The Stanford Youth Diabetes Coaches Program (SYDCP) is a school based health program in which Family Medicine residents train healthy at-risk adolescents to become diabetes self-management coaches for family members with diabetes. This study evaluates the impact of the SYDCP when disseminated to remote sites. Additionally, this study aims to assess perceived benefit of enhanced curriculum.From 2012–2015, 10 high schools and one summer camp in the US and Canada and five residency programs were selected to participate. Physicians and other health providers implemented the SYDCP with racial/ethnic-minority students from low-income communities. Student coaches completed pre- and posttest surveys which included knowledge, health behavior, and psychosocial asset questions , as well as open-ended feedback questions. T-test pre-post comparisons were used to determine differences in knowledge and psychosocial assets, and open and axial coding methods were used to analyze qualitative data.A total of 216 participating high school students completed both pre-and posttests, and 96 nonparticipating students also completed pre- and posttests. Student coaches improved from pre- to posttest significantly on knowledge ; worth (p<0.1 in 2014–15); problem solving (p<0.005 in 2014 camp and p<0.1 in 2014–15); and self-efficacy (p<0.05 in 2014 camp). Eighty-two percent of student coaches reported that they considered making a behavior change to improve their own health as a result of program participation. Qualitative feedback themes included acknowledgment of usefulness and relevance of the program, appreciation for physician instructors, knowledge gain, pride in helping family members, improved relationships and connectedness with family members, and lifestyle improvements.Overall, when disseminated, this program can increase health knowledge and some psychosocial assets of at-risk youth and holds promise to empower these youth with health literacy and encourage them to adopt healthy behaviors. The burden of chronic disease in the US has reached epic proportions and disproportionately affects individuals from low-income, ethnic minority populations. The impaOne such opportunity is the Stanford Youth Diabetes Coaches Program (SYDCP), a school based health program that develops partnerships between high schools and Family Medicine residency programs . Family Medicine residents train healthy at-risk adolescents from low-income, ethnic minority communities to become diabetes self-management coaches for family members with diabetes. A local pilot study demonstrated that, compared to nonparticipants, student coaches showed significant improvements in knowledge, sense of belonging, and feelings of self-worth. AdditionIn this paper we discuss the developmental phases and testing of the SYDCP. Developed using feedback from students, teachers, physician trainees and community members, the project maximizes interaction between physician trainees and students; emphasizes student and family voices; and incorporates technology to enhance engagement. We focus on evaluating the impact of the SYDCP when disseminated to remote sites in the US and Canada; as well as investigating whether the disseminated program can equip at-risk youth with knowledge and skills to enable them to become engaged in their own health and empowered to improve their own health behaviors. Additionally, this study aims to assess the benefits of enhanced curriculum that emphasizes discussion and interaction between physicians and students in class; as well as the perceived benefit of curriculum enhanced with technologies such as text reminders, emails, and embedded video content.The SYDCP is a “train the trainer program” in which Family Medicine residents train high school students to train their family members. The tightly scripted curriculum incorporates evidence- based approaches to chronic disease management, as wellAfter the pilot study (2011–12), a totalStudents were eligible to participate if they were in grades 9 through 12 (approximate ages 14–18). School and camp administrators determined whether the program would be voluntary or mandatory for participating students. In three schools, participation was voluntary, and students were recruited through advertisements posted in the schools. In seven schools and the summer camp, participation was mandatory and incorporated into students’ schedules. All participating students were asked to complete pre- and posttest surveys. In addition, in six participating schools, we obtained pre- and posttest surveys for 96 students not participating in the intervention to be used as a comparison group. The institutional review board at Stanford University approved the study. In the academic year 2012–2013, written informed consent was obtained from a parent or guardian of each participant; and written assent was obtained from each participant. In June, 2013, the institutional review board at Stanford deemed that the involvement of human subjects in our work was in a category that is exempt from the regulations at 45 CFR 46 or 21 CFR 56. The review board waived the need for written informed consent from the participants (including parents or guardians) after June 2013.The process of initiating the SYDCP for Family Medicine residents and other health providers varied by site. Most first learned about the program at national meetings, through internet searches, and through word of mouth. For example, in Atlanta, one Family Medicine resident learned about the SYDCP and brought the information to her program director who made the opportunity available to all residents. In Vallejo, Family Medicine physicians who wanted to partner with a local underserved school asked to use the SYDCP as its complete curriculum would allow them to get started right away; in San Jose, the residency program community health director asked to utilize the SYDCP because he wanted his residents to participate in school outreach during their required community health rotation. In Wilmington, directors of a summer camp aimed at improving the health of at-risk youth and specifically targeting diabetes prevention wanted to incorporate the SYDCP so that Family Medicine residents visiting the camp could have a focused curriculum to provide the youth; in Ypsilanti, a Family physician who runs a school based health center asked to use the program to allow rotating Family Medicine residents to connect regularly with students in the classroom environment; and in the Kainai Blood Tribe Reserve, a community health nurse who was seeking an opportunity to combat the 50% diabetes rate in the community asked to use the SYDCP.Although initial interest varied by site, functional implementation was consistent across all sites. One requirement of the health providers partnering with the SYDCP research team was that they conduct the program with strict adherence to SYDCP guidelines and specifications as described verbally and in written form by a member of the research team. At each site, the practical implementation of the program curriculum was exactly the same, as each site utilized the pre-made power point slides, instructor’s guides, and coaching assignments and held class once a week for an hour for eight consecutive weeks. Aside from the site in Canada needing to adapt the curriculum to show guidelines using the metric system; some sites needing to take a one week break mid-implementation due to mandatory school breaks; and the unavoidable differences in teaching styles of instructors, variability among students, and different site facilities, each site implemented the program the same way.At each site, physicians or other health providers taught one-hour classes once a week for eight weeks using standardized web-based program curriculum focused on health knowledge, communication, problem-solving, and self-management skills. At all sites, Family Medicine residents taught the classes except in a few cases where Family Medicine residents were not available or where other health providers supplemented the teaching of the classes. Specifically, in the Kainai Blood Tribe Reserve, a community health nurse and registered dietitian taught the classes together because no Family Medicine residents were available; in Vallejo, Family Medicine physicians (not residents) taught the classes as they were piloting the work before starting a Family Medicine Residency Program where they would have residents teach the classes; in Wilmington, a dietitian taught together with Family Medicine residents; and in Redwood City, a Family Medicine physician and a school nurse took turns teaching the classes in order to provide the program to an at-risk group of students despite not having Family Medicine residents available. A detailed description of program curriculum can be found in the article describing the pilot implementation of the SYDCP. Each parAs summarized in Student coaches and a group of non-participating students completed pre- and posttest surveys which included questions on knowledge, psychosocial assets, and health behaviors, as well as open-ended feedback questions. Diabetes related knowledge was measured using questions from the validated Michigan Diabetes Research and Training Center’s Brief Diabetes Knowledge Test  and the t tests to determine p values for level of significance. The data was divided by year, setting, and curriculum type into four cohorts: Fall 2012- Spring 2013 with original curriculum, 2014 summer camp, Fall 2014- Spring 2015 with revised curriculum, and Spring 2015 pilot with technologically enhanced revised curriculum. In this paper, we refer to the groups as 2012–13, 2014 summer camp, 2014–15 and 2015. Of the 13 students who enrolled in the Spring 2015 pilot, seven completed both pre- and posttests. Although that cohort (n = 7) is included in our results, the sample size is too small to statistically assess change and was therefore not considered for quantitative analysis. Feedback data was analyzed, however, from all participants in this small cohort who completed a posttest in which they provided responses about the technological enhancements  (n = 10).Participant students with complete pre- and posttest data were included in the analysis. We used SPSS 23 and STATA 13 for the data merge and analysis. To measure improvement in knowledge levels, behavior change and psychosocial assets, we compared mean difference in pre- and posttest scores of participating student coaches using For the qualitative data analysis, we applied open and axial coding methods,13 to deIn total, 311 high school students enrolled in the SYDCP as program participants from Fall 2012-Spring 2015 and completed pre-test questionnaires. 