In Madhya Pradesh, India, the government invited private obstetric hospitals for partnership to provide intrapartum care to poor women, paid for by the state. This statewide program, the Janani Sahayogi Yojana , ran from 2006 to 2012. The partnership was an uneasy one with many private obstetricians choosing to leave the partnership. This paper explores the motives of private obstetricians in the state for participating in the JShY, their experiences within the partnership, their interactions with the state and motives for withdrawal among those who withdrew from the scheme. This study sheds light on the dynamics of a public-private partnership for obstetric care from the perspective of private sector obstetricians.Fifteen in-depth interviews were conducted with private obstetricians and hospital administrators from eight districts of Madhya Pradesh who had participated in the JShY. A Framework approach was used to analyze the data.Private obstetricians reported entering the JShY partnership for altruistic reasons but also as way of expanding their practices and reputations. They perceived that although their facilities provided better quality of care than state facilities, participation was risky because beneficiaries were often unbooked and seen as ‘high risk’ cases. The need to arrange for blood transfusions for these high risk women was perceived as particularly difficult. Cumbersome paper work and delays in receiving payments from the state also dissuaded participation. Some participants felt that there was inadequate engagement by the state, and better monitoring and supervision would have helped. The state changed the financial reimbursement arrangements due to a high proportion of Cesarean births in the early years of the partnership, as these were perversely incentivized. This change resulted in a large exodus of private obstetricians from the partnership.This study highlights the contribution of cumbersome processes, trust deficits and a lack of dialogue between public and private partners. Input from both public and private sectors into the design of a carefully thought through financial reimbursement package for private partners was highlighted as a necessary component for future success of such schemes.The online version of this article (10.1186/s12913-019-4409-2) contains supplementary material, which is available to authorized users. Attaining universal health coverage (UHC) is an important goal for states aiming to provide fair and equitable health outcomes and improved wellbeing for their populations . SustainThe Janani Suraksha Yojana (JSY), on which much has been reported –9, is thMadhya Pradesh (MP) state has seen one of the sharpest rises in institutional delivery proportions under the JSY . Close tTo further expand access to institutional births in MP, the Department of Health in the state entered a collaborative partnership with the private health sector in 2006, naming the new partnership the Janani Sahyogi Yojana . Under the JShY partnership, private accredited obstetricians were paid by the state to provide intrapartum care to women below the poverty line. Between 2007 and 2011, 23,000 births occurred in the private sector under the JShY  That’s when I decided to get associated with this scheme to give something back to society.”Obstetrician, rural, for-profit hospitalThey also saw themselves as partners in reducing maternal mortality and felt they had a useful role to play.“There are losses in running this scheme. But we are a mission organization, we join the JShY and similar projects from the government to increase our approach (service) to poor people. But…the hospital has to bear a loss for each patient in the program.”Administrator, rural, charitable hospitalOne mission hospital stated that even though they made a financial loss from participation in the JShY, they continued with participation because of philanthropic missions.“We thought that our (bed) occupancy would increase, and it increased. Our aim is to decrease delivery (childbirth) costs further and give better care and treatment. When the government gave support to this, it was very good. Patients increased, work increased and people started to know us and our work.”Administrator, urban, charitable hospital“We started our hospital in 2006. In a year, we joined the scheme. Due to this, we became very popular and the JShY definitely increased patient inflow and benefitted us.”Administrator, urban, for-profit hospitalBeyond altruism, providers also perceived advantages for their facilities from participation in the program. These advantages included increasing bed occupancy, gaining experience and building a reputation. One participant perceived the program as being ‘government support’ towards these ends.“Nearly 50% of pregnant women who come here are highly anemic. We have to arrange for the blood if there is heavy bleeding and we generally give blood to women with less than 7 Hb (hemoglobin level 7 g per deciliter (g/dL) of blood). We had to organize (a) minimum (of) 35 units of blood every month during the scheme. We used to have nearly 100 deliveries per month and nearly 35% cases needed blood.”Obstetrician, rural, for-profit hospital“Sometimes we get patients who have no records and they come at 3.00 am morning. They don’t have a sonography report and do not even have a doctor’s prescription. Looking at the plight of the patient, it is impossible to say no and it becomes a problem for us. […] Then (on facing complications in unbooked cases) we start thinking that why are we getting into such problems, and we felt like leaving JShY scheme.”Administrator, urban, for-profit hospitalParticipants perceived a risk to participation because of structural issues that stemmed from the absence of necessary life saving measures (such as access to blood) and poor referral practices. They were concerned because of a clustering of high-risk patients at their practices under the program. These were often women whom they had not seen before during pregnancy (‘unbooked’), arrived late and were often in a critical state. In addition, as most potential beneficiaries were poor, they were also likely to be anemic, which necessitated the arrangement of blood for which there was no formal provision under the program.“Last Tuesday there was a case - she had a PPH (post-partum hemorrhage) and she landed with hysterectomy. We needed 14 units of blood which is never available in any government hospital”Administrator, rural, teaching hospitalAnother obstetrician described handling cases under the program with requirements for blood that even a public sector facility would find hard to meet.“We have to go in for blood transfusion because the patients are referred with very low hemoglobin - 2-3 Hb. We don’t have so much blood available in our blood bank. Also blood components are not available with us.”Obstetrician, rural, charitable hospitalSome private facilities did have small amounts of blood stored at the facility, but this was often inadequate because of the severe anemia with which the women presented.“There is great road block to it (increasing blood bank availability). To get a blood bank license is a big headache. It is lengthy and unnecessarily procedural.” Administrator, rural, teaching hospitalIn general, the lack of access to blood for anemic women that private obstetricians reported seeing under the program was strongly emphasized. One private obstetrician had attempted to obtain permissions to have a blood bank at his facility.“The ANMs  are not competent enough to diagnose high risk cases. Secondly ANM, Dai  or medical officer or gynecologist in the periphery will hold the patient till the last minute. When finally the patient starts bleeding and on the verge of dying, they are sent here.”Administrator, rural, teaching hospital“Generally the patients referred from periphery (remote) places come to us. They are generally referred because they can’t have a normal delivery due to lots of complications. This increases the number of Cesareans. The (regular) patients don’t have much of Cesarean deliveries. In JShY scheme, we had 30–35% Cesareans in which 10–15% cases are always referred from periphery places with lot of complications.”Obstetrician, urban, for-profit hospitalParticipants also felt that field health staff at the periphery were not competent enough to be able to refer a patient on time, and so patients were sent in a critical condition. As the participating facilities had functioning operating theaters and full-time gynecologists, they also often received patients who required an intervention for delivery, or had a complication.On the whole, private obstetricians who participated in the JShY scheme felt they were taking on a disproportionate degree of risk through their participation. This was attributed to a clustering of ‘unbooked’ (not previously seen) women, who were often anemic or suffered from complications that required expensive and risky surgical intervention.“…BPL (below poverty line) families who have little money can come to a private hospital for treatment where the cleanliness, hygiene, care and treatment is better than other government facilities.”Obstetrician, urban, for-profit hospitalDespite this perception of risk, the participants strongly asserted the notion that the private sector provided better care to women in need. They rated the technical quality of care as better than that provided in the public sector, as there was consistently specialist (obstetrician) care available and the ability to do a C-Section when needed; these are elements missing from most secondary level public sector facilities. Besides the technical quality of care, the private sector participants argued that they provided a better, cleaner and safer environment for patients.“They  are getting free service and no one in our hospital asks for a reward if a boy baby is born. In government hospital the patient has to give lot of money as rewards to various people. I can say about my department that no one has the guts (dares) to ask money from the patients after the delivery.” Obstetrician, rural, teaching hospitalAn important dimension of quality that was emphasized by the private sector was that patients would not be asked to pay informal fees as rewards, as ‘in the government hospitals’.Private partners spoke of difficulties in routine processes that they had to adopt as a result of participating in the JShY. These included burdensome paperwork, difficulties with obtaining the required documentation from poor patients and delays in obtaining financial reimbursements from the state.“There are large number of photocopies to be done of the BPL card, declaration form, birth certificate and the case files. I have to keep one copy here because we get call from government to get details about any patient - they would say that they misplaced the file and they want to recheck the amount. Then I send them my copy to show them the actual cost.”Obstetrician, rural, teaching hospitalParticipating private providers were of the opinion that the amount of administration linked to the program was high and consumed a disproportionate amount of time. In one institution, a person was hired only to handle the paperwork. Providers also took extra care to make copies of relevant documents as their receipt of money from the state was dependent on this. They also mistrusted the state to be careful with the paperwork they had already submitted.“The government is only interested in papers and not in actual treatment. One vitamin tablet has to be registered ten times in the register […] yes, because of this we thought of quitting a lot of time due to this paperwork.”Obstetrician, urban, for-profit hospitalThere was some frustration among providers who felt that the paperwork load was over-burdensome and had led to considerations of their leaving the partnership.