Pro-active assessment programs are increasingly used to improve care for older adults. These programs include comprehensive geriatric tailored to individual patient preferences. Evidence for the effects of these programs on patient outcomes is nevertheless scarce or ambiguous. Explaining these dissatisfying results is difficult due to the multi-component nature of the programs. The objective of the current study was to explore and explain the experience of older adults participating in a pro-active assessment program, to help to clarify the effects.Semi-structured in-depth interviews were held with 25 participants of a pro-active assessment program for frail community-dwelling adults aged 65+. This study was part of an evaluation study on the effects of the program. Transcripts were analysed with thematic analysis and cross-case analysis.need for a holistic view which was covered in the program, (2) the scope of the CGA was broader than expected or unclear, (3) the program delivered unexpected but valued help, (4) participants described a very low sense of ownership, (5) timing of the program implementation or the CGA was difficult and(6), participants and care workers had a different view on what to consider as a problem. These experiences could be explained by three program components: the degree of (the lack of) integration of the program within usual care, the pro-active screening method and the broader than expected, but appreciated multi-domain approach.The participants’ mean age was 78.5 (SD 6.9) and 56% was female. The majority of the participants were satisfied with the program but based this on communication aspects, since only a few of them expressed real program benefits. Participant experiences could be clustered in six themes: (1) All participants expressed the Older adults’ need for a holistic view is covered by this outpatient assessment program. However, their engagement and the correct timing of the program are hampered by the pro-active recruitment and the limited integration of the program within existing care. Furthermore, satisfaction seems an insufficient guiding factor when evaluating CGA programs for older adults because it does not reflect the impact of the program.The online version of this article (10.1186/s12877-018-1025-7) contains supplementary material, which is available to authorized users. Traditional ways of organizing health services are often unable to meet the heterogeneous needs of older adults with multi-morbidities . AffordaOne common element of integrated care is the Comprehensive Geriatric Assessment (CGA) . A CGA iThese outpatient assessment programs have been extensively researched, however studies have shown inconsistent effects on clinical outcomes  and scarOne important perspective influencing the implementation and effects of programs is the consumer perspective  – in thiAs part of an evaluation study into the effects of the outpatient pro-active assessment program Sage-atAge, we conducted qualitative, semi-structured interviews into the experiences of older adults participating in an outpatient pro-active assessment program. We complied with the COREQ checklist in conducting and reporting this study . For detn = 708). The CGA consisted of a consultation with a geriatric nurse or elderly care physician  and about how we looked to the future: continue to live here, to live independently. But I actually did not have an image of how that would be. Well I answered her questions, and apart from that we just talked a bit.” P24 F“The scope of the CGA seemed unclear for the participants. They did not know what the CGA would be about beforehand, and they could not recall clearly what it had been about afterwards .“I: Did you have any questions for her? R: No. What could I ask someone like that? I don’t know. {}. Well, she just asked questions about the paper we filled in.” P19 FThough participants expected it to be broader than a consultation at the GP, they were unsure what to discuss within a CGA (D3). The program’s questionnaire seemed to be a barrier to bringing up new – more important – topics. .“I went into this process with the understanding of “you have been picked out. Would you like to participate in the study?” So then I thought okay, that's fine, I want to, not with the preconceived goal that they had to do something for me, or whatever, that developed in the course of the conversation.” P25 FThis can partly be explained by participants thinking the scientific goals of the project were more important than discussing their own problems (D6).“I went to [the ophthalmologist] and then they said “We can’t do anything for you anymore”. After two operations, on both eyes. {} {Then the Sage-atAge nurse advised to go to a vision-aid centre}. {} Then I thought, well, isn’t this something. You go to [the hospital], and they did not know what to do with me.” P22 F.Problems were discussed within the program for which the older adults had not yet sought or found help. This could result in unexpected revelations of (E1) and even to unexpected solutions to problems (E2).“Well, I didn’t know that [topics of conversation], you don’t know those beforehand, right? I had to indicate what I had. So, that’s what I did. I’ve just done what they asked of me.” P8 FAlmost all participants described their own role in the program as passive . They explained their role as ‘wait and see’, because the initiative for the assessment was not their own (F3). They tended to wait for the care workers to bring about subjects during the CGA .“And she [Sage-atAge nurse] told me what I already knew: {} “At some point I’ll report to your GP how I see things.” So, I assume that the report is with the GP. I have not been to the GP since this spring. And he has not been here either, so he probably won’t have discovered anything disturbing.” P15 MParticipants waited for Sage-atAge to schedule appointments when and whenever this was deemed necessary (F6). They expected the GP to be informed by the CGA nurse or physician (F7). Afterwards, they tended to wait for the GP to contact them about the advice given:“I: Will you see [the Sage-atAge nurse] again? P: Well, that wouldn’t be bad. And it may well be that we get another call, from this Sage with Age. It could be. {} I don’t know how it continues. No idea, but there might be a follow-up, or maybe they will ask in a year's time how it is going.” P24Participants almost never acted themselves whenever the expected action had not been carried out by the GP and CGA care workers . Furthermore, participants tended not to resolve their own questions regarding the program design .“I have not heard anything yet [no invitation for a CGA] I had also completed [the questionnaire] but then after that time I got that arrhythmia which I didn’t have before. I didn’t have much at the time and then all of a sudden there is something, right?” Spouse of P5 who was not invited to the CGA because of the absence of frailty on the self-assessment questionnaire.Participants stressed that timing of the program implementation or the CGA was difficult. They attributed this to the fluctuation of symptoms in time and concomitant health concerns (G1). The timing of the program components were therefore delicately balanced in three ways. For instance, occasionally symptoms had already changed or resolved in the time period between completing the questionnaires and attending the CGA (G2). Secondly, sometimes just after the CGA some important deterioration took place or the symptoms occurred only outside of the CGA .“Though I might need someone next week, or this week. But then I have to make an appointment during office hours again. And I find that difficult. I would just like to have someone whom I could call and say to them ‘Hey, I would like to get something off my chest’ or ‘Could you lend an ear to me’. I need that most and I find that with my friends {} but you know, I sometimes want something outside my circle of friends.” P25 FAdditionally, when symptoms had already been covered in other health appointments (or were to be in the future) this seemed to be a barrier for discussion during the CGA . Multiple participants advocated a personal counsellor for this timing difficulty. The latter was described as someone who could be contacted spontaneously with no prior planning for a broader range of problems than those considered appropriate for a GP, for example for reassurance or practical help .“Just gradually you start to put things into perspective again and then everything becomes a bit more common again. First you have to process it and then I think like: gosh we have so much, we have healthy children, we have healthy grandchildren, what more could you wish for? Life is not endless, we [all] have to leave here in the end.” P6 FThere also seemed to be a difference between the participants and the care workers in the definition of problems. The participants differed in four ways in their view on problems highlighted by the questionnaire or care worker. Firstly, they objected to problems revealed by the questionnaire . Secondly, it was sometimes questioned by participants whether problems on domains outside of the physical domain were part of the program scope. This meant these issues would not be expected to be seen as a relevant problem to discuss . Thirdly, participants seemed to stress less importance on preventive actions than care workers. . Finally, sometimes symptoms had been a burden some time ago and were therefore highlighted in the questionnaire, yet as participants had already adapted to them, it no longer seemed important to discuss them in the CGA .“Because sometimes there are a lot [problems]: because I always have a buzzing in my ear. They don’t look further into it. And I thought, well maybe something will result from it, that's why I thought it was fine. I: You had hoped that they might investigate the ear? P: Yes, everything actually. I have a swollen hand and swollen foot, I have pains in my legs every night. {} I went to the hospital several times, [they say:] “well there is nothing wrong with you”. Well, I thought they’ll look at it thoroughly and that was what I thought of the assessment. {} Yes, I really looked at it from a completely different point of view, let’s be honest.” P18These six themes explored the participants’ experience. When trying to explain the experience, the themes coalesced with three program components  in addition to the difficulty of signalling problems with the questionnaire. These problems were also neglected or not solved by care workers from existing care. They were hoping the program would offer a solution for these problems, but were also disappointed that the program was not able to address these problems. H9, H10).0.