Community health service center (CHSC) in China is always regarded as a good facility of primary care, which plays an important role in chronic non-communicable disease management. This study aimed to investigate the blood pressure (BP) control rate in a real life CHSC-based management program and its determinants.The study enrolled 3191 patients  in a hypertension management program provided by the Yulin CHSC , which had been running for 9 years. Uncontrolled BP was defined as the systolic BP of ≥140 mmHg and/or the diastolic BP of ≥90 mmHg, and its associated factors were analyzed by using logistic regression.The duration of stay in the program was 33 ± 25 months. When compared with the BP at entry, the recent BP was significantly lowered  and the BP control rate was dramatically increased (32 vs. 85%) . The age of >70 years , female gender , longer stay of >33 months , doctor in charge , and the use of calcium channel blocker  were significantly related to uncontrolled BP at the recent follow up .This CHSC-run hypertension program provides an ideal platform of multi-intervention management, which is effective in achieving higher BP control rate in community patient population. However, the BP control status could be affected by age, gender and adherence of the patients, as well as practice behavior of the doctors. Hypertension is a major cardiovascular disease and confers the highest risk attributable to cardiovascular death, 2. Low This program was established in 2004 when the Yulin CHSC  was selected as a sample center of chronic non-communicable disease management in China. In 2007, the management of hypertensive patients was included as a basic service item of every CHSC by the national laws, 20. TheOf note, it is a real life disease management program, in which the patients are allowed to come in or drop out at any time and not a pre-specified antihypertensive regimen is adopted. Therefore, initial and maintenance treatment plans for the study patients are made by the doctors based on their clinical judgments and changes of medication are allowed at any time in the program. However, in case of refractory hypertension, hypertension urgencies or significant comorbidies, the patients should be referred to local hospitals of higher levels. The principles of face-to-face patient education at each follow-up are to emphasize adherence to medication and lifestyle modification, however, it is allowed to be individualized between doctor and patient. The management program also provides open classes of patient education on hypertension, usually once a month. Furthermore, a third part is invited to conduct quality control in the program, by giving phone calls to randomly selected patients for details of the services they have received. The primary BP target of the management is set to the 140/90 mmHg criteria for all participants in the program regardless of their comorbidies, which appears simple and feasible in the CHSC setting, 23, 24.Baseline characteristics of the patients and the BP measurements during follow-up are stored in a dedicated database for the program. The diagnosis of diabetes is established according to concurrent guidelines, 26. ThePotential candidates of the management program are those with essential hypertension and the age of ≥35 years, who live in the Yulin community. The hypertensive patients (treated or not treated) found at family medicine clinic at the CHSC, regular health promotion program and home visit in the residential areas were all invited. Unfortunately, some subjects did refuse to participate with unaddressed reasons but the number of patients who refused was not recorded. Those patients who agreed to participate were recruited in the program and each of them was asked to provide an informed consent. As a result, the number of patients in the program has been increasing over the years, from several hundreds to several thousands. Until the data collection, 3389 patients were enrolled in the program and the rate of drop-out during the 9 years was 3.3%. Although the reasons of drop-out were not recorded for each case, they were mainly poor compliance, move out of the community and referral to higher level hospital due to disease complexity.Fourteen family medicine doctors at the Yulin CHSC have been taking care of the recruited hypertensive patients in the program. Among them, 12 (86%) doctors completed a full-time 5-year medical program with a bachelor’s degree in medical school while the other two doctors had 3 years of medicine related training with a medical diploma in technical college. All the doctors also received a part-time training in family medicine for 6 or 12 months. Standardized training was provided to the doctors on how to run the program prior to its commencement and whenever needed throughout the program. However, real practice behavior of the doctors are based on their own clinical judgments, but not pre-specified by the program.This study is an analysis of the data collected prospectively in the BP management program since its commencement in 2004. The data for analysis were exported from the program database in May, 2012. The patients with the duration of stay in the program <1 month or the times of follow-up <2 were excluded. Those who remained in the program for >1 year but had no records of visit from January to May, 2012 were regarded as drop-out cases and therefore excluded. The first BP measurement was labeled as the BP at entry, while the highest office BP measured during January to May, 2012 was labeled as the recent BP. The BP measurements during follow-up were grouped by the calendar year after entry . Optimal or controlled BP was defined as the systolic BP (SBP) of <140 mmHg and the diastolic BP (DBP) of <90 mmHg, while suboptimal or uncontrolled BP as either the SBP of ≥140 mmHg or the DBP of ≥90 mmHg, 24. Thit test or Pearson Chi-square test was used when appropriate. Multivariable logistic regression was adopted to find the associated factors of the recent BP control status. A p value of <0.05 was considered as statistically significant.The data were analyzed using a dedicated software . Continuous variables were expressed as mean ± standard deviation, while categorical data were summarized as frequencies and percentages. Paired student-Finally, 3191 patients were included in the data analysis (Table The mean duration of stay in the program was 33 ± 25 1 to 100) months for the study population. 1196 (38%) patients had stayed for less than 24 months, 1544 (48%) patients had stayed for 24–60 months, and 451 (14%) patients had stayed for more than 60 months. The visits from the 1st to 9th year were 6 ± 4, 7 ± 5, 7 ± 4, 6 ± 4, 6 ± 4, 6 ± 4, 4 ± 3, 5 ± 3 and 3 ± 1, respectively. Both the SBP and DBP during follow-up were reduced . Furthermore, differences in patient management by the 14 doctors were also found, in the number of patients under care, patients with controlled BP and patients with uncontrolled BP . 2058 (65%) patients were receiving calcium channel blocker (CCB), 841 (26%) patients were receiving angiotensin converting enzyme inhibitor or angiotensin receptor blocker, 447 (14%) patients were receiving β blocker, 121 (4%) patients were receiving diuretic and 237 (7%) patients were receiving other medicines. Among them, 823 (26%) patients were put on a combination therapy of two or more drugs. The recent SBP was 133 ± 8 mmHg with a reduction of 14 ± 17 mmHg, while the recent DBP was 75 ± 6 mmHg with a reduction of 8 ± 12 mmHg after entry (both p < 0.001). By using the recent BP, uncontrolled BP was found in 485 (15%) patients, with uncontrolled SBP in 458 (14%) patients or uncontrolled DBP in 98 (3%) patients. Only 377 out of 2177 (17%) patients with uncontrolled BP at entry remained in the uncontrolled group at the recent follow-up. On the other hand, 108 of 1014 (11%) patients who had the controlled BP at entry were found to have the SBP reading of ≥140 mmHg and/or the DBP of ≥90 mmHg during the recent follow-up  and non-diabetic  patients in this study, the SBP achieved in the program was not different , but the DBP was lower in the former group . The BP control rate did not show any difference between the 2 groups according to the 140/90 mmHg criteria0, 32% an, 24 of tIn order to investigate the determinants of suboptimal BP control (the 140/90 mmHg criteria) at the recent follow-up , a multivariable logistic regression model was created including demographics, comorbidity, medication at the last visit, doctor and patient adherence to the program. As shown in Table This study demonstrated that case management of hypertension by a CHSC in China helped to improve BP control among more than 3000 hypertensive patients in a local residential community. It was among the very few investigations on a real life disease management program rather than a pre-specified treatment study. During the mean stay of nearly 3 years in the program, the SBP was reduced from 147 ± 17 mmHg to 133 ± 8 mmHg and the DBP from 83 ± 11 mmHg to 75 ± 6 mmHg. The BP control rate achieved by the program was 85%, significantly higher than the 32% at entry. Shorter duration of stay in the program, older age and male gender were found to be the major determinants of suboptimal BP control.per se.CHSC has gradually become a major model of primary care in urban China since 1997, when the general policy framework of health care reform and specifications of health facilities started to be constructed, 29. TheThe national health care policies consolidate the infrastructures of CHSC services to hypertensive residents, however, the success of this program could also be explained by some other factors. Like many community health service centers in China that transformed from previous local small hospitals or clinics, the Yulin CHSC has its own pharmacy, biochemistry lab, family medicine clinic, day care bed and health promotion unit. It provides an ideal platform for team based multi-intervention management that suggested to be the most effective model in BP control, 30–35. The scope of services provided by CHSC to local residents includes chronic disease management and some other aspects such as health education, family planning, immunization and rehabilitation. Therefore, the doctors in the study do not contribute equally to different parts of work at the CHSC, which explains the heterogeneous distribution of the registered hypertensive patients among the doctors. Although they had similarly good education and training background, the 14 doctors could differ in their practice performance that may impact on the BP control of their own patients. Therefore, it may not be overemphasized the importance of complying with the current international and national practice guidelines among community health service providers. Unlike the generally low training level of community health service staff in China , the doctors involved in the study are undoubtedly able to provide better services to their patients. This woFirstly, the recruitment of study subjects who were largely a self-selected group may limit the representativeness of the findings. However, compared with a treatment study with many inclusion and exclusion criteria, this real life management program would be more representative of a general population that indicated by the distribution of patients among different age groups and both genders. Secondly, it is useful of recording the response rate to the program and the likely reasons for not participating. The lack of data on mortality and the reasons of drop-out may not be excused by the relatively low drop-out rate either. Thirdly, the lack of control subjects in this study makes it difficult to evaluate the actual effect size of BP management program. However, the “absolute” control rate of 85% achieved in the program is still promising by comparing to low control rate in hypertensive population. Certainly, it would be better to collect more information on the change of medication, diabetic control, renal function, lipid profile, amount of alcohol intake and amount of tobacco consumption, though its feasibility would be challenged in a CHSC program.The CHSC-based multi-intervention management program for community hypertensive patients, reinforced by the national health care reform policy of China, shows its effectiveness to achieve a higher control rate in a more general patient population. The BP control status in the program is associated with adherence of the patients and practice behavior of the doctors.


