Exercise, education, and social engagement are critical interventions for older adults for a healthy life expectancy and to improve their physical function.To conduct a combined exercise and education (CEE) program for improved social engagement and physical function of older adults.Based on a short-term program we conducted in our previous study, in this study, the program was conducted for half the number of participants of the earlier study but for a longer duration.A community of older adults in Ami, Japan, was the setting of the study.23 healthy older adults >65 years living in the community were the participants in the study.Five 80-minute sessions conducted once in two weeks comprised 60-min exercise instruction and 20-min educational lectures per session on health. We examined the improvement in physical and social engagement before and after participation. Physical function and health-related questionnaire data were collected before and after the program.Data analysis from 15 participants showed improved physical performance but no effect on social engagement.A higher program frequency, rather than program duration, may be vital to improving exercise performance and social engagement and maximizing the effects of high group cohesion in small groups. Further studies are needed to develop more effective interventions to extend healthy life expectancy. Japan is currently faced with the various challenges necessitating adaptation to one of the highest rates of aging worldwide  program (one 80-min session /week for five weeks) can improve the physical function and social engagement of older adults in a community-dwelling . HoweverTherefore, in this study, we examined the effects of a CEE program conducted for a longer period with half the number of participants on the physical and social engagement of community-dwelling older adults.Participants were recruited in the same manner as in the previous study  through Twenty-three healthy older adults aged >65 years who responded to the advertisements were assessed for eligibility and enrolled. The inclusion criteria for this study were the same as those of our previous study : the parThe frequency and total duration of the sessions differed from that of our previous study , but theIn the CEE program, participants received 60 minutes of exercise instruction and 20 minutes of educational lectures per session. Exercise instruction consisted of warm-up stretching (10 minutes), strength training (20 minutes), and balance exercises (10 minutes) followed by dual exercise . The educational lecture was presented in intervals between exercises. In the educational aspect of the program, lectures about health-related topics  were presented by a physical therapist under the supervision of specialists in nutrition and gerontology.The baseline and post-CEE programs relating to body weight measurement, skeletal muscle mass index, body mass index (BMI), physical performance, and health-related questionnaire matters were carried out by experienced physical and occupational therapists.Body weight and height were measured, and BMI was calculated. For skeletal muscle mass index, body composition measurements were carried out by the bioelectric impedance method with a body fat analyzer . The skeletal muscle mass index was calculated as follows: skeletal muscle mass [kg] / square of height [m].For physical performance measurements, standardized protocols were used for the measurement of the 30-sec chair stand test (CS-30), and the timed up-and-go (TUG) test , 18. To In the questionnaire about health-related matters, each participant’s level of social engagement, mobility, and fear of falling was assessed with the Elderly-status Assessment Set (E-SAS) developed by the Japanese Physical Therapy Association , 20. TheData distribution was assessed using the Shapiro–Wilk normality test. The Wilcoxon signed-rank test was performed to compare the median value of the TUG, fear of falling, and number of falls per year before and after the CEE program because data were non-normally distributed. When the data were normally distributed, paired t-test was performed. Statistical significance was set at p < 0.05. All analyses were conducted with SPSS® 27.0 for Windows . The sample size was calculated after conducting the study using data from the primary outcomes CS-30, grip strength, and LSNS-6, as this information is necessary for planning the next study. The input parameters were effect size  = 1.67, 0.96, 0.08; correlation  = 0.81, 0.96, 0.84; error probability = 0.05; and power = 0.8; G* Power 3.1.9.7 for Windows , 25 was There were missing values for 1.5% of the measured parameters. We used multiple imputations (MI) as a statistical plan to account for missing data values. MI is a procedure used to replace missing values with other plausible values by creating multiple filling-in patterns to avert bias caused by missing data. In the present study, we replaced each missing value with a set of substituted plausible values by creating 50 filled-in complete data sets using MI by the chained equation method . In the We evaluated 23 participants  in the first session. Of these, 17 participants  participated in the fifth session (6 dropouts). Finally, data from 15 participants  who participated in the first and fifth sessions were analyzed. Baseline characteristics of participants and changes in assessment parameters post-CEE program are shown in No significant differences were found before and after the CEE program in body weight, BMI, TUG, LSA, FES, the number of times of exercise, number of falls per year, and social engagement (p > 0.05).We calculated the sample size after conducting the study, using data from the primary outcomes CS-30, grip strength, and LSNS-6, as this information is necessary in planning the next study. The results revealed the need for 4, 6, and 927 participants in each group, respectively.In this study, we investigated the effects of the CEE program with a longer period and half the number of participants than our previous CEE program on the physical and social engagement of community-dwelling older adults . The majThe previous CEE program (one 80-min session 1x/ week for 5 weeks) increased exercise habit (>3 times/ week) and improved the physical function of elderly individuals living in a community dwelling . In thisWe have previously shown that the CEE program (80 minutes x 1 session/week x 5 weeks) improves social engagement of older adults living in a community dwelling . HoweverPerceptions of task and group cohesiveness have been reported to be greater in smaller groups . MembersAlthough the study contributes to the literature by demonstrating how higher program frequency, rather than program duration, may be vital to improving exercise performance and social engagement and maximizing the effects of high group cohesion in small groups, it also has several limitations. Being a nonrandomized controlled trial, it can introduce bias . ParticiIn summary, a CEE program with a longer period and half the number of participants than our previous CEE program improved physical performance but did not affect social engagement, suggesting the need for a higher program frequency, rather than a longer duration, for improving exercise performance and social engagement. A higher frequency program can help maximize the effects of high group cohesion in small groups on exercise performance and social engagement. Further studies are needed to develop more effective interventions to extend healthy life expectancy.