“BecauThe participant experience, was considered in light of the program design in order to provide an explanation for these experiences. We identified three program components which seemed to have a part in the participants’ experience.need for a holistic view that was expressed by the older adults. Secondly, it may, however, also be used to explain the participants’ confusion about the scope of the CGA. Thirdly, it could be a reason for the difference in the view on problems: the explanation why the care worker would focus more on prevention than the participant appreciated.Firstly, the program’s multi-domain approach attended to the expected help. Problems were discussed which had not involved a care worker to-date and where care was not expected (as yet). The pro-active induction had two drawbacks though. Firstly, it was often experienced as wrongly timed because of the dynamic of symptoms related to ageing. Secondly, it seemed to amplify the passive role of participants in the program: they experienced a lack of ownership with regard to the topics to discuss and in terms of adhering to advice.Another program component which seemed to influence the experience was the pro-active approach. The program was pro-actively offered to a(n older adult) population. This meant that the steer towards the CGA was led by answers on the screening self-assessment, more specifically, whether these answers complied with the CGA inclusion criteria. This is contrast to a consult or appointment where patients seek help themselves or are individually referred by their GP. This component had the positive effect of delivering unownership and the uncertainty about the scope of the CGA older adults did not prepare for the CGA and did not actively engage in the agenda during the CGA. Afterwards they sometimes felt important problems had not been discussed. The single contact with the CGA care worker provided a one-time opportunity only, which also caused friction with the timing of the CGA. Reaching consensus on the view on problems in this single contact was also troublesome. The lack of integration in the existing care structure was a barrier to implementing care after the CGA,. Because of the lack of ownership by the older adults, they did not carry out recommendations by themselves and waited for their GP.The third program component which seemed to influence the experience of older adults was the one-off aspect of the program and the way it was incorporated in the existing care processes. Due to the lack of In this article we described the experience of older adults with an outpatient assessment program and aimed to explain the coherence between this experience and program components. Although older adults expressed satisfaction this did not cover their whole experience with the program; they also expressed a lack of ownership in the program, experienced problems with the timing of the program, were uncertain about the scope of the CGA and their views on problems seemed to differ with the care workers. Importantly, the program seemed to address their need for a holistic view and delivered unexpected help.. In aiming to explain this broad range of experiences we found coherence with three program components: multi-domain approach, pro-active sampling and integration in usual care. By connecting the experiences to the program components we gained insight into potentially relevant factors for improving care for older adults.Similar to our findings, Darby et al. reported that satisfaction applied to the contact with the geriatrician within an in-patient CGA program, but it also appeared concurrently with a lack of understanding regarding the meaning of the intervention . For outthe view on problems between older adults and care workers. Extensive literature exists on the change in priorities given to problems experienced when ageing, [The participants appreciated the multi-domain approach of the program as they expressed a need for a holistic view. This need is in line with other research into the experience of older adults with regular health care  and inte ageing,  the decl ageing, , 36. ThiThis program, as most outpatient assessment programs, had a preventive strategy design. Our data showed that the advantage of pro-actively delivered care was the experience of unexpected help. This decreases patient delay: participants were not seeking help for their needs yet because they did not expect any result from a consult with their GP or medical specialist. Reasons provided by the literature for not seeking help for problems have attributed these problems to age  or beingThe difficulty of the pro-active strategy was the sub-optimal timing of the CGA that was experienced by participants. When disabling arises within the process of ageing, it is characterized by multiple and possibly interrelated disability episodes . Van HouAnother finding linked to the pro-active design was the lack of ownership the participants expressed. Lack of ownership is known to decrease commitment to goals and the chance of attaining goals , decreasThe care of Sage-atAge lacked proper integration with existing health and social care. The negative impact of this solitary aspect and (therefore) lack of control of the implementation of recommendations on the effect of a CGA was described in various research. In a long-standing meta-analysis, solitary CGA programs showed no effect , in contThe consequence of the solitary nature of the intervention is amplified by the CGA being a solitary consult lacking follow-up. For appropriate recommendations, adapted to the goals and needs of the older adult, more than one consult is commonly needed, as has been demonstrated in the shared decision making literature , 50.The qualitative design of this paper allowed us to reveal a coherence between experiences and program components, possibly explaining contradictory findings in intervention studies within CGA-research, and a broader insight than a survey would have provided. Two drawbacks of this qualitative study are nonetheless worth noting. Firstly, during the interviews participants repeatedly postulated a link between the interviewer and the Sage-atAge care workers. This could have introduced socially desirable answers. Nevertheless, numerous remarks and complaints about the conduction of the intervention were still voiced.Secondly, the findings might not be generalizable to outpatient assessment programs or CGAs with a different design than Sage-atAge, for example those with only one or two of the program components discussed. Further research could study these components separately in different CGA settings considering their effects on participant experiences and health outcomes.When the screening instrument revealed a ‘problem’ older adults were reluctant to considering this as a problem, even though they had marked the response on the questionnaire. There is possibly a discrepancy between the problems flagged by the questionnaire and the way older adults experience these problems. Questionnaires are increasingly used to guide care (pathways). Hence, more research is needed into these possible discrepancies.An outpatient assessment program fits into person-centred care, as it is able to meet the older adults’ need for a holistic view. Next to that, with its’ pro-active approach it is able to deliver unexpected help to some of the participants. However, the correct timing and engagement of older adults is hampered by pro-active recruitment and limited integration of the program within existing care. More attention needs to be paid to these program components and implementation strategies when designing and evaluating pro-active and person-centred care for older adults.Therefore, there seems to be a need for unscheduled availability of care workers working holistically and integrated within the standard health care of older adults. This was suggested by our participants and has been concluded in other research into the older adults’ perspective for improving standard care , 52.This study underlines that satisfaction seems an insufficient guiding factor when evaluating care programs for older adults as it appears to have no link with the experienced effects of the assessment program. Conversely, three program elements appeared to be of importance for explaining this experience: The multi-domain scope, the pro-active approach and the integration with existing care. These factors should be addressed when developing outpatient assessment programs and evaluation studies.Additional file 1:Detailed applied methodology following the consolidated criteria for reporting qualitative studies (COREQ) 32-item checklist. (DOCX 29 kb)Additional file 2:Topic list for semi-structured in-depth interview with Sage-atAge participants. (DOCX 22 kb)


To determine the prognostic value of lymphovascular invasion (LVI) in patients with bladder cancer who underwent radical cystectomy. Total of 747 patients underwent radical cystectomy; of these, only 164 did not undergo lymph node dissection (LND). The patients were divided into 4 groups: N0, N1, LVI without LND, and non-LVI without LND. Patients in the N1 and LVI groups had significantly higher T stages and grades, as well 1.5- to 2-fold higher recurrence and mortality rates. Overall survival (OS) was significantly poorer in the N1 group, compared with the N0 and non-LVI groups (p = 0.001 and 0.012), and in the LVI group relative to the N0 and non-LVI groups (p = < 0.001 and <0.001). Recurrence-free survival (RFS) was also significantly poorer in the N1 group relative to the N0 and non-LVI groups (p = < 0.001 and <0.001), and in the LVI group relative to the N0 and non-LVI groups (p = < 0.001 and <0.001). Among patients undergoing radical cystectomy, the clinical results predicted by LVI were similar to those predicted by lymph node involvement. Therefore, the role of adjuvant chemotherapy or immunotherapy may need to be prospectively evaluated in LVI-positive patients regardless of T stage after radical cystectomy. Among patients with bladder UC, 75% present with non-muscle-invasive bladder cancer (NMIBC) at the time of diagnosis, 70% will experience a recurrence within 1 year and 20–30% will progress to muscle-invasive bladder cancer (MIBC)4. MIBC is associated with a poor prognosis and is the 13th most common cause of mortality worldwide, and its incidence is gradually increasing with population aging6.Bladder cancer is among the most common malignancies of the urogenital system7. In this study, we analyzed differences in prognosis according to the presence or absence of LVI after radical cystectomy without lymph node dissection (LND), which is a rare event, and discussed the clinical and prognostic value of LVI.A variety of treatment options for UC are available, including surgery, intravesical Bacille Calmette-Guerin (BCG) therapy, neoadjuvant/adjuvant chemotherapy, immunotherapy, and multimodal therapy. The selection of an appropriate treatment with respect to the patient and disease characteristics is prognostically important, and accordingly the tumor stage and grade are important criteria for such treatment decisions. However, several other factors can contribute to a treatment decision, including lymphovascular invasion (LVI). LVI, defined as the presence of tumor cells in the lymphatic vessels and vascular wall, can affect the characteristics of UC and may be predictive of the outcomeThe Institutional Review Board at our center approved this retrospective study (H-1707-067-869) and waived the requirement to obtain informed consent from the patients. All research and related protocols used in this study complied with the principles of the Declaration of Helsinki.We retrospectively reviewed the medical records of 857 patients with N1 or lower UC who underwent