Callinectes sapidus) harvests and effort, we show that removing 34,408 derelict pots led to significant gains in gear efficiency and an additional 13,504 MT in harvest valued at US $21.3 million—a 27% increase above that which would have occurred without removals. Model results are extended to a global analysis where it is seen that US $831 million in landings could be recovered annually by removing less than 10% of the derelict pots and traps from major crustacean fisheries. An unfortunate common pool externality, the degradation of marine environments is detrimental not only to marine organisms and biota, but also to those individuals and communities whose livelihoods and culture depend on profitable and sustainable marine resource use.Every year, millions of pots and traps are lost in crustacean fisheries around the world. Derelict fishing gear has been found to produce several harmful environmental and ecological effects, however socioeconomic consequences have been investigated less frequently. We analyze the economic effects of a substantial derelict pot removal program in the largest estuary of the United States, the Chesapeake Bay. By combining spatially resolved data on derelict pot removals with commercial blue crab ( Unfortunately for the fisher, a common fish stock is not all that is shared. The environment in which harvest occurs is also a common resource, whose collective maintenance or degradation affects individual efficiencies and economic returns. Across many of the world’s oceans and waterways, Hardin’s tragedyThe financial ruin of commercial fisheries, thought to squander US $50 billion in economic benefits annuallyGrowth in global economies, together with the increasing use of long-lasting synthetic materials, has led to significant concerns surrounding marine debris46101112131415The United States Atlantic blue crab commercial fishery lands over 77,000 metric tons (MT) worth US $150–200 million annually181920212223In 2008, following many years of declining harvests, the Chesapeake Bay blue crab industry was declared a commercial fishery failure by the US Department of Commerce, unleashing $30 million in disaster relief. A small portion of these funds was used to support the Virginia Marine Debris Location and Removal Program, a novel initiative in which commercial crabbers were hired during the winter closed fishing seasons to find, document, and remove derelict gear. The program proved to be a success, offering fishers an opportunity to earn supplemental income while also removing considerable amounts of marine debris and generating useful scientific datawould have been harvested had no derelict pots been removed). In the counterfactual it was assumed that the observed increases in blue crab abundance were the result of contemporaneous conservation measures or advantageous environmental conditions, allowing identification of harvest increases arising solely from reduced gear competition. Model results indicate that removing only 9% of the derelict gear in Virginia waters increased harvests by 13,504 MT , or 27% (SE = 0.03). During the removal effort, each actively fished pot was harvesting an additional blue crab on every pull—crab which would have been captured or attracted to the now absent derelict gear.A spatially explicit harvest model was used to predict harvests under two scenarios: actual removals and a counterfactual of zero removals , or about 60% the improvement seen following the full removal program, ceteris paribus.Without the removal program, US $21.3 million in blue crab revenues would have been lost. These benefits far outweighed the program’s total cost of US $4.2 million. Derelict pot removals were found to be net beneficial in every year of the program, though the difference between average benefits and costs per pot removed was greatest during the last two seasons, when limited program funds were used to target derelict gear hotspots . During Derelict fishing gear is a global problemTotal global landings from all crustacean trap fisheries grossing US $20 million or more annually  average Increases in severe weather, boating traffic, and gear conflicts, arising from continued climate change281113The harvest enhancing effects of derelict gear removals explored here were entirely the result of reduced gear competition and improved efficiency. Other studies have found derelict gear to be a source of mortality for target and non-target species10111213141519202122Improvements in crustacean harvests resulting from the removal or reduction of rival derelict pots and traps can be biologically sustainable and offer clear, unfettered economic benefits. In the removal program analyzed here, it is estimated that approximately 60 million additional crab were harvested over the program’s six years. This level of supplementary take averaged 2% of the estimated annual abundance, and throughout the removal program, commercial exploitation rates were found to be well within or below biological targetsThe economic costs of derelict gear examined here are likely not unique to pot and trap fisheries. Lost trammel-nets, gillnets, longlines, and bottom trawl gear pollute marine environments all over the world11The dilemma of derelict gear is, at its core, a common property problem. Assets which are owned by all are all too often of value to no one. The lost time, effort, and materials which result from needlessly inefficient gear represent a source of non-recoverable economic waste. These costs, though previously unacknowledged, are perhaps equally tragic to the ecological and environmental damage more commonly associated with derelict gear. Reducing or removing dominant sources of marine debris from the world’s oceans, bays, and estuaries is essential not only to restoring and protecting local ecologies and environments, but also to revitalizing resource dependent communities and cultures.The Virginia Marine Debris Location and Removal Program employed commercial crabbers to locate and remove derelict fishing gear from Virginia tidal waters. Participants were assigned to broad areas according to anticipated derelict pot abundance, travel time, and other logistical considerations such that excessive overlap was avoided. Individuals were provided with a side imaging unit  preprogrammed to scan using 23 m (75 ft) swaths and acquire GPS points (survey tracks) every 30 seconds. The date, time, and location (waypoint), as well as various item descriptors, were recorded for all retrieved pots. During the first four years of the program (2008–2012), 32,421 derelict blue crab, peeler, and eel pots were recovered. The last two years of the program saw an abbreviated removal program in which 1,987 derelict pots were removed.Dt and Rt are the stock and removals of derelict pots in year t, respectively. Using this formulation, intense removal efforts during the first three years of the program would have decreased the standing stock of derelict pots by 15%. Targeted hotspot removals later in the program likely led to localized decreases, however, the total stock of derelict pots would have increased during this time. Over the program’s six years, removals are thought to have reduced the quantity of derelict pots by ~9% on average.There are approximately 300,000 pots licensed and fished in Virginia, 20% of which, or about 60,000, are lost each yearTo investigate the impact of the removal program on the blue crab fishery, harvests were modeled using a modified SchaeferHit is the harvest in area i at time t; qit is an area- and time-specific catchability coefficient; Eit is the effort in area i at time t; Xt is the stock at time t; Rit is the amount of derelict gear removed from area i at time t; and ηe, ηx, and ηr are elasticity parameters.where Data necessary to estimate equation Evaluating the impact of removals on harvests was accomplished through comparison of model predictions with and without derelict pot removals:Effectit is the difference in predicted harvests for area i at time t attributable to the removal of derelict gear. Summation of equation i and t produced a measure of total program effects. Harvest effects were converted to revenues using average annual ex-vessel prices for Virginia hard shell blue crab in 2014 dollars.where cv(Rt) = 0.73, cv(Ri) = 1.52), providing a rich set of data with which to identify marginal removal effects. Second, effort did not appear to respond to removals. That is, areas which saw more removals did not experience corresponding increases in effort. Were this not the case, a more complex counterfactual environment would be required to evaluate the removal program. Finally, the statistical harvest model included parameters to control for extraneous factors affecting harvests that were unrelated to the removal program. Area random effects enabled differences in catchability across areas to be modeled apart from any differences in area-specific removals, while a dummy indicator variable was included to control for exogenous shifts in catchability occurring contemporaneously with the removal program. Similar quasi-experimental empirical methods have been used to evaluate fisheries policies and isolate program effects in other contexts33While the potential for confounding bias in equation To calculate the global impacts of wide-spread derelict gear removal or reduction, it was assumed that the following ratio would be maintained across crustacean pot and trap fisheries:i, in an amount proportionate to that removed through the Virginia Marine Debris Location and Removal Program , would depend on the rate of gear loss in that fishery. This relationship might be expected as most crustacean fisheries utilize pots and traps constructed from similar materials and operate in near-shore coastal environments, suggesting similar rates of gear decay. Proportionate removals from a fishery with a high rate of gear loss would imply many pots and traps were removed, and thus a large harvest increase should be expected. Additionally, as removals from areas of high potting effort were found to be more effective at enhancing harvests, removal benefits should be greater in fisheries with large stocks of derelict gear experiencing significant production inefficiencies.Rather, the increase in harvests which could be expected to result after removing derelict gear from the grounds of fishery Chionoecetes opilio, edible crab Cancer pagurus, and stone crab Menippe mercenaria). Average prices were used to calculate revenues353619202122To predict harvest increases using the ratio (3), our estimate of a 27% increase in blue crab harvests in Virginia, where the gear loss rate has been found to be 20%, was applied to global landings and gear loss data . Mean loHow to cite this article: Scheld, A. M. et al. The Dilemma of Derelict Gear. Sci. Rep.6, 19671; doi: 10.1038/srep19671 (2016).


