Life! Taking Action on Diabetes program in Victoria, Australia.Many public health interventions based on apparently sound evidence from randomised controlled trials encounter difficulties when being scaled up within health systems. Even under the best of circumstances, implementation is exceedingly difficult. In this paper we will describe the implementation salvage experiences from the Melbourne Diabetes Prevention Study, which is a randomised controlled trial of the effectiveness and cost-effectiveness nested in the state-wide The Melbourne Diabetes Prevention Study sits within an evolving larger scale implementation project, the Life! program. Changes that occurred during the roll-out of that program had a direct impact on the process of conducting this trial. The issues and methods of recovery the study team encountered were conceptualised using an implementation salvage strategies framework. The specific issues the study team came across included continuity of the state funding for Life! program and structural changes to the Life! program which consisted of adjustments to eligibility criteria, referral processes, structure and content, as well as alternative program delivery for different population groups. Staff turnover, recruitment problems, setting and venue concerns, availability of potential participants and participant characteristics were also identified as evaluation roadblocks. Each issue and corresponding salvage strategy is presented.The experiences of conducting such a novel trial as the preliminary Melbourne Diabetes Prevention Study have been invaluable. The lessons learnt and knowledge gained will inform the future execution of this trial in the coming years. We anticipate that these results will also be beneficial to other researchers conducting similar trials in the public health field. We recommend that researchers openly share their experiences, barriers and challenges when conducting randomised controlled trials and implementation research. We encourage them to describe the factors that may have inhibited or enhanced the desired outcomes so that the academic community can learn and expand the research foundation of implementation salvage. Traditionally randomised controlled trials (RCTs) are scientific experiments that utilise controlled environments to allocate a treatment to the intervention group, while the control group receives a placebo or no treatment at all . RCTs arThe primary reason for conducting RCTs of public health interventions is to translate them into scaled up, system-wide programs . A missiMany policies based on apparently sound evidence from RCTs encounter difficulties when being scaled up within health systems. Even under the best circumstances, implementation is exceedingly difficult. The road is likely to be full of unexpected detours, blind alleys, new opportunities and changing constraints. These constraints may vary over time leading to a trial and error approach to discover feasible solutions .Not as well discussed in the literature is the process of evaluating an RCT alongside an already established and operational health intervention or program occurring in a real world, primary or community health care setting. We did not find any evidence in the literature of this particular evaluation methodology or the specific problems or issues that may be encountered when embarking on such an evaluation.Implementation Salvage Strategies is a framework proposed by Hoagwood et al. 2011) to describe and understand the possible factors that can influence the conduct of a trial within real world circumstances and the possible solutions to such problems [ to descrLife! Taking Action on Diabetes program (Life!) conducted in Victoria, Australia. This state-wide type 2 diabetes prevention program for high risk individuals is funded by the Victorian Government Department of Health Victoria and delivered by Diabetes Australia – Victoria (DA–Vic), a non-government organisation (NGO), peak consumer body and leading charity representing all people affected by diabetes and those at risk.In this paper we will describe the implementation salvage experiences for the Melbourne Diabetes Prevention Study (MDPS), which is an RCT of the effectiveness and cost-effectiveness nested within the We now describe how the need for adjustments to the real world Life! program created challenges for the nested RCT and our implementation salvage for the MDPS.It was estimated that approximately 366 million adults, 8.3% of the adult population worldwide, had diabetes in 2011. This is expected to increase to 552 million adults, 9.9% of the expected population worldwide by 2030 . These aEncouraging results from small efficacy evaluative trials conducted in the US, Finland and our own Greater Green Triangle Diabetes Prevention Program (GGT DPP) in Australia, have contributed to an emerging evidence base in this field -20. WhilFinland was the first country to undertake a large-scale diabetes prevention intervention. The national Development Programme for the Prevention and Care of Diabetes (DEHKO 2000–2010) was the first of its kind aiming to improve the quality of diabetes care, the support for self-care and the prevention of T2D and its complications . One of Life! is a state-wide, group based, lifestyle change program with the aim of targeting Victorians aged 50 years or over at high risk of developing T2D. The goals of the program are based on modifications to diet and physical activity. The program is conducted by Life! facilitators who are certified health professionals. Life! has direct lineage from the Finnish Diabetes Prevention Study (DPS) , the GooThe Melbourne Diabetes Prevention Study (MDPS) is a research project set up to study in detail a cohort of individuals undertaking the Life! program in order to evaluate the effectiveness of a large-scale prevention program, and importantly the cost-effectiveness. There is a paucity of data to assess the long-term clinical and economic impact of diabetes prevention programs. While there have been some modelling studies that have determined that lifestyle intervention is cost-effective for those with impaired glucose regulation ,33, unceThe MDPS is an RCT which aims to evaluate the efficacy and effectiveness of Life! by monitoring participants’ clinical and behavioural outcomes before and after the Life! intervention, as previously reported . An econIn brief, the MDPS intends to recruit 796 participants for this open randomised clinical trial, 398 will be allocated to the intervention arm and 398 to the usual care arm. Several methods of recruitment will be used in order to maximise the number of participants. Individuals aged 50 to 75 years will be screened with a risk tool (AUSDRISK) to deteThe intervention consists of an initial individual session followed by a series of five structured-group sessions. The first four group sessions will be carried out at two week intervals and the fifth session will occur eight months after the first group session. The intervention is based on the Health Action Process Approach (HAPA) model -39 and sThe primary outcomes under investigation are changes in diabetes and cardiovascular disease (CVD) risk as determined by changes in weight, waist circumference, fasting plasma and 2 h glucose, blood pressure and lipids at the baseline, 3 and 12 month assessments. The reduction in diabetes risk is calculated from the reduction in weight and waist circumference and the reduction in cardiovascular risk from changes to the Framingham risk score which incorporates the changes in the individual risk factors. Secondary outcomes consist of changes in psychosocial and quality of life measurements.Encountering unexpected problems while conducting clinical trials is an inherent part of research, as discussed in detail by many authors ,40-45. TThe MDPS intervention arm sits within an evolving larger scale implementation project, the Life! program. Changes that occurred in the roll-out of that program had a direct impact on the process of conducting this trial. Life! is an evolving and changing program that is subject to modifications made at a political and environmental level beyond the control of the MDPS researchers. The nature of the Life! intervention was changing over time. This custom-tailoring of the Life! program was essential for its progress and success, and to assist with community engagement, promoting risk assessment, program entry, and sustainability. Such changes have implications on the fidelity and usefulness of the MDPS.Life! was initiated in 2007, with the MDPS starting approximately 15 months later. From inception of the Life! program until 2010 numerous adjustments were made to the eligibility criteria, referral process, structure and content, as well as alternative program delivery for different population groups. These adjustments are outlined in detail below.Ethics approval for the MDPS was obtained from Deakin University Human Research Ethics Committee (Project Code 2009–066).It was decided by the research team in 2009–10 to pause the MDPS after a total of n = 92 individuals completed the study and then to decide how to proceed further. This initial phase we now refer to as the preliminary MDPS study (pMDPS) . This siWe have now started again and the new study called MDPS is informed by the pMDPS experience. As there were changes to the intervention and other things, the pMDPS and MDPS and their participants are being treated as separate entities to avoid threats to internal validity in both studies.few key examples explained in more detail below, outlines the issues the study team encountered in the pMDPS and methods of recovery that were and will be employed in the future execution of the MDPS. Implementation salvage strategies and techniques as discussed by Hoagwood et al. (2011) were used as a basis for conceptualising the issues and solutions outlined below [The summary in Table et al. 20 were useTwo major challenges of conducting an RCT are recruitment and retention of participants. Inadequate recruitment is deleterious to RCTs, with consequences being reduction of power to detect intervention effects if target numbers are not achieved, and/or protracted recruitment. Delays may result which affect the generalisability of findings, and increase costs due to extension of time, which can all lead to premature termination of the trial ,43,45. PAs the MDPS aim is to evaluate the effectiveness and cost-effectiveness of the Life! program, recruitment strategies had to be concurrent with what was happening in the real world. In addition to GP recruitment, program referral occurred through accredited Life! Facilitators, the local community, partner agencies, the