radical cystectomy at Seoul National University Hospital from 1991 to 2016, including patients who did not undergo LND. After excluding cases for which the pathologic finding was not UC, 747 patients were included in the analysis.We divided the included patients into four groups: N0, N1, non-LVI without LND and LVI without LND. Patients who underwent LND were divided into N0 and N1 groups according to N stage, whereas patients who did not undergo LND were divided into non-LVI and LVI groups according to LVI status.in situ (CIS) status, LVI, margin-positive status, LND enforcement, number of removed lymph nodes, number of positive lymph nodes, and neoadjuvant chemotherapy enforcement. We also collected various oncological data, including the initial recurrence and mortality.For diagnostic accuracy, the extracted specimens were reviewed by two experienced genitourinary pathologists. The TNM stage and tumor grade were determined according to the 2010 American Joint Committee on Cancer classification and the 2004 World Health Organization/International Society of Urologic Pathology consensus classifications. We additionally collected clinicopathological information such as age, height, weight, body mass index (BMI), sex, American Society of Anesthesiologists (ASA) physical status, pathologic TNM stage, carcinoma In the absence of any recurrence or metastasis, most patients were followed up every 3 months for 3 years after radical cystectomy, every 6 months during years 4 and 5, and annually thereafter. Each follow-up included routine laboratory and urine testing and urine cytology. Neo-bladder patients also underwent an ultrasonic bladder scan for a residual urine check. Radiological examinations such as computed tomography (CT) and bone scans were performed annually.Regarding the statistical analysis, continuous variables are presented as mean values with standard deviations (SDs) or as median values with interquartile ranges (IQRs). Categorical variables are presented as frequencies of events (%). The primary and secondary endpoints of the study were overall survival (OS) and recurrence-free survival (RFS), respectively, and all survival outcomes were estimated using the Kaplan–Meier method and compared using the log-rank test. A Cox proportional hazard regression analysis was used to identify the predictors of various oncological outcomes. All statistical tests were performed using IBM SPSS Statistics, version 22.0 , and a p-value of <0.05 was considered to indicate statistical significance.Table Figure Figure We also performed a multivariate Cox regression analysis to identify significant predictors of OS and RFS after radical cystectomy. Regarding OS, age , LVI , stage N1 disease  and stage T3  or T4 disease  were identified as significant predictors. These parameters were also identified as significant predictors of RFS   in the Nx subgroup without LND. Here, age  and LVI  were identified as predictors of OS, whereas LVI  was the only identified predictor of RFS  or intravesical treatment, although these may have affected the outcomes. Third, there may be potential interoperability variability or limitations in setting up a single center. Fourth, the small sample size of patients who did not undergo LND. Fifth, there is variability in follow-up and at the time of test. Sixth, when cystectomy is performed in UC, LND is performed with cystectomy as standard treatment. The absence of LND can be a confounding bias. Seventh, regimens and time from neoadjuvant chemotherapy completion to surgery was not consistentLVI is an independent predictor of prognosis in patients with bladder UC who have undergone radical cystectomy. Relatively speaking, LVI and N1 are prognostically similar, and both are associated with a poorer prognosis when compared with N0. Therefore, the role of adjuvant chemotherapy or immunotherapy may need to be prospectively evaluated in LVI-positive patients regardless of T stage after radical cystectomy.


Athletics for All program  and 507 pair-matched individuals not participating in any physical activity program . The body mass (kg), Body Mass Index (BMI) (kg/m2), waist circumference (WC) (cm), waist-to-height ratio (WHtR) (-) and body composition (%)  were compared in a gender-related sub-groups using t-Student test (for parametric distributions) or Mann-Whitney U test (for nonparametric distributions) and chi2 test (for the share of sub-groups). After one year of intervention, lower body mass percentile, BMI percentile, WC, WHtR and fat mass share, higher muscle mass share, as well as lower frequency of overweight/obesity and abdominal fat distribution were observed both for boys and girls participating in the physical activity intervention compared to the pair-matched controls. The after-school physical activity program accompanied by nutritional education for trainers may be a highly effective method for reducing the risk of obesity both for boys and girls, as regular participation is ensured.Regular exercise during school hours is encouraged; however many children and adolescents fail to meet the recommendations during this time. Extracurricular activities may be a more appealing way for youth to achieve guidelines, and it is recommended that they attend two sessions each week. The aim of the study was to assess the influence of participation in a national physical activity program accompanied by nutritional education for trainers on the risk of obesity and body composition in a nationwide sample of boys and girls, after one year of intervention. The #goathletics Study was conducted in a group of 1014 adolescents aged 12–13: 507 individuals for the  School-based physical activity interventions are indicated as a valuable approach to improve the physical performance  and geneThe above-indicated insufficient effect of school-based programs on body mass of children and adolescents may result from their general reluctance to participate in, and avoidance of, school-based physical activity . HoweverRegarding after-school physical activity programs, it must be emphasized that the studies conducted thus far have assessed various types and methodologies of interventions which influenced the observed results. The review of reviews by Demetriou et al.  indicateAt the same time, in order to increase the effectiveness of the programs, it was proven to be more effective to include in educational programs not only physical activity, but also nutritional elements . Such anAs the influence of trainers, as prominent adult social leaders, is observed to cause positive changes to the eating behaviors of children , the othThe #goathletics Study was conducted at the Department of Dietetics, Warsaw University of Life Sciences (WULS-SGGW). It was conducted according to the guidelines laid down in the Declaration of Helsinki. All procedures involving human subjects were approved by the Ethics Committee of the Faculty of Human Nutrition and Consumer Sciences of the Warsaw University of Life Sciences in Warsaw, Poland . Written informed consent was provided by all participants and their parents or legal guardians.Athletics for All (in Polish Lekkoatletyka Dla Każdego—LDK), which is a nationwide after-school physical activity program, and the control group included 507 pair-matched individuals recruited from a general population but not participating in any physical activity program.The #goathletics Study was conducted in two groups of adolescents, aged 12–13. The study group included 507 individuals representative of Athletics for All program (http://www.lekkoatletykadlakazdego.pl/), an after-school physical activity program which is free of charge, has been conducted in Poland since 2014. It is organized by the Polish Athletic Association and supported by the Ministry of Sport and Tourism and Nestlé Polska S.A. It is a real life intervention already implemented in all the regions of Poland, both in big cities and small towns in 807 training groups. Since 2014, over 300,000 children and adolescents from 1244 primary and secondary schools have participated in the program. The program was implemented with the aim of increasing physical activity in a group of primary school children and adolescents by providing regular athletics training.The In the current school year, in all the regions of Poland, there are 180,000 participants of the program (majority of them in the youngest age groups); almost 8000 primary school adolescents aged 12–13 participate. The regular attendance in the school year is ensured due to the fact that the program is free of charge and regular participation is a necessary condition (it is controlled for each session and recorded by trainer using a dedicated electronic application). Such an obligation guarantees the low dropout level that, in the group of adolescents aged 12–13, is currently 10% on an annual basis (based on the data for 2017/2018 school year).As a part of the program, physical activity education session and athletics training are conducted in schools in various locations of Poland, while for a group of participating adolescents, three sessions a week are conducted  in which regular participation is required. Each trainer receives the identical outlines of the trainings with the specified aim of each training, necessary equipment and detailed instructions for all the elements of training. All the trainings are planned by the trainers from the Polish Athletic Association and are aimed at creating necessary abilities and skills for the athletics disciplines.Athletics for All program, and it is repeated each year; during this session, additional educational materials are provided, and trainers are obliged to teach their participants not only about physical activity but also about proper balanced diet.An additional nutritional education session was conducted for trainers at the beginning of the Athletics for All program that increased its attractiveness are the athletics events organized exclusively for its participants. In such events, including regular school cups, regional cups and a national cup, professional athletes and even star athletes  take part. So far, 2400 school cups and 300 regional cups have been organized, while the national cup is organized each year. Star athletes have contact with the Athletics for All program participants, meeting them, training together, and contacting them via a dedicated social network.The additional element of the The #goathletics Study aimed to evaluate the effectiveness of the Athletics for All program, not only by the assessment of anthropometric measurements, but also by the assessment of physical performance and nutritional behavior . For thiAthletics for All after-school physical activity program is being conducted. The geographical distribution of schools was based on Polish statistical data, and both big cities and small towns were included in the selection (random purposive sampling).For the study group, the first stage of the recruitment procedure involved a random selection of primary schools in which the Athletics for All program from each school (n = 600). The proportion of boys and girls selected was required to be in accordance with the general proportion of participants of the Athletics for All program (with a higher share of girls) (random