There is a significant gap in our knowledge regarding community-based self-help groups and their benefits for persons living with mental conditions and their family caregivers in low and middle income countries. This study describes a such a program in El Salvador and explores participants’ perceptions of program effectiveness and benefits.The Family Education, Support and Empowerment Program is a multi-component program in the capital that is facilitated by nonprofit professionals but carried out primarily by volunteers. A focus group methodology to build evaluation and research capacity in the organization was used. The study consisted of a questionnaire completed by participants individually, followed by two focus group sessions with the same ten people.The study found perceptions of multiple benefits across social, functional, and economic dimensions and a variety of achievements at organizational and national levels.This study identified a family self-help program in El Salvador as a potentially highly beneficial program for its participants. This appears to be the first study to explore benefits across micro, mezzo and macro social levels and to include discussion of more diverse potential benefits such as individual and organizational social capital, leadership, and advocacy. These factors should be explored in future quantitative studies to help determine the relative importance and usefulness of such programs in meeting World Health Organization goals for access to mental health treatment and quality community-based services.The online version of this article (doi:10.1186/s13033-016-0058-6) contains supplementary material, which is available to authorized users. Mental and substance use disorders are the leading cause of non-fatal illness worldwide, with a higher disease burden than HIV/AIDS, tuberculosis or diabetes. They affect persons of all ages but have the highest impact on children over 10 years of age and young adults. These disorders are also the leading cause of years lost to disability (YLDs). Of years lost, 21 % are due to substance abuse problems and 70 % are due to serious mental illnesses  like ASFAE, AFAPDIM and Cuenta Conmigo are important? Why?”, “How does the FESEP program compare with other services and programs available to users and families?”, and “How has the FESEP program helped to create greater social capital for individuals and the organization ?”. Questions were fully explained and participant questions responded to before launching into open discussion.We managed interpretation through a group of three investigators from two different cultures, and we shared moderator responsibilities between a lead and an assistant moderator.Creswell and Miller , 38 recoAccording to data from 2014, 124 users and caregivers participated in various program components; within the weekly art therapy component for users, 8 of 28 persons were new (29 %); and within the family education component, 20 of 27 were new (74 %). Of 39 users in who participated in any program component, 72 % had schizophrenia, 13 % bipolar disorder, 8 % depression, 3 % anxiety, and 5 % other .Participation rates for most program components were not tracked at the time of the study, but a recent separate analysis of the participation rate of family caregivers in the “From Family to Family” education class showed participants attended an average of 36 % of the classes, a low participation rate. The most prominent barriers to better participation were inability to find others to care while the family caregiver attends the class, cost of transportation, inability to take time off every Saturday morning . For lack of epidemiological studies of mental health in El Salvador, we do not know how many people with mental illness there are in El Salvador or how many lack services. But applying one global estimate of 10 % would put the number of people with mental conditions at over 630,000 in El Salvador . TriplinThe focus group met twice in March 2013, and was composed of ten persons: three persons with diagnoses of schizophrenia (two men and one woman), four family caregivers , and three program staff . User and caregiver study participants represent 10 % of the population of active program participants at the time of the study in early 2013. The program staff and research team are the same, and are composed of an American lead investigator who has volunteered with the program for 12 years and two Salvadoran co-investigators (psychologist and psychiatrist).The sampling strategy was to identify three types of participants—users, caregivers, and staff/researchers—to facilitate comparisons among subgroups . CriteriIndividualized questionnaires were completed by all 10 members prior to the focus group meetings in order to collect demographic and Likert scale responses on program effectiveness, satisfaction and social capital (measured by trust). A researcher was present to assist each person in completing the written questionnaire and clarify meanings . The questionnaires were then translated into Spanish and the two Salvadoran researchers worked with the US lead researcher to ensure that the meaning was both accurately translated and would be clearly understood by focus group participants in the Salvadoran context. The data in the original Spanish was the basis for the summaries and analysis of the data.Risks and risk mitigation were addressed in the consent form  a caregiver who at first went to “charlatans and witches” who promised they would cure her two sons, but now she see these were “stupidities and rip-offs”; and (2) the psychiatric hospital’s day program. Positive experiences included workshops by other non-governmental organizations (NGOs), treatment at a private hospital, support at church, and a short-lived day program that was closed because it was too expensive to maintain clientele.5Participants responded to several questions using a Likert scale. For example, for program effectiveness we used the following terms: 1 = not effective, 2 = little effectiveness, 3 = moderately effective, 4 = effective, 5 = very effective.Effectiveness, satisfaction and sense of belonging were all rated highly. Effectiveness of the FESEP program at improving the mental health wellbeing for program participants was rated 4.5. Level of satisfaction with the program had the same rating. Sense of belonging had the highest response rate across subgroups, with an average of 4.7, indicating that all subgroups had a strong sense of belonging or “community” in the relationships created in the group , but two other caregivers and one user each participated in only one other civil society group (two of these were church communities). Four people did not participate in any civil society association outside of the FESEP program. For some, participation in FESEP was their first experience in a civil society group.Regarding levels of trust, we asked further Likert questions related to generalized trust and trust related to specific mental health programs and institutions as measures of social capital Table . We usedIn terms of trust in specific organizations, international NGO collaborator CHHD was highest at 4.8. This was closely followed by the professional nonprofit ACISAM at 4.6. Trust in the family association AFAPDIM was 4.3 with family members’ trust in their own organization much lower than users’ trust. Private practice providers were rated at 3.6. Next, nearly a point down, came the national psychiatric hospital at a moderate 2.9, with users trusting more in the hospital than family caregivers or professionals. Finally at 2.7 and 2.6  were the Salvadoran mental health system and the Salvadoran government.We asked a series of 11 questions to the focus group. Detailed discussion of the responses are covered in the Additional file At the micro level we identified a number of themes related to individual benefits that people experienced through the program. These include improved quality of life, improved ability to participate in social groups outside the home, increased income earnings, improved self-esteem, improved abilities to deal with illness management, increased illness knowledge and acceptance, awareness of the illness and one’s ability to deal effectively with the illness (self-transformation), increased ability to communicate about mental illness with others in the broader society, increased human rights awareness and opportunities to address stigma , the discovery and development of leadership abilities, and increased purpose and meaning , yet they had lower generalized trust, which refers to how they are treated by people in the wider society. This is a dynamic that researchers of social capital and trust should take into account—that different types of people, specifically those with mental illnesses, will have different levels of trust towards different people and institutions due to their experiences of stigma as well as assistance from those institutions.“If you go to the hospital to see a doctor and your case is not grave, they don’t attend to you. Hospital workers try to avoid working hard in both public health clinics and hospitals. The situation is the same in both the mental health system and the general health care system. Workers complain we patients are not cooperating, not making an effort, but it’s not true. If we’re not taking our meds or going to follow-up appointments it’s often because we don’t have the money to do so. The psychiatric hospital staff doesn’t trust anyone. They are more concerned with themselves than with the patients.”Overall, responses regarding generalized trust and trust in private mental health services was moderate, while trust in the government and governmental mental health services was low. Trust in nonprofit programs benefiting people with mental illness and their families was very high. For example, one user noted,Comparison of educational levels of focus group participants revealed that both user and family subgroups had several participants with professional degrees. Calling the staff and volunteers “professionals” as a group differentiator is thus a misnomer and reflects bias on the part of we researchers. In future studies we recommend changing terminology to “non-family volunteers and staff,” although participants have also recommended “friends.”Despite many participants having higher education, only the professional group had stable employment. This reflected challenges faced by focus group members who have mental illness or caregiver commitments to care for loved ones with mental disabilities limiting their ability to obtain and maintain employment. It is consistent with World Health Organization and International Labor Organization reports on extremely high unemployment rates for those with mental disabilities . AccordiIn general, focus group analysis indicates that participants responded positively to questions about the program due to the program’s ability to meet their needs, to transform their perspective through new understanding, and to provide them with tools to address the challenges of mental illness. We identified a large number of themes related to the benefits of program participation across micro , mezzo , and macro  levels.This study potentially indicates benefits such as increased and effective advocacy, inclusion of persons with disabilities, perception of reduced stigma in both communities and across society, and civil society development. Focus group members felt an identity through the organization and a sense of common purpose, which we think may be heightened through the methodology of supported peer leadership and service provision.Family