272 participating high school students completed posttests. Of these 272 participants, 216 students completed both pre-and post tests matched by unique identification codes. Based on direct verbal and written communications with high school staff who facilitate the SYDCP at all sites, explanation of the discrepancy between the numbers of students enrolling (taking the pre-test), finishing (taking the posttest), and completing the full program (taking both the pre- and posttest) stems from the fact that many of the student participants have multiple life-stressors that prevent them from attending school each day. Often students who begin the program are unable to complete it due to such factors as: poor school attendance; other commitments such as caring for elderly family members or younger siblings; or schedule conflicts with other activities. For similar reasons, students often join the program after the first session and are not offered the opportunity to complete a pre-test. We also collected pre- and posttest survey data for 96 nonparticipating students in six of the schools to serve as a comparison group.Although the demographic characteristics were similar between participating students and the comparison group, nonparticipants did not demonstrate improvements in any of the measures analyzed (data not shown). These results were similar to those reported in our pilot study which demonstrated statistically significant improvements in the areas of knowledge, belonging, and worth in participants versus nonparticipants.As summarized in As described in Additionally, we further categorized the data based on whether the program was offered in a mandatory or elective setting. Pre-test scores for knowledge and worth for student coaches in elective programs (n = 50) were consistently higher  than pre-test scores for students in mandatory programs (n = 166). When pre and post-test scores were compared, student coaches enrolled in mandatory programs demonstrated significant improvement in knowledge levels, worth, problem solving and self-efficacy. Student coaches in elective programs showed significant improvement in pre and post test-scores in knowledge levels, but not in worth, problem solving, or self-efficacy.When asked what they would like to change or make better about the program, student coaches answered with three main themes: making the program more interactive or including more hands-on activities; improving instruction, and improving program structure. As shown in Several themes emerged in the analysis of the qualitative feedback from student coaches answering the question “What did you like best about the program?” When asked if they had considered making any changes in diet, physical activity, or some other behavior after program participation, 82.3% of student coaches responded affirmatively. When asked to describe the behavior changes, 60% cited improving their diets, 39% cited increasing physical activity, 3% cited weight reductions, and 2% cited reducing stress or improving sleep.Of those who received the technologically enhanced curriculum, all students reported that the videos were useful in becoming better diabetes coaches; that the emails increased their confidence in creating good habits for the future; and that receiving texts was useful and helped remind them about their coaching work. Ninety-two percent reported the in-class videos were interesting; and 83% reported sharing the email tips with the family members they were coaching.This study demonstrates that the SYDCP can be reproduced in a variety of settings in North America and has the potential to equip at-risk youth with knowledge and skills to enable them to become engaged in the health of their family members and empowered to improve their own health behaviors. All cohorts displayed significant improvements in diabetes and health related knowledge, confirming that the program structure reliably and effectively boosts diabetes and health related knowledge.Results from early dissemination of the program (2012–13) demonstrated, however, that 1) program participation was not improving student coaches’ psychosocial assets; and 2) student coaches wanted a more interactive program. These results were used to revise the SYDCP curriculum to emphasize discussion and interaction between physicians and students. Results after the curriculum revision show that incorporating these interactive elements into the program increases the potential to improve psychosocial assets such as self-efficacy to solve problems and work with others, while simultaneously improving student coaches’ perception of the program. Improvements in psychosocial assets are particularly important in empowering youth to improve their health behaviors and reduce risk-taking behaviors as emphasized in Healthy People 2020 and demoThe results also indicate that the SYDCP has potential to improve psychosocial assets among high school students who are required to participate in the program, as well or even more than those who elect to participate. One likely explanation for student coaches in mandatory settings showing more improvement than those in elective settings may stem from the baseline differences between student coaches in elective versus mandatory settings. On the whole, student coaches who participated in elective programs have higher pre-test scores for knowledge and assets than those in mandatory programs (data not shown), and thus, less room for improvement.Often it is easier for schools with few resources to have SYDCP sessions taught during the school day in a mandatory setting during an already existing class because school staff is not available to organize and manage elective sessions. The observation that students participating in mandatory compared to elective settings show more improvement will help the SYDCP research team assure these sites that mandatory classes are effective for their students. However, the research team will also encourage elective classes because it is the experience of the research team that in elective classes, the students’ desire to participate creates a more engaged and peer-supportive dynamic.The SYDCP does not appear to have a consistent impact on health behavior change of the participant youth based on the quantitative behavior change questions utilized in the survey. It may be that in focusing on health coaching, the SYDCP curriculum does not sufficiently encourage youth behavior change. Alternatively, it may be that the quantitative behavior change questions do not capture the changes the youth are making, as the vast majority of student coaches reported making a behavior change to improve their health secondary to program participation. The significant improvements in consumption of fruits and vegetables seen in summer camp students  could haLastly, use of short embedded video to teach basic content quickly in each class allowed more time for meaningful interaction between student coaches and physicians in class. Text messages and emails have been shown to be an effective tool for engaging youth in positive health behaviors,19 and iThe qualitative data provides a window into the value of the program for the student coaches, the shortcomings of the program, and the influence of the program on behavior change.Themes extracted from the question “What would you like to change or make better about this program?” were valuable in the iterative development of the program. In the final years of implementation there were fewer students suggesting program improvements compared to earlier years, indicating that the modifications made to the curriculum at subsequent stages of implementation played a role in addressing these program shortcomings.The themes extracted from the open-ended survey question “What did you like best about the program?” are consistent with themes extracted from interviews with participants in the SYDCP pilot study and are The qualitative data describing the behavior change plans of the student coaches suggest that program participation may play an important role in encouraging at-risk youth to adopt healthy behaviors . The quaIn review of the literature, a number of programs aim to reduce risk factors for and/or prevent the onset of diabetes in ethnic minority youth. One program found that using a community based participatory research approach was an effective strategy to adapt the highly successful National Diabetes Prevention Program for adulth grade student participants completed pre-tests, attended all eight program sessions, but did not complete posttests because the school site staff member was ill and not able to provide the posttest before the seniors finished their shortened academic year.The logistics of partnerships between underserved schools and residency programs can present challenges in communication and scheduling. It is the experience of our research team that underserved schools are frequently understaffed and overburdened, and as a result, lapses in communication about the SYDCP have occurred. Additionally, unforeseen occurrences such as inclement weather or special programs contribute to challenges of scheduling. Furthermore, it is frequently difficult to obtain data from all participating high school students. The research team is frequently unable to evaluate the impact of the program because many students to not complete either the pre or the post-test due to challenges described above in the results section. Additionally, because school staff have multiple responsibilities and rarely have assistance, staff usually offer the pre- and posttests at one time only and do not offer “make-ups.” Likewise, if the designated SYDCP school site staff member is not available, pre- and/or posttests may not be offered at all. For example, one group of 12This study was limited in that post participation evaluation only occurred immediately after the eight-week program and therefore could not assess duration of program benefits. Additionally, apart from student coaches’ qualitative reporting of family member benefit and phone interviews during the pilot testing phase of the project, our research team did not assess program impact for the family members being coached. Evaluation was limited because it included self-report measures to assess changes in health behaviors which are known to be less accurate than objective measures; and because the sample size was so small for the evaluation of the technologically enhanced curriculum pilot, it is difficult to draw any formal conclusions. Lastly, there is inherent variability of program administration based on differences in instructors, students, and program sites. Although we could analyze program impact for specific settings, instructors, and students, here we are combining sites for much of the analysis, and therefore representing only an overall median outcome.Currently, the SYDCP is only an eight-week intervention. Our research team aims to encourage prolonged engagement with health promotion methods and the use of self-management skills beyond the eight weeks. By utilizing online resources and social media, as well as mobile technology such as text messages, the program could allow student coaches, family members, and physician instructors to stay connected, share resources, and gain access to current health information. Concordantly, our team plans to evaluate the student coaches at several time points after participation to assess the duration of program benefits. Additionally, our team will assess the program impact on family members being coached in the program.The SYDCP is an effective, scalable intervention that can be reliably reproduced at sites around North America. This program can increase health knowledge and some psychosocial assets of at-risk students and holds promise to empower student coaches with health literacy and encourage them to adopt healthy behaviors. In concert with training primary care physicians to better partner with their patients, the SYDCP has the potential to equip at-risk populations to become engaged in healthcare and empowered to improve their own health. This program illustrates the potential of partnerships between schools, physicians, and families, and the benefit of an iterative process of program development and dissemination in order to meet the needs of all partners. The SYDCP effectively leverages the inherent altruism of teens to help their family members and the aspirational goals of physicians in training to help communities realize a diabetes education and prevention system that is accessible, sustainable and reproducible—even for under resourced communities.


