Lipid oxidation of membrane phospholipids is accompanied by the formation of oxidation-specific epitopes (OSE). These epitopes are recognized by specific antibodies and represent danger-associated molecular patterns that are generated during chronic inflammatory processes. In a murine model for hepatic inflammation during non-alcoholic fatty liver disease (NAFLD), increased antibody levels targeting OSE were found to be protective. Here, our aim was to determine an association between OSE-specific antibody titers and NAFLD in humans.n = 71) and healthy controls (n = 68). Antibody titers were comprehensively analyzed in patients with NAFLD after classification by histological evaluation of liver biopsies. Statistical analysis was performed to determine significant correlations and odds ratios. To study the specificity for NAFLD, plasma antibody titers were measured in patients with hepatitis C (n = 40) and inflammatory bowel disease (n = 62).IgM and IgG levels with specificity for various OSE were assessed in the plasma of patients with NAFLD  contains supplementary material, which is available to authorized users. Non-alcoholic fatty liver disease (NAFLD) constitutes a spectrum of liver diseases characterized by hepatic lipid accumulation (steatosis), which when combined with hepatic inflammation is known as non-alcoholic steatohepatitis (NASH). Steatosis is generally considered to be a benign and reversible condition that is present in about two thirds of patients with the metabolic syndrome . The preLdlr−/− mice with heat-inactivated pneumococci, which induce the production of anti-OxLDL IgM due to molecular mimicry with OxLDL, had less hepatic inflammation than control mice after a Western diet. Moreover, we recently showed that increased levels of IgM antibodies as a result of Siglec-G deficiency inhibits diet-induced hepatic inflammation and atherosclerosis in Ldlr−/− mice [Immune reactions triggered by oxidative stress have been shown to be involved during the progression of NAFLD to fibrosis . Moreove−/− mice . HoweverHere, we aimed to determine an association between plasma antibodies targeting OSE and NAFLD in humans. For this purpose, IgM and IgG antibody titers against different model epitopes of oxidized lipids were measured in the plasma of patients with NAFLD and compared to those in control subjects. Liver biopsies from patients with biopsy-proven NASH were examined for the presence of MDA epitopes by immunohistochemistry. Additionally, to test the specificity of our findings for NAFLD, antibody levels were determined in two cohorts consisting of patients with hepatitis C and inflammatory bowel disease (IBD). Our data highlight the importance of immune recognition of OSE by IgM antibodies in NAFLD and suggest that low IgM levels against end products of lipid oxidation during fatty liver disease are a consequence of obesity.Human MDA-LDL, MAA-LDL, CuOx-LDL, and PC-BSA were prepared as previously described . MDA2 (ahttp://www.federa.org). The staining was performed as described previously (antibody dilution 1:2000) and biopsies were evaluated for the presence of MDA [Immunohistochemistry for MDA using the monoclonal antibody MDA2 was performed on 10 liver biopsies diagnosed as NASH, originating from the Maastricht Pathology Tissue Collection. Collection, storage, and use of tissue and patient data were performed in agreement with the “Code for Proper Secondary Use of Human Tissue in the Netherlands” (3 (pH 8.5) coating buffer and incubated overnight at 4 °C. After washing and blocking with Tris-buffered saline (TBS) with or without EDTA , 30 min at room temperature), the plate was incubated with plasma samples in their respective dilutions  in 1 % BSA in TBS with EDTA (pH 7.4) for 2 h at room temperature or overnight at 4 °C. Alkaline phosphatase (AP)-labeled goat anti-human IgM  or AP-labeled goat anti-human IgG  was used for detection. AP-conjugated secondary reagents were detected using Lumi-Phos  and a Synergy 2 Luminometer . Washing steps were performed on an ELx405 Select Deep Well Microplate Washer  with PBS or PBS-EDTA. Internal controls were included on each microtiter plate to detect potential variations between microtiter plates. The intra-assay coefficients of variation for all assays were 5–15 %.Chemiluminescent ELISA was performed as previously described . In brien = 68) were recruited by advertisement and patients classified as NAFLD (n = 53) were recruited from the metabolic clinics of the Cleveland Clinic and MetroHealth Medical Center in Cleveland, OH, USA. The study protocol was approved by the Institutional Review Boards at the Cleveland Clinic and MetroHealth Medical Center. A detailed clinical history was obtained for each participant, followed by a physical examination. Hepatic ultrasonography was performed on all participants by the same investigator (S. Dasarathy) in order to confirm the absence of steatosis in controls. Moreover, plasma transaminase levels were determined in all participants. Where steatosis and increased plasma transaminase levels were detected, a liver biopsy was taken for further characterization of NAFLD. Liver biopsies from patients were reviewed in a blinded manner by the same pathologist and NASH was defined as an NAFLD activity score ≥4 and a histologic diagnosis of NASH by the pathologist. Participants with other forms of chronic liver disease were excluded by screening for autoimmune liver disease , for metabolic liver disease , for alpha-1 antitrypsin deficiency, and for viral hepatitis (hepatitis B and hepatitis C). Participants with a history of daily alcohol intake , intravenous drug use, or a history of bowel surgery were also excluded. None of the participants were on any medications known to cause hepatic steatosis or taking vitamin supplements. Written informed consent was obtained from all participants after having the procedure fully explained. Blood and liver sampling was done as described before [2. Further clinical and biochemical data for all patients are summarized in Table Healthy controls (d before –13. Plasn = 20) were recruited by advertisement and patients with chronic hepatitis C (n = 20) were recruited from the Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Austria. The study protocol was approved by the Institutional Review Boards at the Medical University of Vienna. Hepatic ultrasonography and liver biopsy was performed on all participants prior to scheduled antiviral therapy. Moreover, plasma transaminase levels were determined in all participants. Liver biopsies of patients were reviewed in a blinded manner by two independent pathologists. Participants with other forms of chronic liver disease or with a history of daily alcohol intake were excluded by screening. Written informed consent was obtained from all participants after having the procedure fully explained. Further clinical data for the patients are summarized in Table Healthy controls n = 0 were reBetween September 2009 and December 2010, consecutive patients with IBD were recruited during routine follow-up at the Gastroenterology Outpatient Clinic of the MUMC+ and participated in a prospective 1-year follow-up study . All patt-test or the Mann–Whitney U test  was used to compare a variable between two subgroups. Multivariate logistic regression models were used to assess the association between P1-specific IgM levels and NAFLD in the specific cohort after adjusting for age, gender, BMI, and total IgM levels. All reported p-values are two-tailed and considered significant at p < 0.05. Statistical procedures were carried out using Graphad Prism 6 or IBM SPSS 20.Continuous variables are presented as means and standard deviations or as medians and interquartile ranges for skewed distributions. Categorical data are presented as absolute frequencies and percentages. Student’s To determine whether OSE are generated during the spectrum of NAFLD, immunohistochemical staining for MDA epitopes with the monoclonal antibody MDA2 was performed on liver biopsies of patients with biopsy-proven NASH. As illustrated in Fig. n = 71) and control participants with confirmed absence of steatosis (n = 68). The values of the different measurements were tested for normality with Shapiro–Wilks test and the results indicated that data were not normally distributed for most of the measurements in either of the groups , P1 (a highly specific peptide mimotope of MAA ), Cu-OxLp = 0.0019; Fig. p = 0.0026; Fig. p < 0.0001; Fig. p = 0.0004; Fig. p = 0.0096; Fig. In line with our expectations, patients with NAFLD had significantly lower IgM titers than controls against MDA-LDL  because a normal ALT level is expected to be <50 IU/L. Interestingly, P1-IgM levels were reduced in participants with moderately elevated ALT levels (25–50 IU/L) or high ALT levels (>50 IU/L) when compared with the P1-IgM levels of participants with ALT levels <25 IU/L Fig. . MoreoveNext, we evaluated the relationship between IgM to P1 and different classifications based on histological scoring of liver biopsies taken from patients with NAFLD. First, the potential of anti-P1 IgM to distinguish simple steatosis from NASH was tested. Whereas IgM titers were lower in NAFLD compared with controls, no difference was observed in specific IgM levels between patients with steatosis and NASH Fig. . MoreoveTo determine the power of low plasma IgM titers against the P1 mimotope to predict the presence of fatty liver disease, age, gender, BMI, total IgM levels, and anti-P1 IgM levels were combined in a single logistic regression model. To account for skewness in their distribution, base-2 logarithms of P1-specific IgM levels were used in the model. Thus, adjusted odds ratios (OR) for this variable reflect the change in odds for an increase of one log2  in the measure. Without adjustment for other risk factors, age , BMI , total IgM , and P1-IgM  were all significant predictors for the presence of NAFLD, and female gender was not , indicating an increased likelihood of NAFLD with decreasing P1-IgM levels, independent of age, gender, BMI, and total IgM levels  curve analysis was performed to assess the diagnostic value of anti-P1 IgM titers for NAFLD. An area under the curve (AUC) of 0.703  for the diagnosis of NAFLD using IgM titers towards P1 was found Fig. . In addiels Fig. , Table 3p = 0.0009, Fig. p = 0.02, Fig. p = 0.0026, Fig. p = 0.0006, Fig. p = 0.041, Fig. p = 0.0033, Fig. p = 0.047, Additional file p = 0.037, Additional file First, the correlation between P1-IgM and plasma lipid levels in all participants was tested. No correlation was found between IgM levels towards P1 and plasma triglycerides , 46 had Crohn’s disease , 15 ulcerative colitis , and one patient had indeterminate colitis. IBD is characterized by fluctuations in the inflammatory state of the gut [n = 23), 1–2 refers to mild to moderate activity (n = 10), and 3 indicates severely active disease (n = 29). In contrast to our measurements in patients with NAFLD, total IgM levels were not influenced by the inflammatory activity state in patients with IBD , dominant cell types in mediating the pathogenesis of NASH [Recently, Tsiantoulas et al. showed that MDA epitopes are present on circulating microparticles and are recognized by specific IgM antibodies, thereby potentially