general public and the workplace. The political and environmental context influenced recruitment strategies. One was Victorian state-wide roll out of Life! which impacted on specific areas of metropolitan Melbourne that were originally reserved for MDPS recruitment only. This left the MDPS to compete within its allocated recruitment area with the Life! program. It is probable that when competing side by side like this, potential participants would prefer to enrol in the Life! program as they are guaranteed to receive the intervention .General Practitioners (GPs) were required to confirm eligibility for the Life! program through completion of a referral form that included biochemical and anthropometric measures. Newly diagnosed T2D was a specific exclusion criterion. During this process GPs may have experienced some degree of ‘clinical equipoise’  whereby MDPS salvage strategies have centred on establishing a systematic process for monitoring the success of recruitment streams at regular intervals and adapting recruitment activities accordingly. While the preliminary MDPS demonstrated that direct community recruitment yielded the highest numbers of recruits , a more Potential contamination of control participants by them receiving the intervention (Life! program) is being monitored and will be taken into account during the analysis. Further analysis may also be undertaken to determine if there are any effects of selection bias. This will be done by comparisons between recruitment areas and between groups with different patient characteristics (such as motivation or perceived risk of diabetes) to see if there are any substantial differences.The MDPS utilised messages promoting free clinical tests. Our observations indicated that this may not have been an effective incentive to attract participants. This is in contrast to literature from the US that suggests that free health checks are an incentive to participate in clinical trials ,51. ThisAlso the perceived importance of diabetes prevention by the public is low. Berryman et al. (2009) have shown that diabetes is not regarded as an issue of great concern compared with other diseases, that perceived personal risk of contracting diabetes is low, and the seriousness of diabetes is underestimated because management appears straightforward .Changing attitudes towards diabetes and participation in its prevention is difficult. Motivating individuals to attend a diabetes prevention program and change lifestyle behaviours requires more than an advertising message. Recruitment strategies used in RCTs require personalisation of the risk message by a suitable health professional as they are a trusted source of information and advice , but GP Although many of the participant characteristics that influence recruitment into clinical trials were outside of the control of the study investigators, there are some ways to overcome these challenges. Reallocating resources and effort to source ‘recruiting’ staff and mobilise them to develop a presence at local community organisations such as health clubs/gymnasiums, local churches, University of the Third Age campuses and community fetes and expos is a method to try and increase familiarity, trust and knowledge of the study with community members. Recruitment was also extended to community pharmacies in the local area. Strengthening relationships with potential participants is a method to reduce the barriers participants encounter when receiving health advice from a non-trusted source.It has been demonstrated that strategies focusing on increasing potential participants’ awareness of the health problem, its impact on health, and their engagement in the learning process may increase recruitment into trials . These pThe Life! facilitator and participant workbooks were adapted from the course content delivered in the GGT DPP , GOAL ImIn early 2010, new participant manuals were introduced to accommodate individuals from various culturally and linguistically diverse backgrounds and those with low literacy levels. This new version included use of more illustrations to convey messages and supplementary materials for specific cultural needs. Additionally a more ‘streamlined’ approach was undertaken with regards to the structure of the sessions, with some changes made to content appearance and timing, to avoid repetition of curriculum. The dietitian and a physiotherapist/exercise physiologist changed to co-facilitating sessions two and four. This modification was made in response to requests from participants to have dietary information appear earlier in the course.Originally individuals at high risk of developing T2D aged 50 years or over were eligible for Life! High risk was defined as scoring 15 or over on the AUSDRISK tool . Those oEligibility criteria were revised in July 2010 to include individuals aged 50 years or over at high risk of T2D, who score 12 or more on the AUSDRISK, and additionally, any individual over the age of 18, regardless of AUSDRISK score, who were of ATSI descent or had previously been diagnosed with either gestational diabetes mellitus or cardiovascular disease . In addition, individuals who had received an occupational health assessment , and hadDue to the numerous adjustments made to the eligibility criteria, referral processes, structure and content as described above, it was decided to make a small number of modifications to the MDPS intervention, to ensure consistency between the number of sessions offered to the future MDPS participants, and the content within those sessions. When re-started, MDPS will examine the version of Life! that we anticipate will be implemented in 2012.One of the major changes to the MDPS version of Life! is that instead of running a six group-session program, the MDPS version of Life! will be modified to consist of an individual session at the beginning of the intervention phase and five group sessions. This parallels the Life! Program, which has a separately funded ‘first visit’. Participants will still receive the intervention from Facilitators employed or contracted through accredited Life! providers using the current Life! materials and manuals. It will be delivered using a standardised approach for all MDPS participants. To achieve this, required partnership agreements between local service providers of the Life! program and Life! facilitators were created, and they will run the new agreed version of MDPS. Approval for this was given by DA-Vic. It is hoped that this approach can be rolled out as a successful model to efficiently and systematically create partnerships with other sites who may be involved in the trial, therefore becoming a multi-site trial.Although there were these changes to the Life! eligibility criteria, the MDPS research team decided to stay with the original criteria of adults aged 50 years or over with an AUSDRISK score of 15 or more, as this was what the funding body had endorsed and would contribute information on the cost-effectiveness of alternate design options.Although the MDPS research team did not perform a formal risk analysis, some potential roadblocks were identified when designing the MDPS. These included issues such as recruitment and dropout rates, and the impact of these were based on previous experience of implementing DPPs. Also, the issues surrounding usual care and other potential government or community diabetes initiatives impacting on the study were outlined in the study proposal and are monitored by the study now. Monitoring occurs through policies and procedures to identify potential roadblocks in the form of risk registries which are managed by the MDPS study board and implementation team.However, the nature of implementing prevention programs in the real world means that some of the roadblocks could not be predicted at any early stage and the study team had to deal with issues as they arose. Furthermore, once the Life! program was implemented as part of government policy, time pressures and program momentum impacted on the ability to do a detailed risk analysis.The issues encountered when implementing the MDPS are similar to those outlined by leaders in population level diabetes prevention initiatives ,24. TheyThe experiences of conducting such a novel trial as the MDPS have been invaluable. Table The authors declare that they have no competing interests.JD, EJ and RC and were responsible for the research question, design of the study, and for obtaining funding. AH and NDL wrote the first draft of this manuscript and were responsible for the revisions, along with EJ and JD. DA, SO, AT, ES, CB and GJ contributed to specific sections of the manuscript. RC is the team's expert in economic evaluations and was involved in the design of the study. JD is the general supervisor of the study and was involved in revising the article. All authors read and approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/806/prepub


The biopsychosocial model of successful aging is aimed at developing a sense of well-being, high self-assessed quality of life, and a sense of personal fulfillment even in the context of illness and disability. The purpose of this study was to explore key outcomes of a new Successful Aging Mind Body program. We hypothesized the program would increase self-efficacy, which would lead to improved feelings of well-being.Sixteen patients completed assessments. The average age of participants was 75 (range: 66-91). The program consisted of weekly 90-minute sessions for nine weeks. Topics included a range of psychological and physical exercises including mindfulness and relaxation training. For measures, we used the Coping Self-Efficacy Scale (CSES) and Philadelphia Geriatric Center Morale Scale (PGCMS). We performed paired t-tests on pre/post data, and used the Wilcoxon signed rank test for the conservative validation.We found that both the CSES and PGCMS increased among completers of the Successful Aging intervention , although the change for PGCMS was not quite significant. In addition, we found a moderate correlation between the pre- to post-intervention changes in CSES and PGCMS , although the association was not significant. The CSES change pre-post was still significant (p<.05) after a sensitivity analysis.We found significant changes in self-efficacy after the intervention and an increase in morale with a trend towards significance. A moderate correlation was found between CSES and PGCMS, but the correlation was not significant. These results support the hypothesis that participants can develop greater self-efficacy as a result of a mind body program for successful aging. Future research is needed to explore the relationship between self-efficacy and objective health outcomes.