support repeated surfaced as a benefit. It was seen as facilitating both improvements in family relations within the home and moving the user toward participation in the program, from which the user could progress on many fronts. This is consistent with research related to the influence of family attitude on relapse , but that more remained to be achieved. We think social capital is essential if groups are to assume a leadership role in grassroots advocacy for change in mental health systems.Participants reflected progress in understanding illness and acceptance of illness, both of which are key to successfully participating in treatment , 48–50. Comments reflected how this transformational change results in practical gains—people take on responsibilities in the group, they develop leadership skills, and they offer their voluntary services –54. SuchGenerally the data from the individual questionnaire and the focus group data corresponded well, especially related to high levels of support for the FESEP program, defining a broad array of benefits, and seeing those benefits across multiple social levels. While the focus group espoused horizontal leadership and leadership development, the reality reflected in the individual questionnaires showed that in fact was quite different for users. They did not perceive themselves as leaders and had not been given leadership positions in the organization. As a result, their social capital was not being fully realized.Group interviews are recognized as having multiple benefits, including stimulating discussion, opening up new perspectives for the participants, hearing the ideas of others helps participants to formulate their own opinions, and encouragement to speak for marginalized participants . We founThe facilitation and support of ACISAM  and CHHD  were perceived as key to the sustainable development of a quality program for families and users that fostered their own development as leaders and as advocates in the defense of their rights. We note that the methodology employed by ACISAM in facilitating the FESEP program is similar to the bio-psycho-social model of community based rehabilitation promoted by the Pan American Health Organization, which carries the following benefits: empowerment, participation, strengthening of civil organizations, decentralization of services for accessibility, and multi-sectorial participation .In our study, professionals and support organizations were strategic partners with families and users. Chien and Norman  reviewedWe identified suggestions for program improvements: further development of user leadership skills and increased participation for users in leadership positions; incorporation of logic model outcomes and impacts into planning, evaluation processes, and organizational reports; strengthening the employment component of the program; and continued nurturing of trust with key mental health institutions in the country. The high levels of trust in NGO mental health programs serving users and families should be leveraged to work more closely with low-trust institutions such as the government and the institutions of the mental health system, because these institutions are key to systemic change.All focus group participants were thus able to gain knowledge regarding how and why their program may be effective, as well as what outcomes might be useful and measurable for future program evaluation that could include their participation. Salvadoran co-investigators developed knowledge and skills in helping to carry out this type of research, including standards for research on human subjects, and established a foundation for future work on evaluations and research for their organizations and programs.The study highlighted the need for community based mental health organizations in Latin America to improve evaluation processes by focusing more on outcome and impact measures and to involve professionals and program participants in research in order to build research capacity. This could result in an appreciation for the important role that they themselves must play in program improvements and the identification of best practices for mental health within the Latin American socioeconomic and political context.Users and family caregivers are a potential large pool of volunteers to assist in carrying out community based programs such as support, education, income generation, and advocacy. They are a powerhouse of volunteerism that the government should nurture and support as it seeks low-cost ways to address the gap in treatment and services. User and family self help groups, organizations and programs appear to have a dramatic impact on the mental health wellbeing of both users and their family members, and these integrated, multi-component programs should be an important part of national collaborative interventions. Lund et al.  state thCombining best practices in community-oriented psychiatry with best practices in organizational development for civil society mental health groups could result in significant improvements in mental health systems for LMICs. Partnerships between multiple stakeholders that include those with the most at stake (users and their family caregivers) hold promise for achieving significant change—improved services and closing the treatment gap for persons with mental illness and the budget gap for government health ministries.It is clear that governments in LMICs cannot address the challenge of mental illness alone. But nor can the nonprofit and civil society sectors. Together they must address the gap in public awareness around mental health needs, stigma, and lack of services. National mental health care budgets need to be drastically increased, services decentralized and improved, and marginalized users and families placed in the center of the mental health care model.This is the first study to explore potential benefits of these groups across micro, mezzo and macro social levels and to include discussion of more diverse potential benefits such as individual and organizational social capital, leadership, and advocacy. These are factors that should be explored in future quantitative studies that could confirm the broad types of benefits and effects of those benefits for these populations. Such studies should contrast these impacts with treatment as usual and cost effectiveness in order to help determine the relative importance and usefulness of such programs in meeting World Health Organization goals for access to mental health treatment and quality community-based services , 61.Based on the outcomes of this focus group study, we recommend further study, particularly quantitative and mixed methods studies of the multi-component FESEP and similar programs in order to establish causality and generalizability. Two other studies of similar programs call for randomized trials, longitudinal and qualitative descriptive studies of people who participate in these types of programs , 27.Programs vary widely from country to country. Until recently across Central America these programs had little contact to share program models, knowledge, experiences or resources. As a result, further comparative qualitative studies could lay the groundwork for identifying commonalities and variables that would be measurable across different programs in different Latin American countries, contributing to an increased ability to use quantitative studies and to identify best practices for such groups.This study does not address the use of medications. We recommend evaluation of the role of pharmacological treatment in community programs, because it appears to us that smaller doses are achievable for maintaining stability for those in community based programs versus hospital based programs.While the FESEP program is designed for LMIC countries, many of the benefits identified may appear to be universal. Is the FESEP model something HIC countries can use? We don’t think so because the program is so heavily molded to the socio-political-economic reality of El Salvador, where there is no disability income, very high unemployment, no government community mental health programs, a frequent shortage of medications, very low educational levels, very high stigma, constant violence, and many other differences. One thing we can share is a common understanding that our struggle is global—users and family carers the world over share a common experience. We also share a need for the same basic qualities of life—health, work, respect, friends, opportunities, and love.The greatest limitation of this study was the small sample size; the study could have been strengthened through a larger number of focus groups . HoweverThe potential for researcher bias was strong because the professionals in the focus group also served on the research team. This could potentially result in both biased researcher interpretation and biased data from FESEP program participants who might have felt they could only report positive outcomes. Still, for the purposes of this study, the researchers felt the benefits of this approach outweighed the potential negatives, including group learning across the different types of program participants, the synergistic thinking that would be generated, and what the researchers as professional participants could bring to the study’s findings.Because one criterion was longterm duration of participation, the sample was likely to be composed of those FESEP program participants who were most helped and therefore most appreciative and most likely to talk positively about the program. This points to the need for further studies with larger samples, randomized designs, and outside interviewers.None of the questions focused on negative outcomes or problems with the program. This appears to be a tendency in other qualitative mental health studies of self-help groups reviewed in this paper as well. Future studies should include questions about negative effects, shortcomings and problems with user and family self-help programs, groups and organizations.The right to choose between being compliant or non-compliant with medication adherence and other doctor/hospital/intervention demands was not discussed in this study –65. ThisWhile we were able to comply with most criteria in the Consolidated Criteria for Reporting Qualitative Studies (COREQ) 32-item checklist , some cr


