Clostridium difficile infections (CDI) among 26 patients with osteoarticular infections. The aim of the study was to define the source of C. difficile and to evaluate the impact of general infection control measures and antibiotic stewardship on the incidence of CDI.Here we describe a cluster of hospital-acquired C. difficile strains and analysis of possible patient to patient transmission. Infection control measures comprised strict isolation of CDI patients, additional hand washings, and intensified environmental cleaning with sporicidal disinfection. In addition an antibiotic stewardship program was implemented in order to prevent the use of CDI high risk antimicrobials such as fluoroquinolones, clindamycin, and cephalosporins.Epidemiological analysis included typing of n = 15) were caused by C. difficile ribotype 027 (RT027). Most RT027 isolates (n = 9) showed high minimal inhibitory concentrations (MIC) for levofloxacin, clindamycin, and remarkably to rifampicin, which were all used for the treatment of osteoarticular infections. Epidemiological analysis, however, revealed no closer genetic relationship among the majority of RT027 isolates. The incidence of CDI was reduced only when a significant reduction in the use of fluoroquinolones (p = 0.006), third generation cephalosporins (p = 0.015), and clindamycin (p = 0.001) was achieved after implementation of an intensified antibiotic stewardship program which included a systematic review of all antibiotic prescriptions.The majority of CDI (The successful reduction of the CDI incidence demonstrates the importance of antibiotic stewardship programs focused on patients treated for osteoarticular infections. Clostridium difficile is a gram-positive, anaerobic bacterium which is ubiquitously present in the gastrointestinal tract of humans and animals [C. difficile has the ability to persist and to remain infectious in the environment for extended periods of time. Spores are highly resistant to desiccation and alcohol disinfectants [C. difficile infection (CDI) are (i) previous antibiotic treatment, in particular with high risk antibiotics such as 3rd generation cephalosporins, clindamycin, and fluoroquinolones, (ii) long hospitalization, (iii) underlying comorbidities, and (iv) high age of patients [ animals , 2. As afectants . The maipatients , 3. Alsopatients . Despitepatients –7. The ipatients , 9. Howepatients . In addipatients . A much patients .C. difficile RT027. The aims of this study were to define risk factors, possible sources of infection, and to evaluate the impact of general infection control measures and antibiotic stewardship on the incidence of CDI in this difficult to treat group of patients.Between June 2014 and December 2015 we observed an increased incidence of CDI among patients suffering from mostly implant-associated osteoarticular infections, where the majority of CDIs (57%) was caused by The current study was initiated after recognition of a possible CDI outbreak in the first quarter 2015 on the septic ward of the department of orthopedic surgery. This department with three independent wards is part of an 1,100 bed tertiary care university hospital and acts as a regional referral center for the treatment of osteoarticular infections. Patients with osteoarticular infections stay on a specialized ward to which we refer as “septic ward”.C. difficile toxin genes by PCR. Severe CDI was defined by the presence of at least one of the following symptoms: fever >38.5 °C, decreased kidney function (creatinine >1.5x103g/L) and/or high leukocyte count (>15 × 109 cells/L). A recurrent CDI case was defined as new onset of CDI within 8 weeks after resolution of a previous CDI episode. No children were included in the study. An outbreak situation was defined as two or more CDI cases on a single ward within 28 days. Risk factors for infection with C. difficile RT027 were evaluated by comparing patients with CDI caused by RT027 with patients infected with non-RT027 ribotypes.For the study hospital-acquired CDI was defined as new onset of diarrhea 48 h after hospital admission and laboratory-confirmed detection of C. difficile or other bacteria and secondly spores of C. difficile, (ii) use of hygienic bags for bedpans, (iii) strict isolation or cohorting of infected patients, (iv) personalized use of all materials with direct contact to the patient e.g. stethoscope, and (v) disinfection of surfaces and equipment in all wards, operating rooms and physiotherapy with peracetic acid and peroxide hydrogen vaporization after discharge of patients. Intensified environmental cleaning procedures were controlled by sampling of surfaces as described below. Additionally, health care workers were educated on diagnosis, treatment and prevention of CDI and provided with an antibiotic risk checklist which groups of antibiotics in 3 risk categories . Physicians were instructed to follow the in-house guidelines for antibiotic therapy and microbiological diagnostic of osteoarticular infections and to avoid the prescription of high risk antibiotics for therapy. In quarter 3/2015 an intensified antibiotic stewardship program was implemented which included a weekly review of all antibiotic prescriptions by an orthopedic surgeon and a clinical microbiologist trained in antibiotic stewardship. The organization of the team was not changed since the beginning of the intervention. If possible antibiotic therapy was adjusted in order to avoid CDI high risk antibiotics as described above.Infection control measures were implemented after recognition of an enhanced CDI incedence. The infection control bundle included (i) handwashing with soap after disinfection, to reduce first vegetative forms of In order to control the impact of infection control measures and antibiotic stewardship the CDI incidence was monitored as number of cases per 1,000 hospital bed days per quarter.In addition the impact of the antibiotic stewardship intervention was controlled by quarterly monitoring of antibiotic consumption on the septic ward. Antibiotic consumption was calculated as defined daily doses (DDD) per 100 hospital bed days according to WHO standards .Diagnostic stool specimens were collected from 63 adult patients showing symptoms of diarrhea between June 2014 and December 2015. Stool diagnostic was performed as part of the routine microbiological diagnostic in a two-step algorithm.Clostridium difficile GDH, R-Biopharm, Darmstadt, Germany) using the protocol provided by the manufacturer. In case of positive results (n = 29) DNA was extracted from the original stool sample. In brief, 100 μl stool in 900 μl sample buffer were used, followed by centrifugation at 1,000 x g for 5 min. Subsequently 400 μl supernatant was transferred into Precellys® Soil grinding SK38 tubes  and homogenized by centrifugation  using the MagNA Lyser System . The lysate was clarified by centrifugation at 1,000 x g for 5 min and subsequent incubated for 10 min at 70 °C in a thermoshaker. DNA-extraction was performed using the QIAamp® DNA Mini Kit  according to manufacturer’s instructions.First, clinical samples were primarily screened with a Clostridium glutamate dehydrogenase (GDH)-specific enzyme-linked immunosorbent assay  and B (tcdB) genes were detected using the RealStar® Clostridium difficile PCR Kit 1.0 . The binary toxin gene and the Δ117 deletion in the tcdC gene were detected using Xpert® C. difficile/Epi PCR assay . All tests were performed according to manufacturer’s protocol.Second, purified DNA samples were tested for the presence of n = 10) or from isolated strains (n = 16). The MLST was performed as described before [C. difficile: adk, atpA, dxr, glyA, recA, sod and tpi. The sequencing reactions were run on a 3130xl Genetic Analyzer (Applied Biosystems). Editing, alignment, and phylogenetic analysis of sequences were performed with the program MEGA 6.0 [C. difficile sequence types (ST) were received from the website [MLST was performed with DNA either isolated from feces  using a chromogenic medium . The medium was inoculated with 10 μl feces and incubated anaerobically at 35 ± 1 °C for 7 days. Presumptive C. difficile colonies were confirmed by MALDI-TOF MS .C. difficile in saline as described previously [The minimal inhibitory concentrations (MIC) of metronidazole, vancomycin, rifampicin, levofloxacin, and clindamycin were determined by gradient strip test  on Brucella blood agar  inoculated with 100 μl solution of a 1.0 McFarland suspension of eviously . Agar plC. difficile was performed as described [2 sponge swabs pre-moistened with neutralizing solution . Frequent contact surfaces of the patient room  and the en-suite bathroom  were sampled. After sampling sponge swabs were placed aseptically into the sterile sample transport bag prefilled with 10 ml neutralizing solution. The laboratory bags were opened and supplemented with 40 ml sterile phosphate-buffered saline  to yield a final volume of 50 ml. Sponge bags were resealed and homogenized manually by massaging the bag for 1 min. After 10 min. incubation at room temperature the whole volume was passed through a 45 μm membrane filter . Filters were aseptically put onto Brazier's CCEY agar  and incubated 48 h in an anaerobic atmosphere at 35 ± 1 °C. After 48 h, suspected C. difficile colonies were further analysed by MALDI-TOF MS. Confirmed C. difficile isolates were tested for toxin production and typed by MLST.Sampling of the inpatient environment for the presence of escribed . BrieflyC. difficile in Homburg/Saar . PCR-ribotyping was performed for each isolate according the standard protocol  as described earlier [Ribotyping and MLVA analysis of 11 ST1 isolates was performed by the National Consultant Laboratory for  earlier  which in earlier  with Bio earlier .C. difficile risk factors (non RT027 CDI versus RT027 associated CDI) and the two-sample independent t Test for the means of antibiotic consumption data before and after intervention with a significance level of p values <0.05. The Microsoft Excel statistic tool, OpenEpi (http://www.openepi.com) was used to analyze the data. The upper and lower statistical boundaries were defined as the mean CDI incidence