Toxoplasma gondii can be worrisome because transmission to the fetus may lead to congenital toxoplasmosis (CT). Neonatal diagnosis is usually performed by serological profile comparison of the mother and newborn. As previously reported in 2012 by C. L’Ollivier et al., three IgM bands at 75, 90 and 100 kDa called the “IgM triplet” has caught our attention and seems to be pathognomonic of CT. This retrospective multicenter study involved nine reference laboratories included in the French National Reference Center for Toxoplasmosis network and concerned determining the specificity and sensitivity of this IgM triplet. On this basis, we were able to propose a new read of the comparison of IgG and IgM immunoblot profiles of mother and infant to increase the sensitivity of this diagnostic marker. The effect of the trimester of pregnancy at the time of infection, but also of maternal treatment with pyrimethamine/sulfadiazine/folinic acid on the presence of this IgM triplet in the infant, could be studied. The presence of the triplet appears pathognomonic for the diagnosis of CT, and it increased the sensitivity of the immunoblot assay from 55.04% to 72.48%. As a result, it would be wise to enhance conventional immunoblot reading by adding the presence of the three IgM bands in the infant pattern for neonatal diagnosis of CT.Primary infection during pregnancy by the protozoan  Toxoplasma gondii is an intracellular protozoan that infects many people worldwide. While most human infections are asymptomatic, this parasite leads to significant harm in newborns and immunocompromized patients  is significantly higher than in the second trimester .In all CT cases, the trimester of maternal infection was the first trimester in 16/258 cases (6.2%), second in 74/258 cases (28.7%), third in 133/258 cases (51.5%), and unknown in 35/258 cases (13.6%). Depending on the knowledge of the trimester of infection, the percentages of the presence of the infant IgM triplet or its absence were: for the first trimester 43.8% (7/16) versus 56.2% (9/16), the second 37.8% (28/74) versus 62.2% (46/74), the third 67.7% (90/133) versus 32.3% (43/133), and when unknown 42.9% (15/35) versus 57.1% (20/35). The trimester of contamination had a significant influence on the occurrence of the IgM triplet , in 56 and 30 when qPCR has not been performed (98 cases) or data were missing (38 cases), respectively. Sampling in each category was too small to be compared statistically.T. gondii antigens through measurement of lymphocyte proliferation and interferon-gamma production [T. gondii IgG and IgM, rubella IgG, and CMV IgG, in serum, whole blood, and saliva using novel plasmonic gold (pGOLD) chips with promising results [n = 237). This enables us to increase sensitivity of the immunoblot assay appreciably from 55.0% to 72.5%. It is emphasized that the new reading comprises both the conventional reading and the presence of the infant’s IgM triplet, regardless of whether it is present or not in the mother’s pattern. This is the first time that a test has shown a specific marker of infection in the newborn at birth, using different immunologic patterns. For the IgM triplet, a different profile showing antibody neosynthesis should not be sought. This is a new concept because these three IgM bands do not reflect neosynthesis, but probably an immunologic response against proteins involved in mother-to-child transmission. We also emphasize that this new interpretation must be integrated into the overall approach to CT diagnosis and in no way replaces the IgM/IgA immunoanalysis assay or the monitoring of IgG kinetics during follow-up. The preferential occurrence of the IgM triplet when the time of infection is the third trimester is interesting because it is sometimes too late to program prenatal diagnosis at this term. The IgM triplet can then make up for this lack of information. A proteomics analysis should be undertaken to identify these specific proteins. Most of the studies on the pathogenesis of vertical T. gondii focus on the immune response to parasite antigen stimulation, but few data describe the proteins involved in transplacental invasion [T. gondii is one of the few pathogens that can cross the placenta, which probably involves a strict specific invasive process. Moreover, based on French National Reference Center data, most CT diagnoses are made on post-natal diagnosis, which highlights the utility of the triplet [T. gondii infection. Finally, a larger study could be performed among diagnostic laboratories in association with the NRCT to extend these data.Diagnosis of CT is based on biological tests performed during the prenatal and postnatal periods and mainly on serological tests in the neonatal period. The goal is to initiate treatment of the infected offspring as soon as possible to minimize clinical sequelae. It is recognized that comparing mother and infant IgG and IgM immunoblot profiles enables early neonatal diagnosis , 14. To oduction , 3. Othe results . However results , reachin triplet . The IgMhttps://www.parasite-journal.org/10.1051/parasite/2023020/olm.The supplementary material of this article is available at Table S1. Detail of the retrospective reading of the immunoblot mother-child pairs in the CT group. POS: positive result; NEG: negative result; trim: trimester; ND: no data; NP: not performed.


Pregnancy, and childbirth can encounter many challenges for the teen mother, family, and health system. The simultaneity of two transition periods, i.e. transition to adulthood and post-partum period may disrupt the acceptance of new roles. Lack of knowledge, information and life skills in managing this situation may threaten the physical and mental health of the mother, and child, as well as reduce the level of role adaptation. One way to increase women's empowerment in postpartum care is self-efficacy promotion training program. The current mixed methods study will be conducted to provide an interventional program sensitive to the culture of the Iranian society for adolescent mothers to improve their self-efficacy.This study will be conducted as an exploratory sequential mixed methods study  based on a pragmatism paradigm in four phases. In the first phase, a qualitative study will be performed using a directed content analysis method to explore the needs and strategies related to promote postpartum self-efficacy from the viewpoint of teen mothers, their family, healthcare providers, and policymakers. In the second phase, using a scoping review, self-efficacy promotion strategies, and postpartum care service packages, programs, guidelines, and protocols in other countries will be identified. In the third phase, with integrating the results of qualitative phase and scoping review, the first draft of program will be developed, and validated by an expert panel based on the Delphi approach in three rounds. In the last step, the effectiveness of the interventional program will be evaluated on postpartum self-efficacy of teen mother.Developing an interventional program that includes teen mother’s experiences, evidence based practice principles, and health staff opinions in a distinct cultural and social context can supply new direction to lead manager, policymakers, and other health care provider to improve the maternal self-efficacy in infant, family, and self-care with considering their age characteristics. Adolescence as a transition period is considered one of the most sensitive life stages for adolescents and their families . Upon enInvesting in the health of adolescents is also important from a demographic rationale. Adolescents make up a fifth of the world’s population, and 85% of them live in developing countries . It is eAdolescents make up about a fifth of Iran’s population, and according to the report of the Iran Statistics Center, and Office of Women’s Studies and Research in 2016, the marriage of men aged 20–24 to women aged 15–19 accounted for the largest number of registered marriages. Also, only 33 percent of them used contraceptive methods and one-third of them got pregnant in the first year after marriage  OR confidence[tiab] OR self-concept[mh] OR competence[tiab] OR self-confidence[tiab] OR self-perception[tiab] OR confidence[tiab])) AND ) AND . In addition, hand-searching in gray literature databases , Open Grey SIGLE, World Cat, NTIS, UW Libraries Search) and screening reference lists of