Various physiotherapeutic evaluation methods are used to assess the functionality of dogs with stifle problems. Neither validity nor sensitivity of these methods has been investigated. This study aimed to determine the most valid and sensitive physiotherapeutic evaluation methods for assessing functional capacity in hind limbs of dogs with stifle problems and to serve as a basis for developing an indexed test for these dogs. A group of 43 dogs with unilateral surgically treated cranial cruciate ligament deficiency and osteoarthritic findings was used to test different physiotherapeutic evaluation methods. Twenty-one healthy dogs served as the control group and were used to determine normal variation in static weight bearing and range of motion.The protocol consisted of 14 different evaluation methods: visual evaluation of lameness, visual evaluation of diagonal movement, visual evaluation of functional active range of motion and difference in thrust of hind limbs via functional tests (sit-to-move and lie-to-move), movement in stairs, evaluation of hind limb muscle atrophy, manual evaluation of hind limb static weight bearing, quantitative measurement of static weight bearing of hind limbs with bathroom scales, and passive range of motion of hind limb stifle (flexion and extension) and tarsal (flexion and extension) joints using a universal goniometer. The results were compared with those from an orthopaedic examination, force plate analysis, radiographic evaluation, and a conclusive assessment. Congruity of the methods was assessed with a combination of three statistical approaches , and the components were ranked from best to worst. Sensitivities of all of the physiotherapeutic evaluation methods against each standard were calculated.Evaluation of asymmetry in a sitting and lying position, assessment of muscle atrophy, manual and measured static weight bearing, and measurement of stifle passive range of motion were the most valid and sensitive physiotherapeutic evaluation methods.Ranking of the various physiotherapeutic evaluation methods was accomplished. Several of these methods can be considered valid and sensitive when examining the functionality of dogs with stifle problems. The role of animal physiotherapy has grown tremendously in modern post-operative rehabilitation of canine orthopaedic patients. The tests used to evaluate patients are mostly adapted from human physiotherapy. Although the assessment protocols may have been tested for reliability and validity in humans, this is not the case in dogs.Cranial cruciate ligament deficiency (CCLd) is one of the most common causes for hind limb lameness in dogs -3. NumerVarious methods to evaluate the functional status of the dogs with surgically treated (ST) CCLd have been used by physiotherapists -9. The rThe aim of this study was to determine the most valid and sensitive physiotherapeutic evaluation methods for assessing functionality of hind limbs in dogs with stifle problems.Two groups of dogs were evaluated. The study group consisted of 43 dogs, 19 males and 24 females, with unilateral ST CCLd that had been surgically treated at least one year earlier. Their average age (±SD) was 7.0 ±2.5 years and body weight 37.6 ±9.4 kg. This group comprised 15 Labrador Retrievers, 6 Rottweilers, 3 Golden Retrievers, 3 mixed breed dogs, 2 Bernese Mountain Dogs, 2 Newfoundland Dogs, 2 Nova Scotia Duck Tolling Retrievers, and 1 of each of the following: Black Russian Terrier, Bordeaux Dog, Bullmastiff, Collie, Dalmatian Dog, Doberman Pincher, Giant Schnauzer, Karelian Bear Dog, Pointer, and Short-Haired German Pointer.The control group consisted of 21 dogs, 7 males and 14 females, with intact CCLs and no diagnosed musculoskeletal problems. Their average age (±SD) was 3.2 ±1.6 years and body weight 35.5 ±8.3 kg. These dogs also had radiographic screening results that were free of hip dysplasia according to the Federation Cynologique Internationale screening protocol (grade A or B). The breeds comprised 12 Labrador Retrievers and 9 Rottweilers.The study design was prospective. It was approved by the University of Helsinki Ethics Review Board (UHERB) at Viikki Campus, and a written consent from dog owners was obtained.The physiotherapeutic evaluation was limited to 20 min and included 14 different evaluation methods. All physiotherapeutic evaluation methods are described in Table A numerical evaluation was used to describe the dog’s level of performance in each task as follows:Visual evaluation of lameness, diagonal movement and movement in stairsTasks are described as physiotherapy tests 1,2, and 7 in Table In addition, possible oblique body position during movement was noted: 1 = symmetrical, 2 = oblique, hindquarters to the right, 3 = oblique, hindquarters to the left.Visual evaluation of functional AROM and thrust of hind limbsTasks are described as physiotherapy tests 3–6 in Table Symmetry in hind limb thrust from sitting and lying positions to standing position was classified as 1 = symmetrical thrust between hind limbs, 2 = less thrust in left hind limb, or 3 = less thrust in right hind limb.AtrophyTask is described as physiotherapy test 8 in Table Manual evaluation and quantitative measurement of static weight bearing of hind limbs and measurement of PROM of stifle and tarsal jointsTasks are described as physiotherapy tests 9–14 in Table An orthopaedic examination consisting of palpation of the limbs and spine, evaluation of conscious proprioception and withdrawal reflex, and lameness evaluation through a five-point grading  was done2 were recorded. Means of body weight-corrected peak vertical force (PVF) and impulse (IMP) were calculated. Based on these means ± SD and the difference between left and right limbs by , dogs were classified as 1 = hind limbs symmetrical or applying less force on either 2 = left or 3 = right hind limb.Signals from a force platform  and a start-interrupt timer system were processed with a computer-based software program . The setup has been described elsewhere . Five vaRadiographs of stifle and hip joints were taken under sedation bilaterally from the dogs in the study group. Mediolateral and craniocaudal views were taken from stifle joints. An extended ventrodorsal view was taken from the hip joints. Radiographs were graded according to the amount of OA seen, using a scale from 0 to 3, where 0 = no OA findings, 1 = mild OA findings, 2 = moderate OA findings, and 3 = severe OA findings . Based oFinally, a conclusive assessment of the hind limbs was done by combining the results of the orthopaedic, force platform, and radiographic evaluations. The hind limbs were classified as 1 = no findings in hind limbs, findings in either 2 = left, 3 = right hind limb, or 4 = bilaterally.All physiotherapeutic evaluations were performed by the same qualified physiotherapist specialized in veterinary physiotherapy (HH). The orthopaedic examination, force platform study, and conclusive assessment were also performed by one examiner (SM). Radiographs were evaluated by two examiners . During orthopaedic examination and physiotherapeutic evaluations the examiners were blinded to the surgically treated limb, at least until palpation of possible scar tissue.All 14 physiotherapeutic evaluation methods were compared with the results of the 6 veterinarian-used evaluation methods: orthopaedic examination, force platform analysis including PVF and IMP, radiological evaluation of only stifles, and stifles and hips together, and conclusive assessment (hereafter these will be referred to as “the standards”). This was done to determine how well each evaluation method was able to recognize the functionally symptomatic hind limb.Congruity between the 14 different physiotherapeutic evaluation methods and the six standards was evaluated with three different statistical approaches. Three methods were selected because none alone could answer the question of congruity fully. Together, however, they are able to provide a plausible assessment of the reliability of the methods, as the weaknesses of these methods partly cancel each other out.Fisher’s exact test was first used to evaluate the significance of the association between each physiotherapeutic evaluation method and each standard. Secondly, the proportion of observations where the evaluation method and standard agreed was calculated. Thirdly, similar proportions were calculated, but here agreement was also granted for observations where the evaluation method at hand resulted in an “asymptomatic” and the standard resulted in a “symptomatic” finding. This was done to account for the difference in assessing some variables into four groups and others only into three, as some methods cannot differentiate bilaterally symptomatic from bilaterally asymptomatic. This is referred to as the adjusted proportion of agreement.The 14 physiotherapeutic evaluation methods were then ranked based on each of these three statistical approaches within the six standards. Thus, 18 different ranking lists were constructed, one for each standard – statistical approach combination. The three rankings within a standard were then summed to place the evaluation methods into a total rank order within a standard. Finally, these six ranking numbers were summed over the standards. A final ranking list was then constructed based on these sums, where the first evaluation method of the list was considered to be the most congruent one . Further, sensitivities of all of the physiotherapeutic evaluation methods were calculated against each of the six standards. Statistical analyses were done using SAS® System for Windows, version 9.3 .P < 0.0001). Three dogs in the study group either did not have platform analysis or radiographs taken due to uncooperativeness or poor general condition of the dog. Due to behavioural problems, two dogs did not tolerate manual evaluation of weight bearing. Out of the tested dogs, two performed the runs over the force plate in range of 1.72-2.10 m/s, and all of the rest within range of 2.10–2.50 m/s.The difference between ages of the two groups was highly significant  technique . A loss Consistent with an earlier report , our stuThe effect of age on the PROM of dogs stifles is currently unknown. In the present study, there was a highly significant difference between ages of the two groups. For