of the four previous quarters plus/minus standard deviation (MA ± SD).Statistical analyses were performed using the Fisher’s exact Test for bivariate analysis of p = 0.036). Orthopedic infections in our patient cohort were associated with endoprosthesis , soft tissue/wound infections , septic spondylitis , and osteomyelitis .Retrospective analysis showed that already in the third quarter of 2014 the CDI incidence  on the septic ward, a special unit for treatment of patients with osteoarticular infections was significantly above average incidence of the whole department . After implementation of an intensified antibiotic stewardship program in quarter 3/2015 the CDI incidence dropped in the first quarter 2016 to no case per quarter which was significantly below the mean CDI incidence of the 4 previous quarters minus SD of 2.13 infections per 1,000 hospital bed days  were typed as ST1 and were further identified as RT027 by CE-ribotyping. The following sequence types were identified: ST3 (n = 2), ST6 (n = 2), ST14 (n = 2), ST8 (n = 1), ST15 (n = 1), and ST92 (n = 1). In all samples both toxin encoding genes were detectable, whereas the binary toxin gene and the Δ117 in the tcdC gene were only present in samples typed as ST1.From June 1st 2014 to December 31th 2015 a total number of 63 patients with gastrointestinal disorders were tested for the presence of C. difficile RT027 (ST1) and non-RT027 strains. The only significant risk factor for CDI caused by RT027 was a patient’s stay on the septic ward.The time between admission of patients to the septic ward and diagnosis of CDI ranged from 2 to 72 days. Characteristics and co-morbidities of patients were summarized from patients records Table . Renal iC. difficile RT027.Non-severe CDI was initially diagnosed in 18 from 26 patients (69.2%) and in 6 from 15 patients (40.0%) infected with RT027. Treatment of CDI was initiated in all cases according to current European Society of Clinical Microbiology and Infectious Diseases guidelines . After pAfter clustering of CDI cases was first recognized in the quarter 1/2015 a primary infection control and antibiotic stewardship bundle was implemented (see methods section).Orthopedic infections generally require a long-term (≥6 weeks) antibiotic treatment –24. In mInitial review of antibiotic prescription data indicated an overuse of CDI high risk antibiotics Table  althoughst and 2nd generation cephalosporins and clindamycin were the most prescribed antibiotics on the septic ward, even after the initial recommendation to avoid these antibiotics after recognition of the enhanced CDI incidence in quarter 1/2015 , linezolid (+111%), and rifampicin (+41%). The total average antibiotic consumption before intervention was 131.3 DDD per 100 hospital bed days and after intervention 127.3 DDD per 100 hospital bed days, respectively. Thus, although consumption of high risk antimicrobials was significantly lowered total antibiotic consumption remained on a high level after the intervention.Significant reduction of antibiotic consumption of C. difficile isolates (ST1 (n = 11), ST6 (n = 2), ST8 (n = 1), ST14 (n = 1), and ST92 (n = 1) (Table In vitro antibiotic susceptibility tests were performed with 16 1) Table . All ST1The inquiry by infection control personal yielded no noticeable epidemiological association among patients with identical non-RT027 strains (data not shown). In order to confirm a possible epidemiological association of RT027 isolates form the septic ward subtyping by MLVA was performed. The typing of 11 RT027 isolates revealed two genetically related clusters (defined as ≤10 repeat differences). The larger cluster comprised 9 isolates (isolates 1–4 and 7–11) and the minor cluster 2 isolates (isolates 5 and 6) Fig. . Only thC. difficile RT027 in patient rooms after discharge of the patient and cleaning of the room, environmental investigations of surfaces of patient rooms were performed. Among 60 environmental samples taken in August 2015, December 2015, and January 2016 C. difficile RT027 was isolated from only one sample from the telephone set of an inpatient infected with RT027, without any transmissions of this particular strain to other inpatients up to now. Thus indicating that cleaning procedures were adequate and a persistent environmental C. difficile reservoir in patient rooms was highly unlikely.In order to further exclude a remnant reservoir of viable C. difficile RT027 with an elevated MIC for rifampicin among patients suffering from osteoarticular infections and the successful control of CDI by implementation of an antibiotic stewardship program focused on this difficult to treat group of patients.Here we report an increased incidence of CDI mainly caused by C. difficile RT027 among patients with orthopedic infections observed in the current study could be due to a number of different reasons. During the primary outbreak analysis, the investigation focused on a possible common source of C. difficile RT027 isolates. The only risk factor for CDI caused by RT027 was a patient’s stay on the septic ward neither molecular epidemiological analysis, nor analysis of inpatient contacts, nor environmental sampling suggested a possible common source of RT027 isolates. Probably, CDI was mainly restricted to the septic ward due to the higher exposure of inpatients to CDI high risk antibiotics required for the treatment of osteoarticular infections. Antibiotic consumption of high risk antibiotics on the septic ward was 2 to 3-fold higher compared to the other wards of the orthopedic department (data not shown). The majority of complications was associated with RT027, however due to the low number of patients the observed differences between patients infected with RT027 and non-RT027 were not significant.The dominance of C. difficile high risk antibiotics. The incidence of CDI was significantly reduced only after implementation of an intensified antibiotic stewardship program which lowered the prescription of fluoroquinolones, clindamycin, and cephalosporins in favor of low risks antibiotics such as penicillins and linezolid.The bundle of optimized antibiotic treatment, environmental cleaning procedures and education of health care workers effectively controlled nosocomial CDI thus corroborating previously published studies , 25–27. Average total antibiotic consumption before intervention was 131 DDD/100 hospital bed days and after intervention 127 DDD/100 hospital bed days. The antibiotic stewardship intervention shifted antibiotic therapy towards the use of narrow spectrum penicillins , linezolid (+111%), and rifampicin (+41%). The DDD of benzylpenicillin is 3.6 g. Treatment of serious infections, however, generally requires a dose of 12 g or even higher. Thus calculating DDD while using much higher therapeutic doses results in an overestimation of the prescribed doses . If corrThe average consumption of fluoroquinolones was 34.5 DDD (33.3 RDD) per 100 hospital bed days before and 11.5 DDD (10.3 RDD) per 100 hospital bed days after implementation of intensified antibiotic stewardship program. Despite after the intervention roughly 70% less quinolones were used overall quinolone consumption was still significantly above the national benchmark (75% quantile 6.9 RDD/100 patient days) , 29. TheIn Germany regionally between 5.3% and 33.5% of CDI are caused by RT027 , 31. In C. difficile. Thus the reduced susceptibility of RT027 to rifampicin might increase the risk of CDI among patients treated with rifampicin [ClosER (Clostridium difficile European Resistance) study reported elevated MICs of C. difficile for fluoroquinolones and clindamycin among various ribotypes, whereas elevated rifampicin MICs were mainly associated with a few ribotypes such as RT027, RT018, and RT356 which are more common in South Eastern Europe [C. difficile strains with an elevated rifampicin MIC [C. difficile strains, it has been hypothesized that rifampicin might prevent CDI in osteoarticular infections [Antimicrobial therapy of osteoarticular infections often requires prolonged antibiotic treatment for 6 to 12 weeks –24. Accofampicin , 32, 33.n Europe . It has icin MIC . In viewC. difficile was initiated by the laboratory after recognition of the epidemic situation in May 2015 the initial epidemiological analysis was performed based on PCR and MLST only. Sequence type 1 (ST1) can correspond to several ribotypes in particular RT176 [C. difficile in outbreaks [Our study has a number of limitations. Firstly, because culture-based diagnostic of ar RT176 , 36. In ar RT176 , 38, andutbreaks  MLVA anaC. difficile, which was switched from a toxin-specific enzyme-linked immunosorbent assay to primary screening with a GDH-specific ELISA followed by a toxin gen-specific PCR test. Thus, initially the increased number of patients with positive C. difficile tests was interpreted as result of the improved sensitivity of the new diagnostic test. Gould et al. reported an increase of the CDI incidence ranging from 43% to 67% after switching from toxin enzyme immunoassays to PCR-based C. difficile diagnostic tests [Secondly, the initially increased incidence of CDI in quarter 3/2014 correlated with the introduction of a new diagnostic test for the detection of ic tests . Beginniic tests , 34, 41.C. difficile [Third, despite the analysis of patient to patient contacts did not reveal a direct connection of our patients from which highly related RT027 were isolated we cannot strictly exclude a possible epidemiological connection. We could not exclude possible patient contacts outside the hospital and environmental screening was performed after cleaning and, therefore, the environment cannot be strictly excluded as source of infection. Also, screening of health care workers and asymptomatic patients was not performed which have been reported to act as vector for nosocomial transmission of ifficile , 43.C. difficile RT027 with elevated MICs for rifampicin among patients with osteoarticular infections. The successful reduction of the CDI incidence demonstrates the importance of antibiotic stewardship programs focused on patients treated for osteoarticular infections. The impact of antibiotic stewardship on the restriction of C. difficile high risk antimicrobials should be tightly monitored in order to ensure that antibiotic stewardship recommendations are followed.To our knowledge, this is the first report of an enhanced incidence of CDI caused by