eligible articles will be used to find more relevant records. All type of articles including quantitative, qualitative, and mixed methods studies will be assessed. The Endnote software ver.X9 will be used for omitting duplicate studies in different databases.After checking the titles and abstracts of all articles, the full text of the studies will be evaluated to identify the articles that met the inclusion criteria. All observational, and interventional studies, and programs will be assessed based on the needs, recommendation and strategies for self-efficacy promotion of teen mother during postpartum period.After finding the full texts of relevant articles, data of each article including the author's name, publication date, type of studies, setting, the sample size, intervention development, the time of the interventions, measurement tool, the needs, recommendation and strategies for promoting self-efficacy of teen mother, and main findings will be extracted using a structured form. Using the results of a scoping review, the needs, solutions and strategies for improving the self-efficacy of teen mothers will be extracted.In this step, the quantitative and qualitative information of each relevant article will be analyzed separately by two reviewers.In this stage of the research, after extracting the self-efficacy needs of teen mothers through qualitative study and scoping review, the decision matrix will be used to prioritize the strategies. In the first round of Delphi, a number of specialists  will assign to each proposed strategy a score of 1 to 9 based on four criteria including cost, time spent, place of implementation and feasibility. A score of 9 corresponds to the option “It is expected benefits are greater than its harms” and a score of 1 is related to the option “It is expected harms are much greater than its benefits”. The average score for each question will be obtained, if the score is between 1 and 3, it will be considered as an inappropriate option and will be removed from the program. Scores from 7 to 9 will be entered into the program as suitable options, and scores from 3 to 7 will be entered into the second round of Delphi to achieve general consensus.In the second round of Delphi, experts will be invited again to attend the face to face meeting to discuss the prioritization of strategies, the components of the program, its structure and application, the team members involved in it and other points of disagreement in the first Delphi phase. In the end, based on the panel members’ views, Comments and suggestions will be collected and applied to the design of the intervention program, and subsequently finalized and implemented in the quantitative phase.The quantitative phase of the research will be carried out using a two-group semi-experimental study.The targeted population is all adolescent mothers referred to health care centers affiliated to Isfahan University of Medical Sciences.The study sample will be formed from a group of teen mothers who will be selected by convenience sampling method and have all inclusion criteria for the study.This study will be carried out in selected comprehensive health care centers, obstetrics and gynecology offices, perinatal clinics of hospitals and all places where teen mothers are accessible. The reason for choosing such kind of environment is easy access to teen mothers and includes the majority of cultural and social classes. Considering that the present research is a mixed method study, the type and time of the intervention will be determined based on the findings of the previous stage, but our prediction is that the intervention will start from pregnancy.The sample size will be calculated using a pilot study. The sampling will be conducted by convenience and non-probabilistic sampling methods. The researcher by referring to the research environment on consecutive days will choose the number of teen mothers who have inclusion criteria in the easy method. Thereafter, participants will assign to the intervention and control groups based on ALLOCATION and RANDOM software. The sample size will be calculated based on pilot study.Pregnant women aged between 15 and 19 years, pregnancy age over 36 weeks, low-risk singleton pregnancy, Iranian citizenship, consent to participate in the study, not having history of any diagnosed mental or chronic diseases undergoing drug treatments, and ability to read and write.Unwillingness to continue cooperation during the study, occurrence of high-risk obstetric conditions , failure to receive 50% of the intervention for any reason.In this study, the designed interventions are considered as an independent variable, and postpartum self-efficacy is considered to be the dependent variable. Variables affecting self-efficacy will be determined using different constructs of Bandura’s self-efficacy theory , and based on the results of a qualitative study and scoping review, different areas of self-efficacy  will be determined.Researcher-made questionnaires evaluating postpartum self-efficacy in adolescent mother will be applied in the quantitative phase of this trial. After qualitative interview and searching in existing questionnaire, the validity and reliability of this questionnaire will be determined. In order to assess the content and face validity, the scale will be given to 15 faculty members of the midwifery, gynecology, and psychology department, and their expert’ opinions will be qualitatively received and the suggested changes will be applied in the questionnaire. In order to check face validity, the questionnaire will be provided to a number of women with the characteristics of the research units. The reliability of the tool will be done by test–retest method and the internal correlation will be evaluated with Cronbach’s alpha test.Based on the opinion of expert panel, a part of the strategies and goals will be determined in the form of an intervention program. After approving the protocol of the study with Ethics Committee, and obtaining the necessary coordination between the authorities of healthcare centers and hospitals, the researcher will implement the designed interventional program. After explaining the aim of the study (by Samaneh Youseflu), verbal, and informed consent will be given from the eligible women, and if they agree, they will enter the study and be randomly divided into two groups. For sampling, eligible women will be entered into the study using the convenience sampling method. Then, for randomized assignment, the women will randomly assign either to the trial or control groups based on the table of random numbers that will be generated by Random Allocation Software 2.0. To prevent selection bias, allocation concealment to the trial or control group will be done by a researcher who does not participate in the data collection (Shahnaz Kohan).At first, in the 36th week of pregnancy, a pre-test will be taken from both groups and the average self-efficacy scores will be compared between the two groups. The intervention group received the self-efficacy promotion program and the control group did not receive any intervention. After delivery, their self-efficacy score will be checked between two groups. The type of intervention , the time of the program implementation , the people involved in the program will be determined based on the opinion of the expert panel.The data analysis will be done using SPSS software ver. 16 by descriptive, and inferential statistics including paired t-test, repeated measure ANOVA, Chi-squared test, Fishers exact test, ANOVA, Wilcoxon test, and Mann–Whitney test.Adolescent pregnancy can encounter many challenges for the teen mother, family, and health system. Similar to the increase in the global fertility rate in adolescent pregnancy, it is expected that due to human population planning policies in Iran and the provision of childbearing incentives, in the not too distant future, Iran will experience an increasing growth of adolescent pregnancy rates. This matter highlights the urge to develop comprehensive reproductive health care program in order to care for themselves, their infants, and family. Therefore, the current mixed methods study will be conducted as a sequential exploratory approach to provide an interventional program sensitive to the culture of the Iranian society for adolescent mothers in postpartum care. The combination of qualitative