the purposes of this study, it was assumed that there are no changes in PROM due to ageing alone, but further research in this area is warranted.The authors recognize some limitations to the study. Different number of categories in the different evaluation methods is one limitation of the study. Diagonal movement, stairs, thrust from sitting and lying positions, evaluation of atrophy, qmSWB, meSWB, and force platform analysis had only three categories , whereas visual lameness evaluation, evaluation of sitting and lying positions, measurement of PROM, orthopaedic examination, conclusive assessment, and radiological examinations had four categories.When the two types of classification groups were compared, some of the first groups’ symmetrical dogs may have belonged to either the “bilaterally problem-free” or “bilaterally problematic” categories, but the categorization method with three options does not differentiate these two. This was, however, taken into consideration in the statistical analysis by allowing agreement in observations where the result of the four-category method was bilaterally problematic and the result of the three-category method was either a left or a right hind limb problem. Thus, in this case, it was assumed that finding a symptomatic dog was sufficient.Also, some of the physiotherapeutic evaluation methods aimed at assessing functional status of the dog and the ability of the dog to manage in activities of daily living. The standards may give a result of “symptomatic” regardless of the dog’s actual functional level in its activities of daily living. This was also taken into account in the statistical methods used; in the third statistical approach (adjusted proportion of agreement), when the physiotherapeutic evaluation method resulted in “asymptomatic” and the standard resulted in “symptomatic”, agreement was allowed.Further, when new variables are validated, there is often a problem that they cannot be compared against similar parameters, and therefore the comparisons have to be done with the best existing ones. Hence we do acknowledge, that the fact that the compared parameters do not measure exactly the same thing, may have an effect to the results to some extent.Evaluation of atrophy, sitting position, quantitative measurement of static weight bearing, lying position, stifle flexion and extension, thrust from sitting and lying, and manual evaluation of static weight bearing were the most valid and sensitive in detecting hind limb abnormality in our group of dogs, surgically treated for CCL and suffering from OA. We propose that these methods could be used when evaluating rehabilitation outcome of dogs with stifle problems.AROM: Active range of motion; CCL: Cranial cruciate ligament; IMP: Vertical impulse; meSWB: Manual evaluation of static weight bearing; OA: Osteoarthritis; PROM: Passive range of motion; PVF: Peak vertical force; qmSWB: Quantitative measurement of static weight bearing; ROM: Range of motion; ST CCLd: Surgically treated cranial cruciate ligament deficiency; SWB: Static weight bearing; UG: Universal goniometerThe authors declare that they have no competing interests.HH carried out the physiotherapy evaluation and drafted the manuscript. SM carried out the orthopaedic, radiological, and conclusive evaluations in addition to contributing to the manuscript. JJ performed the statistics and participated in drafting the manuscript. OL-V participated in study design, contributing to the manuscript, and conceiving the study. AH-B participated in drafting the study, study design, and conceiving the study. All authors read and approved the final manuscript.


Body Image is a major factor affecting health in a range of age groups, but has particular significance for adolescents. The aim of this research is to evaluate the efficacy of the “Girls on the Go!” program delivered outside of the school environment by health professionals to girls at risk of developing poor self-esteem on the outcomes of self-esteem, impairment induced by eating disorders, body satisfaction, self-efficacy, and dieting behaviour.A stepped wedge, cluster randomised controlled trial that was conducted in two phases on the basis of student population . The waiting list for the “Girls on the Go!” program was used to generate the control periods. A total of 12 schools that requested the program were separated into study 1 or 2 on the basis of student population . Schools were matched on the basis of number of students and were allocated to receiving the intervention immediately or having a waiting list period. Study 1 had one waiting list period of one school term, creating two steps in the stepped-wedge design (i.e. 3 schools were provided with “Girls on the Go!” each term over 2 terms). Study 2 had two waiting list periods of one and two school terms, creating three steps in the stepped-wedge design (i.e. 2 schools were provided with “Girls on the Go!” each term over 3 terms). Primary outcome measures were self-esteem and impairment inducted by eating disorders.There is a lack of preventative interventions currently available that address low self-esteem, low self-efficacy and body dissatisfaction in young women. This project will be the first group-based, professional-led, targeted program conducted outside the school environment amongst school age young women to be evaluated via a randomised control trial. These findings will indicate if the “Girls on the Go!” program may be successfully used and applied in a culturally diverse environment and with young women of all shapes and sizes.ACTRN12610000513011)(The online version of this article (doi:10.1186/2193-1801-2-683) contains supplementary material, which is available to authorized users. Body image is the “mental picture” we form of our physical body and encompasses how we feel and think about our physical appearance , the setting of delivery (e.g. within or outside the school/classroom setting vs. community setting), whether the program is a group or individual (counselling) program, and the facilitation method of the program  . Stepped wedge designs are similar to cross-over trials, however only involve uni-directional cross-over resulting in all participants receiving the intervention by the conclusion of the trial. The waiting list for the “Girls on the Go!” program was used to generate the control period. The intervention program was designed to be delivered to a group of participants from the same school at the same time, thus randomising students in clusters (school) was seen as an appropriate unit of randomisation.A total of 12 schools that requested the program were separated into Study 1 or 2. Within each study, schools were matched on the basis of number of students (into triplets for Study 1 and pairs for Study 2) and then randomly allocated (computer generated sequence developed by investigator blinded to school identity) to receiving the intervention immediately or having a waiting list period. Study 1 had one waiting list period of one school term, creating two steps in the stepped-wedge design  of its population born overseas, and 51% from nations where English is not the main spoken language. An influx of approximately 2300 newly arrived settlers per year since 2006 has sustained this diversity. The City of Greater Dandenong has also been described as one of the lowest socio-economic indexes for (SIEFA) Melbourne  ABS, .The community-based, health professional led program that formed the intervention for this research is called the “Girls on the Go!” program.Girls on the Go!” in response to an identified need and demand by local schools and communities for a program designed to address body dissatisfaction and promote healthier lifestyles. The program developers were unable to model elements of this program on what was known to be successful in 2001 due to a paucity of evidence from experimental studies investigating the efficacy of programs to improve self-esteem in young women. Indeed the concept of using programs to enhance self-esteem in order to minimise disordered eating was only proposed in the late 1990s  that can be placed within the allied health spectrum and the program was set up within a primary health setting. Hence similarities existed in their approach to working with young people. The program was developed therefore, with an overarching theme of engaging young women in a holistic manner within an early intervention bio/psycho/social health model . Questions examining self-esteem, self-efficacy , and satisfaction with body image  were compared between pre and post program assessments using ordered logit regression analysis with clustering by participant to account for dependency between pre and post assessments within participant.Ordered logit regression calculates the increase or decrease in odds of moving up one level in the ordinal dependent variable associated with a one unit change in the independent variable. The location of the interquartile range for each of these items was located higher in the scale range in the post program assessment compared to the pre-program assessment indicating that the program was beneficial to these outcomes. The odds (95% CI), p-value of moving up one level for self-esteem with completing the program was 4.89 , p < 0.001, for self-efficacy was 4.65 , p < 0.001, and for satisfaction with body image was 3.68 , p < 0.001. Despite these promising results, the limitations of the pre-post intervention research design dictated that further work using randomised trial methodology was necessary to establish the efficacy of the “Girls on the Go!” program.The Rosenberg self-esteem scale ] developed by Bohn and colleagues , sometimes (1), yes (2). The scores are then summed up and higher scores represent higher dieting behaviour. Scores range from 0–48. This scale has demonstrated excellent reliability, Cronbach’s α = 0.80 restrained eating, Cronbach’s α = 0.81 emotional eating, and Cronbach’s α = 0.74 external eating, . The trial was conducted in two phases that comprised Study 1 and Study 2.Study 1 was prospectively registered with the Australian and New Zealand Control Trial Registry (ACTRN12610000513011). We then received notification of further funding to conduct this and Study 2. We submitted an amendment to our ethics application  to conduct Study 2 with the