The Radiation Injury Treatment Network (RITN) began in 2006 with the ambitious vision to provide a resource to help with the surge of casualties following a mass casualty incident with marrow toxic injuries. Through the efforts of the National Marrow Donor Program and American Society for Blood and Marrow Transplantation with the support of the Office of Naval Research, the initial 13 hospitals and cancer centers have grown to 76, training over 13,500 hospital staff and conducted, funded, and supported 580 disaster exercises testing preparedness. After a decade, there is more to do, but much laudatory work has been accomplished. This continues to be a lofty goal that the RITN strives for, but the gap between where we were following the tragedy of 9/11 and today is significantly smaller. The National Marrow Donor Program (NMDP) has had the great fortune to have a grant from the Office of Naval Research to conduct research to improve outcomes from hematopoietic transplantation. As part of this grant, there has been a sub-line item to conduct contingency planning in preparedness for a national disaster. This effort was half-heartedly fulfilled for a few years then the efforts were greatly accelerated following 9/11. The NMDP began by holding focus sessions with pre-imminent Hematology and Oncology physicians that were part of the NMDP’s network of transplant centers. These meetings led to the close partnership with the American Society for Blood and Marrow Transplantation (ASBMT) which broadened the audience and helped to continue to engage those who would be involved in a response. These focus groups, surveys, and meetings culminated in the formation of the Radiation Injury Treatment Network in 2006 with the commitment of 13 blood and bone marrow transplant units at NMDP affiliated hospitals/cancer centers.Hematology and oncology teams have extensive expertise in caring for patients that have been purposefully exposed to high levels of ionizing radiation in preparation for hematopoietic stem cell transplantation. The resulting complications can be directly correlated to the care needed for a radiation casualty suffering from Acute Radiation Syndrome resulting from exposure to an ionizing radiation. A radiological disaster could be as catastrophic as the detonation of an improvised nuclear device (terrorist nuclear bomb) or a less devastating incident such as a radiological exposure device , a radiological dispersal device , a nuclear power plant accident, or a mustard agent incident. Regardless of the incident, there will be casualties that require specialized supportive care to salvage their damaged hematopoietic systems.From these small beginnings, the group would debate the focus, vision, and even the name of what would become the RITN, culminating in 2006 with the signing of the first 13 contracts. This was no easy task as initially the language stated the hospitals would accept patients from a radiological disaster, which the hospital administration and legal staff expressed concern over. After going a few rounds of review, with each hospital, language that was strong enough to show commitment yet flexible enough to appease the lawyers solidified. The sales pitch to new institutions was a repeat of selling the pros of participation; imagine asking a senior administrator at a hospital if they would like to join a group of hospitals preparing to receive casualties from the detonation of a terrorist’s nuclear device. Needless to say there was some pushback. However, fortunately for RITN the physicians we worked with were passionate and persuasive. Since those humble beginnings RITN has grown into a conglomeration of 76 cancer treatment centers, hospitals, blood donor centers, and cord blood banks as of late 2016.Barnes-Jewish Hospital at Washington University School of Medicine Cincinnati Children’s Hospital Medical Center City of Hope National Medical Center Dana-Farber/Partners Cancer Care Duke University Medical Center M.D. Anderson Cancer Center Memorial Sloan-Kettering Cancer Center Presbyterian/St. Luke’s Medical Center Seattle Cancer Care Alliance Stanford Hospital and Clinics Texas Children’s Hospital University of Minnesota BMT Program University of Pennsylvania Medical Center The hospitals, cancer centers and the physicians that led the charge at the initial cohort of cancer centers that joined RITN should be recognized for their efforts:www.RITN.net/About**a complete list of current RITN hospitals by location can be found at As stated, these 13 have grown to 76 which can be seen in Fig. To encourage participation, we appealed to each hospital’s sense of greater good as well as offered a token stipend to offset some of the costs, this grant did not cover the cost of staff time fully but at least eased the sting. To help with this effort, the funds were provided through a fee for service agreement to reduce the restrictions on how they could be used. However, to ensure that we were “getting our monies worth,” we began assigning annual tasks. These included the development of a standard operating procedure, incorporation of the RITN acute radiation syndrome treatment guidelines, training, conducting an exercise (emergency drill), and testing the satellite telephone and emergency calling card (Government Emergency Telecommunications Service) that were issued to each center. To ease this burden, we developed the training and exercise so that each center could readily apply them with minimal effort. We still ask each center to accomplish similar tasks each year; however, we have added a dozen training options so that it does not get stale and broadens the perspective on impact on a local center in the event of a nuclear disaster. This initiative grew to include training, emergency preparedness exercises, and regular workshops bringing world-renowned experts together to plan and prepare for a catastrophe, that everyone hopes will never happen.RITN has developed and made available to the public many of the resources developed over the past 10 years to improve preparedness including training materials, disaster exercises/drills materials, treatment guidelines, medical order sets for adult and pediatric patients, and referral guidelines Fig. . All of Since the inception of RITN, exercises have been a part of the annual requirements for each hospital. Each year, RITN would develop a tabletop exercise, where a disaster scenario would be reviewed by appropriate staff at the hospital and, when appropriate, with the emergency preparedness teams of the community. They would then provide responses to questions on what they would have done in said situation. These efforts grew to include functional exercises, where portions of the response plans are acted out, to full-scale exercises where mock casualties with moulage wound makeup, ambulances, and aircraft are mobilized for a close to realistic situation as possible. All told, over 580 exercises have been coordinated or funded by RITN from 2006 to 2016 Fig. . RITN doHospitals preparing for a mass casualty incident require more than training and exercises. Just-in-time tools are often requested, and we have tried to meet these needs through the development of many resources. These include the RITN ARS Treatment Guidelines, RITN Hospital Referral Guidelines, RITN Concept of Operations, the Adult and Pediatric Medical Ordersets  website) for implementation of a standard approach to patient care for those individuals who might experience an acute radiation illness.RITN has come a long way; we still see many challenges ahead; need for continued growth of the network, how to engage distant unused medical capacity through telemedicine, and increasing awareness within the medical and public health community, as well as many other local issues that are identified during the exercises we support. However, based on the great success we have seen to date, we are confident that the Radiation Injury Treatment Network will continue to step up to the challenge presented.The Radiation Injury Treatment Network® (RITN) provides comprehensive evaluation and treatment for victims of radiation exposure or other marrow toxic injuries.Many of the casualties with radiation injury will be salvageable but require outpatient and/or inpatient care. Recognizing this, the US National Marrow Donor Program (NMDP), US Navy and American Society for Blood and Marrow Transplantation (ASBMT) collaboratively developed RITN, which comprises of medical centers with expertise in the management of bone marrow failure, stem cell donor centers and umbilical cord blood banks across the US.RITN’s mission and goals are as follows:The Radito develop treatment guidelines for managing hematologic toxicity among victims of radiation exposure,to educate health care professionals about pertinent aspects of radiation exposure management,to help coordinate the medical response to radiation events, andto provide comprehensive evaluation and treatment for victims at participating centers.The goals of RITN are as follows:Since RITNs inception, it has been fortunate to have many partners including the support of the Office of Naval Research, Department of Health and Human Services Health Resources Services Administration, Department of Health and Human Services Assistant Secretary for Preparedness and Response, and the Radiation Emergency Medical Management website operated by the National Library of Medicine as well as many other prominent supporters including the National Association of County and City Health Officials (NACCHO), Association of State and Territorial Health Officials (ASTHO) National Alliance for Radiation Readiness (NARR), European Society for Blood and Marrow Transplantation (EBMT), World Health Organization-Radiation Emergency Medical Preparedness and Assistance Network, Radiation Emergency Assistance Center and Training Site (REAC/TS), and many others.