sampling). Afterwards, the individuals meeting the inclusion criteria .For the control group, the first stage of the recruitment procedure involved the selection of primary schools in which Athletics for All program nor participants of any other physical activity program. The pair-matching procedure was applied, and the variables used for matching included gender, age, and city of residence. During this stage, the individuals eligible for recruitment, after being pair-matched with study individuals, were first identified, and then for each study individual, one pair-matched control individual was randomly chosen (pair-matched random sampling).The second stage of recruitment of the control group involved a random selection of adolescents who were neither participants in the -Caucasian,-adolescents aged 12–13,-Athletics for All program training sessions regularly (three sessions a week),participating for at least 1 year in the -participating in any other physical activity program neither at school, nor after school,-consent agreement of adolescents for participation,-consent agreement of the parents/legal guardians for the participation of their children.The inclusion criteria for the studied group were as follows:-any data missing,-diagnosed disabilities in cognitive or motor functions,-pacemakers and other stimulators ,-diagnosed with epilepsy .The exclusion criteria for the studied group were as follows:-Caucasian,-adolescents aged 12–13,-Athletics for All program neither currently, nor in the past,participating in the -participating in any other physical activity program neither at school, nor after school,-consent agreement of adolescents for participation,-consent agreement of the parents/legal guardians for the participation of their children.The inclusion criteria for the control group were as follows:-any data missing,-diagnosed disabilities in cognitive or motor functions,-pacemakers and other stimulators ,-diagnosed with epilepsy .The exclusion criteria for the control group were as follows:The group of Caucasian adolescents was chosen as typical for the Polish population, i.e., a homogenous Caucasian one ; similarIn spite of the fact that in the systematic review of Bacil et al.  there isAthletics for All program, including 210 boys and 297 girls, and 507 pair-matched individuals not participating in any physical activity program including 210 boys and 297 girls) recruited for the study. The geographical distribution of the participants is presented in At the end of the procedure, there were a total of 1014 adolescents ).The body mass and height were measured by a professional dietitian, according to the widely accepted and applied rules , using aFollowing measurements, the obtained values were assessed on the basis of the Polish growth reference values. The body mass percentile, the height percentile and the BMI percentile of each participant were specified by gender and age  using thAdditionally, the BMI was interpreted according to the growth reference cutoffs for school-aged children and adolescents of the WHO , which aThe BMI percentile of the studied group stratified by region is presented in WC was measured by a professional dietitian, using a nonelastic flexible measuring tape (accuracy ± 0.5 cm). According to the widely accepted and applied rules, which were defined by the WHO  and InteOn the basis of the previously obtained measurements of body height and WC, the WHtR was calculated by dividing WC by height (waist (cm)/height(cm)) . The WHtThe body composition was assessed using bioelectrical impedance analysis. The measurements were taken by a professional dietitian using BIA 101/ASE . According to the commonly-applied rules, the measurements were obtained in the morning, in the fasting state , after a day when no excessive physical activity was performed; that is, no training was conducted on the previous day . The mea2) were placed (with distance between the electrodes being at least 5 cm) for taking measurement in a tetrapolar electrode configuration. The measurements were conducted with arms separated from the trunk by about 30° and with legs separated by about 45° [The participants were asked to lie down on a two-layer polyurethane foam matte with no metal or conductive elements, and after 5 min of resting, measurements were recorded in a supine recumbent position according to the recommendations . Before bout 45° .During the measurement, the data of resistance and reactance at a frequency of 50 kHz were recorded, while they remained stable. Following measurement, the Bodygram 1.31 software  and its equations were applied to calculate body cell mass , fat-free mass (content and % of body mass), fat mass (content and % of body mass), total body water , extracellular water (content and % of water content), intracellular water (content and % of water content), and muscle mass (content and % of body mass).t-Student test (for parametric distributions of continuous variables). The categorical variables were compared using a chi2 test. A level of significance of p ≤ 0.05 was accepted. The statistical analysis was conducted using Statistica, version 8.0  and Statgraphics Plus for Windows 4.0 .The obtained data were analyzed using Shapiro-Wilk test to assess the distribution. Afterwards, due to nonparametric distributions, the sub-groups were compared using Mann-Whitney U test (for nonparametric distributions of continuous variables) or The basic anthropometric characteristics of the boys in the study group participating in a national athletics program and boys in the pair-matched control group are presented in The basic anthropometric characteristics of the girls in the study group participating in a national athletics program and girls in the pair-matched control group are presented in The body mass and abdominal fat distribution of the boys in the study group participating in a national athletics program and boys in the pair-matched control group are presented in The body mass and abdominal fat distribution of the girls in the study group participating in a national athletics program and girls in the pair-matched control group are presented in The body composition of the boys in the study group participating in a national athletics program and boys in the pair-matched control group are presented in The body composition of the girls in the study group participating in a national athletics program and girls in the pair-matched control group are presented in On the basis of the Polish study conducted in a nationally representative random sample of involving 17,000 children and adolescents, it was stated that the prevalence of excessive body mass for the age group of 7–12 years is, depending on the applied definitions, 21.7–30.4% and 18.4–23.2% for boys and girls, respectively, as well as for the age group of 13–18 years—14.6–19.4% and 10.3–13.0% for boys and girls, respectively . In the In spite of the fact that the prevalence of excessive body mass in Polish adolescents is lower than in a number of European countries, the alarming trend of increase is indicated, as for the age group of 15 years, since from 2001 to 2014, the share of overweight and obese youth more than doubled . Taking According to the WHO, it is recommend that children and adolescents aged 5–17 years should accumulate at least 60 min of moderate- to vigorous-intensity physical activity daily, while a higher amounts provide additional health benefits . SimilarIn the conducted own study, it was not surprising to observe beneficial anthropometric measurements and body composition in the group of adolescents participating in a national athletics program in comparison with the pair-matched control group. However, the finding that all the observed parameters were better in the study group may be considered important, as it confirms the comprehensive positive effect of the after-school physical activity program assessed in this study. As the pair-matched samples of adolescents participating and not participating in a national athletics program were compared, while the gender and regional segmentation did not differ between sub-groups, the results may be interpreted as valid.The present study showed that the recommended level of physical activity influenced not only BMI but also adiposity and the general body composition of the participants. For all the indicated parameters, physical activity was beneficial, which may confirm the positive influence of the national after-school athletics program. However, it must be emphasized that in some studies, even if after a physical activity intervention, some assessed parameters are improved, no success in adiposity reduction was observed .The extracurricular program, assessed in the own study, was conducted in a school setting, included three sessions a week, and ensured regular participation, which made it most effective . In partWhile a new concepts of the educational programs are regularly analyzed ,61, it iMoreover, the fact that the program was an extracurricular one, but conducted in a school setting, may have influenced the observed results. No school-based obligation was applied, so it may be supposed that the participating adolescents were making their own decision to participate, which may have influenced their compliance, as, in general, such an association may be observed .An additional advantage of the program was that it involved professional sport activities, but within the capacity of participants, as the program was organized by Polish Athletic Association and supported by the Ministry of Sport and Tourism. In spite of the fact that it aimed just to increase physical activity in a group of children and adolescents, by conducting regular athletics training, it also allowed adolescents to pursue sport as a future career by providing them with opportunities to meet professional trainers and even star athletes. Thus, the program was very attractive for participants, and it may be supposed that they were willing to participate.The conducted program may be suggested to be effective after one year of intervention, but an important limitation of this study was that it was conducted in Poland and has not been verified in other countries thus far. Moreover, due to the fact that no baseline data were gathered, the progress attained by participants may not be assessed, and therefore, further studies are needed. However, the one-year intervention and the fact that the study was conducted in a randomly chosen group of adolescents participating in a real life program may allow us to conclude that the applied approach should be verified in other populations.Such effective interventions, as implemented in Poland, may be crucial, as the excessive body mass and low physical activity levels observed in childhood and following through into adolescence  may contThe extracurricular physical activity program, conducted in school settings, including three sessions a week and ensuring regular participation, was highly effective for reduction of body mass, adiposity and improving body composition of adolescents after one year of intervention. To make any physical activity program effective, attractive training sessions and other elements must be planned, so that participants may be willing to participate.