Childhood obesity is a concern in Australia and across the world. Community-based weight management programs are an important response to address childhood obesity. However, the scientific literature suggests that their effectiveness could potentially be enhanced by providing a structured incentive scheme. This proposal aims to determine the effectiveness of enhanced goal setting linked to a structured incentive scheme designed to improve the sustained health and wellbeing of overweight/obese children within the context of an existing community-based program.n = 40 sites, 570 participants) that compares the effectiveness of small changes to the program in which children were asked to set goals (supported by text messages) and were given rewards for achieving them (intervention). This will be compared to the standard/existing program (control), which did not have the same structured incentive program. Data will be collected for all participants at baseline, end of program, and at 6 and 12 months. The primary outcome is a mean change in body mass index (BMI) z score at the 12-month follow-up. Secondary outcomes include anthropometric measures  and behavioral measures collected via validated questionnaires. A process evaluation (comprising surveys and focus groups) to determine acceptability and sustainability and to inform downstream translation will also be conducted.This study is a cluster randomized controlled trial delivered within the context of the existing NSW “Go4Fun” program with a 10-week and 6- and 12-month follow-up (This study will inform policy and program delivery as well as the broader evidence base regarding goal achievement and incentive schemes directed at children’s health-related behaviors and will provide evidence that is likely to be transferrable across a range of health conditions.ACTRN12615000558527 registered on 29 May 2015. The prevalence of childhood overweight and obesity is increasing, contributes to a major public health problem, and has implications for current and future health services . Resultsn = 169) [n = 165) [n = 111) found that a parent-directed approach based on parenting skills training with lifestyle education improved BMI z scores by approximately 10 % compared to approximately 5 % with parenting-skills training alone or wait-listing for intervention [Community-based weight management programs are an important response to address childhood overweight and obesity. International recommendations identify that the core elements of any initiative to address the widespread problem should involve the family and include nutrition education, promote physical activity and include strategies that target behavior modification , 7–9. Twn = 169)  and HIKCn = 165)  highlighrvention . This strvention , 14.The United Kingdom Mind Exercise Nutrition Do it (UK MEND) program is an evidence-based community-based child weight management program with effectiveness in weight outcomes , 16. The2) and waist circumference (1.7 cm) as well as improvements in physical activity and self-esteem [While Go4Fun has demonstrated short- and medium-term health benefits for those who complete it, opportunities to improve retention and completion, goal setting and outcomes, and sustained outcomes after the program have been identified. A recent process evaluation found that despite the potential as a community-based population-wide program, widespread reach and attendance could be improved . End of f-esteem . Some Gof-esteem . TherefoChallenges in facilitating behavior change, as it relates to human health, has led to increasing prominence of research investigating whether the use of incentive schemes  might positively influence health-related behaviors . As suchn = 1,589) investigated the effects of a school-based incentive program aimed at promoting physical activity [Despite encouraging developments in adults, to date there has been very little research investigating the value of incentives for improving health-related behaviors in children. One French nonrandomized study  at the end of the program (10 weeks), 6 months, and 12 months;Health outcomes (body mass index (BMI) and waist ii.Completion of at least 75 % of the Go4Fun weight management program and;iii.Achievement of physical activity and nutrition goals during the Go4Fun program.To determine the effectiveness of a structured goal setting incentive scheme on the following:i.z scores, BMI, waist circumference, nutrition, physical activity, and self-esteem) at 6 months, and 12 months after the program; andSustained health outcomes , 6 months, and 12 months after the program.To determine the effectiveness of post program text message reminders highlighting a lottery prize draw on the following:To determine the acceptability  of the structured incentive scheme to inform widespread policy translation and implementation.In summary, early research suggests that the use of incentives for promoting behavior change in overweight/obese children has potential, but to date, this is a relatively unexplored area. The overall objective of this research is to apply behavioral insights to determine the effectiveness of a structured goal setting and incentive scheme to improve health-related behaviors in overweight/obese children. The opportunity also exists to test, using text message reminders and lottery prize draw, whether any gains made during the program are maintained and whether the effects of incentives are sustained after the program, as a cost-effective way of engaging with families after the program. The specific aims of this research are as follows:n = 40 sites, 570 participants), which compares the effectiveness of participation in the standard Go4Fun program with an enhanced goal setting and structured incentive scheme (intervention) versus participation in the existing Go4Fun program (control). Individual randomization is not possible given the nature of the intervention, so randomization by site will be conducted. Building on our existing research platform, we propose a pragmatic and feasible trial to determine the effectiveness, acceptability, and sustainability of the enhanced intervention at 6 and 12 months after the program. The CONSORT statements for cluster RCTs [The study is a cluster RCT Fig.  delivereter RCTs  and for ter RCTs  will be Are delivering the standard Go4Fun program in 2015;Show a 2014 attendance average of at least 10 children enrolled per program per term; andAre willing to participate in a trial and adhere to standardized procedures for the duration of the trial.To be eligible to participate in the trial, sites must meet the following criteria:For site recruitment, all NSW LHDs (where Go4Fun is delivered) were invited to participate, 40 programs agreed to participate, and ethical approval was secured from the relevant LHDs. Based on prior process evaluation work  and fromi.Aged 7 to 13 years;ii.Have a body mass index > 85th percentile for their age and sex (according to AIHW classification of overweight/obesity in children) , 45;iii.Be enrolled in and meet the general criteria to participate in the Go4Fun program at one of the sites participating in this study, which includes having a parent or adult carer able to accompany them to each session; andiv.Parent/guardian provides written and informed consent.To be eligible to participate in this trial, leaders were instructed that children must meet the following criteria:Participant/child eligibility for the Go4Fun program is assessed at the time of referral/contact with their LHD. No changes will be made to this standard program enrolment process. Eligibility will be determined by the program leaders based on assessment of the above criteria once the child attends the initial intake appointment, and written informed consent will be sought prior to collection of baseline data.Eligible sites have been randomized to either deliver the intervention (standard Go4Fun plus incentives) or control (standard Go4Fun) program for 10 weeks. Randomization was conducted using a computer-generated sequence (1:1) managed by the research team based at The George Institute and independent of the Department of Premier and Cabinet NSW (DPC), any program leader or LHD. Clusters were stratified according to local health district to ensure equal representation across groups within each LHD.In late 2014, an iterative process combining literature review, focus groups, and consensus meetings took place with three aims: namely, to (i) identify the best possible incentive scheme based on available literature, (ii) standardize the existing Go4Fun attendance rewards system across all treatment and control sites, and (iii) develop and agree on the goal setting scheme and incentive structure to be used for the intervention group. Participants included representatives from authorship group, program leaders representing all LHDs, DPC , Better Health Company, and the NSW Office of Preventive Health. In addition, investigators from DPC conducted six field research visits (including interviews) to collect feedback and ideas from the Go4Fun leaders about potential ways to enhance the goal setting process and practical considerations regarding delivery and impact as well as post-program engagement opportunities. A literature review demonstrated the importance of incentivizing behavior rather than outcomes. This approach was confirmed by Go4Fun leaders during early fieldwork so that, despite being a core part of the Go4Fun program, goal-setting structures could be improved by making the goals specific, measureable, achievable, relevant, and timely (SMART) . This emPreliminary work highlighted the need for a standardized reward system for the control program, and “healthy,” positive, and low-cost incentives  were needed for the intervention group. It was also agreed that incentives should be of increasing value as they become harder to achieve. Once consensus was reached regarding the control program and the incentive scheme for the intervention, formal standard operating procedures were prepared and circulated for revision and refinement until consensus was reached. This process was important to facilitate engagement and satisfaction of site leaders and to minimize potential variability between sites. Specific rewards and associated delivery structure are outlined further in the “intervention” section of this proposal.Sites randomly allocated to the control group will continue to deliver the standard Go4Fun program. As described above, the standard program consists of weekly group sessions (one per week) for 10 weeks during the school term. Exercise sessions involve one hour of activities that progressively develop skills, strength, fitness, confidence and self-esteem . NutritiSites randomly allocated to the intervention arm will deliver the Go4Fun program with the enhanced goal setting and structured incentive scheme developed during our preliminary work. As described above, the standard program consists of weekly group sessions (one per week) for 10 weeks during the school term. No sessions have been lengthened or combined for the intervention sites. All children participating in the intervention sites will receive the same information and participate in the same exercise and nutrition sessions as the control group. They will also receive the same system of “reward stickers” and standardized attendance rewards throughout the program. However, at intervention sites, participating children will be eligible to participate in an enhanced goal-setting component and receive incentives for reaching certain levels of goal attainment. That is, for the intervention, participants will set SMART  behaviorGoal setting: At the third session in the program, the children and their parent/ guardian in the intervention group are provided with an enhanced resource to guide them through jointly setting an exercise and a nutrition goal (child and parent/guardian in collaboration). Examples include ‘I will play soccer for 30 minutes on 3 days a week at the park with dad’ and ‘I will try a new vegetable two times a week for dinner on Wednesday and Sunday nights.’Goal attainment incentives: Children will receive milestone-based incentives for achieving their set goals. There will be three levels as follows: (i) a vegetable slicer once two exercise and two nutrition goals are achieved; (ii) a sports store voucher  once four exercise and four nutrition goals are achieved, and (iii) a height-adjustable tennis set once six exercise and six nutrition goals are achieved. In addition, Go4Fun leaders will ask the children on a weekly basis if they have achieved their goal and prompt them to reset them if they were too easy.Goal attainment reminders via text message and lottery style incentive: After the 10-week program, parents/ guardians will receive weekly mobile phone text message reminders to support and encourage children to achieve their goals (and set new ones where relevant). Parents/ guardians will be encouraged to text back with goal achievements with each goal achieved being rewarded with a ticket entry (maximum of eight tickets per month) into a prize draw (one per program) for a family pass to a local zoo  that will be drawn at 6 months.The goal setting component and incentive scheme was developed and agreed upon during the preliminary work for this study with an overview of the goal setting enhancement and incentives being as follows:z score at 12-month follow-up. BMI z scores indicate how many units (of the standard deviation) a child’s BMI is above or below the average BMI value for their age and sex. BMI z scores will be calculated from raw BMI measures using the Centers for Disease Control growth reference data [z scores, waist measures in centimeters will be converted to a waist circumference z score based on reference data [n = 564) [Data will be collected for all participants at baseline, end of program, at 6 months, and 12 months. The primary outcome is a mean change in BMI nce data . Secondance data  and behance data . The Phyn = 564) . Scores n = 564) . For nutn = 564) . These qn = 564) . An adapn = 564) . This scn = 564) .Table 1PData will be collected at baseline, end of program, 6 months, and 12 months by research assistants. For baseline measures, staff members have been trained by the Better Health Company investigator team in measuring height, weight, and waist circumference using standardized procedures . All parz score. To detect a between-group difference of 0.24 (±0.43) in the BMI z score  [Intraclass correlation was calculated based on preliminary data  across the recruited 40 sites and was found to be 0.16 for the BMI z score at 12 months between control and intervention groups will be analyzed after adjusting for the baseline characteristics using regression models. Similar regression models will be used for the secondary outcomes. These models will account for the between-cluster variance and will be adjusted for baseline characteristics. All analyses will be undertaken using SAS 9.4 for Windows , and statistical significance will be set at P < 0.05.Analysis will be conducted at the individual level and will follow the intention-to-treat principle. The control and intervention groups will be compared on baseline characteristics using independent t-tests for continuous variables or chi square tests for categorical variables. For the primary outcome, the mean difference in BMI Process evaluations explore the implementation, receipt, and setting of an intervention and help in the interpretation of outcome results . InformaThis study will adhere to the Australian National Health and Medical Research Council ethical guidelines for human research. Lead ethical approval has been obtained from the Sydney South Western LHD Research and Ethics Office (HREC/13/LPOOL/157), and necessary governance clearances have been approved as follows: South West Sydney Human Ethics Committee: HREC/14/LPOOL/480 and local project number: 14/278; South Eastern Sydney Local Health District Research Governance: SSA/14/G/398; Western Sydney Local Health District Research Governance: SSA/15/WMEAD/ 40; Hunter New England Local Health District Research Governance: SSA/15/HNE/110; Northern Sydney Local Health District Research Governance: SSA/15/HAWKE/110; and North Coast Local Health District Research Governance: SSA/14/NCC/126. Written informed consent will be obtained from all child participants and their parent/guardian prior to their participation. Participants will be free to withdraw at any time.Scientific literature suggests that providing an incentive scheme linked to goal achievement may improve motivation and completion of behavior change programs, but the potential of such schemes and their optimal delivery remain relatively unexplored in children. This study will inform policy and program delivery as well as the broader evidence base regarding goal achievement and incentive schemes directed at children’s health-related behaviors that will provide evidence that is likely to be transferrable across a range of health conditions.If the intervention is effective, it is likely to improve behavior change and enhance the outcomes for participants, thus reducing morbidity and mortality as well as the incidence of heart and cardiovascular disease in the future. The intervention aims to target prevention through incentivization of improved behavior change in a high-risk population of children. It is of great significance that the study is being conducted by a collaborative team that includes research leaders, behavioral change experts, and policymakers who are responsible for delivery of the government-funded weight management program. Ultimately, this will facilitate downstream translation and make a more effective program available to more high-risk children.As at 1 July 2015, recruitment has commenced and follow-up assessments are ongoing. No data cleaning or analysis of results had begun at the time of this submission.