and quantitative research methods will result in a more comprehensive view of the self-efficacy needs of teen mothers, and developing programs in postpartum care.For a teen mother, the simultaneity of two transition periods, i.e. transition to adulthood and transition to the post-partum period, disrupts the acceptance of new roles. The transition from one stage to another is associated with instabilities and requires the acquisition of skills and abilities to adapt to new roles. Teen mother should be able to balance between multiple roles and mood changes. Therefore, a healthy transition requires mental well-being, mastery of roles and good and logical relationships. On the other hand, having a healthy transitional stage depends a lot on the amount of information, the type of attitude and acquired behaviors. Lack of knowledge, information and life skills in managing this situation may threaten the physical and mental health of the mother, family and children and reduce the level of role adaptation. Previous researches show that in adolescent mother, the perceived stress following pregnancy and childbirth is higher than adults; moreover, the perceived stress after childbirth is much higher than pregnancy. Therefore, it seems critical to develop fundamental culturally sensitive community-based interventions in accordance with the biological, cognitive, psycho-social structure of teen mother in order to increase their self-efficacy.Despite the influence of the adolescent health in many health indicators, investing, and planning in various aspects of their health is often overlooked. Shortage of knowledge of maternal health care providers in the caring of teen mothers along with lack of comprehensive guidelines are the main reasons for neglecting them. By implementing this program, teen mothers can access postpartum services that are appropriate for their age characteristics. Moreover, in this program, in addition to improve the health of mothers, they will also improve their self-efficacy. In the meantime, the conduct of this program is considered as a logical and efficient solution for improving postpartum outcomes, and reduces their medical and treatment costs.Developing an interventional program that includes mother’s experiences, evidence based practice principles, and health staff opinions in a distinct cultural and social context can supply new direction to lead manager, policymakers, and other health care provider to improve the maternal and child health outcome, as well as quality of postpartum care for teen mothers with considering their age characteristics.


Recently, encouraging data of suprapapillary inside stents for biliary strictures have been reported, and threaded inside plastic stents have been increasingly utilized to manage hilar stricturesA 75-year-old man with refractory hilar strictures due to IgG4-related sclerosing cholangitis developed acute cholangitis. After dilatation of hilar strictures, a 7-Fr threaded inside plastic stent  was additionally placed in B6. However, the stent completely migrated into B6 when trying to place another inside stent in B8 . The miThe “coupler” technique for endoscopic removal of a threaded inside stent that migrated above tight hilar strictures.Video 1In the presence of tight biliary strictures, the retrieval thread could be useless. This technique can be a helpful coping strategy for endoscopic removal of a threaded inside stent that migrated above tight hilar strictures.Endoscopy_UCTN_Code_TTT_1AR_2AZ


Pulmonary embolism (PE) is a serious condition that often poses a diagnostic challenge. We report a case of a 57-year-old man with tobacco dependence who presented with multiple trauma, with chest imaging findings concerning for malignancy. While performing bronchoscopy with endobronchial ultrasound (EBUS), an echogenic material was incidentally found in the left pulmonary artery. Computed tomography pulmonary angiography (CTPA) was immediately obtained and confirmed the diagnosis of PE. This case illustrates the utility of routine pulmonary artery examination during EBUS procedures in patients at risk of PE and the importance of prompt management including confirmation with CTPA. Pulmonary embolism (PE) is a common and potentially life-threatening disease, which often poses a significant diagnostic challenge. Once diagnosed, prompt interventions such as therapeutic anticoagulation are indicated. While computed tomography pulmonary angiography (CTPA) is considered the standard diagnostic modality for PE , endobrohttps://doi.org/10.1164/ajrccm-conference.2021.203.1_MeetingAbstracts.A2223).This article was presented at the American Thoracic Society 2021 International Conference Thematic Poster Session in May 2021, and its abstract form has been published in the Conference Abstract Issue of the American Journal of Respiratory and Critical Care Medicine  performed during the initial evaluation for trauma. He reported a two-month history of blood-tinged sputum and weight loss but had no fever, cough, dyspnea, or chest pain symptoms. His past medical history was unremarkable. His social history was notable for current cigarette smoking (49 pack-year) and occupational asbestos exposure while he was in military service, as well as one prior incarceration. The chest CT with contrast showed right upper lobe patchy consolidation with central cavitation and necrosis, left upper lobe nodular consolidation Figure , and milBronchoscopy was performed with EBUS-guided transbronchial needle aspiration (TBNA) of the hilar and mediastinal lymph nodes, and transbronchial biopsy followed by bronchial brush and bronchoalveolar lavage (BAL) at the right upper lobe lesion. While visualizing the left hilar region with EBUS, the bronchoscopists found an echogenic material in the left pulmonary artery concerning a thrombus Figure .Consequently, the patient underwent CTPA, confirming new pulmonary emboli in the left main pulmonary artery extending into the left upper and lower lobar branches Figure . While tThe EBUS-TBNA samples from bilateral paratracheal, subcarinal, and right hilar lymph nodes showed cellular evidence of lymph nodes without malignant cells. A transbronchial lung biopsy of the right upper lobe lesion showed fragments of lung parenchyma with chronic inflammation, interstitial thickening, and reactive pneumocytes. The bronchial brush showed hemosiderin-laden macrophages, and the bronchial brush and BAL fluid specimens were negative for bacteria, mycobacteria, or fungi. While the exact etiology for the abnormal chest CT findings remained unclear, malignancy appeared less likely and therefore a decision was made to manage pulmonary contusion and possible infection. He was given amoxicillin-clavulanate for seven days and a repeat chest CT in six weeks was recommended. Because he resided more than 100 miles away, he elected to follow up with outside medical providers near his home.To the best of our knowledge, the present case is the first report of PE in a patient with multiple trauma incidentally diagnosed with EBUS. It illustrates two potential implications in clinical practice.First, although EBUS is primarily used to aid in TBNA, bronchoscopists should consider the examination of the pulmonary vasculature, especially in patients who are at high risk of developing PE. In 2008, Casoni et al. first reported that EBUS is useful in differentiating PE from pulmonary artery sarcoma in a patient with equivocal CT findings . AumilleSecond, if an incidental diagnosis of PE was made with EBUS, prompt confirmation with CTPA would be reasonable. Recent case reports describe that EBUS can be used as a primary diagnostic test in critically ill patients who are too unstable to undergo CTPA. This includes a patient in cardiac arrest who improved with intravenous thrombolysis therapy for massive PE diagnosed with bedside EBUS , and patWe describe a case of PE incidentally diagnosed during EBUS performed for a patient with multiple trauma. Bronchoscopists should consider performing a pulmonary artery examination routinely during EBUS procedures, particularly in patients who are at high risk of developing PE. If EBUS findings are concerning for PE, confirmation with better-studied modalities such as CTPA would be reasonable as long as it can be immediately performed. Future studies are desired to further establish the role of EBUS in the diagnosis of PE.