In Canada, there are limited occasions for youth, and especially at-risk youth, to participate in cooking programs. The paucity of these programs creates an opportunity for youth-focused cooking programs to be developed, implemented, and evaluated with the goal of providing invaluable life skills and food literacy to this potentially vulnerable group. Thus, an 18-month community-based cooking program for at-risk youth was planned and implemented to improve the development and progression of cooking skills and food literacy.This paper provides an overview of the rationale for and implementation of a cooking skills intervention for at-risk youth. The manuscript provides information about the process of planning and implementing the intervention as well as the evaluation plan. Results of the intervention will be presented elsewhere. Objectives of the intervention included the provision of applied food literacy and cooking skills education taught by local chefs and a Registered Dietitian, and augmented with fieldtrips to community farms to foster an appreciation and understanding of food, from 'gate to plate'. Eight at-risk youth  completed the intervention as of November 2010. Pre-test cooking skills assessments were completed for all participants and post-test cooking skills assessments were completed for five of eight participants. Post intervention, five of eight participants completed in-depth interviews about their experience.Cook It Up! program can provide an effective template for other agencies and researchers to utilize for enhancing existing programs or to create new applied cooking programs for relevant vulnerable populations. There is also a continued need for applied research in this area to reverse the erosion of cooking skills in Canadian society.The  Poor dietary habits during adolescence ages 13-18) have negative impacts on several health and wellness indicators including: day-to-day wellbeing and functioning; achievement and maintenance of healthy weights; proper growth and development patterns; and dental health 3-18 have. Researcself-efficacy, food knowledge and literacy, self-confidence, and self-esteem, while potentially improving the social determinants of health [Cook It Up! Results of the intervention will be presented elsewhere. Cook It Up! was a community-based cooking program for at-risk youth implemented in May 2009 and concluding in February 2011. This paper will inform future program planners and researchers in the creation, development, implementation, and evaluation of similar cooking skills programs.While an "official" definition for food literacy is not presented in the literature, it can be defined as the ability to make healthy food choices by having the skills and knowledge necessary to buy, grow, and cook food  with impf health . Cookingf health  which noCook It Up! was an 18-month community-based cooking program for at-risk youth that focussed on food education and building cooking skills. The London Community Resource Centre was the host agency for Cook It Up! Locally, there were no other evaluated cooking programs for youth. The primary objective of Cook It Up! was to provide education and to increase skills and awareness of agriculture, healthy eating, food preparation, and food purchasing skills among London, Ontario youth. This objective was accomplished by introducing youth to the local Ontario agricultural industry and building new and essential life skills through cooking classes. With the erosion of cooking skills among youth [ng youth ,27,28, tCook It Up! provided youth-centred, hands-on food literacy education that highlighted general nutrition, food safety, selection, preparation, and cooking skills. Agriculture fieldtrips showcased seasonal Ontario-grown food commodities which enhanced the participants' learning about locally grown foods. Local chef facilitators targeted, coordinated, and implemented activities within each cooking and fieldtrip session relevant to the needs and desires of the youth. Effort was taken to build upon existing skills each week in order to improve skills while empowering the youth by building upon their food-related self-esteem and self-efficacy. Baseline skills were measured using a previously developed and piloted pencil-and-paper administered pre-test cooking skills assessment questionnaire [ionnaire .Cook It Up! to engage in new or non-traditional community partners with interest in promoting the local agri-food industry and the public health benefits of Ontario grown products. With this requirement in mind for program planning, key stakeholders were selected to direct the project. The Steering Committee was comprised of 10 individuals and included membership of local chefs (for cooking skills education) local farmers , education specialists (for guidance about how to work with at-risk youth), social service agency representatives focusing on the youth population (to assist in participant recruitment and youth engagement), public health representatives , food service industry representatives (to provide opportunities for fieldtrips), academic representatives , community members with interest and skills in this project and/or priority group , and a food specialty store owner (to provide business representation and program resources).The Steering Committee was a necessary consideration to assist in successful program development. The funding agency required Cook It Up! met the Program Coordinator at a community meeting where food literacy was discussed. He was invited to serve in this role in the Cook It Up! program because he had worked in the food service industry and shared a passion for local food, youth education, and cooking. His greatest strength was his existing connections to local chefs, farms, and farmers' markets. The Program Coordinator's role was to engage and build rapport with local chefs, farmers, and farmers' markets to ensure broad and diverse opportunities for cooking sessions and fieldtrips.Equally important to the Steering Committee recruitment was the recruitment and selection of the Program Coordinator. The Executive Director of the host agency for Cook It Up! program and its need for guest chef involvement at a local chefs' association meeting. Chefs in this association were provided an overview of the initiative and were encouraged to become involved in some capacity, either by providing a cooking demonstration and skill session with the youth or assisting with the Steering Committee in whatever capacity they chose. In addition to this method of chef recruitment and selection, the Program Coordinator reviewed the proposed "menu" of cooking skills and seasonal availability of local produce, and paired local chefs with particular interest and/or skill in certain cooking methods and recipes.The Steering Committee promoted the Cook It Up! volunteer opportunities with her students, four of whom became involved in the program as part of the community placement component of their course. The Public Health Dietitian from the Middlesex-London Health Unit supervised three graduate students who participated as volunteers with Cook It Up! and also contributed to proposal writing, research, and program content development.The Steering Committee had a strong connection to the University of Western Ontario and the Foods and Nutritional Sciences program at Brescia University College (BUC). One of our Steering Committee members, and also a professor at BUC, promoted Cook It Up! was an ideal combination when working with youth who were easily distracted, demonstrated behavioural issues, and with whom were, at times, difficult to connect. Additionally, the Steering Committee recruited a teacher with expertise in secondary school family studies/food and nutrition curriculum as a volunteer. The volunteers' roles and responsibilities were to keep the participants on track in terms of completing preparation and cleaning tasks, help participants navigate through the fieldtrip when independently completing assigned tasks , assist the participants in the completion of their weekly "journals," which summarized the youths' weekly involvement, monitor safety issues in the kitchen, remind participants to be safe, clean, and organized, ensure cooking and field trip sessions ran smoothly, and assist the Program Coordinator or chefs in any way required. The volunteers recruited were very positive about the program; however, some of them had never worked with at-risk youth in the past. For this reason, it was necessary to implement sensitivity training. We engaged one qualified member of our Steering Committee members to facilitate sensitivity training for all volunteers.The Steering Committee recommended that volunteers with a specific background working with at-risk youth be recruited. One volunteer was a retired teacher who specialized in working with children with special needs. Her background, patience, problem-solving strategies, and general demeanour with the participants in Cook It Up! program involved a significant time and participation commitment; therefore, the Steering Committee wanted to ensure the participants involved in this pilot project were fully committed to the program. To recruit potential youth participants, the Steering Committee utilized local media outlets to introduce the program to the community. Key Steering Committee members were interviewed in local newspapers and on television programs. The initiative was also promoted on local agencies' websites, on social media outlets such as Facebook® and YouTube®, and via word of mouth. An online and paper application form was available for potential participants. Interested parties were directed to the London Community Resource Centre's website to learn more about the program and complete the application form. In addition to the application form, the potential participants met with members of the Steering Committee who conducted informal interviews with the youth to determine fit, interest, enthusiasm, and commitment to the program. This proved to be