Monash Health Human Research Ethics Committee as the population of Study 2 and study design only varied slightly from Study 1 . We then amended the Australian and New Zealand Control Trial Registry so that the sample size listed on the registry was increased from 60 to 120 participants.High schools that contacted the Greater Dandenong Community Health Service in 2010 to receive the “Girls on the Go!” program that year were notified of the research and that their school’s placement on the waiting list that year would be determined at random. School welfare officers and teachers forwarded to the Greater Dandenong Community Health Service the list of student names who they determined met the study and program inclusion criteria. An investigator (LT) gained consent from participant’s parents (with assent from the participant) to participate in the research from all referred students. This investigator administered the data collection surveys at baseline and follow-up assessments at the time points indicated . The “Girls on the Go” variable will be entered into the model as a fixed factor, while assessment, student and school will be entered as random factors. Assessment will be nested within student which will be nested within school which will create a 3-level model that takes into account the longitudinal, clustered nature of data collected in this study. Maximum likelihood methods of estimation will be employed to address issues of missing data under the assumption of Missing At Random.To investigate whether the effect of the “Girls on the Go!” program was sustained, a “Girls on the Go” by assessment interaction effect will be added to the same analysis models. A significant interaction effect in these models will indicate whether any changes brought about at the initial post-“Girls on the Go!” follow-up assessment were sustained. We will also examine the data from the group that received the “Girls on the Go!” program first and compare student results between the first and subsequent post-intervention follow-up assessments in isolation using linear regression clustering data by individual student.Analysis of data from the pilot study indicated that the effect of the “Girls on the Go!” program on participant self-esteem was very strong (ie. Change in outcome is 1.5 times the width of the standard deviation). Assuming 80% power, only 10 participants per group will be required in a standard randomised trial with randomisation of individual participants. This study will be a cluster randomised trial however to account for a variance inflation factor (design effect) of 3  then a total of 120 participants in both the primary (n = 60) and secondary (n = 60) schools will be required.Low self-esteem and its associate health consequences such as body dissatisfaction and eating disorders are important societal, cultural, familial and individual matters. They demand urgent attention, greater resources and evidenced based approaches to both assist young people, and girls in particular with low self-esteem and body image concerns and to prevent others from its development. High self-esteem is known to be a protective factor against the development of body dissatisfaction, and disordered eating and therefore this project may have the potential to contribute to the field of prevention of disordered eating. “Girls on the Go!” was developed to deal with these particular issues. To our knowledge this is the first group-based, professional-led, targeted program conducted outside the school environment amongst school age young people with such culturally diverse backgrounds to be evaluated.This research will enable clinicians to evaluate a new community preventative intervention and thus to apply research into clinical practice. Before the expansion of “Girls on the Go!” it should be subjected to evaluation to demonstrate that it does achieve its objectives. These findings will indicate if the “Girls on the Go!” program may be successfully used and applied in a culturally diverse community and with disadvantaged participants. The results of the two individual studies will allow for comparison of the intervention’s effect at various age groups (i.e. primary school vs secondary schools age young women). Furthermore, “Girls on the Go!” targets girls who have diverse body shapes and sizes and this control trial results will indicate if a holistic approach focused on self-esteem will lead to overall improved health and wellbeing. Therefore, these findings will support a relatively new paradigm shift where self-esteem enhancement and overall health and well-being are emphasized and used as a prevention strategy and it will potentially support the notion that improving self-esteem would lead to improved self-efficacy and body satisfaction in young women (O’Dea and Maloney, Information collected by the present research, that documents the development of a preventative intervention originated from a health service delivery, and evaluation of these data, will contribute new information to the field of prevention of eating disorders and health promotion delivery.


Integrative medicine is defined as relationship-centered care that focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing, including evidence-based complementary and alternative medicine. Pediatric integrative medicine (PIM) develops and promotes this approach within the field of pediatrics. We conducted a survey to identify and describe PIM programs within academic children’s hospitals across North America. Key barriers and opportunities were identified for the growth and development of academic PIM initiatives in the US and Canada.Academic PIM programs were identified by email and eligible for inclusion if they had each of educational, clinical, and research activities. Program directors were interviewed by telephone regarding their clinical, research, educational, and operational aspects.Sixteen programs were included. Most (75%) programs provided both inpatient and outpatient services. Seven programs operated with less than 1 FTE clinical personnel. Credentialing of complementary and alternative medicine (CAM) providers varied substantially across the programs and between inpatient and outpatient services. Almost all (94%) programs offered educational opportunities for residents in pediatrics and/or family medicine. One fifth (20%) of the educational programs were mandatory for medical students. Research was conducted in a range of topics, but half of the programs reported lack of research funding and/or time. Thirty-one percent of the programs relied on fee-for-service income.Pediatric integrative medicine is emerging as a new subspecialty to better help address 21st century patient concerns. The National Institutes of Health (NIH) defines complementary and alternative medicine (CAM) as a group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine . IntegraIntegrative medicine is similar to the biopsychosocial model of medicine  in that Rates of reported CAM usage among children vary between studies, but prevalence is notable across populations. Approximately 10-40% of healthy children and more than 50% of children with chronic, recurrent, or incurable conditions use CAM, most often in conjunction with conventional care -10. ThisThe hesitance that families have in discussing their health related preferences, values, and beliefs raises significant concern for pediatricians providing family-centered care. Integrative pediatrics is meant to address this concern by equipping clinicians with the education to address families’ health related preferences and communication about CAM. Most pediatricians have stated they are interested in learning more about CAM therapies, and are starting to feel more comfortable referring to CAM providers .By 1998, over 60% of US medical schools had incorporated some education about CAM into their curriculum . FoundedParalleling the increased visibility of integrative medicine in academic health centers, academic pediatric integrative medicine (PIM) programs are also developing and promoting an evidence-based integrative approach within children's hospitals. Few studies have evaluated the state of pediatric integrative medicine.We conducted a survey to identify and describe PIM programs within academic children’s hospitals across North America by interviewing program directors to assess their activities with respect to clinical, research, and educational initiatives in pediatric integrative medicine. Key barriers and opportunities were identified for the growth and development of academic PIM initiatives in the US and Canada.A survey was developed by content experts, pilot tested, revised, and sent by email to 20 North American programs (the survey is available upon request). We used a snowball technique for sampling, i.e. respondents were asked to identify additional academic PIM programs until no more programs were identified by any respondent. Inclusion criteria were having clinical, research, and education activities; programs meeting only one or two of these criteria were noted, but did not meet inclusion for this study. The survey was deployed on multiple occasions within an 18 month period, until no additional programs were identified by any of the previous respondents.For each included program, interviews were conducted with directors of the included PIM programs between March and August 2007. Each interview was conducted by two study authors (DM and SV or PG) and lasted 60–120 minutes. Information was collected on clinical, research, educational, and operational aspects of the programs in order to capture information on the achievements, challenges and opportunities that were faced, and advice was sought on the factors critical to success or failure, including staffing and resources required for program initiatives (the interview guide is available from study authors upon request). Descriptive analyses were conducted . Since program directors were encouraged to forward the survey invitation to other programs, non-response could not be calculated. Ethics approval was granted for this study from the University of Alberta Health Research Ethics Board.Of the 143 accredited medical schools in North America in 2007, 16 met our inclusion criteria as having an academic PIM program , chronic pain (50%), and