Emergence agitation (EA) is a frequent phenomenon in children recovering from general anaesthesia and increases the risk of self-injury. Previously, our group reported that stimulating the heart 7 (HT7) acupuncture point bilaterally using two neuromuscular transmission monitoring devices (NTMs) decreased the incidence of EA. However, bilateral stimulation is a barrier to clinical use because two NTMs are needed for one patient.The objective of this study was to examine the efficacy of unilateral electrical stimulation of HT7 using an NTM to prevent EA in children.Prospective, double-blinded, randomized clinical trial.Kanagawa Children’s Medical Centre, Yokohama, Japan.One hundred children (ages 18–96 months) with ASA-PS I or II, who were scheduled to undergo inguinal hernia repair or orchiopexy under sevoflurane anaesthesia.Patients were randomly assigned to one of the following two groups: (1) HT7 group: unilateral (right side) stimulation of the HT7 acupuncture point using a single-twitch electrical stimulus  throughout the surgery, and (2) control group: electrodes alone were attached to the HT7 point on the right side; an electrical stimulus was not applied.The primary outcome was the incidence of EA evaluated using the pediatric anaesthesia emergence delirium (PAED) scale. The secondary outcomes were the incidence of EA evaluated using Aono’s scale, the severity of EA, PACU stay duration, and postoperative pain.There was no statistical difference between the incidence of EA in the HT7 and the control group . The risk ratio was 1.17 .We observed that there was no effect of unilateral single-twitch electrical stimulation to the HT7 on the incidence of EA, contrary to the findings with bilateral HT7 stimulation. Emergence agitation (EA) is a major postoperative problem in pediatric anaesthesia. PreventAcupuncture is considered to be one solution without pharmacological therapy.Acupuncture at the heart 7 (HT7) which is located on the ulnar side of the wrist seems to be effective in treating anxiety or a neeAcustimulation using a neuromuscular transmission monitor may be easy to perform because many anesthesiologists are familiar with this device compared to using a capsicum plaster or needle. However, in the previous study, bilateral HT7 stimulation was performed, which is a barrier to clinical use because two machines are needed for one patient. To utilize this method in a clinical setting, the conditions by which HT7 is electrically stimulated must be optimized.The objective of this study was to examine the efficacy of unilateral electrical stimulation of HT7 using a neuromuscular transmission monitor (NTM) to prevent EA in pediatric patients.Approval was obtained by the institutional review board of Kanagawa Children’s Medical Centre (No. 1308-07) on February 25, 2014. The study protocol was registered in the UMIN Clinical Trial Registry . Written informed consent was obtained from the parents of all patients. The study was conducted in accordance with the principles of the Declaration of Helsinki. This study took place at Kanagawa Children`s Medical Center from October 2014 to August 2015.This study was a prospective, double-blinded, parallel-group, randomized clinical trial. We recruited patients who were scheduled to undergo inguinal hernia repair or orchiopexy under sevoflurane anesthesia. Children were 18–96 months of age, with American Society of Anesthesiologists physical status I or II. Exclusion criteria were developmental delay, neurological or psychological disorders, abnormal airways, reactive airway diseases and usage of sedatives. We assume that there is no laterality on the effect of unilateral stimulation of HT7. We choose right hand to stimulate HT7 in this study. The enrolled patients were randomly assigned to one of the following two groups: in the HT7 group, unilateral right-side stimulation of the HT 7 acupuncture point was performed on patients using a single-twitch electrical stimulus throughout the surgery; in the control group, electrodes were attached to HT7 point on the right side, and an electrical stimulus was not applied.Group assignment was determined by opening a sealed, opaque, sequentially numbered envelope with a computer-generated random allocation. Both patients and observers were blinded to group allocation. Observers did not participate in anesthetic care in the operating room. Attending anesthesiologists opened the envelope after the completion of anesthesia induction. Attending anesthesiologists could not be blinded after starting electrical stimulation of HT7 because we don’t use the neuromuscular blockade in this trial. Electrical stimulation of the HT7 evoked movements of the patients’ hand, whereas patients in the control group did not move. To reduce bias, we used a standardized anesthetic protocol throughout the trial.Patients were not premedicated. We assessed patient’s anxiety using the short version of the modified Yale Preoperative Anxiety Scale (m-YPAS),12 beforDuring the operation, if the heart rate or blood pressure increased by more than 10% of the baseline data, 1 μg/kg of fentanyl was administered. After the operation was completed, 100% oxygen was administered and the tracheal tube or LMA was removed under deep anesthesia when adequate spontaneous ventilation was confirmed . After removal of the tracheal tube or LMA, the attending anesthesiologist confirmed that the patient was breathing spontaneously without any respiratory complications such as holding their breath, upper airway obstruction, or laryngospasm. The patients were transferred to the post-anesthesia care unit (PACU) with a stable airway and appropriate ventilation.The HT7 acupuncture point is located at the wrist crease on the radial side of the flexor carpi ulnaris tendon, between the ulna and pisiform bones. After the induction of anesthesia, electrodes were attached to the patient on the right arm, one electrode on the HT7 acupuncture point and another on the dorsal side of the acupuncture point . In the The primary outcome was the incidence of EA, evaluated by the Pediatric Anesthesia Emergence Delirium (PAED) scale. The secTrained observers, who were blinded to the patient allocations, assessed and recorded the patient’s recovery condition, including the PAED score in the PACU. Patients were evaluated every 5 min from the time they opened their eyes in response to a verbal command or light touch, until they left the PACU. The theoretical scores on the PAED scale range from 0 to 20; on Aono’s scale, the scores range from 1 to 4. If the highest recorded score while in the PACU was ≥ 10 on the PAED scale or ≥ 3 on Aono’s scale, this was considered as EA, 14. TheWe used the data from the previous study by our group for sampStatistical analyses were performed using the R statistical software package, version 3.0.2 .The Shapiro–Wilk test was used to assess the normality of the data distributions.t-tests. Categorical data are reported as percentages, and were analyzed using Fisher’s exact test or the chi-squared test as appropriate. Data not distributed consistent with normality are reported as the median and interquartile range (IQR), and were analyzed using the Mann–Whitney U test. The risk ratio (RR) with a 95% confidence interval (CI) was calculated for our primary outcome . Statistical significance was declared at the 0.05 level.Data distributed consistent with normality are reported as mean ± standard deviation and were analyzed using unpaired All 100 enrolled subjects completed the study  and recrP > 0.99) . The risk ratio (95% CI) was 1.17 (0.60–2.27) . A simil > 0.99) .There was no statistically significant difference between the PAED scores between the HT7 and control groups  . DuratioIn this study, we showed that unilateral electrical stimulation of the HT7 did not have a significant effect on preventing EA. The severity of EA was similar to the control group, in which no electrical stimulation was applied. No adverse event was produced by electrical stimulation.Although we could not confirm the effect of unilateral HT7 stimulation on preventing EA, several studies have reported the effect of bilateral HT7 stimulation to prevent EA–10. The In this study, we applied stimulation to the HT7 under general anesthesia because children would not tolerate electrical stimulation while awake. However, stimulation under general anesthesia may have diminished the effect of acustimulation, 19. We This study has several strengths. First, we evaluated EA using both the PAED scale and Aono’s scale. Although the PAED scale is the only validated scale to measure EA, a previThis study has some limitations. First, the attending anesthesiologists could not be blinded to the group allocations after starting electrical stimulation of HT7. As we did not use a neuromuscular blocking agent, hand motion in patients provoked by electrical stimulation of the HT7 revealed the group allocations. Therefore, we used a standard anesthetic protocol to reduce bias in this study. In addition, to ensure data integrity, the patients and the observers were blinded to the group allocations. Second, we enrolled patients who were scheduled to undergo hernia repair or orchiopexy under sevoflurane anesthesia. We cannot extrapolate the results of this study to patients who received propofol anesthesia or those undergoing other operative procedures. Third, the current study may be underpowered because power analysis was performed based on the data of previous study on our group. In this study, incidence of EA in control group was lower than previous study of our group . This could be another reason for having obtained negative results in this study.In conclusion, there was no difference in the incidence of EA between the unilateral HT7 stimulation group and the control group, contrary to previous findings with bilateral HT7 stimulation. Further research is warranted to elucidate all the effects of HT7 stimulation.S1 FigA: One NTM electrode was attached just above the HT7 acupuncture point. B: Another electrode was attached on the dorsal side of the HT7 acupuncture point. We stimulated HT7 on both sides using NTM (TOF-Watch). Single-twitch stimulation at 1 Hz  was applied throughout the operation.(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S1 File(DOC)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S3 File(DOCX)Click here for additional data file.