“If we need to get some money from the government, we have to follow some process. It is okay, the only thing is they can change some of the things (aspects) in the process for our comfort (convenience). If there is no process, then unwanted people (those who want to take advantage) will come inside (participate in the scheme) and take undue advantages.”Obstetrician, urban, for-profit hospitalHowever, there was also an acceptance of the need for some degree of paperwork in the program. Participants acknowledged that this was required to monitor implementation and to prevent misuse.“No (paperwork did not discourage us from continuing in the program). Generally in all government projects, there is a lot of paper work.”Administrator, rural, charitable hospitalSome providers accepted the additional paperwork as a given when it came to working with government, and did not consider leaving the program because if it.“It was like how it is in every government transaction. It was delayed all the time and was full of obstacles.”Obstetrician, urban, for-profit hospital“We have run many government programs and in all the projects money always comes late. So, we are used to it.”Administrator, rural, charitable hospital“When everything runs smoothly, there is no problem. But when the government starts delaying the release of funds for 6 months then it becomes a problem. We have to pay salaries and maintain the hospital. Even we have financial crunches. Then it becomes really difficult to manage.”Administrator, rural, charitable hospitalBesides paperwork, private providers also spoke about delays in receiving payments from the state that was owed them under the program. While some hospitals with prior experience of participating in government programs had factored in delays in payments, in other hospitals, it did cause a degree of financial hardship.“This is a very bad perception (the state’s perception of excessive private sector C-Sections) because Cesarean delivery helps in saving the mother as well as child in many complicated cases. I, being an obstetrician, can tell you that we are doing our job honestly and this is a misperception that we do more unnecessary Cesareans for more money. A few doctors may be doing such malpractices, but majority are doing their work properly and honestly.”Obstetrician, urban, for-profit hospital“It is not like that (that we do excessive C-Sections). The cases where we do Cesarean, they are always indicated. In JSY, it is a case of clear cut indicated C-Sections. We can’t trial the patient for labor, when she is already in labor for past 3-4 days. These type of cases come to us at the last minute.”Obstetrician, rural, charitable hospitalWhen the program first began, the state reimbursed private providers differently for vaginal and C-Section births (the latter reimbursed at five times the cost of the former). When the government saw that the proportion of C-Section births seemed disproportionately high under the JShY, the government decided to move to another reimbursement structure. As the state believed that the high C-Section birth rate could be driven by the structure of the financial incentives, the state subsequently changed the incentive structure to a fixed reimbursement per 100 deliveries, regardless of the number of C-Sections and vaginal deliveries. This saw a number of private obstetricians leave the partnership. The private partners in this study had an awareness of this allegation of ‘over-performing’ of C-Sections leveled against them by the government, and justified why they had performed so many.“One more problem is that our institution is a secondary or tertiary institution and the number of patients is very high - we have nearly 30–35% Cesarean delivery. They (government) used to pressurize us that we should not have more than 20% deliveries through operation.”Obstetrician, urban, for-profit hospitalAnother private obstetrician stated that the nature of the facility being a secondary or tertiary level one meant that there would be higher CS rates which the government was pressuring him to lower.“There should not be any stringent rules like this. It depends from patient to patient and conditions differ. I think obstetricians’ observations should be of main importance.”Obstetrician, rural, charitable hospitalA private obstetrician felt the requirements of the program curtailed her ability to decide the appropriate delivery procedure for the patient as an obstetrician.“No, we would have never pulled out from this scheme if it was the earlier terms and conditions.”Obstetrician, urban, for-profit hospitalFollowing the new restructuring, a number of private obstetricians left the program, on the grounds that the new payment mechanism was untenable.“I don’t know why government is paying the same amount for both deliveries […] Cesarean is more expensive than normal delivery which we all know. I don’t think this is a good idea to give equal money for both types (of births).”Administrator, rural, charitable hospitalThere also seems to have been some difficulty for providers to understand the rationale of the new reimbursement structure which assumed 15% complicated births and 85% normal births, and paid private obstetricians a package price based on these assumptions.“The fixed amount of Rs 1, 80,000  for 100 cases was there, which meant Rs 1,800 ($28) for each case. The only problem was if there are Cesarean deliveries, then we would be in a fix.”Administrator, urban, for-profit hospitalOthers felt that the new reimbursement would not work if they had a high number of C-Sections.“They put a condition that in that 100 deliveries, 85 should be normal deliveries and only 15 should be Cesarean delivery. It was not possible to fulfill this condition because we generally have 85% Cesarean delivery and only 15% normal delivery. They never stopped the scheme at our place, but they sent us the new proforma and asked us to comply with it. It is not possible to have maximum (i.e. a majority of) normal deliveries because we generally get referred cases.”Administrator, rural, charitable hospitalOthers withdrew because it was not viable given the high number of referred cases they received.“If I am the government then I would come for a visit again and again and look into the treatment and the management of the hospital.”Obstetrician, rural, charitable hospitalPrivate sector participants expressed a strong desire for more interaction with the government over the program. This took the form of asking for more supervision, more opportunities for joint interactions and space for clarifications. Some private sector participants believed there should have been much more oversight from the government.“Government wants you to do the delivery, make a record and send it to them and then they would reimburse the money. The problems which are involved in this full process are overlooked by the government and they never support us with solving these problems.”Administrator, urban, charitable hospital“Whom should we call in government? We have many day to day problems and if we go to CMO  office, they should have time to listen to us and even if they listen to us, they are not going to provide any solution.”Administrator, urban, for-profit hospitalMany participants referred to the ‘hands off’ approach by the government. They perceived that support from the government was not forthcoming enough to enable the smooth implementation of the program.“Regarding delay in funds, we wrote them letters frequently for the fund release. They never wrote to us back but they only verbally told us that even they have not received funds from the head office.”Administrator, rural, charitable hospitalOther participants spoke of the centralization of the program, and that local arms of government close to them were not able to respond to their queries or problems.“If the policies were decided at district  level, then this scheme would have continued in our place without any conditions.”Administrator, rural, charitable hospitalOne participant stated that the inability of the local government to make decisions locally led to his institution withdrawing from the program.“We never had a problem at local level. The Chief Medical Officer (CMO) was very friendly and all the people in CMO office helped us many times. We used to convey our problems to them and they tried to solve it. They can’t change the schemes which come from the state government, so it was not the fault from the local level.”Administrator, urban, for-profit hospitalOne participant spoke about the local arm of government trying to help resolve the issues he had, but that they had limited space to maneuver.“They were very good and they solved many problems. One instance about 2–3 years back was when we had to get nearly INR 1, 100, 000 ($1560) from the CMO and it was getting delayed. We went and presented our case and the money was reimbursed quickly.”Obstetrician, urban, for-profit hospitalDespite the difficulty with the paucity of interactions with the government, there were also some positive experiences.Most participants felt that the partnership was a good one to increase access to institutional delivery among vulnerable groups. Participants felt that the program would help reduce maternal mortality as poor women had access to C-Sections under the program.“Everyone wanted to get benefit of this scheme. All affluent people used to come in cars and they wanted to have the benefit as they had procured a BPL (below poverty line) card through other sources . The people who were really needy could not get the benefit because they didn’t have a BPL card.”Obstetrician, urban, for-profit hospital“They had the cards and we knew that they are from very affluent families, but we had no option and we had to give them the benefit of the scheme.”Obstetrician, urban, for-profit hospitalBesides the concerns about the clustering of high risk cases among vulnerable women, participants also had concerns about misuse of the program by people who weren’t really below the poverty line but had identification cards to the contrary.“I have a very poor patient with ruptured uterus and I feel very sorry for her. But I can’t do anything because she doesn’t have a card. I have to submit records so I can’t do anything.”Obstetrician, rural, teaching hospitalBecause of the above problem, private physicians reported that they were unable to treat patients who were genuinely poor under the program because of an unfair distribution of BPL cards.