dampening their pro-inflammatory effects . Micropa of NASH . Moreove of NASH . Another of NASH . In lineThe similarities between atherosclerosis and NAFLD, and our observations regarding the correlations with BMI and waist circumference allow us to hypothesize that low IgM titers towards oxidized lipids are a consequence of obesity and are specifically associated with related diseases. In contrast to lipid-induced inflammation during obesity, IBD is believed to result from an inappropriate inflammatory response to intestinal microbes in a genetically susceptible host . AlteredImportantly, increased serum levels of MDA and lipid oxidation were found to be present in individuals with chronic hepatitis C , which mSo far, the reason behind the lower OSE-specific IgM levels in comparison to healthy participants is not clear. Similar to the view in CVD , one posIn the current manuscript we point out that IgM titers to epitopes on oxidized lipids are negatively associated with NAFLD using the P1 mimotope, which serves as a highly reproducible antigen to assess antibody titers in patients. While the link between anti-P1 IgM measurements and NAFLD, which is independent of classical risk factors for NAFLD, provides critical insights into the pathophysiology of chronic fatty liver disease, plasma levels of anti-P1 IgM are not suitable as a biomarker for the progression of NAFLD. This conclusion is based on the inability of anti-P1 IgM titers to distinguish steatosis from NASH, the correlation between P1 IgM titers to BMI, and the large overlap between NAFLD and control participants for the different measurements. Of note, our findings suggest that obesity/hyperlipidemia is a causal factor for reduced IgM levels, rendering people more prone to develop fatty liver disease and related disorders such as atherosclerosis. Additional studies assessing IgM antibodies towards different OSE, and in particular the P1 mimotope, in multiple larger cohorts are necessary to confirm the inverse correlation with NAFLD and to address the potential causal link with obesity.ALT, alanine aminotransferase; AST, aspartate aminotransferase; AP, alkaline phosphatase; AUC, area under curve; BMI, body mass index; BSA, bovine serum albumin; CuOx-LDL, Copper oxidized low-density lipoprotein; HDL, high-density lipoprotein; IBD, inflammatory bowel disease; Ig, immunoglobulin; IL-1β, interleukin 1 beta; IL-6, interleukin 6; LDL, low-density lipoprotein; MAA, malondialdehyde-acetaldehyde; MCP-1, monocyte chemoattractant protein 1; MDA, malondialdehyde; NALFD, non-alcoholic fatty liver disease; NAS, NAFLD activity score; NASH, non-alcoholic steatohepatitis; OR, odds ratio; OSE, oxidation-specific epitope; OxLDL, oxidized low-density lipoprotein; PC, phosphocholine; RLU, relative light units; ROC, receiver operating characteristic (curve); TBS, Tris-buffered saline; γGT, gamma-glutamyltransferase.


Objectives. To evaluate the results of one-stage buccal mucosal urethroplasty in treatment of long urethral strictures. Methods. This retrospective study was carried out on 117 patients with long urethral strictures who underwent one-stage transperineal urethroplasty with dorsally placed buccal mucosal grafts (BMG). Success was defined as no need for any intervention during the follow-up period. Results. Among 117 patients with mean age of 39.55 ± 15.98 years, the strictures were located in penile urethra in 46 patients (39.32%), bulbar urethra in 33 (28.20%) and were panurethral in 38 (32.48%). The etiology of the urethral stricture was sexually transmitted disease (STD) in 17 (14.53%), lichen sclerosus in 15 (12.82%), trauma in 15 (12.82%), catheterization in 13 (11.11%), transurethral resection (TUR) in 6 (5.13%), and unknown in 51 (43.59%). The mean length of strictures was 9.31 ± 2.46 centimeters. During the mean followup of 18.9 ± 6.7 months success rate was 93.94% in bulbar strictures, 97.83% in penile strictures, and 84.21% in panurethral strictures . Conclusions. The success rate of transperineal urethroplasty with dorsally placed buccal mucosal grafts is equal in different sites of strictures with different etiologies. So reconstruction of long urethral strictures may be safely and effectively performed at a simple single operative procedure using this method of urethroplasty. Urethral stricture is a relatively common disease in men with different etiologies . There aIn this retrospective study we evaluated 117 patients who underwent buccal mucosal graft urethroplasty for treatment of long urethral strictures at the Urology Department of Imam Reza Hospital between December 2006 and December 2012. Preoperative studies included retrograde urethrography, voiding cystography, and urethroscopy.All of the patients underwent one-stage transperineal repair of long urethral stricture with dorsally placed BMG. In lithotomy position and under general anesthesia a circumcisional incision was made and the penis was degloved. Midline of the perinea was incised and the penis was brought to the perineal incision . The corThe urethral catheter was kept for 21 days. At the end of the 3rd week, retrograde urethrography was performed . If extrCystoscopy was done at the end of the third month. If there were symptoms, such as poor urine flow rate, retrograde urethrography was done to rule out a stricture. Failure was defined as a need to any intervention during the follow-up period. We also recorded and evaluated the complications including wound infections, development of meatal stenosis, urethrocutaneous fistula formation, recurrent stricture, erectile dysfunction, penile chordee or deformity, urethral diverticula formation, urinary incontinence or other urinary dysfunctions, lower limb complications due to lithotomy position, and buccal donor site complications. To minimize complications we used different strategies. To avoid wound infections we used intravenous prophylactic antibiotic (cefazolin 1 gr) 30 minutes before operation and continued oral antibiotic while the patient had foley catheter. If wound infections occurred, they were treated with appropriate suppressive antibiotics. To minimize neurologic complications of the lower extremities we decided to change the position of the patients who underwent long time operations (more than 3 hours) for a while during operation from lithotomy to supine. The patients have ambulated 3 days after surgery and physiotherapy exercises have been used while they were on bed rest. All the patients were advised to use antiseptic mouthwashes postoperatively to reduce buccal complications.P values less than 0.05 were considered statistically significant. We analyzed the results including success and complication rates and age, history of previous surgery, and etiology of strictures in three distinct groups according to the site of stricture .The data were analyzed using SPSS software (version 16.0) with chi-square test. 117 patients with mean age of 39.5 ± 16 years underwent buccal mucosal graft urethroplasty in our reconstructive centre. The etiology of the urethral stricture was sexually transmitted disease (STD) in 17 (14.53%), lichen sclerosus in 15 (12.82%), trauma in 15 (12.82%), catheterization in 13 (11.11%), transurethral resection (TUR) in 6 (5.13%) and unknown in 51 (43.59%). The strictures were located in penile urethra in 46 patients (39.32%), bulbar urethra in 33 (28.20%) and were panurethral in 38 (32.48%). The mean length of strictures was 9.31 ± 2.46 centimeters. The previous treatments done for the patients included the following: urethrotomy in 29 (24.79%), dilatation in 24 (20.51%), and urethroplasty in 2 (1.70%), and 62 patients (52.99%) did not receive any treatment before.With mean follow-up time of 18.9 ± 6.7 months overall success rate was 92.31% and failure rate was 7.69%.P value: 0.061). Characteristics of the patients who failed are shown in 46 patients were involved with penile strictures. The mean length of the stricture was 7.87 ± 2.74 centimeters. The etiology of strictures in this group was lichen sclerosus in 11 (23.91%), catheterization in 10 (21.74%), STD in 5 (10.87%), TUR in 4 (8.70%), and unknown in 16 (34.87%). Success rate was 97.83% and failure rate was 2.17%. Also bulbar strictures were seen in 33 patients. The mean length of the stricture was 5.67 ± 1.53 centimeters. The etiology of strictures in this group was trauma in 7 (21.21%), catheterization in 3 (9.09%), TUR in 2 (6.06%), STD in 2 (6.06%), and unknown in 19 (57.58%). Success rate was 93.94% and failure rate was 6.06%. Finally 38 patients were involved with panurethral strictures. The mean age of patients was 44.5 ± 13.8 years. The mean length of the stricture was 14.39 ± 3.12 centimeters. The etiology of strictures in this group was STD in 10 (26.32%), trauma in 8 (21.05%), lichen sclerosus in 4 (10.53%), and unknown in 16 (42.10%). Success rate was 84.21% and failure rate was 15.79%. So there was no significant difference in success rate between these three groups , ring stenosis resulting in urethrotomy in 9 (7.69%), meatal stenosis in 5 (4.27%), and mild chordee in 2 (1.70%). There were no erectile dysfunction, urinary incontinence, and other urinary problems as well as urethral diverticulum postoperatively. Six patients (5.12%) experienced paresthesia in their lower extremities after the operation, which in all cases resolved during the hospitalization period, and were all able to walk normally at the time of discharge. Obturator neuropathy occurred in one patient which was maybe due to compression of obturator nerve during long time lithotomy position, but it was resolved gradually using physiotherapy exercises.Minor buccal discomfort occurred in 20 patients (17.09%) after surgery but all of them became symptom-free during their followup. We did not meet any major bleeding during the procedure and we did not need any blood transfusion during the procedure and in postoperative period.Urethral strictures are a frequent source of lower urinary tract disorders in adults. In the developed world today postinflammatory stricture is rare. Iatrogenic causes such as TUR, urethral catheterization, cystoscopy, prostatectomy, brachytherapy, and hypospadias surgery account for about half of the cases of urethral stricture disease treated with urethroplasty. In about 33% of cases no obvious cause can be identified and it may be higher in special locations as Barbagli et al. reported 65.3% of bulbar strictures with unknown etiology , 4. LichDilation and urethrotomy continue to be the most commonly used techniques, but their failure rates are high with recurrence in 47.6% of patients and many patients progress to surgical repair. Moreover, repeated dilation or urethrotomy exacerbates scar formation, thus adding to stricture length and predisposing to a more difficult definitive open repair and a lower success rate . In our Open urethroplasty is the gold standard treatment for urethral strictures, but it is not a routine operation for a general urologist. Since 1993 El-Kasaby et al. reported the first experience with buccal mucosa urethroplasty for treatment of penile and bulbar urethral strictures . In 1996The surgical technique for penile urethral reconstruction is basically selected according to the etiology of the urethral stricture disease. The