A 46‐year‐old male with a superior mediastinal mass presented with a one‐month history of hoarseness and chest pain and was referred to our hospital. Although endobronchial, ultrasound‐guided, transbronchial needle aspiration (EBUS‐TBNA) was initially performed, we could not obtain an adequate specimen because of his severe cough and an inadequate EBUS view. During the same endoscopic session, we performed endoscopic, ultrasound‐guided, bronchoscopic fine‐needle aspiration (EUS‐B‐FNA) via a transoesophageal approach using the BF‐UC290F , a third‐generation EBUS‐TBNA endoscope. The BF‐UC290F enabled smooth access through the oesophagus and a clear EBUS view of the mass, attributable, respectively, to the compact distal tip and the powerful angulation. Rapid on‐site cytology revealed that an adequate specimen had been obtained, and we terminated the procedure without inducing a severe cough. Histologically, the mass was a squamous cell carcinoma. EUS‐B‐FNA employing the BF‐UC290F was useful to diagnose the superior mediastinal mass. Endobronchial, ultrasound‐guided, transbronchial needle aspiration (EBUS‐TBNA) appears to be at least as effective as mediastinoscopy for mediastinal staging of non‐small‐cell lung cancer but has a lower rate of complications, rendering the former procedure the initial investigation of choice in many institutions. If the tumour is located near or adjacent to the large airway, EBUS‐TBNA is diagnostically useful and safe A 46‐year‐old male who had presented with a one‐month history of hoarseness and chest pain was referred to our hospital. He had no relevant medical history. On physical examination, chest auscultation revealed slightly diffuse expiratory rhonchi, but no other significant abnormality. His peripheral arterial blood oxygen saturation was 96% on room air. He was a current smoker. Chest computed tomography (CT) revealed a superior mediastinal mass Fig. A and pulWe initially chose EBUS‐TBNA for diagnosis. A total of 5 mL 2% (w/v) lidocaine was sprayed into the pharynx, and another 5 mL of 2% (w/v) lidocaine was administered via the channel during the procedure. A conventional flexible bronchoscope  was employed; intubation was achieved using a siliconized, uncuffed tracheal tube of internal diameter 7.5 mm . A bronchoscope  was orally inserted during fentanyl‐ and midazolam‐induced conscious sedation. The patient received fentanyl 100 μg) and midazolam (8 mg) during the procedure. However, the EBUS‐TBNA approach failed because of his severe cough and an inadequate EBUS view (Fig. 00 μg andThe BF‐UC290F, a third‐generation, reliable, Olympus EBUS‐TBNA endoscope In conclusion, EUS‐B‐FNA performed using the BF‐UC290F effectively diagnosed a superior mediastinal mass. EUS‐B‐FNA can be performed in the same endoscopy session if bronchoscopy and EBUS‐TBNA fail.Appropriate written informed consent was obtained for publication of this case report and accompanying images.


The Clinician Scholar Program (CSP) is an enhanced-skills (R3) residency program to train clinician researchers/educators/leaders for academic family practice. This article intends to share Laval University’s CSP development and evaluation strategy, and provide recommendations for similar innovations in other disciplines/settings.This article uses Kern’s model to present the program development, and a program-oriented approach for program evaluation, carried from 2011 to 2017 using descriptive data. Questionnaires, reflexive texts and an Objective Structured Teaching Exam supported data collection.Seven CSP graduates and 14 controls participated in the program evaluation. Residents were highly satisfied with the program, nevertheless they suggested to allow physicians to come back for training later in career. The CSP enriched knowledge, skills and attitudes about academic practice. CSP increased residents’ entrustment level about academic competencies. All graduates joined an academic practice within five years of program completion.Key recommendations to implement similar programs include academic medicine core training, project- based learning with learner-centered objectives, relevant and authentic learning and assessment, and multi-level program evaluation approach. Programs should consider concomitant graduate studies and opportunity to offer such training after a few years of clinical practice to meet other needs at a timely stage of career. As in United States,7 in all three academic missions.Since 2009, the College of Family Physicians of Canada (CFPC) has been encouraging medical schools to offer a Clinician Scholar Program (CSP) as an enhanced-skills  program. Currently, most CSPs offered in Canada are research- oriented and offered in English. Université Laval’s CSP is intended to train clinician researchers, educators and leaders in clinical and academic francophone settings, promoting scholarship5 this article intends to share our CSP development and first five years’ program evaluation strategy and provide recommendations for similar academic fellowship in other settings.As proposed by Thompson,The CSP aims to train competent faculty who are aware of the importance of scholarship as a way to enhance their institution’s national and international outreach, as well as their own. Residents involved in this program mostly complete it as a full-time PGY3, but may also spread it over PGY2 and PGY3 during completion of their second year of family medicine residency training. The CSP curriculum starts with a core Academic Medicine rotation where all residents are trained around academic practice requirements, strategies, and its expected scholarship. An elective in clinical research, medical education or academic management/leadership then allows them to enhance their skills in a one of these academic missions, and clinical activities are spread over the rest of the year , to prov2,5,6 This article uses Kern’s steps to present the program development8  to discuss local needs around training for academic practice. Needs assessment included discussions with local faculty, analysis of the CFPC standards for the new CSP programs, and a literature review. The program therefore built on similar existing programs.lopment8 .http://www.fmed.ulaval.ca/programmes-detudes/etudes-en-medecine/residences-etudes-medicales-postdoctorales/residence-en-clinicien-erudit/presentation/) and targeted solicitation by site directors facilitated resident recruitment.Presentation of the program to medical students at Laval University “Salon des programmes de residences”, program website , informed consent and confidentiality in data management and reporting results.Reaction. We assessed reactions to the program activities using a feedback questionnaire at program completion, providing a satisfaction score (product of relevance (/5) x met expectations (/3)) and assessing general satisfaction and workload. Since the Medical and Academic Leadership/Management elective was particularly innovative, we analyzed the strengths and avenues for improvement of this rotation with a preceptor survey.Learning. We assessed learning using a retrospective pre-post self-evaluation questionnaire.11 Self-assessment scales regarding achievement of program evaluation objectives drew on Bloom’s (knowledge),12,13 Simpson’s (skills),14 and Krathwohl’s (attitudes)15 taxonomies. We also asked each resident to identify three take-home messages from the program.Behaviour. We assessed the impact of the CSP on resident behaviour also using a retrospective pre-post self-evaluation questionnaire,11 as well as content analysis of reflective texts written by residents upon completing the program, applying a framework for analysis relating to the three academic missions.16 translated and adapted with permission. The assessment grid was adapted from the CFPC’s fundamental teaching activities framework.17Finally, we assessed the impact of the Medical Education track on residents’ teaching behaviours using Objective Structured Teaching Exams (OSTE) held at the outset and the end of the program, each learner being paired with another resident of equivalent level of training demonstrating a similar interest in education (control). The examination used Morrison et al.’s teaching scenarios,Results. The “results” component of this program evaluation compares the scholarship of CSP graduates with other new clinical faculty who joined our department between 2011 and 2015 (control group), and their intention to practice in an academic setting five years of graduation. We assessed the factors influencing this intention with a social cognitive theory-based questionnaire.18Five to seven CSP of the 7 graduates (71-100%) and 14 of the 20 new clinical faculty who joined our department between 2011 and 2015  took part in the program evaluation . One third of graduates and 20% of the control group held graduate degrees in addition to their medical degree.The general satisfaction with the program was high (4.7±0.5/5). The workload was appraised as demanding to very demanding (4.3±0.5/5). The most appreciated activity was the Academic Medicine intensive workshops . All graduates would recommend the program to colleagues interested in academic practice.clinical: local/regional/provincial; academic: teaching site/program/department/faculty level), as well as the resident project spinoffs for the teaching site. Suggested improvements included focusing on some activities and choosing a limited number of supervisors to enhance educational continuity, dispersion across activities and supervisors, better defining resident and supervisor roles and responsibilities, and allowing later enrollment into the program, i.e. after at least 2-5 years of clinical practice including experience in leadership/management.Program evaluation specific to the Medical and Academic Leadership/Management elective has highlighted the various levels of practicum exposure  at program completion highlights the development/improvement of a number of behaviours associated with practice in the three academic domains : graduatIntention to practice in an academic setting five years of graduation was similar between graduates  and controls (4.9±0.36/5). Despite small sample size, available research/leadership opportunities, academic workload and seeking professional-personal life balance seem to influence CSP graduates’ intention to practice in an academic setting five years after graduation, whereas the possibility to practice in a large urban center, reduced clinical exposure and available teaching opportunities seem to have more influence on other new clinical faculty.  focuses mostly on teaching and scholarly projects, with leadership training components. This program increased confidence in teaching skills, and increased scholarly work output.20 While we noticed an interest in the CSP during residency program promotion events or information requests, more specific data about impact on applicants to our family medicine residency program would be helpful.The CSP at Université Laval offers a francophone training environment for a new wave of academic family physicians working towards a scholarship perspective. It is one of the rare programs targeting basic skills development in the entire range of academic medicine missions. Some schools have developed similar programs, but we found only two who have published their program description and/or evaluation. The first, from the Department of Family Medicine of the University of Western Ontario  aimed “to produce academic family physicians who exhibit […] outstanding clinical skills, professional interest in the organization and transmission of knowledge, and a scholarly approach through research and skills of leadership.3,6,21-25 Despite the absence of obvious impact of the CSP on the factors influencing intention for academic practice, it succeeds in providing tools supporting early academic career.The reactions to the program are strongly positive, particularly for the academic medicine rotation. This is probably related not only with its content (principles of scholarship being new for many residents) and structure (project-based learning), but also by residents’ discovery of and involvement in a new community of academic practice. In general, our program resulted in learning, behaviours, and results that are comparable to those obtained in related programs, with similar challenges.27 , which undeniably affected the program’s recruitment capacity and might explain decreased academic productivity following the program. Finally, the small size of the contingent of residents we can enroll and the choice we made of choosing an outcomes-based evaluation strategy do limit the conclusions we can draw from the program evaluation. Assessment of other aspects than outcomes  would also be relevant for program directions. Nevertheless, our program evaluation strategy provided some qualitative data reinforcing that we meet the training needs of the new generation of family medicine faculty.This program development and evaluation has certain limitations. To date, the CSP has mostly attracted applicants for the Medical Education track. The Clinical Research track might be more attractive if combined with a master’s degree, therefore facilitating a clinician-researcher career for graduates. Furthermore, the limited number of applicants for the Medical and Academic Leadership/Management track suggests that interest in and need for this type of training emerges later in one’s career. We are currently considering the possibility of offering this training after a few years of clinical practice in addition to the current third year residency enhanced-skills program. Other limitations result from political pressure to take on unattached patients in Quebec since 2014Université Laval’s CSP is a unique francophone residency program supporting new family physicians in an early academic career, balancing their clinical and academic roles with confidence in an environment fostering scholarship, mentorship, and networking. Program structure and content appears easily transferable to other specialties. We are confident that other medical schools should succeed in implementing similar programs in their own setting, to prepare the next generation of academic medical faculty. Key recommendations to implement similar programs  include