“Government’s scheme is very good and it will help in increasing institutional deliveries. For maternal and infant health, this scheme is very necessary.”Administrator, urban, for-profit hospitalDespite these concerns, on the whole private obstetricians felt that the partnership in principle was a good one to promote maternal health.This study documents private sector obstetricians’ experiences of participating in a state-led public private partnership in the Indian state of MP. Many private obstetricians situated their decision to join the partnership within an altruistic narrative; at the same time, it was acknowledged as an opportunity to increase bed occupancy in their practices. Participating private institutions saw themselves at risk because of possible clustering of complicated cases, that the poor women they provided care to under the program were often high risk, anemic, in need of blood transfusions, or experienced other complications. There was also a perception that as private sector hospitals, they provided better care than public sector ones in terms of hygiene and overall quality of care. While there was some understanding of the need for detailed paperwork, cumbersome procedures and delayed reimbursements from the state also deterred obstetricians. Some private obstetricians also discussed misuse of the scheme by people who were not considered authentic BPL (below poverty line) card holders, as well as a lack of adequate engagement and supervision by the state in the partnership.The stated altruistic rationale for joining the JShY was contextualised by participants feeling they had a stake in bringing down maternal deaths or serving disadvantaged clients. Charitable private obstetric facilities stated a mission to work with the underprivileged, and saw their objectives as aligning with those of the state with regard to the JShY i.e. providing access to intrapartum care for poor women. These claims complement the global drive to achieving UHC. For both groups, the declared motivation of altruism was seen as consistent with the ethical code of the Indian Medical Act to which all doctors are required to adhere . As founPrivate obstetricians reported a number of difficulties in the partnership which are likely to have contributed to their decision to leave the partnership program. Chief amongst these was the presence of high risk (anemic) women under the program, resulting in the need for blood transfusions as well as a high C-Section rate. The difficulty of accessing blood bank services in India has been documented previously . Given tPublic sector C-Section rates have remained steady in MP between 5 and 7% between 2006 and 2016 . PrivateDifferential payment for vaginal and C-Section births are widely known to drive C-Sections –34. WithWhile some private obstetricians were critical of what they regarded as burdensome paperwork, delays in payment and the inconvenience this caused to some of their practices, there were others who seemed to accept the need to comply with this level of documentation to prevent malpractice. Yet, despite the high levels of paperwork required from the private partners, there was a sense of inadequate engagement by the state in the partnership. Private obstetricians suggested the need for more intense supervision and engagement from the state with regard to the JShY. There was an inability of the local district health administration to make decisions in regard to issues raised by private obstetricians which was also seen as a problem. A lack of dedicated human resources to oversee the implementation of the JShY at the district health office probably resulted in difficulties in resolving implementation challenges experienced by private sector obstetricians in a timely manner. This is consistent with findings from studies exploring similar PPPs, with concern about contact management and scheme monitoring by the state reported in the similar ‘Chiranjeevi Yojana’ PPP .Private obstetricians were also discouraged and expressed irritation at what they observed as misuse of the JShY by disingenuous clients (non-poor clients carrying BPL cards). Providing services free of charge to clients who would otherwise need to pay was a source of discontent for them. For those for whom altruism was a key motivating factor to participate, the misuse of the program by non-poor women possibly diluted their altruistic zeal for participation. In India, BPL cards are issued based on population surveys at regular intervals and remain controversial as 40% of cards are reportedly issued to non poor families . ResolviThere are important implications for this and similar PPPs of the reflections of private obstetricians on this partnership, such as the JShY requiring detailed thought through planning. The rationale for the PPP needs careful consideration, importantly the size and location of the private partners. In MP, the private obstetric sector is small, providing less than a tenth of all facility birth services . FurtherWhere it is a suitable choice, the state needs to pay particular attention to designing an appropriate reimbursement scheme and engage in consultations with a broad set of stakeholders, including private partners or their representatives to obtain buy-in and understanding of the rationale for the reimbursement plan. In addition, resources for managing, supervising and coordinating a PPP program from the state need to be carefully considered and factored in. Although the evidence clearly indicates that differential payment for individual cases would lead to an over-performance of C-Sections, the state chose this as the reimbursement method. Policy makers will benefit from discussions with academic, professional bodies, private obstetricians, NGOs and other stakeholders when planning an appropriate reimbursement mechanism.Extensive paperwork is a poor replacement for close monitoring and supervision. It is important for both parties in the partnership to adequately engage and for the state to provide the leadership required of it. As this was a state led program, effective and timely responses to issues raised by the private partners would have gone a long way to building trust and strengthening the implementation of the program. State led PPP programs in India have often relied on existing health department staff taking on additional work over their routine tasks to oversee these programs, which results in inadequate oversight and engagement. Investment in a PPP program also requires investment in human resources to manage and oversee the program.Structural issues within the health system and beyond need attention prior to beginning a PPP, although they cannot always be dealt with and redressed entirely, they need attention to avert undermining the partnership program. In the case of the JShY, given its focus on intrapartum care and the magnitude of the maternal morbidity / mortality from anemia and postpartum hemorrhage, access to blood was clearly an important element to secure. The structural issues that compromise access to blood in the health system also adversely affected the partnership program. Similarly, the inappropriate distribution of BPL cards to non-poor households is a problem that would compromise the objectives of the partnership program to provide coverage to those who need it most. This has led to a demoralization of the private partners, some of whom contend that they participate for altruistic reasons. Arguably, if India is to achieve its desired goal of attaining UHC through this (and other) means, then substantial reform may be required across both private and public sectors of healthcare. Success of such schemes requires a strengthened and suitably financed public sector to confidently co-design, deliver and monitor the programs in tandem with their private sector partners, so that it may be of mutual benefit to both partners and the populations whose ultimate aim it is to serve. At the same time, evidence suggests that increasing the reach of health care coverage does not result in better outcomes by default , 40. ExpWe conducted these interviews across eight districts of MP to reflect views from across the state. We selected facilities to include various types of private obstetric partners under the JShY – teaching hospitals, charitable mission hospitals and for profit private facilities. This variation allowed us to capture common shared experiences around participation in the JShY as well as areas of difference. The research team has had many years of experience researching in the state, the first two authors live and work in MP which allowed them to quickly establish a rapport, generate discussion and gather detailed accounts of participation in the JShY. The last author has lived and worked with maternal health in the project over the last decade.Although issues raised by private obstetricians that either encourage or deter participation in a PPP program to promote facility births are very context specific, the issues raised in our study in MP demonstrate a number of similarities to those raised by private obstetricians participating in the Chiranjeevi Yojana PPP in Gujarat. This would indicate the transferability of our findings to other PPP programs to promote intrapartum care in other parts of the country.Despite the strengths of varied views across the state, the study has limitations. The absence of the perspective of the state side of the partnership is a limitation as is the potential for social desirability bias with reference to altruism as a motivating factor for participation.Private obstetricians report that altruism and the possibility to build and expand on clinical practices are important drivers for participation in a PPP to raise facility births. However, deterrents to participation included changes in the reimbursement structures by the state, the clustering on high risk women among program beneficiaries, poor engagement by the state, cumbersome procedures and delays in reimbursements and misuse of the scheme by non-poor families. Participatory designing of carefully debated financial reimbursement packages for private partners so that there are no perverse incentives is key. The state needs to ensure adequate human resource commitments to allow appropriate levels of engagement in, monitoring and oversight of the PPP program. This is particularly important so that women receive the care most appropriate to their needs and unnecessary C-sections are avoided. Also broader structural issues like more accurate BPL identification need attention so that programs intended for these groups are not undermined. Our findings provide important considerations for policy makers and planners in the design and implementation of PPP in the area of maternal and child heath in low-middle income settings.Additional file 1:Topic Guide. (DOCX 21 kb)


The aim of this study was to investigate the injury patterns and the hospitalizations of patients who were admitted to hospital following the 2009 earthquake in the city of L’Aquila, Central Italy. To the best of our knowledge, this is the first study to analyze the patterns of earthquake-related injuries in Italy. We reviewed the hospital discharge data of 171 patients admitted to hospital within the following 96 h from the mainshock. This is an observational and descriptive study: We controlled for variables such as patient demographics, primary and secondary ICD-9-CM  diagnosis codes in order to identify the multiple injured patients, main type of injury that resulted in the hospital admission, discharge disposition, and average length of stay (LOS). Seventy-three percent of the 171 patients were admitted to hospital on the first day. Multiple injuries accounted for 52% of all trauma admissions, with a female to male ratio of 63% versus 37%. The most common type of injuries involved bone fractures (46.8%), while lower extremities were the most frequently affected sites (38.75%). The average LOS was 12.11 days. This study allows the evaluation of the impact of earthquake-related injuries in relation both to the health needs of the victims and to the use of the health care resources and assistance. In the last 100 years, earthquakes have claimed millions of lives and injured thousands of people ,3. Thus,The earthquake that struck the city of L’Aquila in 2009 consisted in a series of foreshocks, which began in December 2008 and ended in 2012 , with epDuring the L’Aquila earthquake, the treatment of injured patients was delayed due to collapsed roadways and the severe structural damages of the main local hospital, the ‘Ospedale San Salvatore’  ,15. GeneIn their systematic literature review on the impact of earthquakes on human health, Doocy et al. reported that soft tissue injuries (including lacerations and contusions), fractures , and crush injury to head, thorax and abdomen caused by buildings collapsing, are the most common types of injury . They caThis study aimed to analyze the trauma admissions within the first 96 h after the mainshock, with a focus on the injury patterns, the features of earthquake-related injury admissions, the in-hospital mortality rates, and other related health outcomes. Although an