gastrointestinal or other chronic illness (28.5% each). The most commonly addressed outpatient conditions were cancer (57%), mental health (50%), and chronic pain or abdominal pain or headaches (42.8% each). Abdominal pain, mental health issues, and headaches were more commonly addressed in outpatient  than inpatient services . Two of the programs dealt solely with pain. Most programs served all children (0–16 or 0–21). One outpatient program did not see children under 3 and another saw primarily adolescents. Two programs continued to see chronically ill patients after they had become adults.Referral experiences varied between centers. For example, self-referrals were accepted by 86% of outpatient vs. 57% of inpatient services. In one case, pediatric referral was required in order to create dialogue with physicians around CAM and to insure that patient load could be accommodated. Physician referral was preferred in the inpatient settings. One service only accepted physician referral because they did not want to be perceived as going behind any physician’s back, while another accepted self-referral if the patient’s insurance accepted it.The gatekeeper model of having one person make care decisions predominates in both the inpatient and outpatient settings. Only one program had a team approach to inpatient care, while four programs had this for outpatient care.The range of CAM services offered in inpatient or outpatient settings varied  a patient wanted only massage therapy but energy work (e.g. reiki) was also provided; (ii) minor bruising from acupuncture; and (iii) one patient had a post-traumatic stress flashback post hypnotherapy.Nine programs operated with between 1 and 11 FTE divided among MDs, RNs, psychologists, nutritionists and CAM providers. Seven programs had less than 1.0 FTE clinical personnel, usually an MD.There was a wide variability in methods for credentialing both conventional and complementary practitioners to provide CAM. Credentialing of acupuncturists, massage therapists and other CAM professionals varied substantially across the programs and between inpatient and outpatient services. Sometimes credentialing was an internal hospital process; other times it was external, for example, through state licensure. In one inpatient program the CAM provider came in under the auspices of a family “visitor”, but this meant that they could not chart their visit. In another case, an inpatient program with a physician provider of CAM was put on hold for six months in order for the physician to obtain the proper CAM credentials. Outpatient programs often referred patients to community providers vetted by the program’s physician or through word of mouth.Programs stated the importance of making sure that the CAM providers were comfortable working within the conventional system and had some pediatric experience or formal training with children, and that the modalities chosen reflected the community’s interests.Most of the programs had few, if any, policies and procedures in place at their onset, and a few lacked formal administrative support at the time of the interviews. Only 31% of programs reported having a policy on natural health products (NHP)/dietary supplements (DS), and these varied in what products were addressed. Existing natural health products policies included guidelines for pharmacy approval of patients’ herbal supplements as well as dietary supplement policies for outpatient/inpatient programs. Many of the programs indicated an interest in developing/obtaining institutional policies for CAM and NHPs. Clinical and administrative challenges were identified as barriers.The 16 programs offered a variety of elective educational initiatives ranging from clinical electives for medical students and residents to community outreach presentations. Almost all (94%) described programs for residents in pediatrics and/or family medicine (25% of which were mandatory), 81% reported educational programs for medical students (19% of which were mandatory), 56% had training opportunities for fellows, and one program has a dedicated pediatric integrative medicine fellowship program. More than half (56%) offered continuing education opportunities for faculty and/or community physicians. One third (33%) provided programs for nurse and nurse practitioners, and six offered some education or training for families.Only two programs offered research training: one mentored research projects, the other offered research-specific training in pediatric integrative medicine.Educational strategies included: lectures, presentations , rounds, conferences, lunch & learns, information sheets, training at CAM schools, online educational resources, newspaper and magazine articles, and TV interviews. One quarter of PIM programs offered some online training.Team members involved in PIM education consisted at a minimum of pediatricians, nurses, and medical students . The inclusion of CAM practitioners was variable.Most (81%) of the programs were interested in a collaborative pediatric training program, but identified funding and time as barriers. Two frequent comments were that: i) interest would increase with the presence of funding or ii) interest existed, but programs were already overwhelmed by current commitments.Half of the programs had become inactive in research due to lack funding and/or time and resources. Research initiatives most commonly comprised health services research (50%) and randomized controlled trials (31%). Clinical research topics included massage therapy, antioxidants and music therapy for cancer patients; and guided imagery, hypnotherapy, Reiki, and acupuncture for chronic pain. Dietary supplements were also a frequent topic of research. No PIM program reported conducting basic research on CAM, though basic research may have been conducted in other departments in academic health centers.Research funding was mostly obtained through peer-reviewed grants, foundations and philanthropy. Amounts ranged from tens of thousands to several million dollars. At the time of the interviews, no research funding had been obtained from industry.Research was published in both conventional and CAM journals. Some programs emphasized the need to publish in mainstream medical journals in order to avoid “preaching to the choir” and to further educate the broader medical community on pediatric CAM.Most PIM programs were located in an affiliated hospital or medical school and had some salaried employees. Space was a concern and/or a limiting factor for several programs. Funding came from varied sources: philanthropy, research grants, institutional, and tuition. Almost one third (31%) relied on fee-for-service income. Inpatient costs were often covered through integration into existing programs. Costs of outpatient programs were covered in a variety of ways: some by philanthropy, some modalities were covered by some insurance, some care was billed as a physician consult, and many fees were charged out-of-pocket on a sliding scale. Programs engaged in limited promotional activities; relying mostly on websites, presentations, and brochures. Two programs did no promotion: one because they could not handle more patients, the second because the administration asked them not to due to limited space and personnel. Two programs mentioned being supported by their institution’s marketing department. Only half of the programs reported engaging in strategic planning; those that did used regular business meetings, retreats, discussions with other subspecialties and developed 1–5 year plans with which to move forward.The most common advice offered for others considering developing an academic PIM program was to build slowly and to work within the conventional system: “utilize people already within the system and call upon them to be part of the team,” “go where you are invited.” This encompassed maintaining a strong professional reputation, not alienating potential allies by being adversarial: “no turf battles,” “avoid fights you don’t have to fight,” and basing decisions on sound evidence. It was also noted that having a champion, both within the program and within the other groups that the program dealt with  was very important: “leadership vision – to be in a house that wants you.” Financial considerations were essential, and issues ranged from sustainability to the importance of looking for funding in non-traditional places, such as philanthropy. It was considered difficult to maintain the programs, particularly clinical endeavors, without additional outside support. One general piece of advice was to “Lay down some policies, guidelines, program structure before program launch.” Finally, establishing rapport through sound research was very important: “research is key – helps to gain acceptance.”Academic PIM is a new and growing field in North America with an already rich history, . These barriers were also noted by some of the programs actively engaged in research. Given current insurance funding which does not consistently cover CAM services, it is also difficult to maintain pediatric integrative clinical services without external support. Seeking guidance for accessing the various funding sources is a must as there are different standards for each one. The care provided in PIM clinics is typically low volume, with few procedures, but resource- intense in terms of health care provider time. The financial impact of this kind of care must be considered at the inception of such programs. Integrative medicine programs are potentially beneficial as a way of differentiating a health organization from competitors, increasing patient satisfaction . attractNetworking and creating relationships with other medical groups  was important in order to avoid turf battles, which can negatively affect the perceived legitimacy of the program within the institution and community.Most programs offered educational opportunities to medical students and residents, but only about half offered continuing education opportunities to physicians and even less offered anything to nurses, CAM practitioners or to families. Educational outreach to other conventional health care professionals and to families is an important activity. There was also a lack of research training available to students, which means that new researchers in this field are