controversy over the best means of reconstructing the penile urethra has been renewed and, in recent years, free grafts have been making a comeback, with fewer surgeons using genital flaps , 17. PenAlthough recently a new one-stage technique that involves a deeply longitudinal midline incision of the urethral plate and the suturing of buccal mucosal tissue as an inlay graft into the bed obtained within the urethral plate has been described by different authors, the long-term results in a large series of patients treated with this new one-stage penile graft urethroplasty are not available in the current literature . In our The surgical technique used in the repair of the bulbar urethral stricture is selected mainly according to stricture length. BMG urethroplasty is the most widespread method for the repair of long strictures in the bulbar urethra, but the location of the graft on the urethra surface  has become a contentious issue. In Barbaglie's experience, the placement of the grafts on the ventral, dorsal, or lateral surface of the bulbar urethra provided the same success rates (83% to 85%) and stricture recurrence was uniformly distributed in all patients . Also otP value: 0.061). Also postoperative complications seen in this group were comparable with other two groups. So our technique of urethroplasty may be a successful method in the management of panurethral strictures and its success is relatively comparable with the results of other studies.Management of panurethral strictures is challenging for urologists and how to treat these patients is still a difficult and controversial issue in the field of reconstructive urethral surgery. In the authors' first experience in which the BMG was placed dorsally in treatment of panurethral strictures the success rate was 88.2%, which was comparable with other methods. Furthermore, complication rate was higher in older aged group, but success rate was the same in older and younger groups of patients . Also KuThe main weakness of our study is that it is retrospective and not prospective. Also, more followup is mandatory to calculate long-term failures.Reconstruction of long urethral strictures may be effectively performed in a single operative procedure using a transperineal approach with combinations of dorsal BMG.The results are comparable to those of published series using the dorsal BMG through the standard dorsal two-stage urethroplasties, in which there is a good and direct exposure of the stricture segment. Also this method may be effective in all types of urethral strictures  with relatively acceptable complications.Dorsally placed buccal mucosal graft urethroplasty using one-stage transperineal approach is a feasible method in treatment of long urethral strictures with minimal complications.Urethral stricture is a bothersome disease and all patients who underwent successful urethroplasty experienced a great change in their quality of life.


Benign esophageal strictures arise from a diversity of causes, for example esophagogastric reflux, esophageal resection, radiation therapy, ablative therapy, or the ingestion of a corrosive substance. Most strictures can be treated successfully with endoscopic dilation using bougies or balloons, with only a few complications. Nonetheless, approximately one third of patients develop recurrent symptoms after dilation within the first year. The majority of these patients are managed with repeat dilations, depending on their complexity. Dilation combined with intra lesional steroid injections can be considered for peptic strictures, while incisional therapy has been demonstrated to be effective for Schatzki rings and anastomotic strictures. When these therapeutic options do not resolve the stenosis, stent placement should be considered. Self bougienage can be proposed to a selected group of patients with a proximal stenosis. As a final step surgery is an option, but even then the risk of stricture formation at the anastomotic site remains. This chapter reviews refractory benign esophageal strictures and the treatment options that are currently available. Benign esophageal strictures are caused by a diversity of esophageal disorders or injuries, for example gastroesophageal reflux, radiation therapy, ablative therapy, or the ingestion of a corrosive substance. In addition, stricture formation may be a complication of esophageal resection with gastric tube formation , 2. MoreSimple strictures are considered to be short, focal, straight, and to allow passage of a normal diameter endoscope. Examples include Schatzki rings, esophageal webs, and peptic strictures . OverallDysphagia is the most common symptom in patients with a benign esophageal stricture. Remarkably, most patients do not experience severe weight loss, as can be seen in malignant esophageal strictures . TreatmeThe first step in managing benign esophageal strictures remains dilation with an inflatable balloon or a (Savary) bougie , 9, 11. Adding steroid injection to endoscopic dilation into the stricture followed by dilation to avoid recurrent dysphagia has been reported to prevent stricture recurrence. This method, advocated since 1966, has shown encouraging results in patients with peptic strictures . HoweverHirdes, et al., recently evaluated the efficacy of intralesional triamcinolone injections combined with endoscopic dilation in a relatively large group of patients with anastomotic strictures •. A totaIn conclusion, there is evidence that steroid injection in combination with dilation is able to reduce the risk of recurrent dysphagia in refractory benign esophageal strictures of peptic origin. Nonetheless, this result comes from various small-sized studies with poorly defined patient populations. Furthermore the optimal injection dose, technique and frequency remain to be determined. On the contrary, adding steroid to dilation was not found to be effective in anastomotic strictures. The pathogenesis of anastomotic strictures differs from that of peptic strictures, in that the former is due to ischemia whereas the latter develops as a result of inflammation and ulceration from reflux of gastric acid . SteroidIncisional therapy with a needle knife was first reported for the treatment of Schatzki rings , 26. SubDilation of an esophageal stricture with a balloon or a bougie is usually done for a period of a few seconds or some minutes. It can, however, be imagined that if the dilator can be kept in place for a longer time, the benefits of dilation may be longer lasting. In the past few years, temporary stent placement has increasingly been used for refractory benign esophageal strictures. Self-expandable plastic stents (SEPS) are FDA approved for this indication, and have been used , 35. ParUncovered SEMS were initially used for the treatment of refractory benign esophageal strictures –41. In mTo overcome the problem of stent ingrowth, fully covered stents (SEMS or SEPS) seem preferable for benign esophageal strictures. Currently, data on the use of fully covered SEMS is limited. In the first study performed by Eloubeidi, et al., a total of 36 stents were placed in 31 patients over a period of 16 months. A clinical success rate of 29 % was reported. A total of 47 % of these patients had no recurrence of dysphagia . Bakken,SEPS have been proposed as an alternative to SEMS to minimize hyperplastic tissue reflection. In 2010, Repici, et al., performed a pooled data analysis of all available studies on the use of SEPS for benign esophageal strictures. A total of 130 treated patients were included from 10 studies. Stent placement was technically successful in 98 % of the patients. In 52 % of patients no further dilations were required after a median follow up of 13 months after stent removal. Median stenting time in these studies was not reported. In patients with a proximal stricture the success rate was somewhat lower (33 %). As can be expected, due to the fully covered stent design, a relatively high percentage (24 %) of stents migrated within four weeks, resulting in a high rate of endoscopic re-interventions (21 %). Major complications were seen in 9 % of patients. One patient died of massive bleeding . More reIn general, more studies are needed to compare different stent designs head-to-head for the treatment of benign esophageal strictures. An alternative treatment option that has recently been introduced is the placement of a biodegradable stent Fig. . Van BoeOnly a small number of cohort studies on the use of biodegradable stent placement in the esophagus have been published, with only a few studies including 10 or more patients •, 58–66.The optimal duration of stent placement for treating refractory benign esophageal strictures is unknown, but likely depends on a number of variables, such as stricture type, severity of the inflammation, stricture length, and stent type. These factors should be evaluated in all patients. The general principle is to leave the stent in place until the inflammation is resolved. In strictures longer than 5 cm or those due to ischemic injury, dilation for a period of at least 8–16 weeks is recommended. For shorter strictures and other etiologies shorter stenting times can be recommended, but still these strictures may also be refractory. Only fully covered stent designs can safely be removed after a prolonged time of stenting. When partially covered stents are used, repeat endoscopy should be performed at 2–4 week intervals to evaluate embedding of the stent in the wall. After biodegradable stent placement, a completely different treatment strategy can be followed. Only when patients treated with a biodegradable stent present with recurrent dysphagia should a repeat endoscopy be performed. In most cases this means that the stent is dissolved and a new stent, either biodegradable or SEMS, can be placed.In absence of evidence based treatment guidelines for patients with dysphagia due to refractory benign esophageal strictures , 69, an Randomized trials are needed to determine the optimal treatment strategy in patients with refractory and recurrent benign esophageal strictures. One such trial includes a comparison between Savary or balloon dilation therapy and stent placement, either a fully covered SEMS or biodegradable stent, to determine whether stent placement could be positioned at an earlier stage in the treatment algorithm. Furthermore, biodegradable stents should be compared with fully covered stent designs (as discussed earlier). Finally, the use of a  treatment aiming to improve oxygenation (anastomotic strictures), and/or to reduce the inflammatory process in strictures, could be an important step.The treatment of refractory benign esophageal strictures remains a challenge for clinicians. Dilation of the stricture with Savary or balloon remains the first step. Dilation combined with intra lesional injections with steroids can be considered for peptic stenosis, while incisional therapy is found to be effective for Schatzki rings and anastomotic strictures. After failure of these therapeutic options stent placement can be considered. A final step includes self bougienage or surgery. Following this treatment algorithm means that most patients with a difficult to treat esophageal stricture can be managed without an invasive surgical procedure.