Good physical fitness is the foundation of a healthy lifestyle. For students, the school becomes the main place to improve their physical fitness. The traditional physical education class places little emphasis on improving physical fitness and students’ physical fitness have continued to decline. To address these challenges, this study aimed to design and develop a functional training program that can be incorporated into existing physical education lessons to improve students’ physical fitness levels.This study adopted the instructional design framework of the Analysis, Design, Development, Implementation, Evaluation (ADDIE) model to guide the design and development of the functional training program. After development, the program was implemented and evaluated.The results showed the program aroused students’ interest and significantly improved students’ physical fitness.This study showed the usefulness of functional training in improving the physical fitness of primary school students. In addition, it provided a reference for how to use functional training in conjunction with the physical education syllabus. For One way to improve physical fitness is through functional training. Functional training began in sports medicine, then was introduced to the field of athletic training by coaches, subsequently being introduced to gyms, where the general public had access to a vast array of methods associated with it . NowadayThis study was conducted to design and develop a 12-week functional training program that could be incorporated into existing PE lessons. The design and development were based on the ADDIE model. The study could verify the feasibility of incorporating functional training into the primary school PE curriculum as well as provide a reference for other researchers who were interested in improving the effectiveness of PE.2.The study mainly used the ADDIE framework to guide the process of designing and developing a functional training program. The ADDIE framework is a process model developed for the military and enthusiastically adopted by the army due to its clear delineation of instructional design steps, namely Analysis, Design, Development, Implementation, and Evaluation , 30. The3.3.1.PE in primary school is the basic organizational form of PE teaching and an important part of the school curriculum in China. It plays an important role in improving students’ physical health, enhancing social adaptability, and cultivating students’ awareness of lifelong PE . During First, each PE lesson had a total of 40 min. Second, the lesson had four parts, which were the initial part, the preparatory part, the fundamental part, and the final part. Third, the teaching tasks of different parts were also different. The initial part focused on organizing students, focusing on students’ attention, and preparing for class. The preparatory part, also known as the warm-up part, was to improve muscle temperature and prevent sports injuries, improve the function of internal organs, and adjust mental state . The fun3.2.Understanding and mastering the characteristics of children’s growth, such as the skeletal system, cardiovascular system, respiratory system, and nervous system, was critical for guiding the development of the PE curriculum. In terms of the skeletal system of students, their bones were elastic but had poor hardness and firmness and were easy to bend and deform; their range of joint motion was more extensive than that of adults, but the firmness was relatively poor; their muscles were weak contractile function, poor endurance, and easy fatigue –48. In t3.3.Athletes’ Performance Institute (API), the functional training center established in 1999, had been widely acclaimed for its advanced training system, which classified functional training as seven modules: pillar preparation, movement preparation, plyometric training, movement skill training, strength training, energy systems development, and recovery and regeneration  Table 1Table 1. 4.The objectives of PE for primary school students were that through the study of PE and health curriculums, students would master various physical training methods, and could actively participate in various physical exercises, and their physical fitness levels would be significantly improved, meeting the corresponding requirements of the 2014 revised Chinese National Student Physical Fitness Standard (CNSPFS) .5.5.1.During the analysis stage, a needs analysis was mainly carried out to differentiate between their current level of physical fitness and what they needed to improve by the end of the lessons . Firstly5.2.At this stage, a 12-week program was proposed to develop students’ physical fitness based on the feedback from the first stage. The program was divided into three stages: basic stage, advantage stage I, and advantage stage II. The previous stage was the foundation of the following stage. It was arranged in the auxiliary part of the lesson according to the characteristics of the PE curriculum setting and HPECM.The first step was the choice of content. According to the results of the analysis stage, the speed of students’ physical fitness dropped sharply . Therefo5.3.This phase was to develop the program and mainly included three steps. Firstly, according to the knowledge obtained in the first two stages of the model, the corresponding functional training components were selected and incorporated into the 12-week PE syllabus. According to the school’s PE timetable and schedule, there were three PE lessons a week, contributing to a total of 36 functional training programs that were developed. All the movements within the program were recorded into videos to assist teaching and learning. Secondly, when completing the development of the 12-week program, to validate the draft program and ensure a variety of voices were heard, the developed materials were sent to the same experts as those from the analysis phase and to six additional PE teachers with at least 6 years of teaching experience for their review of the proposed program. The data were collected by WeChat which is a widely popular social media in China –59 and a5.4.The implementation was the process of transforming a plan into action . In this5.5.α: 0.81–0.94)  . The ChiAs for physical fitness, the 2014 revised CNSPFS test battery was used to measure the physical fitness of the students before and after the intervention. Baseline data were obtained from the analysis phase, while the post-test was conducted after the implementation phase, at the end of the 12-week functional training program.6.According to the 2014 revised CNSPFS test conducted on the students, the current status of students’ fitness showed that the 50 m sprint dropped sharply which needed to be improved . Combine6.1.After reviewing the draft program, the experts gave their feedback, which was analyzed by NVivo 12 from word cloud and Sentiment.Words commonly used to express positive or negative feelings are the most important indicators of feelings . The datSentiment identification also called subjectivity identification is to determine whether the opinion orientation in the given text is position, negative, or neutral . The sen6.2.6.2.1.Students’ situational interests were measured to provide information on whether the program could stimulate students’ motivation to learn. The results of students’ situational interest in the program are shown in 6.2.2.p < 0.01) were achieved in all physical fitness tests .Student physical fitness test results were collected and analyzed before and after the 12-week PE lessons to assess the actual efficacy of the program. 