Laparoscopy has numerous clinical benefits compared to laparotomy. However, a functional laparoscopy program requires significant investment and, as a result, remains unavailable for the majority of the world’s population in low- and middle-income countries. The effort to bring laparoscopy to low-resource settings has produced variable outcomes resulting from the challenges inherent to a complex surgical program. This paper highlights these shortcomings and identifies opportunities to improve future laparoscopy programs. Since its introduction, laparoscopy has evolved into an indispensable surgical tool. The clinical benefits are well-documented and include reduced blood loss, lower infection rates, shorter hospital stay, faster return to normal activity, improved cosmesis, and less pain and medication use compared to laparotomy 23456789.23456781789101112Global health investors have historically prioritized infectious disease and maternal-child health over surgical care, despite the fact that nearly one third of the global burden of disease arises from surgical conditions 1516. The1515917181920172122Laparoscopy programs in LMICs face numerous limitations including a lack of skilled providers; increased operating time; limited resources, equipment, and maintenance capacity; and absence of safe procedure guidelines 6791113212425.13212412891021This model fails to address the aforementioned shortcomings, resulting in foreseeable challenges. Programs offering intermittent in-country clinical support may result in inadequate training and program discontinuation after training concludes 212425. G212414916810One of the challenges in developing sustainable laparoscopy programs is the limited ability to assess development due to lack of evaluation metrics. To determine a laparoscopy program’s success, it is necessary to obtain the data describing whether a population has adequate access to laparoscopy.The Lancet Commission on Global Surgery 2030 defined surgical access as safe, affordable, and timely surgical capacity, using three Bellwether procedures  for the metric . Similar61027282930Publications of underperforming or failed laparoscopy programs exist but are likely underreported 24. This Currently, most site selection depends upon pre-existing institutional relationships 221. This2Impartial criteria for appropriate site selection developed by implementing organizations and professional societies can optimize resource utilization. Important factors to consider include the presence of a functional underlying safe surgery program to ensure laparoscopic complications can be managed. Institutions that train providers who remain in-country or work with underserved or disadvantaged populations can promote access by larger populations. Additionally, organizations possessing strong research infrastructure and experience will facilitate program assessment and assist with training additional investigators .Including a comprehensive group of stakeholders increases the ability of a laparoscopy program to respond to challenges and threats; increases responsiveness and inclusion; determines priorities and standards; and improves coordination, efficiency, and resource mobilization 32. Each Surgeons, gynecologists, anesthetists, nurses, clinical engineers, and professional societies should be included in programmatic development. Anesthetists are of critical importance, as safe general and neuraxial anesthesia is fundamental to laparoscopy. A holistic approach that includes referring providers (e.g. primary care providers) and those who assess patients post-operatively (e.g. emergency medicine providers), may also improve access and outcomes.International professional societies often have members from LMICs and affiliated local and national professional groups. Collaborations between societies can facilitate laparoscopy program development by leveraging trust, generating diverse viewpoints, and maintaining greater objectivity and impartiality in selecting sites. Such associations can improve quality by implementing standardized protocols, guidelines, and evaluation metrics. Professional organizations can combine and coordinate resources, liaising between local, national, and international actors. They can also help assess potential sites and identify local providers who possess critical knowledge of local issues. Such a partnership may be similar to the American Cancer Society’s Global Capacity Development program, which provides programmatic assessments, guides organizational development, and invests in national cancer networks . ParticiIn addition, health economists, epidemiologists, and researchers are needed to collect and analyze the data to assess program performance, identify shortcomings, evaluate new potential sites, and seek funding. Training research and development personnel in LMICs to analyze these programs from inception can increase the workforce capacity, improve local relevance of research, and, over time, ensures that the LMIC program can partner in future multinational projects .Government Ministries of Health, regulatory bodies, and public-sector institutions are key to developing laparoscopy programs as they know local conditions and can coordinate larger, complex efforts. Collaborating with such institutions can guide novel technology introduction by streamlining regulatory barriers, efficiently allocating human and physical capital, and provisioning logistical and technical support. In particular, expedited device review may reduce the costs and risks of seeking regulatory approval, encouraging investment from private industry . For insLaparoscopists in LMICs have described numerous device workarounds, implying a market for private industry to engineer devices for reusability, durability, cost, simplified maintenance, and avoidance of consumables 5671934. 5671916An entire laparoscopy program may be suspended when donated devices become incapacitated; thus, programs require sufficiently skilled clinical engineers or private industry representatives to maintain, repair, or replace equipment 92435. Cl924To finance laparoscopy development, interest among philanthropic bodies and global health funding sources must be promoted. Surgical capacity requires long-term investment and therefore often receives lower priority than programs promising faster results . BuildinHowever, long-term programs may be more politically feasible if the economic risks to service providers and governments are mitigated; social or development impact bonds may be useful funding mechanisms to achieve this 3637. Con361616As highlighted in the above example, domestic resource mobilization, particularly in middle-income countries, may be possible through private industry foundations operating in those countries 37. For t1It is also essential for laparoscopy programs to assess out-of-pocket patient costs. Hidden patient expenses, including fees related to hospitalizations, peri-operative services, medications, or under-the-table provider payments may be barriers to access 3741. Stu376Rigorous programmatic evaluation, involvement of key community, government and health care stakeholders, and development of stable financing options are required for sustainable laparoscopy programs in LMICs. To improve and standardize assessment of access to laparoscopy globally, we propose four Laparoscopic Bellwether procedures, appendectomy, cholecystectomy, gynecologic adnexal procedures and diagnostic laparoscopy. Laparoscopic surgery capacity, measured by the safe, timely, and affordable availability of these procedures is needed to ensure the most effective surgical care for all patients worldwide.