Self-management (SM) programs for people with arthritis or other chronic diseases are commonplace and usually delivered by lay leaders. There is evidence indicating these programs are effective, although systematic reviews show these improvements are small.The self-management program for Osteoarthritis of the Knee (OAK) differs from other programs in a number of aspects. It is disease-specific and tailored for people with OAK. It was developed using an ENAT survey, a collaborative approach, and a Plan Do Study Act (PDSA) model. It was planned purposely for implementation in hospitals or community settings. The program is detailed for delivery by health professionals. In particular, exercise and disease coping strategies are promoted within a SM construct to improve quality of life and general health as well as reducing pain.The program was tested using an uncontrolled quality assurance study and the results were positive in pain, quality of life and physical function.A randomised controlled trial (RCT) was undertaken, where, the OAK group showed statistically significant improvements when compared with the control group with regard to pain, quality of life and function on the basis of WOMAC and SF-36 measurements taken 8 weeks and 6 months from baseline.The OAK program is conducted in a group setting over six weekly sessions of 2.5 hours. This allows participants to progress over time by incorporating and consolidating new information learned each week. In addition to the weekly sessions, handouts and reference book readings are given.For optimum group dynamics, the program is delivered by the same two health professionals to a group of 12-14 participants. The fidelity of the OAK program is maintained by the use of a scripted facilitators’ manual.Using a holistic approach, the program addresses multiple aspects of care: osteoarthritis (explanation and implications), SM skills , medications , pain management strategies (cognitive and pharmacologic), fitness and exercise , joint protection, nutrition and weight control, falls prevention , environmental risks, and coping skills.The OAK program has been sustained by development of health professional training workshops. OAK programs are delivered throughout Australia primarily by physiotherapists especially those working in district hospitals or primary care settings. To reduce costs, we have recently trialled programs using self-management trained peer leaders and health professionals which has worked extremely well.


The objectives of this research were to examine the effectiveness of Health Behavioral Modification based on the Client Center Program (HBMCCP) and to study behavioral change in relation to self – efficacy, self- regulation, self-care behaviors and body weight. The sample was 59 undergraduate students, who were selected by cluster random sampling. 29 participated in the HBMCCP for 8 weeks, and were followed up 4 weeks after the program, and 30 students in the control group. Data was collected 3 times, before, immediately after and 4 weeks after the program, by 6 scale – questionnaires which had high reliability of Cronbach’s alpha-coefficient between .81 to .94. The stratified variables were psycho-social variables, being a positive attitude towards health behavior and social support. Data were analyzed by MANOVA and ANCOVA. Results showed that 1) Obese students in the experimental group with HBMCCP had self – efficacy, self- regulation and self-care behavior at immediately after and 4 weeks later program significantly higher scores than before the program (p<0.000). For body weights at immediately after program were significantly lower scores than before the program (p=0.02), 2) Obese students in the program had self – efficacy, self- regulation and self-care behavior scores at immediately after and 4 weeks after the program significantly higher than obese students in the control group (p=0.009) and significantly lower body weights than obese students in the control group (p=0.026), and 3) No three - way interaction among positive attitude towards health behavior, social support and the program was found, although there was a two-way interaction between positive attitude towards health behavior and the program (p=0.001) and effect size=0.272. A study of the obesity among young Americans revealed that there were 32% are obese and 40% of those remain obese in adolescents and that 75 to 80% of obese adolescents will remain obese as adults. In 2004, health studies in the Asia Pacific region showed that the prevalence of overweight and obesity in Thailand was 50% higher compared to 14 countries and ranked fifth following Australia, Mongolia, Republic of Vanuatu, and Hong Kong (2) compared to the previous survey conducted in 2003 to 2004 which shows obesity was increasing markedly. The prevalence of obesity in women had increased from 34.4 to 40.7% and in men increased from 22.5 to 28.4%. For obesity prevalence in Thai newborn to 12 years old was 40% and in adolescent obesity was 30% in 2007. The survey also, found that Bangkok had the highest prevalence of obesity at 44.2% of population  are obese and this study could predict that 80% of these children will grow up into obese adults . Today, To examine the effectiveness of HBMCCP in relation to self – efficacy, self- regulation, self-care behaviors and body weights in the experimental group by comparing those with the control group between before and after program and to studying the interaction between the psychosocial variables of, a positive attitude towards health behavior and social support.The concept of the program developed from behavioral modification by the concepts of 1) Self-efficacy  for esta4.1 Obese students are trained with HBMCCP have scores of the health behaviors at a higher level and have body weight at lower level immediately after the trial and 4 weeks after the trial than before the trial.4.2 Obese students in the experimental group have the health behaviors at a higher level and body weight at a lower level immediately after the trial and 4 weeks after the program than in the control group.4.3 Students with high psychosocial characteristics, i.e. a positive attitude and social support when attending the HBMCCP will have high scores of self-efficacy, self-regulation and self-care behaviors too.2 was 75 students or obesity prevalence was 34.09%, which is higher than the adolescent obesity prevalence in the population in Thailand.The undergraduate students, who studying in the health science field, 220 students from the Faculty of Physical Education and Faculty of Nursing at Srinakharinwirot University, Thailand. The number of those overweight a BMI> 25 kg/m2. Based on calculations by Undergraduate students whose body mass index ranged upwards from 25 kg/mth, 2012. Participants meeting the following criteria were eligible to participate, 1) Undergraduate students having a body mass index ranging upwards from 25 kg/m2  VoluParticipants were available for a four month period from November 2012 to February 2013.The experimental research model with Factorial Design as follow in Table 1The research project took measurements before trial, immediately after trial at 8 weeks and 4 weeks after the completion of the trial at 12 weeks.This program has been developed based on the theory of health behavior modification techniques and concepts learned through activities that focus on the service-centric processes and group processes together with the theory of self-efficacy, self-regulation and self –care. This program has been assessed for content validity by 3 highly experts in that area. The participants in the study were involved at all stage of the study, planning, setting goals and finally, taking responsibility for 8 activities by 2-3 hours/week as the process in details follow as (a)The behavior melting; Assess the expectations and skills, the openness to accept the terms and conditions and extract stimuli that cause hunger, suppress the emotions that lead to overeating draw attention is to pick friend in their group to help them not to exceed their eating limits.(b)Group activity, separated participants into 5 groups and the members of each group select 1 person to represent their group. At this point, the members were asked to introduce themselves to be familiar and share their experiences of being obese. Members help each other to calculate their body weight, height, and BMI and take a photo before commencing the program.(c)Membership in a group was help to set targets and create a weight lose plan on their own initiative and crest menus that was adjusted to the correct caloric intake for each individual together with a modified plan and pattern of the exercise to burn calories to meet their goal.(d)Group members helped to record changes in weight during the training and exercise including, eating and mood management. They arranged for the group meetings to monitor progress, weighting daily. A health behavior logbook was given to everyone and finally pathways to integrate the knowledge that has been gained from the sub-group to group as a whole were established.(e)Member within the group were helped to familiarize themselves with topics such as, exercise, nutrition and stress management. Members of the group were trained on food selection skills, amount of food to lose weight that is suitable for themselves in accordance with their experience and verify its accuracy with feedback from the group.(f)Collaboration skills and brainstorming. To find ways to solve problems. Review goals and plans for weight lose within the group and improve mental health and learning of all members of the group.(g)Members were to encourage each other with the appreciative comments. Congratulate other members through, telephone calls, emails, Facebook that is coaching as a buddy. Keeping close contact to monitor and discuss problems within the group.