Dr. Tianzhuang Huang is not included in the author byline. He should be listed as the seventeenth author and affiliated with Yunnan Key Laboratory of Primate Biomedical Research, Kunming, Yunnan, China. The contributions of this author are as follows: Contributed reagents/materials/analysis tools and performed the experiments.There are errors in the Funding section. The correct funding information is as follows: This work was supported by National Program on Key Basic Research Project , the National High-Tech R & D Program of China (863 Program 2012AA020701), the Strategic Priority Research Program of the Chinese Academy of Sciences, Grant No. XDB02020005, the Key Research Program of the Chinese Academy of Sciences, Key Program of the Chinese Academy of Sciences (KZCC-EW-103-2), Training Program of the Major Research Plan of the National Natural Science Foundation of China (91332120), National Natural Science Foundation of China , the Yunnan Provincial Project to Attract One-hundred Exceptional Talents from Overseas, and Selected Frontier Scientific Significant Breakthrough Project of CAS, International Cooperation Projection (2011C14026) of Zhejiang Province Department of Science and Technology. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.


On May 12, 2008, an earthquake with a power of 8.0 M on the Richter scale occurred in the Wenchuan County of Sichuan Province in southwest China, which was unprecedented in magnitude and aftermath. Approximately 70,000 people were killed and nearly 20,000 went missing. The earthquake caused a wide number of mental and physical health outcomes among survivors, and posttraumatic stress disorder (PTSD) was one of the most commonly studied.We conducted a systematic overview to assess research achievements about PTSD in the past 6 years after the Wenchuan earthquake, including symptoms and risk factors about PTSD among Wenchuan earthquake survivors, as well as research developments in genetics, molecular biology, and treatment of PTSD.The large body of research conducted after the Wenchuan earthquake suggests that the burden of PTSD among persons with high exposure was substantial. Adolescents and adults were among the most studied populations with high prevalence rates. Phytotherapy with Chinese herbs as well as acupuncture were rarely studied as of yet, although published data indicated promising therapy effects. Genome-wide microarray technologies are widely used in experimental mice and rat models to study PTSD mechanisms as well as in patients suffering from PTSD and other psychosomatic disorders to search for novel biomarkers and to monitor the effectiveness of treatment interventions.Using genomic and transcriptomic technologies, our future research will focus on the efficacy and safety of Chinese medicine to find potential interventions and effective treatments of PTSD.


Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) of mediastinal lymph nodes is essential for lung cancer staging and distinction between curative and palliative treatment. Precise sampling is crucial. Navigation and multimodal imaging may improve the efficiency of EBUS-TBNA. We demonstrate a novel EBUS-TBNA navigation system in a dedicated airway phantom.Using a convex probe EBUS bronchoscope (CP-EBUS) with an integrated sensor for electromagnetic (EM) position tracking, we performed navigated CP-EBUS in a phantom. Preoperative computed tomography (CT) and real-time ultrasound (US) images were integrated into a navigation platform for EM navigated bronchoscopy. The coordinates of targets in CT and US volumes were registered in the navigation system, and the position deviation was calculated.The system visualized all tumor models and displayed their fused CT and US images in correct positions in the navigation system. Navigating the EBUS bronchoscope was fast and easy. Mean error observed between US and CT positions for 11 target lesions (37 measurements) was The feasibility of our novel navigated CP-EBUS system was successfully demonstrated. An EBUS navigation system is needed to meet future requirements of precise mediastinal lymph node mapping, and provides new opportunities for procedure documentation in EBUS-TBNA. Lung cancer is the second most frequent cancer worldwide, and five-year survival rates are only 10–15 % . The cliEndobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is now the method of choice for tissue confirmation of mediastinal lymph node metastasis –9, and hFor real-time TBNA guiding of lymph nodes positioned close to the central airways, the convex probe EBUS bronchoscope (CP-EBUS) is superior . In CP-Ementclass2pt{minimmentclass2pt{minimAlthough the method’s sensitivity and diagnostic accuracy are excellent , 12, 15,In lung cancer staging, CP-EBUS-TBNA has previously targeted mainly lymph nodes that are pathologically enlarged , can facilitate endoscopic access to mediastinal lymph nodes –23. In EReal-time position tracking of any EBUS bronchoscope (RP-EBUS and CP-EBUS) has not been available so far. Only a few research groups have addressed this issue. Luo and Mori have presented a research system for navigated RP-EBUS, trying to improve position control during sampling of lung tumors in the peripheral airways . The sysAnother system for multimodal image guiding in bronchoscopy was recently presented by Zang et al. . Their pOur research group has previously developed software and hardware platforms for image-guided interventions –33. In tWe suggest that EM navigated CP-EBUS and multimodal imaging may improve CP-EBUS-TBNA precision in lung cancer staging, shorten the procedure time, provide new possibilities for documentation, and serve as a learning tool for apprentice endoscopists. The purpose of this phantom study was to validate the preclinical feasibility of the navigated CP-EBUS experimental platform. The paper describes technical components, accuracy measurements, and possible future applications of the new technology.http://www.custusx.org) [The navigated EBUS system is based on an existing navigation research platform, CustusX  . Figure Computer and softwareDesktop computer [AMD FX(Research navigation software platform (CustusX)Bronchoscopy equipmentFlexible bronchoscope  for ENBCP-EBUS bronchoscope  for navigated EBUSVideo processing unit Light source Ultrasound processor Electromagnetic position tracking systemTracking sensor PhantomAn in-house prepared gelatin-based airway phantom, containing silicone tumor models/targetshttp://www.custusx.org). The system is used by researchers and commercial vendors both internationally and as part of a national research infrastructure. CustusX is already applied in other clinical areas, f.i. neurosurgery, laparoscopy, endovascular therapy, and lung endoscopy [The research and development system for intraoperative image guiding upon which the navigated EBUS platform is based, CustusX, is open source  and line segments representing the airway centerline Fig. . A time-The navigation platform allows several opportunities for graphical user interface (GUI) organization , e.g., fThe exact location of the bronchoscope during sampling  and the relevant anatomical area covered during the procedure are documented and stored in the navigated EBUS system, and the whole procedure may later be replayed.Our research group has previously modified a flexible bronchoscope, integrating an EMT sensor for position tracking . We haveThe position of the EMT sensor and hence the US transducer of the EBUS bronchoscope is measured using the Aurora Electromagnetic Tracking Systemfacturer .For this navigated EBUS feasibility experiment, we prepared a gelatin-based airway phantom mimicking the trachea and main bronchi, containing silicone tumor models serving as targets Fig. . The tarR was attached to the phantom, and another position sensor B was mounted close to the tip of the EBUS bronchoscope. The tracking system reported the position of sensor B relative to the reference sensor R, i.e., the transformation R to B at time i. The probe calibration, i.e., the transformation from the US image coordinate system to the EBUS sensor coordinate system, is denoted as The transformations between the coordinate systems described in this paper are illustrated in Fig. An image registration matches the CT image data to the patient at the start of the bronchoscopy Figs. , 6. BothCustusX also has a built-in automatic image-to-patient centerline-based registration method , but thiR was attached to the calibration arm, and the position of the center of the sphere In order to find the spatial relation between the real-time US image and the EMT sensor on the EBUS probe, a probe calibration  had to bThe calibration arm was then attached to a six-axis robot arm  and submerged in water. The EBUS probe was located in a fixed position directly above the imaging target. The robot arm then moved the plastic sphere slowly (1 mm/s), first through the ultrasound image plane and then in the opposite direction along the same path, resulting in two sequences of recorded US images of the sphere passing through the US plane. This was repeated for nine positions evenly distributed throughout the image plane. For each US image, the transformation Next, the position of the plastic sphere within each of the totally 18 US recordings was manually located. Each recording was read into the software MATLAB  and displayed. The image within the recording where the center of the sphere passed through the US image was found. Furthermore, the location of the sphere center within that image was found by adjusting the position of a virtual circle of the same diameter as the sphere, until its circumference corresponded with the surface of the imaged sphere  already familiar to the operator during CP-EBUS-TBNA, increasing the user-friendliness of the multimodal image guiding.The results presented in this paper have to be carefully interpreted, as they originate from one phantom experiment only. Real-life respiratory