We describe an interprofessional educator development program, designed intentionally, that was implemented at an academic healthcare centre. In 2014, we purposefully adapted our pre-existing educator development program to be able to include all interprofessional educators at our institution. The program’s goals were to enhance educator skills, a common need due to requirements of accreditation, and to create a local interprofessional community of teachers. The framework of the program was based upon adult learning principles, reflective practice, experiential learning and peer groups, all key characteristics of faculty development programs. It was also longitudinal and immersive. Kirkpatrick’s program evaluation model was used for identifying results; participants’ self-reported evaluation forms were collected and their narrative comments were analyzed.After we opened our educator program to all interprofessional staff, our number of program participants increased. The interprofessional participants included, but was not limited to, physicians, physician trainees, nurses, physician assistants, audiologists, perfusionists, and basic science researchers. Our number of program sessions and program faculty were expanded. Our interprofessional participants reported that they were able to learn essential knowledge, skills and attitudes for their growth and development as educators, in the context of an interprofessional community, while also appreciating the diversity of their peers.We share our insights with the redesign and implementation of an interprofessional educator program so that others can learn from our experiences. Key takeaways include using a conceptual framework for teaching effectiveness, involving interprofessional stakeholders and obtaining their perspectives, reviewing interprofessional literature and competencies, and highlighting best practices across the disciplines. Professional development in education is increasingly a requirement across health professions education programs, as accreditation bodies for undergraduate and postgraduate medical education programs, nursing schools, and a variety of health professions education training programs require instructors to be trained in aspects of teaching and assessment –3. In unInterprofessional education has been defined as two or more healthcare professions learning ‘from, with and about each other to improve collaboration and the quality of care’ . At the In this paper, we define professional development in education as those activities which enhance the knowledge, skills, attitudes and behaviours of healthcare professionals in their roles as teachers and educators. While clinical content is obviously different across healthcare fields, the ‘content’ of educational programs is fairly similar. All educators must possess knowledge of and requisite skills in curriculum design, teaching, instructional design, and assessment. Familiar challenges across healthcare fields include: limited resources at the department or institution level, lack of dedicated time for both instructors and participants, and lack of recognition for participants seeking to improve their competency in teaching . SteinerInitially, we used Steinert’s model as a theoretical framework to guide program development and refinement , 11. We Essentials Program was initially designed in 2005 to meet the professional development needs of faculty and instructors who taught physician trainees in a new medical school. In 2013–14, with new leadership, the program was redesigned to allow all health professions instructors at our institution to participate as educators. Goals for our program redesign included: meeting needs common to all health professions education programs, developing a wider community of learners [The Essentials Program for Health Professions Educators include: adherence to adult learning principles and reflective practice, a longitudinal curriculum [Essentials program includes a 3-hour mini retreat focused on educational theory and approximately 25 bi-monthly workshops (1.5–3 h in length). Topics include teaching skills, curriculum design, feedback , competency-based education and assessment, objective writing, clinical reasoning, and technology-based education. Sessions utilize pre-readings, offer opportunities to practise new skills and reinforce knowledge, and provide feedback to participants. While participants often move through the program as a cohort, they are able to sign up for individual sessions to meet their specific educational needs.Key features of the current rriculum , use of rriculum . The 10-Participants include, but are not limited to, faculty and instructors who teach physician trainees, nursing trainees, physician assistants, audiologists, perfusionists, nutritionists, and basic science researchers. In 2015, we welcomed postgraduate medical education trainees into the program.Essentials workshops are assessed using a 10-item feedback form which includes 7–8 Likert-response items and 2 open-ended questions. The Likert scale is un-numbered and ranges from Strongly Disagree to Strongly Agree, with no neutral option. Participants are queried about their perceptions of the learning environment and teaching techniques, and their own learning.There has been a steady increase in the number of program participants, from 54 individuals in 2013–14 to 152 individuals in 2016–17. The number of sessions offered increased from 13 (2013–14) to 28 (2016–17). Workshop participation in 2016–17 ranged from 6 individuals per session to 41 per session, for a total annual participation count of 507 across all sessions in 2016–17 (up from 221 in 2013–14). Instructional hours increased from 25.5 h (2013–14) to 54.5 (2016–17). The number of instructors in the program grew from 8 to 16 during the same time period.For the December 2014–17 time period , 944 evaluations were collected from 1,132 total Essentials workshop participants, for an average of 83.4% evaluation response rate. In aggregate, participant assessment of individual workshop teaching techniques ranged from 3.5 to 4.0/4.0 (mean = 3.8). Participants’ assessment of their own learning ranged from 3.35 to 4.0/4.0 (mean = 3.7). Respondents’ assessment of their own learning and perception of teaching techniques indicate that a high degree of satisfaction was maintained as the program moved to an interprofessional educator development model.Narrative comments from feedback forms are routinely collected as part of quality improvement efforts from year to year. Comments comprised two main categories: general comments about the sessions and remarks about the interprofessional nature of the sessions. Comments were related to perceptions of new knowledge and skills, opportunities to practise, changes in attitudes, desires to use new teaching skills with learners in the workplace, and appreciation of interactive techniques Tab. .Table 1NWe have described a longitudinal model for professional development in education which is innovative in its goals, design and inclusion of interprofessional participants. To our knowledge, this program’s focus on skill development for interprofessional educators appears unique in the health professions literature. The evaluation of our program provides support for the development of local, institutional and interprofessional educator professional development programs. We believe our educator development program has been successful in accomplishing several goals: improving and enhancing teaching skills; standardizing teaching practices at the institution; and fulfilling accreditation agencies’ requirements to provide professional development in education for key instructors.What follows is a list of lessons learned over the past four years which may be helpful to other programs as they design and implement interprofessional educator development programs.When planning your program and sessions, reflect upon current stand-alone offerings of professional development for educators or existing programs with an openness for adaptation and innovation to meet the needs of diverse participants . SteinerObtain ongoing feedback from key stakeholders, representing your many constituencies, to help support a safe, collaborative and interprofessional learning environment. We routinely send draft cases to faculty to ensure our scenarios are authentic and representative of their learning environments.By utilizing a variety of health professions educators, your program not only reflects institutional support for interprofessional interactions but also provides professional role models for participants in the program.We recommend that program planners ensure that the program’s mission and values drive program development. Everything from session objectives to workshop materials to the instructors themselves should reflect the interprofessional nature of the program . Even ouWe recommend assigning seating to ensure opportunities for interprofessional interaction during educator development sessions. This can be accomplished by attaching numbered cards  to session handouts which participants pick up at the beginning of a session. Tables or seating areas are also numbered accordingly and participants sit at the assigned tables. We have found that colleagues from specific fields or disciplines often arrive in pairs.During sessions, continuously work to illustrate commonalities across fields, but also highlight best practices across fields which everyone can learn from. Lastly, be open to unplanned and unexpected outcomes . For exaOur experience in offering interprofessional educator development may not generalize to all settings. This description is limited to one setting, and our measures of success relied heavily on participants’ self-reports, our only outcome measure. Our sessions have elicited high engagement from participants, which may not be the case in all environments.Interprofessional educator development is critical in today’s complex healthcare environments, where there are limited resources and increasing needs for professional development of educators. We have described a longitudinal professional development program for educators that aims to meet the needs of a wide spectrum of adult learners. We speculate that the success of this program may be related to considerations of program planning, engagement of stakeholders, use of feedback to improve sessions, and workshop topics , which may have had significant appeal for our interprofessional audience. We believe that the development of programs like this is an evolving area, and lessons learned within our context may be helpful to other program developers as they design and implement their own programs.


Like many other proteins, those belonging to the signal transduction cascade initiating sporulation (Spo0 pathway) have conserved protein domains (Capra and Laub in Annu Rev Microbiol 66:325–47, Similar to the report of Davidson et al. (PLoS Genet 14:1–33,  Comparative genomic analysis is a valuable tool to explore new genomes and metagenomes to search for functional processes, phylogenetic relationships, and evolutionary traits among organisms. An example of this comparative analysis is finding that proteins involved in the Spo0 pathway constitute of at least a sensor kinase, the phosphotransferases Spo0F and Spo0B, and the response regulator Spo0A , were suPfamA database [hmmscan program from the HMMER suite [hmmsearch program [The data are a collection of predicted protein architectures defining the proteins shaping the Spo0 pathway in Firmicutes. As a guide, we used the proteins shaping the sporulation cascades in the model organisms shown in Data File 1 . Using tdatabase , we consdatabase . The arcdatabase –7, usingER suite . We presER suite . COGs we program . This HM program , 10. The program . The lis program .Table 1Ohmmscan using the profiles of the PfamA shown in Table Clostridium thermocellum, which is composed of a HisKA, an HATPase, and a response regulator domain (Table To detect orphan histidine kinases (HKo), defined as kinases not having as a neighboring response regulator , we perfSpo0 pathways found for each endospore former are shown in Table Experimental evidence of a sporulation phenotype is not available for a vast number of strains since the conditions have not been identified.New protein profiles should be constructed to identify novel orphan kinases.A study should be performed in newly sequenced genomes to increase the collection; nonetheless, the groups presented in this note are probably enough to confirm the main conclusions found by both groups.The data presented in this note were not published as a research article since the main findings were published while our manuscript was under review. Nonetheless, the data are still important and useful since they are a collection of well-curated Firmicutes species for which a Spo0 pathway was present or absent.