an effective recruitment and retention strategy. Originally, 30 youth applied to the program, but through self-selection out of the program due to a variety of different reasons  and the interview process with Steering Committee members, the final number of participants in Cook It Up! was nine. There was attrition of one participant due to personal issues. The other eight participants remained for the entire duration of the program (18 months).The At times, at-risk youth in the program presented with a variety of behavioural problems which negatively influenced the learning environment, as described in the literature . This neCook It Up! for cooking sessions twice monthly from August 2009 to November 2010 on Mondays between 4:00 and 6:00 pm. During the 18-month program, youth engaged in a variety of cooking opportunities focusing on seasonal and local food ingredients and the sessions were facilitated by local chefs. Each session consisted of the Program Coordinator outlining the recipe for the session and introducing the guest chef who would be working with the youth. The chef taught participants skills necessary to complete the selected recipes. Each session featured an overview of the historical context of the foods chosen to create the recipe in service of educating the youth about the origins of foods. A variety of recipes was introduced but effort was taken to ensure that the skill required to perform the execution of each recipe also incorporated skills that had been used previously, thus building upon the youths' development of their cooking proficiency from week to week. This approach was an effective way to empower the youth participants because they gained confidence and pride in their cooking abilities. Youths' gratification with their skills was shared with a broader audience with the publication of a cookbook highlighting the recipes used in the program and giving the reader a glimpse into the fieldtrip experiences through the eyes of the participants. Though not a planned component of the program, the cookbook provided a summary of the recipes used and fieldtrips experienced over the course of the program and generated some modest funds for the initiative. The cooking sessions took place at a centrally located faith-based organization with excellent kitchen facilities which were approved by the local health unit. The Minister of the faith-based organization was amenable to having the Cook It Up! program utilize these facilities and an excellent partnership was developed as a result.Youth participants attended The participants engaged in fieldtrips to local farms and farmers' markets once monthly. Fieldtrips were selected to connect the youth to their cooking experiences. For example, specific farms growing particular commodities were selected given their produce could complement the recipes well. In the spring, a trip to a local sugar bush to learn how maple syrup was made complemented the cooking session on pancakes. A fall fieldtrip to a local dwarf apple tree orchard led to recipes for applesauce, apple pie, apple crisp, and homemade pie crust.Cook It Up! program were invited to visit the college-level culinary program and observe a food demonstration in the test kitchen, learn about the culinary programs available at the post-secondary institute, and speak to the first year Coordinator of Chef Training and Culinary Management in the School of Tourism and Hospitality. This fieldtrip inspired some of the youth to seriously consider post-secondary school education in this field as a future academic goal.In addition to "food" related fieldtrips, other fieldtrips were provided. An opportunity to expand the participants' appreciation for formal culinary education resulted in a fieldtrip to the local community college. Youth in the Cook It Up! program throughout the duration of the intervention that further developed participants' cooking skills. First, the group was asked to cater the inauguration of a neighbourhood community centre. The group prepared recipes, served the food, and enjoyed the rewards of positive feedback from the 100 guests who attended. The second event was a catering opportunity for a local youth club during National Youth Week. Again, the participants organized, prepared, and served recipes they had previously made to approximately 50 guests. Both opportunities allowed the youth to perform the tasks required with confidence and enthusiasm.There were two additional opportunities that were presented to the Cook It Up!, participants were included in the development of the session thus encouraging their engagement and participation. Youth engagement was an important approach implemented in Cook It Up! and ensured the intervention was meeting the needs of the participants at all times.For all cooking components and fieldtrip activities of Cook It Up! program. Costs associated with the operation of the program including food, transportation to cooking sessions and fieldtrip locations, basic kitchen equipment for youth (provided to them at the end of the program), and other incidental fees were included in the grant budget.There was no cost to youth to participate in the Cook It Up! program.A pre/post cooking skills assessment questionnaire was used to monitor participants' progress and allow for a baseline comparison. This design also provided preliminary evidence for the future development of cooking skills assessment for at-risk youth or other populations. Additionally, qualitative interviews were undertaken to determine the effectiveness of the program from the perspective of all participants involved . Also, Photovoice methodology  was intrCook It Up! was designed to provide participants with life skills necessary for leading a responsible, independent life  which served to enhance their self-efficacy. Offering the program was only the first step; without knowing participants' receptiveness to and experiences with the program it is difficult to identify whether it should continue, be expanded, or if it had any unanticipated negative effects. Therefore, a formative evaluation was implemented to assess the Cook It Up! program to determine its value from the perspective of participants, as well as what could be done to "assess the relevance, comprehension, and acceptability of activities, materials, methods," of the program [According to Bandura , one's p program .Cook It Up! over the 18-month period. The objectives of the formative evaluation were three-fold. First, the evaluation assessed the strengths and weaknesses of the program and its delivery. Secondly, we anticipated uncovering obstacles, barriers or unexpected opportunities that made the program more effective. Finally, this evaluation generated understandings about how the program content and implementation could be improved. Verbal informed consent was received from research participants. A purposeful sample of participants was sought for the in-depth interviews to maximize the richness of information obtained pertinent to the research question. Interviewing continued until interpretation of the interviews revealed no new significant insights, thus attaining data saturation. It was estimated that between 10 and 20 in-depth interviews would be necessary before data saturation was realized [The formative evaluation appraised the education and skill building initiative focusing on nutrition, food safety, food preparation and cooking skills, and agriculture fieldtrip experiences to a variety of local farms. The research qualitatively assessed participants'  experiences with realized . A totalCook It Up! was a Photovoice project which qualitatively assessed the barriers and facilitators youth participants experienced with respect to the development of healthy cooking skills in their environments peripheral to the Cook It Up! program. Verbal informed consent was received from research participants. Participants also took part in a discussion group to discuss the photographs taken and select the ones that best exemplified their perceived barriers and facilitators to the progression of their cooking skills. Upon completion of the project, participants were invited to share their photographs at a local art display/gallery, to showcase their work and involvement in the project.The final research project for Cook It Up!, ethical approval was obtained from the Office of Research Ethics at the University of Western Ontario.For all research components of Our eating and meal preparation culture is changing. Domestic cooking skills are in a state of erosion, or at the very least, are in transition, such that the types of foods people cook, or perhaps more accurately "reheat," how they use food preparation skills, and where they cook are influenced by social, economic, and cultural contexts . In mostOn the upside, studies have demonstrated that hands-on cooking education has a very positive impact on behaviours and attitudes toward cooking and healthy eating such as increased consumption of fruits and vegetables, improved food safety behaviours, higher frequency of cooking, increased nutrition knowledge, higher self-efficacy, and less money spent on food -43. NutrCook It Up! program provided a unique intervention to improve these important life skills in a population that is already at risk of experiencing challenges for many reasons.Cooking skills programs for youth provide numerous benefits, including the development of necessary life, social and economic management skills and education about healthy eating required for the promotion and enhancement of health. With the removal of food and cooking skills syllabi from school systems and narrow opportunities to learn food literacy in the home environment, there are limited opportunities for youth to learn and apply basic life- and food-related skills such as proper food selection, preparation, storage, and usage. Effective interventions that promote and foster cooking skills development targeting youth are needed. The This manuscript provides detailed applications of this community-based cooking intervention for other practitioners who want to create a similar program with their populations. Our hope is that the details provided enable other practitioners to build upon our work rather than creating an entire intervention from the ground up. It is through the sharing of this type of programmatic information that researcher-practitioners can co-create programs that will ultimately facilitate healthier food-related options among those in need.The authors declare that they have no competing interests.HMCT was in involved in all aspects of the development of the program, research design, data collection and analysis, and participated in the writing of the manuscript. JDI provided support and expertise related to the design and implementation of the study, provided revisions and comments to the manuscript, and approved the final version. Both authors read and approved the final version of the manuscript.