analysis of the patterns of injury admissions following the L’Aquila earthquake has not yet been conducted, it may be relevant to enhance the assistance capability in high-income countries with high-standard health care services, and to provide recommendations to improve the Italian health care system during and after major disasters. On an international level, research studies that specifically target the injury patterns following high-magnitude earthquakes have not yet been conducted at a high level of scientific standards, due to the scarcity and poor quality of the data collected. As reported by Bortolin et al., the characterization of a specific disaster-related injury pattern is crucial to build an effective disaster preparedness and response system, including the development of guidelines and the definition of standards-of-care (SOC) specific to any, natural or man-made, mass casualty event .This is an observational and descriptive study based on current data. We reviewed the hospital discharge forms of 171 patients involved in the L’Aquila city earthquake, and from the so-called “seismic crater” geographic area , who were admitted to 30 regional and extra-regional hospitals . We condχ2-Test and the Fisher Test. To perform the analyses of numerical data, such as the LOS, we used the T-Test or the Wilcoxon test if the normality requirement was not respected. Furthermore, we used the Cramér’s V test to measure the association between two nominal variables. For the statistical analysis, we used software R, version 3.4.3  for Windows.Data on the admissions of the population from the seismic crater area (L’Aquila city and province), were collected from file A of the HDRs , and they refer to the time period from 6 April 2009 to 9 April 2009. The hospital discharge forms were retrieved from the information and health statistics management service of the Abruzzo Region Health System. For the analysis of data expressed in terms of frequencies, we used the It is a geographical subset of the province of L’Aquila, which comprises of the city of L’Aquila, with a population of 72,696 inhabitants, and 41 smaller municipalities  [This study was approved by all of the participating researchers and the Ethical Committee  of the University of L’Aquila on 16 January 2018 and registered on 1 February 2018 with no. 4904.The use of HDRs in epidemiology has strengths, limitations and may introduce biases. The most important strengths are that data already exist, are large and are collected independently from research purposes. The limitations are that data are pre-collected by non-researchers, with a low or unknown quality. Biases may be also introduced, like misclassification as the result of unclear or erroneous clinical documentation, or like the fact that expensive medical procedures are usually documented better than those less costly.In the few days following the earthquake under investigation, the Abruzzo hospitals and in particular the L’Aquila hospital, focused on the management of the emergencies related to the event. All other emergencies were redirected to other hospitals like the ‘Ares Marche’ field hospital. However, there is no written note on the HDRs that may guarantee that all admissions are directly due to the earthquake, and—for privacy reasons—we could not contact the patients involved in the study for a confirmation.From 6 to 9 April 2009, injury-related hospitalizations in the seismic crater area accounted for 30.4% of all admissions, with 171 hospitalized patients, ranging from 48.5% on 6 April with 125 inpatient admissions in the day and as leading cause of hospitalization, to 12% on 9 April with 11 hospitalized patients and as third cause of admission .On 6 April, 125 patients were admitted to hospitals  accountiWomen had almost a twofold higher rate of injury than men, with frequency rates of 63.7% and 36.3%, respectively. Fractures (ICD-9: 820–829), internal injury of thorax, abdomen, and pelvis (ICD-9: 860–869), contusion with intact skin surface (ICD-9: 920–924), traumatic complications and unspecified injuries (ICD-9: 958–959), and late effects of injuries and other external causes (ICD-9: 905–909) were more frequent in women, while intracranial injuries, excluding those with skull fracture (ICD9-CM: 850–854), were more common among males.We then compared the overall frequencies sorted by sex and the average LOS for the injury-related admissions from 6 to 9 April 2009 among the population in the seismic crater with the number of hospitalizations among the overall Abruzzo population during 2010–2016 .p-value = 0.045 *. In 2010–2016, the ratio of male to female hospitalizations was similar in the fractures, with a (M 47% vs. F 53%), and in the overall injury-related hospitalizations with a (M 48% vs. F 52%), compared to the admissions from 6 to 9 April 2009, where the fracture-related admission ratio was (M 35% vs. F 65%), and the overall injury hospitalizations had a ratio of (M 36% vs. F 64%), with a p-value = 0.002 *.Comparisons with the 2010–2016 hospital admissions showed that women reported a higher number of fractures (+24%), and hospitalizations (+24%) than males , with a p-value= 0.08), except for the “open wounds of head, neck, and trunk” and “sprains and strains of joints and adjacent muscles”, which had a longer LOS in 2010–2016. A difference of +2.2 days in the average LOS for all hospitalizations is observed between 6–9 April 2009 and 2010–2016, p-value= 0.03 *.As displayed in As mentioned above, fractures were the most prevalent injury pattern. The most commonly injured anatomic sites within the four days after the mainshock were lower extremities (38.75%), spine and trunk (32.5%), and upper limbs (21.25%). Skull fractures accounted only for 7.5%. On 6 April 2009 b, fractuAdditionally, p-value = 0.19) and a weak association is shown (Cramér’s V = 0.14).The reviewed data on the patients from the seismic crater area show a female to male ratio of 1.75:1 (F = 64% vs. M = 36%), with an age range of 0–104 years . The meap-value shows no statistical significance.In The review of the hospital discharge forms highlighted that on 6 April, 59% of the patients were admitted to hospital with secondary ICD-9-CM diagnosis codes in the range 800–959 . In the The following frequencies in the discharge patterns in the days following the earthquake were observed:As summarized in A further analysis compared the percentages of the discharge patterns for the patients admitted within the days following the earthquake with the discharge rates for all injured hospitalized patients in 2010–2016 across the seismic crater area.Comparison of in-hospital mortality rate between the earthquake days and 2010–2016 (1.8% vs. 1.3%) did not show any noteworthy difference. The discharge to home pattern (no.2) among the inpatients admitted within the days following the earthquake was approximately 15% lower than 2010–2016 period. Conversely, the rate of discharge pattern no.6  was higher among the patients admitted from 6 to 9 April (8.2% vs. 1.7%); the rate for pattern no.8 were also higher in the days following the earthquake. The inferential analysis regarding the discharge patterns shows no statistically significant differences in terms of gender, statistically significant differences in terms of period.As shown in Conversely, On 6 April 2009, approximately 50% of patients  were admEarthquake-related injuries were mostly caused by the collapse of buildings, like in the 2013 Lushan earthquake (China) . This fiFurther, the review of the medical records of patients admitted with an injury diagnosis highlighted a recurring injury pattern in the L’Aquila city earthquake: It outlined how females had almost a two times higher incidence of injuries than males  were accounted for by females, who also had longer median LOS (with a higher severity score), and half of the inpatients were older than 60 years at the time of admission to the hospital.The paediatric population constituted only 4% of all inpatient admissions, differently from other earthquakes, such as the Kocaeli earthquake of 1999, in Turkey , where tMuch of the extant literature has highlighted that multiple-injured patients are an important component of the injury pattern following earthquakes , as, comAlthough fracture-related admissions were the main cause in both periods (2009:46.8% vs. 2010–2016: 45.6%), the comparison with the period 2010–2016 shows that the average LOS for the fracture-related admissions was longer in 2009 (+2.9 days). Moreover, the types of injuries treated by the clinical surgery units after the earthquake had frequencies different from the average rates reported for the period 2010–2016: internal injury of thorax, abdomen, and pelvis (ICD-9: 860–869), +5.1%; intracranial injury (ICD-9: 850–854), +7.2%. These findings, if supported by further studies on the earthquakes occurring in Italy over the past years, have important implications for the regional and national health care system preparedness, in order to ensure the provision of critical public health and medical services during an earthquake, and the adequate clinical and surgical management of the injured (Preparedness).Notwithstanding the overloading of health care delivery due to the immediate surge of injury-related admissions , compounThe analysis of patient discharge disposition and the comparison with 2010–2016 showed no significant difference between in-hospital mortality percentages (2009:1.8% vs. 2010–2016:1.3%). Discharges to patient’s home (no.2) decreased by 15%, while a rise was observed in the number of interhospital and intrahospital transfers for both acute and rehabilitation care (no.6–8) compared to 2010–2016. This highlights an increased need for health care and rehabilitation in the earthquake-related patients (possibly due to the severity of the injuries) with respect to the patients admitted in the years following the earthquake. Furthermore, a longer-than-average LOS is to be related to psychological trauma and to logistical difficulties due to the collapse or damage of buildings.Unfortunately, earthquakes are unpredictable in their timing, location and intensity. Italy is a country prone to seismic activity and, despite the number of studies on the earthquakes both prior to and after 2009, none of them have targeted a systematic analysis of the injuries and of their short- and long-term management. However, the analyses of the injury patterns of the patients admitted to the hospital following the L’Aquila earthquake represent an initial step to understanding the effects and the health care needs during a major natural disaster in Italy.Earthquake-related injuries should be a rare event in high-income countries, such as Italy, in particular those injuries caused by the collapse of buildings, as occurred in the L’Aquila earthquake. However, we believe that in Italy further studies on injury patterns are needed to enhance emergency preparedness and response of the national health care system. Further research might focus on the analysis of the patients admitted to the rehabilitation and long-term care facilities to establish whether they developed permanent disabilities and whether there had been inequalities in relation to the delivery of and access to health care, in particular for special needs or vulnerable populations. In conclusion, considering the types of injuries observed and the features of the majority of the injured admitted to the hospital following the L’Aquila earthquake, we can state that the study on the injury types and patterns caused by natural or man-made disasters, and their surgical and rehabilitation treatment, is critical to planning special surgical emergency units for the operational management and treatment of specific patient profiles affected by natural disasters, particularly in Italy, a country with a high seismic risk .