movement, heart beats, and disturbances in the EM field from other medical technical equipment could influence the navigated CP-EBUS system accuracy. In clinical cases, time constraints and unforeseen patient-related events can also challenge the workflow of any image-guiding system. Further validation studies are therefore needed before routine clinical use.The manual shift correction from US to CT volumes for system accuracy calculations may have introduced error to the experiment, potentially avoided or minimized by letting several persons perform the shift correction. Another limitation to the experimental platform is that the TBNA needle is not traceable in the navigation system. As for now, the operator have to rely on US guidance during the target sampling situation, like in conventional CP-EBUS. By implementing tracked sampling tools, we could get a better impression of the usefulness of fused EM navigation and US during the sampling process, and hopefully increase TBNA precision. Traceable TBNA needles, which are disposable, would however be more costly than using only a permanently mounted position sensor on the bronchoscope.As far as the research and development platform for navigated CP-EBUS is concerned, both software and hardware are in-house solutions. However, since the software recently has been made available through open source, reproducing the study results will be easier.Some commercial systems involve a position tracking sensor within the working channel of the bronchoscope . In our Although multimodal image guiding in bronchoscopy is increasingly called for by endoscopists, similar studies implying navigated EBUS (RP-EBUS or CP-EBUS) are scarce. The commercial systems previously combining EBUS and EM navigation in clinical studies applied sequential procedures with no real-time tracking of the EBUS images , 25. TheThe image-guiding system of Zang et al is, like our navigated CP-EBUS system, addressing the problem of 2D EBUS not being directly linked to preoperative CT images. Zang’s system does however require an extensive amount of planning and manual image preprocessing, probably making it more suitable for postoperative analysis and learning purposes. Luo and Mori’s method for navigated EBUS distinguishes from ours in several aspects. They use an RP-EBUS probe, with a different clinical field of use than the CP-EBUS bronchoscope. Tracking of the radial probe is possible due to an external sensor that could be vulnerable to mechanical strain intraoperatively. The attachment site of the sensor could possibly interfere with the US image, which is an important part of the diagnostic tool for the operator. Neither Luo’s system nor ours have traceable sampling tools.The main improvement over existing solutions is that our system allows actual guiding of a convex probe EBUS bronchoscope designed for transbronchial lymph node sampling in the mediastinum. Even when bronchoscope vision is reduced due to blood or mucus within the airways, the combined CP-EBUS and preoperative CT in the same image provides concurrent, real-time image-guided position control and needle puncture. Our navigated CP-EBUS system also makes recording of US imaging combined with the equivalent CT slice possible for documentation purposes. This is not available in current EBUS-TBNA systems. The endoscopist can thereby replay the entire navigated procedure, ensuring that the correct lymph nodes are sampled and in the correct sequence. This is important in lung cancer staging, where mediastinal lymph node sampling should be carefully planned and evaluated to avoid errors depriving patients of life-saving surgery.All our technological solutions are focused on user-friendliness and availability through open-source access, and imminent implementation in the clinic is a paramount aim. Basically, anyone can perform EM navigated EBUS with an available EBUS probe and an Aurora or similar EM sensor. The commercial providers currently do not sell their systems with EM-based tracking for any type of EBUS.CP-EBUS-TBNA is now the method of choice for mediastinal lung cancer staging in all patients with potential to cure . IntraopImproving a successful technique such as CP-EBUS is indeed a challenge. Like many other developments in diagnostic or surgical procedures, the navigated CP-EBUS system presented might not be able to improve success rates. Hopefully, the new approach can increase diagnostic confidence in closely located lymph node stations, where puncturing the wrong lymph node will have important clinical implications. Locating smaller lymph nodes in technically challenging positions could be easier with combined CP-EBUS/navigation technology. Fast and easy target localization, reproducible sampling, and improved quality control could also minimize the inter-operator performance variability.The clinical use of CP-EBUS-TBNA will become more widespread and challenging in the future lung cancer work-up due to international agreement on routine systematic mapping . StrategNavigated CP-EBUS seems promising for increased efficiency throughout the lung cancer diagnostic patient course, potentially saving time and health resources in line with governmental areas of priority. Traceable TBNA needles may increase the diagnostic reach in the mediastinum, and together with 3D US provide more detailed overview and needle position control than by 2D US guidance alone. The image acquisition store and replay functionality is interesting for medical record procedure documentation, interventional training, multidisciplinary meetings, and therapeutic decision making. Future challenges in refining the navigated CP-EBUS system are improved integration of sensors into the instruments and sampling tools, correction of errors from respiratory movement, and refining visualization techniques and software to better suit the procedure workflow.A CP-EBUS navigation system is needed to meet future requirements of lung cancer staging in the mediastinum. Our novel platform for EM navigated CP-EBUS performed well in a lung phantom concerning basic functionality, image fusion, target localization, robustness, accuracy, and user-friendliness. Even though some technological solutions must be refined, the EM navigated CP-EBUS system is ready to be applied in the clinic. Human studies are ongoing.


Research on long-term health effects of earthquakes is scarce, especially in low- and middle-income countries, which are disproportionately affected by disasters. To date, progress in this area has been hampered by the lack of tools to accurately measure these effects. Here, we explored whether long-term public health effects of earthquakes can be assessed using a combination of readily available data sources on public health and geographic distribution of seismic activity.We used childhood stunting as a proxy for public health effects. Data on stunting were attained from Demographic and Health Surveys. Earthquake data were obtained from U.S. Geological Survey’s ShakeMaps, geographic information system-based maps that divide earthquake affected areas into different shaking intensity zones. We combined these two data sources to categorize the surveyed children into different earthquake exposure groups, based on how much their area of residence was affected by the earthquake. We assessed the feasibility of the approach using a real earthquake case – an 8.4 magnitude earthquake that hit southern Peru in 2001.Our results indicate that the combination of health survey data and disaster data may offer a readily accessible and accurate method for determining the long-term public health consequences of a natural disaster. Our work allowed us to make pre- and post- earthquake comparisons of stunting, an important indicator of the well-being of a society, as well as comparisons between populations with different levels of exposure to the earthquake. Furthermore, the detailed GIS based data provided a precise and objective definition of earthquake exposure. Our approach should be considered in future public health and disaster research exploring the long-term effects of earthquakes and potentially other natural disasters. Earthquakes are natural disasters that impact health and society. During the past two decades alone, earthquakes have caused nearly one million deaths globally . Other sResearch into the health effects of earthquakes has overwhelmingly focused on immediate consequences, such as on injury and mortality. Furthermore, most studies concentrate on high-income settings , althougOne way to quantify long-term effects of earthquakes could be to monitor changes in important public health indicators. Such indicators often reflect living conditions, socioeconomic status and other factors that affect the general well-being of a population, and that can be affected by an earthquake. Furthermore, such indicators are often routinely collected in national health surveys. For example, Zolala et al considered maternal mortality a useful indicator to measure long-term health effects of the 2003 Bam earthquake, since maternal deaths were likely to be affected by the earthquake’s impact on women’s living conditions and access to health care . ChildhoData on the distribution of earthquakes and other natural disasters have also recently become more accessible due to the increasing use of geographic Information Systems (GIS) . For exaIn this study we explored whether long-term public health effects of earthquakes can be assessed using a combination of readily available data sources on public health and geographic distribution of seismic activity.We tested the approach using a real case—an earthquake that hit southern Peru on June 23rd 2001. Three criteria were used to select the case. First, DHS data had to be available both before and after the earthquake, with significant time (at least two years) elapsing between the earthquake and the last measuring-point. Second, the ShakeMap atlas had to include GIS-based intensity data for