The indirect immunofluorescence assay (IFA) is considered a reference test for scrub typhus. Recently, the Scrub Typhus Infection Criteria  were proposed as a reference standard for evaluating alternative diagnostic tests. Here, we use Bayesian latent class models (LCMs) to estimate the true accuracy of each diagnostic test, and of STIC, for diagnosing scrub typhus.Orientia tsutsugamushi, three different PCR assays, IFA IgM, and the Panbio IgM immunochromatographic test (ICT). True sensitivity and specificity of culture (24.4% and 100%), 56kDa PCR assay (56.8% and 98.4%), 47kDa PCR assay (63.2% and 96.1%), groEL PCR assay (71.4% and 93.0%), IFA IgM (70.0% and 83.8%), PanBio IgM ICT (72.8% and 96.8%), presence of eschar (42.7% and 98.9%) and STIC (90.5% and 82.5%) estimated by Bayesian LCM were considerably different from those obtained when using STIC as a reference standard. The IgM ICT had comparable sensitivity and significantly higher specificity compared to IFA .Data from 161 patients with undifferentiated fever were re-evaluated using Bayesian LCMs. Every patient was evaluated for the presence of an eschar, and tested with blood culture for The low specificity of STIC was caused by the low specificity of IFA IgM. Neither STIC nor IFA IgM can be used as reference standards against which to evaluate alternative diagnostic tests. Further evaluation of new diagnostic tests should be done with a carefully selected set of diagnostic tests and appropriate statistical models. Orientia tsutsugamushi, is endemic in South, East and Southeast Asia, as well as some areas in northern Australia [Leptotrombidium mites (chiggers). Scrub typhus can be severe and fatal when left untreated, with reported mortality ranging from 14% to 30% in Southeast Asia [Scrub typhus, a bacterial infection caused by ustralia ,2. The oast Asia . The diaast Asia ,7.O. tsutsugamushi (culture) and polymerase chain reaction (PCR) assays targeting the 56kDa, 47kDa, and groEL O. tsutsugamushi genes [O. tsutsugamushi in patient serum, and is regularly used as a reference test against which alternative diagnostic tests for scrub typhus are evaluated [There are two main laboratory methods for diagnosing scrub typhus, namely bacterial and antibody detection. Bacterial detection methods include isolation of hi genes –12. Antihi genes ,13–15. Ivaluated ,16. Howevaluated .O. tsutsugamushi is isolated, (b) at least two out of three PCR assays targeting the 56kDa, 47kDa and groEL genes are positive, (c) an admission IFA IgM titre is ≥ 1:12,800 or (d) there is at least a four-fold rise in convalescence IFA IgM titre compared to the admission IFA IgM titre [We recently proposed the Scrub Typhus Infection Criteria (STIC), a combination of culture, PCR assays, and IFA IgM, as a reference standard for scrub typhus diagnosis ,18. STICgM titre ,18. The gM titre ,18. In sgM titre ,18.Nonetheless, we hypothesized that STIC, when used as a comparator, might have been falsely assumed to be perfect (100% sensitivity and 100% specificity), and as a consequence the accuracy of the alternative diagnostic tests might have been inaccurately estimated. Bayesian latent class models (LCM) are increasingly used to estimate accuracy of diagnostic tests since it does not need to assume that the accuracy of reference tests is perfect –24. In tThe data set analysed in this study was from a prospective study of acute febrile illness in a scrub typhus endemic area, Chiang Rai, Northern Thailand ,18. In bEthical approval for the prospective study was obtained from the ethical committees of Chiang Rai Hospital, the Ministry of Public Health, Thailand, and from the Oxford Tropical Research Ethics Committee, United Kingdom. Signed written inform consent was obtained from every subject enrolled into the study ,18.in vitro isolation of O. tsutsugamushi (culture), nested 56kDa PCR assay, 47kDa-based real-time PCR assay, and GroEL-based real-time PCR assay as described previously [O. tsutsugamushi.All patient specimens were tested for evidence of acute scrub typhus infection using a set of bacterial and antibody detection methods ,18. All eviously ,17,25–27O. tsutsugamushi  as previously described [O. tsutsugamushi Karp strain [IgM-based IFA was used to measure IgM-specific titers against pooled whole-cell antigens from three strains of escribed . The scrp strain .O. tsutsugamushi was isolated, (b) at least two out of three PCR assays targeting the 56kDa, 47kDa and groEL genes were positive, (c) an admission IFA IgM titre was ≥ 1:12,800 or (d) there was at least a four-fold rise in convalescence IFA IgM titre compared to the admission IFA IgM titre [The accuracy of each diagnosis test was estimated by comparing with STIC, which were considered as a perfect reference test (100% sensitivity and 100% specificity), as previously described ,18. STICgM titre ,18. A cogM titre ,18.groEL genes, were positive, and IFA IgM positive when admission IFA IgM titre was ≥ 1:12,800 or there was at least a four-fold rise in convalescence IFA IgM titre compared to admission IFA IgM titre.The true accuracy of each diagnostic test was then estimated using Bayesian LCMs. Detailed explanation on how Bayesian LCMs determine the unbiased accuracy of diagnostic tests has been given elsewhere –24,29,30To estimate the accuracy of a diagnostic test using LCMs, the best-fitting model, as determined by the presence or absence of correlation between diagnostic tests, was used. We evaluated possible correlations based on existing knowledge and external evidence. Therefore, correlations between bacterial detection tests (culture and a combination of PCR assays) and between antibody detection tests (IFA IgM and PanBio IgM ICT) were evaluated. As the Deviance Information Criterion (DIC) is not applicable to the random effect model used, the Akaike Information Criterion (AIC) was used to evaluate goodness of fit and to compare the models. A difference in AIC of more than 10 was taken as indicating definite support for the model with the lower value, while a difference between 5 and 10 was considered substantial support, and less than 5 inconclusive support.th and 75th percentiles. The best-fitting model was used to determine the accuracy of each diagnostic test evaluated and combinations thereof. The Bayesian p values were used to compare accuracies between diagnostic tests. All Bayesian LCMs assumed that no prior information (non-informative priors) about unknown parameters  was available, except that the specificity of culture was fixed at 100%. Sensitivity analysis was performed in which different prior information were used. All parameters with respective 95% credible intervals (CrI) were estimated using a Markov chain Monte Carlo method and WinBUGS 1.4 . InterquRickettsia typhi Wilmington strain in paired specimens using slides purchased from the Australian Rickettsial Reference Laboratory[We searched for other complete individual-level data sets in PubMed using MeSH terms (“Scrub Typhus” and “Sensitivity and Specificity”) for analysis with Bayesian LCMs. To validate the low sensitivity of IFA estimated by the Bayesian LCMs, we also estimated naïve sensitivities of those tests in only those who were culture and/or PCR assay positive in our data set . To valiaboratory. Dengue aboratory.One hundred and sixty one patients with acute febrile illness were recruited into the study. The median age was 41 years , and 99/158 (63%) were male. The median fever days before admission to hospital was 5 days (IQR 3–7 days), and convalescent samples were available for 138 patients (85.7%). Fifty-five were diagnosed with acute scrub typhus infection by STIC, giving a prevalence of 34.2% (95%CI 26.9–42.0%). There were 9, 27, 46 and 31 patients with positive scrub typhus test results on culture, using a combination of PCR assays, with the IFA IgM and with the PanBio ICT IgM, respectively. Seventeen patients had an eschar.Bayesian LCMs were then applied to obtain an unbiased estimate of the accuracy of each diagnostic test. There was no substantial difference between all Bayesian LCMs used . The modGroEL-based real-time PCR assay (71.4%), PanBio ICT IgM (72.8%), and presence of eschar (42.7%) estimated by the Bayesian LCM were much higher than those estimated by assuming that STIC were perfect  and 90.8%  and 95.9% ) are low. We confirmed this finding by performing a sophisticated statistical analysis, which did not a priori assume that either IFA IgM or STIC was a gold standard test with 100% sensitivity and 100% specificity. In addition, we also observed that a prototype IgM ICT had a better performance than IFA IgM. We demonstrated that the gold standard model inaccurately estimated the accuracy of the alternative diagnostic tests, and suggest that further evaluation of new diagnostic tests for scrub typhus should be performed with appropriate statistical models. Our study also has an implication for clinical practice. Our new finding supports the usage of a combination of IgM ICT assay and presence of eschar as a point-of-care diagnostic test for scrub typhus in resource-limited settings where PCR for scrub typhus is not part of standard of care. Various combinations of PCR, IgM ICT and presence of eschar could also be considered as a point-of-care diagnostic test for scrub typhus in developed countries.To the best of our knowledge, this is the first study to systematically evaluate the accuracy of each diagnostic test and of reference tests for scrub typhus using Bayesian LCMs. We validated the low sensitivity of IFA by determining naïve sensitivities of each diagnostic test within different strata of the disease; the method that is also recommended to be used in the absence of a gold standard . The lowO. tsutsugamushi or PCR assay positive [O. tsutsugamushi may take several weeks to become detectable by IFA, and some patients might also fail to develop the antibodies against the organism even after a long period following infection [O. tsutsugamushi strain causing the infection may also contribute to this lack of accuracy.The finding that IFA IgM has a low sensitivity is neither novel nor surprising since IFA IgM have been found to be negative in scrub typhus patients who are blood culture positive for positive . This isnfection . FurtherO. tsutsugamushi used in the IFA IgM assay [The confirmation that IFA IgM has a low specificity is alarming. A high rate of false positivity provided by IFA IgM has long been suspected ,16,32,33gM assay . The lowA major effect of the low accuracy of STIC is that the accuracies of alternative diagnostic tests have been inaccurately estimated. The true sensitivities of blood culture, individual PCR assays, Panbio ICT IgM and presence of an eschar are much higher than those estimated by assuming that STIC is a perfect reference. The Panbio ICT IgM was erroneously discarded and not further developed into the market because of its apparent low sensitivity . Sensitivity of the Panbio ICT IgM was reported as 47.3% by comparing with STIC as a gold standard ,18. In tO. tsutsugamushi Karp strain, which was purified and may explain the high specificity of PanBio ICT [O. tsutsugamushi , and these whole-cell antigens may cross react to antibodies from other diseases. We found that although ICT IgM used the 56-kDa protein from a single Karp strain, the sensitivity of ICT IgM is comparable to the IFA IgM which used whole-cell antigen from the Karp, Kato and Gilliam strains. It is possible that the ICT IgM is also positive for scrub typhus patients infected with strains other than Karp. This is supported by the previous study showing that the 56-kDa protein from a Karp strain reacts to immune serum of mice infected with Kato, Gilliam and other strains [The high diagnostic accuracy of the ICT IgM could be due to the different antigen used in the test . The ICTnBio ICT . The IFA strains .The high diagnostic accuracy of presence of an eschar in our study could be explained because other diseases that can cause eschars, such as anthrax and spotted fever group rickettsioses are not common in Thailand . Brown sThis study has some limitations. The sample size in our study was small. We could not identify other data sets of suspected scrub typhus to prove whether the result observed in our study is generalisable in different settings. We could not evaluate the effects of other factors such as duration of symptoms, antimicrobial received prior to presentation, and different cut-off values of IFA IgM in our model.We conclude that the current reference tests (STIC and IFA IgM) are imperfect in our setting, and there is an urgent need for improvement of serological reference tests for scrub typhus. Future evaluation of alternative diagnostic tests for acute scrub typhus should be done using a carefully selected set of diagnostic tests and appropriate statistical models.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.S2 Text(DOCX)Click here for additional data file.