Endoscopic balloon dilation (EBD) has been effective for small-bowel strictures in patients with Crohn's disease (CD). However, its efficacy and indication for small-bowel strictures in non-CD patients have not been established. This study evaluated the clinical efficacy and safety of EBD for small-bowel strictures in non-CD patients compared with CD patients.  Ninety-eight consecutive patients  with small-bowel strictures diagnosed by double-balloon endoscopy were retrospectively evaluated at Hiroshima University Hospital from August 2003 to April 2017. The average number of procedures, short-term and long-term EBD success rates, and safety profiles between the non-CD and CD groups were examined.  Surgery was selected as the initial treatment in 44 cases (45%) ; CD group, 17 (39%)) as EBD is not indicated. Fourteen non-CD patients had strictures due to malignant tumors, while 13 patients had benign strictures. Twenty-three patients  underwent EBD. Forty-three EBD procedures were performed for 17 stricture sites (average: 2.5 procedures/site) in non-CD patients and 41 EBD procedures for 18 stricture sites (average: 2.3 procedures/site) in CD patients. The short-term success rate was 100% (23/23), whereas the long-term success rate was 92% (11/12) in non-CD patients and 82% (9/11) in CD patients. No significant differences in the surgery-free rate occurred between both groups. Furthermore, one adverse event, bleeding after EBD, was encountered in the non-CD group .  EBD for small-bowel strictures demonstrated good clinical outcomes in non-CD patients. Recently, small-bowel diseases such as ulcerations, angiodysplasias, tumors, and strictures can be diagnosed by balloon endoscopy and capsule endoscopy (CE). Particularly, double-balloon endoscopy (DBE) and single-balloon endoscopy have been widely used for the diagnosis and endoscopic treatment of small-bowel diseases. In 2001, Yamamoto et al. .Small-bowel strictures are often caused by chronic inflammatory diseases such as Crohn's disease (CD). In CD patients, the risk of surgery 10 years after a diagnosis of intestinal stricture was 38–55% in a population-based cohort study . CD patiEndoscopic balloon dilation (EBD) has recently been effective in treating small-bowel strictures caused by CD . HoweverThe causes of small-bowel strictures in non-CD patients are diverse, including neoplasms, nonsteroidal anti-inflammatory drug- (NSAID-) induced ulcerations, intestinal tuberculosis, enteritis, and postsurgical strictures. Although the utility of EBD in CD has been reported, there are few reports on the efficacy and safety of EBD for small-bowel strictures caused by non-CD conditions, such as strictures caused by NSAID-induced ulcerations , 11. CurThis study thus is aimed at evaluating the efficacy and safety of EBD for small-bowel strictures in non-CD patients compared with CD patients.We retrospectively examined 98 consecutive patients  with small-bowel strictures, who were among 1,318 patients who underwent DBE from August 2003 to April 2017 at Hiroshima University Hospital. Regardless of the presence of abdominal symptoms from gastrointestinal obstruction, a small-bowel stricture was defined as a lesion wherein an endoscope could not pass through. We excluded the cases that we could not observe for more than 1 year in this study. We performed EBD for small-bowel strictures in 23 patients . Hence, a total of 23 patients were evaluated in this study.This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of the Hiroshima University Hospital . All patients were informed of the risks and benefits of EBD and provided written informed consent prior to the procedure. None of the patients refused to undergo EBD for small-bowel strictures during the study period.The indications for EBD were as follows: (1) small-bowel strictures causing obstructive symptoms or proximal extension from the stricture site as shown by diagnostic imaging (fluoroscopic examination or computed tomography), (2) benign strictures wherein an endoscope could not pass through, (3) stricture length ≤ 5 cm, and (4) strictures without a fistula, abscess, deep ulceration, severe adhesion, or curvature .Our management for small-bowel strictures was as follows. In cases of small-bowel stricture due to malignant tumor, we selected surgical resection or bypass considered by general condition. In cases of benign small-bowel stricture, we selected EBD as the first choice when the above adaptation was satisfied. We selected surgery if patients did not satisfy the EBD indication. In asymptomatic cases of benign small-bowel strictures, we selected medical treatment or follow-up.The patients underwent overnight fasting in preparation for EBD. In principle, we selected the antegrade approach for the procedure. EBD was carried out using a DBE  and an 8–18 mm through-the-scope (TTS) balloon catheter  measuring 7.5 Fr and 5.5 cm in length. The size of the balloon was determined according to the size of the stricture site. The balloon was positioned across the stricture and filled with diluted Gastrografin and was inflated to a pressure of 1–8 atm for 30 s. Dilation was performed by monitoring the pressure of the inflated balloon using a dilator under X-ray guidance. The maximum dilation diameter and balloon pressure were confirmed by fluoroscopy and determined at the discretion of the operating endoscopists. After dilation, we performed a small-bowel follow-through using Gastrografin to confirm leakage outside the intestinal tract .We evaluated the average number of procedures, short-term and long-term EBD success rates, and safety profiles between the non-CD and CD groups. Complications were defined as perforation and active bleeding requiring surgery or blood transfusion after EBD. Short-term EBD success was defined as the disappearance of abdominal symptoms due to gastrointestinal obstruction and long-term EBD success as having no surgery for >1 year. Oral-side intestinal extension was defined as existence of a clear stricture of the small-bowel toward the oral side by computed tomography or transabdominal ultrasonographic examination. Meanwhile, endpoint of EBD was defined as successfully passing the endoscope through the stricture site. In our hospital, EBD was performed repeatedly when an endoscope could not pass through the stricture site. Redilation was performed when abdominal symptoms recur due to gastrointestinal obstruction.P value of <0.05 was regarded as statistically significant. The software program JMP Pro 13  was used for the statistical analyses.The chi-squared test or Fisher's exact test was used for comparison of frequencies. The Kaplan-Meier method and log-rank test were used for analyzing the cumulative surgery-free rate. A We performed EBD for 12 cases of small-bowel strictures in the non-CD group. The primary diseases of these EBD cases are shown in All EBD procedures were performed successfully in both CD and non-CD groups. All 23 patients had confirmed disappearance of abdominal symptoms after EBD. Thus, the short-term success rate was 100% in both groups. Five patients underwent surgery during the observation period: two patients in the non-CD group  and three patients in the CD group . In the additional surgery cases in the non-CD group, the etiologies of small-bowel strictures were intestinal tuberculosis and circumferential small-bowel ulceration due to intraperitoneal band. The cases received repeated EBD, but their symptoms did not improve. Therefore, we selected surgery. The reasons for surgery were as follows: recurrent abdominal symptoms resistant to medical treatment or EBD  and remaining strictures that could not be approached by DBE . Two patients (1 from each group) underwent surgery >1 year after initial EBD. The long-term success rate was 92% (11/12) and 82% (9/11) in the non-CD and CD groups, respectively. As shown in Bleeding occurred in only one case in the non-CD group (8%) after EBD for stenosis, due to scar after ML chemotherapy. In this case, EBD was performed repeatedly because of recurrent symptoms of abdominal obstruction. After four EBD procedures, the patient had a melena and progression of anemia. Although the patient required blood transfusion, the bleeding was stopped by conservative treatment including fasting and infusion of hemostatic drugs. No complications were found in the CD group.This study investigated the therapeutic management of small-bowel strictures with EBD in both non-CD and CD patients. With the development of the endoscope, we can easily observe the small-bowel using DBE. DBE can be used for histological diagnosis by forceps biopsy and for endoscopic treatment of small-bowel disease . In clinRecently, a few cohort studies reported that EBD can be an alternative treatment to surgery for small-bowel strictures in CD , 13–16. To our knowledge, there are only few cohort studies or case reports on the efficacy and safety of EBD for strictures in non-CD patients , 18–21. A few cases of EBD for small-bowel strictures due to NSAID-induced ulceration, one of the representative conditions causing gastrointestinal strictures in non-CD patients, have been reported , 11, 25.Our study revealed that the observation period was significantly longer in the CD group. CD patients are required long-term follow-up because of repetition of relapse and remission. On the other hand, it is rare to repeat relapse by eliminating the causes in non-CD cases of benign small-bowel strictures, such as NSAID-induced ulceration. There are many benign strictures, and their clinical backgrounds seem to have difference in the observation period in this study.This study has some limitations. First, it is a single-center retrospective study. The retrospective design could have resulted in recruitment bias. Second, the number of participants was relatively small. Hence, further large prospective cohort studies will help evaluate the key predictors of long-term EBD success. Third, small-bowel strictures were caused by several etiologies. Although we examined various etiologies of small-bowel strictures in the non-CD group, the list remains limited. Lastly, the procedures were not performed according to a defined study protocol. Balloon diameter, interval between dilations, length of follow-up, or technical approach may vary even between patients analyzed in the same study. Therefore, large cohort studies that evaluate the long-term results of EBD according to each etiology and follow a defined endoscopic approach are necessary.EBD is a safe and effective treatment for small-bowel strictures in both non-CD and CD patients. In cases of benign small-bowel strictures, EBD was an effective treatment regardless of the etiology. However, it is necessary to prospectively observe a larger number of patients for a longer period to confirm these results more precisely.