Use of the Internet to deliver cognitive behavioural therapy, a frontline treatment for anxiety disorders, is emerging as an option to increase access to treatment among adolescents with anxiety disorders. This study examined the usability of the Internet-based component of Breathe, a CBT program designed for adolescents with mild to moderate anxiety and impairments.A mixed-method usability testing design with semi-structured interviews, task completion, and survey by trained usability moderators was undertaken with two interactive cycles to determine the usability  of the user interface and content areas of the program. Purposeful sampling was used to recruit mental health clinicians with expertise in treating adolescent anxiety disorders and young people aged 15 to 24 years involved. Testing involved using Web-conferencing software that allowed remote participation through personal computers. Two testing cycles involved participants completing structured ‘think aloud’ and ‘cognitive walkthrough’ tasks within the program. At the end of each cycle participants completed a 15-item global usability evaluation survey and were asked a series of open-ended questions. Descriptive and simple content analyses were used to identify and score usability issues for frequency and severity.Five clinicians and four young people  participated. Most participants described their computer skills as ‘good’ , and attitudes toward Internet-based health care ranged from negative (75 % young people) to positive . Scores from the global usability evaluation after both testing cycles ranged from 3.5 to 5 out of 5 in strong agreement/support of the program in terms of user performance indicators  and user satisfaction. Participants were able to complete all critical tasks with minimal errors. Errors and issues identified during testing were predominantly around enhancements to the visual design and navigational support. Opinions across usability elements did not differ between young people and clinician participants.A multi-method remote usability approach provided the opportunity to improve the technical interface, therapeutic messaging and user experience of an Internet-based treatment program for adolescent anxiety disorders. In their lifetimes, approximately 1 in every 3 adolescents will meet criteria for an anxiety disorder  for an aCBT for anxiety problems in adolescence is very effective at reducing symptoms and improving daily functioning ; this inWe developed an Internet-based, CBT treatment program (named Breathe) for anxious adolescents with mild to moderate distress and impairment. The program includes online (CBT treatment modules) and Internet- (e-mail support) based features as well as telephone support provided by a trained health care professional (‘Anxiety Expert’). Development of the treatment modules was overseen by research team members with expertise in treating anxiety disorders, and translation of the modules for online delivery was led by research staff at the Centre for Research in Family Health  with extensive experience in developing and delivering online interventions , 24. TheModule 1 (Introduction to Breathe/Anxiety Overview)Module 2 Module 3 (Common Thinking Traps)Module 4 (Relaxation Strategies and Positive Coping)Module 5 (Avoid Avoiding/Preparing to Face Fears)Module 6 (Fear Ladders/Strategy Planning)Module 7 Module 8 (Maintaining Gains)Breathe Module Topics:Treatment modules include the following: (a) video-delivered education about anxiety problems and approaches; (b) safety-monitoring and assessment of different intensities of need and anxiety severity; (c) activities to teach adolescents how to identify anxious thoughts and develop realistic thinking about anxiety-producing situations; (d) coping skill activities with self-assessment and rewards; (e) development of a hierarchy of feared situations and steps for gradual and repeated exposure to feared situations (using imagery and in vivo activities); (f) contingency management; and (g) peer modelling. Automated e-mail support to parents is also an option within the program.The Breathe program is powered by the Intelligent Research and Intervention Software (IRIS ©) platform that supports persuasive technology elements that make the program more than a static Internet-based treatment on a computer. IRIS provides customization , personalization , and notifications  to ensure the program adapts to the adolescent user to provide a tailored treatment approach.Internet-based health programs and interventions require a robust and bug-free underlying architecture, and user experience design that aligns with skill and knowledge level . The faiThe purpose of the present study was to explore the usability of Internet-based component of the Breathe program in terms of 1) how quickly users were able to learn the new interface and program layout (learnability); 2) the ease with which users could navigate through the components of the intervention (efficiency); 3) the frequency and severity of usability issues and 4) satisfaction with program content and the Website interface.Drawing on lean user experience design (UX)  and agilA purposive sample of mental health clinicians with expertise in treating adolescent anxiety disorders and young people aged 15 to 24 years involved in peer advocacy for mental health and illness were recruited. There were no exclusion criteria for youth as usability testers; youth could self-identify for study participation out of interest based on personal  or professional  reasons.Clinicians and young people were recruited through a national contact (e-mail) list maintained by the National Infant, Child and Youth Mental Health Consortium in Canada. Individuals on this list volunteered their contact information to the Consortium through participation in national mental health related activities and involvement in advocacy and education groups for mental health. All individuals on the contact list were e-mailed a study information letter inviting them to participate. This method was supplemented by convenience sampling of clinicians contacted during a Canadian Mental Health Association (CMHA) webinar hosted by the research team and youth volunteers working on mental health related projects at the Centre for Research in Family Health.We employed a broad age range for recruiting young people that is consistent with the World Health Organization and United Nations age-range for “young people” . While tAll study participants gave informed consent over the phone/email to the research assistant and were given the opportunity to ask any questions. Participants were mailed headsets with voice-cancelling microphones in advance if needed in order to ensure high quality audio experience during testing and to optimize data quality for transcription. An e-mail notice was sent out 2 weeks prior to the scheduled testing session, providing a Web link to a test session so that participants could ensure their computer had the necessary JavaScript updates and to test their audio set-up.Prior to starting the session all participants verbally confirmed informed consent. Participants were then asked to complete a general information questionnaire on demographic characteristics and level of comfort with computers and the Internet. Participants then logged into the Breathe program site and participated in standardized ‘think aloud’  and ‘cogTwo session moderators co-led each testing session. These moderators were skilled in qualitative interviewing and trained in using the Elluminate Live! software. Moderators made detailed notes during each session and created summary reports based on their observations. After each testing cycle, the research team and IRIS software programmers identified and prioritized usability issues and solutions.Participants were asked by usability testing moderators to rate their own comfort level with computers from 1 ‘very bad’ to 5 ‘very good’ and provide information on how frequently they used computers for various purposes on a scale of 1 ‘never’ to 4 ‘daily’. Additional questions identified attitudes toward Internet-based health interventions, preferred Websites for accessing health-related content and demographic characteristics.This 15-item self-report measure collected participant evaluations of Breathe on a likert scale ranging from 1 ‘strongly disagree’ to 5 ‘strongly agree’. Items were adapted from System Usability Scale (SUS)  and the A semi-structured interview was used to explore user satisfaction and interface performance. The content of the questions included questions related to 1) usability as a feature in treatment adherence ; 2) how motivation influences impressions of usability ; and 3) context issues for usability . A moderator used probes to elicit specific examples . Participants were asked for suggestions or alternatives and given the opportunity to provide any other relevant comments about the Breathe program.Questionnaire data were analysed to determine measures of central tendency and distribution of values. As each cycle of testing focused on different module components of the program, repeated measures analysis was not appropriate. Simple content analysis was performed after each testing cycle on the transcribed data relating to the think aloud and cognitive walk-though activities, and semi-structured interviews. Consideration was given to both positive and negative feedback. Usability researchers commonly rely on the frequency of errors to prioritize changes; however, there is little evidence of the correlation between frequency and severity of usability issues . For thin = 4; child mental health clinicians, n = 5) participated in Cycle 1 and eight of that original group participated in Cycle 2 . Usability sessions were conducted between June 27th and July 24th, 2014 (Cycle 1) and between September 4th and 10th, 2014 (Cycle 2). On average, usability testing sessions took 133 min to complete.Nine participants  and clinician  participants. The clinician group included three clinician scientists/professors, a social worker and a family therapy coach, all with advanced university education. Clinicians ranged in age from 20–40 years (n = 1) to > 40 years (n = 4) with both males (n = 2) and females (n = 3) participating. Young people were all younger than 20 years of age. Both males (n = 2) and females (n = 2) participated. Information on participant technology use is presented in Table Place of geographic residence spanned Canada for both youth  a short virtual tour of all the menu options and site features was recorded and users were encouraged to watch the video before beginning Module 1; 2) wording was changed to provide more explicit instructions on next steps and what actions were required by the user; 3) more internal links were added to help users navigate between pages of the intervention . Minor changes to page layouts, reduction of redundant or repetitive language, adding or removing page breaks and making more use of bulleted lists and pop-ups were minor solutions put in place to make the workflow more efficient without sacrificing important therapeutic messages.In structured CBT-based modules where content is delivered with a certain chronological logic  there is a structure to the treatment that require certain elements remain ‘unopened’ until other elements have been completed. During Cycle 1 most of the young people commented on automated restrictions around which content they could access, in which order, how much control they had over choices . Following Cycle 1, an animated video introduction CBT approaches was created and reviewed with users during Cycle 2 testing. Both youth and clinician testers commented that this introductory video would help program users manage their expectations about what would be involved in treatment, how long it would take and why CBT sessions were structured sequentially. Additional, positive language was added to the text in exposure focused Modules (5–7) to help users understand why a stepped approach was being used and to encourage them to continue. A frequently cited benefit of the intervention in terms of learnability and ease of use was automated email notifications for youth that would offer encouragement and reminders for completing activities if you had not logged onto the system or completed a module after a given amount of time.The majority of usability issues identified in both cycles were identified as Level 1, cosmetic or minor . The most common suggestions for additional personalization included: 1) additional space for expression , and 