Restricted mobility is the most common impairment among older adults and a manual wheelchair is often prescribed to address these limitations. However, limited access to rehabilitation services results in older adults typically receiving little or no mobility training when they receive a wheelchair. As an alternative and novel approach, we developed a therapist-monitored wheelchair skills home training program delivered via a computer tablet. To optimize efficacy and adherence, principles of self-efficacy and adult learning theory were foundational in the program design. A participatory action design approach was used to engage older adult wheelchair users, care providers, and prescribing clinicians in an iterative design and development process. A series of prototypes were fabricated and revised, based on feedback from eight stakeholder focus groups, until a final version was ready for evaluation in a clinical trial. Stakeholder contributions affirmed and enhanced the foundational theoretical principles and provided validation of the final product for the target population. Canada has a rapidly aging population  and it iThe international classification of functioning, disability, and health (ICF) provides a conceptual framework for describing factors that contribute to or impede participation , includiOlder adults typically receive little training when they obtain a wheelchair , 18, andTo address this problem, we set out to develop a monitored home program for wheelchair skills training. Delivering rehabilitation training as a monitored or self-managed home program among older adults has been effective for a wide variety of outcomes including strengthening , physicaFor rehabilitation home programs targeting motor skills in older adults, maximizing training frequency and practice in the natural context of use are essential elements. A 2010 Cochrane Review identified several factors related to adherence in exercise interventions. Programs that incorporated social cognitive theory , were clinician-monitored, and increasingly graded the complexity of training activities were more successful improving participants' adherence, frequency and duration of exercise . EducatiWith advances in affordability, size, portability, accessibility, and user-interface simplicity, computer-related devices are becoming increasingly useful for rehabilitation interventions. Computer and popular gaming systems  have shown promising results in rehabilitation by casting therapy in a more engaging context. More recently, their use in rehabilitation among older adults has also been explored. For example, Aarhus et al.  providedPurpose. The purpose of this project was to develop a prototype Wheelchair Skills Training Program that could be delivered as a home program using a computer tablet, entitled Enhancing Participation in the Community by Improving Wheelchair Skills or EPIC Wheels. This involved the development of specific program content as well as a system of delivery. The intent was for content to include evidence-based skills relevant to novice older adult MWC users, incorporate Andragogical educational strategies, promote self-efficacy, and be delivered in an engaging and accessible format. The specific objectives were toengage older adult MWC users in the research and development process,incorporate stakeholder input through the design and evaluation phase,produce a prototype intervention program for proof of concept. during the process of intervention development is crucial  it just seems to be easier just to [use a DVD]” .During the demonstration, we indicated that the training content on the tablet would be delivered using the Internet. Participants expressed apprehension about this dependence on Internet connectivity and what might happen if trainees were without Internet access. Finally, there was considerable discussion around receptivity and capacity of older adults to use the tablet technology. In particular, some participants wondered whether older adults would have the cognitive and attention ability to learn to use the tablet in addition to learning wheelchair mobility skills. This discussion generally reflected participants' perceptions about other older adults and, in particular, those in their late 70s and 80s. All of the focus group participants were over 60 and felt this technology would not be particularly challenging or intimidating for them to use; however, some felt that this might not be the case for others older than they were:In particular, participants wondered whether some older adults would have difficulty navigating through multiple menus and icon options and become “lost.”Revisions to Initial Program Prototype. The participants' reporting on common challenges to wheelchair mobility provided confirmation for the content areas proposed in our initial prototype. The specific skills related to addressing environmental barriers, such as propelling straight, turning, and popping casters, were all contained in the training curriculum. The initial prototype had, by design, only a limited repertoire of video content as we anticipated substantial revision. In response to the challenges noted with negotiating small, crowded spaces, we expanded the content related to turning and maneuvering skills. For example, wheelchair casters have an off-center pivot, swinging into a trailing position when initially moving forwards and a leading position when reversing. During these transitions, the wheelchair has a tendency to veer towards one side. A training segment was added specifically addressing this response and how to best control caster swivel. Content was expanded to include explanation of the “mechanics” of turning a wheelchair and broken down into small progressive segments including stationary turns, stopping and turning, moving turns, spin turns, and backward turns. Manipulating body position within the wheelchair to improve stability, safety, and responsiveness of the wheelchair became a separate content area early in the program, as it is a prerequisite for many advanced mobility skills. Additional content was also added related to safety, based on participants' feedback. A separate section identifying equipment  was added as well as educational information regarding tips and falls, spotting/supervision, feedback during training, and injury prevention. errors to illustrate how and why unsuccessful performance might occur. These included both naturally occurring and contrived errors. Naturally, occurring errors emerged when models were initially unsuccessful attempting a skill and proved useful in demonstrating how to correct mistakes as the models adjusted their approach. Contrived errors were useful as a “3 bears” approach to learning  and addressed the recommendation to link potential consequences with skill performance.For convenience and expediency, the initial prototype included video demonstrations featuring the first author. In the subsequent prototype, two individuals over 65 years of age  were recruited to model skill performance and training activities. As suggested in the focus groups, a number of skills were enacted with commonTo address concerns about network connectivity, the system was modified so that it could operate with only sporadic Internet access. In particular, video viewing and training could take place with or without being connected; however, brief connections were still occasionally required so that data and messages could be exchanged with the monitoring trainer. challenges to wheelchair use, optimizing strategies for learning skills, and critiques of the tablet training device. There was overlap between the stakeholder group feedback as well as unique contributions from the three perspectives.For the second round of focus groups, which involved MWC users, care providers, and clinicians, their responses were again categorized into three general themes: transient wheelie  was unquestionably a useful and productive strategy to learn.With the revised prototype, most of the situations and environments stakeholders identified (and the requisite skills for performance) were contained within the training program content. The clinicians highlighted the challenges of uneven, undulating, and irregular surfaces for older adult MWC users, which were particularly taxing on their endurance. This included working against gravity pushing both up- and downhill and lost momentum when stopping to overcome small gaps or changes in elevation. There was general consensus that performing a sustained wheelie was not an essential or even high priority skill for this user group, but theThe care provider groups identified functional upper extremity activities as problematic. This included reaching for objects on the floor and at height, such as operating a ticket kiosk in a public transit station. Using doors was also noted as difficult because it involved manipulating the wheelchair and the door simultaneously and can be compounded by mechanical closers. One MWC user group proposed inclusion of a section on carrying objects, a skill not previously identified specifically in the literature. Since propulsion is often a bilateral activity, transporting an object (such as a cup of hot coffee) is particularly problematic.Both the MWC user and clinician groups noted the particular challenges of propelling on snow and ice; this was true at both sites, despite the substantial differences in climate between the cities . Snow can be particularly soft and conforming to the casters, causing them to become buried and the wheelchair to “snowplow” or stop suddenly, causing a risk of forward tipping. In addition, low friction reduces traction at the rear wheels, resulting in one or both wheels spinning.The clinician groups identified that in training older adults, memory for new learning is often a challenge and needs to be addressed through increased repetition and breaking skills into smaller steps. While they spoke positively about the content of the training videos, both the MWC user and clinician groups indicated the importance of using lay terminology and avoiding excessive technical jargon. At the same time, the MWC users suggested value in using accurate terminology for the wheelchair components to ensure consistency and clarity throughout the learning process. Consistent with the MWC users in round one, the clinicians identified value in describing the benefit of each skill for trainees but also suggested this was important for family and care providers to secure their support in the training process. The care providers wondered whether there might be a benefit to trainees being able to navigate through individual videos to rewind or fast-forward depending upon their learning needs and desires. They affirmed the use of games and interactive activities to engage the trainee in practice, such as the “roller coaster” activity that requires trainees to lean backwards, forwards, and sideways in their wheelchair as the roller coaster car ascends, descends, and turns along the tracks. Care providers also highlighted the need for flexibility to select individual skills and activities, rather than having to follow a prescribed sequence.The clinician groups suggested that the training program should include not only skills for independent mobility targeting the user but also skills and techniques for care providers to assist older MWC user when independent mobility is not feasible. This was particularly true for skills that might not be reasonably achieved independently, such as managing steps or curbs safely.The clinicians commented that the instruction and demonstration videos were not all of one uniform size and suggested greater consistency and, more importantly, maximizing the size of the video image. Care providers commented that the tablet surface has a significant glare which compromised viewing, particularly when positioned on an angle. The buttons were described as being adequate but somewhat small, and the text was hard to read for some. Likewise, the volume was described as adequate but could potentially be problematic for trainees with compromised hearing. Both the user and care provider groups wondered how the tablet might be positioned and supported during training activities and the risk of it falling to the floor and being damaged.Revisions to Second Program Prototype. In response to the stakeholder feedback, several additional content areas were introduced. Within the training section related to soft surfaces, we added instruction and video footage on propelling over snow and ice. We also incorporated content specific to care provider (assisted) mobility skills such as getting up and down curbs, steps, and ramps and using the tipping bar to get over small obstacles. Managing doors (with and without closers) and strategies for carrying objects were incorporated as distinct sections.Several changes were made to the tablet display and user-interface. Video clips were configured to display in the same size configuration. Navigation buttons  were relocated from below the video image  to the right of the image  to maximize image height and permit a widescreen display. The vertical orientation also permitted an increase in the size of the buttons for easier targeting , along wWe proposed a training schedule of 30 minutes per day (1-2 sessions per day for 15–30 minutes each) at least 5 days per week totaling a minimum of 150 minutes per week. These guidelines are based on the National Blueprint consensus document on promoting physical activity for adults over 50 years, which advocates that lifestyle- or endurance-related activity of moderate intensity should be undertaken for at least 30 minutes (in bouts of at least 10 minutes) 5–7 days per week [To address the potential issues with users becoming “lost” during program navigation, we developed 2 strategies—pretraining and reference material. The EPIC Wheels program incorporates two 1 : 1 training sessions with an experienced trainer. In practice, these sessions might occur shortly after an older adult obtains their wheelchair. As part of the initial evaluation and training session, we included a 30-minute interactive orientation to the tablet for the user and care provider. Trainees also receive a handbook that provides instructions for tablet navigation, including screenshots for visual assistance. For simplicity, menus were configured to have 3–8 options related by content area, limiting clutter, and distraction without requiring an excessive number