(h)Giving awards to the successful, at both an individual and group level to promote self-evaluation by group members.Participants in the control group were given information regarding obesity upon the completion of the research.Tools used to collect data for this research were developed through a literature review of relevant research that focused on behavior modification for health programs based on self-efficacy theory and self-monitoring by Being collected 3 times as before the trial, immediately after trial at 8 Weeks and 4 weeks after completed trial at 12 weeks.To test the hypothesis by determining the points before the trial as a covariate variable and test the interaction between the psychosocial variables and HBMCC Program predict health behaviors and body weight by using Repeated Measures ANCOVA analysis and Three-way MANOVA with Repeated Measures for the Multivariate F test of significance.The participants in the control group remained obese. It was found that a focus on self-efficacy, self-regulation, and self- care behaviors, those measured at 8 weeks and at 12 weeks was higher than before the trial. And body weight was lower From The obese students in the program had self-efficacy, self-regulation, and self-care behaviors at 8 weeks and 12 weeks, higher than those in control group. And body weight was lower than the control group as shown 7Found that participants having different psychosocial characteristics having attended the program at its completion had a different attitude regarding self-efficacy, self-regulation and self-care behavior. Follow as As shown in The results of testing the 3 hypotheses indicate that the Health Behavior Modification program Client-centered are effective modifiers of health behaviors and the body weight of participants. Those entering the program had a weight decrease (p <.05) which is in agreement with the study of spell triggers and extracted to achieve self-confidence. Their behavior is directed towards positive activities and good diet. Regular exercise and stress management. Which corresponds to the concept of Also, when considering the activities in this research focused on learning by the program participants and positive reinforcement, friends helping friends using repeatedly words as In this study the self-regulation was found to changes over the program correlating with the duration of the trial. At this point, we could summarize that the program that based on the client-center, extract by prompting the group members. Weight loss goals which are based on the concept of The results of the hypothesis testing showed the interaction between good attitudes towards the healthy behavior program and outcome, based on the social cognitive theory of The social support variables were associated with behavior and that led to positive effects on health status. Persons who have adequate social support have reduced stress and are able to adapt well and have good health. In addition, social support can be predictor of quality of life. And the study of 8.1 Health caring agencies should develop the ability to focus on health behavior that focuses on client-centered.8.2 Before the activity / project the social context and reality of the risk group should be investigated, to come to an understanding of the way of life of patients as much as possible, so as to gain the trust and readily instigate the activity plan, monitoring and achieve results for both the service providers and service recipients.8.3 Based on the research results it was found that a good attitude of the enrolled in the program is important and should be open to candidates who voluntarily participate in the program group and have good self-esteem to change health behavior and can act independently, joining in the program for better success.8.4 Universities should have a policy to be Healthy Universities, giving extra curriculum time to the promotion of health for students, at least eight weeks to raise a students' health awareness.8.5 Future research should study behavioral modification for health programs with different techniques and learning activities, such as individual activities that focus on teaching knowledge. Online activity should be studied in the multiple experimental groups.The Health Behavioral Modification based on the Client Center Program for obese university students could be cause increasing of self – efficacy, self- regulation and self-care behaviors and the beneficial effect on body weight of reducing.


Among staff working in elderly care, a considerable proportion lack formal competence for their work. Lack of formal competence, in turn, has been linked to higher staff ratings of stress symptoms, sleep disturbances and workload. Objectives: 1) To describe the strengths and weaknesses of an e-assessment and subsequent e-training program used among elderly care staff who lack formal competence and 2) to study the effects of an e-training program on staff members’ working life  and well-being . The hypothesis was that staff who had completed the e-assessment and the e-training program would rate greater improvements in working life and well-being than would staff who had only participated in the e-assessments.An intervention study with a mixed-methods approach using quantitative (2010–2011) and qualitative data (2011) was conducted in Swedish elderly care. Participants included a total of 41 staff members. To describe the strengths and weaknesses of the e-assessment and the e-training program, qualitative data were gathered using semi-structured interviews together with a study-specific questionnaire. To study the effects of the intervention, quantitative data were collected using questionnaires on: job satisfaction, psychosomatic health, psychological empowerment, structural empowerment and quality of care in an intervention and a comparison group.Staff who completed the e-assessments and the e-training program primarily experienced strengths associated with this approach. The results were also in line with our hypotheses: Staff who completed the e-assessment and the e-training program rated improvements in their working life and well-being.Use of the e-assessments and e-training program employed in the present study could be one way to support elderly care staff who lack formal education by increasing their competence; increased competence, in turn, could improve their self-confidence, working life, and well-being. Today, there is a need for more qualified staff in elderly care -3. In EuIn Sweden in 2011, approximately 213,024 people were working in municipal elderly care and the largest professional group included nursing assistants and licensed practical nurses . SeventyAssessing non-formal and informal learning and providing competence development among staff working in elderly care may be seen as a way of improving lifelong learning. European countries stress the importance of prioritizing lifelong learning in education , where IOne model of healthy workplaces is the Practices for the Achievement of Total Health (PATH) model ,24. The The intervention under study here was designed to assess staff members’ knowledge and abilities, i.e. their established knowledge, skills and abilities learned over years of professional work in elderly care, as well as their needs for competence development. The intervention included both practical and theoretical e-assessments and a subsequent e-training program supported by ICT. Research has found that elderly care staff who lack formal education experience more stress symptoms and sleep disturbances . TherefoThe aim was twofold: 1) to describe the strengths and weaknesses of e-assessments and subsequent e-training program used among elderly care staff who lack formal competence and 2) to study the effects of the e-training program on staff members’ working life  and well-being . The hypothesis was that staff who had completed both the e-assessments and the subsequent e-training program would rate greater improvements in their working life and well-being than would staff who had only participated in the e-assessments.An intervention study was conducted using a mixed-methods approach with quantitative (2010–2011) as well as qualitative data (2011) .In central Sweden, one municipality, which provides healthcare and general services in residential homes and in-home care for older people, was involved in the project from 2010 to 2011. In 2009 an inventory of formal education in care was completed by all staff members (n = 887) and became the basis for the e-assessment to 89 staff in relation to their job requirements. Of them 87 underwent both the practical and the theoretical e-assessments. The e-assessments were voluntary and offered by the manager via personal meetings and email. The competence needs  identified at the individual level in the e-assessments were the basis for implementation of a professional e-training program tailored to every individual’s needs. The e-assessments – three practical and eight theoretical e-assessments of staff members’ knowledge, skills and abilities – as well as the completed education were based on the curriculum of the Swedish upper secondary school care program, which includes a total of eight learning objectives .Three practical assessments – morning, lunch and evening – were conducted in a specifically designed apartment with video cameras and ICT technology. They included a total of 5 learning objectives with different grades and were related to everyday work: “Basic health care”, “Communication”, “Rehabilitation”, “Ergonomics, hygiene, esthetics, environment” and “Assistive technology”. The practical skills assessments were carried out by creating everyday situations and took about 40 minutes/person/situation. One test leader was involved, a qualified teacher working in the national care program, who supervised the practical assessments on the computer via video transmission, with both picture and audio transfer. The test leader also judged the staff members based on strict checkpoints and guidelines for the situation. The check points and guidelines were based on the curriculum, goals and grading criteria for the Swedish national care program’s first course “Healthcare and Social Work” and are established by the Swedish National Agency for Education [ducation .The theoretical assessments were performed using a workplace-based ICT tool (computer) that consisted of 8 learning objectives: “Health”, “Communications”, “Oral care”, “Ergonomics, hygiene, esthetic, environmental”, “Rehabilitation”, “Assistive technology”, “Basic health care”, and “Law and organization”. The items were arranged in order, from those expected to be easiest to those expected to be more difficult. The pedagogical aim was to highlight the individual’s strengths and self-esteem. The assessments took about 30 minutes/person/situation.After completion of the e-assessments, staff received a document accredited by the Center for Adult Education in the municipality that was to be used for the individual’s future competence development. The subsequent e-training program was individualized and linked to staff members’ practical and theoretical e-assessment outcomes as well as tailored to suite their learning styles. The e-training program began with the teacher giving an individual follow-up, a debriefing, in relation to the completed e-assessment. After that, the teacher helped the staff member tailor his/her competence development and he/she began studying the areas of deficiency. When the staff member felt he/she was ready to take the practical and/or theoretical test/tests, which were the same as in the e-assessments, he/she was to contact the teacher. The theoretical part was performed through an ICT tool that could be used either at the workplace or at home. This meant that the e-training program could be carried out independent of time and place and be done all at once or divided up. This, of course, depended on how many e-assessments the staff members had failed on. The range of number of failures for the theoretical e-assessments was 2–8, and for the practical