2) additional choices . Additional opportunity for open-ended comments and more opportunity for program users to select from among a range of options were added. Being designed as a largely self-directed intervention, young people’s responses to questions around ease of use , etc.). While still acknowledging that young people needed a certain degree of autonomy in the intervention, clinicians were concerned about formal rules around privacy. Young people’s comments tended to focus more on the practice of privacy, of deciding how much information parents received and when. Young people were very positive about how the intervention allowed them more freedom to be honest, to work at their own pace and in their own time. Youth did not show the same concern about online security of their information and did clinicians.Prior to conducting the usability testing, three of the four (75 %) young people participants indicated they generally held negative attitudes about Internet-based health care and preferred to access mental health resources from their health care provider. During testing sessions young people in particular emphasized concerns about online privacy and credibility. During Cycle 1 testing both young people and clinicians suggested a more transparent/personalized view of the study team  and evidence of the program’s credibility/usefulness . Access to the Anxiety Expert via a messaging feature, personal phone follow-up and secure e-mail interaction was frequently noted by test users as a benefit of the program and something that provided a sense of credibility and trust. Two young people commented on how just knowing that “someone” was there was comforting and reassuring even if they never needed to access that part of the intervention. To further enhance this program feature we created an “Our Team” page on the site, which included cartoon portraits of team members along with biographies, and more prominent display of partnering institution logos. The “Ask an Anxiety Expert” feature was also described in the virtual tour video so users would be aware that this feature was available to them during program use.The iterative approach used in this study enabled us to determine that our Internet-based CBT program was easy to use and understand, was efficient with relevant content, and provided satisfactory user experience. Participants generated innovative suggestions on ways that the Breathe program’s user interface and content could be improved. Although recruitment of youth for health research is frequently cited as challenging  our studThis study highlights the value of conducting formal usability testing to ensure new Internet-based treatments to deliver evidence-based care are usable and developmentally appropriate for the desired population. Our usability testing results included differences in how clinicians and youth may approach Internet-based interventions—with different kinds of scepticism or apprehension. Future research could examine the implementation and decision-making processes used by different stakeholder groups for using online therapeutic interventions. Clinicians in our study focused more on legalities and mechanisms of risk-management in an online environment whereas youth focused more on transparency and personal autonomy .Given that adolescents are more confident technology users and are increasingly accessing information online  it was nOur findings extend the body of research on usability of Internet-based mental health interventions to show that remote usability testing can produce valuable data and allow for testing with a geographically diverse group. Our study demonstrates that young people can be enthusiastic test users but comparative usability research on age-related difference in testing techniques  and testing modality  is still needed , 53. In This study was limited by sample size. A more diverse sample  would have allowed us to examine whether personal or experiential factors  were related to satisfaction. In keeping with usability testing recommendations, our sample was sufficient to identify the large majority of usability issues . It has This usability study provides evidence for the learnability, efficiency and reliability of a Internet-based CBT program for anxious young people. Iterative testing provided crucial technical and design feedback needed to improve young people’s experience with the intervention. Testing also provided important insights into interactions between context, content and user; particularly how expectations may affect subjective usability results. Breathe is now being evaluated in a pilot randomized controlled trial where issues of feasibility and usability can be further explored with a larger group of youth participants.


Implementation of health education programs is often inadequately considered or not considered at all in planning, developing and evaluating interventions. With the focus being predominantly on the adoption stage, little is known about the factors influencing the implementation and continuation stages of the diffusion process. This study contributes to the understanding of factors that promote or impede each stage of the diffusion process in the school setting using the sex education program Long Live Love (LLL) as an example. A survey integrating different diffusion-related concepts was completed by 130 teachers. Results showed that teacher curriculum-related beliefs were associated with all stages in the diffusion process. Although adoption of LLL was predominantly related to teacher curriculum-related beliefs, implementation completeness and fidelity and continued use of LLL were also enhanced by contextual factors, namely teacher training and interactive context variables , respectively. The results of this study can be used to optimize the adoption, implementation and continuation of school-based  health promotion programs. School-based sex-education programs are the primary means by which adolescents in the Netherlands receive information and skills related to safe sex, communication about sex and managing relationships . A multiThere are few published accounts of the process of implementation of interventions once they have been formally adopted by schools, particularly in relation to sex education. Little is known about if, how or how well the material is covered. Research conducted in the implementation field has tended to focus primarily on the adoption stage . ConsideThis study attempts to fill that gap by focusing on all the stages in the diffusion process, providing a holistic explanation of the adoption and implementation behavior of teachers in the school context. The present study addresses the promoting and inhibiting factors of teacher adoption, implementation and maintenance of a Dutch school-based sexual education program called Long Live Love (LLL). The LLL program is one of the most successful, evidence-based programs in the field of school-based sex education in the Netherlands targeted at adolescents (13–15 years) in secondary vocational schools. The effectiveness of previous versions of this program has been largely accredited to the quality and extent of its implementation , 11. In In the Dutch education system, schools and teachers are autonomous in their selection and use of health education programs, without the interference of external authority. Sex education is also provided on a voluntary basis, mostly by biology teachers . LLL is LLL is a relational and sexual education program composed of 26 learning activities divided over six lessons of one hour each. 22 of these activities are core and 4 are optional. LLL is designed to provide students with communication and negotiation skills to enable safe sex practices. It compromises a teacher’s manual, a student magazine and DVD. The main objective is the prevention of STDs/HIV and unplanned pregnancy . The preThe general outline of the research framework for this study was derived from an integration of Roger’s Diffusion of Innovations theory, the Theory of Planned Behavior (TPB), Social Cognitive Theory and from previous research on innovation in AIDS education in Dutch schools , 15.Roger’s Diffusion Theory  describeet al. [The TPB claims that intention is the most important predictor of behavior . Accordiet al. , intentiThe framework used in our study included the adoption of a revised version of LLL and the implementation and the continuation stages of the current version of LLL. Adoption of the ‘revised’ LLL program was focused on instead of the ‘current’ LLL program because all respondents included in the study have already adopted the current LLL program and there was more interest in inquiring what factors need to be taken into consideration to promote adoption of the revised LLL. Furthermore, past experience with programs has been found to influence future use of it , 19–21.The framework is presented in Teacher’s classroom implementation is best explained by their curriculum-related beliefs which include their attitudinal, normative and self-efficacy beliefs toward that particular innovation , 22, 23.Important individuals might provide normative standards for teachers’ decision to implement a new program . ‘SubjecTeachers are expected to deliver more of the program (completeness) with higher integrity (fidelity) if they have a more positive judgment of the curriculum , if they think that others believe they should use the curriculum (what do my colleagues think?) and the more they are able and skilled to work with the curriculum . Teachers’ experience with the program in turn will influence their intention to use LLL again (continuation) and/or to use the revised LLL (adoption). Their intention is expected to be higher if their attitude toward the program is positive, if they believe other teachers also intend to use the program and if they have the skill and ability to work with the program .et al. [In the Netherlands, a study about the adoption and implementation of HIV/AIDS education among 956 Dutch secondary schools showed that teacher’s decision making was most strongly related to highly specific adoption-related beliefs  . Similaret al.  investigThe ‘interactive context’ consists of environmental and organizational conditions in which teachers have to implement sexual education in their school. The interactive context refers to a schools’ formal sexual education policy, governing body support (context), the frequency of collegial interaction about sexual instruction, the extent of use of sexual education curriculum by colleagues (descriptive norm) and the students’ response to the curriculum. Teachers have to teach in collaboration with their colleagues and within the boundaries set by the policy of their school . CurricuThe ‘information source’ refers to support from external consultants, namely the municipal health services (MHS) and additional training for teachers to implement the innovation. In the Netherlands, the MHS is responsible for regional health promotion and supports schools in delivering health education programs. Attending teacher training and receiving external consultation can facilitate adoption and implementation by enhancing teachers’ skills and self-efficacy with regard to sexual education . It has Several demographic characteristics of both teachers and their schools may influence adoption and implementation of LLL such as teachers’ gender, age, years of experience with LLL, schools denomination  and class composition.To complement the determinant study, several constructs that are not represented in the framework were added, namely what LLL program components teachers use in their lessons , the hours they spend on teaching the LLL program and the extent of familiarity with the program prior to using it, as this could influence implementation behavior . AdditioA list from the educational publisher of teachers who have ordered the LLL program since 2006 was used to recruit teachers. A questionnaire was sent by post to a total of 610 teachers who are working or have worked with LLL. A total of 130 teachers from 110 schools completed the questionnaire, a response rate of 21.3%. Twenty-five questionnaires were returned due to incorrect addresses or teachers no longer working in those schools. Non-responders got a reminder by post, e-mail and eventually by telephone and were given 2 more weeks to fill out the questionnaire. No official non-response research was conducted due to a shortage of time and schools closing for the summer holiday.N = 66) had no religious background and a small school size (≤500 students) with 58% (N = 73) of teachers having a class compositions of predominantly native students. Of the participating teachers, 104 were female (80%). The mean age was 44 years (SD = 10.4). Years of teaching experience ranged from 1 to 42 years , whereas years of experience teaching sexual education ranged from 1 to 34  and years of experience with LLL ranged from 1 to 10 . About 94% were teachers of biology and healthcare.The participating schools were well distributed over the different regions of the Netherlands. Half the schools  were offered as reward. Teachers were given 2 weeks to complete and send back the questionnaire. Anonymity and confidentiality were preserved throughout the study.et al. [et al. [The items included in the questionnaire were based on the scales used by Paulussen et al.  and Wief [et al. . Impleme‘Completeness' or ‘extent of use’ of LLL was expressed as the percentage of the program (i.e. learning activities) being implemented. For each of the 22 core learning activities in LLL, teachers were asked if they had completed that activity. The completeness of implementation of the other four activities was not included in the analyses as these were optional. In the end, completeness was calculated for each teacher by adding up all the activities they completed per lesson, dividing them by the total number of activities (maximum 22) and multiplying them by 100.