Standard Accident Number (ISAN) facilitates digital rescue sheets, providing benefits for availability and functionality. This work addresses design considerations raised by previous research to suggest a process for the creation of digital rescue sheets. Our process transforms high-resolution models provided by car manufacturers and vendors into small files by shape abstraction of the components. The system maps the body of the car to generic representative models of defined car body types reducing the number of models that need to be stored. We develop a hierarchical tree data structure with three levels that allows appending new components of the increasingly complex cars. Our data format for transmission of the rescue sheet sends all relevant data for visualization while still retaining a small file size to account for a poor internet connection. In the future, we aim to evaluate our approach involving car manufacturers and other stakeholders.

Fake paper identification in the pool of withdrawn and rejected manuscripts submitted to Naunyn-Schmiedeberg's Archives of Pharmacology.

Honesty of publications is fundamental in science. Unfortunately, science has an increasing fake paper problem with multiple cases having surfaced in recent years, even in renowned journals. There are companies, the so-called paper mills, which professionally fake research data and papers. However, there is no easy way to systematically identify these papers. Here, we show that scanning for exchanged authors in resubmissions is a simple approach to detect potential fake papers. We investigated 2056 withdrawn or rejected submissions to Naunyn-Schmiedeberg's Archives of Pharmacology (NSAP), 952 of which were subsequently published in other journals. In six cases, the stated authors of the final publications differed by more than two thirds from those named in the submission to NSAP. In four cases, they differed completely. Our results reveal that paper mills take advantage of the fact that journals are unaware of submissions to other journals. Consequently, papers can be submitted multiple times (even simultaneously), and authors can be replaced if they withdraw from their purchased authorship. We suggest that publishers collaborate with each other by sharing titles, authors, and abstracts of their submissions. Doing so would allow the detection of suspicious changes in the authorship of submitted and already published papers. Independently of such collaboration across publishers, every scientific journal can make an important contribution to the integrity of the scientific record by analyzing its own pool of withdrawn and rejected papers versus published papers according to the simple algorithm proposed in the present paper.

Challenges of Integrating ICD 11 into Automatic Alerting Systems.

Automatic alerting systems (AASs) can identify adverse health events but emergency communication relies on human operators and natural languages. For complete automation, we need to code the diversity of adverse events in a granularity that supports optimal dispatches. Hence, AAs shall integrate with the International Classification of Diseases (ICD). The ICD-11 coding system includes chapters for external causes of injury. However, ICD-11 supports coding injury incidents in electronic health records (EHRs) after they have occurred, while disregarding integrating real-time injury reporting within its framework. We explore the potential challenges associated with integrating ICD-11 into AAS by analyzing external causes of morbidity or mortality and the dimensions of external causes as potential areas of integration. We recognize the themes: (i) incident of injury, (ii) mode of transport, (iii) indoor location, (iv) outdoor location, and (v) type of building, and identify four challenges: (i) conceptual differences between the two systems, (ii) injury identification, (iii) presence of entities below the shoreline in ICD-11, and (iv) lack of specificity in certain ICD-11 codes related to AASs. For easy integration of ICD-11 into AASs, we recommend an AAS data dictionary and propose ICD-11 updates related to external causes of injury.