e-assessments 1–3. As the e-training program was individualized, it took various lengths of time (1 day to 6 months) for the staff members to complete it. ICT supervision and support were given to the individual by the teacher, whose role was also to serve as a coach when the individual felt the need for guidance and/or support.Of the 87 staff members with no formal education who had completed the e-assessments, 59 remained in 2011 when the e-training program was to be started. During 2010, 28 staff members had dropped out for different reasons . All eligible staff (n = 59) were invited to take part in the e-training program. In 2011, 37 of the 59 staff began the e-training program and, of these, 36 completed it. Twenty-two of the staff members declined to participate in the e-training program. Several of them were not interested, while others felt they were too old. Of the 36 who completed the e-training program, 15 were interviewed. Purposive sampling was used to ensure variation in staff members’ age, gender and e-assessment results. Of the 36 staff who completed the e-training program, 29 had completed both the pre- and post- questionnaires (see data collection) and had responded to the statements about the e-training program. Two staff members only responded to the statements about the e-training program . Those who did not participate in the e-training program, but who completed the questionnaires on both occasions, comprised the comparison group (n = 12) ; the same time interval was used for the comparison group.The Satisfaction with Work Questionnaires (SWQ) [Job satisfaction, quality of care and psychosomatic health were measured using es (SWQ) . The Jobes (SWQ) .The Conditions of Work Effectiveness Questionnaire II (CWEQ II) [Structural empowerment was measured using CWEQ II) , which wCWEQ II) . The insCWEQ II) ,38. ConsCWEQ II) ; this apCWEQ II) .Spreitzer’s Empowerment Scale [nt Scale  has beennt Scale  and is unt Scale . A seconnt Scale .The interview data were analyzed using qualitative content analysis ,34. The The Central Ethical Review Board in Uppsala approved the study (reg. no. 2009/430). The study was also approved by the head of operations for elderly care in the municipality. The study participants received written information about the study, were informed that participation was voluntary and were ensured confidentiality.In total, 41 staff participated in the study, and of them 15  were interviewed. The mean age was 42 years , and number of years working in elderly care ranged from 6 to 28 . In all, 41 staff were included in the quantitative analysis: 29 in the intervention group; 25 women and 4 men ranging in age from 22 to 54 years. Number of years working in elderly care varied between 4 and 32. The comparison group included 12 staff: 11 women and 1 man, ranging in age from 25 to 57 years. Number of years working in elderly care varied between 7 and 34. The intervention and comparison groups’ characteristics are presented in Table Analysis of staff members’ reflections on the e-assessments and subsequent e-training program resulted in two main categories: “Obstacles/Barriers” and “Enablers”, each of which were derived from three sub-categories. Each category and its subcategories are presented separately. Under the respective headings, the content of each category is described and illustrated using staff members’ statements, which are inserted into the text and marked with quotation marks and italics.Obstacles/Barriers consisted of three subcategories representing staff descriptions of Being nervous, Not having confidence in their own abilities, and Internal and external demands. Such descriptions were particularly common in relation to the practical e-assessments carried out in a specifically designed apartment equipped with ICT, including video-recording. However, several of the staff also described being nervous about the subsequent e-training program. No one in the staff passed all of the assessments.The category “Before it I was nervous about being filmed from all angles.... I was actually nervous…” (Informant 4). Others said that it was “… mostly the first morning part… and then once you’re in there and have started ‘yeah, yeah, the cameras’ you thought after a couple minutes, but then you felt like no I’ve forgotten them… I didn’t think about them” (Informant 3). Several of the staff described the morning assessment as “artificial” because they had to work with an adult-sized doll, which was “so different, it was like what should I do what should I say and talking yes it was more difficult to talk in a natural way…” (Informant 5). Lunch and evening assessments were experienced as more real because there they worked with a person posing as an older care recipient. “Couldn’t find things in the apartment but that’s what it’s like when you’re in a client’s home. The actor was true to reality” (Informant 5). These situations were more realistic and “everyday-like”. Concerning the theoretical assessments, none of the staff reported being nervous, though some were concerned that there would be a great deal to read. “It was fun but I was a bit worried there’d be a lot to read” (Informant 2).Before starting the practical e-assessments and the e-training program, most of the staff described being nervous about what was to come and what was expected of them. Concerning the practical e-assessments , some of the staff were nervous about being observed by the cameras set up in every room: “… mostly if I made a mistake and then I thought God if I do something wrong here it means I don’t know my job, that’s how it felt because really I’m supposed to know this” (Informant 2). In the apartment, several of the staff felt they spent a great deal of their energy keeping an extra sharp eye on where things were. “It felt like meeting a new pensioner.... but I know what I know and I know what to do during the morning work” (Informant 6). Regarding the theoretical assessments, some of the staff found them troublesome, because they felt that some of the issues were invented, which made them uncertain about passing the tests. Issues related to oral care and hearing aids were seen as odd, because some of the staff had no knowledge in these areas. Others said that the theoretical assessments were not in concordance with how they worked every day: “I thought the questions on the computer were difficult, well I thought so, you work in a certain way… yeah, it was a bit difficult” (Informant 10).Several of the staff placed high demands on themselves regarding both the practical and theoretical assessments, while some were surprised about not having passed more tests than they did. Concerning the practical assessments, especially the morning assessment, they felt that it was difficult to know what to say or talk about. The situation in itself made it easy to make mistakes, which could be interpreted as them being unable to do their work : “ … can I manage this, I really don’t have a head for studying”, “.... you don’t think you can do things, but that’s how it is, you can do more than you think” (Informant 11). One staff member said she felt her employer made demands on her. She thought it could depend on a previous occasion when she was dismissed due to cutbacks. She was later re-employed and felt motivated to continue the training program though she was not sure she could manage it. “But I feel that the municipality is demanding this of me and I want a job. And I might not end up with a job. I was fired once two years ago. But that wasn’t because I don’t have the right education but because of cutbacks” (Informant 7). Concerning the theoretical assessments, some of the staff experienced pressure because there was a time limit and lack of information and support from the teacher. At the same time, they felt they were motivated to continue the e-training program despite feelings of uncertainty. Regarding the e-training program, some of the staff experienced time pressure and placed great demands on themselves. “Not much gets into my brain, I have so much other crap in there, there’s no room for more and it doesn’t matter how much I read about things they just don’t stick” (Informant 9). Although some of the staff felt these kinds of demands both before and during the e-training program, most of them completed it. As can be seen in Table Prior to the e-assessment and subsequent e-training program, some of the staff experienced negative feelings, such as not being able to cope with the challenge and being afraid of misinterpreting the information: Enablers consists of three subcategories: Having opportunities to develop in a flexible and easily accessible way, Becoming aware and being able to influence and Feeling stronger. The staff described this category in terms of being able to test their skills and knowledge in an easy, flexible and accessible way as well as feeling motivated to receive grades, seeing possibilities and experiencing that their self-confidence increased during the process.The category “Great, they presented it really well, and there were a lot of us who thought finally… because they were anxious for us to do it. That made it more fun too” (Informant 3). Most of the staff were motivated to take part in the assessments and the e-training program as a way to highlight their skills and knowledge using ICT. This was also shown in the study-specific questionnaire (Table “…you got feedback right away so you knew what you’d done wrong” (Informant 1). Concerning the program using ICT, the teacher could give feedback directly and staff could carry out the e-training program (tests) at their own pace. These results corresponded to the study-specific statements, where nearly all agreed that the program was tailored to meet individual needs , that the implementation was good  and that the communication between the teacher and staff had been very good .When staff heard about the e-assessment and the subsequent e-training program, their first thoughts were positive. They saw it as an opportunity to highlight their skills and knowledge in an easy and accessible way, especially when the employer wanted it: re Table  with reg“why they do it and what they do it for”. In their daily work, the new knowledge made them think differently: “I think more now, when I’m working, about what I’m doing” (Informant 5). They were also more aware of how their colleagues worked: “… now I see how my workmates are stuck in their patterns, and so I can, if you have newer information about what you can do at work” (Informant 5). In some cases, staff reported having transferred what they had learned to their workplaces: “good that there were also changes at the workplace” (Informant 3) and that they could now also discuss “this new knowledge” with their workmates. Several of the staff felt it was a great opportunity to test their skills and knowledge, so as to have some influence on their work. If they wanted to advance at work in nursing, they must have some