‘Fidelity' or ‘quality of use’ was measured by asking teachers to indicate, per lesson, how well they followed the instructions in the teacher’s manual . The scores per lesson were added up for each teacher and divided by the total number of lessons (6) to produce an average.‘Continuation’ of current LLL was measured with one item: ‘Do you intend on using the current LLL program next school year for your sexual education lessons?’ . Teachers were asked in an open-ended question to explain their intention level.‘Adoption’ of the ‘revised’ LLL program was measured with one item: ‘Do you intend on using the revised LLL program in the coming years for your sexual education lessons?’ . Adoption has been conceptualized as teacher’s intentions to use the innovation in various other studies , 18, 23.In relation to LLL, teachers were asked whether they used the DVD, teacher manual and student magazine in the LLL lessons , how familiar they were with the program before using it and how many hours they had spent on teaching the LLL program. ‘Extent of familiarity’ with the program was measured on a 4-point scale from (0) I only bought the program, to (3), I reviewed the program completely and thoroughly.P < 0.05) were included in the regression equations to understand how much variation in the outcome variables can be predicted by the independent variables. This regression analysis was done separately for each outcome variable. Several factors were dichotomized and included in the regression analysis as dummy variables, namely, school policy, descriptive norm and class composition. Multilevel regression analysis was not necessary because only one or two teachers per school participated in the study. Differences were interpreted as significant when P < 0.05.Descriptive analyses were first conducted to get an overall picture of the research sample. Next, Pearson’s correlation coefficient was used to reveal the correlations between the independent variables and the outcome variables . Backwards stepwise multiple regression analysis was then used to identify factors associated with these outcome variables. All independent variables were entered at the same time for each outcome variable, respectively. Only variables with significant bivariate associations . More than half of participating teachers had not received a training in sex education at all (58.5%) whereas 38% had received a training specifically for the use of LLL and 3.5% had received a general training in sex education (not LLL specific). The majority of teachers (58.9%) did not have any contact with the MHS in the past 4 years. Those who did have contact predominantly received a training specifically for LLL from the MHS (52.8%).n = 77). Few teachers only superficially reviewed the program  or solely bought it .Teachers generally spent 2–12 h teaching the LLL program, depending on how much time they had available and needed to complete the program. Furthermore, teachers were familiar with LLL; the majority of them had reviewed the program completely and thoroughly before use  of the 22 learning activities included in the analyses. Each activity was completed by over 80% of the teachers except homework activities (ranging between 19% and 68%). All components of the LLL program  were used by over 90% of the teachers.Completeness correlated significantly with numerous factors, namely teacher benefits, instrumentality, subjective norm, social support and self-efficacy, student response, contact with the MHS, following a training specifically for LLL, spending more hours on LLL, fidelity and extent of familiarity with the program see . TeacherM = 2.1, SD = 0.6). Especially lessons on risks of unsafe sex, negotiating condom use and resisting social pressure to practice unsafe sex were considerably modified compared with the rest.In general, teachers tend to follow the lessons as prescribed or slightly modify their lessons . Factors that appear to significantly predict and explain intention to continue using LLL are instrumentality, subjective norm, social support, self-efficacy, student response, governing body support, school policy, completeness and hours spent on LLL, as shown in The intention level of the group to continue using the current LLL was generally high (N = 91). Teachers with higher intentions to continue using the current LLL were more positive about the curriculum (34%) and believed it appealed to students (20.9%). Other teachers are happy to use this program until something better appears on the market (12.1%). Explanations for lower intention levels are that teachers find the material outdated, especially the DVD, and prefer to wait for a new version (13.2%). Some teachers claimed the material no longer appeals to students due to being outdated (6.6%), whereas others found the program lacking modern-day information (5.5%) or found the program too time-consuming (4.4%). Some teachers simply were no longer teaching subjects in which LLL was usually provided (3.3%).Explanations for intention level were reported by teachers in the open-ended questions of the questionnaire . The intention to use the revised LLL was high (N = 74). Teachers with higher intentions to adopt the revised LLL program namely had hopes and expectations that the new program will be an improvement on the previous version  (52.7%). Lower intention levels to adopt the new LLL can be explained by teachers’ uncertainty about the content of the new program and a preference to judge for themselves first (47.3%).Explanations for a level of intention to adopt the revised LLL program were reported by teachers in the open-ended questions of the questionnaire  was especially related to following a training specifically for LLL, greater instrumentality of the program, higher self-efficacy and greater familiarity with the program. Teachers who followed the guidelines of the LLL program more closely (fidelity) also completed more of the program (completeness). These findings are similar to a process evaluation study of a school-based adolescent sexual health intervention in rural Tanzania, where teachers delivered the program to primary school students with remarkable integrity and this fidelity was enhanced by a training course . TeacherFidelity was however hindered in our study when teachers had more years of experience with LLL. Several studies indicate that programs are frequently modified in the process of implementation , 36–38. ‘Continued use’ of LLL was positively related to interactive context variables  and curriculum-related beliefs . Furthermore, the more of the curriculum the teacher completed and the more hours they spent on LLL, the higher the intention to continue using LLL. Information source variables did not correlate with continued use.‘Adoption’ of the revised LLL was predominantly related to curriculum-related beliefs, namely teacher benefits, instrumentality, subjective norm and social support. Also, teachers who had a higher intention to continue using LLL were also more likely to adopt the new LLL. Information source variables and interactive context variables did not correlate with adoption. Self-efficacy correlated with adoption but not significantly. This runs counter to the findings of other studies, in which self-efficacy appeared to be a dominant predictor of teachers’ decision making on innovations . PerhapsTo date, only one study is comparable to the current one: the Sexual Health and Relationships: Safe, Happy and Responsible (SHARE) program in Scotland . The SHAResults of this study show that adoption is predominantly related to individual level factors, whereas implementation and continuation are also influenced by external factors, namely information source variables and the interactive context, respectively. Teacher training is an information source variable that is especially important in stimulating complete and correct use of LLL. It has been identified previously as a major determinant of success in the implementation of school-based programs , 43. PreContinued use of LLL is largely dependent on conditions that enable structural embedding of LLL, namely a supportive school management and school policy formally establishing sexual education in the school. Also, observing positive student responses reinforces implementation behavior of teachers . In SoutThe study had some limitations. Due to the cross-sectional design of this study, conducted at one moment in time, it is impossible to determine whether the teacher curriculum-related beliefs precede teacher’s implementation behavior or if they are a result of it. No present conclusions can be drawn about causality, only associations, unless a longitudinal study is conducted. Also, the same measures were used to predict implementation and continuation of the current LLL as adoption of the ‘revised’ LLL, which could limit interpretations of the adoption results. Past experiences with a program have however been found to predict future use , 20, 21.Additional methodological limitations of the study are self-reports by teachers, a self-selected sample, limited measurements on the outcome measures of adoption and continuation with a single item and lack of assessment of student outcomes. An effectiveness study was however conducted in 2001, where LLL was found to have positive outcomes for students, proving that it is a worthy program . ProcessWith this study, we hope to share lessons for successful implementation in the school setting. The results reveal that each stage of the diffusion process is influenced by different kinds of factors. This implies that it is necessary to consider all three stages when planning and evaluating the implementation of interventions. It also implies that different strategies are needed to enhance adoption, implementation and continuation of an innovation as the Diffusion Theory suggests . To enhaMuch needed insight has been provided for the facilitating and inhibiting factors influencing the different stages of the implementation process of a school-based sex-education program, LLL. This information becomes especially relevant in the field of health promotion intervention development, where the importance of implementation is being increasingly acknowledged . Underst


BCR and ABL1 genes followed by genomic deletions that produced the BCR-ABL1 hybrid gene. We present an alternative model that fits the origin of the patient’s rearrangement better. The present model links submicroscopic inversions with the occurrence of the t translocation and opens a new approach on the research on the disease.A complex chromosomal rearrangement observed in a patient with chronic myeloid leukemia was explained as the consequence of a multistep process. The explanation involved an initial t translocation with breakpoints distant from the  BCR and ABL1 genes; then, specific genomic deletions occurring in a cell with such t translocation produced the BCR-ABL1 hybrid gene q34;q11.2) translocation in chronic myeloid leukemia (CML) .bDuplicons marked as A’-B’, C’-D’, E’-F’ and G’-H’ in the Albano’s et al. work [http://dgv.tcag.ca/dgv/app/home (GRCh37/hg19)].al. work  map at ccThe 126 bp exon maps at chr9:132101071–132101196 .