HIV/AIDS stigmatizing behaviors are a huge barrier to early detection and treatment of individuals with the AIDS virus. HIV/AIDS stigma and related consequences are debilitating, especially for vulnerable populations. This study sought to assess whether young women’s HIV/AIDS knowledge levels and exposure to mass media (television and radio) have an influence on their stigmatizing behaviors and role as agents of stigma towards individuals living with HIV and AIDS. The data used for this study originated from the Ghana Multiple Indicator Cluster Survey 2011. Binary and multiple (stepwise) logistic regression analyses were used to examine the associations between HIV/AIDS knowledge, frequency of exposure to mass media, and HIV/AIDS stigmatizing behaviors among young women aged 15–24 years in Ghana. Of the 3573 young women, 80% of 15–19-year-olds and 76% of 20–24-year-olds had at least one stigmatizing behavior towards persons living with HIV/AIDS (PLHA). Young women with increased knowledge regarding HIV/AIDS and frequent exposure to mass media (television and radio) had lesser tendency to stigmatize or act as agents of stigma towards PLHA . There was a graded negative ‘exposure–response’ association between the ranked variables: HIV/AIDS knowledge, mass media, and HIV/AIDS stigmatizing behaviors. The significant inverse association between HIV/AIDS knowledge, frequency of exposure to mass media, and HIV/AIDS stigmatizing behaviors persisted even after adjusting for all other covariates in the multiple logistic regression models. It is extremely important to increase HIV/AIDS-related knowledge and reduce stigma among young women in Ghana through targeted HIV/AIDS factual knowledge transfer. The use of mass media for communication of issues regarding HIV/AIDS, its mode of transmission, and associated stigma should be emphasized among women in Ghana. Sub-Saharan Africa alone accounts for 71% of persons living with HIV and AIDS (PLHA). The pandemic has become a major public health issue in this region [Young people are generally considered to be the most vulnerable group with regard to HIV/AIDS, as they become sexually active and engage in risky sexual behaviors including unprotected sexual intercourse ,3. The bStigma plays a huge role as a barrier in the prevention and control of HIV/AIDS –10. FactThe stigma associated with the disease often excludes PLHA from seeking voluntary counseling and testing services, and accessing the highly effective antiviral drugs that exist –10,17. AOne such study conducted in South Africa in 2004 and 2008 concluded that individuals with higher knowledge scores on HIV/AIDS, previously tested for HIV, as well as those who knew a family member or friend who was infected with HIV or had died of AIDS had significantly lower stigma scores .Among the Ghanaian population, voluntary counseling and testing for HIV are low, which in many studies is attributed to the stigma and discrimination associated with HIV ,16,21. TStudies have shown that mass media  is a powerful way of sending public health and health promotion messages to the population and particularly for sending culturally sensitive messages to young people ,24. HoweThis cross-sectional study used data that originated from the women’s questionnaire included in the Ghana Multiple Indicator Cluster Survey (MICS) 2011 . The detHIV/AIDS stigmatizing behavior was the outcome of interest for this study. This study used indicators of social distancing to assess HIV/AIDS stigma in the form of potential behaviors, thoughts, feelings, and discriminatory attitudes that express prejudice against PLHA. Detailed explanation of all the measures is provided in the Supplemental Data.HIV/AIDS knowledge was created using responses to nine questions on HIV/AIDS knowledge. The total HIV/AIDS knowledge score ranged from 0 to 9  where a score of zero represented no HIV/AIDS knowledge and a score of nine represented the highest HIV/AIDS knowledge. HIV/AIDS knowledge was further regrouped into six homogeneous subgroups  based on an initial analysis using box plots.The variable do you watch television?and (b) do you listen to radio?The response options were (1) almost every day, (2) at least once a week, (3) less than once a week, and (4) not at all.Frequency of exposure to television and radio was independently assessed by the questions: (a) p-value of 0.05 was chosen as the significance threshold.The data were analyzed using Statistical Package for the Social Sciences version 22.0 (SPSS 22). Chi-squared tests and simple and multiple logistic regression were used for analyses. A A total of 3573 young women were included in the study of which 1899 (53.2%) were 15–19 years old and 1674 (46.8%) were 20–24 years. About 1 out of 4 (23.5%) had the highest HIV/AIDS knowledge score whereas 0.9% scored 0 (the lowest). About 78% of the participants reported at least one stigmatizing behavior towards PLHA. Stigmatizing behavior against male PLHA in the workplace was slightly higher (49.7%) compared with female PLHA (43.1%). Stigmatizing behavior against PLHA was more prevalent in the community (70.1%) than in the family (28.6%). Detailed sample characteristics are provided in Table S2 in the Supplemental Data.The final model adjusted for age, region, ethnicity, area of residence, and education. ‘Not at all’ users of mass media were twice as likely to stigmatize PLHA compared to the reference group. The models that included mass media exposure were not adjusted for wealth status since calculation of the wealth index encompassed ownership of household assets such as television and radio.The study revealed a statistically significant association between increased HIV/AIDS knowledge and decreased HIV/AIDS stigmatizing behaviors among young women (15–24 years) in Ghana. A statistically significant association between more frequent exposure to mass media (radio and television) and decreased stigmatizing behaviors towards PLHA was also found in the same population.The findings that HIV/AIDS stigmatizing behaviors were reduced among young women with the highest HIV/AIDS knowledge are consistent with those from previous studies ,19,26, stelenovelas (television novels) to maximize their positive effects among the youth. Specifically designed programs could be initiated for targeting both the agents of stigmatization and the stigmatized. According to Xiao and colleagues [The present study also found that frequent exposure to mass media (TV and radio) decreases young women’s stigmatizing behaviors towards PLHA. This is consistent with previous studies that reported mass media as one of the important sources of HIV/AIDS information in terms of prevention and decreasing stigmatizing behaviors ,27,28. Tlleagues , mass meThe study also found that the majority of young women (70.1%) were unwilling to buy fresh vegetables from a person that they knew had the AIDS virus, but in contrast, most (71.4%) of them were willing to care for a family member infected with the AIDS virus. This finding is consistent with previous studies ,19. TherFinally, there was a statistically significant association between increased formal education, being wealthy, and urban residence, and decreased HIV/AIDS stigmatizing behaviors. This requires appropriate intervention from the government to create opportunities aimed at bridging the socioeconomic gap among the youth, including young women. There should be periodic evaluation of the approaches used in countering HIV/AIDS stigmatizing behaviors among young women and tailored HIV/AIDS information and messages to specific cultures and groups. Further research is needed to examine the nature of the association between the use of social media or other mass media, including the Internet, as a tool for HIV/AIDS knowledge transmission and reduction of stigmatizing behaviors.The comprehensive nature of the information available in the data-set and the representativeness of the entire 10 administrative regions of Ghana are major strengths for this study. Therefore, the results may be generalized to all Ghanaian young women who are 15–24 years of age. Additionally, this is the first study of its kind in Ghana to examine the impact of media exposure on HIV/AIDS stigmatizing behaviors. The graded negative association between the ranked HIV/AIDS knowledge, mass media exposure, and HIV/AIDS stigmatizing behaviors lends further support to the validity of the findings. Causality cannot be inferred between the covariates and HIV/AIDS stigmatizing behaviors due to the cross-sectional nature of the data. Also, the study used secondary data that were self-reported, which can be subject to bias. On the one hand, using an aggregated ‘series of questions’ to define stigmatizing behaviors could help minimize underreporting of the stigmatizing behaviors due to the socially sensitive nature of the issue. On the other, young women with higher HIV/AIDS knowledge could have underreported their potential stigmatizing behaviors, due to a bias towards social desirability.The present study suggests an urgent need to reduce HIV/AIDS stigmatizing behaviors among young women in Ghana through comprehensive sexuality education using dynamic approaches. It is extremely important to promote programs that increase HIV/AIDS-related knowledge among young women, especially among those with low wealth and/or low education. The use of mass media for communication or knowledge transfer concerning issues related to HIV/AIDS, its mode of transmission, and associated stigma should be emphasized among women in Ghana.Click here for additional data file.


The aim of this study was to gain insight into how robots can be practically implemented into current education and therapy interventions for children with autism spectrum disorder (ASD). This qualitative study included focus groups and co-creation sessions. 73 Participants  took part in 13 focus groups to elicit requirements for robot assisted interventions. Additionally, 22 participants  generated ideas for interventions using robot KASPAR in three co-creation sessions. This study resulted in: an overview of requirements concerning the robot, end-user, environment and practical implementation; a template to systematically describe robot interventions in general and for KASPAR in particular; and finally new interventions. Personalised and early therapy and intervention plans are effective in supporting individuals to cope with autism spectrum disorder (ASD) associated symptoms  studies in education/therapy settings is KASPAR   are activated by the child, as well asas a controlled operating mode used by the accompanying professional or a child by means of a remote control for KASPAR, and/ora combination of both which creates a semi-autonomous mode of KASPAR.Customisation software allows for the creation of new  KASPAR scenarios. This customisation software enables users to make new KASPAR poses, behaviour, speech or sounds and scenarios and to fine-tune or personalise existing ones. It can be installed on any regular laptop on which the KASPAR application is running.Studies indicate that KASPAR can contribute to positive results in the area of increasing body awareness, encouraging collaborative skills . After the demo, the discussion on requirements started by asking a general question: what are the requirements of a meaningful KASPAR intervention? People were asked to think about aspects required for a successful implementation of a KASPAR intervention. If participants got stuck in the discussion researchers used prompting.. The specific prompts used in the focus groups were: “child”, “professional”, “environment/room/setting”, “KASPAR”, and “school as an entity”.Of the 13 sessions; 12 sessions consisted of a group of professionals and 1 session included individuals with ASD. The professionals work with children with ASD at special needs schools, (youth and child) care organisations, pedagogic organisations, ASD treatment centres and medical day care centres in The Netherlands.The sessions were conducted at the venues of the organisations and the session with participants with autism took place at a meeting room of the Zuyd University of Applied Sciences. Organising these sessions at the venue of the organisation themselves created a familiar and trusted atmosphere for the participants to facilitate free and open minded discussions. The research team prepared the room in advance, creating a U-shape setup to facilitate interaction between participants and preparing beamer/projection facilities in the front for the demonstration of KASPAR.The background of the professionals was multidisciplinary: ASD teachers, assistants at special need schools, speech therapists, psychologists, physiotherapist, occupational therapists, psychomotor therapist, treatment coordinator, case managers, behavioural therapists and people working in care management functions. The average work experience was 14 years with a standard deviation of 9.5 years. Table The completed participants demographic forms were collected on paper and the data was imported in an Excel sheet. Audio recordings were made during the sessions (after obtaining informed consent of the participants). One of the researchers present at the sessions literally