Falls reflect sentinel events in older adults, with significant negative consequences. Although fall risk factors have been identified as intrinsic  and extrinsic , most prevention programs target only intrinsic factors. We present the rationale and design of a home-based multicomponent fall prevention program—the LIVE LiFE program—for community-living older adults. The program adapts and expands the successful Lifestyle Intervention Functional Exercise (LiFE) program by adding home safety, vision contrast screening, and medication review. The specific aims of the study are to (1) adapt the LiFE program to a US context and expand it into a multicomponent program (LIVE LiFE) addressing intrinsic and extrinsic fall risks, (2) examine feasibility and acceptability, and (3) estimate program impact on multiple outcome measures to prepare for an efficacy trial.n = 25) or the control group . The open-label pilot participants (n = 3) receive the program without randomization and are assessed based on their experience, resulting in a stronger emphasis on the participant’s personal goals being integrated into LIVE LiFE. Fall risk and balance outcomes are assessed by the Timed Up and Go and the 4-Stage Balance Test at 16 weeks. Additional outcomes are incidence of falls and near falls, falls efficacy, fear of falling, number of home hazards, and medications assessed at 16 weeks. Incidence of falls and near falls, program adherence, and satisfaction are assessed again at 32 weeks.The study involves two phases: an open-label pilot, followed by a two-group, single-blinded randomized pilot trial. Eligible participants are community-living adults 70+ years reporting at least one injurious fall or two non-injurious falls in the previous year. Participants are randomized in a 2:1 ratio to the program group  contains supplementary material, which is available to authorized users. Falls reflect a sentinel event severely impacting the health and quality of life of older adults as well as resulting in healthcare costs. As the demographic profile of countries continues to reflect dramatic age transformation, the risk of falling will persist. Each year in the USA, ~ 29 million 28.7%) adults 65 years of age and older fall, leading to 7 million injuries . In 2015.7% adultAlthough it is recognized that there are multiple contributors to falls and fall risk in older adults, in most cases the programs designed to prevent and reduce falls only address one or two risk factors. Which ones that are addressed and how they are addressed vary greatly.Balance and lower-limb strength exercise are well known to effectively reduce falls in older adults , but a lHowever, to address both intrinsic and extrinsic fall risks, multicomponent programs are needed. A 2012 Cochrane review showed that exercise programs, home safety, medication reduction, and treatments for vision problems reduce the risk of falling . A recenAlthough there is evidence of effective strategies to reduce falls, implementation of community-based fall prevention programs in the USA has been limited and varies by state and county . In addiWe present the rationale and design of a two-step pilot study of a home-based, multicomponent fall prevention program for community-living older adults (LIVE LiFE), building from the successful LiFE program  and addin = 3). The second phase is a single-blind randomized pilot trial (n = 37). Participants are randomly assigned on a 2:1 ratio to the LIVE LiFE group or the control group. The program is conducted by OTs in the home of the study participants with referral to optometrist and primary care provider when indicated. The program group receives the 12-week LIVE LiFE program, and the control group receives a written fall risk assessment using data from baseline measures. During home visits, trained research assistants conduct the data collection at baseline, at 16 weeks, which is the primary endpoint of the trial, and at 32 weeks to determine whether program gains are maintained. The study will be implemented and reported in line with Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines [This study is a single-site study conducted in Baltimore, Maryland, USA. We have combined an open-label pilot and a single-blind randomized pilot trial in a two-phase protocol. First, we conducted an open-label pilot study to refine content and optimize the delivery of the program in which the first three participants received the program  and participants randomized to LIVE LiFE (n = 25) or to the control group (n = 12).We assume an attrition rate of 13% during the 16-week follow-up based on our experience with previous clinical trials of similar duration and intensity and in the same community . Based oThe overarching theoretical framework for the program is Verbrugge and Jette’s Disablement Process, which stresses that both intrinsic (body and mind) and extrinsic (environment) factors can contribute to a process of disablement . Also, wBased on what we learned in the open-label phase, the home-based multicomponent fall prevention program included goal clarification, balance and strength training integrated into daily habits, home safety assessment, home hazards removal, vision screening, and medication review  . The conThe home safety component includes an assessment of safety features in the home and ≤ US $500 to address home hazards such as lack of banisters and grab bars, holes in the floor, dim lighting, or slippery floors. After the home safety assessment, the OT suggests possible solutions and provides small adaptations such as nightlights or fluorescent tape applied to slippery steps. For more extensive home hazards, the OT and the participant brainstorm and agree on prioritized modifications and repairs . The OT sends a work order to a licensed handyman. When the handyman obtains the order, she or he usually visits the participant twice, first to plan and then to install the adaptations and repairs. This component of the program is provided by Civic Works, an AmeriCorps site in Baltimore, MD.For the vision screening component, the OT does a contrast sensitivity vision screening with the Mars Letter Contrast Sensitivity Test . To reflFor the medication review component, a pharmacologist specializing in older adults reviews a list of the prescribed and over-the-counter drugs collected at the baseline visit and provides simple recommendations in a letter to the participants to share with their primary care provider. The review is based on the updated Beers criteria for potentially inappropriate medication use in older adults . We specParticipants in the control group receive a written fall risk assessment by mail based on their baseline scores. They are also sent the “Stay Independent” brochure on how to reduce the risk of falling published by the CDC .Data collectors receive project-specific training in the measures used. Data are collected via encrypted, password-protected tablet computers at participants’ homes at baseline and follow-up at 16 weeks. A second follow-up is completed by phone interview at 32 weeks. All data are uploaded to the online data entry and management system software REDCap. The study implements several data quality features offered by REDCap, including range checks, branching logic, and calculated fields to minimize data entry errors. Study visits are audio-recorded with patient consent for the study data manager to listen to in the event an error is identified. Audio recordings are destroyed at the end of the study after all data quality checks have been completed. The participants receive a $25 gift card after each completed data collection .For feasibility and acceptability measures, we collect data on refusal to be enrolled after being explained the study, and study retention rates. The OT documents the number (dose) and duration (intensity) of sessions to capture intervention delivery. Documentation on adherence to strength and balance training is provided through an activity log completed daily by the participant and reviewed weekly by the OT. At the end of the program, the OT follows up with the participants as to whether or not they had received the vision and medication referral, whether they have acted on them, and whether the handyman portion of the program has been completed. For acceptability, we collect data on program satisfaction at baseline and at 16 and 32 weeks.To prepare for an efficacy trial, we explore multiple outcome measures to estimate program impact.For fall risk and balance, we use the Timed Up and Go (TUG) test  and the Number of falls and near falls are recorded daily by the participants using an investigator-developed monthly falls calendar. A fall is defined as a person unintentionally coming to rest on the ground, floor, or other lower level . A near Because fear of falling is central to decreasing falls risk and is considered on the causal pathway, we used multiple measures to learn more about this important concept. Falls efficacy is measured by the 10-item Falls Efficacy Scale (FES), which asks the participant to rate from 0 to 10 their confidence in doing ten activities in or outside the home without falling . Fear ofTo assess reduction in home hazards, we use the Home Safety Self-Assessment Tool (HSSAT) checklist—a 67-item checklist filled out by the data collector during a home tour with the participant. The house tour includes front and back entrances, hallway, living room, kitchen, bathroom, bedroom, basement/laundry room, stairways, and garage . The HSSFor the medication review component, we assess use of medications as a simple count and listing of the participant’s prescribed and over-the-counter drugs. Participants are also asked whether they have discussed their medications and any associated fall-related concerns with their doctor in the last year (yes/no). The participants are asked whether they have recieved a vision check-up in the last year and whether they use bifocals (yes/no).We consider possible confounding by assessing difficulties in Activities of Daily Living (ADL) with the Katz ADL Index on eight basic  and eight instrumental ADLs  , 44. TheThe fidelity plan, based on the National Institutes of Health (NIH) Behavior Change Consortium , addressWhen the open-label phase participants had completed more than half of the intervention sessions, a study team member interviewed them over the phone. They were asked open-ended questions on the content and delivery of the balance and strength component, home safety component, medication review component, vision screening component, and documentation of the program. The PI interviewed the OT on the same components. The open-label phase revealed that participants did not always feel intrinsically motivated to do the prescribed exercises. Subsequently, drawing upon the health promotion literature on Purpose in Life , we adapFor feasibility and acceptability of the program, we will examine percentages of people who stay in each arm of the study, and conduct descriptive correlational analyses of the association between the program compliance and demographic and participant health variables. Also, the feasibility of delivering the program will be assessed by exploring the OTs’ documentation of dose and duration. For program compliance analyses, we will distinguish non-compliance with the program from attrition or loss to follow-up, i.e., missing data. We will use the participant satisfaction data to examine the acceptability of the program. To examine whether the program group continues with the exercise component beyond the end of the program, we will use data collected up until 32 weeks to inspect frequency distributions derived from the adherence tracking logs and examine correlations with demographic and other factors to explore predictors of adherence. Also, we will continue to collect fall diaries and examine group differences in falls and near falls up through 32 weeks after the onset of the program.n = 3) from the remaining LIVE LiFE group participants. For the primary aim, the outcome will be improvement in the TUG and the 4-Stage Balance test between baseline and 16 weeks. Effect sizes will be estimated based on Cohen’s D. We will decide on a parametric or non-parametric testing approach after reviewing sample sizes and skewness of data. Otherwise, our general analytic approach for the primary outcome will be standard analyses of covariance (ANCOVAs) on the 16-week outcome data, with the baseline value of each respective outcome variable serving as a covariate. For the secondary aims, analyses will use chi-square tests or logistic regression analyses to examine group differences for data collected at 16 and 32 weeks.All analyses of primary and secondary outcomes will follow the intention-to-treat principle: all participants will be counted in their assigned study group once the assignment has been made. We will then perform a sensitivity analysis by excluding the open-label pilot participants


African Americans (AA) are 17% less likely to be diagnosed with arthritis compared to Whites, yet disproportionately burdened by arthritis symptoms. AA are overrepresented in the diagnosis and burden of other chronic conditions , highlighting the need to engage them in evidence-based Chronic Disease Self-Management Education (CDSME) Programs. This study examines how disease profiles may influence program attendance. Using a multinomial logistic regression, data were analyzed from AA with arthritis  who attended CDSME programs in 48 states. Relative to those with only arthritis, participants with more complex disease profiles were less likely to attend an arthritis-specific program (P<0.001) and more likely to attend a diabetes-specific program (P<0.001). Those with more complex disease profiles were more likely to attend programs at healthcare organizations and residential facilities, and less likely to attend in faith-based organizations (P<0.001). Understanding barriers and facilitators to program attendance have policy and public health implications.