not necessarily being trained. Research training was identified as a critical need in the IOM report . Part ofInpatient care costs were, for the most part, covered by existing programs at the various hospitals and thus available to all the patients. Outpatient care costs were sometimes covered by insurance or philanthropy but most often, the requirement for patients to co-pay out-of-pocket affected accessibility of the various CAM modalities.Currently, academic PIM is heterogeneous. At the time of the interviews the most well-developed aspect of the 16 PIM programs was the clinical portion, while the education and research arms were uneven across the programs. In contrast, integrative family medicine developed a residency program offered at several medical schools that included a distributed learning fellowship in integrative medicine and expanded family medicine residency from 3 years to 4 years . This prth century as a specialty within medicine to better address the need of children [st century concerns. Children are not small adults and need health care that addresses their needs; within CAM and integrative medicine, as in conventional medicine, this requires research and training specific to pediatrics. Furthermore, in the field of CAM, very little pediatric training is available to practitioners, which makes the development of PIM even more important. Just as the field of pediatrics took time to win recognition and credibility within medicine, PIM will also have to prove itself in order to be acknowledged within conventional domains.Pediatric integrative medicine (PIM) is one of pediatrics’ newest subspecialties. Like the development of pediatrics beginning in the mid 19children , PIM hasPIM: Pediatric Integrative Medicine; CAM: Complementary and Alternative Medicine; NHP: Natural Health Product; IOM: Institute of Medicine.Three of the authors have launched academic pediatric integrative medicine programs.SV made substantial contributions to the conception and design of the study, acquisition of data, and its interpretation. SS made substantial contributions to the analysis and interpretation of the data, and drafted the article. DM made substantial contributions to the design of this study, acquisition of data, and its interpretation. LDR made substantial contributions to the conception and design of the study. PG made substantial contributions to the conception, acquisition of data, and its interpretation. KK contributed to the design of the survey and interpretation of its data. SV, DM. LR, PG and KK helped revise the draft article for important intellectual content. All authors have read and given approval of the version submitted for publicationSV is founder and Director of the CARE Program for Integrative Health & Healing the first pediatric integrative medicine program in North America,and Professor, Department of Pediatrics, Faculty of Medicine and School of Public Health, University of Alberta, Edmonton, AB, Canada. LDR is the founder of the Whole Child Center, Oradell, NJ, USA. PG is the assistant director of the Program for Integrative Medicine and Health Care Disparities; Department of Family Medicine, Boston University School of Medicine, Boston, MA, USA. KJK is the Caryl Guth Chair for Integrative Medicine and Professor of Pediatrics, Social Science and Health Policy, and Family and Community Medicine at Wake Forest University Health Sciences, Winston-Salem, NC, USA.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/12/123/prepub


Lupus anticoagulant (LA) is known to inhibit thrombin generation although patients have an increased risk to develop thrombosis. We tried to determine whether thrombin generation is altered in plasma samples of patients with abnormal test results in LA routine diagnostics and whether its measurement may improve the risk assessment of thrombosis.Samples from 63 patients  were included in the study. Measurement of diluted Russel’s viper venom time (dRVVT) was part of the initial guideline conform diagnostic procedure for detection of LA. In addition, measurement of anticardiolipin-IgM, -IgG and β2-glycoprotein-I-IgM, -IgG were performed. Thrombin generation was measured using two different phospholipid concentrations in the starting reagent.Analyzing all samples by logistic regression, thrombin generation after induction with high phospholipid concentrations was the best predictor of thrombosis. After preselection of samples with alterations in dRVVT, specificity of selected thrombin generation derived parameters for the detection of previous thrombosis increased in this subgroup.In patients with phospholipid-dependent prolongation of dRVVT, thrombin generation is variably inhibited and the degree of inhibition corresponds to the occurrence of previous thrombosis. Measuring thrombin generation in patients with phospholipid-dependent dRVVT prolongation may improve risk assessment of thrombosis. Antiphospholipid syndrome (APS) is characterized by the presence of antibodies against a complex of phospholipid-binding protein and phospholipids. These antibodies are primarily directed against the phospholipid-binding protein β2-glycoprotein I (β2-GPI) or cardiolipin (aCL) and can be detected by ELISA. If the antibodies interfere with coagulation assays they are described as lupus anticoagulant (LA). Presence of the β2-GPI dependent LA was associated with a high risk of thrombosis in a recent study . LaboratMeasurement of endogenous thrombin potential (ETP) by thrombography has been attracting attention throughout the last years. Although the methods lack standardization  measuremThe hypothesis of the present study was that ETP and parameters derived from the measurement of ETP (TG-derived parameters) are altered in patients with abnormal test results of LA diagnostics. It was further evaluated whether alterations correlate with previous thrombotic events.Samples from 63 patients were retrospectively selected from the LA testing program of the laboratory from January to December 2009 Figure . IndicatFactor-V-Leiden mutation leads to altered thrombin generation only after addition of activated protein C (APC) ,18 but nsample/ LAC Screen normal plasma) and were negative if the ratio was < 1.2. Samples with LAC Screen ratio > 1.2 were tested with increased phospholipid concentrations by LAC Confirm. Samples were included if the normalized ratio  was ≥1.2.Samples were centrifuged twice to obtain platelet-free plasma  and storCalibrated automated thrombin generation was measured in platelet-poor plasma using Bio-Tek FLx800 TC fluorometer. Reagents, calibrators and controls were used according to the recommendations of the manufacturer . Two assays were performed simultaneously, one with high  one with a low phospholipid concentration  in the starting reagent as described recently . CoagulaImprecision was measured by repeated analysis (N = 16) of one quality control sample. Calculations were performed using Analyse-It , Excel  and SPSS 19 . Comparisons between groups were performed by Mann–Whitney-Wilcoxon-test. Information on the history of the patients was obtained from the hospital information system. The study was approved by the local ethics committee.Characteristics of patients included in the study are summarized in Table Total imprecision for RC-low reagent were 11.7%, 14.6%, 12.9%, 8.1% and for RC-high reagent 11.7%, 11.5%, 10.8%, 6.0% with respect to lag time, time to peak, peak height of thrombin formation and AUC.Comparison of TG-derived parameters between the group with (N = 11) and the group without β2-GPI IgM- and/or IgG-antibodies (N = 52) and between the group with (N = 19) and without aCL IgM- and/or IgG-antibodies (N = 44) revealed no significant differences. (p > 0.05). Therefore, positivity for β2-GPI and aCL antibodies was not considered for further analysis.All parameters  were included in a forward stepwise logistic regression model to identify independent predictors of thrombosis. Using this model variables were selected in the order in which they maximize the statistically significant contribution to the model. Variables were stepwise included in the order which they contribute to the model and the model is recalculated until only variables with p < 0.05 remain. Of all parameters tested RC-high AUC was the best independent predictor of thrombosis Table .TG-derived parameters differed significantly (except peak thrombin generation with RC-low reagent) between samples from patients with and without thrombosis Figure  while thComparison between the subgroups revealed that TG-derived parameters after induction with RC low reagent differed significantly between samples from patients with history of thrombosis/positive LAC Screen ratio and the other samples Figure . After iPerforming ROC (receiver operating characteristics)-analysis of all TG-derived parameters on preselected, LAC Screen ratio positive samples  revealed high AUC (area under the curve) for all parameters with respect to previous thrombosis  but on the initial, quantitative changes in coagulation assays which are most likely associated with the titer of a coagulation inhibitor the latter being in most cases LA.TG-generation is reduced in samples from patients with alterations detected by dRVVT hinting towards the presence of LA. In addition, presence of reduced thrombin generation in these samples was associated with a history of thrombosis. Therefore, TG should be evaluated in a larger patient collective with respect to it diagnostic role when testing for LA.LA: Lupus anticoagulant; dRVVT: diluted Russel’s viper venom time; APS: Antiphospholipid syndrome; ETP: Endogenous thrombin potential; APC: Activated protein C; SCT: Silica clotting time; KCT: Kaolin clotting time; β2-GPI-IgG, IgM: β2-glycoprotein-I-IgM, -IgG; aCL-IgG, IgM: Anti-cardiolipin-IgG, IgM; ROC: Receiver operating characteristics; AUC: Area under the curve.This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.KB conceived and designed the study; carried out experiments; performed parts of the statistical analysis; helped to draft the manuscript LC carried out experiments; performed parts of the statistical analysis; helped to draft the manuscript WL participated in the design and coordination of the study and helped to draft the manuscript. All authors read and approved the final manuscript.