Endobronchial ultrasound-guided trans-bronchial needle aspiration (EBUS-TBNA) is minimally invasive technique used for diagnosis and/or staging of benign and malignant pulmonary and non-pulmonary disease. Previous studies have established the utility of EBUS-TBNA in narrowly defined indications and populations. In this pragmatic ‘real world’ study we have analysed the use of EBUS-TBNA for a variety of clinical presentations and its clinical application in conjunction with other invasive investigations.All EBUS-TBNA procedures performed at Sir Charles Gardiner Hospital in 2012–2014 were reviewed retrospectively, using relevant hospital databases.A total of 327 patients underwent 337 EBUS-TBNA procedures. EBUS-TBNA procedures were used to diagnose a wide spectrum of benign and malignant conditions. The main application was in the diagnosis and staging of malignant conditions (70.6%), and in the diagnosis of benign conditions such as sarcoidosis 40 (12.2%), and silicoanthracosis 17 (5.2%). EBUS-TBNA was sufficient to diagnose and stage the disease as a single stand-alone invasive procedure in 191 (59.2%) patients. EBUS-TBNA was the final invasive procedure undertaken in 283 (87.6%) patients. Only 13.3% of non small cell lung cancer (NSCLC) patients who had EBUS-TBNA as a first investigation required multiple procedures compared to 51.1% of all NSCLC patients undergoing EBUS-TBNA. Overall sensitivity, specificity, NPV and diagnostic accuracy for EBUS-TBNA were 89.7, 100, 85.1 and 89.9%, respectively and three minor complications (0.9%) occurred as a result of the procedure.EBUS-TBNA was undertaken for a wide variety of clinical conditions. Good diagnostic accuracy and safety profiles were demonstrated for the procedure, supporting its application as a first line investigation in the diagnosis and/or staging of a range of malignant and benign conditions. Our study was unique in its documentation of the use of EBUS-TBNA in a real-world setting in conjunction with other invasive modalities. EBUS-TBNA was utilised as a stand alone invasive procedure in more than half of the patients. Importantly, in NSCLC, when EBUS-TBNA was performed as primary diagnostic and staging investigation, less patients underwent subsequent invasive procedures. Endobronchial ultrasound-guided (EBUS) procedures utilise ultrasound imaging for visualisation and sampling of lung tissue and lymph nodes through the wall of the trachea and bronchi. EBUS is a minimally invasive procedure with a very low complication rate, which has become standard practice in many institutions internationally , 2. The EBUS is available in two forms: EBUS guided trans-bronchial needle aspiration (TBNA) via the linear probe (EBUS-TBNA) and the EBUS radial probe via a guide sheath (EBUS-GS). Each form has specific benefits and services different patient disease presentations.EBUS-TBNA uses a dedicated bronchoscope and allows real-time TBNA of mediastinal and hilar lymph nodes and masses. A frequent application of EBUS-TBNA is in the accurate nodal staging of lung cancer , 3, howeComputed tomography guided transthoracic needle aspiration (CT-TTNA) can be used to gain peripheral tissue samples from the lung and provides good diagnostic accuracy, however carries a risk of pneumothorax  and expoA strong evidence base addressing the effectiveness, efficacy and safety of the EBUS-TBNA technique already stands, however most studies have analysed the diagnostic performance in narrowly defined populations , 16, 20.We retrospectively reviewed all EBUS-TBNA procedures performed at Sir Charles Gardiner Hospital (SCGH) between 1 January 2012 and 31 December 2014. Data regarding the clinical application, diagnostic performance and safety of EBUS was extracted using relevant hospital databases. Patient details such as age, gender, smoking history and Eastern Co-operative Oncology Group Performance Status (ECOG)  were recEthics approval was granted by the SCGH Human Research Ethics Committee (Ref. No 2013–233). Waiver of consent was granted for inclusion of patients who had EBUS in 2012, 2013 and January–February 2014, while patients included in the study after February 2014 provided consent for access to their medical records.Patients at SCGH were generally presented to the lung multidisciplinary meeting (MDM) after an initial CT scan of the thorax and upper abdomen and, in the majority of the cases results of a positrom emission tomography (PET) scan, which guided recommendations for an EBUS-TBNA investigation. Mediastinal lymph nodes were sampled if they were enlarged radiologically (> 1 cm) in the short axis and/or were PET positive. In general, if there was a pulmonary mass or nodule and evidence of mediastinal or hilar lymph node involvement, the lymph node was sampled first on the grounds that diagnosis and staging might be achieved with one procedure. Lymph node sampling was undertaken by first needling the lymph node that constituted the highest stage (N3) and progressing down to the lowest stage. Rapid on-site evaluation (ROSE) was undertaken and the adequacy of the sample was assessed by the presence of lymphocytes and evaluation by the pathologist. The site and number of lymph node stations sampled and the number of passes per lymph node were determined by the operator. At least three needle passes were made per lymph node unless the diagnostic material was reported adequate on ROSE. If the lymph node samples were non diagnostic then the pulmonary lesion would be targeted for diagnostic purposes by EBUS-GS if suitable, or otherwise by CT-TTNA. Some patients were referred to our service from other sources and may have had a diagnosis already established but required staging or sampling for molecular analysis.Hilar and mediastinal lymphadenopathy or mediastinal masses were directly sampled by EBUS-TBNA. EBUS-TBNA was performed under general anaesthesia.For the purpose of this study, cases referred for EBUS-TBNA were divided into two categories based on the intention of the procedure: 1) to confirm, stage or exclude malignancy, 2) to obtain tissue diagnosis for suspected benign conditions, based on clinical or radiological evidence. Cases were also classified into four sub-groups, based on radiological manifestations: those with a lung mass or nodule only, those with a lung mass or nodule and hilar or mediastinal lymphadenopathy, those with a hilar or mediastinal mass only, or those with hilar or mediastinal lymphadenopathy only.malignant when malignant cells were present, and benign when normal lung or lymphatic tissue with no malignant cells were seen. Inadequate samples were excluded from sensitivity and specificity analysis, but included in diagnostic accuracy. Standard definitions of sensitivity and specificity were used.Pathology results were reported as Cyto- and histo-pathological specimens for cases in category one were considered true positive if malignant cells were reported and true negative if an adequate sample showed no malignant cells and further clinical follow-up, pathological findings, or medical imaging confirmed the result. False negative specimens failed to detect malignancy in an adequate sample and malignancy was later clinically, radiologically or pathologically detected in the same lymph node, mass or region.Cyto- and histo-pathological specimens in category two were considered true positive if the sample was adequate for diagnosis of a benign condition, and false negative when the sample was normal and diagnosis was established by other means. Specimens were considered true negative if pathology was not identified in an adequate sample.All available clinicial documentation, radiological investigations, invasive investigations and pathological results relevant to the same provision of care were reviewed and recorded. All additional invasive investigations and their temporal relationship to EBUS were recorded if they related to the same provision of service. Four patients, referred from external sources, with incomplete records were excluded from the analysis of additional invasive procedures. The minimum follow up time for records after EBUS-TBNA procedure was 12 months, however patients without a clear final diagnosis or with non-diagnostic results of EBUS were followed up for two years.Data was analysed using the IBM SPSS Version 22 statistical software package. A descriptive analysis was performed where categorical variables were expressed as absolute and relative frequencies, and continuous variables were calculated as means.The demographic characteristics of all patients are recorded in Table A total of 327 patients underwent 337 EBUS-TBNA procedures. Of these, 317 patients had one and ten patients had two EBUS-TBNA procedures.EBUS-TBNA sample site locations , and 30 for patients with suspected benign conditions (category 2). Within category 1, 249 (81.1%) procedures were performed for diagnosis with