of embedded submenus  . We alsoThe first author (Edward M. Giesbrecht) and a rehabilitation engineer created a lap-mounted support to enable viewing and practice without risk of loss of or damage to the tablet while trainees sit in their wheelchair. A nylon strap and buckle were integrated into a rigid platform with a neoprene foam base, upon which a commercial tablet holder  was mounted using hook and loop fasteners see . The tabFollowing revision, we met individually with one of the MWC users and one clinician for a final review of the beta prototype. Both reviewers provided confirmation of the scope and presentation of the training content and usability of the user interface, and no substantive revisions were required. In particular, the MWC user was pleased with the tablet holder, indicating it was easy to don and doff in the wheelchair and provided a good viewing location with adequate adjustability. Subsequently, we conducted pilot testing of the EPIC Wheels program in preparation for a randomized controlled trial. A primary intent was to evaluate the robustness and feasibility of the EPIC Wheels home program and supporting technology. We selected two older adults with diverse wheelchair backgrounds who had no previous involvement in the study. One participant was very experienced, having used a MWC for over 30 years following a spinal cord injury, including participation as a wheelchair athlete in earlier years. The second participant had recently transitioned to MWC use (<6 months) following an above-knee amputation. Participants with diverse wheelchair experience were intentionally selected to obtain perspective from individuals new to MWC use  and proficient users (to ensure comprehensiveness and accuracy of the program content). Because the feedback from the reviewers and pilot participants was obtained during tablet use, it was not audio-recorded and transcribed as with the focus groups. Observations and concerns were recorded by the first author and consolidated with the previously obtained data.The EPIC Wheels intervention was 4 weeks in length. Participants attended a 1 : 1 session with their trainer  at the beginning of weeks 1 and 3 and trained at home the remaining days using the tablet device, with the trainer making follow-up calls at the end of the first and third weeks. Participants can use the voicemail feature as a built-in function of the EPIC Wheels program to exchange messages with their trainer, if desired; trainers can respond via their website interface. Because many potential trainees will not have broadband Internet access at home and the Android tablets used in EPIC Wheels are Wi-Fi only, trainees were also given a mobile cellular hotspot device. The tablet can connect through this device to the Internet to upload training data and exchange voicemail messages with the trainer.After the study period, participants completed a program evaluation questionnaire and provided informal feedback on their experience. As anticipated, the experienced participant indicated he had not learned any new skills but had already been fully proficient with all desired mobility skills for many years. He indicated he would have appreciated such a program when he first obtained his wheelchair and felt there were no important skills or components missing from the program. He commented that the training activities were engaging and fun, although he modified some to increase the challenge because of his level of proficiency. The novice user also found the program comprehensive and identified a substantial benefit, not only due to his capacity for wheelchair mobility but also due to his ability to participate in meaningful activities of daily living. In particular, he identified improvement in turning (related to mobility in tight spaces) and learning to “pop the casters” enabled him to traverse small obstacles like doorway thresholds and propel over soft surfaces like carpet and snow. The lack of large open spaces and hard floor surfaces in his condominium presented some challenges with training activities. The experienced user did not use the voicemail feature, while the novice user had several voicemail exchanges with the trainer. Intermittent connectivity issues with the hotspot device resulted in some data uploading delays and this participant reverted to telephone calls rather than voicemail.Several additional changes were made to the clinical prototype, which would be used in a subsequent randomized controlled trial . Upgrade to the User-Interface Software Program. The training program was given a more bright and appealing appearance, similar to a commercial software application. The EPIC Wheels program automatically loads upon powering up or waking up the tablet. To increase ease of use and minimize distraction, there are no other applications or features visible. The home screen provides information on the number of minutes spent viewing instructional videos, minutes spent on training activities, and a graphic with weekly progress compared against the goal of 150 minutes (see (1)utes see . Videos  Upgrade to the Trainer Web-Based Monitoring Software. As participants are enrolled, an account is created on the trainer's monitoring website. Approximately every 24 hours the tablet attempts to connect with the server via the Internet to upload tablet usage data, providing the trainer with updated information on the number of minutes spent on various training components with each tablet session as well as the number of visits and time spent on each training activity. The data can be viewed at the website or downloaded in tabular form for further analysis.(2) Self-Contained Training Program. While tablet functionality remains intact, the EPIC Wheels program is being operated as a stand-alone program with other applications hidden using a custom launcher program. All training content is included on the tablet and can be operated independent of Internet connectivity. A mobile WiFi device  automatically connects the tablet to the Internet when it is in range (up to 34 metres indoors). The tablet can then update any voicemail messages between trainee and trainer as well as perform its daily upload of tablet training data. However, even if the tablet fails to connect through the hotspot to the Internet, it will continue to operate and record data independently until such time as the connection is reestablished.(3) Protection and Safety. To protect trainee information, the program requires a password for access to protect trainee information and all data is encrypted before storage and uploaded to the secure server. A screen protector on the tablet reduces glare and protects the viewing surface from damage. The software requires trainees to complete the safety content section before permitting access to the remaining training content, and for higher risk content  a pop-up window requires trainees to acknowledge compliance or click on a link to review the safety section. The BORG perceived rate of exertion scale was introduced in the safety section and trainees instructed to limit their effort to “somewhat hard” to prevent overexertion. In addition, content specific to care providers is provided including strategies to enhance effective training, safe spotting, and demonstration of techniques for assisting the wheelchair user during challenging or high-risk activities .(4)We were successful in achieving the three objectives of this project. Our older adult MWC user partners were engaged throughout the design and implementation process and all stakeholder groups provided substantial contributions to the development of a clinical prototype that is currently being evaluated in a RCT. The PAD framework proved to be a valuable approach to creating the EPIC Wheels program. The iterative consultation process provided critical input into the evolving content and user interface. Incorporating a number of stakeholder groups provided validation for relevance and appropriateness of the included content. The MWC users confirmed the scope of skills included was comprehensive and contributed to inclusion of additional material such as the task of carrying an item while propelling a wheelchair. Care providers negotiated that training content around some high-level skills  should be restructured with assisted, rather than independent, strategies. The clinician groups confirmed skills that were most enabling and often neglected among older adults, such as transient wheelies, and provided input on teaching strategies. Focus groups were particularly useful as they facilitated interaction and discussion among participants. The resulting dialogue was often animated and engaging, and there was not always agreement or consensus. While this made analysis more challenging, the outcome was a richer and more comprehensive product with greater potential for application to a broad audience. mastery experience which has the strongest influence on self-efficacy [ vicarious experience or the observation of a comparable peer achieving success in a given skill, which is the penultimate factor influencing self-efficacy [ verbal persuasion. Stakeholders advocating for regular monitoring and follow-up by the trainer and for inclusion of spotting, training, and feedback strategies specifically for care providers in the EPIC Wheels program were particularly relevant in this regard. Finally, appropriate management and interpretation of one's physiological state is important to wheelchair confidence. The inclusion of games and other engaging training activities increase motivational investment while distracting trainees from the demands of performing mobility skills. While some older adults may be unfamiliar with computer games, we anticipate their inclusion will increase training time as recent studies show promising results in this regard, even among the very old [The critiques and recommendations by stakeholders proved to be consistent with, and confirmatory of, the theoretical bases with which EPIC Wheels was created. Four key components of self-efficacy, as proposed in Social Cognitive Theory , were evefficacy . Early sefficacy , 56. Theefficacy . Knowlesefficacy  also proefficacy . A thirdvery old , 33. We very old  and paravery old .Stakeholders also provided input that aligned with Andragogical principles. Adult learners, particularly older adults, prefer an autonomous and self-directed approach that is goal-oriented and respectful . The EPIA key benefit of the PAD approach was optimizing the tablet interface. Despite the numerous benefits that a tablet offers, such as touch screen access, interactivity, portability, and Internet connectivity, acceptance and adherence by older adults are critical to the success of this home program. By bringing evolving prototypes back to the target users, as well as other stakeholders, we were able to ensure usability by older adults. Although older adults are less likely to use technologies such as computers and cell phones than young people, computer use is continuing to grow. Recent studies in the United States found 84% of those over 60 years had experience with computers . Use of At the conclusion of the PAD process the EPIC Wheels program and training tablet demonstrated robust and consistent performance and are currently being evaluated in a randomized controlled trial with novice older adult MWC users . The traFuture development will focus on several improvements. Communication between trainee and trainer is currently conducted via voicemail, but the capacity for recorded video communication is already in place. Expediting video data transfer and integration of a video player applet are under development and the potential for real-time video communication is also being explored. The software content and user interface are self-contained and preloaded on the trainee tablet. A content management software program will provide the potential for trainers to customize a trainee's program, adding and removing content as desired. In the future, this would allow a trainer to release new content over time via the Internet. Using built-in or external sensors could expand the scope of interactive training activities used and collection of performance-based data.Some limitations with the EPIC Wheels program should be noted. The training content specifically targets MWC users who propel with both upper extremities, including those who also use one or both lower extremities. Other propulsion strategies, such as one arm and one leg used by individuals with hemiplegia, and mobility equipment  are common and require a different set of skills. Such content will need to be created to address these users groups. The software developers were proficient with the Android platform and EPIC Wheels is currently available only on these devices; creating a version compatible with the Apple iPad would facilitate broader appeal and availability. Finally, while the tablet tracks all program interactions and uploads detailed activity information to the trainer website, there is no way to verify that trainees physically engage in training beyond viewing the program content. In future, synchronizing training activities with input from a data logger or tablet accelerometer may address this issue.A participatory action design process proved valuable in the development and refinement of a tablet-based wheelchair skills home training program. The involvement of older adult wheelchair users, as well as care providers and clinician stakeholders, was critical to achieving a product that was both comprehensive and acceptable to the target users. The contributions of these research partners confirmed the underlying theoretical principles of self-efficacy and adult learning theory upon which the program was developed. The clinical prototype that emerged is currently under evaluation in a randomized controlled trial and further enhancements to the current program are anticipated in the near future.The supplementary material includes a copy of the Training Progress Sheet. Participants receive a print copy of this handout in their user guide. All training content is outlined in sequence and broken down into sections that correspond to the EPIC Wheels software interface. This sheet allows participants to locate specific content easily and visually track progress through the entire program. At each training session, the trainer can highlight specific content for the participant to work on and make written comments for future reference.