Strength at Home (SAH), a 12-week cognitive-behavioral and trauma-informed group treatment designed to reduce and end IPV use among military and veteran populations.The U.S. Department of Veterans Affairs (VA) has recently implemented a comprehensive national program to help veterans who use or experience intimate partner violence (IPV). One important component of this plan is to implement SAH at 10 VA medical centers.The present study describes initial patient and clinician findings from the first year of a training program tasked with implementing SAH was associated with significant pre- to post-treatment reductions in the proportion of veterans who reported using physical and psychological IPV toward a partner, the types of IPV used, and posttraumatic stress disorder symptoms. Overall, veterans reported high satisfaction with the quality and nature of services received, and with the program materials. In addition, 70% of sites and 34% of the 79 clinicians trained were successful in launching the program in the first year. The mean number of days between site training and initiation of the first group session was 135.86 .Results from 51 veterans who completed both pre- and post-treatment assessments indicate Results suggest that the training and implementation program was successful overall. However, average length of time between in-person training and initiation of group services was longer than desired and there were three sites that did not successfully implement the program within the first year, suggesting a need to reduce implementation barriers and enhance institutional support. Strength at Home program (SAH).Over the past decade numerous research studies have indicated that high rates of intimate partner violence (IPV) among U.S. military veterans may convey risk for physical and mental health problems, as well as social, occupational, and legal difficulties , 2. WomeSAH at 10 VA hospitals. SAH is a 12-week cognitive-behavioral and trauma-informed group treatment to end IPV in military and veteran populations. Based on the social-information processing model of IPV in military populations [SAH has led to reductions in the use of physical and psychological aggression in pilot, effectiveness, and efficacy trials [SAH [SAH model, in part because they do not account for the influence of trauma exposure, do not programmatically address core themes linking trauma to relationship problems and abuse, and often discount the importance of mental health symptoms commonly linked with IPV [Prior to the implementation of the VA DV/IPV taskforce recommendations described above, few VA hospitals offered any programming for veterans using IPV beyond general anger management. This manuscript describes program outcomes from the first year of a pilot training program to introduce ulations , SAH hasy trials –9. Imporals [SAH , 12. Treals [SAH , depart with IPV , 14. Trawith IPV .SAH was developed with the goal of establishing a model IPV treatment program for military and veteran populations. SAH consists of twelve 120-min group sessions organized into four treatment phases designed to address deficits in social information processing that increase risk for IPV: 1) psychoeducation on IPV and common reactions to trauma; 2) conflict management skills; 3) coping strategies and negative thought patterns; and 4) communication skills. All treatment components use military and veteran relevant language and examples. Practice assignments are completed at home. For example, veterans complete anger analysis worksheets designed to facilitate early recognition of anger signs and cognitive distortions, as well as the use of new skills and strategies learned in group. Group sessions start with a review of the practice assignment completed by each group member with feedback and discussion provided by the group members. This is followed by the introduction of new skills.In light of the above considerations, SAH, all veterans complete an intake assessment, during which the assessing clinician prioritizes rapport building and uses motivational interviewing skills to enhance readiness for treatment [SAH was not designed as a treatment for PTSD, the program addresses the impacts of trauma and core themes underlying trauma that may relate to IPV in relationships. Therefore measures of PTSD symptoms are also included.Prior to enrollment in reatment . During reatment , 17. AltSAH is partner outreach to ensure that any affected partners receive hotline numbers and information about other resources, safety planning, and the opportunity to complete a telephone assessment regarding their IPV experiences. Partner outreach is an important component of IPV treatment programs because partners may not have had the opportunity to reach out to available sources of aid and support, and they may not be aware of the resources available to them in the community. Research has suggested this direct outreach is an often overlooked opportunity to support those who have experienced IPV [A key component of nced IPV .SAH. We also present information on our initial approach to implementing this trauma-informed treatment for IPV. Specifically, we report on clinician success in the training program (number of clinicians facilitating groups within the first year of the program). We report on the number of veterans initially enrolled in the program and their demographic information. We also examine changes in the number of different types of IPV used, changes in the prevalence of physical and psychological IPV, and changes in both PTSD symptoms and alcohol misuse among those veterans who attended the majority of the program sessions (8 or more). We also examined veteran satisfaction with the treatment.Using anonymous program evaluation data from veterans who completed the program at 10 VA hospitals, this manuscript describes patient outcomes from the first year of the VA pilot roll-out of SAH trainings attended by personnel from 11 different hospitals in the first year of the roll-out. All sites participated voluntarily in the training program. The six rapid implementation sites were chosen by the VA DV/IPV taskforce because these sites had evidenced early commitment to the development of programming to address DV/IPV. Three additional training sites were added; two of these three sites were considered to have evidenced success in implementing other DV/IPV programming . Another training site was chosen due to its prior research experience with SAH; however, this site subsequently dropped out of the training program and is not included in analyses. In addition, clinicians from two other hospitals in close proximity to one of the designated pilot sites also completed SAH training. In total, 10 VA hospitals and 79 clinicians received SAH training and were enrolled in the pilot training program. All sites were required to have an IPV Coordinator tasked with overseeing the program and at least 4 clinicians who would volunteer to receive the training and commit to facilitating groups. All clinicians were required to be licensed mental health providers at the VA . The training expectation was that at least one group would be initiated at each site within six weeks of the in-person training.As part of larger implementation efforts following the VA DV/IPV task force recommendations, six hospitals were designated by the VA DV/IPV task force as “rapid implementation sites” for the program. An additional three sites were added, for a total of nine in-person SAH master trainers who were involved in developing SAH as well as in the conduct of the original SAH clinical efficacy trial [SAH curriculum. The training consisted of one day focused on the theoretical underpinnings, program evaluation, and general therapeutic approach of SAH, with approximately 3 h of training in the use of motivational interviewing skills with veterans who may be using IPV. Attention was paid to ethics and mandated reporting statutes as well as to basic information on risk for IPV, dynamics of IPV in veterans, and clinical work with individuals using IPV. This was followed by a second day of detailed training on how to facilitate each of the 12 SAH sessions, augmented with role-plays of critical skills. Clinicians were provided with a treatment manual that described in detail the theoretical aspects of SAH and included all treatment materials. Also included in the manual was an assessment protocol detailing how to conduct the SAH intake interview and partner calls, clinician fidelity checklists, IPV fact sheets, SAH research publications, advice and materials for administering the protocol with LGBTQ and women veterans, and sample materials for publicizing the program and communicating with the justice system. Shortly after the in-person training, all clinicians were invited to an assessment and program evaluation training call.Prior to the training, IPV coordinators received a brief pre-training orientation call to answer any questions they had regarding the training, program expectations, and implementation tasks. Training was delivered in person over two days by the three cy trial , 9. EachSAH session, clinicians used a fidelity checklist to track their completion of all required elements for that session (using a yes/no checklist). All clinicians were required to complete weekly clinical consultation with the lead program developer while they led groups, and IPV Coordinators were required to attend monthly implementation consultation calls. In addition, the master trainers were available by phone and email for supplemental consultation as needed. To successfully complete the training program, clinicians were required to: 1) attend the full 2-day SAH training, 2) complete at least 2 SAH groups, 3) attend and participate in at least 75% of consultation calls, and 4) return program evaluation materials. After completing these requirements, clinicians could be cleared to facilitate SAH groups without concurrent clinical consultation.After facilitating each Demographic information, session attendance, and scores on the program evaluation measures completed by program participants at the intake assessment and again at session 12 were summarized by site clinicians, and de-identified data were sent to the coordinating site. Summary information on recent IPV gathered from