transcribed all the data of the 13 sessions in Word files. Subsequently, the software program Nvivo was used to transform the data into written text to be able to start the analysis.For the analysis of the qualitative data of the focus groups, researchers applied conventional content analysis ”, “role(s) of KASPAR”, “goal of the session”, “session characteristics” as well as a schematic representation for the envisioned interaction between the professional, KASPAR and the child. For all the elements and the format of the intervention template we refer to “The aim of the co-creation sessions was to create new robot interventions, incorporating the identified requirements of the focus groups, in a multidisciplinary group of participants.Three co-creation sessions had a duration of 2–3 hours each. After a short welcome, an introduction round to briefly introduce oneself to the others , an explanation of the aim and nature of the session, and a presentation of the intervention template, an interactive live demonstration of KASPAR was given. Participants provided informed consent for making audio recordings during the sessions. After answering questions, participants were asked to think about a certain child with ASD that they have experience with, and to create a meaningful KASPAR intervention using the template. Participants then split up in smaller subgroups to work on a new intervention. The allocation of people to groups was done in a rather organic manner; people seemed to gather around a common theme/idea rather easily; so the creation of groups happened spontaneously based on the topic for the intervention. In all the subgroups, a researcher was present to guide the brainstorm process and answer potential questions. At the end of the session the subgroups gathered around the big table again and presented their interventions to the entire group in order to receive feedback and suggestions for improvement of everybody. Every group delivered at least 1 new intervention for robot KASPAR based on and written down on the intervention template.The three sessions where organised at an inspiring venue. The session started with a welcome and introduction part in a group setting. After the introduction, people started the group work on different dedicated tables in the same room. The composition of the groups  was multidisciplinary; such as professionals being teachers or ASD therapists/caregivers, individuals with ASD, parents of children with ASD and partners of people with ASD. In total 22 people participated  after the session to prepare them for the analysis and further implementation as actual scenarios to be developed in the actual robot.The person who accompanied that particular subgroup discussion during the session performed the data analysis, not to miss the context and depth of the discussions that took place when creating these interventions. The data analysis was rather straightforward for these interventions since no actual analysis took place on the content of the interventions, but merely an understanding was necessary in order to implement these into the robot platform.First the requirements for KASPAR mediated interventions and the intervention template are presented and subsequently the new KASPAR interventions made during the co-creation sessions are described.The intention was to elicit factors that are crucial for a meaningful intervention  rather than ‘only’ understanding technical robot requirements. As a result, the focus groups delivered a number of different categories of requirements for KASPAR mediated interventions. Table This section presents the requirements with respect to various aspects of the robot.KASPAR’s looks were important according to professionals. They mentioned that KASPAR needs to look cool. He needs to get a set of cool and nice different clothes suitable for different seasons and weather types. When choosing clothes they mentioned to pay attention to the texture of and prints on the clothes. Some children might get an overload if there are a lot of colours, prints or images on clothes. Moreover, KASPAR needs attributes as well that can boost a cool image that children can identify with, such as a cap (that he could wear backwards) and maybe (sun) glasses. When the lesson in the classroom starts, KASPAR has to take of his cap and sunglasses, just like the children. By changing KASPAR’s clothes one can use him in a different context or different role. Some professionals asked if they can change his hairdo and some asked if there is also a girl version of KASPAR.With this hairdo he could be a girl, while he has the voice of a boy.—Adult with autism, who has a partner and children with autism.please try this again). If KASPAR will use other sounds than his own voice (e.g. a song), he should always announce this first using his own voice (i.e. I will now play a song for you).A few professionals indicated that for some children it would be good if KASPAR would get the voice of a recognisable person for them (e.g. mum or dad) in the beginning and that KASPAR would then get another voice later. However, more professionals suggested to use an artificial voice from the start. This can be a computerised voice as long if this does not sound too artificial, jerky, canny or robot-like. This voice should be soft in nature and sound friendly not to scare them. The sentences KASPAR utters should be short to increase understanding. The talking speed should be rather slow. If the children make a mistake, or if something does not go as well as hoped, KASPAR should give a positive reaction in a neutral voice, without an angry tone . Many professionals mentioned their expectations with respect to the use of all kinds of songs. This will give them joy and might very well stimulate interaction between children, since many children love music and react positively to it.Parents imitate unfamiliar sounds as well. What sound does the dog make? Waf, Waf. And the cat? Miauw, miauww…I think KASPAR should indicate that he will produce these sounds.—Adult with autism, who has a partner and children with autismImagine a child goes on a school trip. KASPAR can say “I heard you are going on a school trip, I know some sounds that you will hear there, shall I let you hear them?—Adult with autismProfessionals indicated that they need some training to be able to operate KASPAR during the session and to be able to create new scenario’s tailored to the specific needs of a child. They indicated that it should not take a lot of time to get KASPAR up and running before a session since they are already very busy with many things in a classroom or therapy setting. Also they expressed relevance for being flexible in changing KASPAR’s settings or behaviour when the situation demands improvisation. The behaviour of children can hardly be predicted. It is desirable to be able to fine-tune some KASPAR aspects rather easy and quickly if needed.Professionals indicated that KASPAR should behave in a consistent, clear, playful and accessible manner of interacting with children. When KASPAR moves his body parts, one can hear a sound of the motors being activated. Professionals expected that this might distract some children. They suggested not to use too much movement and speech at the same time since this might cause an information overload for children. KASPAR should either move or speak first, then do the other thing, so that children only have to pay attention to one aspect at the same time. In this sense, the amount of simultaneous stimuli needs to be limited as much as possible.Some professionals suggested it would be good if KASPAR could fetch, grasp, manipulate or hold objects. In that case he would be able to make a difference between pinching and caressing a cheek for example. At this moment KASPAR’s fingers are fixed, they cannot move separately from each other. It was suggested a number of times that it would be interesting if KASPAR could make gestures and use sign language rather than verbal commands only since quite a share of these children have no or limited verbal skills. KASPAR could then also point to things. Similar as with the use of sounds, KASPAR should not start to move in a very abrupt fast manner as it might scare children. If he was sitting without moving for a while, the start of the movement should be gradual and smooth.Professionals had ideas to integrate KASPAR in other activities or give him objects or tools that they can work with. They mentioned KASPAR could get different attributes such as glasses, or musical instruments and use materials from other methods. For example, by dressing KASPAR up in a police uniform, he gets a different role as when he wears a sporty outfit.Obtaining a clear insight on who would be a suitable target group for KASPAR should be learned from ongoing work and experiences according to the professionals. However, quite some of them immediately had particular children in mind when they were thinking about for whom KASPAR could be of added value. These are some examples that give an indication of children they could see benefiting from KASPAR; i.e. children who:have a strong need for proximity and prompting;experience difficulties making contact or are anxious in nature to engage in contact with other people;have difficulties with the unpredictable nature of people and peers in particular;have a kind of urge for ‘safe’ discovery (and like action-reaction interactions);might have limited verbal skills or (other) difficulties to express themselves with words;have difficulties relating to social-emotional or communicative aspects;feel confident and excited using technology;seem to be in ‘their own world’;are from around 4 years of age and older . Professionals expected that it is not so much the biological age that defines the KASPAR target group, but rather the socio-communicative–cognitive development of the child;have a cautious attitude and do not  engage in interaction with humans;experience problems related to attachment.Some professionals also described children for who KASPAR would probably not be a success in their eyes. Some children (or adolescents) might not consider KASPAR as being “cool” or may be applicable for young(er) children only. For others KASPAR might not be an appropriate choice because of their high activity level, high ‘aggression’ levels or because they are easily bored.—Adult with autism, who is a professional as well and has a son with autism (Asperger)I showed a picture [of KASPAR] to my son, who has Asperger who said: “why don’t you give me a normal robot that I can use, this is not a real robot but a doll.Some professionals saw possibilities of using KASPAR in a group setting, for example in the middle of a classroom where all children sit in a circle around the robot. When they suggested individual sessions, they referred to a quiet, calm and peaceful room where there are very little distracting (sensory) stimuli or triggers outside the classroom.Working with KASPAR demands some requirements from the professional  according to the participants:professionals need basic instructions on how to operate KASPAR;some  professionals need to know how to make new scenario’s using KASPAR’s configuration software or how to fine-tune/modify existing ones.Professionals with varying backgrounds are proposed to be working with KASPAR as he can be used for different therapy and educational objectives. Professions such as a speech therapist, an occupational therapist, a teacher, pedagogical staff, a physiotherapist, a play therapist, psychologist and also parents have all been suggested as potential end-users. It is important that they have knowledge of and are experienced in working with children with autism and that they can see how to move to transfer and generalisation of required knowledge or skills step by step. Several characteristics and skills have been suggested to be important, such as being very alert and aware, knowledgeable about and attentive to the child and understanding how to dynamically control KASPAR in a proper manner, having an open mind to use new technology, having a positive and enthusiastic attitude and nature, seeing opportunities rather than problems in trying new ways of working with these children, feeling confident that they can work with KASPAR, and last but not least, being able to use their professional intuition and creativity. The professionals expected that the person operating KASPAR is a huge determiner of the success of the interaction and thereby of the intervention. It is recommended that over time children work with different, but not too many professionals (after the child feels at ease) in order to stimulate generalisation and transfer.It will depend on what you put in as a teacher or therapist. The success of it is not only dependent on the child, it will actually be a result of various skills of the person operating KASPAR.—Teacher at special needs schoolI think you ask quite a bit of a teacher working with such a vulnerable target group to let go and try something new. We will have to see what the effects are. Being brave to step back a bit in the interaction and put something else in between.