training. However, others said that they had thought about educating themselves, but felt they had too much catching up to do to get a degree. Still, several said they wanted to continue studying to become licensed practical nurses, if they could do it in the same way as in the e-training program “really it makes me want to continue, it does. Well I do hope they do more of this… so that everyone who wants to can keep learning all the licensed practical nurse material this way” (Informant 3). These results corresponded to responses on the study-specific questionnaire, where most of the staff  were willing to continue taking part in the assessments and training program supported by ICT, while only 3 staff members neither agreed nor disagreed . “I’m glad I did it, I’m done, the fact that I could do it at all, what I didn’t think I could” (Informant 10). They said that their independence and self-confidence increased during the process and that they felt stronger: “… I can manage myself to a greater degree, and I mean if you need help there is a back-up” (Informant 3). Results from the interviews are also consistent with responses to the study-specific questionnaire statements: “I feel that the IT-based training program has made me more independent, in that I’ve been able to manage on my own” .In this subcategory, staff described being proud and having trust in their own abilities. Several were happy and proud that they had passed the e-training program: The interviews revealed that the staff felt stronger, and the quantitative data over time support these results. Staff in the intervention group (n = 28) rated their psychosomatic health as better over time  as well as the factor “sleep problems” . For both the factor and total scale, higher scores mean fewer health problems. In the comparison group, staff rated their sleep significantly worse over time . Staff in the intervention group also rated their job satisfaction as better over time for the factors “personal development”  and “position in the group” . Furthermore, they rated quality of care as better over time; total score of quality of care . When differences over time were compared between the groups, there were significant differences for the factor sleep . No other significant differences were found between the groups when comparing differences over time.Staff in the intervention group gave significantly higher scores, over time, for the factor “impact” on the psychological empowerment scale . Furthermore, they rated better structural empowerment over time , as well as for the factors “formal power”  and “informal power” . When differences over time were compared between the groups, there were significant differences for the scale Psychological empowerment  as well as for the factors “self-determination”  and “impact” . Regarding Structural empowerment, no significant differences were found over time between the groups.The present study showed that most of the staff who completed the e-assessments and the subsequent e-training program in elderly care primarily experienced strengths associated with this approach. Several of the staff would also recommend this approach to colleagues. If additional education/training could be performed in this way instead of traditional education, most of the staff would choose it. However, before and during the e-assessments and the e-training program, some of the staff expressed that they were nervous and that they did not have confidence in their own abilities. They also experienced internal demands from themselves and external demands from the employer, workmates and family, which sometimes made it difficult to cope with the challenge. During and after conducting the e-training program, staff talked about how their self-confidence increased. The interviews revealed that staff felt stronger and the quantitative data over time supported these results, which were also in line with our hypotheses, i.e. that staff who had completed the e-training program would rate greater improvement in working life and well-being than would staff who had only participated in the e-assessments.To our knowledge, this is the first study to measure working life and well-being outcomes following e-assessments and an e-training program intervention among elderly care staff lacking in formal education, and where results support the PATH model. The PATH model ,24 indicA review  of whichStudies  have shoIn summary, staff who had completed both the e-assessments and the subsequent e-training program rated greater improvements in their working life and well-being than did staff who had only completed the e-assessments. The results support the PATH model. Assessing and evaluating informal learning, such as knowledge, skills and abilities, and thereafter offering an e-training program based on assessment results, may be a way of improving lifelong learning.The present study has some limitations that need to be considered. Its non-randomized design might have induced selection biases, and the small sample size and high drop-out rate limit generalizability. Another limitation is that a test of inter-rater reliability regarding the e-assessment tool was not performed in this study and that the sample was taken from only one municipality in Sweden. Workplace culture may have played a role in how the individuals felt about the e-training program and may limit generalizability. However, staff members in the intervention group did not differ from those in the comparison group in sociodemographic characteristics and the study variables at baseline. Strengths were the use of a mixed-method design and of validated instruments with satisfactory internal consistency; in the present study, Cranach’s Alpha for all factors and total scores were <0.70. However, to our knowledge, this is the first study to measure working life and well-being outcomes following e-assessments and an e-training program intervention among elderly care staff lacking in formal education. Future studies should test e-assessments and e-training programs using larger samples sizes and in different areas of health care.The present e-assessments and the e-training program could be one way of helping elderly care staff who lack formal education develop their competence, which would, in turn, improve their self-confidence, working life and well-being. Thus, the e-assessments and the e-training program lead, in accordance with the PATH model, to healthy workplaces and organizational improvements. In order to increase quality and security in elderly care, it is important to test different pathways when identifying needs for competence development among staff and to give them opportunities to learn and develop through training.


Presently, the modal pushover analysis procedure is extended to multidimensional analysis of structures subjected to multidimensional earthquake excitations. an improved multidimensional modal pushover analysis (IMMPA) method is presented in the paper in order to estimate the response demands of structures subjected to bidirectional earthquake excitations, in which the unidirectional earthquake excitation applied on equivalent SDOF system is replaced by the direct superposition of two components earthquake excitations, and independent analysis in each direction is not required and the application of simplified superposition formulas is avoided. The strength reduction factor spectra based on superposition of earthquake excitations are discussed and compared with the traditional strength reduction factor spectra. The step-by-step procedure is proposed to estimate seismic demands of structures. Two examples are implemented to verify the accuracy of the method, and the results of the examples show that (1) the IMMPA method can be used to estimate the responses of structure subjected to bidirectional earthquake excitations. (2) Along with increase of peak of earthquake acceleration, structural response deviation estimated with the IMMPA method may also increase. (3) Along with increase of the number of total floors of structures, structural response deviation estimated with the IMMPA method may also increase. In recent years, a challenge for performance based seismic design is to establish an effective and feasible procedure to evaluate structural seismic capacities. The pushover analysis procedure, due to its simplicity and efficiency, is increasingly applied to estimate seismic demands of structures. During past years, the theory and application of pushover analysis procedure have been developed adequately –7, and tA problem for pushover analysis is that the higher mode effects of building structures cannot be considered in the procedure . In ordeThe previous studies about pushover analysis are almost based on symmetric building structures and single-directional earthquake excitation. Both theoretical studies and seismic disasters indicate that asymmetric-plan structures with irregular distributions of mass or stiffness are likely to undergo torsional responses coupled with the translational vibrations, and this type of structures is likely to suffer more severe displacement demands at the corner elements under earthquake excitations. In addition, the torsion coupling response will induce the structural space effects that cannot be solved in two-dimensional analysis. So, several research efforts have been made to extend and apply the pushover analysis to asymmetric-plan structures whose inelastic seismic responses are intricate –26. At px- and y-axes, respectively, and peak response of two directions is combined through SRSS rule, which is applicable to elastic analysis but not applicable to inelastic analysis for having no regard for inelastic coupling of structure responses caused by earthquake excitations of different components. For solving the problem, an improved multidimensional MPA (IMMPA) idea is presented in the paper: superposed bidirectional earthquake acceleration acting on modal ESDOF system can be regarded as an unidirectional “combined earthquake excitation”; in the procedure, to solve structural responses, seismic demand spectra may be established based on SDOF system subjected to the “combined earthquake excitation.”For multidimensional MPA, which is applicable to the analysis of asymmetric-plan structures, the modal equivalent single-degree-of-freedom (ESDOF) system is actually subjected to the superposition of bidirectional earthquake excitations. In the current MPA procedures, the response of ESDOF system is calculated according to single-directional earthquake excitation, the The main objective of this paper is to propose an MPA procedure for evaluating the seismic capacities of asymmetric-plan structures subjected to bidirectional earthquake excitations. An outline of this paper can be expressed as follows. First, the improved procedure is presented based on the assumption of modal equivalent SDOF system which is subjected to the superposition of bidirectional earthquake excitations. Then, the