In the present study, we aimed to investigate the presence of biomarkers and evaluate RT-QUIC assay in patients with gPrD, as the utility of RT-QUIC as a diagnostic tool in gPrD has yet to be determined.The definitive diagnosis of genetic prion diseases (gPrD) requires pathological confirmation. To date, diagnosis has relied upon the finding of the biomarkers 14-3-3 protein and total tau (t-tau) protein in the cerebrospinal fluid (CSF), but many researchers have reported that these markers are not sufficiently elevated in gPrD, especially in Gerstmann-Sträussler-Scheinker syndrome (GSS). We recently developed a new 56 CSF samples were obtained from gPrD patients, including 20 cases of GSS with P102L mutation, 12 cases of fatal familial insomnia , and 24 cases of genetic CJD (gCJD), comprising 22 cases with E200K mutation and 2 with V203I mutation. We subjected all CSF samples to RT-QUIC assay, analyzed 14-3-3 protein by Western blotting, and measured t-tau protein using an ELISA kit. The detection sensitivities of RT-QUIC were as follows: GSS (78%), FFI (100%), gCJD E200K (87%), and gCJD V203I (100%). On the other hand the detection sensitivities of biomarkers were considerably lower: GSS (11%), FFI (0%), gCJD E200K (73%), and gCJD V203I (67%). Thus, RT-QUIC had a much higher detection sensitivity compared with testing for biomarkers, especially in patients with GSS and FFI.RT-QUIC assay is more sensitive than testing for biomarkers in gPrD patients. RT-QUIC method would thus be useful as a diagnostic tool when the patient or the patient's family does not agree to genetic testing, or to confirm the diagnosis in the presence of a positive result for genetic testing. Sc) in the CNS. The genetic form of human PrD (gPrD) is caused by mutations in the prion protein gene (PRNP), and is classified into genetic CJD (gCJD), Gerstmann-Sträussler-Scheinker syndrome (GSS), and fatal familial insomnia (FFI). Patients with GSS and FFI have symptoms such as dementia, dyskinesia and sleep disorders, but show no specific signal in diffusion-weighed MR imaging, and therefore the clinical discrimination of GSS and FFI from non-prion diseases such as spinocerebellar degeneration (SCA) Prion diseases (PrD) are fatal neurodegenerative disorders characterized by the accumulation of abnormal prion protein ”, for the detection of PrPSc in CSF of sCJD We recently developed a new We retrospectively analyzed 56 CSF samples obtained from gPrD patients in Japan, South Korea and Germany, including 22 cases of E200K gCJD, 20 cases of P102L GSS, 12 cases of FFI and 2 cases of V203I gCJD . PrP-genWe analyzed all CSF samples by RT-QUIC method as previously described Recombinant PrP, equivalent to residues 23–231 of the human PrP sequence, (codon 129 M) was expressed, refolded into a soluble form (rHuPrP-sen), and purified essentially as described previously We prepared reactions in a black 96-well optical bottom plate  to a final volume of 100 µl. To avoid contamination, we prepared non-infectious materials inside a biological safety cabinet in a prion-free laboratory and used aerosol-resistant tips. The final concentrations of reaction buffer components were 500 mM NaCl, 50 mM PIPES pH 7.0, 1 mM EDTA and 10 µM Thioflavin T. The rHuPrP-sen concentration was 50 µg/ml, and only freshly-thawed rHuPrP-sen was used. CSF (5 µl per well) was used to seed the RT-QUIC reactions. The 96-well plate was covered with sealing tape (Nunc 236366) and incubated at 37°C in a plate reader  with intermittent shaking, consisting of 30 s circular shaking at the highest speed and no shaking for 30 s, with a 2 min pause to measure the fluorescence. The kinetics of fibril formation was monitored by reading the fluorescence intensity every 10 min using 440 nm excitation and 485 nm emission and monochromators (Infinite M200) or filters (Infinite F200).Sc was detected in 18 of the cases by RT-QUIC, all of which were also positive for both t-tau and 14-3-3 proteins. In the GSS and FFI cases, RT-QUIC was positive in 90% of GSS and 83.3% of FFI  fibril formation in CSF of sCJD patients with those of gPrD patients, and found no significant difference .Sc amplification assay for diagnosis of prion disease has shown 84% sensitivity and 100% specificity in CSF samples from sporadic CJD patients.The RT-QUIC in vitro PrPTo determine the value of RT-QUIC in genetic prion disease diagnosis, we analyzed a total of 56 CSF samples from patients with various genetic forms of human prion disease . Our stuSc, and we were able to detect as little as ≥1 fg of PrPSc in diluted brain homogenate from sCJD patients. While we were not able to detect PrPSc in all sCJD CSF samples, the reasons for this are unclear and we assume that the amounts of PrPSc are very much lower in CSF samples of negative gPrD patients.RT-QUIC method was capable of detecting an extremely low volume of PrPBecause the majority of GSS patients remain alive with only relatively mild symptoms one year after the onset Moreover GSS and FFI show considerable phenotypic variability Interestingly, one patient with E200K gCJD was negative by RT-QUIC when sampled at 2 months after the symptom onset, but became positive when a second sample was obtain two months later. Thus, it is important that even if the CSF analysis by RT-QUIC is negative at an early stage, it should be re-examined at a later time point. Additionally, the use of RT-QUIC along with testing for the biomarkers should prove valuable for monitoring clinical trials of therapeutic agents use in gPrD patients.We believe that RT-QUIC analysis of CSF will become invaluable in the differential diagnosis of suspected prion diseases, since not all patients with the genetic mutation go on to develop prion diseases. AlphaIn conclusion, RT-QUIC enables the early diagnosis of GSS and FFI in many patients for whom a differential diagnosis is otherwise not currently possible.


Analysis of arterial blood has an important role in the clinical assessment of critically ill patients. Particularly, measured arterial lactate (a-Lac) provides valuable information on peripheral circulatory failure, although it is invasive and frequent measurement is often impractical. The aim of this study is to clarify the relationship between a-Lac and the more easily accessed venous lactate (v-Lac) and to generate a formula to predict a-Lac using v-Lac and other laboratory data.P value of 0.05 for entry, 0.1 for removal) was used to generate an equation including v-Lac and other potentially relevant variables including age, sex, systolic blood pressure, heart rate, and venous blood parameters . A Bland-Altman plot was drawn and the two equations were compared for model fitting using R-squared.A prospective cohort study was conducted from June to November 2011 in the emergency department at a tertiary-level community hospital in Tokyo, Japan. Patients were eligible for entry into the study if an arterial blood gas (ABG) analysis was required for appropriate diagnostic care by the treating physician. Arterial and venous samples were taken within 5 minutes of each other from the ipsilateral radial artery and cephalic vein. Samples were analyzed as soon as possible after collection on the same blood gas analyzer. Univariate linear regression analysis was conducted to generate an equation to calculate a-Lac incorporating only v-Lac. Then, a multivariate forward stepwise logistic regression model (2 (v-pO2), generated the following equation: (a-Lac) = -0.469 + (v-pO2) × 0.005 + (v-Lac) × 0.997. Calculated R-squared values by single and multiple regression were 0.94 and 0.96, respectively.Seventy-two arterial samples from 72 patients  were included in the study. Indications for ABG included respiratory failure (16%), assessment of shock (21%), altered mental status (26%), and others (36%). An initial regression equation was derived from univariate linear regression analysis: (a-Lac) = -0.259 + (v-Lac) × 0.996. Subsequent multivariate forward stepwise logistic regression analysis, incorporating venous lactate and venous pOVenous lactate estimates showed a high correlation with arterial values and our data provide two clinically useful equations to calculate a-Lac from v-Lac data. Considering clinical flexibility, Lac = -0.259 + VLac × 0.996 might be more useful, while avoiding a time-consuming and invasive procedure.