—Teacher at special needs schoolIntegration was mentioned very often during the sessions as being crucial for a proper implementation of robot-mediated interventions, meaning that KASPAR should not function as a standalone platform, but its use should be integrated in common practices. It is crucial to integrate the work with KASPAR in the overall education/therapy plan of the children. Often schools or care organisations work with an individualised therapy/education/care plan that describes what learning objectives the focus is on for a particular child for the upcoming weeks or months. Based on this personalised plan, education or therapy actions will be taken by professionals. Each child has his/her own plan which is updated regularly. Professionals indicated that when KASPAR is used therapeutically, it has to be part of a conscious decision of knowing for which children KASPAR will be used, what objective(s) to work on, how, when, where, how long and often, and by whom. This all has to be documented  in the individualised plan as any other intervention. KASPAR is considered to be simply another means, a tool that professionals have at their disposal that is imbedded in the plan and protocols, not used in an ad hoc manner. It is envisioned that there will be kind of “KASPAR scenario library”  from which can be chosen depending on the needs of the particular child at that moment.Finally, time is crucial. Professionals stressed the need to give the children the time they need to get used to KASPAR. Changes are difficult for children with autism and they normally take quite some time to accustom to new situations. Time is also required for the professionals who have to learn how to work with KASPAR.Professionals argued that on an organisational or management level a vision needs to be developed and deployed on how to implement and use KASPAR. This plan and strategy prevents KASPAR to be used in an ad hoc manner without relevant effects. This entails aspects such as ensuring proper  communication, training, planning, and adequate allocation of resources.It will be crucial to have realistic expectations of this [KASPAR interventions], that we see it as a tool and not more than that. This is important because we do not want to present it as thé Holy miracle solution that makes promises but then creates a disappointment.—ASD therapy expert and coachProfessionals mentioned it is important to inform parents of the children that will be interacting with KASPAR and maybe even (actively) involve them and ask their feedback or help in optimising the use of KASPAR for their children. Professionals suggested that parents might provide situations that are difficult for their children that can function as training situations in a KASPAR session. Moreover, it was suggested that possibly on a longer term (some) parents might also become users of KASPAR in the home environment. Furthermore, according to professionals it was crucial that there is a kind of feedback and learning loop between and from the professionals who work with KASPAR to the rest of the team to share the experiences and ideas.Participants distinguished between aspects that are important factors in using KASPAR in different phases in the intervention trajectory: training, introduction, session preparation, actual usage and evaluation. They indicated that the person(s) who will work with KASPAR and the children receive a proper training on how to configure, prepare, and use the robot. According to them, part of this training should include a number of hours practice with KASPAR before they are actually going to use it in a session with children. Training should contain a technical component of how to set-up and operate the robot. Besides this, participants suggested that also a social interaction component is crucial for developing a feeling and skill to ‘read’ the child and being able to provide prompt KASPAR (re)actions. In their view, training and practicing are crucial to be able to create success experiences, both for the children and the professionals.You can place KASPAR in a room and do nothing, the child will notice him, and you’ll see immediately if there is interaction or not…because if he will be introduced formally then you bring in the anxiety factor as well for something unknown, while if you can explore yourself you know best what you want and don’t want—Adult with ASDintroduction many professionals suggested to place KASPAR on a table in a room and let the children approach him in their own pace and own preferred way. They compared introducing KASPAR with mastering the art of simplicity in the beginning; exposing a child to a fully equipped and completely extensively programmed robot will probably create adverse effects. Rather, they suggested to dose more interaction/initiative from KASPAR in a slow and step by step way, in a manner that matches the needs of the child. They stressed the importance that the child has the freedom and time to explore KASPAR for him/herself and decides if and how there will be interaction in the first moments. The amount and intensity of the triggers  that KASPAR gives shall be gradually adjusted by the professional according to the needs and capacities of the child. Participants reported that, for some children this might be a matter of some days, while others may need weeks or even months to get familiar and at ease with KASPAR. Others might not like interaction with KASPAR at all, which is fine as well.For the session preparation will be done in which the professional decides on what objectives (s)he will work on that day with KASPAR for whom and what scenarios are needed. Fine-tuning and adjusting scenario’s will be done during the preparation phase as well, according to the needs of the children that will take part in the KASPAR sessions. Professionals suggested to create and use a dedicated symbol for KASPAR in line with the Picture Exchange Communication System (PECS) method that these children work with in their day structure. The KASPAR symbol would then be placed in the day structure/-programme of the child, so that the child also knows that there will be a session with KASPAR that day and when. Besides this, they stressed that in the planning of the professionals it is assured that also other professionals are available to work with the group of children while a trained KASPAR professional works with one or a small group of children in a dedicated KASPAR session.After the introduction and training took place, participants stressed a number of important aspects in preparing for each session. When getting ready for the day the During the actual usage, conscious experimentation and adaptation will be needed in the views of the participants to learn what works for a particular child and what not once the child received a basic KASPAR training. They expected that the success of the intervention will depend on how the child reacts, but also very heavily on the way the professional is able to control KASPAR in the interaction. Professionals should guide the children through the interaction, build up the sessions in a pace that matches the needs and capabilities of the child, and be attentive to prevent sudden abrupt moves, actions or sounds of KASPAR. Participants expected that the duration of a session will vary per child and possibly also per phase in the intervention. To increase chances for transfer/generalisation, KASPAR should be used in different rooms, according to participants, at different moments and by different people at appropriate times.Creating (regular) evaluation moments is suggested, both with the children to learn more about their experiences as well as with professionals using KASPAR and their management. Possibly one can consider recording some sessions in order to learn from experiences. Moreover, celebration of success moments was expected to be crucial as well.Professionals saw possibilities for using KASPAR in different kinds of sessions; individual sessions like a 1-1-1 setting , a group session , or in a 2/3-1-1  setting. With very young children KASPAR might be used in a ritual in a group to start the day; this creates a safe and predictable moment. For a large number of children they expected to be working in individual sessions (since these children have difficulties functioning in group settings).I feel very curious, you will have children with whom I want to work very goal oriented, and there are also kids of which I simply would love to see their reaction.—Teacher at special needs schoolAnother distinction that was made is the degree of structure in the session; it can be a rather free explorative session, semi-structured, or structured. In all three cases, professionals stressed that if the child is not interested (anymore) in KASPAR, the session will be stopped, persuasion of the child to continue is absolutely out of the question.With respect to the duration of KASPAR sessions, professionals suggested to make it rather short time frames to match the attention span of the children with autism .Insights gained from the focus groups as well as findings  from previous work  are used that show an activity/task and these actual activities/tasks are stored in separate baskets. In this intervention KASPAR will help the children to work more independently using this picto/basket system by giving step by step instructions, prompts for working on the task and positive reinforcements to reward their behaviour. The entire intervention  can be seen in “Appendix Based on the input gathered at the session, the intervention template was further refined (e.g. use of better wording) and also a girl version of robot KASPAR was created since multiple professionals indicated this would be desirable see Fig. .Moreover, participants suggested that KASPAR should also be able to give a “thumbs up” to reward children in a non-verbal manner. This was created as well (see Figs. The aim of this study was to gain understanding on how to implement robots in interventions for children with ASD. Highlighting a case for the use of robots in interventions for this target group was made decades ago, but actual use is still scarce. We intended to contribute to an increase of awareness and insight on how to actually embed robots in current education and/or therapy practices. The approach was to involve a large number of ASD practitioners and other stakeholders in the field, including people with ASD and parents of children with ASD, in focus groups as well as in co-creation sessions.Results indicate that besides requirements related to the robot itself such as appearance, the use of voice and sound, the operation, the robot’s behaviour and a robots attributes/toolbox, many other factors need to be taken into account. Personalisation to the needs of the individual child at hand is the main message. Keeping that in mind, it is clear that the look and behaviour of the robot is a crucial aspect, but also the role of the professional, the environment, and educational and organisational integration will be key in actual implementation in practice.These results are in line, yet go beyond other published work on robots for children with autism that often tends to focus on human robot interaction matters. The utmost importance as well as a sense of urgency for robot research to be sensitive and adhere to end-users’ requirements and to grow closer towards clinical integration into robot-mediated-interventions has been clearly argued in a number of recent publications (Cabibihan et al. The adoption of this iterative multidisciplinary co-creation approach is expected to contribute to qualitative and meaningful robot interventions. This study provides a tool, the robot intervention template, for systematically developing and implementing new robot interventions and can contribute to an increase in awareness and the creation and uptake of robot assisted interventions for children with autism. It can be used by both professionals, stakeholders and engineers, for many different robot platforms, not only for KASPAR.Although the study has reached its goals, some limitations should be taken into account. First of all only participants from The Netherlands were included in the study which might hinder generalisability because other countries might have different practices in place regarding care or education for children with ASD. On the other hand, it is expected that when considering the heterogeneous nature of ASD, involving more than 75 participants covers a wide range of knowledge and experiences on ASD. Additionally, ideally, we would have immediately implemented the co-created interventions in KASPAR and would have like to test it in practice rather quickly to evaluate the applicability of these interventions. However, technical implementation of the interventions in the robot, practically training professionals to operate the robot themselves as well as assuring approval of medical/ethical committees is needed before we can actually test these interventions with children with autism.The heterogeneous nature of ASD causes a demand for different and multiple treatment or interventions for different children. There seems to be consensus that a “one-size-fits-all” solution for all children with ASD does not exist (Stahmer et al.