Cystic adventitial disease (CAD) of the popliteal artery is a rare vascular disorder in which a mucin-containing cyst develops in the adventitial layer of the artery. We report two such cases, each of which was treated differently. The first case was of a 49-year-old man, treated by excision of the involved arterial segment and interposition of an autologous saphenous vein graft. The second case was of a 36-year-old man, treated by local excision of the affected arterial segment and interposition with prosthetic bypass grafting. Both patients presented with rapidly progressing intermittent claudication of the lower extremities, but without remarkable evidence of atherosclerotic disease. Physical examination revealed diminished or absent popliteal, posterior tibial and dorsalis pedis pulses in the lower extremities. Color Doppler ultrasound of the popliteal artery revealed hypoechoic cystic lesions surrounding the vessel, and popliteal arterial stenosis, in both patients. Surgery resulted in immediate improvement of the arterial pulse distal to the lesion. Both patients recovered uneventfully. Thus, resection of the involved artery segment and interposition bypass grafting, using either patient or prosthetic veins, offers favorable results for CAD of the popliteal artery. Cystic adventitial disease (CAD) is an uncommon non-atherosclerotic condition in which a cystic collection of mucinous material accumulates in the adventitial layer of the artery. The subsequent extrinsic compression of the arterial lumen leads to peripheral vascular insufficiency and intermittent claudication. CAD most often affects the popliteal artery, with 85 % of documented cases involving this region. Other involved arterial segments that have been reported include the external iliac, common femoral, radial, and ulnar arteries. CAD patients are typically young to middle-aged men, with a male-to-female ratio of approximately 15:1 and an average age in the fourth to fifth decade of life [A 49-year-old man presented with a 3-month history of intermittent claudication of the left lower extremity. Physical examination revealed diminished popliteal, posterior tibial, and dorsalis pedis pulses in the left lower extremity and a systolic murmur in the popliteal fossa. Color Doppler ultrasound showed a hypoechoic cystic mass anterolateral to the popliteal artery and popliteal arterial stenosis Fig. a. An axiAt surgery, the popliteal artery was exposed from a posterior approach through a longitudinal incision, revealing a firm, pinkish-white, multilobulated cystic lesion, with well-defined margins Fig. d. There A 36-year-old man presented with a 2-year history of a cold left foot and left calf pain after exercise, and reported that these symptoms had worsened over the past month. Physical examination revealed mild amyotrophia and a 7 °C difference between the thigh and calf skin on the left leg. No pulse was palpated below the popliteal artery on the left side. Color Doppler ultrasound showed a multilobulated cystic mass, 40 mm × 11 mm in size, which was posterior to the popliteal artery and resulted in hemodynamically significant endoluminal stenosis. Only a thin linear arterial blood flow signal of 0.9–1.1 mm thickness was observed inside the affected popliteal artery, caused by compression from the cystic mass (Fig. At surgery, a cystic protuberance, 6 cm long, was found at the junction of the femoral and popliteal artery Fig. b. The trCAD is a rare disease characterized by a mucoid cyst in the adventitia, which compresses the affected artery and restricts blood flow. This entity was first reported by Atkins and Key , who desThe etiology of CAD is still not completely understood, although four theories have been proposed , 5. The 2-weighted images and have low to intermediate signal intensity on T1-weighted images, caused by the variable amount of mucoid material within the cysts [CAD of the popliteal artery generally occurs in males during the fourth and fifth decades of life. The CAD cysts progressively compress the lumen of the popliteal artery, which manifests as intermittent claudication. The patient will experience this symptom with sudden onset and rapid progression. Thus, when a middle-aged adult presents with intermittent claudication in the lower extremities and no evidence of atherosclerotic disease, the treating physician should consider CAD of the popliteal artery. On physical examination, the popliteal and pedal pulses can be normal or weak; therefore, gray-scale ultrasound is often used to identify the suspected cysts as hypoechoic or anechoic masses adjacent to the affected vessel, especially since this imaging modality is noninvasive and readily available in many clinics . Color Dhe cysts . Cyst-meThree treatment options are currently recommended for CAD: resection of the cyst with arterial preservation, excision of the involved arterial segment with interposition bypass grafting, and CT- or ultrasound-guided percutaneous cyst aspiration. The treatment of choice is surgical removal of the cyst, which achieves complete excision of the cyst wall and preserves the medial and intimal layers. This approach is most suitable for patients without severe popliteal stenosis and minimal adherence between the cyst wall and the artery . In caseIn conclusion, CAD should be suspected in middle-aged male patients who present with intermittent claudication of lower extremities but without solid evidence of atherosclerotic disease. Ultrasound, CT and MR imaging modalities are valuable tools for acquiring a correct diagnosis of CAD. When surgical removal of the CAD does not release the popliteal arterial stenosis, excision of the involved arterial segment and interposition bypass grafting produces excellent results.


Unbalanced inflammatory response and lymphocyte apoptosis is associated with high mortality in septic patients. Decoy receptor 3 (DcR3), a member of the tumor necrosis factor receptor superfamily, is an anti-inflammatory and anti-apoptotic factor. Recently, DcR3 expression was found to be increased in septic patients. This study evaluated the therapeutic effect and mechanisms of DcR3 on cecal ligation and puncture (CLP)-induced sepsis in mice.in vitro lymphocyte apoptosis regulation.C57BL/6 mice were subjected to CLP-induced polymicrobial sepsis. DcR3 Fc was intravenously injected 30 min before and 6 h after CLP. Bacterial clearance, cytokine production, histology, lymphocyte apoptosis and survival were evaluated. Furthermore, we investigated the systemic effects of DcR3 in p <0.05). Treatment with DcR3 protein significantly reduced the inflammatory response and decreased lymphocyte apoptosis in the thymus and spleen. Histopathological findings of the lung and liver showed milder impairment after DcR3 administration. In vitro experiments showed that DcR3 Fc inhibited Fas-FasL mediated lymphocyte apoptosis.Our results demonstrated that DcR3 protein treatments significantly improved survival in septic mice (Treatment with the DcR3 protein protects mice from sepsis by suppressing the inflammatory response and lymphocyte apoptosis. DcR3 protein may be useful in treatment of sepsis. Despite advances in supportive care, sepsis remains one of the most challenging clinical problems due to its high morbidity and mortality in children and adults , 2. The Expression of some co-stimulatory/inhibitory molecules is markedly altered in sepsis. These molecules appear to be associated with morbidity and mortality in septic models as well as patients with sepsis , 12. DecWe recently found that DcR3 expression is elevated in patients with sepsis and is related to sepsis mortality . These fIn this study, we investigated the effect of DcR3 on survival in a murine cecal ligation and puncture (CLP) model of sepsis. In addition, we attempted to elucidate the potential mechanisms underlying the putative beneficial effect.Adult C57BL/6 mice (8–10 weeks age), with a body weight of 22–30 g, were obtained from the Animal Center of the First People’s Hospital Affiliated with Shanghai Jiaotong University China. They were maintained in a specific pathogen-free facility at a temperature of 22 ±2°C with 12 h light and dark cycles and 50% relative humidity. All procedures were approved by the Committee on the Ethics of Medical Scientific Research of the First People’s Hospital, Shanghai Jiaotong University (Permit Number: 2012KY041). All treatments were humane and in accordance with the guidelines for the Care and Use of Laboratory Animals of the National Institutes of Health.The sepsis model was induced as previously described . BrieflyFor the survival study, we used the death as the clinical endpoint. All mice were monitored every 6 h for 7 days and euthanized when they were found in a moribund state as identified by labored breathing and/or non-responsiveness to cage tapping. Moribund mice were anesthetized with ketamine prior to cervical dislocation. At the end of the experiment, all surviving mice were euthanized with ketamine followed by cervical dislocation.DcR3 Fc and Ig Fc were purchased from Sigma . Briefly, DcR3 Fc was produced from a DNA sequence encoding the signal peptide from human CD33 joined with amino acid residues 24–300 of human DcR3 which was fused to the Fc region of human Ig G1 by a polypeptide linker. The recombinant DcR3/Fc chimera was measured by its ability to inhibit the biological activity of Fas-ligand-induced apoptosis of Jurkat cells. Forty mice were randomly divided into four groups (ten mice per group): sham group, CLP group, CLP plus Ig Fc group, and CLP plus DcR3 Fc group. DcR3 Fc was dissolved in sterile distilled saline and 100 μg DcR3 Fc was intravenously injected in mice 30 min before CLP and 6 h after