Overexpression of Decoy Receptor 3 (DcR3), a soluble member of the tumor necrosis factor receptor superfamily, is a common event in several types of cancer. In renal cell carcinoma (RCC), DcR3 overexpression is associated with lymph node and distant metastasis as well as a poor prognosis. However, the functional role and regulation of DcR3 expression in RCC is so far unknown.Modulation of DcR3 expression by siRNA and ectopic gene expression, respectively, was performed in ACHN and 769-P RCC cell lines. Functional effects of a modulated DcR3 expression were analyzed with regard to migration, invasion, adhesion, clonogenicity, and proliferation. Furthermore, quantitative RT-PCR and immunoblot analyses were performed to evaluate the expression of downstream mediators of DcR3. In further experiments, luciferase assays, quantitative RT-PCR and immunoblot analyses were applied to study the regulation of DcR3 expression in RCC. Additionally, an ex vivo tissue slice culture technique combined with immunohistochemistry was used to study the regulation of DcR3 expression in human RCC specimens.Here, we show that DcR3 promotes adhesion, migration and invasiveness of RCC cells. The DcR3-dependent increase in cellular invasiveness is accompanied with an up-regulation of integrin alpha 4, matrixmetalloproteinase 7 and urokinase plasminogen activator (uPA). Further, we identified a signaling pathway regulating DcR3 expression in RCC. Using in vitro experiments as well as an ex vivo RCC tissue slice culture model, we demonstrate that expression of DcR3 is regulated in a PI3K/AKT-dependent manner involving the transcription factor nuclear factor of activated T-cells (NFAT).Taken together, our results identify DcR3 as a key driver of tumor cell dissemination and suggest DcR3 as a promising target for rational therapy of RCC. Renal cancer accounts for 2.6 percent of all malignant diseases, with RCC  as the main type of tumor. Around 25% of patients diagnosed with RCC present with advanced disease, including metastasis of the primary tumor. With the onset of metastasis the median survival times for patients range between 10.9 and 29.9 months, depending on the drugs used . The devAs our previous work demonstrates a clinical significance of DcR3 overexpression in RCC , we wereUsing these RCC cell lines, we aimed at characterizing the involvement of DcR3 in the regulation of cellular migration, invasion and adhesion. To analyze the effect of DcR3 expression on migratory ability we either downregulated DcR3 using two different siRNAs Figure C or estaNext, we tested whether an alteration in DcR3 expression affects the ability of RCC cells to invade the extracellular matrix. While knockdown of DcR3 substantially reduced the invasive capacity Figure A, overexAs both migration and invasion are dynamic processes involving attachment and detachment to extracellular matrix proteins, we wondered whether the alteration of DcR3 expression might have effects on cellular adherence. To this end, we analyzed the ability of cells with modulated DcR3 expression to attach to cover glasses coated with fibronectin, which is present in RCC  and metaBoth the expression data derived from human RCC samples  as well GSK-3β and the family of FOXO transcription factors are both known to negatively regulate the transcription factor NFAT (nuclear factor of activated T-cells) . TherefoTo confirm the importance of PI3K signaling for DcR3 expression in human RCC, we incubated freshly resected human RCC tissue slices with the PI3K-inhibitor LY294002. The inhibition of PI3K signaling significantly diminished DcR3 expression in all six examined cases, as assessed by immunohistochemistry Figure A. These In our previous work we found a significant association of DcR3 expression levels and both lymph node and distant metastasis in a large collection of 560 human RCC samples . FurtherOur results indicate that DcR3 is an important driver of adhesion, migration and invasiveness in RCC. Since these functional characteristics are hallmarks of the metastatic process the findings are in accordance with the clinical correlation of DcR3 expression and metastasis. Similar results obtained by studies of other types of cancer, such as breast and nasopharyngeal cancer, confirm the promoting effect on metastasis and invasiveness of DcR3 ,27. In aThe mechanisms of regulation of DcR3 expression in RCC have not yet been investigated. Our study demonstrates that DcR3 expression is regulated by a PI3K/AKT-dependent mechanism. In human pancreatic adenocarcinoma, DcR3 expression has been linked to PI3K/AKT signaling in cooperation with NFκB (nuclear factor κB), however, without further investigation of possible downstream mediators . AnotherAs DcR3 emerges as a multimodal molecule capable of promoting tumor progression by neutralizing apoptosis-inducing ligands, modulating the immune system in a pro-tumorigenic way as well as promoting metastasis of cancer cells, DcR3 might be a promising therapeutic target. The fact, that DcR3 is a secreted protein implies that DcR3 is capable of acting on its different target cells in a paracrine as well as a systemic manner, rendering it a powerful tool of the tumor to modulate the host system to form metastasis. On the other side, DcR3 is easily detectable in the blood serum of patients, opening up the possibility to use DcR3 as a biomarker for risk of metastasis and aggressive disease. Moreover, DcR3 expression could qualify as an indicator for the response and efficacy of a PI3K/AKT-targeting therapy. If the correlation between DcR3 expression and PI3K/AKT signaling activities proves to be stable in patients, the evaluation of DcR3 levels in urine or blood samples of patients could allow a selection of patients for treatment with PI3K/AKT-targeting therapeutics such as NVP-BEZ235 or SF1126 which are already in clinical trials for RCC and other solid tumor entities . SF1126 is a RGDS-conjugated LY294002 prodrug which is converted to the active compound LY294002 under physiologic conditions . SF1126 This is the first study on the regulation and function of DcR3 in RCC. Our experiments identify DcR3 as a driver of adhesion, migration and invasiveness in RCC cells. These results confirm previous data demonstrating that DcR3 expression can be used as a biomarker for poor prognosis and risk of metastasis. Furthermore, we identified that DcR3 is regulated via a signaling axis involving PI3K/AKT and NFATc1. This newly discovered signaling pathway could be therapeutically exploited, since the subgroup of patients with DcR3 positive RCC might benefit from the inhibition of the drugable targets PI3K/AKT and NFATc1.Everolimus (#07741) was obtained from Sigma Aldrich , LY294002 (#70920) was purchased from Cayman Chemicals Company  and AKT-inhibitor IV (#124011) was purchased from Calbiochem . Cyclosporine A (#BML-A195) and CD95L (#ALX-522-001) were bought from Enzo life science . FK-506/Tacrolimus (#10007965) was purchased from Biozol .2 atmosphere. For experiments, cells were cultured for no more than 10 passages. In addition, cell lines were regularly tested for contamination by multiplex PCR performed in the Genomics and Proteomics Core Facility [Human RCC cell lines 786-O, 769-P, ACHN, HTB-45 and 293-T were purchased from ATCC . At ATCC the cell lines were authenticated by short tandem repeat profiling. KTCTL-2, KTCTL-26, KTCTL-30 and KTCTL-84 were obtained from the tumor cell bank of the German cancer research center . All cell lines were maintained in RPMI1640 medium  supplemented with 10% fetal calf serum, 1 mM glutamine, 25 mM glucose and 1% penicillin/streptomycin (Life Technologies) and cultured at 37°C in a 5% COFacility   oligonucleotides at a concentration of 25 nM using Lipofectamine 2000 . All siRNAs were obtained from Dharmacon : DcR3_si1 (#D-008102-02), DcR3_si2 (#D-008102-04), GSK-3β_si (#J-00310-12). A non-specific siRNA served as a control (#D-001810-10). For transient or stable overexpression, cells were transfected with pcDNA3 (Invitrogen), pcDNA3-DcR3 (generated as outlined below), myrAkt δ4 (Addgene Plasmid 10841)  and NFAT2 incubator. After 24 hours, slices were treated with LY294002 for further 24 h. After treatment, tissue slices were fixed in 10% neutral-buffered formalin and embedded in paraffin. Four micrometer sections were stained with H&E or subjected to immunohistochemistry.The usage of tumor tissue for research purposes was approved by the local ethics committee of the University Hospital of Heidelberg, Germany. All data were analyzed anonymously. Written informed consent from the donors or the next of kin was obtained for use of these samples in research. Fresh human renal cell carcinoma tissue samples were obtained from the Tissue Bank of the Center for National Tumor Diseases  directly after surgery and maintained in DMEM medium on ice. Tissue samples were cut into 300 μm thick slices by a Leica VT1200 S vibrating blade microtome . Slices were then placed on porous filter membrane inserts in six-well plates and cultured in DMEM supplemented with penicillin (100 U/mL) and streptomycin (100 mg/mL) (Sigma Aldrich) in a conventional COParaffin-embedded tissue sections were dewaxed and rehydrated using xylene and a series of graded alcohols, followed by heat-induced antigen retrieval with a target retrieval solution  in a pressure cooker for 15 min. For staining an automated staining system  with avidin-biotin-complex peroxidase technique using aminoethylcarbazole for visualization and hematoxylin for counterstaining was used. Sections were incubated with primary antibody  for 30 min at room temperature and processed according to manufacturer’s protocol for the following kits: ChemMate Detection Kit , ChemMate Buffer Kit , Avidin/Biotin Blocking Kit . For negative control of the staining procedure, primary antibody was omitted with all other experimental conditions kept constant.Cells were seeded into 12-well dishes and co-transfected with Renilla luciferase pRL-SV40P  and FHRE-Luc (Addgene Plasmid 1789)  or pGL3-Quantitative real-time PCR was performed as described previously . FollowiDcR3: 5′-CCACTACACGCAGTTCTGGA-3′ (forward)5′-GTGCTCCAAGCAGAAACCAG-3′ (reverse)MMP-2: 5′-CTTCCAAGTCTGGAGCGATGT-3′ (forward)5′-TACCGTCAAAGGGGTATCCAT-3′ (reverse)MMP-7: 5′-GAGTGCCAGATGTTGCAGAA-3′ (forward)5′-AAATGCAGGGGGATCTCTTT-3′ (reverse)MMP-9: 5′-TTGACAGCGACAAGAAGTGG-3′ (forward)5′-ACATAGGGTACATGAGCGCC-3′ (reverse)integrin alpha 4: 5′-GAGTGCAATGCAGACCTTGA-3′ (forward)5′-GGCCTTCCAGTTGGATATGA-3′ (reverse)integrin beta 1: 5′-AACTGCACCAGCCCATTTAG-3′ (forward)5′-ACATTCCTCCAGCCAATCAG-3′ (reverse)uPA: 5′-GCCATCCCGGACTATACAGA-3′ (forward)5′-ACACAGCATTTTGGTGGTGA-3′ (reverse)18S: 5′-CATGGCCGTTCTTAGTTGGT-3′ (forward)5′-ATGCCAGAGTCTCGTTCGTT-3′ (reverse)3, 10 mM NaPPi). After 15 min incubation on ice, lysates were centrifuged at 16 000 g for 20 min. For cytoplasmic and nuclear fractions cells were harvested and processed with the Nuclear Extraction Kit  according to manufacturer’s protocol. For protein isolation from human tissue, frozen tissue samples kindly provided by the Tissue Bank of the Center for National Tumor Diseases  were suspended in 100 μl lysis buffer and shock frozen in liquid nitrogen. Thereafter 5 mm grinding balls were added. The tissue samples were homogenized by the use of a Mixer Mill MM 200  and centrifuged for 10 min at 16 000 g. For the isolation of proteins from supernatant, cells were incubated in serum free medium. After 24–48 h the medium was harvested and centrifuged for 5 min at 1000 g. 200 μL of the supernatant were used for precipitation [Cells were rinsed with ice-cold PBS and lysed with lysis buffer , 5 mM EDTA, 0.5% Triton X-100) containing phenylmethylsulfonyl-flouride (1 mM), proteinase inhibitors  and phosphatase inhibitors  were seeded into 12–well culture dishes. 24 h thereafter, a 100 μm scratch was placed within the confluent monolayer with a pipette tip. Cells were then placed into the incubation chamber of an Olympus IX81 microscope and cultivated at 37°C, 40% humidity and 5% CO2. Throughout 24 h pictures were taken at intervals of 1–2 h with an Olympus U-CMAD3 camera by CellR software. Migratory activity was calculated with Image J software, based on the cell-free areas.Cells  according to manufacturer’s protocol. Briefly, cells were starved for 24 h with serum free medium. After trypsinization, 10Cells (75 000–100 000) resuspended in 20 μL medium were suspended on the lid of a 100-mm Petri dish to form spheroids. 48 h later, spheroids were placed in cell culture dishes, coated with 2% sterile agar (Merck)/PBS (solidified) and filled with growth medium. 24 h later, spheroids were embedded into collagen gels. Collagen gels were made by mixing Vitrogen  with 10-fold concentrated minimal essential medium (Life Technologies) and sterile 0.1 M sodium hydroxide, resulting in a final concentration of 2.4 mg/mL collagen. Collagen solution was distributed into 24-well plates (0.5 mL/well) which had previously been coated with 2% sterile agar (Merck)/PBS (solidified). After solidification gels were overlaid with growth medium. Cell invasion was monitored at intervals of 24 h by photographing spheroids with an inverted Olympus IMT2-RFA/340 phase contrast microscope.4 cells were plated in 96-well plates, adhered for 24 h, and exposed to CD95L for 24 h. The percentage of surviving cells was assessed by staining with crystal violet [For acute cytotoxicity assays, 10l violet . Brieflyt test. Throughout, P values < 0.05 were considered significant and are indicated as follows: *P < 0.05, **P < 0.01, ***P < 0.001.For all data, significant differences were identified using the unpaired 2-sided Student The authors declared that they have no competing interests.DW carried out the experiments, participated in study conception and design, analyzed and interpreted the data, and was involved in drafting the manuscript. KET participated in study conception and design, analyzed and interpreted the data, and was involved in drafting the manuscript. SMG participated in study conception and design, and revised the manuscript for important intellectual content. AH participated in study conception and design, and revised the manuscript for important intellectual content. NW participated in study conception and design, and revised the manuscript for important intellectual content. WR participated in study conception and design, analyzed and interpreted the data, and was involved in drafting the manuscript. All authors read and approved the final manuscript.(A) Quantitative real-time-PCR assaying relative DcR3 mRNA expression levels. Expression data were normalized to internal 18S rRNA expression. (B) Cytotoxicity assay of ACHN and 769-P cells transfected with two different DcR3-specific siRNAs or a non-specific siRNA (scram). Cells were treated with CD95L (200 ng/μL) for 24 h prior to crystal violet staining . (C) Cytotoxicity assay of CD95L sensitive LN18 glioblastoma cells stably overexpressing DcR3 or an empty vector control (neo). Cells were treated with CD95L (200 ng/μL) for 24 h prior to crystal violet staining . Since ACHN and 769-P RCC cells are resistant to CD95L induced cytotoxicity, CD95L sensitive LN18 glioblastoma cells were chosen to analyze the protective effect of DcR3 overexpression. (D) Scratch motility assay of ACHN and 769-P cells transfected with two different DcR3-specific siRNAs or a non-specific siRNA (scram). Migration was measured over a time course of 24 h. Representative images are shown (magnification: 100×). (E) Scratch motility assay of ACHN and 769-P stably overexpressing DcR3 or an empty control vector (neo). Migration was measured over a time course of 12 h (ACHN) or 24 h (769-P). Representative images are shown (magnification: 100×).DcR3 expression in RCC. Click here for file(A) Proliferation assay of ACHN and 769-P cells 24, 48 and 72 h after transfection with two different DcR3-specific siRNAs or a non-specific siRNA (scram). Cells were trypsinized and counted . (B) Proliferation assay of ACHN and 769-P cells stably overexpressing DcR3 or an empty vector control (neo) after 24, 48 and 72 h. Cells were trypsinized and counted . (C) Clonogenicity assay of ACHN and 769-P cells transfected with two different DcR3-specific siRNAs or a non-specific siRNA (scram). Cells were grown for 7–9 days, subsequently stained with crystal violet and colonies were counted . (D) Clonogenicity assay of ACHN and 769-P cells stably overexpressing DcR3 or an empty vector control (neo). Cells were grown for 7–9 days, subsequently stained with crystal violet and colonies were counted .DcR3 expression does not affect proliferation or clonogenicity in RCC. Click here for file(A) Relative Forkhead response element–luciferase reporter activity of ACHN and 769-P cells 24 h after treatment with LY294002 (50 μM) or AKT-inhibitor IV (10 μM) . (B) Relative Forkhead response element–luciferase reporter activity of ACHN and 769-P cells 24 h post transfection with myrAKT or an empty vector control (neo) . (C) Representative immunoblot analysis of whole-cell lysates of ex vivo tissue 48 h after treatment with LY294002 (100 μM).NFAT mediated DcR3 expression is PI3K/AKT dependent. Click here for file


To evaluate the impact of the Resilience Training (RT) Program on depressive symptomology, QoL and presenteeism at 2 and 12 month follow-up assessments.Forty healthcare workers with major depressive disorder were enrolled in the study. The first 20 eligible employees who responded to study advertisements were assigned to RT program. The second 20 eligible employees had an 8 week waiting period before starting the RT program. Primary outcomes were changes in depression, QoL, and presenteeism. For the RT group, questionnaires were completed before and after the 8-week RT program. The wait-list group completed questionnaires before and after an 8-week wait period and after completion of the RT. Both groups also completed the questionnaires 2 and 12 months after their completion of the RT program.Overall, 34 of the 40 participants completed the 2-month follow-up. Averaging results across all 34 participants, PHQ-9 scores dropped from 11.4 at initial baseline to 4.3 at 2 months (p<.0001) with 74% achieving remission (PHQ-9 of less than 5). The SF-12: mental status subscale improved from 32.4 to 47.5 (p<.0001). Presenteeism decreased from 34.2% to 10.9% (p<.0001). Using established procedures, this reduction in presenteeism translates to a cost savings of over $2,169 per participant over the 2-month period. The results persisted through the 12 month assessment. Averaging results across all 24 participants who completed the 12 month follow-up, PHQ-9 scores remained low with a score of 4.6 and 67% remained in remission. SF-12 scores remained high at 46.6. Presenteeism scores remained low at 7.9% and with cost savings of $13,037 per participant over the 1 year time period.Results from both 2 and 12 month follow-up assessments demonstrate that the RT program significantly improves clinical outcomes (depression and QoL) and could provide a significant return on investment if used in a healthcare workplace setting.