The hepatitis B virus is second only to tobacco as a known human carcinogen. However, chronic hepatitis B usually does not produce symptoms and people feel healthy even in the early stages of live cancer. Therefore, chronically infected people should perceive it as a serious health problem and move on to appropriate health behaviour. The purpose of this paper is to develop and validate an online program for promoting self-management among Korean patients with chronic hepatitis B. The online program was developed using a prototyping approach and system developing life cycle method, evaluated by users for their satisfaction with the website and experts for the quality of the site. To evaluate the application of the online program, knowledge and self-management compliance of the subjects were measured and compared before and after the application of the online program. There were statistically significant increases in knowledge and self-management compliance in the user group. An online program with high accessibility and applicability including information, motivation, and behavior skill factors can promote self-management of the patient with chronic hepatitis B. Findings from this study allow Korean patients with chronic hepatitis B to engage in proactive and effective health management in the community or clinical practice. The hepatitis B virus is known as not only the second highest carcinogen after smoking, but also the cause of 75% of primary hepatocellular carcinoma . A carriCurrently, a significant number of hepatitis B patients in Korea are caused by vertical infection from the mother during the perinatal period. Due to the fact that these patients live several years unaware that they are infected, several generations of a family may be affected by hepatitis B, and when they reach the age of 40–50, it is highly likely to progress to liver cirrhosis or liver cancer . Most paAccording to precedent studies, it was reported that hepatitis B patients have a high level of noncompliance to the regular health checkups or prescriptions , have a When considering the chronic progress characteristics throughout several decades of hepatitis B, the promotion of patient's self-management ability of chronic hepatitis B is very important. The theoretical frameworks for a program to promote self-management ability of the patients with chronic diseases include knowledge, motivation, and behavior skill factors of disease control , 15. TheThere must be a premise of an understanding on the fundamental basis of the chronic hepatitis B patients' health behavior to promote their self-management, and health management suitable for an individual's disease progress state, health issues, and health needs must be carried out based on that premise . HoweverThe online program is a system which allows the patient to systematically receive required information with the most updated content through a personal computer without limitation of time and location, to consult one's disease-related health issues with experts, and to be able to foster one's health care ability through various multimedia learning. However, the existing Internet information system mainly consists of content focusing on unidirectional knowledge delivery on the prevention and treatment of hepatitis B and is evaluated as having a lack of utility since it is unable to reflect the reliability assessment of information and user needs . Rather An online program to promote self-management capacities in patients with chronic hepatitis B can be used to increase the knowledge level on the disease's management and to promote the compliance to overall self-management through enhancing the motivation and behavior skill factors of the patients with chronic hepatitis B. The levels of knowledge and self-management compliance in this study will be measured through self-reporting questionnaires. The compliance to self-management will allow patients to avoid serious consequences such as liver cirrhosis or liver cancer in advance and furthermore will be helpful for the patients to establish a healthy lifestyle from the aspect of lifelong health management. Therefore, the purpose of this study is to develop an online program for patients with chronic hepatitis B to enhance their self-management capacities of the disease, and to evaluate its application. A design with a combination of software prototyping approach and system develop life cycle  was applThe major issues and health issues related to the management of chronic hepatitis B were identified through literature review, websites, patients, and their families. Initially, the contents that are related to self-management of the chronic hepatitis B disease were analyzed by reviewing literature and websites to form questionnaire issues. Through consultations with an expert panel, a questionnaire including 25 items was established. Author and research assistants of this study requested patient participation in the questionnaire survey through face-to-face advertisement of the study to the hospital-visiting chronic hepatitis B outpatients. By recruiting 52 chronic hepatitis B patients and 15 family members of the patients (who signed the written consent form), the program requirements and Internet utilization characteristics were investigated. Also, additional interviews were conducted to confirm the unrecognized or misinformation on the management of chronic hepatitis B.To analyze the data collected in the first stage, an expert panel was formed consisting of two physicians, three nurses, and one online health program coordinator, all of whom are involved in the treatment or management of chronic hepatitis B. First of all, major issues and health problems associated with lifelong health management of patients with chronic hepatitis B were uncovered, their priority was then set, and strategies for solving the problems were sought out. Discrepancies were discussed and a consensus was reached. Furthermore, each item related to the program was verified for its content validity by eight other experts among the expert panel pool in this study. Each item was graded on a 4-point scale, where 4 points equate to “Strongly agree” and 1 point equates to “Strongly disagree,” and the issues with a minimum content validity index (CVI) of 0.80 were selected. Based upon the analysis results, the foundation of the program contents was established.Through this basic process, an online program for lifelong health management with high accessibility and applicability was constructed for promoting self-management of the patient with chronic hepatitis B. This online program broadly consists of 6 main menus: Introduction to Lifelong Management of hepatitis B, What is hepatitis B?, Lifelong Health Management, Management of My Liver Health, Bulletin Board, and Sharing Board, with 24 submenus under them. Apart from this, three menus with much importance and applicability were extracted separately and set vertically on the right hand screen. If the main menu is connected to the information factor, motivation factor, and behavior skill factor, which are the factors to promote self-management in chronic disease patients, the menu “Introduction to Lifelong Management of hepatitis B” was designed as a foundation for strengthening these three factors. The menu, “What is hepatitis B?” is a stage for strengthening disease-related knowledge, which is an information factor. To enhance the learning effect, various audiovisual materials such as PowerPoint presentations, photos, and videos were utilized. The menu “Lifelong Health Management” strengthens the behavior skill factors by assisting in setting specific goals and establishing an action plan. The menu “Management of My Liver Health” strengthens the behavior skill factor by helping the patient understand and implement disease control through pop-up windows or alert messages, as well as individual algorithms. The menu “Bulletin Board” was made to enable viewers to get the latest information. Finally, in “Sharing Board,” motivation factors were strengthened through one-on-one consulting with experts and experience sharing with other patients. http://www.hepb.co.kr/. Submenus were completed after going through discussions on whether to use images and videos, ways of expressing content, and navigation strategies depending on the topic and content. The developed online program is the uppermost system, which is the initial screen, and is registered at the web address: The developed online program conducted the evaluation on user satisfaction and expert panel review with a survey. The evaluation on user satisfaction used a tool developed by Park et al. . This toThe evaluation of the online program by experts used the health care website evaluation tool developed by Chung & Park . This toThe questionnaire evaluation by users and experts was carried out after receiving written consent on participation in the study after the author and research assistants explained the purpose and method of the study, the spontaneity of participation and withdrawal, and the content of the questionnaire to the subjects. The current online program for promoting self-management was completed after going through numerous revisions through these evaluation results. The evaluation on the application efficacy of the online program was conducted on patients with chronic hepatitis B through a survey that measured hepatitis B related knowledge and self-management compliance after using the online program for three weeks. During this period, the author and research assistants checked and encouraged the use of the online program twice a week. t-test. The study was performed by subjecting 42 patients with chronic hepatitis B, who were recruited through the outpatient bulletin board at the university hospital and through face-to-face promotion of the online program during their outpatient visits. The author and research assistants initially explained the method of application evaluation by phone or by face-to-face meeting with participants and received their written consent forms. After that, the participants were asked to respond to a questionnaire survey by mail for pretest that measured patients' knowledge and self-management performance level in regard to hepatitis B. For those patients who responded to the questionnaire, the website address was given and allowed them to utilize the online program using their own computers for three weeks in their homes. The author and research assistants of the program phoned them more than twice a week to encourage them to use the program continuously and checked for any presence of difficulty in utilizing the program. For those patients who used the program for three weeks, a postquestionnaire was mailed and asked them for response. The collected data was analyzed through paired The hepatitis-B-related knowledge assessment tool is a questionnaire consisting of 28 questions revised and supplemented by Yang . The conTo investigate the needs related to the online program for promoting self-management in patients with chronic hepatitis B, data was collected through literature review, existing websites as well as patients, and their families. The main issues were analyzed from the collected data, and its priority and topic for each issue were set by the expert panel. Finally, other experts reviewed its content validity. 