7.To fill the gap in the application of functional training in primary school PE, this study designed and developed a 12-week functional training program, that could be incorporated into PE lessons, to improve students’ physical fitness. The design and development were guided by the ADDIE model. The applicability and acceptability of the program were evidenced by both the positive feedback from experts and students and the significant changes in students’ physical fitness after implementation.When experts gave feedback on the program, most of them were positive about the program. They used words that generally express positive attitudes and express approval of the program, such as ‘全面’ (comprehensive), ‘可操作性’ (operability), and ‘可行性’ (feasibility).Other than feedback from experts, it was also important to get feedback from students, in terms of their interest in the program. Interest is both a psychological state of attention and affection toward a particular object or topic and an enduring predisposition to reengage over time . It had Conversely, the challenge dimension had the lowest score. However, it is possible that this dimension had little influence on the program as in a follow-up study to Chen and Darst , a path As for the physical fitness performance, the results of the physical fitness test indexes showed that the baseline scores were significantly different from the post-test scores. All students had a positive growth rate and improved their physical fitness performance after the 12-week functional training program. Participants’ BMI, a sensible indication of children’s overall adiposity , increasThis study is not without some limitations. The goodness of movement completion is influenced to some extent by the cognitive level of students in the process from movement understanding to movement execution. In addition, in the selection of movements in the program, some simple and easy movements were chosen, which to some extent reduced the intensity of the exercises . Finally8.Children, whose health set the stage for adult health, are vital to the nation’s present and future . SchoolsThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by The University Malaya Research Ethics Committee . The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.HL and JC: conceptualization and methodology. HL: data curation, software, and writing – original draft. JC: supervision and writing – review and editing. All authors contributed to the article and approved the submitted version.


The Cancer Center Cessation Initiative (C3I) is a National Cancer Institute (NCI) Cancer Moonshot Program that supports NCI-designated cancer centers developing tobacco treatment programs for oncology patients who smoke. C3I-funded centers implement evidence-based programs that offer various smoking cessation treatment components . While evaluation of implementation outcomes in C3I is guided by evaluation of reach and effectiveness (via RE-AIM), little is known about technical efficiency—i.e., how inputs  influence implementation outcomes . This study demonstrates the application of data envelopment analysis (DEA) as an implementation science tool to evaluate technical efficiency of C3I programs and advance prioritization of implementation resources.DEA is a linear programming technique widely used in economics and engineering for assessing relative performance of production units. Using data from 16 C3I-funded centers reported in 2020, we applied input-oriented DEA to model technical efficiency . The primary models used the constant returns-to-scale specification and featured cost-per-participant, total full-time equivalent (FTE) effort, and tobacco treatment specialist effort as model inputs and reach and effectiveness (quit rates) as outcomes.SD = 24.56). When stratified by program characteristics, technical efficiency was higher among programs in cohort 1  vs. cohort 2 , with point-of-care  vs. no point-of-care services , larger  vs. smaller center size , and higher  vs. lower smoking prevalence .In the DEA model featuring cost-per-participant (input) and reach/effectiveness (outcomes), average constant returns-to-scale technical efficiency was 25.66  relative to program outcomes . This study demonstrates the appropriateness and feasibility of using DEA to evaluate the relative performance of evidence-based programs.The online version contains supplementary material available at 10.1186/s43058-023-00433-3. Contributions to the literatureThis study demonstrates the utility of data envelopment analysis (DEA) as a novel implementation science tool for evaluating program efficiency.DEA allows for the identification of program factors associated with higher levels of relative efficiency, which can be leveraged to increase efficiency across peer programsDecision makers can use findings from DEA to improve efficiency of existing tobacco treatment programs within oncology settings by identifying the types of programs that maximize reach and effectiveness while minimizing costs.Maximizing efficiency of tobacco treatment programs can promote better program sustainability long term.Tobacco use is a preventable risk factor that can exacerbate adverse health outcomes for individuals with cancer, increasing risk for all-cause mortality, cancer-specific mortality, cancer recurrence, and worsening response to cancer treatment , 2. FailThe importance of smoking cessation for individuals with cancer is widely recognized by cancer organizations and the Surgeon General , 2. HoweIn response to this gap, the Cancer Center Cessation Initiative (C3I) was launched in 2017 as part of the National Cancer Institute (NCI) Cancer Moonshot program with the aim of integrating tobacco cessation treatments into routine cancer care. The goal of this multilevel implementation initiative has been to foster and sustain evidence-based tobacco cessation programs for patients with cancer and to encourage system-level change by identifying and referring patients who use tobacco to cessation treatments , 9. C3I C3I is guided by the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework, which facilitates multilevel assessment of the programs’ health-related impact  –13. IdenProgram reach and effectiveness are two key outcomes of interest that are reported by C3I-funded cancer centers as standardized outcomes and have been used to evaluate the success of the tobacco treatment programs. Reach is defined as the proportion of patients who received at least one component of evidence-based, tobacco treatment. Effectiveness is defined as patient-reported 7-day point prevalence abstinence at 6-month follow-up. C3I centers’ reach and effectiveness rates varied as a function of center characteristics, including cancer center size, implementation strategies used, and types of treatments offered. For instance, Hohl et al.  found thmedian = $11,045), with most costs going towards personnel [median = $454) and cost per quit was less than $3500 across centers. Overall, C3I centers achieved satisfactory quit rates at reasonable costs [In addition to reach and effectiveness, cost is an important factor that can affect program sustainability . An econersonnel . Cost pele costs , and theTo compare C3I program outcomes relative to expended resources, we