The prevalence of mental illness among children and adolescents in a rural town far from the earthquake epicenter is unknown.On May12To assess the prevalence of posttraumatic stress disorder (PTSD) and depression among junior middle school students in a rural town Ningqiang county, 327 km from the earthquake epicenter.A population-based mental health survey was conducted in March, 2009.Survey Self-designed General Condition Survey Scale, Children's Revised Impact of Event Scale (CRIES-13), and the Depression Self-rating Scale for Children (DSRSC) were used to sample 1,841 junior middle school students in Ningqiang county, ten months after the Wenchuan earthquake.The prevalence rate of a high-risk for PTSD was 28.4%, with 32.7% among females, 23.8% among males , 38.6% in the severe exposure group and 24.3% in the mild exposure group . For depressive symptoms, the overall prevalence was 19.5%, with 24.0% among females, 14.7% among males, 24.5% in the severe exposure group and 17.5% in the mild exposure group . In multivariate analysis, factors such as “having felt despair”, or “danger” and “having own house destroyed or damaged” were significantly associated with PTSD symptoms. Female gender and delayed evacuation in females, and earthquake related experiences in males were significantly associated with depression.Traumatic events experienced during the earthquake were significantly associated with symptoms of PTSD and depression in children and adolescents, ten months after the Wenchuan earthquake. These data highlight a need for mental health services for children and adolescents in rural areas, far from earthquake epicenters. It is well established that natural disasters, such as earthquakes lead to increased prevalence of mental illness in the range of 5 to 40%, although this prevalence is dependent upon the disaster severity and population exposure On May 12, 2008, a devastating earthquake measuring 8.0 on the Richter scale, occurred in the Wenchuan county of Sichuan Province, in southwest China Figure 1Many studies conducted after the Wenchuan earthquake focused on survivors close to the epicenter and its surrounding areas Ningqiang county (Ningqiang), located in the southwest of Shaanxi Province of China, is a small rural area under the jurisdiction of Hanzhong city, and lies approximately 327 km from the Wenchuan earthquake epicenter Figure 1The initial random data included 2,048 students from Yifu Junior Middle School (grades 7–9), the largest junior middle school in Ningqiang county. This school encompasses almost all junior middle school-aged children within the county and around the town, excluding several remote mountain areas. Ordinary cluster sampling methodology was used, and the survey was performed in school, during classroom time. Of all surveyed subjects, 1,967 (96.0%) completed the investigation. When invalid questionnaires were removed (based on pre-established exclusion criteria), the final sample, consisted of 1,841 (89.9%) valid questionnaires. This final sample comprised 896 males (48.7%) and 945 females (51.3%), with a mean age of 14.2±1.2 years and range from 11 to 20 years. This large age range was due to two main phenomena. Firstly, children from low-income families, particularly those from mountainous areas often enroll in school at a later age. Secondly, pupils who fail year-end examinations are required to repeat the grade, even in elementary and junior middle school, leading to older than average pupils. Of the subjects, 1827 (99.2%) were Han Chinese and 14 (0.8%) were ethnic minorities Table 1.This study was conducted with the permission of the National Science and Technology Ministry, and the survey protocol was approved by the Human Research Ethics Committee of Xi'an Jiaotong University (Permit Number: 2008LLKZ128). Permission was also obtained from the Education Bureau of Ningqiang county and School Boards. The interview procedures were explained to students, and parents and teachers gave written consent for children to participate. Written informed consents were obtained from all surveyed subjects. The investigation was conducted by 8 interviewers, including two psychiatrists with at least 5 years of experience in general psychiatric practice and six psychological consultants. All interviewers participated in a 2-day training program to ensure appropriate understanding and consistent application of the questionnaires and scales.The data were collected in March 2009, ten months after the earthquake. The investigation process was completed within one day. The initial assessments were made using self-report measures, including the General Condition Information, Children's Revised Impact of Event Scale (CRIES), and Depression Self-Rating Scale for Children (DSRSC).Demographic data included age, gender and grade. Personal experience during the earthquake was assessed using the following questions:Whether you were trapped;Whether you were injured, hospitalized or required surgery;Whether you felt danger or despair;Whether family members were killed or injured;Whether own house was destroyed or severely damaged;Whether you witnessed a death or injury to someone , or witnessed a collapse of buildings.According to the degree of exposure during the earthquake, surveyed subjects were divided into two groups:Severe exposure group: students in this group experienced at least one of the following five exposures: 1) trapped in a collapsed buildings; 2) suffered injury, hospitalization or surgery; 3) family members killed or injured; 4) own house destroyed or severely damaged and uninhabitable; 5) witnessed a death or injury to someone  or collapsed buildings.Mild exposure group: did not experience any of the above five exposures.CRIES-13 is a newly developed 13-item scale adapted from the impact of event scale DSRSC t-tests were used to evaluate differences in continuous variables, when the data was of normal distribution and homogeneity of variance. If the normal distribution and homogeneity of variance were not met, Wilcoxon rank sum test was used instead. Pearson correlation was used to analyze the interrelationship between the CRIES-13 and DSRSC scales.Prevalence of PTSD and depression was calculated and analyzed using SPSS version 18.0 . The total scores and various subscale scores from CRIES-13 and DSRSC were computed according to each respective manual, and frequencies, percentages, mean value and standard deviations or standard errors were calculated. Chi-square tests were used to evaluate differences in categorical data, and Student Logistic regression models were used to identify factors influencing CRIES and DSRSC scores. The score groupings of CRIES and DSRSC were taken as the dependent variables while gender and age characteristics, related experiences during the earthquake and the situation after the earthquake, were selected as independent variables. Multivariate models were set up using the Forward Selection (Likelihood Ratio) method. In addition, Chi-square automatic interaction detector (CHAID) decision trees were established to screen the risk indicators in high risk subjects with PTSD and depression. The decision tree models were fitted for categorical variable PTSD and depression. The total scores of CRIES and DSRSC were taken as the result variable, and independent variables were the same as mentioned previously. The optimal minimum parent and child nodes were set up to 100 and 50, respectively, and a maximum growth depth of 4 layers was selected in the final tree structure p values of less than 0.05 were considered statistically significant.All independent variables with an α value of 0.05 or lower in bivariate analysis were entered into models, and the removal standard was α ≥0.10. For all analyses, On site, 2,048 questionnaires were issued, 1,967 were collected, and of these, 1,841 were evaluable. This gave a response rate of 96.0% and an effective response rate of 89.9%. Of the surveyed subjects, 7.8% had suffered destruction or damage to their house; 2.4% had family members killed or injured; 1.5% suffered injury, or were hospitalized or had surgery and 0.6% were buried or trapped in a collapsed building. The demographic characteristics, including the living environment after earthquake, are shown in 2 = 1.9599, p = 0.162; age: χ2 = 2.8317, p = 0.726).Surveyed subjects were divided into two groups according to their experiences during the earthquake, for statistical analysis purposes. The severe exposure group totaled 522 students (28.4%) including 241 males (46.1%) and 282 females (53.9%), with a mean age of 14.17±1.14. The mild exposure group totaled 1319 students (71.6%) and included 655 males (49.7%) and 663 females (50.3%), with a mean age of 14.15±1.19. There were no differences between the mild and severe exposure groups . The mean scores on CRIES-13 including total score and three subscales scores  were 22.74±11.85, 7.14±4.78, 7.32±5.16 and 8.28±5.23, respectively Table 2.2 = 18.04, p = 0.001; and 38.6% vs. 24.3%, χ2 = 37.92, p<0.001, respectively). There was no difference in the distribution of a high-risk for PTSD with age .Using a cut-off score of 30 on CRIES-13 , 522 (28.4%) students were estimated high risk for PTSD . As presented in Logistic Regression Analysis was performed to analyze multivariate factors affecting PTSD after the earthquake Table 4.p<0.001). Predictably, significantly higher DSRSC scores were found in the severe exposure group compared with the mild exposure group . There were no differences related to age . Using 15 as a cut-off value, 19.5% (359) of students would be considered as having depressive symptoms . As shown in 2 = 25.28, p<0.001). Additionally, the estimated prevalence of a high risk for depression in the severe exposure groups, was 24.47%, significantly higher than in the mild exposure groups (17.5%) . There were no differences in the distribution of depression risk with age .Normality testing showed that total scores of DSRSC did not meet the normal distribution . Total scores on DSRSC ranged from 0 (0.33%) to 30 (0.11%) with a mean of 10.36±5.16. On average, females scored significantly higher than males  Table 6.There was a significant, positive correlation between CRIES-13 (PTSD) and DSRSC (depression) scores  or “feeling despair but also having hope” (OR: 2.2) during the earthquake, “having their own house destroyed” (OR: 2.9) or “having their house damaged but inhabitable” (OR: 2.0), “witnessing an injury or death” (OR: 2.2), “witnessing a building collapse” (OR: 1.9), and being female (OR: 1.7) were identified as high-risk PTSD factors. Using CHAID decision trees analysis, we found that “feeling despair during the earthquake” was the strongest related factor to PTSD, consistent with other natural disasters such as Tsunamis In our study, the main risk factors for depression were feeling despair during the earthquake (OR: 3.5), and being of female gender (OR: 1.8). It is also of interest that the early reopening of school classes was a critical risk factor for depression. Our study showed that reopening classes after a minimum time of one month after the earthquake reduced the risk of depression (OR: 0.3–0.47). Although, other researchers indicate that the severity of post-disaster depression could be predicted by the extent of loss of significant others and perceived threat and fear during the earthquake Unfortunately, there are some limitations to this study, the main one being that our survey was conducted 10 months after the earthquake, and no early data was collected. Thus, we could not evaluate acute stress reactions to trauma in this cohort. Furthermore, our sample included several students with ages higher than would typically be expected in junior middle school (16–20 years). This wider age range was due to two main phenomena: firstly, children from impoverished and rural areas often enroll in school at a later age and secondly, in China, the grade repetition system applied even in elementary and junior middle school.This study showed a high prevalence of PTSD and depression among junior middle school students in a rural area, 10 months after the Wenchuan earthquake. The prevalence of PTSD and comorbid depression was high among children and adolescents, even though their homes were not located in the severe disaster area, but 327 km from the epicenter. Our data indicates that mental health interventions are necessary for children and adolescents in rural areas, far from the epicenter to reduce the prevalence of PTSD and depression.