Behavioral incentives have been used to encourage smoking cessation in older adolescents, but the acceptability of incentives to promote a smoke-free lifestyle in younger adolescents is unknown. To inform the development of novel, effective, school-based interventions for youth, we assessed middle school students' interest in participating in an incentive-based tobacco abstinence program. We surveyed 988 students (grades 6–8) attending three Connecticut middle schools to determine whether interest in program participation varied as a function of (1) intrapersonal factors , smoking history, and trait impulsivity) and/or (2) aspects of program design . Primary analyses were conducted using multiple regression. A majority of students (61.8%) reported interest in program participation. Interest did not vary by gender, smoking risk status, or offering cash prizes. However, younger students, non-Caucasian students, behaviorally impulsive students, and students with higher levels of self-regulation were more likely to report interest. Inexpensive awards  offered monthly motivated program interest. In sum, middle school students reported high levels of interest in an incentive-based program to encourage a tobacco-free lifestyle. These formative data can inform the design of effective, incentive-based smoking cessation and prevention programs in middle schools. Tobacco use is the leading cause of preventable morbidity and mortality in the United States , 2. AccoUnfortunately, few well-designed prevention or intervention trials have shown promise in middle schools ; successIncentive-based programs, which provide rewards  in exchange for confirmed tobacco abstinence, have promise for application in middle schools. Prior research indicates that community-based “Quit and Win” programs, which enroll smokers into contests wherein they may win prizes for being tobacco-free, are most appealing to younger smokers . BehavioAlthough self-determination theory , 25 arguWith regard to evaluating the effectiveness of classroom-based, behavioral incentive programs, a recent meta-analysis of “The Smoke-Free Class” competition , a progrTo our knowledge, no incentive-based smoking prevention/cessation programs have been developed for use with middle schools in the United States. To inform the development of such a program, the current study evaluated the extent to which intrapersonal factors  and program-design features  influence students' interest in participating. participating in an incentive-based prevention/intervention program. Impulsive adolescents may be less interested if they perceive the rewards to be neither immediate nor guaranteed and lack the foresight to appreciate the long-term health benefits of living smoke-free. However, impulsive adolescents may be more interested in participating if the prospect of receiving a reward is reinforcing in itself and is perceived to be proximal relative to the distal experience of future health benefits ; impaired self-regulation: Cronbach's α = .71, mean = 7.89 [SD = 2.52]). The two subscales were correlated moderately (r = .48), indicating that behavioral impulsivity and deficits in self-regulation are related domains of impulsivity. However, further examination of the data based on median split demonstrated that there was considerable individual variability in scores on these related, yet distinct, subscales , two primary prize types emerged: cash and electronics . We created two binary variables reflecting cash and electronics.Monetary Value of Prizes. To determine the minimum monetary value of the prize needed to motivate program interest, students were asked the following question: “What is the smallest prize that would make you interested in participating and staying tobacco-free for the rest of the school year?” Answer choices were $25, $25–50, $50–$75, $75–$100, and $100+.Frequency of Rewards. To determine an ideal reinforcement schedule, students were asked the following question, “How often should the contest be run?” Response options included monthly, every two months, every grading period, every semester, and once a year.We conducted data analyses using MPLUS 7. Data were double entered and cleaned. Random spot checks of the original surveys ensured data accuracy. We employed multiple regression to evaluate the extent to which students' interest in program participation was influenced by intrapersonal factors  and aspects of the incentive-based program design . We treated the following as categorical predictor variables: gender, race/ethnicity, smoking risk status, and prize type. We included age, impulsivity, prize value, and frequency of reward as continuous predictors. 18.0% of students were missing data on one or more central study variables (at random), so missing data were handled using full information maximum likelihood (FIML).The regression model including all variables accounted for 11.2% of the variance in program interest see . YoungerOur results suggest that the majority of middle school students (61.8%) reported interest in participating in an incentive-based program designed to encourage a smoke-free lifestyle. The program appealed to male and female students. Furthermore, the program appealed to students irrespective of smoking status, suggesting that it has the potential to target both smoking prevention and cessation among middle school students.Although most students expressed program interest, several variables significantly influenced students' interest level. As anticipated, younger students were more interested than older students. As such, the proposed incentive-based program may be most impactful among younger students, which is encouraging given that the peak ages of cigarette experimentation are 11 to 13 years . The proRegarding program design, less expensive prizes offered monthly sufficiently motivated student interest, suggesting that implementing an incentive-based program needs not be costly. Consistent with their tech-savvy moniker “the iGeneration” , studentn = 43) limited our statistical power to detect effects specifically within this group. As such, we relied on a broader conceptualization of smoking risk in the current study [While the current study provides novel information about middle school students' interest in participating in an incentive-based tobacco prevention/intervention program, several limitations merit note. Program interest was assessed using a single question and all data were self-reported. It is worth noting, however, that while reliance on self-reported smoking history introduced the potential for misreporting, our smoking estimates were consistent with national estimates . Our datnt study . FinallyThe current study provides formative data that can inform the development of maximally effective smoking cessation/prevention programs for middle schools that complement existing tobacco education by behaviorally reinforcing a tobacco-free lifestyle. Importantly, students reported strong interest in a cost-effective program irrespective of smoking status. Our data suggest that targeting younger middle school students and offering monthly rewards may maximize program impact. To help boost participation, especially among students with deficits in self-control/planning, automatic enrollment of all students in the program (with the option to opt out) may prove to be a superior voluntary approach to automatic nonenrollment. Adjusting the optimal default to participation may seem unconventional, but drastic measures are warranted given the exorbitant social, economic, and health costs associated with cigarette smoking.


Decoy receptor 3 (DcR3) expression in kidneys has been shown to predict progression of chronic kidney disease. We prospectively investigated a cohort comprising 96 renal transplant recipients (RTRs) undergoing graft kidney biopsies. Computer-assisted quantitative immunohistochemical staining value of DcR3 in renal tubular epithelial cells (RTECs) was used to determine the predictive role of DcR3 in kidney disease progression. The primary end point was doubling of serum creatinine and/or graft failure. A multivariate Cox proportional hazards model was used to assess the risk of DcR3 expression in rejected kidney grafts toward the renal end point. In total, RTRs with kidney allograft rejection were evaluated and the median follow-up was 30.9 months. The greater expression of DcR3 immunoreactivity in RTECs was correlated with a higher rate of the histopathological concordance of acute T cell-mediated rejection. Compared with 65 non-progressors, 31 progressors had higher DcR3 expression (HDE) regardless of the traditional risk factors. Cox regression analysis showed HDE was significantly associated with the risk of renal end point with a hazard ratio of 3.19  after adjusting for other variables. In repetitive biopsies, HDE in tissue showed rapid kidney disease progression due to persistent inflammation. Both immunological and non-immunological risk factors contribute to long-term kidney allograft survival. The demographics and comorbidities of donors and recipients change continuously and thus it is necessary to develop precise models for prediction of allograft outcome. The optimal organ allocation system was used initially to determine factors associated with graft failure1345Decoy receptor 3 (DcR3) is a member of the tumor necrosis factor receptor (TNFR) superfamily, but it lacks the transmembrane domain as a secreted protein791211in situ hybridization of human kidney tissue, RTECs up-regulated TNFR-2 mRNA, which is characteristic of allograft rejectionSoluble DcR3 has emerged as a pleiotropic immunomodulator which is immune-evasive and able to promote type 2 T helper cells (Th2) in organ transplantation. Indeed, a very high dose of DcR3-Fc can suppress alloantigen-stimulated mouse T cell activation and inhibit cytotoxic T lymphocyte development815In time-zero biopsy samples without acute tubular injury that served as the controls, DcR3 immunoreactivity was undetectable . Among pvs 42.3%; P = 0.006), especially in the subgroup of acute T cell-mediated rejection (TCMR).The median optimal quantitative immunohistochemical staining value (QISV) of DcR3 was 0.156 for identifying the primary end point and the cutoff value (QISV = 0.156) was validated by the area under the ROC curve  for predictive accuracy. The high DcR3 expression (HDE) and low DcR3 expression (LDE) groups did not differ significantly with respect to age, gender, and risk factors associated with prognosis of kidney disease . There w218218vs 1.04 ± 0.97; P = 0.013; i-score: 1.81 ± 0.95 vs 1.44 ± 0.97; P = 0.033)  . Glomeru= 0.033) .vs LDE; P = 0.037) and interstitial mononuclear leukocyte infiltration . Although there were cases of high DcR3 in the acute ABMR group, the relationship between HDE and pathologic representation  staining by immunohistochemistry ) of acute ABMR was not statistically significant  had a two-fold increase in serum creatinine, 20 patients (17.7%) had reached end-stage renal failure requiring renal replacement therapy, and 5 patients (4.4%) died with deteriorated renal function. Other independent associations with worse graft function were found, including low serum albumin (P = 0.001), increased proteinuria (P = 0.004), low eGFR (P < 0.001), severe interstitial fibrosis/tubular atrophy (IF/TA) (P = 0.006), high chronic allograft damage index , and C4d staining by IHC (P = 0.049) at the time of biopsies .The Kaplan-Meier survival analysis revealed that 9 of 52 cases of LDE and 22 of 44 cases of HDE progressed to the primary end point  . To test14The 28 cases with diagnoses of acute rejection and repetitive biopsy during the study