that specific earthquake. Finally, the clusters surveyed in DHS had to be geo-referenced. The latter two criteria were deemed necessary to geographically link households to the corresponding earthquake intensity level.Peru is a middle income country . Rapid ePeru lies on an area of intense seismic activity and is frequently affected by earthquakes. The earthquake investigated in this study struck outside the southern coast and measured 8.4 on the Richter scale see . Over 30standard DHS [continuous DHS [Two DHS surveys were considered for our study: one dard DHS  and one uous DHS ,24. The uous DHS  and 98% uous DHS . About 9uous DHS ,23,24.The surveyed clusters were geo-referenced, and data files with the geographical location (GPS) of the clusters were provided in addition to the survey data sets. To assure respondents’ confidentiality, the GPS positions were randomly displaced up to two kilometres in urban areas and ten kilometres in rural areas .In USGS ShakeMaps, seismic intensity levels are derived instrumentally, by combining instrumental measurements with information about local seismic conditions and the earthquake source . SeismicWe used a GIS software program (ArcGIS version 10.1) to link each surveyed cluster to the corresponding MMI value in the area. The MMI zone map and the cluster GPS-point map were overlaid and joined using the software’s spatial join tool. This created a data set that contained the unique cluster numbers and the corresponding MMI values. This data set was subsequently merged with the full DHS data set, using the cluster number as the common variable.This study was based on secondary analysis, using data from publically available databases (DHS and USGS Shakemap archive). The DHS surveys were approved by the the Peruvian National Institute for Statistics (INEI) and the ICF Macro at Calverton in the USA. Data were collected with informed consent and anonymity of respondents was assured. Geographical data did not disclose the location of individual households .Stunting was defined as a height-for-age more than two standard deviations below the median of the World Health Organization (WHO) growth reference population . BiologiThe MMI values were categorized into three intensity level zones. MMI values I through IV, were not portrayed on the intensity map and were therefore collapsed into the low intensity zone. The remaining observations were divided into medium and high intensity zone by the median MMI value. As a result, the medium intensity zone included MMI value V and the high exposure zone values VI through VIII.Children were categorized into pre- and post-earthquake groups according to their year of birth. This categorization minimized the risk of including prevalent cases of stunting in the post-earthquake group, i.e. children who were already stunted before the earthquake. Children born before the earthquake (1995–2000) comprised the pre-earthquake reference group. The two post-earthquake groups consisted of children born shortly after (2001–2003), and a few years after (2004–2008) the earthquake respectively. The cut-offs between these two groups was defined by the median birth year.Other covariates collected from the DHS survey data sets included age of the child , motherhe child , and availability of household electricity . The latter two were considered proxies for socioeconomic status.We first conducted descriptive analysis by comparing the prevalence of stunting between the birth year groups and, in turn, comparing these differences between the intensity zones. The descriptive analysis was restricted to children over two years of age, as few incident cases occur after this age . MultileUsing the results of the spatial join between the ShakeMap and the DHS clusters, we developed a GIS-based map that portrays the earthquake affected southern part of Peru divided into the three intensity zones, with the triangle shaped points marking the locations of the surveyed clusters . This maThe median and high intensity zones included just over 1,000 children each . Over 11We determined that the high intensity zone was mainly urban and the majority of the population was of Spanish ethnicity . This zoDue to these large pre-earthquake differences in socioeconomic indicators and other important risk factors of stunting, we stratified our analyses by intensity zone. We found that in the high intensity zone 14% of the children born before the earthquake were stunted . The corWhen we investigated the association between birth year group and stunting in the multilevel analysis and adjusted for age of the child, the odds of stunting were not significantly different between any of the birth year groups. The exception was the low intensity zone, in which the odds of stunting among children born several year after the earthquake (2004–2008) was 20% lower than in the pre-earthquake reference group , Model 1Our results indicate that long-term public health effects of earthquakes, more specifically effects on childhood stunting, may be evaluated using a combination of ShakeMap and DHS data. Both data sources are readily available online, and may be combined using the geographical coordinates of the surveyed clusters. The repeated measuring-points of DHS surveys allow comparing stunting levels before and after an earthquake, a prerequisite to draw conclusions about its effects. Follow-up data was available for up to seven years after the earthquake, which gives a unique opportunity to study long-term effects. Most previous information about public health effects of earthquakes come from studies with short-term follow up, and/or without baseline data ,29. DHS Our work shows that the level of stunting in Peru was elevated among children born after the 2001 earthquake only in areas exposed to high seismic intensity levels. These results are consistent with previous findings indicating that the societal impact of earthquakes swells with increasing levels of intensity . The facOur results underline the importance of GIS-based disaster data for assessing effects of a disaster on a given population with high precision. As the intensity levels of the earthquake cut across administrative borders, a division based on administrative boundaries would have resulted in misclassification of earthquake exposure. Our results therefore confirm previous findings that GIS data provide a more precise estimation of disaster affected populations than when administrative borders are used to demarcate disaster zones .We identified a few factors that limit the usefulness of the approach. Firstly, DHS samples are not designated to be broken down into intensity zones. As the sample sizes in the medium and high intensity zones were relatively small in our Peruvian model, they yielded decreased statistical power, especially in the high intensity zone, where stunting prevalence was low compared to the other zones. The same issue has been discussed previously in a Tsunami Recovery Impact Assessment and Monitoring System (TRIAMS) workshop, where the use of national household survey data was recommended to follow the recovery process of the 2004 Indian Ocean tsunami . A suggeAnother disadvantage was the large difference between the earthquake intensity zones at “baseline” (i.e. before the earthquake hit). The area most affected by the quake was mainly urban, had relatively high socioeconomic status, and significantly lower levels of stunting than the rest of the country. According to Ukoumunne et al., such baseline imbalance might bias results of effect evaluation studies, because changes over time are dependent on the levels at baseline . For exaThe cross-sectional design of DHS is another potential weakness of the approach. Large migration from the earthquake-affected areas might change population composition and bias prevalence estimates. For example, if well-off families migrate to a larger extent than poorer families, an artificial increase of stunting would occur in the remaining population. To rule out this possibility, the same children would have to be followed over time in a longitudinal study. To assess the validity of results based on cross-sectional data, it will be important to study patterns of population displacement from affected areas.A limitation of our study is that we did not have a gold standard of comparison to know if the approach generated valid results. The lack of previous research also precludes comparing our results to other studies. The social and economic impacts of earthquakes are well-known, at least in the short-term, as is the link between socioeconomic factors and stunting. However, a direct link between earthquakes and stunting has not been reported in previous literature. Nevertheless, the main aim of this study was to test the feasibility of the approach, not to determine the validity of the results.Our study only evaluated a single earthquake, and some of our assumptions and results may not be applicable to other locales and earthquakes. In addition, the availability of DHS and ShakeMap data differs from case to case. For example, not all DHS surveys collect GPS data, which is necessary to link the respondents to the respective seismic intensity zones. Considering the wealth of both DHS and ShakeMap data, however, it is likely that our approach can be applied to other earthquakes and potentially even other natural disasters, using other sources of GIS disaster data. For example, Guha-Sapir et al.  reportedLong-term public health effects of earthquakes are understudied in disaster research, which may be attributed to the lack of systematically collected health data in affected regions. Our study suggests that a combination of readily available data sources can be used to increase knowledge about such long-term effects. Although limitations exist, given the wealth, easy access, and good quality of DHS and ShakeMap data, it is an approach worth investigating further and considering in future public health and disaster research.