or without staging, 53 (17.3%) were for cancer staging, and 5 (1.6%) for material for molecular tests.There were 297 (90.8%) category 1 patients where EBUS-TBNA was requested to confirm, stage or exclude malignancy. Of these patients 166 (55.9%) presented with a lung mass/or nodule and hilar/mediastinal lymphadenopathy, 105 (35.4%) with hilar/mediastinal lymphadenopathy, 26 (8.8%) with a hilar or mediastinal mass.There were 30 (9.2%) category 2 patients where EBUS-TBNA was requested to obtain tissue diagnosis for suspected benign conditions.Of the 323 patients with records of their invasive investigations, EBUS-TBNA was sufficient to diagnose and stage the disease as a single stand-alone invasive procedure in 191 (59.1%) patients. One hundred and eight (33.0%) patients underwent other invasive investigations in addition to EBUS-TBNA, and 24 (6.7%) had multiple EBUS procedures  required EBUS-TBNA alone  mutation, although in the initial stages of this study such testing was undertaken after discussion at the MDM since the test did not have Government remuneration. Kirsten rat sarcoma (KRAS) mutation was not performed if the EGFR was positive, since EGFR and KRAS are mutually exclusive in a patient, and since KRAS is not yet a targetable lesion. Anaplastic lymphoma kinase (ALK) gene rearrangement testing was performed in patients with adenocarcinoma who were EGFR negative; BRAF was performed in patients with melanoma, and C-MYC mutations in patients with lymphoma. Of 60 EBUS-TBNA samples sent for molecular testing, positive results were reported for 25 (41.7%) and 35 (58.3%) were negative. KRAS mutations, which were not routinely tested, were identified in 12 (20%) samples, EGFR mutations in five (8.3%), and ALK rearrangement was demonstrated in two samples (3.3%). A BRAF gene mutation was detected in five (8.3%) patients with metastatic melanoma and a C-MYC mutation was detected in one (1.7%) patient with non-Hodgkin lymphoma..Three complications (0.9%) occurred as a result of EBUS-TBNA. Two procedures were complicated by haemorrhage. One case was registered on a postprocedural X-ray and resolved without additional interventions, the second occured at the time of TBNA and while haemostasis was restored during the procedure, the presence of hypoxia required an overnight admission for observation. One patient developed wheeze, dyspnoea and cough following EBUS-TBNA and was admitted for treatment and observation. There were no obvious complications during the procedure and the post-procedural symptoms were thought to be due to gastro-oesophageal reflux and laryngospasmThis study showed that EBUS-TBNA was utilised for a wide variety of clinical conditions in our institution. The main application was for diagnosis and staging of lung cancers, with 81% of these being non small cell lung cancer (NSCLC). EBUS-TBNA has previously been shown to have an essential role in the diagnosis and staging of lung cancers. It is recommended in current international and Australian guidelines as a first line investigation of lung malignancies with mediastinal lymph node involvement , 18, 22,In our study, five EBUS-TBNA procedures were indicated for the specific purpose of determining molecular characteristics of lung cancers, and molecular testing was performed in 17.8% of EBUS-TBNA procedures. With further development of targeted oncological therapies it is expected that the use of EBUS-TBNA in this area is likely to expand in the future .The literature reports typical diagnostic yields for EBUS-TBNA ranging between 80 and 100% –29. Our The relatively high diagnostic accuracy of EBUS-TBNA in our study could be due to the availability of ROSE, which allows for confirmation of true positive results, reducing the need for unnecessary additional passes, and confirmation of sample adequacy through the presence of lymphocytes . FurtherEBUS-TBNA is often used in the diagnosis of sarcoidosis with various levels of diagnostic accuracy reported. Two meta-analyses reported a pooled diagnostic accuracy of 79% (range of 54 to 93% and SD 24%) , 34, andThe highest observed sensitivity was for samples with malignant final diagnosis (91%), however the NPV of this group was much lower than that of cases with benign final diagnosis . The low NPV mandates further sampling if clinical suspicion of alternative disease is ongoing and a negative result is obtained. In our study the sensitivity and specificity of EBUS-TBNA for NSCLC was 90.8 and 100%, respectively, higher than the median sensitivity of 89% (range 46 to 97%) reported in a recent meta-analysis .This study was unique in its recognition of the clinician’s real-world use of EBUS-TBNA in combination with other invasive investigations. In the past decade, the refinement of EBUS procedures has allowed patients to experience a less invasive and expediated process in diagnosis and staging of cancer. Ideally, the initial invasive investigation for lung cancer should simultaneously provide tissue for histopathological diagnosis, allow for additional molecular testing and accurately stage the disease. Minimising procedures required to diagnose and stage malignancy spares patients additional risks associated with procedures and importantly, expediates decision making and time to treatment commencement.In suspected cancer cases included in our study, 56.7% of EBUS-TBNA procedures were adequate as a stand alone invasive procedure for diagnosis and staging. This figure is reassuring and suggests an appropriate use of EBUS-TBNA in line with clinical practice guidelines.Although ideally diagnosis and staging are performed simultaneously with EBUS-TBNA, our study included a wider variety of clinical presentations including patients with extrathoracic disease requiring additional staging with EBUS-TBNA or metastatic spread from an intrathoracic origin requiring other invasive modalities. Inadequate prior samples, which may represent poor modality choice (EBUS or other) was recorded for 13 patients, representing 9.8% of those who underwent tests in addition to EBUS-TBNA.The largest radiological group requiring additional invasive sampling techniques were those with lung lesion and lymphadenopathy, where 89 (53.3%) required tests in addition to EBUS-TBNA. This group included 58 (65.2%) patients with established diagnosis where tissue sample was required for further tests or staging. Forty eight of these patients had undergone initial sampling with CT FNA, bronchoscopy, or other thechniques and EBUS was the last invasive modality. For 34 NSCLC cases EBUS-TBNA was done for staging and if it was considered as the first invasive investigation potentially multiple procedures may have been avoided. Furthermore, our study supports previous findings that when EBUS-TBNA is performed as primary diagnostic and staging method in NSCLC, patients are less likely to require subsequent invasive sampling procedures . Only 13Our hospital was the only institution performing EBUS-TBNA in the state at the time of data collection and thus some patients in this group may have not had access to the procedure, accounting for the choice of alternative initial invasive investigations.The literature reports an excellent safety profile, with a complication rate of 0.15% for EBUS-TBNA .We have assessed a heterogenous group of patients referred for EBUS-TBNA for different indications to one of the largest tertiary hospitals in Western Australia, and the only hospital in the state offering EBUS at the time. We recognise that this study has limitations. This was a single-centre retrospective study and the data is limited to the information available from hospital records. Due to its pragmatic approach, the study depicts the application of EBUS-TBNA procedures at our institution and our findings may have limited generalisability particularly given the performance of EBUS procedures under general anaesthesia.The diagnostic power and excellent safety profile of EBUS-TBNA already documented in the literature was reflected at our institution supporting its use as a first line investigation in patients with mediastinal and hilar lymphadenopathy with or without suspicious pulmonary nodules or masses. The application of EBUS-TBNA at SCGH is largely in the diagnosis and staging of lung cancer, with promising results to support its use in the diagnosis of a variety of benign and malignant conditions. EBUS-TBNA was used in conjunction with other invasive investigations with the aims of maximising diagnostic ability, providing material for molecular testing and accurately staging malignancy, while minimising invasive procedures required. EBUS-TBNA was effectively utilised as a stand alone invasive procedure in more than half of patients at our institution. Importantly, in NSCLC, when EBUS-TBNA was performed as primary diagnostic and staging investigation, patients underwent less subsequent invasive procedures.