CLP. For the sham and CLP groups, mice received an equal volume of saline. For control purposes, the CLP plus Ig Fc group received an equal amount of Ig Fc. Twenty-four hours after surgery, blood, lung, liver, spleen and thymus were collected. Peritoneal lavage fluid was collected by injecting 2 ml phosphate buffered saline (PBS) into the peritoneal cavity. Another forty mice were observed for the survival of animals over the subsequent 7 d.Tissue samples, including lung and liver, were collected 24 h after surgery and immediately fixed in 4% paraformaldehyde. After 12 or 24 h, tissue sections were embedded in paraffin, cut into 4–5 μm sections, and stained with hematoxylin–eosin. Two experienced pathologists who were blinded to the protocol performed the histological examinations. To grade the degree of lung injury, a scoring system was used based on the following histological features: edema, hyperemia and congestion, neutrophil margination and tissue infiltration, intra-alveolar hemorrhage and debris, and cellular hyperplasia. Each feature was graded as absent, mild, moderate, or severe, with a score of 0 to 3, and total scores were calculated for each animal . The scoBlood and peritoneal lavage fluid were harvested from mice 24 h after surgery and centrifuged for 10 min at 300 g. The levels of TNF-α, IL-6, and IFN-γ were quantified using a murine ELISA kit  according to the manufacturer’s instructions.In Situ Apoptosis Detection Kit  according to the manufacturer’s instructions. Briefly, after fixation with 4% paraformaldehyde, spleen samples were incubated for 10 min in equilibration buffer. The TUNEL reaction mixture was added and sections were incubated for 1 h in a 37°C humidified chamber. After stopping the reaction, sections were visualized using the anti-digoxigenin-peroxidase antibody and DAB, and counterstained with bis-benzamide. Positive cells were identified and counted using light microscopy. The percentage of TUNEL-positive cells was used to determine the apoptosis rate. At least 1000 cells per section were examined in five randomly selected fields (400×). At least four sections were used to calculate the apoptosis rate of each group.Thymus and spleen tissues were harvested from mice 24 h after surgery. Single-cell suspensions from thymus were prepared. CD3+ T cells were stained using fluorochrome-conjugated annexin V and propidium iodide (PI), and analyzed using a FASCalibur apparatus and CellQuest software . Annexin V-positive cells were considered apoptotic cells. Terminal deoxynucleotidyl transferase- mediated dUTP nick-end labeling (TUNEL) assays were performed using the ApopTag Plus Peroxidase Blood, spleen, and thymus were collected 24 h after CLP. For spleen and thymus, single-cell suspensions were first prepared. After erythrocyte lysis, the total cell number was recorded. Lymphocyte subgroups were also stained with fluorochrome-conjugated antibodies against cell subset-specific surface markers. Lymphocyte counts were calculated based on the total cell count and lymphocyte subgroup percentage obtained by FACS analyses.Using lymphocyte separation media, lymphocytes were separated from whole blood from septic persons and randomly divided into four groups: normal, FasL, FasL plus Ig Fc, and FasL plus DcR3 Fc. Cells were pretreated for 1 h with 10 ng/ml DcR3 Fc or 10 ng/ml Ig Fc, followed by incubation for an additional 12 h with 100 ng/ml recombinant human FasL . Cells were then collected and apoptosis was detected using annexin V and PI double staining and western blot analyses.Cells were lysed with raidoimmunoprecipitation assay (RIPA) reagent  in the presence of protease inhibitors  and total protein quantified with the bicinchoninic acid (BCA) protein assay kit . A total of 20 μg of protein were separated by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS–PAGE) and electro-transferred onto a polyvinylidene fluoride (PVDF) membrane . Expression of cleaved caspase 8 was detected using mouse anti-human caspase 8 monoclonal antibody  and HRP-conjugated sheep anti-mouse antibody (Amersham Bioscience). Expression of cleaved PARP was detected using rabbit anti-human PARP polyclonal antibody  and horseradish peroxidase (HRP)-conjugated sheep anti-rabbit antibody (Amersham Bioscience). Expression of GAPDH was detected using rabbit anti-human GAPDH polyclonal antibody (Amersham Bioscience) and HRP-conjugated sheep anti-rabbit antibody (Amersham Bioscience). Protein expression was visualized using ECL Plus reagent (Amersham Bioscience) and a Chemilumino analyzer GelDoc XR system .p<0.05 was considered statistically significant.SPSS 19.0 statistical software was used for all analyses. Data are expressed as the mean ± standard deviation (SD). Kaplan–Meier plots were used to describe survival data and a log-rank test was performed to assess the statistical differences. For multiple comparisons, one-way analyses of variance (ANOVA) were used to compare differences between groups. A value of p<0.05)  . The admTo investigate whether DcR3 Fc administration is associated with pathological changes in lung and liver tissue, Hematoxylin–eosin staining was performed. Lung injury, accompanied by infiltration of inflammatory cells into the lung interstitium and alveolar space, alveolar wall thickening, consolidation, and alveolar hemorrhage, was noted in the CLP and CLP plus Ig Fc groups. Liver injury was evidenced by swollen hepatocytes and absent hepatic sinusoidin the CLP and CLP plus Ig Fc groups. DcR3 Fc treatment significantly prevented these pathological changes . These rTo assess the effects of DcR3 Fc administration on cytokine production during the CLP model of sepsis, the levels of TNF-α, IL-6, and IFN-γ in the blood and peritoneal lavage fluid were analyzed. Twenty-four hours after surgery, the levels of TNF-α, IL-6, and IFN-γ were significantly higher in the blood and peritoneal lavage fluid of the CLP group compared with the sham group. Administration with DcR3 Fc significantly attenuated inflammatory cytokine production in the CLP group . These rp <0.05) (p <0.05)  . DcR3 Fcp <0.05) . These rTo investigate the effects of DcR3 Fc administration on lymphocyte apoptosis, lymphocyte numbers in peripheral blood, spleen and thymus were detected by flow cytometry. The number of total lymphocytes was higher in the blood of the CLP plus DcR3 Fc group compared to the CLP-only or Ig Fc control groups. Similar results were observed in the spleen and thymus . These rTo better understand some of the mechanisms whereby DcR3 inhibits lymphocytes apoptosis during the CLP model of sepsis, we induced apoptosis by stimulation with recombinant FasL. We found that preincubation with DcR3 Fc significantly inhibited FasL-mediated lymphocyte apoptosis. Western blot assays indicated that cleavage of caspase 8 and PARP was also inhibited by pretreatment with 10 ng/ml DcR3 Fc . These rOur previous study demonstrated that DcR3 expression was upregulated in patients with sepsis  and the DcR3 expression has also been demonstrated in various acute and chronic inflammatory conditions, including inflammatory bowel disease (IBD) and acute respiratory distress syndrome (ARDS) , 24. In In this study, we found that administration DcR3 before and after CLP effectively protected mice from CLP-induced sepsis. The potential mechanisms underlining this therapeutic effect might associated with different aspects of sepsis, including reduced inflammatory responses and decreased lymphocyte apoptosis.Sepsis is a systemic inflammatory response caused by infection. Unlike other inflammatory diseases, it is characterized by two distinct phases . The earin vitro overexpression experiments. Peripheral lymphocytes cells obtained from septic shock patients were incubated with FasL in the presence of DcR3 Fc or Ig Fc. Our data revealed that DcR3 pretreatment decreased FasL-induced peripheral lymphocyte apoptosis.DcR3 is suggested to inhibit apoptosis by binding to FasL and LIGHT. FasL exists on most immune cells. Increased apoptosis in response to polymicrobial sepsis and CLP has been reported, primarily in the immune cell population expressing the FasL receptor . In addiHowever, clearance of the bacterial burden from the blood and peritoneal lavage fluid of septic mice was not altered (data not shown). We suggest that the unaltered level of bacterial burden clearance may be related to the suppression of macrophage phagocytic activity by DcR3. Unfortunately, all mice were euthanized after observation for 7 days, and no further data were obtained. Moreover, there is an apparent contradiction between the assumption that DcR3 concentration is related to sepsis mortality , and theOne limitation of this study is that we only harvested blood and peritoneal lavage fluid after 24 h to detect the bacterial burden. The host immune response, rather than the pathogen, is primarily responsible for the morbidity and mortality associated with sepsis. DcR3 is a potent anti-inflammatory and anti-apoptotic factor that could activate inflammation-resolution programs and enhance host defenses to remove microorganisms. However, because DcR3 can inhibit apoptosis of infected cells, intracellular pathogens may survive and cause chronic infection. Further studies should extend the observation time past 24 h to evaluate the effects of DcR3 on CLP-induced mice, as well as to examine the efficacy of DcR3 in patients in the clinical setting.Taken together, our results suggest that DcR3 may have a vital role in the balance of pro-inflammatory and anti-inflammatory responses during sepsis. Because the available therapeutic strategies for sepsis are limited, DcR3 alone or in combination with antibiotics may be beneficial for patients with sepsis.