Aims. To evaluate the long-term effects of two school-based prevention programs administered to a universal mixed-sex sample of school-going adolescents on disturbed eating attitudes, aesthetic ideal internalization, and other eating disorder risk factors, when compared to a control group. Methods. Participants were 200 adolescents aged 12–15 selected by means of incidental sampling from second-year compulsory secondary education at schools. An interactive multimedia media literacy program  and a program focused on the same topics using dramatic arts (Theatre Alive) were applied and compared with a control group. Pretest, posttest (1 month later), and 5- and 13-month follow-up measurements were taken. Analyses were conducted with two-way mixed 3 × 3 ANCOVA (group × phase) adjusted by baseline levels, body mass index, and sex. Results. Participants in both experimental groups showed significantly higher self-esteem scores than the control group over time. The ML + NUT group also presented lower aesthetic ideal internalization scores than the control group. Discussion. Both programs can benefit students' self-esteem. Moreover, ML + NUT program was useful in reducing thin-ideal internalization. However, differences in body dissatisfaction and disordered eating attitudes were not found. The programs may be protective on the core psychological variables, which are essential to adaptive adolescent development. In different countries of Europe, in community samples, eating-related problems in around 15–30% of adolescent girls have been reported , it is cYouth may spend 33–50% of their time with some form of mass media . InsteadEating disorder prevention programs produced significant reductions in measures of eating disorder symptoms according to Stice et al.'s review . ProgramBearing in mind this consideration, we developed a universal school-based disordered eating prevention program aimed at reducing disturbed eating attitudes and diminishing ideal aesthetic internalization. Thus, its components were designed to modify some ED risk factors identified prospectively , 12 baseThis modified intervention was evaluated by several studies –19 in adRecent studies have verified that theatre can play a preventive role in weight-related problems, since performing in a play offers adolescents a leadership opportunity in which they get to teach, thus increasing their sense of self-empowerment and ownership of the messages , 22. VerHence, the purpose of this study is to evaluate the middle- and long-term effects of two school-based prevention programs administered to a universal mixed-sex sample of school-going adolescents on disturbed eating attitudes, aesthetic ideal internalization, and other ED risk factors such as body dissatisfaction and self-esteem. Thus, the interactive multimedia program based on the philosophy of media literacy and another program focused on the same topics but with a methodology based on the dramatic arts were both compared to a control group at posttreatment and at 5- and 13-month follow-ups. We hypothesized that over time both groups receiving preventive interventions would experience lower disturbed eating attitudes, aesthetic ideal internalization, and body dissatisfaction and higher self-esteem than the nontreatment control group.Participants were recruited from second-year compulsory secondary education at five urban state and state-subsidised schools in the city of Manresa, located in the Barcelona region , who agreed to participate. They were selected by means of incidental sampling. Of the 207 initial participants, data were obtained from 200 adolescents  aged 12–15 , the reduction in sample size being due to some of the questionnaires not being fully answered. Mean body mass index, based on in situ measurements of height and weight, was 20.0 (SD = 3.1) for girls and 20.6 (SD = 3.6) for boys. Weight status, according to international criteria that take sex and age into consideration , 25, wasThe schools were assigned to the experimental conditions taking into account the schools as the sample unit, not individual participants, in order to avoid the spill-over effect between the experimental condition participants. Therefore, the biggest school served as the control group, two schools received the ML + NUT program, and two more schools were assigned to the theatre program. One hundred and fifty-six participants (75.4%) remained until the last follow-up, with the reduction in sample size being due to absences on the testing days, changes in school, or blank questionnaires being returned .Personal, family, and social details were collected; we ascertained the socioeconomic status based on the parents' educational level and occupation according to Hollingshead's index .Weight and height measurements were taken using a 100 g Tefal scale sensitive computer and a 2 m Kawe Kw 444440 human height measuring system, and then data were averaged and body mass index (BMI) was calculated.never) to 6 ; the three least pathological responses receive 0 points and the other responses receive 1, 2, and 3 points to denote increasing severity. The total score is obtained by a sum of the items, after reversing them when necessary, and higher scores indicate more disordered eating. We applied the Spanish adaptation [α ≥ .91 for each assessment point). The cutoff is a score of 10.This 26-item self-reported questionnaire assesses feelings and behaviours that are characteristic of individuals with disordered eating and is therefore considered a good screening tool to assess and identify people at risk of having an ED. The items provide six response options ranging from 1 , and the total score is the sum of the positive answers. We applied the Spanish adaptation [The SCOFF is a screening questionnaire to assess disordered eating. It contains 5 dichotomous questions (aptation  of this aptation . A scorestrongly disagree) to 5 (strongly agree). The SATAQ-R consists of two subscales: awareness (11 items) and internalization (10 items). Awareness has been defined as knowledge that a standard of appearance exists, while internalization is a profound incorporation or acceptance of these values that affects one's attitudes or personal behaviour. Scale scores are obtained by the average of the corresponding items, after reversing them when necessary, and higher scores indicate a stronger presence of the corresponding construct. In the present sample, the internal consistency was satisfactory for both the awareness and internalization scale scores , similar to Cusumano and Thompson [This self-reported questionnaire was developed to assess awareness of and the tendency to strive toward social standards of appearance . We usedThompson . extremely thin (1) to very obese (9). Participants are asked to rate their ideal figure  and their current size (perceived figure). We used the discrepancy between the ideal and current size scores in absolute value as an index of body size dissatisfaction, which can range from 0 to 8, with higher scores indicating more dissatisfaction. Evidence of satisfactory validity and test-retest reliability in male and female undergraduates and early adolescent girls has been reported [The CDRS consists of nine drawings of a female or male figure, depending on the sex of the respondent. Each drawing increases in size fromreported , 36.strongly disagree) to 4 (strongly agree). The total score is obtained by a sum of the items, after reversing them when necessary, and higher scores indicate better self-esteem. Satisfactory psychometric properties have been demonstrated for the English version [α ≥ .81 for each assessment point).We used the Spanish adaptation . This is version , as well version . In the P > .01), since α comparison tests showed no statistical differences between groups, except for the RSES scale score .Cronbach's alpha values for all questionnaire measures were equivalent across sex , first follow-up (5 months), and second follow-up (13 months).While the control participants took normal classes, the participants assigned to the improved ML + NUT or theatre program participated in the interventions once a week in 10 sessions of 120 minutes each facilitated by some of the authors of the program and trained psychologists and professional actors. These sessions were held during academic year 2011-2012 in mixed-sex classes with an average of 30 students per class. Data were collected by our team at the schools, ensuring that there were two team members for each class plus the teacher in charge. After securing the teachers' agreement and after issuing general instructions in class, the participants answered the assessment battery individually and anonymously in the classroom during normal class time. Confidentiality was assured, as was the possibility of getting feedback through a mnemonic code. In situ height and weight measures were taken by two members of the team individually and privately to ensure confidentiality.Eating, feminine aesthetic beauty model, and the mass media: how to train critical students in secondary school” [“ school” : the two activism activities that involve critical analysis of advertisements were proposed, such as learning about how to write letters of complaint to the media, as well as new activities about a collective and collaborative production including both an “analysis of advertising messages” and a “parody making-of video” from fashion advertisements  levels. “Theatre Alive” promotes critical analysis of the ideals of male and female beauty that are transmitted in the media, revealing the tricks and montages used in advertisements. The program is based on preparing and performing a play called “Teen Spirit.” A special script created by playwright J. Faura with advice from our research team was developed for the play using the core of the media literacy multimedia program along with information gathered in interviews with adolescents.This program is based on the premises of social cognitive theory  and the Students learned the script and dramatic expression in 10 sessions conducted during class time under the guidance of professional actors. Each student played a character in the play. The program ended with a performance for parents and the school community.t-test procedures. Next, ANCOVA procedures were used to assess the effectiveness of the ML + NUT and Theatre Alive programs over follow-ups, as in previous studies [ Theatre Alive and control) × 3  two-way mixed design adjusted by preprogram scores, BMI, and sex, for each of the six outcome variables considered: EAT-26, SCOFF, SATAQ-R , CDRS, and RSES. For hierarchical models as ours, the interaction effect (group × phase) was evaluated first and, when not statistically significant, main effects were then interpreted, the α level being set at .05. Corrections for lack of homogeneity and/or lack of sphericity were applied when necessary, by adjusting the degrees of freedom of the F-distribution (lower-bound adjustment method for the former). When the main effect of group was found to be statistically significant in absence of a higher-order interaction effect, Bonferroni-adjusted post hoc analyses were conducted to value mean differences  among groups, and effect sizes were calculated through Cohen's d  and participants who were absent  did not differ in terms of sex (P = .172), age (P = .658), group allocation (P = .223), weight status (P = .067), BMI (P = .348) or baseline SCOFF scores (P = .101), self-esteem (P = .089), SATAQ-R awareness (P = .974), and SATAQ-R internalisation (P = .491). However, the participants who remained scored lower at baseline than those who dropped out at any assessment point for EAT  and CDRS body dissatisfaction .Participants who completed the three follow-ups  and self-esteem (P = .005) scores. When compared to participants in the control group, the adolescents who received the ML + NUT program scored 0.25 points less on SATAQ-R internalisation scores  and 1.66 points more on self-esteem scores . When compared to the control group, participants who received the Theatre Alive program also scored 1.58 points higher on self-esteem scores , whereas differences regarding SATAQ-R internalisation scores were only nearly statistically significant .  