calls with veterans’ partners was likewise sent to the coordinating site. As the purpose was program evaluation only, no identifying information was collected by the evaluation team. To facilitate de-identification of the data, each participant was assigned a unique code by clinicians, and the same code connected veteran and partner data. The institutional review board at VA Boston reviewed the procedures and determined that the program evaluation did not meet the criteria for human research and thus was exempt from further IRB review.no), 1 (yes). Following the recommendations of Straus and colleagues, prevalence scores were then calculated by summing the number of positive responses for each subtype of IPV, and converting the sum into a dichotomous variable representing the presence or absence of each type of IPV in the past three months [Recent use of IPV was measured with an adapted version of the Centers for Disease Control’s 2010 National Intimate Partner and Sexual Violence Survey . This 30e months . SummaryPTSD symptoms were measured with the PTSD checklist for DSM 5 (PCL-5) . The PCLThe 10-item Alcohol Use Disorders Identification Test (AUDIT) was used to assess problem drinking behavior over the past year . The AUDSAH and services received. Patients rated their satisfaction on a 4-point scale (from 0 to 3), and also responded to an open-ended question regarding the most and least helpful aspects of the program. Analyses of the open-ended responses were outside the scope of the current project and are not reported here. The CSQ-8 has been shown to evidence excellent internal consistency and to correlate positively with self-reported symptom change, as well as client and therapist reported improvement [Veterans also completed a 10-question post-treatment satisfaction measure, which was based on the 8-question Client Satisfaction Questionnaire (CSQ) , 28. TheHospital adoption was the length of time in days between receipt of the in-person training and the start of the first group session for each site. Clinician adoption was the length of time in days between receipt of the in-person training and the start of the first group session for each clinician. We also report the percentages of clinicians who fully or partially completed the training program, as well as those who dropped out of the training program and their reasons for drop-out. For those sites who were not successful in implementing the program in the first year, we report the reasons why this may have occurred.t-tests were used to determine the significance of pre to post-treatment changes in measures of patients’ use of IPV, PTSD symptoms and alcohol misuse. Effect sizes for repeated measures designs (Hedge’s grm) were also calculated [Paired samples lculated ; an effelculated . The McNSAH group and the mean number of days between receipt of the training and the first group session was 135.86 . Of the sites that did not successfully begin a group in the first year of the rollout, reasons were: difficulty establishing institutional buy-in (n = 1), change in duties of the IPV Coordinator (n = 1), and lack of referrals (n = 1).One year into the pilot rollout, seven of the ten sites had initiated at least one SD = 83.81, range 72–378). Of the trained clinicians who had not facilitated any groups by the end of the first year, 21 (26.58%) indicated they still intended to lead a SAH group while 31 (39.24%) indicated they were no longer participating in the training program. Reasons for therapist drop-out included: competing responsibilities/increase in workload (n = 5), difficulty recruiting veterans (n = 2), lack of supervisor approval (n = 2), leaving VA employment or current position (n = 6), participated in training as program leader or veterans’ justice outreach specialist (n = 7), and unknown/no response (n = 9).With regard to clinician outcomes for the hospitals that did successfully begin a group, 27 (34.18%) clinicians had facilitated at least one group and six (7.59%) clinicians had completed all requirements of the training program. The mean number of days between receipt of the training by a clinician and the first group session led by the clinician was 175.82 (SAH program and 89 of these veterans were justice-involved (66%), meaning they had been charged with a crime related to IPV and/or were part of a deferred adjudication program or veteran’s treatment court. The average age of veterans who entered the program was 43.13 . All other demographic and military service history information collected is presented in Table There were 132 male veterans who completed a baseline assessment for the There were 59 partner calls completed at intake, and 14 partner calls completed at post-treatment. No demographic information was collected from partners, only collateral information on their experience of IPV.SD = 4.42, range = 0–12). There were 53 veterans who attended 9 or more sessions and thus would be considered program “graduates”; there were 14 veterans who attended 0 sessions. Attendance data was missing for approximately 42 veterans. There were 51 veterans who completed a post-treatment assessment. Of the 51 veterans with completed post-treatment assessments, the mean number of sessions attended was 10.58 .Of the 132 veterans who completed intakes for the program, the mean number of sessions attended was 7.26  from baseline (the 3-months prior to treatment) to post-treatment t (50) = 3.39, p < .01, Hedges grm = .56 (medium).Initial results from 51 veterans who completed both pre- and post-treatment assessments (see Table p < .01). Specifically, of the 18 veterans with self or partner reported physical IPV use prior to treatment, 78% (n = 14) had no reported physical IPV use at the post-treatment assessment. Results also revealed a significant change in the proportion of veterans with self or partner reported psychological IPV use from baseline to the post-treatment phase . Of the 33 veterans with self or partner reported psychological IPV use prior to treatment, 58% (n = 19) had no reported psychological IPV use at the post-treatment assessment. There was also a significant change in the proportion of veterans with self or partner reported coercive control behaviors baseline to the post-treatment phase . Of the 25 veterans with self or partner reported use of coercive control behaviors prior to treatment, 64% (n = 16) had no reported use of coercive control at the post-treatment assessment. The McNemar test for change in proportions for those with self or partner reported use of reproductive control behaviors was not significant; however, there were only two veterans with self or partner reported use of reproductive control behaviors at baseline.There was also a significant change in the proportion of veterans with self or partner reported physical IPV use from baseline to the post-treatment phase  = 3.29, p < .01, Hedge’s grm = .39 (medium). Mean scores on the PCL5 decreased from 46.40 (SD = 22.42) to 37.58 (SD = 21.08) from pre-post-treatment. The change in alcohol misuse was not significant, p = .20; the mean AUDIT score was 4.74 (SD = 6.64) at pre-treatment and 3.62 (SD = 8.20) at post-treatment. Findings for PTSD symptoms were not hypothesized, as SAH is not a PTSD treatment, although results suggest that the trauma-informed nature of the intervention may have an impact on PTSD.Results also indicate a significant pre-post-treatment decrease in PTSD symptoms, Post-treatment satisfaction data indicates that veterans were generally satisfied with the program  and the current results are consistent with that earlier research. Second, the outcome measures were limited in scope, most notably because we obtained only prevalence and not frequency counts for specific acts of IPV. However, the summary scores used in the current study are closely modeled after a widely used scoring method for measures of IPV, labeled “variety scoring,” which involves dichotomizing reports for each specific act of IPV and then summing the number (or variety) of different aggressive behaviors used [SAH. Further research is needed on program efficacy with women.The observational research design of program evaluation imposes important limitations on the interpretation of findings. The lack of a control group limits our ability to account for regression to the mean in IPV and PTSD symptoms. The naturalistic process of assigning patients to groups may increase effects by excluding patients who are less likely to benefit from the treatment, and non-randomized assignment precludes an intent-to-treat analysis. However, a previous randomized controlled trial  demonstrors used . Third, grm = .56) is reasonable compared to a prior randomized clinical trial of SAH. The current effect size is larger than the effect size found in the prior research control condition , but smaller than the prior research treatment condition . Some gap in efficacy is to be expected in initial broad-scale implementation as a result of clinician expertise, experience with the population and intervention, and treatment integrity. However, methodological factors likely contributed here as well. Most notably, the selection criteria for the original controlled trial required all participants to have engaged in recent physical IPV, whereas the implementation sample included participants with less recent IPV or only psychological IPV, thus reducing the potential magnitude of observed pre- to post-treatment reduction in physical IPV. In addition, the controlled trial also used more precise measures of IPV frequency. Importantly, in the implementation sample, the prevalence of any physical IPV at post-treatment for those who reported physical IPV at baseline (22%) is essentially identical to rate reported for SAH in the controlled trial (23%), and considerably lower than the rate observed in the treatment-as-usual control (43%).The observed effect size for pre- to post-treatment reduction in IPV in the current evaluation (SAH suggest that the intervention can be effectively delivered in real-world clinical practice at the VA. The observed reductions in IPV use in this implementation evaluation were consistent with the reductions observed in a highly controlled clinical efficacy trial [Preliminary results from the implementation of cy trial . Given dcy trial –12. Howe