AbstractAllothereuawilsonae Dobroruka, 1979; Chinobiusalenae Dobroruka, 1980; Lithobiuscorrigendus Dobroruka, 1988; Lithobiuscreticus Dobroruka, 1977; Lithobiuserythrocephalusmohelensis Dobroruka, 1959; Lithobiusevae Dobroruka, 1958; Lithobiusmagurensis Dobroruka, 1971; Lithobiuspurkynei Dobroruka, 1957; Lithobiustatricus Dobroruka, 1958; Lithobiustatricusmonounguis Dobroruka, 1958; Monotarsobiushomolaci Dobroruka, 1971; Monotarsobiuskrali Dobroruka, 1979; Pachymeriumdilottiae Dobroruka, 1976; Pachymeriumhanzaki Dobroruka, 1976; Scolopendraaztecorum Verhoeff, 1934 and Strigamiaolympica Dobroruka, 1977. Of these 16 taxa, five were described from the Czech Republic, three from Slovakia and eight from other countries . The eight taxa described from the Czech and Slovak Republics are now considered as junior synonyms but the eight taxa described from the other countries are still valid.The centipede collection in the National Museum in Prague contains type material of 16 taxa (14 species and two subspecies), of which 15 were described by Luděk J. Dobroruka and one by Karl W. Verhoeff:  Scolopendra species based on material collected by Czech acarologist Prof. Jaroslav Štorkán (20 April 1890 – 1 June 1942) who was collecting for the NMP in 1920s and 1930s. Thus, it is not surprising that a part of material collected by him came back to the NMP.The most important part of the zoological collection of National Museum in Prague (NMP) is the type material. Up to now, catalogues of the type material of spiders , vertebrThe collection of centipedes (containing ca. 1500 specimens representing ca. 150 species and subspecies from about 40 countries) is perfectly organized and catalogued thanks to RNDr. Ing. Luděk Jindřich Dobroruka (20 October 1933 – 4 July 2004) who worked in the NMP as a curator of Invertebrates in 1956 and continued with his work on centipedes in the NMP also in 1970s. His work resulted in publishing of catalogues of non-type Bulgarian , Greek  and BrazAll the specimens are preserved in 80% ethanol. Nomenclatural issues follow the International Code of Zoological Nomenclature , 2012. OPageBreakScutigeromorphaOrder: ScutigeridaeFamily: Allothereuawilsonae Dobroruka, 1979Orig.Allothereuawilsonae Dobroruka, 1979b: 101, figs 1–5 (♀).Now.Allothereuawilsonae Dobroruka, 1979. The status of this species has never been revised since its original description.Holotype. NMP P6E-1761, ♀ in poor condition , collected by Jane M. Wilson on 14 October 1971 in one of the tents of the camp, near Mahendra Cave, Pokhara Valley, Nepal; 28°14.00'N, 83°59.00'E.ScolopendromorphaOrder: ScolopendridaeFamily: Scolopendraaztecorum Verhoeff, 1934Orig.Scolopendraaztecorum Verhoeff, 1934: 49.Now.Scolopendraaztecorum Verhoeff, 1934. Valid species according to Syntype. NMP P6E-1303, one adult specimen in good condition, collected by Jaroslav Štorkán in 1930 under decaying cactuses, La Paz, Baja California Sur Region, Mexico; 24°8.28'N, 110°18.58'W.Note. Other syntypes are deposited in the Zoologisches Museum der Humboldt-Universität, Berlin, Germany under number ZMB 13378 .PageBreakNow.Pachymeriumdilottiae Dobroruka, 1976. The status of this species has never been revised since its original description.Holotype. NMP P6E-1326, ♀ in reasonable condition , collected by Vlasta Kálalová-di Lotti in 1929 in Baghdad, Iraq; 33°20.43'N, 44°24.05'E.Paratypes. NMP P6E-1327, 1♂ in good condition and 1♂ in reasonable condition , same data as holotype.Pachymeriumhanzaki Dobroruka, 1976Orig.Pachymeriumhanzaki Dobroruka, 1976: 260, figs 2A–E (♂).Now.Pachymeriumhanzaki Dobroruka, 1976. The status of this species has never been revised since its original description.Holotype. NMP P6E-1328, ♂ in reasonable condition (head mounted separately on a permanent slide), collected by Vlasta Kálalová-di Lotti in 1929 in Baghdad, Iraq; 33°20.43'N, 44°24.05'E.LinotaeniidaeFamily: Strigamiaolympica Dobroruka, 1977Orig.Strigamia (Strigamia) olympica Dobroruka, 1977b: 163, figs 5–8 (♀).Now.Strigamiaolympica Dobroruka, 1977. Valid species according to Holotype. NMP P6E-1352, ♀ in reasonable condition, collected by Karel Táborský on 5 June 1935 in Óros Ólympos Mt., Greece; 40°3.72'N, 22°20.70'E.LithobiomorphaOrder: LithobiidaeFamily: Lithobius (Chinobius) alenae Orig.Chinobiusalenae Dobroruka, 1980: 92, figs 1–6 (♀).Now.Lithobius (Chinobius) alenae . The status of this species has never been revised since its original description.Holotype. NMP P6E-3912, ♀ in reasonable condition, collected by Alena Čepická on 5 July 1977 under bark of fallen trees in Voronezhskove, 30 km NE from Khabarovsk, Khabarovskiy Kray, Russia; 48°41.67'N, 135°13.20'E.Paratype. NMP P6E-3913, ♀ in good condition, same data as holotype.PageBreakLithobius (Lithobius) corrigendus Dobroruka, 1988Orig.Lithobiuscorrgendus (sic!) Dobroruka, 1988: 6 .Now. Junior synonym of Lithobius (Lithobius) lucifugus L. Koch, 1862 ; designated by Note. Another (non-type) female specimen in excellent condition (NMP P6E-3902) determined by Dobroruka as Lithobiuscorrigendus was revised as Lithobius (Lithobius) latro Meinert, 1872 by Jolanta Wytwer, Ivan H. Tuf and Karel Tajovský in 2006.Lithobius (Lithobius) creticus Dobroruka, 1977Orig.Lithobiuscreticus Dobroruka, 1977b: 161, figs 1–4 (♀).Now.Lithobius (Lithobius) creticus Dobroruka, 1977. Valid species according to Holotype. NMP P6E-1350, ♀ in good condition, collected by Josef Mařan and Otakar Štěpánek in 1937 in Óros Ídi Mt., Crete, Greece; 35°14.04'N, 24°46.84'E.Paratype. NMP P6E-1351, ♂ in good condition, same data as holotype.Lithobius (Lithobius) erythrocephalusmohelensis Dobroruka, 1959Orig.Lithobiuserythrocephalusmohelensis Dobroruka, 1959: 105, figs 3 (♂), 4 (♀).Now.Lithobius (Lithobius) erythrocephalus C. L. Koch, 1847 , collected by Luděk J. Dobroruka in April and June 1955 in Serpentine Steppe of Mohelno, Třebíč District, Vysočina Region, Czech Republic; 49°6.47'N, 16°11.25'E (6863c).Lithobius (Lithobius) evae Dobroruka, 1958Orig.Lithobius (Lithobius) evae Dobroruka, 1958b: 26, figs 1 (♂), 2 (♀).Now. Junior synonym of Lithobius (Lithobius) tenebrosus Meinert, 1872 , collected by Eva M. Homoláčová and Miloš E. Homoláč on 14 September 1956 among fallen beech leaves in Bukovec Hill near Jizerka, Jizerské hory Mts., Jablonec nad Nisou District, Liberec Region, Czech Republic; 50°48.86'N, 15°21.47'E (5158c).Note. Male holotype and three female paratypes were not labelled and thus indistinguishable among the type material mentioned.PageBreakLithobius (Monotarsobius) homolaci Dobroruka, 1971Orig.Monotarsobiushomolaci Dobroruka, 1971: 262, fig. 2 (♂).Now. junior synonym of Lithobius (Sigibius) burzenlandicus Verhoeff, 1931  by Miloš E. Homoláč in September 1959 in Spišská Magura Mts., Kežmarok District, Prešov Region, Slovakia; 49°17.04'N, 20°22.38'E (6788a).Paratype. NMP P6E-1455, ♀ in reasonable condition, same data as holotype.Lithobius (Monotarsobius) krali Orig.Monotarsobiuskrali Dobroruka, 1979c: 161, figs 1–3 (♂♀), 4 (♀).Now.Lithobius (Monotarsobius) krali . Valid species according to Holotype. NMP P6E-1762, ♂ in good condition, collected by Josef Král on 8 July 1976 in Ala Archa, Chüy Region, Kyrgyzstan; 42°38.70'N, 74°28.73'E.Paratype. NMP P6E-1763, ♀ in reasonable condition, collected by Josef Král on 3 July 1976 in Gora Chimgan Mt., Toshkent Region, Uzbekistan; 41°40.45'N, 69°42.90'E.Lithobius (Lithobius) magurensis Dobroruka, 1971Orig.Lithobiusmagurensis Dobroruka, 1971: 261, fig. 1 (♂).Now. Junior synonym of Lithobius (Lithobius) muticus C. L. Koch, 1847 .Paratype. NMP P6E-1453, ♀ in good condition, same data as holotype.Lithobius (Lithobius) purkynei Dobroruka, 1957Orig.Lithobius (Lithobius) purkyněi Dobroruka, 1957: 174, figs 1A–B (♀).Now. Junior synonym of Lithobius (Lithobius) macilentus L. Koch, 1862 , collected by Luděk J. Dobroruka on 17 and 22 June 1956 in Boreč, Litoměřice District, Ústí nad Labem Region, Czech Republic; 50°30.85'N, 13°59.31'E (5449d).PageBreakNote. Female holotype and four female paratypes were not labelled and thus indistinguishable among the type material mentioned. Other (non-type) male and female specimens (NMP P6E-1290) determined by Dobroruka as Lithobiuspurkynei were mentioned in Lithobius (Lithobius) tatricus Dobroruka, 1958Orig.Lithobius (Archilithobius) tatricus Dobroruka, 1958a: 115, figs 1-2 (♂♀), 3 (♀).Now. Junior synonym of Lithobius (Lithobius) mutabilis L. Koch, 1862 , collected by Luděk J. Dobroruka on 26 June 1955 from sieved material and under bark of fallen trees in Bielovodská dolina Valley, Belanske Tatry Mts., Poprad District, Prešov Region, Slovakia; 49°13.31'N, 20°6.14'E (6786d).Note. Male holotype, three male and one female paratypes were not labelled and thus indistinguishable among the type material mentioned. Other (non-type) male and female specimens  determined by Dobroruka as Lithobiustatricus were mentioned in Lithobius (Lithobius) tatricusmonounguis Dobroruka, 1958Orig.Lithobius (Archilithobius) tatricusmonounguis Dobroruka, 1958b: 27.Now. Junior synonym of Lithobius (Lithobius) latro Meinert, 1872 , collected by Eva M. Homoláčová and Miloš E. Homoláč on 14 September 1956 under moist beech leaves in Bukovec Hill near Jizerka, Jizerské hory Mts., Jablonec nad Nisou District, Liberec Region, Czech Republic; 50°48.86'N, 15°21.47'E (5158c).Scutigeridae) and scolopendromorphs (Scolopendridae) are represented by one species, geophilomorphs (Geophilidae and Linotaenidae) by three species and lithobiomorphs (Lithobiidae) by 11 species and subspecies. Five species from the first three orders  and three species from Lithobiomorpha  are currently valid. The eight remaining lithobiomorph species and subspecies  are now considered as junior synonyms.The zoological collection of the National Museum in Prague hosts (among others) type material of 16 centipede taxa. Both sctutigeromophs (PageBreak


Substance misuse is a leading public health concern in the United States. Emergency departments (EDs) are thought to be an efficient environment in which to deliver screening, brief intervention, and referral to treatment (SBIRT) because a relatively high proportion of patients present with substance misuse. We developed a discrete event simulation model to track SBIRT program costs and revenues in an ED. The results inform the extent to which SBIRT can be sustained by insurance reimbursement in EDs.Model parameters are based on nationally-representative public data sources and administrative, observational, and interview data gathered on the Substance Abuse and Mental Health Services Administration (SAMHSA)'s third cohort of SBIRT grantees. SBIRT costs and revenues for approximately 52,000 patients over one year were modeled for a representative ED/trauma center. Results from hypothetical policy scenarios were compared to a base case.In the base case and all scenarios, the SBIRT program in an ED setting faced an annual deficit. Under the base case, the program generated $235,420 in revenue and incurred $449,504 in costs, leading to a deficit of $214,084. Populations with higher rates of insurance and/or higher rates of risky substance use led to greater program revenue, as did a higher rate of prescreen completion.Under current model assumptions, SBIRT in ED/trauma settings is unlikely to generate enough revenue to cover all associated costs. However, the program may be financially sustainable if the host hospital system were to subsidize some components of program costs. Future work in this area will extend the model to other healthcare settings  and account for provider heterogeneity.