This research program examined the effectiveness of the Recovery is Possible for Everyone(RIPE) a community based transdiagnostic group treatment program for adults with eating disorders.p<.05); there were no difference between the CBT and ACT versions of the program (p>.05). High levels of client satisfaction and clinically significant reductions in binging and purging were reported (n=100).Study 1 used retrospectively collected clinical data to evaluate the effectiveness of two versions of the RIPE program, the original CBT-based program and a more recent ACT-based program. Pre and post EAT26 scores improved for both groups . Weight preoccupation and drive for thinness, dietary restraint, internally responsive eating, body image satisfaction, self-esteem and quality of life improved significantly (p < .05). Interpretations are limited by the small sample size.Study 2 used prospectively evaluated the effectiveness of the RIPE program (ACT-based). Participants  reported elevated levels of eating disorder and general psychopathology (This is one of the first studies evaluating ACT based eating disorder treatment and one of the few studies evaluating the 'real world' effectiveness of eating disorder intervention. Results provide preliminary evidence for the effectiveness of ACT in the treatment for eating disorders. This study highlights the viability of proving evidence based intervention and conducting practice based research in real world settings.Adult Treatment and Services stream of the 2013 ANZAED Conference.This abstract was presented in the


Ichthyoses are a heterogeneous group of rare genodermatoses. Patients and their families face difficulties related to daily care and management that may be aggravated by social isolation.To evaluate the impact of therapeutic educational programs in improving the knowledge of ichthyosis patients, and their relatives, about their disease.We organized a two sessions-program of “know-how” dedicated to the overall management of ichthyoses. These sessions were conducted based on a tool specifically designed for the study, which addressed our various areas of expertise through a collective game. The participants (patients and their parents and siblings) were divided into groups, and the questions were tailored according to the participants’ age. The program was conceived as a knowledge reinforcement program that took place during a weekend of education and rest, organized away from healthcare structures. Our aim was to facilitate the program in a neutral place to encourage respite care and to ensure the availability of a multidisciplinary healthcare team.After the reinforcement session, children aged from 6 to 12 years and their families acquired the targeted know-how and social skills.Benefits of TPE in the management of ichthyoses are the following: (1) the trust between patients their families and the caregivers was strengthened; (2) the context of the program encouraged self-expression, answered questions and provided mutual aid; and (3) the more self-sufficient families could better manage emergencies. Inherited ichthyoses form part of a large, clinically heterogeneous group of Mendelian Disorders of Cornification, which usually involves all or most of the integument. They are characterized by chronic -mild or severe- dryness, hyperkeratosis and scaling. Individually, they are rare and considered as orphan diseases. Ichthyoses seriously impact motor development during childhood. In particular, restricted movements, as well as sensory impairment (ectropion and ear plugs) are common . The essThe use of TPE varies depending on the healthcare system, area healthcare provisions, and on the mindsets of healthcare professionals and patients -4. In FrIn fact, pediatric publications in the field of TPE has been on the raise in the last decade, although they have mainly focused on asthma and diabetes -11. In dChildren aged above six years with a clinically and/or molecularly confirmed diagnosis of ichthyosis who were regularly assessed in the center and had already achieved the individual initial TPE session were contacted to participate in the weekend of therapeutic education focusing on knowledge reinforcement. Individual initial TPE sessions focused on pathophysiology of chronic disease, importance of daily care and on management of pruritus. The parents and the siblings of each included child were included in the program.Given the limited capacity of the reception center (Avène® Spa), the families included were the first 31 families who confirmed their interest in the program and fulfilled the inclusion criteria. Written consent for the publication of the study results was taken from patients and their families.Before the weekend, educational diagnosis was performed by the same interviewer on each of the patients and their families, through a standardized questionnaire designed by the multidisciplinary MAGEC team. Educational diagnosis is the first step of the educational process. It is a systematic comprehensive, iterative collection of information by the health care provider concerning the patient’s bio, clinical, educational, psychological and social status. This information is to serve for the construction of individualized TPE. An educational diagnosis is made individually for each patient and leads to define the goals tailored to each patient. It was used to assess the level of knowledge and autonomy of the respondents and to set goals which were divided into three fields: knowledge, know-how and social skills.A percentage of less than 50% of correct answers was an inclusion criterion. To facilitate the progress of the program, a neutral place which was away from hospital was chosen. The aim was to encourage respite care and guarantee availability of the multidisciplinary healthcare MAGEC team.Two sessions of two hours each, called 123 Tem’peau sessions, led by a physician and a paramedic team member, addressed the following issues/questions:- For affected children and their siblings aged 6 to 12: “What is ichthyosis? Why do I need the cream? Why am I sick? Is it normal to have pain? What about school and me? What about the hospital and me?” (session 1)- For parents, the affected children and siblings (age > 12): “What is ichthyosis? What are the treatments? What is genetics? What is functional management? What are my social rights?” (session 2)A game with a set of multiple-choice questions was used. It addressed various topics: therapy, genetics, care, pain, rehabilitation and social rights. This tool is designed for collective TPE performed as a fun team game. The game’s aspects are underscored by hints.The matrix of the skills assessment of the patients session 1, Table , Table 1In total, the number of participants was 82, including the children’s parents and siblings. Thirty-one affected children aged between 6 to 15 years old participated in the study . The group consisted of 14 girls and 17 boys. Clinically, they suffered from Netherton syndrome (seven boys and five girls), keratinopathic ichthyosis (two boys and four girls), lamellar ichthyosis (six boys and four girls), congenital ichthyosiform erythroderma (one boy and one girl), and ichthyosis follicularis, atrichia, and photophobia . Twenty-one cases were sporadic. The other ten belonged to the same three families. They were accompanied by 44 parents , and their unaffected siblings . None of the parents suffers from ichthyosis.Knowledge before the session . The main data are reported in Tables The children had difficulties to explain the origin of their disease, more specifically, the concept of "genetics" and the need for multidisciplinary consultations as part of their medical management . Also, the children had difficulty to explain the measures taken to improve the pruritus (16.1% of children thought that there was no possibility of improving the pruritus). A large percentage of children (35.4%) were afraid to tell the physician that they did not understand what was discussed, 54.8% thought that they should not express lassitude to the treatment and 71% could not explain the purpose of their treatment.For parents, educational diagnosis revealed difficulties mostly in different area such as: understanding the concept of "genetics" (27.3%), the usage of treatments (only 16% knew how to store the drugs), the management of pruritus, which remains very "disheartening" (25% knew how to develop a strategy to manage the itching), and communication with the school (75% did not know how to explain the disease to the school).In affected children, the skills acquired after the 123 Tem’peau session (session 1) have a good level of significance in the fields of knowledge, know-how and social skills  were associated with this TPE program mostly for reasons of practical family organization. However, the experience confirmed the importance of holding TPE sessions for siblings as well, allowing a better control of a chronic disease that impacts the whole family history. Brothers and sisters ask themselves many questions but receive little information about the illness of their affected sibling. Therefore, specific TPE sessions may be proposed to siblings which should focus on personal need, i.e. genetic aspects of the disorder, and general information useful for social relationship.In addition, a specific session for teenagers was deemed essential. For logistical reasons, we chose to include the six children, patients and siblings, over age 12 with the parents’ group. Teenagers’ participation was interesting, but we observed a resistance related to the nature of that particular group.Overall, this original group program was a success for all participants, as shown by the families' responses to the satisfaction questionnaires (data not shown).Most of the objectives set during the educational diagnosis were achieved throughout the program. This significantly helped the affected child Table , but alsFinally, it became clear that a TPE program for patients in the context of rare, orphan and chronic disease is also a training program for the caregivers themselves. The design of a collective tool covering all areas of the patients' experience and, therefore, all the necessary multidisciplinary medical and paramedical management, has led care providers to “educate” themselves in the techniques and expectations of their colleagues and to better understand the disease in all its dimensions. Clearer, shared explanations, better mastered by different caregivers, allow them to avoid the collection of inaccurate information, which is a source of confusion and anxiety for families. This common language contributes to build a climate of trust among the different actors and preserves the privileged exchanges they establish. The benefits to caregivers were also important in terms of training, motivation and interaction. Evaluation tools for this dimension of TPE are being developed within the framework of our reinforcement program, which will combine individual and group sessions.In conclusion, collective therapeutic educational programs seem to be suitable for ichthyosis. These collective programs should be coupled with individual specific programs taking into account personal needs of patients according to their age. More generally, the contributions of a therapeutic education program in the management of rare genodermatoses may be the following: (1) the trust between the patients, their families and the caregivers was strengthened; (2) the context of the program encouraged self expression, answered questions, and provided mutual aid; and (3) the more self-sufficient families could better manage emergencies. Also, the mobilization strengthened the links between team members, which has improved their training.MAGEC: Maladies Génétiques à Expression Cutanée; MDPH: Maison Départementale des Personnes Handicapées ; PAI: Projet d’accueil individualisé ; TPE: Therapeutic Patient Education; IFAP: Ichthyosis Follicularis Atrichia Photophobia.The authors have no conflict of interest to declare.HD was involved in establishing conception and design of study, acquisition and interpretation of data, helped to draft the manuscript and participated in revising it critically. SHR was involved in acquisition of data and was involved in writing and revising the manuscript for important intellectual content. CT was involved statistical analysis and revising the manuscript. CB contributed in establishing conception and design of study, and was involved in writing and revising the manuscript for important intellectual content. All authors read and approved the final manuscript.