applied a mathematical optimization method called data envelopment analysis (DEA). DEA is widely used in economics and engineering for measuring the relative performance of production units , 20. OneThis is a descriptive study using DEA to examine reach and effectiveness of the C3I program relative to resources expended. DEA applications in health services give insights into which organizations are more efficient than others using program outcomes as outputs and resources expended as inputs . This stTobacco treatment program evaluation data were reported to the C3I Coordinating Center, based at the University of Wisconsin-Madison Carbone Cancer Center. The Coordinating Center assisted grantees with integrating evidence-based tobacco treatment services into cancer care  and creaData reported included: size of the cancer center, smoking prevalence for patients at the center, presence of a point-of-care tobacco cessation intervention  , and wheC3I sites reported the types of evidence-based treatments offered in their programs. These treatments included the following: in-person individual or group counseling, telephone-based counseling, point-of-care counseling, interactive voice response system track and triage services , Quitline referral, SmokefreeTXT text messaging service, online resources , and smoking cessation medications.Measures indicating presence of a TTS on site, total FTE, and cost were collected through the biannual cost surveys and used as input measures. C3I cancer centers reported FTE of tobacco treatment specialists employed in the program. Sites also reported FTE associated with all tobacco treatment program staff by personnel type, which was summed across personnel types to derive the total FTE measure. “Other personnel FTE” was calculated by subtracting TTS FTE from total FTE. We calculated cost-per-patient by dividing total monthly operating costs of each participating C3I center by the number of patients participating in a tobacco treatment program within the 6-month reporting period. Details of how total monthly operating costs were calculated can be found elsewhere . Reach was assessed as the proportion of unique patients seen during the 6-month reporting period who used tobacco and received at least one type of evidence-based tobacco treatment , relatiWe applied DEA to assess the relative performance of C3I centers . We usedWe used DEA to estimate efficiency scores for each program as the ratio of the weighted sum of outcomes to the weighted sum of inputs, and graphically plotted the efficiency scores according to cost and reach/effectiveness. We applied the input-oriented DEA approach with constant returns-to-scale , 28. UndSlacks represent excess input utilization or shortages in outcomes within DEA . We asseModel 1 input: cost per participant; outcomes: reach, effectiveness.Model 2 inputs: TTS, other personnel; outcomes: reach.Model 3 inputs: TTS, other personnel; outcomes: effectiveness.Three DEA models assessed the relative efficiency of the sixteen C3I programs with complete data.Analyses were also stratified by C3I center characteristics. We conducted all analyses using the PIM-DEA V.3.2 software.standard deviation, SD = 21,596, median = 22,075, range = 507–89,485) patients during the 6-month reporting period, and median smoking prevalence was 9.3% (range = 2.2–47.1%) across centers; 44% of cancer centers had implemented point-of-care interventions and 69% were part of cohort 1 (vs. cohort 2). Mean number of tobacco treatment specialist FTE was 0.66 (SD = 0.60), and mean total FTE was 1.39 (SD = 0.74). Average cost-per-patient was $572 , and average cost-per-quit was $2981 . Overall, programs reached 24.4% of patients who smoked  and had a 20.4% effectiveness , on average.Table In the first DEA model Fig. , we asseNext, we used DEA to assess effectiveness and reach relative to total costs, stratified by program characteristics . C3I cenAdditionally, we used DEA to assess the reach and effectiveness of C3I centers relative to the personnel involved in tobacco treatment administration . For the first set of models, the inputs were TTS and other personnel, and the output was reach. C3I centers clustered around the origin, suggesting that most had generally low other personnel and TTS relative to reach. Only one C3I center was located on the best practice frontier. Nine C3I centers had higher FTE for other personnel (vs. TTS) relative to reach, whereas seven C3I centers had higher TTS FTE (vs. other personnel) relative to reach Fig. . Next, wTable The performance analysis identified the slacks, representing either excess input utilization or shortages of output production. Table This study demonstrated utility of DEA for implementation research by assessing reach and effectiveness of tobacco treatment programs within NCI-designated cancer centers relative to their operating costs. We identified factors associated with the most optimal programs that could be leveraged to increase efficiency of tobacco treatment programs across centers that function less optimally. Programs that were in cohort 1 , programs that had implemented point-of-care interventions, and programs in cancer centers that were larger in size tended to be more efficient.This information is particularly useful for program evaluation because it directly compares how well C3I programs converted their available resources into measurable outcomes . Variability in efficiency was high across C3I centers, which is unsurprising given that some centers had existing infrastructure for tobacco treatment programs, whereas others implemented these programs for the first time. Existing program infrastructure may have contributed to program efficiency, given that these sites would have already implemented some tobacco treatment program-related protocols into their workflows. There was also variability in how long tobacco treatment programs had been implemented across centers. Thus, DEA is an important tool for program evaluation because it can identify which programs effectively maximize their resources given budget constraints. Identifying how resources can be allocated to foster sustainability of C3I centers has implications for other tobacco cessation programs in oncology settings. For instance, DEA may be used to characterize treatment efficiencies in others areas of oncology practice, such as value-based care, enrollment in clinical trials, and improving palliative care and cancer survivorship.Although research using DEA to assess tobacco treatment programs for oncology patients is limited, DEA has been applied in other healthcare settings. For example, DEA has been applied in examining the efficiency of primary healthcare centers, including inputs and outputs such as number of patients and staff, costs, procedures, prescriptions, and referrals . AdditioDEA can be used as a stand-alone analysis, given its unique ability to assess the relative efficiency of production units. DEA has been widely applied in other fields such as economics , 20 as wOverall, we found that many C3I sites had low efficiency relative to the best practice frontier. In the DEA model assessing reach and effectiveness relative to program costs, only one program was located on the best practice frontier, and this program appeared to achieve substantially higher efficiency compared to other programs. We examined additional DEA models stratified by key organizational characteristics. C3I centers that