10 main issues emerged in total . The structure of the online program was created by applying relevant theories such as social cognitive behavior theory , self-efOnce you enter the website through the initial screen, it was designed so that the entire menu of the online program can be viewed at a glance . The strBesides this, three separate menus in addition to the main menu, with contents of much importance and applicability, were designed horizontally on the right hand side. “Treatment Guidelines” suggest standards of beginning treatment, treatment, safety precautions upon treatment, disease monitoring, and standard of finishing treatment. The glossary was designed to instantly provide a description once a patient or his family clicks on a word hyperlinked to a terminology that is difficult to understand. “Recommended Websites” allows patients to conveniently obtain support by providing links to various Korean websites such as hepatitis-B-related societies, government institutions, and social support networks in Korea.The evaluation of the online program established in this study was carried out through an evaluation conducted by an expert panel involved in the treatment and health management of patients with chronic hepatitis B, and user satisfaction of patients with chronic hepatitis B. First, as a result of analyzing the responses from 28 respondents who voluntarily participated in the program, user satisfaction evaluation among outpatients with chronic hepatitis B turned out high in the order of 4.01 points for contents usefulness, 3.85 points for contents relevancy, 3.82 points for design, 3.75 points for system convenience, and 3.68 points for system efficiency out of a perfect score of 5 . As a result of analyzing the responses from 17 health professionals comprised of physicians and nurses who engage in treatment or management of patients with hepatitis B and three medical informatics experts, purpose had 4.35 points, appropriateness 4.22 points, ease of use 4.14 points, and credibility 4.07 points, which were higher than other criteria; currency had the lowest score of 3.54 points . For eacAfter recruiting 42 patients with hepatitis B through one-on-one promotion at the outpatient clinic and the hospital outpatient bulletin board to evaluate the application of the online program developed in this study, an analysis was conducted on the knowledge and self-management compliance related to hepatitis B to test the effect before and after application . As a reAs a result of analyzing domestic online systems operated under the topic of “hepatitis B,” a significant number of websites were found to exist to advertise pharmaceutical companies or primary clinics. Most of the information was focused on pathological anatomy and the disease itself, which provided excessively professional or overly superficial information. In cases overseas, there were many websites related to management of hepatitis B, which tend to be more specialized and subdivided than in Korea. However, most of these websites were focused on unidirectional knowledge transfer on disease prevention and management of hepatitis B .It is considered that the management of chronic disease is effective when a program for promoting self-management is carried out in consideration of multidimensional factors, rather than knowledge-oriented education to allow proper health behavior to be internalized from the aspect of lifelong health management, along with specific disease management behavior. To patients with chronic hepatitis B, internalization of continuous disease monitoring, treatment compliance, and proper health behavior are important above everything else . HoweverAs a consequence of additionally analyzing the subject's disease-related knowledge prior to applying this online program, with regard to questions with incorrect answers at a correct answer rate below 50%, it implied that there is a problem in disease control since patients had an inaccurate knowledge of details. For example, “If my level of liver enzyme is normal, I do not have to do my regular checkup,” and “If my level of liver enzyme goes down to normal levels, I can stop taking medication” is essential knowledge in managing chronic hepatitis B. Many hepatitis B virus carriers' inadequate understanding of the disease resulted in indifferent or inappropriate health-seeking behavior towards their disease management . Additio As a result of additionally analyzing the self-management compliance of subjects before the application of the online program, items below the average rating of 3.5 points included “I do not use nutritional supplements or folk therapy on my own discretion,” and “I regularly do my checkup or take my medications as prescribed.” Especially, regular checkups or steady intake of medication are essential items for preventing liver cirrhosis or liver cancer and, ideally, should be a perfect score of 5 points. This lack of compliance, however, is believed to be due to the disease characteristics of chronic hepatitis B, which attack without specific symptoms and progress for a prolonged period . TherefoThe ultimate aim of the online program for promoting self-management is to prevent severe liver diseases such as liver cancer beforehand and, furthermore, establish a healthy lifestyle from the aspect of lifelong health management by raising the subject's awareness on the importance of hepatitis B infection management while promoting regular disease monitoring, treatment, and health management compliance. In order to achieve this objective, it is of paramount importance for the patient to understand the characteristic of their disease and promote self-management ability against chronic diseases. In the case of the online program, a lifelong health management support system, taking on the approach of fostering problem solving and self-management ability to patients with hepatitis B with various disease progress statuses will be more effective. This online program enhances the effectiveness of self-management with the latest updates through a tailored approach using an individual algorithm without limitation in time and space, web-based interactive learning, consulting with experts, vitalization of self-help group with other patients, and virtual situations and various multimedia materials. Therefore, there is significance in that this research finding allows patients with chronic hepatitis B to engage in proactive and effective health management when applying such online programs for promoting self-management in the community or clinical practice.


With specific focus on how the informants described the program, results showed that the descriptions were mainly positive in nature, suggesting that the program was well received by the program participants. When the informants were invited to name three metaphors that could stand for the program, positive metaphors were commonly used. Beneficial effects of the program in different psychosocial domains were also voiced by the program participants. The qualitative findings integrated in this paper provide further support for the effectiveness of the Tier 1 Program of Project P.A.T.H.S. in promoting holistic development in Chinese adolescents in Hong Kong.An integration of the qualitative evaluation findings collected in different cohorts of students who participated in Project P.A.T.H.S.  ( There are two contrasting research approaches in social sciences . Having Because of the limitations of positivistic research, there is a growing emphasis on qualitative research in social sciences . QualitaThese two main approaches of research are also seen in the field of evaluation. In the biomedical fields, the experimental and quantitative evaluation method is commonly regarded as the “gold” standard in assessing the outcomes of a program. In contrast, in social service settings, such as the fields of social work and education, the nonexperimental and qualitative evaluation method is commonly used to understand the process of implementing the program and the lived experiences of the program participants. As pointed out by Patton , there iProject P.A.T.H.S.  is a youth enhancement program that attempts to promote holistic youth development in Hong Kong . There aIn a pioneering focus group study conducted by Shek et al. , five foAs a research methodology, focus groups have emerged as a popular tool for generating qualitative data and are used across a wide variety of disciplines and applied research areas . Since tThere are several advantages of focus groups . PrimariInterestingly, in spite of its current popularity in different fields of social sciences, little has been documented about the use of the focus group methodology in program evaluation. Ansay et al.  highlighAlthough the focus group as a qualitative method is widely used, it has been criticized as lacking rigor . TherefoThe purpose of this paper is to present an integrated picture of the qualitative findings collected in a series of focus group studies with students participating in the Tier 1 Program of P.A.T.H.S. Project. In each focus group study, a general qualitative research approach  was adopFrom 2005 to 2009, in the Experimental and Full Implementation Phases, the total number of schools that participated in Project P.A.T.H.S. was 244, with 669 schools in the Secondary 1 level, 443 in the Secondary 2 level, and 215 in the Secondary 3 level. Among them 46.27% of the respondent schools adopted the full program , whereas 53.73% of the respondent schools adopted the core program .n = 19) incorporated the Tier 1 Program into the formal curriculum  and 32.1% (n = 9) used the class teacher's period or other modes to implement the program. For the consenting schools, the respective workers randomly selected students to join the focus groups. In all, 252 students joined 29 focus groups of approximately 1 h each, with the number of informants in each focus group ranging from 3 to 12 students. The characteristics of the schools that joined this qualitative evaluation study can be seen in A total of 28 schools were randomly selected for the study of student focus group evaluation , in which 23 schools joined the full program (20 h) and five schools joined the core program (10 h) of the Tier 1 Program of P.A.T.H.S. Project. Among the schools that joined this study, 67.9%  proposed by Shek et al. .An interview guide was used for conducting focus group interviews with students . In the There were 390 raw descriptors used by the informants to describe the program, and they could be further categorized into 78 categories see . Among tFor the metaphors that were used by the informants that could stand for the program, there were 188 raw objects involving 242 related attributes . Resultsn = 305), followed by benefits on the interpersonal level (n = 152). The findings showed that 597 responses (79.2%) were coded as positive responses and 35 responses (4.6%) were counted as neutral responses. In order to examine the reliability of coding, the research assistants recoded 20 randomly selected responses at the end of the scoring process. The average intrarater agreement percentage calculated from these responses was 98.1% (range 95–100%). The raw benefit categories were coded again by another two research staff members who did not know the original codes given. The average inter-rater agreement percentage calculated from these responses was 95% (range 90–97.5%).The perceived benefits of the program to the program participants are shown in n = 252 students in 28 secondary schools) were involved. Second, different datasets collected at different points of time were analyzed. Third, views of students in different grades were collected. Fourth, this is the first known scientific study of focus group evaluation of a positive youth development program based on different cohorts in China. Finally, this is also the first focus group evaluation study based on such a large sample of participants in the global context.The purpose of this study was to evaluate the Tier 1 Program of Project P.A.T.H.S. using findings based on focus groups involving program participants in the Experimental and Full Implementation Phases (2005–2009) of the project. There are several characteristics of this study. First, a large sample of participants . Primarily, several general limitations involved in focus groups are worth noting. First, focus groups provide descriptions about the perceptions of the program, and they are not useful for testing hypotheses in the traditional experimental design. Second, although group interaction is generally seen as an advantage of focus groups, there is always the possibility that intimidation within the group setting may inhibit interaction. Further, caution must also be exercised because the quality of the findings is tied to the skills of the moderator. Regarding the second and third limitations, the use of experienced moderators in this study could minimize the problems. In addition, the inclusion of other qualitative evaluation strategies, such as in-depth individual interviews, would be helpful to further understand the subjective experiences of the program participants. Despite these limitations, the present study provides pioneering qualitative evaluation findings supporting the positive nature of Project P.A.T.H.S. and its effectiveness in promoting holistic youth development among Chinese adolescents in Hong Kong.