An efficient parallel computation using graphics processing units (GPUs) is developed for studying the electromagnetic (EM) backscattering characteristics from a large three-dimensional sea surface. A slope-deterministic composite scattering model (SDCSM), which combines the quasi-specular scattering of Kirchhoff Approximation (KA) and Bragg scattering of the two-scale model (TSM), is utilized to calculate the normalized radar cross section (NRCS in dB) of the sea surface. However, with the improvement of the radar resolution, there will be millions of triangular facets on the large sea surface which make the computation of NRCS time-consuming and inefficient. In this paper, the feasibility of using NVIDIA Tesla K80 GPU with four compute unified device architecture (CUDA) optimization strategies to improve the calculation efficiency of EM backscattering from a large sea surface is verified. The whole GPU-accelerated SDCSM calculation takes full advantage of coalesced memory access, constant memory, fast math compiler options, and asynchronous data transfer. The impact of block size and the number of registers per thread is analyzed to further improve the computation speed. A significant speedup of 748.26x can be obtained utilizing a single GPU for the GPU-based SDCSM implemented compared with the CPU-based counterpart performing on the Intel(R) Core(TM) i5-3450. Studying the electromagnetic (EM) backscattering characteristics from an electrically large sea surface plays an important role in the synthetic aperture radar (SAR) imaging, ocean parameter inversion, targets detection, and monitoring ,2,3. ComNowadays, graphics processing units (GPUs) are specialized for compute-intensive, highly parallel scientific problems due to their multi-threaded, many-core processor with tremendous computational horsepower and very high memory bandwidth . In 2006In this paper, a new GPU-based SDCSM implemented with five CUDA optimization strategies is developed for calculating the NRCS from an electrically large sea surface. This paper is organized as follows: first, based on the electrically large oceanic surface simulated by double superimposition model (DSM) ,5, the SThe conventional oceanic surface is generally divided into two scales: the large-scale gravity waves and small-scale ripples superimposed on them, where the large-scale gravity can be simulated as millions of triangular meshing. In order to calculate the EM backscattering echoes from diverse triangular meshing on the electrically large sea surface, a hypothesis should be followed that the EM backscattering echoes from diverse facets on the oceanic surface are de-correlated . In thisp and q represent radar reception and incident polarizations, respectively; When the incident angle is small σpqx and y directions, respectively.As the incident angle increases, EM backscattering echoes from the electrically large sea surface are dominated by the Bragg scattering mechanism caused by small-scale ripples. In this case, The NRCS of the electrically large sea surface can be calculated by small perturbation method (SPM) as (2)σpqSPh  and v  polarizations, respectively; For co-polarization, the coefficient matrix The ripples which contribute to the EM scattering are modulated by large-scale gravity waves, as shown in M and N represent sample points of the sea surface model in the x and y directions, respectively; x and y directions, respectively; A is the area of the electrically large sea surface.For different radar frequencies at diverse incident angles, EM backscattering echoes from diverse triangular meshing on the electrically large sea surface correspond to different scattering mechanisms. When the incident angle is close to the specular reflection region, The SDKAM ,7 is adeThe cutoff wavenumber sults in  when thesults in . For backscattering NRCS computation, The NRCS of an electrically large sea surface compared with the experiment data  is illusIn this paper, NVIDIA Tesla K80 GPU with CUDA is exploited to improve the calculation performance of NRCS from electrically large sea surface. The GPU accelerator features and the GPU-based SDCSM algorithm are detailed in this section.NVIDIA Tesla K80 is engineered to deliver superior performance with more powerful servers. It is designed to boost throughput by CUDA was introduced in 2006 by NVIDIA as an extension of conventional C program to leverage the high performance computing (HPC) capability of GPUs, which enables scientists and engineers to solve massive computational problems in a more efficient way. In this paper, an efficient GPU-based SDCSM model is developed with CUDA to improve the calculation performance of NRCS from an electrically large sea surface. The entirely parallel program consists of two components: the sequential parts performed on CPU and the parallel parts performed on GPU.Threads are the smallest executable unit in a CUDA program, in which a three-dimensional thread forms a thread block, and a grid is made up of a three-dimensional thread block. Initialize the size of electrically large sea surface Transfer the electrically large sea surface data from the CPU to the GPU.Compute the NRCS of individual triangular meshing on the electrically large sea surface independently in parallel on the GPU by all threads within a block.Copy the results from the GPU back to the CPU.The typical processing flow of the GPU-based SDCSM algorithm can be expressed as follows:In this paper, the EM backscattering echoes from different triangular meshes are de-correlation, thus the EM backscattering echoes from diverse triangular meshes on the electrically large sea surface can be calculated independently in parallel on the GPU by all threads. Each thread is responsible for calculating the EM backscattering from individual triangular meshing on the sea surface. The computational performance of a GPU-based SDCSM algorithm will be detailed in this section, and five CUDA optimization strategies are adopted to further accelerate the computation of NRCS of electrically large sea surface. The frequency The GPU-based SDCSM parallel program executed on the Tesla K80 was compiled by the nvcc 5.0 with –O3 –arch=compute_35 –code = sm_35 –Xptxas –v compiling option while the conventional serial C program executed on Intel(R) core (TM) i5-3450 CPU was compiled by g++ with –O2 compiling option. Threads inside each block may access data from diverse memory space each time that the kernel is called. Memory performance optimizations are particularly important for the massive parallel computation performance. When the CUDA program is launched, all threads performed on the SMXs will access the same global memory, which has the greatest access latency. For the Tesla K80, each SMXs provides an on-chip shared memory which can be accessible by all threads inside each block within one thread block with much higher bandwidth and lower latency. In order to achieve high memory bandwidth, shared memory is utilized to coalesce cache global memory, thus reducing the number of accesses to the global in our parallel program. By utilizing the shared memory __shared__ zsea_float ,17, the In our CUDA program, all threads within a grid utilize the same parameters For single-precision floating-point operations performed on the device, the nvcc compiler provides an option –use_fast_math which coerces all functions in the CUDA program to compiler to CUDA intrinsic functions. Intrinsic functions are compiled with fewer instructions and greater throughput compared with their equivalent standard counterpart. As a result, the CUDA program with fast math compiler option can achieve more aggressive optimization with less accuracy. The runtime and speedup for the GPU-based SDCSM program with fast math compiler option is provided in It is advisable to exploit the fast math option whenever speedup is more important than precision. In order to verify the correctness of the outcomes with the –use_fast_math compiler option, the mean absolute error (MAE) and MEA/mean are exploited to ensure that the results of the parallel program are consistent with those of serial program. The percentages of GPU runtime consumed by different GPU operations after using the fast math compiler option are shown in In order to hide the data transmission time, asynchronous data transfer (ADT) was utilized, which can perform data transfer between host and device memories and kernel execution simultaneously. The Tesla K80 GPU provides two copy engines, namely, a host-to-device engine and a device-to-host engine, allowing one data transfer from the host to the device, one kernel execution, and one data transfer from the device to the host to overlap. Data transfer and kernel execution perform simultaneously through streams, which can be seen as a sequence of commands that perform on the GPU in order.In this paper, a slope-deterministic composite scattering model (SDCSM) was exploited to calculate the NRCS of the EM backscattering echoes from the electrically large sea surface. Both the quasi-specular backscattering caused by large-scale gravity waves and the Bragg backscattering caused by small-scale ripples are taken into account for calculating the NRCS. Moreover, the NVIDIA Tesla K80 with CUDA has been utilized to accelerate the calculation of NRCS from electrically large sea surface. Compared to the conventional serial C program, our parallel program has significantly improved the performance of the NRCS calculation and a significant speedup of 2104.2× has been achieved. Four optimization strategies have been adopted in our GPU-based SDCSM parallel program. First, coalesced global memory access was used to reduce access to global memory. Following this procedure, constant memory is exploited to reduce repetitive computations in the CUDA program. The compiler option with –use_fast_math was adopted to further improve the computational performance and the correctness of outcomes is verified to ensure the results of the parallel program are consistent with that of the serial program. Then, in order to hide the data transmission time between the host and the device, asynchronous data transfer (ADT) was exploited to further improve the computational performance of the GPU-based SDCSM parallel program. The proposed GPU-based SDCSM parallel program only calculates the NRCS of the EM backscattering under low sea state (