This article is aimed at researchers interested in organic molecules which contain a heteroatom but who have never considered using inductively coupled plasma mass spectrometry (ICPMS) or who have used ICPMS for years and developed numerous methods for analysis of target elemental species. We try to illustrate (1) that ICPMS has been very useful for speciation analysis of metal(loid) target species and that there is now a trend to replace the costly detector with cheaper detection systems for routine target analysis, and (2) that ICPMS has been used and will be used even more in the future for non-targeted analysis of elements which are not normally associated with ICPMS analysis, such as non-metals such as sulfur, phosphorus, chlorine and fluorine. What is speciation? This has been clarified in the IUPAC definition: the speciation of an element means the distribution of an element amongst defined chemical species in a system. Chemical species are defined as chemical elements: the specific form of an element is defined as to isotopic composition, electronic or oxidation state, and/or complex or molecular structure . HoweverThe speciation community arose mainly through the rise of atomic spectrometry and in particular elemental MS; that is, inductively coupled plasma MS (ICPMS). The ionization source of an argon plasma is so powerful that that no species information on the introduced molecule remains. Although it sounds like an oxymoron, this is exactly what makes ICPMS the ideal detection method for speciation analysis. The detector, however, needs to be coupled to something which is selective to the nature of the molecule rather than the elements in it. Since the early 1990s, classical methods for separating molecules such as chromatography [high-performance liquid chromatography (HPLC) and gas chromatography] have routinely been coupled with ICPMS, which acts as an element-specific detection method , 4. ElecHowever, ESI-MS by itself has not had the impact ICPMS had in the area of speciation analysis, although the technique can be more sensitive than ICPMS. The reasons are firstly that for the quantification of elemental species, species-specific standards are needed because of the ionization of the compounds being compound specific. Secondly, the signal intensity of a compound can dramatically be reduced when an easy-to-ionize compound is co-eluting with the compound in question. The latter can be addressed by separation of the compound of interest from the matrix by use of multidimensional chromatographic systems in which at least two or three different separation modes are combined  or by usIn contrast to ESI-MS, detection of heteroatom-containing compounds by ICPMS is easy, and that is why ICPMS became a very useful tool for non-target analysis of elements. It is particularly useful when combined with ESI-MS. But not only can ICPMS help find the “needle in the haystack” in the big data sets from ESI-MS, it can also be used for mass balance approaches because of the compound-independent element-specific response, which makes the quantification of novel compounds possible, often without direct knowledge of the molecular structure. It should be mentioned, however, that when a solvent gradient is used especially with organic solvents such as methanol, the response factor of the element can change during the chromatographic run and needs to be corrected as explained in more detail by Amayo et al. . All theBespoke methods for robust quantification of target elemental analytesNon-targeted screening methods for identification of novel chemistry in biological and environmental sciencesExamples of ICPMS use in speciation analysis can be divided into two main areas Fig :Fig. 1ChThis area of speciation has been the focus of significant method developments. Species-specific isotope dilution methods have been described for tributyltin , methylmFor arsenic, the situation is more advanced. Speciation of arsenic is now integrated in legislation : a maximSimilar developments can also be seen for methylmercury, and these developments can, with the aid of preconcentration methods, easily be used for accurate determination of methylmercury at background-level (low parts per quadrillion) concentrations in HPLC–cyclic voltammetry–atomic fluorescence spectroscopy . This isWhen environmental and biological processes of a certain element rather than an established target species are the focus of a specific study, then it is important to understand how the different molecular forms of the element interchange in the system studied. Hence, it is necessary to identify all the different molecular forms of this one element in the sample. This means that we need a non-targeted speciation analysis which looks at all elemental species of the element studied. This type of non-targeted analysis is, however, more focussed than the classical non-targeted studies in metabolomics in which the information from the entire mass spectrum is used and only chemometric methods can unravel the importance of individual molecular species. Therefore, we should label these as selective non-target analysis, another oxymoron, but we feel that this describes it well, since the selectivity comes from looking at the molecules which contain one specific element only.The non-targeted analysis of elemental species using mainly HPLC–ICPMS can not only identify the wealth of different molecular forms of an element but can also be used for mass balance approaches Fig. , since tWhen the redox chemistry and the organic chemistry of an element are as diverse as they are for selenium or arsenic, where hundreds of different molecular forms of these elements are known to occur in biota, then the simultaneous use of ICPMS and ESI-MS for a chromatographic separation is vital. Not only can the species be quantified (ICPMS), it can also at the same time be identified with use of use the ESI-MS data at the time the elemental species is eluted from the column according to the ICPMS signal. With use of this concept, a whole series of unstable arsenic, mercury and selenium phytochelatin or glutathione species have been identified which seem to be important for the transport mechanisms of these elements in plants , 31.Predominantly, main-group elements which form a stable carbon bond have been studied with this approach, because the elemental species are relativity stable and can be separated by liquid chromatography. Non-targeted speciation studies of arsenic, selenium and in part mercury have dominated the literature in the past decade simply because there is a plethora of possible species and the analytical method used (here HPLC–ICPMS) can in general guarantee their stability .Transition elements only rarely form stable carbon bonds . These elements are, however, key essential elements in larger molecular compounds such as metalloproteins. The stabilities of the element–protein bonds often depend on the ternary structure of the protein, which means that their stability during sample preparation and separation is often compromised because of the denaturating non-cytosolic conditions used for extraction/cleaning or preconcentration steps. Additionally, complexation of metals by small organic molecules is important for metal trafficking and homeostasis in cells. However, that knowledge is obtained from molecular biology methods and crystal structures rather than from the use of HPLC–ICPMS.The instability of these transition element complexes can, however, be overcome, as a recent study by Ghssein et al.  on nickeThere is, however, a warning sign for non-targeted speciation analysis, and that is the possibility of analytical artefact formation. Since no information is available on the elemental species in the sample, it is impossible to validate analytical results with the usual approaches, such as use of isotopically labelled elemental species or other orthogonal methods such as X-ray absorption near-edge spectroscopy or extended X-ray absorption fine structure spectroscopy. Therefore, species integrity cannot be guaranteed nor can it be known if the detected species are formed in situ during the sample preparation process.Some elements have rarely been studied by non-targeted elemental analysis despite their forming a large number of biological important compounds . Among tm/z 35 and 37 with use of ICPMS–MS and hydrogen as the reaction gas can result in sub-part-per-million detection limits: for example, chlorine was measured as H2Cl+ [Most chlorinated pesticides are volatile and are analysed with relatively selective detectors such as an electron-capture detector, but the use of electron-capture detection for non-targeted analysis is limited to volatile compounds. Chlorinated compounds can, in principle, be identified from ESI-MS data and their isotopic pattern, but cannot be quantified without species-specific standards. Although chlorine is not efficiently ionized in the argon plasma  of the ICPMS system, elimination of the polyatomic interfering ions of as H2Cl+ . Schwan as H2Cl+  separate+. Screening of standard compounds by high-resolution ICPMS has been attempted, resulting in detection limits at the high parts per million level. These detection limits are, however, not low enough to measure background levels of perfluorinated compounds in environmental and biological samples. We have investigated the formation of polyatomic fluorine ions (such as BaF+) in the plasma, which can be used for the indirect detection of fluorine by ICPMS–MS and can be coupled with HPLC for fluorine speciation [- and/or atomic F0 form polyatomic ions such as BaF+, which can be detected in trace concentrations (micrograms of F per litre range). This method has not yet been applied to environmental samples for speciation, but for total fluorine it looks promising [The situation for fluorine speciation seems, however, to be different. There are more than 2000 organofluorine compounds, mainly perfluorinated, registered by the chemical industry because of their interesting properties such as hydrophobicity and lipophobicity. Since these compounds are not biodegradable, the most prominent compound, perfluorooctanesulfonic acid, has been banned by the Stockholm Convention for further use. Hence, the analytical community developed targeted analysis for 10–15 perfluorinated compounds using isotopically labelled standards with HPLC–ESI-MS detection . Althougeciation . Organofromising . In thisromising . HoweverThere is evidence that study of the elemental species which are studied by the analytical community is driven not necessarily by need but more often by instrumental capabilities. Many articles about arsenic speciation exist and are published on a weekly basis without driving the field of arsenic speciation forward, whereas there is a real need to understand ligand–metal interactions, especially for essential elements. But those elemental species often remain elusive because of the lack of stability outside cytosolic conditions, whereas an entire community of environmental scientists interested in perfluorinated compounds is looking for a selective non-targeted analysis method for fluorinated compounds. We expect that ICPMS systems, in the long term, will be replaced by dedicated instruments for target species, whereas fundamental studies and applications are expected for non-metal non-targeted analysis, with a focus on sulfur, chlorine and fluorine speciation.