Theatre Alive programs) showed significantly higher self-esteem scores than the control group after the intervention and at the 5-month and 13-month follow-ups. Furthermore, the ML + NUT group showed lower aesthetic ideal internalization scores than the control group after the intervention and at later time points. Therefore, these findings suggest both that the two prevention programs are effective in producing significant changes in the treated groups, increasing their self-esteem and partially reducing their internalization, and that these changes are sustained over time.This study used a longitudinal design with a follow-up at 5 and 13 months in a school-based ongoing prevention program with a universal mixed-gender sample. The aim was mainly to reduce disturbed eating attitudes and diminish ideal aesthetic internalization through an interactive multimedia program based on media literacy or a program focused on the same topics but based on the dramatic arts, when compared to a control group. The main effect of intervention was statistically significant for some variables, since participants in both experimental groups  and moderate self-esteem (d = 0.57) when compared to the control group. Working on life-skills variables through media literacy preventive programs could strengthen the participants by making them more resilient to harmful media influences, limiting the impact on body dissatisfaction and interrupting the progress towards dangerous weight loss behaviours and later towards an ED.The results suggest that the process of body ideal internalization is not the most antecedent variable in pathways toward body dissatisfaction. Likewise, Karazsia et al.  uphold t Theatre Alive program may be an effective strategy for use in school-based interventions aimed at preventing ED by increasing self-esteem, although its effects may not be important enough to reduce the level of internalization. It appears that the effects of the Theatre Alive program are less specific than those of the ML + NUT program but still moderate for self-esteem (d = 0.50) when compared to the control group. We believe that preventive drama programs are a promising methodology to involve children and their families with health-related messages and an excellent framework for increased resilience to comments from others. They yield positive changes in communication with them and offer a peer leadership opportunity in which children can teach others. Finally, these learning processes help to boost the participants' self-esteem.Our findings also suggest that the Theatre Alive program could be improved, as suggested by Haines et al. [Although our drama-based intervention was inspired by the philosophy of media literacy as well (if we take the content into account), it is not based so much on engaging participants in cognitive criticism and actively challenging these contents as on learning and memorizing a script with health promotion messages and finally performing it. Thes et al. , by giviTaking these results together, our hypotheses have been partially fulfilled. Both programs can benefit students' self-esteem; moreover, our ML + NUT program was useful in reducing ideal internalization, although the broader hypothesised effects on the other specific risk factors such as reduced body dissatisfaction or ED symptoms were not found. In addition to these reasons, it is possible that the weak internal consistency SCOFF could contribute to the absence of significant changes in eating disorder symptoms and maybe EAT is not the best instrument to detect risk for eating disorders at this subclinical stage as well.Some limitations should be taken into account when interpreting these results. First, although we used a control group for comparison purposes, this group did not receive any placebo intervention but continued to maintain their regular school activities. Second, we only used self-reported measures, which are very likely to be underreported  compared Theatre Alive program, and the other with an interactive and multimedia format. Furthermore, we believe that another interesting contribution is developing a media literacy program to challenge the masculine and feminine aesthetic models, the manipulations, and cheatings involved in how both models are conveyed in the media targeted at both female and male adolescents. It is necessary to target preventive efforts to the male population [One of the strengths of this study is that it compares two preventive programs which are linked by a common media literacy philosophy in the same study, one of them with an innovative methodology, thepulation , and thepulation , anotherpulation .Our study suggests that the two prevention programs are effective in increasing the adolescent's self-esteem and partially reducing their internalization and that these changes are stable over time. The influence of the programs is mainly exerted on distal variables working in the beginning of the pathogenic process. Both of the programs would show a protective effect on psychological variables deemed as life-skills. Insisting on life-skills variables through media literacy preventive programs could strengthen the participants by making them more resilient to detrimental media influences, reducing the impact on body dissatisfaction and stopping the progress towards an ED.A great deal of research is needed to clarify these results, and it might be interesting to compare the outcomes of both drama-based methodologies and more conventional media literacy programs targeting ED in larger samples, thereby also increasing their statistical power, with a dismantling approach to determine the beneficial components and the addition of booster sessions and more extensive follow-up to avoid a decrease in benefits from the prevention program .


The use of enzyme-linked immunosorbent assay (ELISA) for the detection of IgG and IgM antibodies antibrucella has become widespread in the diagnosis of human brucellosis. IgM anti-Brucella antibodies are indicative of acute infection. Between 2009–2013, 5307 patients were evaluated for serologic diagnosis at the Microbiology Laboratory of the Albacete General Hospital. A ELISA IgM-positive, IgG-negative anti-Brucella antibody serology pattern was detected in 17 of those patients. Epidemiology data, symptoms, laboratory data, treatment and outcome from these patients were reviewed. Sixteen patients presented with musculoskeletal pain, fatigue and/or fever and 1 was asymptomatic. Five patients received treatment with doxycycline combined with rifampin, gentamycin or streptomycin during 6–12 weeks, with no improvement. None of the 17 patients were finally diagnosed with brucellosis. Our results indicate that anti-Brucella IgM positive serology, per se, is not enough to diagnose acute brucellosis and other methods should be used for confirmation. Brucella serology data should be interpreted taking into account the patient's clinical history and epidemiological context. Brucella spp. is the isolation of the bacteria from body fluids or tissues, but the difficulty in obtaining positive bacterial cultures has led to the development of other diagnostic techniques. Rose Bengal test, Wright agglutination, Coombs antibrucella, immunocapture techniques, and serology to detect specific IgG and IgM antibodies usually by enzyme-linked immunosorbent assay (ELISA), are the serological methods most often used for the diagnosis of brucellosis. The use of ELISA techniques has become widespread in recent years. The detection of specific IgM by using ELISA is considered indicative of acute or recent infection. However, IgM antibody detection in the absence of IgG may lead to an erroneous diagnosis of acute brucellosis. We described a series of patients in which serology detected IgM but not IgG antibrucella antibodies. In these patients the clinical picture and the outcome are not suggestive of active infection caused by Brucella spp. This finding supports the conclusion that Brucella serology data should be interpreted taking into account the patient's clinical history and epidemiological context.Human brucellosis may present with a wide variety of symptoms and signs. Adequate laboratory diagnostic methods become necessary. The diagnostic method that proves infection caused by  Salmonella infections, tuberculosis or viral infections, and even non-infectious diseases Human brucellosis is a zoonosis with a worldwide distribution, with a low incidence in developed countries, but great importance in developing countries. Despite the efforts made to achieve its control or eradication, brucellosis remains prevalent in many countries of the Mediterranean area, the Middle East, lndia, Central Asia and Central and South America Brucella spp. is the isolation of the bacteria from body fluids or tissues. Although the isolation of Brucella spp. confirms the infection, the delay in culture results, the risk of infection of laboratory personnel The diagnostic method that proves infection caused by Brucella spp. differ among studies. Gomez et al. assign a sensitivity of 60% for IgM and 84% for IgG, while the combined specificity for IgG and IgM was 100% et al. found a combined IgG and IgM ELISA sensitivity of 100% but a combined specificity of 71.3% et al. reported a 92.3% combined sensitivity and a combined specificity of 55% ELISA techniques are low cost, require less time to complete and less training for interpretation compared with agglutination techniques The presence of specific IgM is considered indicative of acute or recent infection. However, IgM antibody detection in the absence of IgG may lead to an erroneous diagnosis of acute brucellosis Since April 2009, detection of IgG and IgM by ELISA has been introduced as a technique for serological diagnosis of human brucellosis at the Microbiology Laboratory of the Albacete General Hospital. This technique has replaced the Wright agglutinations and anti-Brucella Coombs test. Since then, some cases have been detected in which positive IgM results in the absence of antibrucella IgG have complicated the correct interpretation of the patient's symptoms, with the risk of misdiagnosis. The aim of this study is to assess the validity of the detection of IgM antibrucella when IgG is negative, by describing a series of patients in whom this serological pattern was found. We analyzed symptoms, medical history and clinical evolution, in order to determine whether these patients had acute brucellosis or not, and to better interpret such a result in clinical practice.We performed a search in the microbiology laboratory of the Albacete General Hospital for serum samples obtained between 2009 and February 2013 in which ELISA detected IgM antibrucella antibodies in the absence of IgG antibodies. This laboratory serves the Albacete General Hospital as well as the hospitals of Almansa, Villarrobledo and Hellin, all of them located in the Albacete Healthcare Region (Spain). The Albacete Healthcare Region has traditionally been an endemic area for brucellosis, although in the last 10 years the incidence has decreased significantly Brucella spp., symptoms