BCR-ABL1 mRNA doubling-times (DTs) could distinguish inconsequential rises in the oncogene's expression from resistance to tyrosine kinase inhibitors (TKIs). Thus, we retrospectively examined BCR-ABL1 evolution in 305 chronic-phase CML patients receiving imatinib mesylate (IM) as a first line treatment. Patients were subdivided in two groups: those with a confirmed rise in BCR-ABL1 transcripts without MR3.0 loss and those failing IM. We found that the DTs of the former patients were significantly longer than those of patients developing IM resistance . Interestingly, the DT values of individuals failing second-generation (2G) TKIs after developing IM resistance were considerably shorter than those observed at the time of IM failure . We next wanted to establish if decreases in BCR-ABL1 transcripts would identify subjects likely to obtain deep molecular responses. We therefore analyzed the BCR-ABL1 halving-times (HTs) of a different cohort comprising 174 individuals receiving IM in first line and observed that, regardless of the time point selected for our analyses , HTs were significantly shorter in subjects achieving superior molecular responses . Moreover, 50 patients receiving 2G TKIs as first line therapy and obtaining an MR3.0  or an MR4.0  displayed significantly shorter HTs than individuals lacking these molecular responses. Our findings suggest that BCR-ABL1 DTs and HTs are reliable tools to, respectively, identify subjects in MR3.0 that are failing their assigned TKI or to recognize patients likely to achieve deep molecular responses that should be considered for treatment discontinuation.In Chronic Myeloid Leukemia (CML), successful treatment requires accurate molecular monitoring to evaluate disease response and provide timely interventions for patients failing to achieve the desired outcomes. We wanted to determine whether measuring  BCR-ABL1 chimeric oncogene (BCR-ABL1 is generated by a translocation involving the breakpoint cluster region (BCR) and the Abelson (ABL1) genes localized on chromosomes 22 and 9, respectively. The ensuing Philadelphia chromosome (Ph+) encodes for a constitutively active tyrosine kinase that promotes cell proliferation, modifies the actin cytoskeleton and modulates the interaction between leukemic cells and the bone marrow microenvironment  is characterized by a single pathogenic alteration: the oncogene . BCR-ABLironment –12.BCR-ABL1 doubling-times (DTs) (expressed in number of days) may be associated with CML progression to blast crisis (BC) (4.0 or better) might be candidates for treatment discontinuation (While first- and second-generation (2G) tyrosine kinase inhibitors (TKIs) have generated unprecedented results for individuals diagnosed with chronic phase CML, solid evidence indicates that patients who do not achieve early molecular responses often display inferior outcomes, with increased risk of disease relapse, progression and death , 14. Hensis (BC) . On the inuation , 18.BCR-ABL1 transcripts in 305 chronic phase CML patients receiving Imatinib Mesllate (IM) as first line treatment to establish if different rises in BCR-ABL1 transcripts could distinguish clinically negligible increases in oncogene levels from those indicative of TKI resistance. The 305 subjects were subdivided in two groups: those with a confirmed elevation in BCR-ABL1 transcripts without major molecular response (MR3.0) loss, and those failing IM according to the latest European Leukemia Net (ELN) guidelines —could be employed to discern which CML patients were likely to achieve deep molecular responses and could be considered for TKI discontinuation. To this end, we analyzed the HTs of 174 patients receiving IM in first line, and analyzed their BCR-ABL1 values at 6, 12, and 18 months of treatment.We also wanted to establish if a decrease in Finally, as previous randomized phase III trials , 21 haveBCR-ABL1 DTs, while the remaining 174, the only individuals experiencing a continuous decrease of their oncogenic transcripts, were recruited to estimate BCR-ABL1 HTs. Responses to therapy were evaluated according to the 2013 ELN criteria  as previously described  or 5-fold (if BCR-ABL1/ABL1IS levels were <0.01%) rise in two consecutive analyses (without therapeutic intervention).For the DT and HT analysis, we considered patients with accurate . An incrBCR-ABL1/ABL1IS transcripts was defined as a >2-fold (if BCR-ABL1/ABL1IS levels were ≥0.01%) or 5-fold (if BCR-ABL1/ABL1IS levels were <0.01%) decrease in two consecutive analyses.For the HTs analysis, a reduction of BCR-ABL1 DTs we employed the following formula: DT = ln2/k, where (k) is the fold BCR-ABL1 rise divided by the number of days over which the rise occurred [k = (ln(b) – ln(a))/d], with (a) the value before the rise, (b) the value at the rise, and (d) days .To calculate (d) days . Similar(d) days . Groups BCR-ABL1 DTs could determine the clinical significance of a rise in the transcripts of the chimeric oncogene, we analyzed the evolution of BCR-ABL1 mRNAs in 305 patients with chronic phase CML that had achieved a major molecular response (MR3.0) after receiving standard dose IM as first line treatment. The rates of treatment response of these individuals are summarized in To establish if 3.0 despite an increase in BCR-ABL1 levels, while 118 (38.7%) failed IM according to the 2013 ELN recommendations   maintained their previously achieved MRndations . Statist 0.0114) .p = 0.0035)  received ponatinib and 10 were subjected to an allogeneic stem cell transplant. Within the 97 individuals treated with a 2G TKI, 76 (78.3%) achieved an optimal response while 21 (21.7%) developed resistance to second line treatment . We calc 0.0035) .BCR-ABL1 levels from those associated with IM failure. Our data also confirm that CML patients failing two lines of treatment have an aggressive and rapidly proliferating disease that requires urgent medical attention.These data suggest that DT analysis may discriminate clinically negligible increases in 4.0) may be considered for treatment discontinuation , 111 specimens were accessible after 12 months  and 104 samples could be tested after 18 months (39 without MR4.0 and 65 in MR4.0) (3.0 was 39 days (range 14.9–142.6) compared to 21.90 days (range 13.0–131.6) for the 40 individuals with an MR3.0. This difference was statistically significant (p = 0.002)  as compared to individuals in MR3 30.60 days (range 7.8–156.1) (p < 0.0001) (3.0 were 76.70 days (range 15.1–179.9), a significantly higher value than that recorded in the 65 patients in MR4.0  (p = 0.0099)  . At the = 0.002) . After 1 0.0001) . Similar 0.0099) .BCR-ABL1 HTs may prove of clinical value to rapidly recognize CML patients that are likely to achieve deep molecular responses on IM.Hence, calculating BCR-ABL1 reduction in patients receiving 2G TKIs, we measured the HTs of 50 individuals treated in first line with DAS or NIL (3.0 after 6 months of treatment had a BCR-ABL1 HT of 43.50 days (range 21.4–195.1) vs. 22.50 days (range 13.2–116.6) for those in confirmed MR3.0 after 6 months (p = 0.003) (4.0 while 9 had attained an MR4.0. Median BCR-ABL1 HTs were 91.60 days for the former patients (range 20.3–290.9) vs. 42.80 days for the latter group (range 19.8–66.5) (p = 0.019) (To investigate the differences in the velocity of S or NIL . The rat= 0.003) . We next= 0.019) .BCR-ABL1 molecular kinetics in CML patients receiving 2G TKIs.These results confirmed the clinical usefulness of assessing BCR-ABL1/GUSIS transcripts at diagnosis, individual comorbidities and expected patient compliance are good parameters to select between IM and 2G TKIs for the initial treatment of chronic phase CML , hase CML . Moreoveidelines . HoweverBCR-ABL1 transcripts may be predictive of a potential loss of IM response. Specifically, in the Australian analysis, short (9 days) BCR-ABL1 DTs were indicative of disease evolution to BC or of IM discontinuation/interruption, while longer (48 days) DTs were associated with TKI failure due to point mutations in the BCR-ABL1 kinase domain without progression to BC. To support these results in a different patient cohort, we calculated the BCR-ABL1 DTs of 305 CML patients receiving standard dose IM in first line. As our patient series was devoid of subjects progressing to BC, we could not confirm the findings of Branford et al. on the extremely brief DT detected in patients with disease evolution. However, in agreement with their results, we found that patients failing IM displayed DTs <42 days, a value extremely similar to that reported by Branford et al. These findings suggest that individuals with DTs of 42–48 days should be quickly considered for a change of therapy  in 3 patients and alternatively spliced variants , in other 5 individuals (data not shown). Our results are in line with those previously reported by Yuda et al. showing that a 35 bp insertion might be correlated with loss of IM response  or received ponatinib . These treatment decisions were guided by mutational analyses performed at the time of drug failure, as the 11 subjects given ponatinib displayed the T315I substitution (6 patients) or compound mutations  responsive to the drug, as previously reported by Zabriskie et al.  indicative of a biological evolution toward a more aggressive disease  as previously reported [(BCR-ABL1 decrease to a deep molecular response (≥MR4.0) may be considered a selective