MET have been detected in non-small-cell lung cancer (NSCLC). However, survival benefit of MET inhibitors remains controversial. We performed this meta-analysis to evaluate the survival benefit of MET inhibitors combined with an epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) or standard chemotherapy in patients with advanced or metastatic NSCLC. A systematic computerized search of the electronic databases was carried out. From seven studies, 2,577 patients were included in the meta-analysis. Compared with patients in the placebo group, patients who received an additional MET inhibitor did not show significantly improved progression-free survival (hazard ration (HR) = 0.92 [95% confidence interval (CI): 0.79–1.08], P = 0.33) and overall survival . In the subgroup analysis, patients with MET-high NSCLC tended to show longer survival when treated with an additional MET inhibitor than those in the placebo group . In conclusion, this meta-analysis indicates that the addition of a MET inhibitor to an EGFR TKI or chemotherapy has no survival benefit over placebo in patients with advanced or metastatic NSCLC. Although patients with MET-high tumor tended to show better survival, further studies to explore more specific biomarkers are warranted to identify ideal candidates for MET inhibitors in NSCLC.The alterations of  Lung cancer is the leading cause of cancer-related death worldwide , 2. MostMET and the tyrosine kinase receptor for HGF , P = 0.97)  and the fixed-effects model was adopted. In the subgroup analysis according to drug types, neither onartuzumab  nor tivantinib  showed OS benefit when added to erlotinib or standard chemotherapy , patients who received a MET inhibitor did not show survival benefit compared with those in the placebo group  Figure . There wy Figure  and 3C.P = 0.90) . In terms of OS, however, patients who received a MET inhibitor tended to show longer survival than those in the control group  .From five studies –31, 34, ) Figure . The ran) Figure . The ranVisual inspection of the funnel plots for PFS and OS showed symmetry, indicating there were no substantial publication biases Figure  and 5B.In this meta-analysis, we evaluated the survival efficacy of MET inhibitors (onartuzumab and tivantinib) in patients with advanced or metastatic NSCLC. The results indicate that the addition of a MET inhibitor to an EGFR TKI (erlotinib) or chemotherapy has no survival benefits over placebo in the intent-to-treat (ITT) population. To our knowledge, this is the first meta-analysis regarding the efficacy of MET inhibitors in patients with NSCLC.MET amplification has been associated with acquired resistance to EGFR-TKIs in EGFR-mutant NSCLC [P = 0.04) and OS  in patients with high level of MET expression, highlighting the importance of identifying biomarkers in drug development. Based on the results of this trial, the global phase III study (METLung) was conducted in patients with previously treated stage IIIB or IV MET-high (MET IHC 2+ or 3+) NSCLC [P = 0.92) and OS . Subgroup analysis did not identify any prognostic factor to expect patients benefiting from addition onartuzumab to erlotinib. Based on promising early-phase results, two randomized phase II trials evaluated the efficacy of onartuzumab when added to first-line platinum-based chemotherapy for patients with squamous or non-squamous NSCLC [There has been a strong rationale behind the trials of MET inhibitors in NSCLC. Increased MET signaling is linked to a worse prognosis for NSCLC –22. A grnt NSCLC , 25. Onant NSCLC . However+) NSCLC . Patientus NSCLC , 31. TheP = 0.24), the potential efficacy was demonstrated, especially among patients with KRAS mutations . Then, two phase III trials (ATTENTION and MARQUEE) investigated the efficacy and safety of tivantinib combined with erlotinib in patients with previously treated advanced or metastatic non-squamous NSCLC [P = 0.019), the study failed to improve OS , regardless of MET status. The western MARQUEE study also failed to meet its primary endpoint of improved OS , despite significant improvement in PFS . Interestingly, however, the exploratory analysis indicated PFS  and OS  benefit with tivantinib in the subgroup of patients with MET-high status.Tivantinib is a selective, oral, non-ATP-competitive, small-molecule inhibitor of MET. A Western randomized phase II study (ARQ 197–209) investigated the clinical benefits of tivantinib combined with erlotinib in patients with previously treated NSCLC . Althougus NSCLC , 34. TheP = 0.33) and OS  in the ITT population. Several plausible hypotheses may explain reasons for these negative results. First, although preclinical data have suggested the crosstalk between MET and EGFR [MET amplification in the development of resistance to EGFR TKIs has been observed mostly in patients with EGFR mutation [EGFR wild-type NSCLC. In our meta-analysis, patients with EGFR mutations in the experimental arm accounted for only about 10% of the patients tested. Thus, it is unlikely that this small proportion of patients would have driven OS benefit when treated with an additional MET inhibitor. Second, although activation of MET pathway can come from MET gen amplification or mutations [MET is the most frequent case in NSCLC. Therefore, there might be difference in the anti-tumor activity between MET monoclonal antibody and MET TKI. In the subgroup analysis, however, neither onartuzumab  nor tivantinib  showed OS benefit when added to erlotinib or standard chemotherapy. Third, MET protein overexpression might not be the best predictor for MET inhibitors in NSCLC. In the METLung study of NSCLC with high MET expression by IHC, the addition of onartuzumab to erlotinib failed to prolong OS over placebo . In the subgroup analysis of our study, patients with MET-high NSCLC tended to show better OS  when treated with an additional MET inhibitor. However, there is a need to identify more specific biomarkers for defining the subset of patients benefiting from MET inhibitors. MET overexpression is considered a late event consecutive to the transformed phenotype, deriving from transcriptional up-regulation of MET in absence of gene amplification or mutations or ligand-dependent autocrine or paracrine mechanism [MET exon 14) or high level of MET amplification lead to significant response to MET inhibitors [MET mutation or MET true amplification may represent a better marker to select patients for MET inhibitors, especially MET TKIs.In the current meta-analysis of those randomized trials, the addition of a MET inhibitor to erlotinib or standard chemotherapy was not associated with significantly improved PFS  and received different combining agents (erlotinib or chemotherapeutic agents with/without bevacizumab) in various treatment settings . Third, one study had no IHC criteria for high MET expression. Finally, we did not include “crizotinib” which was initially characterized a TKI of MET in the search process. To our knowledge, however, there have been no randomized trials in patients with anaplastic lymphoma kinase (ALK)-negative NSCLC.In conclusion, this meta-analysis indicates that the addition of a MET inhibitor to an EGFR TKI or standard chemotherapy has no survival benefits over placebo in patients with advanced or metastatic NSCLC. However, patients with MET-high tumor tended to show longer survival when treated with an additional MET inhibitor. Translational studies to explore more specific biomarkers are warranted to identify ideal candidates for MET inhibitors in NSCLC.We performed this study according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . A systeEligible studies should meet the following inclusion criteria: (i) studies were conducted in patients with NSCLC; (ii) randomized placebo-controlled trial; (iii) randomization of patients to systemic anti-cancer therapy (chemotherapy or targeted therapy) with or without a MET inhibitor. (iii) HRs and 95% CIs for PFS or OS were reported or could be estimated from the data provided; (iv) articles were written in English.Data extraction was carried out independently by two investigators (BJK and HSK). If these two authors did not agree, the principle investigator (JHK) was consulted to resolve the dispute.The following data were extracted from the included studies: first author’s name, year of publication, number of patients, treatment arms, methodology to test MET status, the criteria used to dichotomize MET expression as ‘high (positive)’ or ‘low (negative)’, and HRs and their 95% CIs for PFS or OS.Q statistic and the I2 inconsistency test. The fixed-effects model (Mantel–Haenszel method) was selected for pooling homogeneous outcomes (P ≥ 0.1 and I2≤  50%), and the random-effects model (DerSimonian–Laird method) was applied in the absence of significant heterogeneity (P   <  0.01 and I2 > 50%).Statistical values were obtained directly from the original articles. When papers had no HRs and their 95% CIs, the Engauge Digitizer (version 9.1) was used to estimate the needed data from Kaplan-Meier curves. The effect size of PFS and OS was pooled through HR and its 95% CI. The heterogeneity across studies was estimated by using P-values were two-sided, with P < 0.05 defined as statistically significant. Publication bias was assessed graphically by the funnel plot method [The RevMan version 5.2 was used to combine the data. The plots show a summary estimate of the results from all the studies combined. The size of the squares represents the estimate from each study, reflecting the statistical ‘weight’ of the study. Outcomes are provided as forest plots with diamonds representing the estimate of the pooled effect and the width of diamond representing its precision. The line of no effect is number one for binary outcomes, which depicts statistical significance if not crossed by the diamond . All rept method .


Dipyrone  is a non-steroidal anti-inflammatory drug commonly used both in human and in veterinary medicine. After oral administration, is broken down rapidly to metabolites which largely retain the activity of the parent drug. Its metabolites have analgesic, antipyretic and anti-inflammatory effects.p < 0.05) was proven in case: activated partial thromboplastin time; ratio of activated partial thromboplastin time; hemoglobin; hematocrit; mean corpuscular hemoglobin; mean corpuscular volume; red blood cells volume; white blood cells volume; prothrombin time index.The subjects were eight healthy male Large White post-suckling piglets, weighing between 5.0 to 7.4 kg, of ages 35 ± 10 days. The animals were administered MET (100 mg/kg) by an intramuscular (I.M.) injection. The study calculated the value of several hemorheological parameters. Significant impact of MET treatment  contains supplementary material, which is available to authorized users. The validation parameters that were determined through our work according to the LOO 4MAA↔ PT + [(Hb + Hct)/(RBCATT Pr atio)] generated the following values: Q2asym-Q2 = 0,063, Q2 = 0.8274, R2 = 0.8905, Q2-R2 = 0.0631, SS = 1573.36, PRESS = 271.57. At the same time, our work did not confirm the existence of the same dependency relation to 4AA↔ PT + [(Hb + Hct)/(RBCATT Pr atio)] (p > 0.05).As presented in the form of an arithmetic expression o)] Fig. , there wThe aim of the current study was a verification of piglets as a model reflecting changes in hematological parameters after a single I.M. injection of MET. Thrombocytopenia and pancytopenia after MET administration is related to bone marrow suppression. Mechanism covers drug-dependent suppression of the growth of myeloid progenitors, primitive multipotential progenitors and erythroid progenitors , 32. As Rhamdia sp. based studies . This relationship predictive value with respect to 4MAA, confirms the performed validation procedure. This means that hemorheological parameters after administration of MET may reflect the concentration of 4MAA in piglet blood plasma. Of note, the mechanism of the effect of the 4MAA on hemorheological parameters is significantly different from that of 4AA.In the course of the analysis, we have confirmed the existence of a 4MAA dependence↔ In our study, all the piglets showed tolerance to the dosages given out, and such high doses allowed to analyze precisely the impact of MET on hemorheological parameters. In our study, nine parameters showed significant differences to baseline. Most deleterious effect on blood parameters observed in current study were deep and prolonged decrease of PT and Hb concentration connected with decreased number of RBC. As in humans, the piglet model shown that MET and its metabolites contribute to significant increase of number of neutrophils. The resulting image changes converge to the observations that were noticed in humans. To sum up, our observations suggest that a piglet model is useful for studying MET and its metabolites impact on hemorheological parameters.