corresponding strength reduction factor spectra are discussed and compared with traditional spectra. Next, the step-by-step procedure is proposed. At the end, two examples are considered to verify the accuracy of the proposed procedure.n-storey building. Its plane is asymmetric about the x- or/and y-axes. Each floor diaphragm is rigid in its own plane and has three degrees of freedom defined at the center of mass (CM). The equation of motion governing the response of the n-storey asymmetric structure subjected to bidirectional earthquake excitations  is as follows:M is diagonal mass matrix of order 3n which includes three submatrices m, m, and Io; m is associated with x and y-lateral degrees of freedom, and Io is associated with torsion degrees of freedom. C is the damping matrix and F(u) is the vector of resisting forces. The displacement vector u(t) is equal to [ux  uy  uθ]T; ux, uy, and uθ are the x, y, and torsion-directional displacement subvectors, respectively. The influence vectors, ιx and ιy, are as follows:ith modal vector φi of size 3n × 1 includes three n × 1 subvectors φxi,  φyi, and φθi. Substituting u(t) = Φq into , equals φiTKep(t)φiqi(t); Kep(t) is elastic-plastic instantaneous stiffness matrices; φiTMφi is interpreted as the ith modal equivalent mass, Mi; Modal participation factors, Γxn and Γyn, along the x- and y-axes, respectively, are expressed asMi, and using the orthogonality property of modes, 3n uncoupled equations can be derived asnth mode of the considered structure. In  ⋯ qi(t) ⋯ qn3(t), can be calculated by (u(t), can be solved by +Cufollows:Mu¨(t)+Cue given:φiTMφiq¨irived asq¨i(t)+2ξrived asq¨i(t)+2ξfollows:Mu¨(t)+Cuside of (Cu˙+F(u)=rx and ry to x- and y-components of earthquake motion are determined by nonlinear static analysis, respectively. Associated with components of earthquake motion, the total inertia force vector can be expanded as a summation:x or y) of ground motion is assumed to be uncoupled, and the uncoupled equation of motion is expressed asx- and y-directions are determined, respectively, by combining the peak modal responses using the CQC rule as follows:rx and ry are combined to determine the total response r by the SRSS rule:In the traditional multidimensional MPA procedure, the peak modal responses x,i|⩾abs |Γy,i|, extract Γx,i from the right side of equation and define Γx,i = Γi. The motion equation of equivalent systems is then transformed asy,i|⩾abs |Γx,i|, a similar equation can be established, and it is omitted here because of theoretical consistency. In  = qi(t)/Γi, (di(t) is governed by the equation of motion for the ith modal equivalent SDOF system subjected to earthquake excitation, fi(t), equals Fsi(t)/MiΓi. Equation +2ξormed asq¨i(t)+2ξduced toq¨i(t)+2ξ(t)/Γi, (d¨i(t)+2ξPine, can be expanded aspiine,, can be reduced assi is distribution factor vector of inertia force, and si equalssi, can be interpreted as the distribution factor of modal pushover analysis.According to the derivation above, the expression of inertia force vector, R-μ-T relation [Generally, the response demands of inelastic systems can be obtained by inelastic response spectra, such as strength reduction factor spectra .fi,y = kxdi,y is defined in which kx is linear stiffness and di,y is yield displacement, and the relationship for μi(t) = di(t)/dy is defined, and  is amplification coefficient spectrum corresponding to fixed damping ratio, ξ, natural vibration frequency, ωi, and excitation; Rbi is strength reduction factor; Rbi equals fe,i(t)/fi,y(t) in which fe,i(t) is elastic resisting force of corresponding elastic equivalent system. By solving (μi(t) is ductility factor, μi, that is defined as the ratio between maximal displacement, di,max, and yield displacement, dy. Based on (Rbi-μi-Ti (Ti = 2π/ωi) can be established through iterative calculation.The yield resisting force expression ned, and  can be ted, and (μ¨i(t)+2ξed, and (μ¨i(t)+2ξRb, and ductility factor, μ, the relationship is given asAe is elastic maximum acceleration response (or elastic acceleration spectra); dp,max is inelastic maximum displacement response (or inelastic displacement spectra). Substituting Ae and “Rb-μ-T” model into  are shown in μ is ductility factor and γ is participation coefficient ratio of vibration mode of two spindle axes. The following can be drawn from Rb/Rs spectra analysis. (1) The values of Rb/Rs fluctuate around 1 and have no significant regularity as the period increases. (2) The regularity of Rb/Rs for γ > 0 and that for γ < 0 are different from each other, so it is suggested to analyze them, respectively.The Rb/Rs along with period change is not very significant, so it is suggested to take the same Rb/Rs spectra value within the entire period. In addition, for the reason of disadvantage in Rb/Rs < 1, “mean value − 1.65 × standard deviation” of Rb/Rs within 0.05~5.0 seconds is defined as modification coefficient, α, of traditional Rs. The distribution curves of modification coefficient, α, along with ductility factor changes are shown in α is 0.910 and the maximum value is 0.985, which shows that the influence of the analysis variables on Rs spectra is little. (2) For γ > 0, α decreases while γ increases; for γ < 0, α decreases while γ decreases (it is not so significant for γ < 0 at hard soil site and for γ < 0 at intermediate soil site). (3) For hard soil site, α is maximized while μ = 1.5; α decreases and does not change significantly along with increase of ductility factor while μ⩾2; for intermediate soil site, α increases along with increase of the ductility factor while μ⩾2; for soft soil site, α decreases along with increase of ductility factor.Through the above analysis, the regularity of ωi, and modes, φi, for elastic vibration of the multidimensional building are calculated and the corresponding mode shapes are normalized.The natural frequencies, ith mode, determine the base shear-roof displacement, Vbi-uri, pushover curve by multidimensional nonlinear static analysis applying the force distribution  by conducting pushover analysis up to the already calculated object displacement.Determine the roof object displacement of Repeat steps 1–5 for as many modes as required for sufficient accuracy.r, (including rx- and ry-components) for the excitation of the combined earthquake motion by combining gravity response and the peak modal responses by utilizing the CQC rule.Determine the total extreme responses, A step-by-step summary of the IMMPA procedure is presented as follows.2 for 2th~11th floor; the sectional sizes of columns are 700 × 700 mm2 for 1th~3th storey, 600 × 600 mm2 for 4th~7th storey, and 500 × 500 mm2 for 8th~10th storey. For the 15-storey building, the sectional sizes of beams are 300 × 700 mm2 for 2th~5th floor, 300 × 650 mm2 for 6th~11th floor, and 300 × 600 mm2 for 12th~16th floor; the sectional sizes of columns are 700 × 700 mm2 for 1th~4th storey, 650 × 650 mm2 for 5th~10th storey, and 500 × 500 mm2 for 11th~15th storey. Steel ratios are approximately 1.5% for beam sections and 2% for column sections of the two buildings. Concrete compression strength is selected as 30 MPa for all columns and beams of the structure. The design dead load and live load are, respectively, 6.6 kN/m2 (4.7 kN/m2) and 1.0 kN/m2 (2.0 kN/m2) for each floor (roof). The damping of the building is modeled by the Rayleigh damping, and damping ratio ξ equals 5%.In order to clarify how the proposed methodology should be applied, two simple analytical examples are presented. The structures considered are a 10-storey and a 15-storey eccentric reinforced concrete frame buildings, as illustrated in 2 and 4.0 m/sec2, respectively. The nonlinear response time history analyses (NL-RHA) are implemented for the two example building subjected to the selected earthquake record and the time history responses of roof displacements are illustrated in The bidirectional “Taft” earthquake records  are selected to verify the accuracy of the presented method. The acceleration peak values of the records are adjusted to 3.1 m/secThe restoring force model of modal equivalent SDOF system is established by modal pushover analysis.Qis of the ith mode equivalent SDOF system is solved by NL-RHA, in which the restoring force model obtained in step 1 is used. The dynamic response Qis is converted into the ith modal responses Qi, and total structural dynamic responses Q can be obtained by superposition of modal responses; that is, Q = ∑Qi.The dynamic response uroi, and structural roof objective displacements, uro, are solved, respectively, according to step 2.Corresponding to the eight objective control points given in Qis, corresponding to uroi, are obtained. The total static responses, Qs, are determined by linear combining the response values of each modal pushover analysis; that is, Qs = ∑Qis.The IMMPA is implemented and the modal static responses The demand responses are compared between IMMPA and NL-RHA.The method to compare estimation results of IMMPA with exact results of NL-RHA for verifying the procedure is as follows.The comparisons of story drift ratios and floor displacements between NL-RHA method and IMMPA method are illustrated in A new IMMPA idea is presented in the paper based on traditional MPA method: superposed bidirectional earthquake excitation acting on modal ESDOF system can be regarded as an unidirectional “combined earthquake excitation”; in pushover procedure, the static force replacing “combined earthquake excitation” is assigned to three components of each floor of a structure based on model of vibration.Rb spectra and convert it to seismic demand spectra. It is recommended in this paper to get modification coefficient of Rs spectra by analyzing the relation of Rb/Rs. Define modification coefficient, α, as “mean value − 1.65 × standard deviation” of Rb/Rs within 0.05~5 seconds. Based on selected earthquake records, analyze the influence of soil site classification, ductility factor, and participation coefficient ratio of vibration mode on α.In accordance with this idea, in solution of structural displacement response, it is required to input “combined earthquake acceleration” to modal ESDOF system in order to establish In general, IMMPA method can be used to accurately estimate the distribution feature of plastic deformation of the structure along its floors.Along with increase of peak of earthquake acceleration, structural response deviation estimated with IMMPA method may also increase.Along with increase of the number of total floors of structures, structural response deviation estimated with IMMPA method may also increase.In order to check accuracy of the IMMPA procedure presented in this paper, two structures with mass eccentricity are designed, a bidirectional earthquake ground motion, Taft, is taken as earthquake excitation of the structural system, and deformation distribution of the structure is calculated, respectively, with NL-RHA and IMMPA, and the results are concluded as follows after comparative analysis.