parameter favoring the rapid identification of individuals potentially eligible for TKI discontinuation.Several studies , 32–34 heported [; Figureseported [, 36, 37.BCR-ABL1 decline in patients treated with IM or 2G TKIs, we measured the oncogene's HTs in individuals receiving DAS or NIL as first line treatment. As expected, we found no differences in the velocity of BCR-ABL1 reduction between patients achieving the same molecular responses (MR3.0 at 6 months), regardless of the TKI they were receiving (21.90 vs. 22.50 days). However, we detected a sizeable difference in the number of subjects attaining this response: 44% in the IM group vs. 69% in the 2G TKI group. This finding confirms that individuals displaying excellent responses to IM will obtain a comparable benefit to that achievable with 2G TKIs but that the overall number of these subjects is clearly inferior to that attainable with DAS or NIL. These differences are amplified at later time points, with only 13% of IM-treated individuals achieving an MR4.0 at 12 months (data not shown) compared to 35% for those receiving 2G TKIs. Furthermore, from the 12-month time point onwards, BCR-ABL1 HTs were constantly shorter in patients treated with 2G TKIs explaining the higher number of deep molecular responses observed with these drugs. However, our data suggest that, regardless of the type of inhibitor, after 12 months of TKI therapy a HT value of 40 days is associated with a higher probability of achieving a deep molecular response.Both the DASISION and the ENESTnd studies , 21 haveBCR-ABL1 DTs and HTs are easily measurable molecular parameters that rely on the timely computation of the variations in BCR-ABL1 transcripts that are routinely measured in real life CML monitoring. Both molecular indexes can be of great value in complex clinical situations i.e., in interpreting a rise in BCR-ABL1 levels in patients that have achieved an MR3.0 and in discriminating patients that exhibit modest declines in their oncogenic transcripts from those who will likely achieve a deep molecular response and might therefore be eligible for TKI discontinuation.In summary, All datasets generated for this study are included in the manuscript and/or the The research ethics committee of each recruiting Institution reviewed and approved the study protocol . The stuMP, SSt, and SV contributed to design the study methodology, to carry out the laboratory work, to collect, and to interpret the data. MP wrote the draft manuscript and performed statistical analysis. AP and SD contributed to carry out the laboratory work and interpret the results. CR, ET, and MM contributed to interpret the results. AA, SSi, DM, SI, CM, GM, BM, and VZ recruited and followed the patients. LM contributed to interpret the results and critically reviewed the paper. FS, BM, and VZ recruited and followed the patients, interpreted the results, and critically reviewed the paper. FD interpreted the results and critically reviewed the paper. PV designed the study, supervised the project, contributed to the interpretation of the data, revised the manuscript draft, and critically reviewed the paper. All authors read and approved the manuscript in its present final form.FS honoraria from BMS, Incyte, Novartis, Pfizer. FD research funding from BMS, honoraria from Novartis, Incyte, and Pfizer. PV research funding from Astra-Zeneca and Novartis, honoraria from Astra-Zeneca, Celgene, Incyte, Novartis, Pfizer, Tesaro, and Teva. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Realizing highly sensitive charge sensors is of fundamental importance in physics, and may find applications in metrology, electronic tunnel imaging, and engineering technology. With the development of nanophotonics, cavity optomechanics with Coulomb interaction provides a powerful platform to explore new options for the precision measurement of charges. In this work, a method of realizing a highly sensitive charge sensor based on atom-assisted high-order sideband generation in a hybrid optomechanical system is proposed. The advantage of this scheme is that the sideband cutoff order and the charge number satisfy a monotonically increasing relationship, which is more sensitive than the atom-free case discussed previously. Calculations show that the sensitivity of the charge sensor in our scheme is improved by about 25 times. In particular, our proposed charge sensor can operate in low power conditions and extremely weak charge measurement environments. Furthermore, phase-dependent effects between the sideband generation and Coulomb interaction are also discussed in detail. Beyond their fundamental scientific significance, our work is an important step toward measuring individual charge. Cavity optomechanics exploring the radiation pressure force between the mechanical and optical modes have attracted considerable attention and progressed enormously over the past decades ,2,3,4,5.n represents the sideband order. Specifically, if the pump is red-detuned such that the upper sideband frequency is matched with the resonance frequency In recent years, investigations of optomechanical nonlinearity ,22,23 hasistance ,28. The sistance .Some previous studies ,30 have N identical two-level i-th N. Under the weak excitation, the condition of the Holstein–Primakoff approximation dω/2πΩm , with kBl forces  in our sl forces . All thetions as:x^˙=p^/m,n-th transmission coefficient of the output field. After the fast Fourier transform [n is referred to as the sideband order.Equation  is a grout field . The phyransform , the freNote that if proposed . Under wm = 10 In what follows, we discuss the relationship between the atom-assisted high-order sideband generation and the Coulomb interaction, and a feasible method for achieving highly sensitive charge sensor is proposed. First, it is necessary to evaluate the actual experimental possibilities of such a highly sensitive charge sensor. In the experiment, we chose a microscale optomechanical system with a size of about 50 ndations ,40, so tn. In the absence of two-level atoms, the optomechanical nonlinearity is quite weak so that the anti-Stokes scattering processes are severely suppressed. As shown in n increased to 100, the cutoff order and the amplitude of the sideband spectrum were hardly enhanced. Obviously, it is very difficult to obtain a strong dependency between the high-order sideband generation and the Coulomb interaction when the charge number is not large enough. Upon further increase of the charge number n to 150, as n is observed in n = 2), we can clearly see that the order of the sidebands ended up at the order of 8, and the intensity of each sideband was also distinctly enhanced. More robust high-order sideband generations are shown in n = 3 and 4 are considered. Obviously, not only did the cutoff order extend to 14 and 15 corresponding to the charge numbers n = 3 and 4, but the amplitude of the sideband spectra were increased significantly as well. In addition, the sideband spectra exhibiting a typical non-perturbative nature were quite different from Previous studies have shown that resonantly enhanced feedback-backaction arising from optomechanical nonlinearity can be substantively reinforced by atomic assistance ,28. A stn under the atom-existence case and the atom-free case, respectively. As the red columns show in n held for different optical powers. This monotonous relationship for the cutoff order of the sideband spectrum in the presence of electric interaction is more convenient and useful than the non-monotonous relationship discussed previously [eviously .G, and the atomic detuning In order to investigate the influences of other degrees of freedom of the system on the sideband sensitivity change, the cutoff order of the sideband spectrum as a function of the atom–cavity coupling n = 5 for the purpose of obtaining a robust sideband spectrum. From Finally, phase-dependent effects of the high-order sideband generation with electric interaction were investigated, which remains largely unexplored and may provide applications in phase-coherent measurement. We started with the Hamiltonian of the probe field ng field . Figure To conclude, we demonstrated that the atom-assisted optomechanical system can be employed as a charge sensor with an unprecedented sensitivity. We observed that a strong dependency between the high-order sideband generation and the Coulomb interaction could be greatly reinforced by atomic assistance, and a monotonous relationship between the cutoff order of the sideband spectrum and the charge number was obtained. In addition, the influences of system degrees of freedom on the sidebands generation  were investigated in detail. Compared to previous charge sensing proposals, our scheme proposed here has some obvious advantages. First, our scheme is expected to achieve accurate detection at the level of single charges because the variation of the sideband spectrum is about 300% per charge, which is improved by about 25 times with respect to the atom-free case discussed previously. Second, our solution is suitable for extremely weak charge measurement environments. A robust Coulomb-interaction-dependent effect arises as long as the charged object has a charge, rather than requiring that the amount of charges exceed approximately 30. Third, the power of the control field, about 0.5 mW, is quite weak. Therefore, our proposed charge sensor can operate in a low-power environment. Finally, we found that the effective adjustment of the sideband spectrum could also be implemented via phase manipulation, which may deepen our understanding of optomechanical nonlinear processes and may provide applications in phase-coherent measurement. Using the current experimental parameters, our results show that atom-assisted high-order sideband generation may provide a novel method to achieve a highly sensitive charge sensor.