were part of cohort 1 (vs. cohort 2), had deployed point-of-care tobacco cessation interventions (vs. no point-of-care), were larger  in size, and had higher (vs. lower) smoking prevalence tended to be more efficient . Thus, centers may prioritize implementing point-of-care interventions over other types of tobacco treatment interventions to maximize efficiency. Although point-of-care interventions may be expensive, it is noteworthy that their implementation was associated with greater program efficiency . Similarly, larger NCI-designated cancer centers generally achieved higher reach and effectiveness while mitigating costs, suggesting that C3I programs are more sustainable when implemented in larger  cancer centers, and that smaller cancer centers or community oncology practices may require more resources to sustainably implement tobacco treatment programs.Additionally, centers that had higher smoking prevalence were generally higher in efficiency. It is possible that centers with lower smoking prevalence were less efficient because there were fewer eligible patients to enroll in the program. C3I centers with lower smoking prevalence had lower reach relative to effectiveness, which suggests that these programs may be underutilized and consequently operate less efficiently than programs with higher enrollment rates. This information can be particularly useful for establishing tobacco cessation programs for individuals with cancer. Selecting locations that are more likely to maintain low costs relative to reach and effectiveness may increase the likelihood that cancer centers will sustain these programs long-term. However, this practice may come at the cost of marginalizing patients in settings with limited resources, which may require greater costs to implement and sustain tobacco treatment programs.Moreover, whether C3I centers had existing infrastructure for tobacco cessation treatments prior to the initiative may have impacted relative program efficiency. For instance, centers that had independently focused on promoting tobacco cessation programs before joining C3I may be more efficient than centers that initiated tobacco cessation programs as part of C3I. Implementation readiness has been shown to be associated with higher chances that a cancer center provides tobacco cessation treatments to its patients . Thus, tFurther, programs that employed less TTS FTE and other personnel FTE on average achieved greater efficiency. Previous research regarding the effects of a TTS for tobacco cessation are mixed. Recent studies found that C3I centers with lower TTS-to-patient ratios tended to have higher reach and lower effectiveness  and thatIt is important to note that it can be challenging to find a balance between maximizing research and delivering an effective intervention, particularly in the oncology setting. Individuals who continue smoking after their cancer diagnosis can be especially difficult to treat even with a high intensity intervention. Therefore, assessing the external validity and cumulative impact of smoking cessation interventions in oncology settings is of utmost importance. We assessed reach and effectiveness as separate outcomes, however, both must be considered to assess population impact. The cumulative impact of an intervention is a function of every step of dissemination and participation  . Even inThis study is not without limitations. First, our convenience sample of 16 NCI-designated C3I centers may not be representative of many cancer care programs. This sample consisted of cancer centers that received supplemental funding to improve or expand tobacco cessation resources; thus, results may not be generalizable to other cancer centers and should be interpreted with caution. The programs in this sample reported low proportions of individuals who were American Indian or Alaska Native (≤ 1%), Asian, Native, or Pacific Islander (≤ 1%), or Hispanic (3%); therefore, generalization of findings to these populations may be limited. However, smoking prevalence among C3I centers was similar to estimates of national rates of tobacco use among individuals who have had cancer –37. It is possible that the results do not accurately represent the experiences with efficiency across all tobacco treatment programs in C3I. Therefore, a larger sample of C3I centers is needed before factors affecting program efficiency can be reliably assessed and interpreted. Despite this limitation, we achieved the primary goal of this study, which was to demonstrate the benefits of using DEA as a tool for assessing program implementation and performance. Specifically, we showed that DEA can be used to inform program efficiency by assessing readily available practice parameters, such as program reach, effectiveness, and cost.Another limitation is the reporting of outcomes and program features was voluntary; therefore, data collected from C3I centers may be partially incomplete. Missing data, whether deliberate or coincidental, can skew findings ; therefoFinally, some of the data for this study were collected during the COVID-19 pandemic, when many non-emergent appointments were postponed or canceled. Other pandemic-related changes, such as limited staff due to illness, staff changes, and program changes with implementation of telehealth, may have impacted program costs and efficiency. Reach and effectiveness may have been affected during this time due to pandemic-related restrictions and barriers. On the other hand, reach may have increased with the pandemic related transformation to telehealth treatment models. Data were reported at the level of the C3I center; therefore, we did not have access to individual-level data. Consequently, we were unable to investigate more granular factors that may be associated with program efficiency, such as which specific tobacco treatments patients were receiving, at what frequency, and whether efficiency was moderated by patient characteristics  . Given tDEA is a useful tool for assessing the relative efficiency of organizations that implement evidence-based programs in a way that is not possible with other analytic methods. In the case of C3I, identifying factors associated with high reach and effectiveness, while maintaining low operating costs is important for the sustainability of tobacco treatment programs. Decision makers can use findings from DEA to improve efficiency of existing tobacco treatment programs within oncology settings and evaluate how cancer centers could most effectively support implementation of tobacco treatment programs. This study demonstrated that DEA provides valuable information that can foster more sustainable implementation of tobacco treatment programs in oncology settings.Additional file 1:Supplementary Figure 1. Efficiency frontier for C3I programs in Cohort 1 (left) and Cohort 2 (right): reach and effectiveness relative to cost-per-participant. Supplementary Figure 2. Efficiency frontier for C3I programs with (left) and without (right) a point-of-care intervention: reach and effectiveness relative to cost-per-participant. Supplementary Figure 3. Efficiency frontier for C3I programs at centers larger (left) and smaller (right) than median size: reach and effectiveness relative to cost-per-participant. Supplementary Figure 4. Efficiency frontier for C3I programs at centers with higher (left) and lower (right) than median smoking prevalence: reach and effectiveness relative to cost-per-participant.