Very few programs aimed at improving body image among adolescent boys have been effective, and there is still no clear evidence as to what will work for universal prevention of eating disorders and body dissatisfaction with this group. We combined two previously efficacious programs and used a design thinking framework to optimise program content alongside potential end-users including adolescent boys, teachers, parents, and experts. Goodform is a four-session universal program that aims to reduce body dissatisfaction and prevent the use of muscle-building supplements among 14-to-16 year old adolescent boys.Goodform will be trialled using a cluster randomised controlled trial (RCT) conducted in Australian schools, with Year 9 boys as participants. The intervention is teacher-delivered. Data will be collected at three time points: baseline, post-intervention, and follow-up (2 months). Three primary outcome constructs will be examined, including body dissatisfaction  and attitudes towards appearance and performance enhancing substances  and actual use of APES at each time point. Three secondary outcome constructs will be examined, which are social norms for APES , negative body talk , and internalisation of and pressure to attain appearance ideals . Internalisation of appearance ideals will also be examined as a mediator of change in primary outcomes. Teachers will provide data on adherence to lessons, student engagement/enjoyment, and understanding of the content.The GoodForm RCT will trial a novel, generalizable, and extensively developed program intended to improve boys’ body image and reduce actual and intended APES use. We anticipate that it will provide a novel contribution to the field of boys’ body dissatisfaction prevention.ACTRN12619000725167.This trial was retrospectively registered with the Australian and New Zealand Clinical Trials Registry on May 14th 2019, registration number  Goodform is a four-lesson classroom-based educational program for boys aged 14–16 aimed at improving body image, reducing positive outcome expectations for steroid use, and reducing intentions to use appearance and performance enhancing substances (APES). The program is based on two highly successful existing programs; ATLAS , and useThe intervention will be delivered by Health and Physical Education (HPE) teachers of Year 9 boys in secondary school, during weekly face-to-face HPE classes at participants’ schools. All teachers will receive a facilitator workbook  with structured activities and explanations for how to deliver the program. Resources to support delivery of activities are also provided. Attendance of participants will be monitored using attendance sheets for each lesson. Adherence to session content will be monitored using a self-report checklist completed by the teacher following each lesson.Participants will be allocated to the intervention or control group through cluster randomisation, at the school level. Intervention participants will complete questionnaires at baseline, receive the four-lesson program, delivered once-per week, and then complete 1 week post-intervention, and follow-up (2 months after post-test) self-report questionnaires. Participants in the control condition will complete questionnaires at parallel timeframes, but will not receive the intervention. Comparison of change over time between the intervention and control groups will inform evaluation of program efficacy. We hypothesise that, relative to the control group, the intervention group will show improved scores on primary outcomes  and secondary outcomes .Body dissatisfaction and related psychological disorders, including eating disorders, are now widely recognised as issues for boys and men . While pd = 0.30–1.00) among adult men. Programs that have improved both eating disorder symptoms and body image in boys include a media literacy program  program was one of the first to report a positive impact on the body image of adolescent male athletes in the USA . The fouDissonance-based approaches to body dissatisfaction interventions are theorised to work by creating a divide between how an individual behaves and their internalised attitudes; thus creating cognitive discomfort for the person. The discomfort can be resolved by the individual changing their attitudes to align with the behaviour . In the In order to combine and optimise the programs, we used a design thinking approach. Initially, all authors of the current paper, experts in body image, reviewed the content of the existing programs, obtained from the original authors, and the published papers reporting on these programs. We then held a workshop where we debated the importance, and developmental appropriateness of each of the activities in the existing programs, until we reached consensus on the activities that should be included. The fourth author (ZY) then used her expertise in education to create a proposed draft of the combined program. We worked with a design agency who created the branding and persona of the Goodform program, based on design thinking. The agency interviewed a number of adolescent boys to obtain the boys’ perspective on effective health education programs and school content relating to body image. Responses were presented to the research team, who adopted the suggestions provided in developing the program, such as the use of humour, language, and using a direct approach. As described above, the research team also conducted a range of user interviews with boys, parents, and teachers, described elsewhere . Outcomewww.goodform.org.au.The first lesson of the Goodform program was based on the initial discussion from the first lesson of The Body Project. We worked with the design agency to develop this as an interactive online tool and to align this activity with the guiding principles of 1) privacy and a safe space, and 2) interactive tools and multimedia . IllustrIn collaboration with a professional media agency, we also developed a short film for Goodform to clearly convey the idea that muscle building supplement use is not normal, acceptable, or advisable. This messaging was intended to contribute to the social norms component of the program . The film conveys how friends, girlfriends, parents, and sports coaches might react to discovering that the adolescent boy has been using an unnamed muscle building substance. We left the exact substance open to interpretation so that boys would interpret the film based on their current knowledge and experiences. Public health communication and social marketing campaigns often employ emotional tactics to create behaviour change. We used the literature from these research areas to inform the development and scripting of the film.Year 9 age 14–16) boys from Australian schools will comprise the study population. Inclusion criteria is being a year 9 boy attending a school who has consented to participate in the trial. There are no exclusion criteria. Schools will be recruited by a member of the research team contacting principals and HPE teachers, to invite them to agree to participate in the study and deliver the Goodform lessons as part of their HPE curriculum. To minimise administrative load for schools, we will use informed opt-out consent for parents and adolescent boys. We will use a thorough process to ensure that participants and their parents have sufficient opportunity to understand the research and ask questions of the research team. Three weeks prior to data collection, information sheets and explanatory videos about the project will be given to parents of all participants, and they will be encouraged to contact the researchers if they have any questions about their involvement in the project. To opt their child out of the research, parents will fill in an electronic opt-out consent form (included with the information sent to them). Boys will also be given an information sheet and an explanatory video aimed specifically at them (i.e. with age appropriate language), and encouraged to ask questions of the researchers or discuss the program with their parents. Boys can choose not to complete the questionnaire if they do not wish to participate. Complete details of the study procedure, including enrolment, intervention, and recruitment are displayed in Fig. 4–16 boysHealth and physical education teachers who deliver GoodForm will also provide feedback data for the project, should they consent to do so. HPE teachers will be recruited through direct contact or approached by their school principal, and will indicate their consent to run the program and complete lesson feedback using an electronic consent form, which will be returned to the research team. Principals will provide consent for the school to participate using an electronic consent form, however they will not be asked to provide any data for the study.Participants will be allocated at the school level by a member of the research team using simple randomisation on a computer program with a 1:1 ratio (intervention:control). Neither the participants nor the researchers will be blind to the intervention condition.All measures are self-report measures and were examined for suitability for adolescent males using the Simple Measure of Gobbledygook . All meaNever) to 5 (Always), with higher scores indicating greater dissatisfaction. The mean score for each subscale will be used for analyses. Example items include “I think I have too little muscle on my body”  and “I think my body should be leaner” (body fat dissatisfaction). Scores on the muscularity and body fat dissatisfaction subscales have demonstrated high internal consistency and construct reliability in young adult men [Two variables will assess the primary outcome construct of body image. These will be measured at all three time points. The Male Body Attitudes Scale , 42, a sdult men , and havdult men , 44.Definitely Disagree) to 5 (Definitely Agree) with higher scores indicating greater levels of internalisation or pressure. The mean score for each subscale will be used in analyses. Scores on all subscales of the SATAQ-4-R have good internal consistency in men [The 28-item Sociocultural Attitudes Towards Appearance Questionnaire – 4 – Revised  will be y in men  and havey in men .Strongly Agree) to 7 (Strongly Disagree), with higher scores indicating less favourable attitudes towards steroids. The mean score for item responses from both subscales will be used in analyses. Scores for both scales have good to excellent internal consistency in men (α = .94 for OE-AAS and α = .92 for I-AAS) and evidence of good convergent validity, as demonstrated by correlations of .37–.44 with the Drive for Muscularity Scale [Outcome expectations for using steroids  and intty Scale .no) to 1 (yes). Due to anticipated low baseline rates of use of supplements and steroids, statistical analyses are likely to be under-powered to detect reductions in use. However, frequency of use will be reported for this primary outcome variable.Our final primary outcome is actual use of supplements and steroids, measured by two single items asking if participants have used either a) anabolic steroids within the past 3 months or b) supplements to build muscles or burn fat within the past 3 months. Responses to the items are indicated on a binary scale from 0 (None) to 4 (All), with higher scores indicating greater perceived prevalence of APES use. Items concerning importance (example item: “How important do you think it is to your close friends to avoid taking muscle building supplements?”) are measured on a 3-point scale, from 1 (Not At All Important) to 3 (Very Important), with higher scores indicating greater importance of avoiding APES. Items concerning acceptance (example item: “My friends would disapprove if they saw me using steroids.”) are measured on a 4-point scale, from 1 (Disagree a lot) to 4 (Agree a lot), with higher scores indicating less perceived acceptance of APES use. Scores on the Peer Norms Scale of Physical Activity, from which the scales in the present study were adapted have acceptable internal consistency α = .72, and acceptable one-week test-retest reliability of .78 [Participants’ perceptions of social norms for using supplements and steroids  form three variables measuring the secondary outcome construct of social norms for APES. Items for these variables were adapted from Ling et al.’s  Peer Nory of .78 .Never) to 7 (Always) with higher scores indicating more negative body talk. The subscales have excellent internal consistency in men  and good evidence of convergent validity, with correlations between .20 and .58 on measures of body dissatisfaction and muscle dysmorphia [Our final secondary outcome for boys will be negative body talk, the tendency to talk about concerns about fat and muscularity, assessed with the Male Body Talk Scale . The scasmorphia .not at all/low), to 3 (fully/high). Optional qualitative feedback – specifically, any suggested changes for the lesson, and open-ended