interval provide strong evidence that the biomarker HDE can serve as a good prognosis indicator . In the There is obvious colocalization between common leukocyte antigen (CD45 surface marker) and DcR3 expression over infiltrating mononuclear leukocytes in the renal tubules, renal interstitium, and peritubular capillaries . The oppIn the areas of active inflammation and severe rejection-related architecture, there is intense DcR3 mRNA expression in RTECs infiltrated with mononuclear cells . The patTo the best of our knowledge, this is the first study to demonstrate that DcR3 is significantly expressed in tissues of kidney transplants with acute rejection. We also find that in cases with TCMR, increased expression of DcR3 is correlated with histopathology of Banff i-scores and t-scores. To begin with, the association of HDE with tubulitis and interstitial monocyte infiltration may lead to renal fibrosis and subsequent loss of graft function in RTRs with acute rejection. In addition, the high expression of DcR3 molecules in RTECs is associated with worse prognosis compared to that of allografts with low DcR3 expression. Events are defined as either allograft loss with return to dialysis or persistent (>3 months) doubling of serum creatinine. Intriguingly, the predictive value of HDE in RTECs increases the statistical power for outcome prediction calculated by traditional risk factors.DcR3 is a soluble decoy receptor and member of the TNFR superfamily; it is up-regulated following cell injury and/or inflammation caused by acute rejection817212222232415The second-hit would be caused by subsequent residual inflammation and would promote renal fibrosis . Based o14Endogenous tissue DcR3, which has the characteristic of a molecular classifier, is suitable for consideration as a novel biomarker for acute TCMR. However, HDE, the molecular phenotype, might be associated with future graft dysfunction. The representative HDE in RTECs is better than Banff criteria available now for acute T cell rejection - tubulitis and interstitial mononuclear leukocyte infiltration. This means that the cumulative burden of injury is more correlated with functional disturbance and risk of future graft loss in both living-related and suboptimal grafts. The worsening of tubulitis and interstitial inflammation in cases with HDE suggests that HDE may identify lesions of acute TCMR in particular patients that do not respond to anti-rejection therapy  and may Matching recipient group to donor grade as proposed by the United Network for Organ Sharing (UNOS) will improve renal survival121812Some limitations in this study should be acknowledged. First, our study is prospective and observational in nature, so it cannot prove causality. Second, the IHC staining is described as the computer-assisted QISV value, and it is at best quantitative for the antigen target21In conclusion, we found the overexpression of DcR3 in tissue to be a novel biomarker which correlates with acute TCMR. When the DcR3 molecular classifier is used in combination with pathologic findings and traditional risk factors, it improves prediction of kidney disease progression in RTRs. Further study is needed to explore the possible therapeutic potential or detrimental effects of DcR3 in kidney graft outcome.Declaration of Istanbul as outlined in the ‘Declaration of Istanbul on Organ Trafficking and Transplant Tourism’.Patients were eligible for enrollment if they underwent transplant biopsy for clinical indications such as deterioration in kidney function, proteinuria, and overt kidney allograft dysfunction at Taichung Veterans General Hospital between September 1, 2010 and November 15, 2013. Criteria for inclusion were age >20 years, first kidney transplantation from an inshore deceased or living donor, kidney injury with different spectrum of rejection, mostly acute rejection, and repetitive biopsies. Among the 168 patients who consented to undergo graft kidney biopsy, 18 (10.7%) cases were excluded due to refusal to sign the informed consent document, pure severe acute tubular necrosis (ATN) without kidney rejection, and recurrent glomerulonephritis after kidney transplantation, as well as active malignancy. Sixteen (9.5%) cases were excluded due to non-rejection caused by hemodynamic change, arteriosclerosis or donor conditions, and polyomavirus nephropathy. Thirty-eight (22.6%) cases with repetitive allograft biopsy having first biopsy were included, but the second biopsy was initially excluded. Ninety-six patients who met the inclusion criteria which we focused on kidney rejection1232Kidney specimens were fixed in formalin then immersed in phosphate buffer saline (PBS). After dehydration with a graduated series of ethanol and xylene, the tissues were embedded in paraffin and cut into 4-μm sections. Normal kidney allograft tissues of the 5 control subjects were also processed. After deparaffinization and rehydration, hematoxylin and eosin stain, periodic acid-Schiff (PAS) stain, and Masson’s trichrome stain were used for histological examination, Banff 2009 classificationStandard immunohistochemical (IHC) protocol was also followed after deparaffinization and rehydration. Then, each 4-μm section in 10 mM sodium citrate (pH 6.0) was heated in a microwave oven  for antigen retrieval, after which endogenous peroxidase activity was blocked by 3% hydrogen peroxide. Thereafter, adjacent sections from the same paraffin block were incubated with the primary antibodies: mouse monoclonal antibodies directed against human DcR3  at 4 °C overnight. Then, all tissue sections were incubated with secondary antibody  for 30 minutes at room temperature. Signals were developed with two-component high-sensitivity diaminobenzidine (DAB) chromogenic substrate (DakoCytomation) for 10 minutes and counterstained with hematoxylin. For negative controls, the primary antibodies were replaced by an equal concentration of isotype-matched irrelevant antibodies (DakoCytomation). An adjacent paraffin section of the slide was used as the negative control .For all histopathological findings, the final pathological diagnosis and semiquantitative analysis were conducted according to the Banff 2009 classificationAn evaluation of cortical tubulointerstitial IHC staining for DcR3 as determined by computer-assisted pixel counts  was performed for potential correlation with histologic and outcome parameters. Twenty areas from each IHC sample were randomly selected in the renal cortex and examined under a microscope. Briefly, the selected non-overlapping high-power fields of each section were captured by a DM750 microscope , and then the images were converted to digital files using a CCD camera . The medulla, glomeruli in the cortex, and the large vessels were eliminated using Adobe Photoshop CS6 to specifically measure the DcR3 expression in the RTECs. Before performing the computer-aided quantitative staining analysis, the intensity in the blank area of slides was used for calibration of optical density. We used two color segmentations: one recognized DcR3-positive brown cells and the other DcR3-negative blue background cells. The integrated optical density (IOD) was obtained as the total number of immunopositive brown pixels multiplied by the brown intensity of those pixels, and it was used to avoid the data simply being a correlated metric of inflammatory infiltration12There are mildly stained nuclei of tubulointerstitial infiltration and mononuclear leukocytes with DcR3 in rejection kidneys. To realize the colocalization of DcR3  and common leukocyte antigen , we used paraffin sections following the double stain protocol2, pH 8 and 0.25% acetic anhydrite. Tissues were prehybridized for 2 hrs at 48 °C in a hybridization buffer containing 50% formamide, 5 × SSC, RNase inhibitor and 10 μg/ml Salmon sperm DNA . The above procedures were used to expose nucleic acids. Decoy receptor 3 cDNA plasmid was earlier transformed into Escherichia coli, and it was extracted. Then this plasmid was digested with KpnI, which brought about the 650 bps cDNA template for further probe production. The inserted human DcR3 cDNA was flanked by SP6 and T7 sites for RNA polymerase . The cDNA  was designed to provide high sensitivity for in situ hybridization of DcR3 mRNA from the genein vitro transcription with sense (negative control) and anti-sense the SP6/T7-Polymerase Digoxigenin (DIG)-Labeling and Transcription Kit . The DIG-labeling probe was then added on the slides in new hybridization buffer, denatured for 10 mins at 65 °C and incubated overnight at 45 °C. The slides were washed 20 mins in 2 × SSC, 15 mins in 1 × SSC (twice), 15 mins in 0.2 × SSC at 56 °C and 15 mins in 0.2 × SSC at room temperature. After blocking  for 1 hr, slides were then incubated for 2 hrs at 37 °C with a monoclonal anti-digoxin-alkaline phosphatase antibody (Anti-digoxigenin) produced in mouse  and subsequently washed in a Tris pH 7.5-NaCl buffer. Color was developed for signal detection with NBT/BCIP .Paraffin embedded sections were dewaxed and rehydrated, then the tissue was digested with pepsin 1 μg/mL in 0.1 N HCl (diluted in RNase-free water) for 30 mins at 37 °C and acetylated in freshly prepared 1:10 triethanolamine with MgCl2 test, but for an expected count of less than 5, Fisher’s exact test was used. The Kolmogorov-Smirnov test was used to test whether the continuous variables of the sample had a normal distribution. Continuous variables are expressed as means ± SD or medians and interquartile ranges. For between-two-group comparisons, the Student’s t-test was used for normally distributed data and the Mann-Whitney rank sum test was used for data with a non-normal distribution. A cumulative survival curve of the kidney allograft was generated by the Kaplan-Meier method, and the high and low expressions of DcR3 in the RTECs were compared by the log-rank test. The Cox proportional hazard models are presented as hazard ratios (HR) and 95% confidence intervals (CI). Multivariate Cox regression analysis was used to examine the association between DcR3 expression and the primary end point, with adjustment for potential confounding factors. All demographic variables with a hazard ratio were adjusted for age and gender with a P value < 0.05 .


On 11 March 2011, a devastating earthquake struck off the coast of Japan, causing blustering tsunami that swept over the northeast coast of the country. Many struggled to evacuate from their homes, schools, and workplaces as 8- to 9-m-tall tsunami rapidly reached the coast within half an hour after the earthquake (Emergency Disaster Response Headquarters). The officials reported a record-breaking magnitude of 9.0 Mw, which made this earthquake the most devastating earthquake in the Japan's history. It had not been long since the previous massive earthquake had hit Kobe in 1995, killing 6,434 people . The author presents the outline of the initial mental-health-care responses at various levels. It has focused on the comprehensive strategies and policies that were intended to cover all the affected areas but has not described the individual countermeasures and reactions in each prefecture and city. The psychological effects of the atomic plant accident in Fukushima has not been mentioned in detail, because the scope of the physiological effect of the accident has not been settled yet and the society is not necessarily ready to deal with the accident as a psychological matter rather than a sociopolitical one. A number of psychiatric professionals are deeply concerned with the psychological and prolonged impact of the accident, including those who are in the Fukushima prefecture and conducting heroic efforts to care for the residents.