that led to request serology, the number of times serology was repeated and the number of times in which the result was the same , the performance of other tests to confirm or discard the diagnosis of brucellosis, antibiotic treatment used following the results of the tests, and patient outcomes were collected. The final clinical diagnosis reached for each of these patients was recorded. Data were analyzed anonymously. The review of medical records was performed retrospectively on patient data and serological tests that were performed as part of routine hospital work. The Research Commission of the University Hospital of Albacete approved this study.The medical records of these patients were thoroughly reviewed. Age, gender, history of epidemiological exposure to ELISA detection of IgG and IgM was performed using a commercial kit . The technique was performed according to the instructions from the manufacturer. In brief, 100 µl of diluted serum samples and ready to use control sera were added to the microtest wells with antigen. The samples were then incubated at 37°C for 60 minutes, after which the first wash was performed. Later, anti-human IgM or IgG conjugated with an enzyme  was added and incubated for 30 minutes at 37°C in a moist chamber. All wells were then washed to remove excess conjugate, followed by a new incubation for 30 min at 37°C with the enzyme substrate (paranitrophenylphosphate). Finally, the reaction was stopped by adding 100 µl of stopping solution. The enzyme reaction with the substrate yields a colored product. Color intensity is proportional to the amount of specific antibody and can be measured by photometric methods. In the case of IgM-detection, absorption of rheumatoid factor was performed following the manufacturer's instructions. Titers above 25 IU/ml were considered positive for IgG, and above 20 IU/ml were considered positive for IgM. Titers were considered uncertain between 25 and 20 IU/ml for IgG, and between 20 and 15 IU/ml for IgM. Sensitivity and specificity provided by the manufacturer were >99% and 99.3% respectively for IgG and 91.3% and >99% respectively for IgM From April 2009 (when the ELISA was introduced in our laboratory) to February 2013, ELISA serology was performed on 5307 patients, with a total of 6175 samples processed. Of these samples, 5703 samples were negative for both IgG and IgM, 10 samples were positive for both IgG and IgM, 394 samples were positive for IgG and negative for IgM, and 68 samples were negative for IgG and positive or uncertain for IgM detection. These latter 68 samples were from 26 patients. One of these patients had acute brucellosis with one determination that was positive for IgM and negative for IgG, but subsequent determinations were positive for both IgM and IgG. For the remaining 67 samples, 49 were positive for IgM detection and 18 were uncertain. These uncertain samples were not included in our study.The 49 positive IgM samples were from 17 patients. The number of determinations per patient in whom serology was positive IgM and negative IgG ranged between 1 and 11. The age of these patients at the time of the first ELISA testing varied between 28 and 82 years. 35.3% of these patients were male. We have divided these patients into two groups. The first group included patients who had had brucellosis previously , and theBrucella antibodies by ELISA was requested for an occupational medical check-up while the patient was asymptomatic. The result showed IgM positive and IgG negative antibodies. ELISA testing was performed eight times for this patient. In two occasions sera were also positive for IgG and the other six tests were IgG negative and IgM positive. She did not receive antimicrobial therapy.Only 5 out of the 17 patients had previously suffered from brucellosis. When the serology was negative for IgG and positive for IgM antibodies, the test was repeated for those patients between 2 and 11 times. The definitive diagnosis for each of these patients is shown in One other patient was an 82 year old woman. She had suffered brucellosis when she was 20 years old. Serology was requested due to a low back pain episode. Serology showed a pattern of positivity for IgM and negativity for IgG on two occasions. The final diagnosis was left renal carcinoma. She received no antibiotic treatment.In the other 3 patients, the previous history of brucellosis was more recent. One was a 31 year old woman who had a diagnosis of brucellosis in 2005 because she presented fever as well as agglutinations, and she was PCR positive. During that year she received two cycles of treatment, first with doxycycline and rifampin, and later with doxycycline and streptomycin because of the reappearance of fever and arthralgia. In 2008, the patient received a new cycle of treatment with streptomycin and doxycycline because of the onset of musculoskeletal pain and she had a Wright sero-agglutination test titre value of 1/80. The patient was discharged in January 2009. But, a year and a half later, the patient consulted to the Rheumatology Department because of arthralgia. ELISA detection of antibrucella IgG and IgM antibodies was requested. From then until 2013, the ELISA testing continued being performed for this patient a total of 11 times, always obtaining the same IgG-negative, IgM-positive result.Brucella test was positive at titres 1/40. PCR detection for Brucella was positive. Later and during the follow-up, agglutinations, PCR detection and blood cultures were repeatedly negative until 2008. In 2011 an ELISA was requested, with the result of uncertain IgM and negative IgG on two occasions, and positive IgM and negative IgG on one occasion.Another patient was a 56 year old woman who was treated for brucellosis in 2006. She suffered from osteoarthritis and fibromyalgia and generalized joint pain. At that time, Wright agglutination was positive at titres of 1/40, and the Coombs anti-The last of the patients with a history of brucellosis was a 39-year-old man, who was treated in 2009 due to polyarthralgia and positivity in the Wright agglutination test with a titre of 1/160 and Coombs antibrucella with a titre 1/160. Thus, brucellosis was diagnosed despite the absence of epidemiological exposure history. After treatment with doxycycline and streptomycin, he was asymptomatic. In May 2010, another antibiotic treatment cycle was scheduled because of the appearance of arthralgia and fatigue. ELISA IgM was positive, but the patient did not improve with the treatment. Since 2009 ELISA was repeated 10 times during the follow-up always being IgM-positive and IgG-negative.Brucella spp. Most of these patients had musculoskeletal symptoms as the cause that led to perform serology. Other reasons to perform serology were fever in four patients, and splenomegaly and pancytopenia in one patient. The Rose Bengal test was negative in all of these patients (Of the 12 remaining patients, one was a shepherd, another patient worked in a dairy products factory, and the rest had no history of exposure to patients .The number of samples with positive IgM and negative IgG was usually one. Four patients in this group received antibrucellar antibiotic treatment. One of them was treated with doxycycline for six weeks and also with streptomycin for the first two weeks. Another patient received doxycycline for six weeks and gentamycin for two weeks. One patient was treated with doxycycline, rifampin and gentamycin for the first two weeks and doxycycline and rifampicin until completing three months of treatment. Finally, one patient received doxycycline during 45 days as well as gentamycin during the first 14 days. The musculoskeletal symptoms of these patients did not improve with the use of antibiotics. Another two patients received antimicrobial therapy. One of these received doxycycline for only eight days and the other received levofloxacin.The definitive clinical diagnosis of these patients is detailed in Brucella spp.In our study we described a series of patients with suspected acute brucellosis in whom ELISA serology detected IgM but not IgG antibrucella antibodies. Most patients had symptoms related to the musculoskeletal system such as arthralgia or back pain. Seven of them were treated with antibiotics, but the clinical picture and the outcome were not suggestive of active infection caused by IgM antibodies are considered suggestive of acute infection and appear about a week after the onset of the disease, reaching a peak level one to three months later. IgG antibodies appear approximately three weeks after disease onset, reaching a maximum after six to eight weeks. Some studies give a specificity of 100% for the detection of IgM by ELISA for the diagnosis of acute brucellosis Brucella IgM may be due to the presence of cross-reactions. These cross-reactions are due to antigenic similarity of the lipopolysaccharide of the cell wall with other Gram-negative bacteria. Cross-reactions with Escherichia coli O157, Francisella tularensis, Yersinia enterocolitica, Vibrio cholerae and Salmonella species have been described. Most of the antibodies responsible for these cross-reactions are IgM False positives in the determination of anti-et al., described that situation in three cases of chronic hepatosplenic suppurative brucellosis. Although in two of these cases IgM antibrucella reactions were detected at first, the authors found that IgM became negative when the rheumatoid factor was pre-absorbed with an antiserum et al. described rheumatoid factor positivity in 8.8% of patients with osteoarticular brucellosis Brucella IgM antibodies is recommended, as it may interfere with the test result Furthermore, false positives in the determination of IgM antibodies may also be due to the presence of rheumatoid factor. Diaz et al. conducted a study in which they compared the results from four different commercial kits for the diagnosis of brucellosis by ELISA Possible variability in the determination of antibodies between different commercial kits must be taken into account. Faadel et al. described a case of Brucella suis infection that was diagnosed using cultures from blood and bone marrow isolates, but serology was negative B. abortus and B. melitensis in ELISA tests may give false negatives when the infection is caused by other Brucella species.False negatives can occur in cases of acute and early disease. One study found that up to 11% of patients with brucellosis had no detectable levels of specific IgM Brucella serology by ELISA.This is a retrospective study and therefore it is subject to some limitations. In most of the patients, it was not possible confirm the ELISA results by using other microbiological diagnostic methods. We also cannot rule out any false negative in determining IgG, mainly in those patients with previous brucellosis. However, diagnosis of active brucellosis in these patients may be ruled out with the medical history and clinical course data. Furthermore, our study reflects the real conditions in which clinical practice develops. We therefore believe that our results are valid and with clinical interest in the interpretation of Brucella IgM antibodies should not be regarded as definitive in the diagnosis of this infection. Prior to accepting this result as a true positive, the test should be repeated after pre-absorption of rheumatoid factor. Moreover, this finding should always be evaluated within the appropriate clinical history and epidemiological context and confirmed using another diagnostic method such as Brucella agglutination assay, as recommended by CDC Brucella antibodies, the diagnosis of brucellosis must be confirmed by other methods.In conclusion, the detection of anti-