comments, may also be included.While not part of primary or secondary analyses, we will also examine teacher feedback scores for each topic within the program, using a scale adapted from McLean, Wertheim, Marques, and Paxton . Four itAll of the data for this study will be collected at the schools involved. Data collection will occur in the presence of the teacher facilitating the program. All teachers will be given instructions to conduct the survey in a quiet classroom, and to remind boys that they are free to refrain from answering any questions they do not want to. Boys will be instructed to complete their survey individually and to not look at others’ responses. Boys’ data will be collected using Qualtrics software, and teacher data will be collected using checklists in electronic (a Microsoft Word document) or paper form. Boys will be given a unique code so that their data can be matched over time and remain anonymous, with code lists stored separately from the data. Teachers’ data will only be identifiable to the research team. Upon completion of each stage of data collection, boys will receive information about how to seek support for any distress they may feel, including contact details for free and confidential support services and their school counsellor. Data collection forms can be requested from the research team.All student participant data will be entered electronically using Qualtrics software, and will be stored on password protected Qualtrics accounts accessible only to the researchers. Downloaded data will be stored on a password protected file accessible only to the researchers. All teacher data gathered either in paper format or electronically (a Microsoft Word document) will be transferred to a data sheet by the research team, and stored in a password protected file.The effectiveness of the intervention will be primarily determined through conduct of 16 generalized linear three-level mixed-effects regression models predicting our primary and secondary continuous outcome variables and two three-level logistic regression models predicting our primary categorical outcome variables. The effect of primary interest in these models is the fixed-effect of the intervention at the post-intervention and follow-up time points . We will examine and account for potential clustering effects at both the school and classroom level. Missing data will be estimated using full-information maximum likelihood modelling. Within these models, we will additionally conduct mediation analyses to establish whether, and to what extent, the following variables mediate change in our dependent variables: internalisation – muscular, and internalisation – low body fat. Deviations from the above-described analysis plan will be fully described and justified.To determine the required sample size for these analyses we conducted a comprehensive power analysis using RMASS . We based our analysis on the following parameters; 3 measurement occasions , a conservative attrition rate of 5% from pre to post and 15% from post to 2 month follow up , a small to medium effect size representing the hypothesized effectiveness of the intervention, equal numbers of students in the control and intervention arms, and a conventional alpha of .05. To achieve a power of .80, the analysis indicated that 504 students (252 in each of the intervention and control) were required. Thus, with a sample size of 600 the study is sufficiently powered with an appropriate amount of participants in case of natural attrition and unanticipated events that reduce participant numbers .Regular checks of data that include items to indicate harm  will be regularly monitored by the research team to ensure that the trial is not causing distress to participants. The research team will discuss any responses that indicate distress caused by the study that was not pre-existing , should this occur, and take appropriate action including either modifying the program or stopping the trial, depending on the response. The team is also required to produce a yearly report to the Victoria University Human Ethics Committee. The Victoria University Human Ethics Committee is independent from all members of the research team.Boys have typically been overlooked in body image research, and there are few effective intervention programs for boys. There is evidence that body image, the use of supplements, and attitudes towards doping in sport are interrelated and contribute to anabolic steroid use in adolescent boys. The theoretical frameworks underpinning body image and intentions to use supplements are very different for boys and girls. We will focus only on boys in order to confirm approaches that can be used to target these behaviours in a single sex setting to fill this gap in the literature. This research is novel in that a) it is a boys-only body dissatisfaction prevention program, and b) it is one of the few programs focusing on both body image and APES.Another strength of this trial is the preliminary studies that have been conducted in order to inform the intervention, both from a theoretical and practical perspective. A great deal of our intervention development has been documented, and this will be beneficial to researchers who wish to develop similar programs of their own.Although we are using a cluster RCT as opposed to a traditional RCT, the practicality of running a traditional RCT within a classroom setting is poor – as such, a cluster RCT is appropriate and will result in increased generalisability. Teacher delivery of the program is simultaneously a strength and a weakness; while this will improve our generalisability, we cannot be certain that all teachers will deliver the program with the same skill level or adherence to program activities. As such, it was important for us to include teacher evaluation and feedback.https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12619000725167The research has been approved by the Victoria University HREC (18–027). Additional approval to conduct the research in Victorian public schools has been granted by the Department of Education and Training, approval number 2018_003920. Model consent forms can be viewed at Protocol deviations, including sample size, program content, study populations, or other large modifications will be described in any publications resulting from the program. Data will not be available to the public, as participants are under 18 and we wish to maintain their total privacy as well as the privacy of the schools they attend. The final dataset will be accessible only to the research team.To ensure that access to the program is equitable, the control group is a waitlist control group and their teachers will facilitate the program after completing follow-up measures. We intend to disseminate the research through a) publications in peer-reviewed journals, b) conference presentations, and c) reports to schools and organisations relevant to HPE in schools .Topics for manuscripts or conference presentations will be presented to all authors for discussion, and the order of authorship will be discussed. Authorship order will be determined by amount of contribution to the manuscript writing and design. All authors will be named on papers where they have read, contributed to, and approved the manuscript due to the contribution of all research team members  at all stages of the research.As boys’ body image is becoming increasingly recognised as an issue, it is essential that programs are developed specifically with boys in mind, and trialled to examine their efficacy. Additionally, emerging literature on the role of APES, supplements and steroids in body image , 51 highAlthough there is capacity to discuss Appearance and Performance Enhancing supplements within the Australian Curriculum, very few resources exist to facilitate education about these substances or to facilitate changes in attitudes and behaviours towards APES in the school setting. Traditional resources to support education about performance-enhancing drug use in sport are generally developed along a moralistic, and value-based framework, rather than one that addresses the psychological and behavioural drivers of supplement use. Strengths of the program include alignment with the Australian HPE curriculum for Year 9 and 10, and as such, this program can be incorporated into regular HPE lessons, facilitating broad dissemination of this evidence-based resource.Following the full Randomised Controlled Trial of this program, we will incorporate teacher feedback to refine and update the program, formalise the teacher education materials, and then engage in broad dissemination of the program through online platforms using best practice implementation science frameworks for mental health programs in schools .


Tailored care strategies have potential to address declines in physical and cognitive functioning for people living with dementia (PLWD) while making a positive difference in their daily lives; however, these services are not commonplace. As dementia progresses, PLWD become more dependent upon caregivers, increasing caregiving strain and negatively affecting their ability to provide support. The purpose of this study is to examine the feasibility of a tailored community dementia program (TCDP) prescribed for individual abilities of PLWD and measure the impact on the caregiving dyad. A mixed method design was used for a 12-week TCDP with 8 dyads living in the community. Recreational therapy and exercise physiology specialists led the cognitive and physical components of the program. PLWD and caregivers completed assessments at baseline, 6, 12 and 18 weeks. Daily activity was measured in PLWD with no decline observed during the assessment period. Measurements for family caregivers included caregiver strain, satisfaction and assessment of the PLWD’s abilities. Although quantitative findings were not significant, caregivers praised the program in the follow-up focus group with one commenting that “it is important for the mental health of the family and for the patient to keep them active…and (for) socialization”. Another caregiver wrote in their journal “I feel he has really benefited from this program. It keeps him engaged with people and I do think he is more fit”. Overall the TCPD shows promise as a meaningful intervention. Cohort 2 begins in summer 2019 and will implement changes suggested by the caregiving dyads.


People with dementia value staying active and continuing with their everyday lives in public space, however there is a lack of knowledge about how they experience accessibility, problematic situations and how to manage these situations. The aim is to illuminate experiences of accessibility in public space in people with dementia with focus on places, activities and problematic situations. A Grounded theory approach was used in the thesis with multiple data collection methods . Findings show that having access to everyday activities at different places in the neighbourhood was very important for the participants when they perceived themselves as being a part of the society and being active and independent persons. Engaging in familiar activities in familiar places was important. However, their activity radii in the community became smaller. The findings inspired the development of the questionnaire Participation in Activities and Places Outside Home.


This symposium introduces key aging-in-community models and programs, with a particular focus on program and policy planning strategies. Villages are a new, consumer-directed model that aim to promote aging -in-community through a combination of facilitated social engagement, member-to-member support, volunteer opportunities, and collective bargaining for services. Dr. Graham from the University of California will share results from both a national survey of Village directors and a survey of village members, summarizing Village organizational development trends and members’ perceived impacts. Dr. Gilcksman from Philadelphia Corporation for Aging will share how older adults who do not participate in a Village create their own informal social and service network to maintain themselves and to accomplish the same goals as a Village, building community at the neighborhood level. Additionally, Dr. Hou from the University of Central Florida will discuss lessons learned on program planning strategies among older adults participating in three programs promoting aging-in-community: a university-based lifelong learning program (LLP), a county neighborhood lunch program (NLP), and a Florida Village program as a comparative case study. Finally, Dr. Glass from the University of North Carolina Wilmington will share the current trend of the new senior cohousing model, promises and challenges for older adults providing mutual support to each other as they age together. This symposium will further discuss strengths and weakness, and planning strategies of the various AIC models and programs.


Diabetes is a major contributor to global death and disability. Text-messaging interventions hold promise for improving diabetes outcomes through better knowledge and self-management.The aim of this study was to examine the implementation and impact of a diabetes text-messaging program targeted primarily for low-income Latino patients receiving care at 2 federally qualified health centers (FQHCs).A mixed-methods, quasi-experimental research design was employed for this pilot study. A total of 50 Spanish or English-speaking adult patients with diabetes attending 2 FQHC sites in Los Angeles from September 2015 to February 2016 were enrolled in a 12-week, bidirectional text-messaging program. A comparison group (n=160) was constructed from unexposed, eligible patients. Demographic data and pre/post clinical indicators were compared for both the groups. Propensity score weighting was used to reduce selection bias, and over-time differences in clinical outcomes between groups were estimated using individual fixed-effects regression models. Population-averaged linear models were estimated to assess differential effects of patient engagement on each clinical indicator among the intervention participants. A sample of intervention patients (n=11) and all implementing staff (n=8) were interviewed about their experiences with the program. Qualitative data were transcribed, translated, and analyzed to identify common themes.1c) reduction of 0.4 points at follow-up, relative to the comparison group (P=.06). Patients who were more highly engaged with the program (response rate ≥median of 64.5%) experienced a 2.2 point reduction in HbA1c, relative to patients who were less engaged, controlling for demographic characteristics (P<.001). Qualitative analyses revealed that many participants felt supported, as though “someone was worrying about [their] health.” Participants also cited learning new information, setting new goals, and receiving helpful reminders. Staff and patients highlighted strategies to improve the program, including incorporating patient responses into in-person clinical care and tailoring the messages to patient knowledge.The intervention group had a mean glycated hemoglobin (HbA1c. Patients who were more engaged demonstrated greater improvement. Program improvements, such as linkages to clinical care, hold potential for improving patient engagement and ultimately, improving clinical outcomes.A diabetes text-messaging program provided instrumental and emotional support for participants and may have contributed to clinically meaningful improvements in HbA An estimated 29.1 million people have diabetes in the United States . In addi1c levels in people with diabetes  positive, because it was telling us...what we have to do in our daily lives, and how a diabetic can’t be hopeless because it is a disease that can be controlled.In addition, several participants explained that the program made them feel supported. This theme was especially common among Spanish-speaking participants . For example, 1 participant said:The messages were helping me because these messages were as [if] a person was speaking to me, telling me what I should do, as if that message was from someone that was thinking of me and was telling me that I have to do this for my wellbeing.Another participant said:It felt good...because I knew that someone was worrying about my health.In addition to emotional support, all participants (n=11) cited learning new information and setting new goals as a result of the program. Some participants felt the messages provided more detailed information than they get in medical appointments, and the text message format allowed them to refer back to the information. One participant said:It’s just that the messages explains things...better. Because when I go to an appointment and ask, then the doctors speak in English and if the girls that they provide interpret for you, [they] don’t fully explain the conversation that you would have with a doctor.Most participants also stated that they already knew some of the information , but many participants also struggled to recall specific content from the messages , suggesting that knowledge retention from the messages may be low.Many felt that the messages provided helpful reminders  to check their blood sugar and/or to take their medication. All participants stated that the program led them to set new goals; to contemplate behavior change; or to change their behavior relating to their diet, medication, and/or exercise. For example, 1 participant reported taking their medication more regularly after the messages:[The messages] said that you’re supposed to take [medication] twice a day at about the same time, and so we instituted a little thing where I have the little days of the week [on a]...holder that says, “Noon, Morning, Evening, Night,” and we put the pills in there so I take them on the right times...I’m doing it after the messages.Some participants offered feedback to improve the program. A total of 2 participants felt that the times the messages were sent were not always convenient for them. Most participants wanted more messages, and 2 participants felt it would be helpful to tailor the program to participants’ baseline diabetes self-management knowledge levels. Additional quotes from the interviews with participants organized by theme are provided in Staff who implemented the program identified key facilitators and barriers to the program’s success. The major facilitator cited by the staff was that this text-messaging program allowed them to provide health education to patients using relatively few resources, making implementation more feasible for a resource-limited FQHC. However, they also identified some barriers to program success, particularly for scale-up beyond the initial implementation for this effectiveness-implementation study. The clinic administration chose to use temporary staff (AmeriCorps volunteers) to enroll participants for this pilot, which minimized the program’s disruption to the clinic workflow but also limited integration into routine clinical practice. Interviewees suggested that no staff outside of those directly involved in management or enrollment  knew about the program. In addition, there was no systematic monitoring of patient responses, in part, because the text-messaging platform was not integrated with the electronic medical record system in the clinic. Similarly, identifying patients with diabetes eligible for the intervention was a challenge, requiring the clinic staff to print lists of eligible patients, cross-check them with the clinic schedule, and to identify patients when they presented for appointments. Much of the work to identify patients was done by the AmeriCorps volunteers, but these activities would likely be burdensome for permanent clinic staff if the program were to be scaled up to more patients with diabetes in the future.Finally, staff also provided some feedback to improve the program in the future. A total of 2 staff members suggested that including more clinical staff could improve the program. One suggested that having clinicians mention the text messages during visits could give the program more “standing“ with patients. Staff also suggested hosting an in-person meeting at the start of the program to ensure all involved staff understand the project and their roles.Overall, despite some of implementation barriers cited by staff, most felt the program worked well and had the potential to help patients with diabetes; some felt the program provided an easier-to-understand and more accessible form of health education than the brochures or written materials usually provided by FQHCs.1c. Earlier studies have found evidence of reductions in HbA1c in broader populations who received a text-messaging intervention [1c, suggesting that encouraging patient participation could lead to greater health effects more broadly.Participants of a diabetes text-messaging program described the program as providing instrumental and emotional support, and higher engagement with the program was associated with improvements in HbArvention -7. A recrvention . We also1c. The effect sizes seen in this study have potential to be clinically meaningful based on earlier studies. A meta-analysis of 5 earlier randomized controlled trials reported that a mean 0.9 point reduction in HbA1c significantly reduced events of nonfatal myocardial infarction by 17% and events of coronary heart disease by 15% [1c , about 22% of the intervention group did not attend a follow-up visit in that period, leading to missing outcome data. However, when comparing the baseline HbA1c of patients who came for a follow-up visit with those who did not, we found no evidence of a statistically significant difference in HbA1c among nonreturning patients, reducing concerns about bias. If the long follow-up period had any effect on the results, it would have had an attenuated effect on the intervention group’s outcomes, biasing our results toward the null. A third limitation to this study is that the qualitative interviews were only conducted with patients who volunteered to participate and therefore, might not be representative of all patients’ experiences with the program. Interviewed patients, however, provided critical feedback to improve the program. Another important limitation is that the follow-up patient satisfaction questions and diabetes-related distress (PAID-5) had low rates of response, likely due to the delivery via text message late in the program and the large number of questions delivered. In the future, response rates could potentially be improved by delivering this survey in person during a visit to the clinic (as was done with the PAID-5 measure at baseline) or by incentivizing completion. Finally, we do not have data on the proportion of messages actually received and read by participants, and there is a possibility that mobile phone plans or changes to phone numbers could have affected receipt of the messages. However, 100% of the messages were reported as delivered by the text-messaging platform, and 86% of participants responded to at least 1 question with a valid answer, suggesting that if there were patients who did not receive the messages, it was not a widespread issue.This study has important limitations. First, because the text messages were implemented for this pilot study within the participating clinics’ constraints, the analytic sample is modest. The comparison group patients were also not aware of the intervention or the analysis of their deidentified data, so there is a likelihood that any observed improvements to intervention participants’ HbAThis study contributes to our understanding of the effectiveness of diabetes management text-messaging programs among patients who have low income and are mostly Latino. We found evidence that glycemic control of adult patients of FQHCs with diabetes might be improved through participation in a text-messaging program for diabetes self-management. The findings also suggest that patient engagement with the program could contribute to improved self-management and clinical outcomes. By supporting patients with education, reminders, and positive messages during the course of their daily life, diabetes management text-messaging programs have the potential to increase and sustain healthy behaviors and improve clinical outcomes among low-income patients with diabetes.


The VA has invested in developing the skills of its primary care workforce through the longitudinal Geriatric Scholars Program. The program consists of core components --- intensive course in geriatrics, intensive workshop in quality improvement (QI) and initiation of a micro QI projects in the Scholar’s clinic; electives allow learners to tailor the program to self-identified gaps in knowledge, skills and competencies. The program has demonstrated direct impacts of continuing education through a workforce development process that enhances skills and competencies at a pace and selection that meets clinicians’ self-identified gaps in training. Now in its 11th year, the program has been shown to increase career satisfaction and job retention, standardize provider behaviors, improve clinical decision-making and reduce dispensing of potentially inappropriate medications. This symposium further explores the impact of the program on individual clinicians and on clinical teams.