Sudden cardiac arrest, particularly out-of-hospital cardiac arrest (OHCA), is a global public health concern. However, limited research exists on the epidemiology of OHCAs occurring in public places, trends and impact of bystander intervention, and influence of extraordinary circumstances. This study investigated the epidemiological factors, bystander characteristics, and outcomes of OHCAs that occurred in public places in South Korea from 2016 to 2021 and analyzed the impact of the coronavirus disease 2019 (COVID-19) pandemic. A retrospective analysis was conducted using an Out-of-Hospital Cardiac Arrest Surveillance database, including 33,206 cases of OHCA that occurred in public places. Cases with do-not-resuscitate orders or insufficient data were excluded. A steady increase in bystander-performed cardiopulmonary resuscitation over the years and a constant decrease in bystander automated external defibrillator (AED) use were observed. Survival-to-discharge rates for OHCAs remained relatively steady until a marginal decrease was observed during the pandemic . Factors affecting survival included the presence of a shockable rhythm, witnessed arrest, cardiac arrest due to disease, use of bystander AED, and period relative to the COVID-19 pandemic. These findings emphasize the critical role of bystanders in outcomes of OHCAs and inform public health strategies on better management of OHCAs in public places. Sudden cardiac arrest is a major global public health concern . More thWith increasing public awareness and intervention during cardiac emergencies, bystanders have become critical factors determining outcomes of OHCAs occurring in public spaces ,8. BystaDespite these crucial issues, there is a conspicuous gap in the existing literature regarding the epidemiology of OHCAs occurring in public places, the trends and impact of bystander intervention, and the influence of extraordinary circumstances, such as the COVID-19 pandemic. Therefore, this study aimed to investigate the pre-hospital and epidemiological factors and outcomes of OHCAs that occurred in public places in South Korea between 2016 and 2021. We noted the findings in light of the pandemic and conducted further investigations. Such an understanding is essential for shaping better public health strategies, policy planning, and improving overall survival outcomes of OHCAs.https://www.kdca.go.kr/, accessed on 3 July 2023) to evaluate the characteristics of OHCAs occurring in public places and the prognostic factors associated with the survival and good neurological outcomes from January 2016 to December 2021. The database contains information on all patients presenting with acute cardiac arrest transported to medical facilities by the emergency medical service (EMS), amounting to approximately 30,000 patients each year. As the study data were anonymous, the KDCA has allowed research using this database to be conducted, and this work was exempt from assessment by the institutional review board.This retrospective observational study used the nationwide, population-based Out-of-Hospital Cardiac Arrest Surveillance (OHCAS) database (managed by the Korea Disease Control and Prevention Agency (KDCA)  roads/highways, (2) public buildings, (3) leisure facilities, (4) industrial facilities, (5) commercial facilities, (6) terminals, and (7) other public places. Detailed locations corresponding to each domain of the subclass were predetermined, provided via the OHCAS database manual, and are shown in Data on several variables were collected, including age, sex, place of arrest, witnessed arrest, bystander CPR performed, rhythms initially monitored during the pre-hospital interval (non-shockable vs. shockable), and pre-hospital and in-hospital ROSC. A shockable rhythm was defined as the initial rhythm of pulseless ventricular tachycardia or fibrillation.The OHCAS data collection period included the COVID-19 pandemic period, during which policies, such as social distancing, self-isolation, and restrictions on outdoor activities, were implemented [The primary outcome of this study was survival to discharge, which was characterized by the normal discharge or transfer of the patient to another healthcare facility for ongoing care following acute treatment. A favorable neurological outcome was the secondary outcome. The Cerebral Performance Category (CPC) score was used to classify neurological results. CPC scores of 1 and 2 were indicative of good neurological outcomes.t-test between groups. Categorical variables are expressed as frequencies and percentages. The χ2 test or Fisher’s exact test was used to analyze categorical variables using contingency tables. To identify the outcome predictors, covariates, including the binary variable of the period relative to the COVID-19 pandemic (pandemic or pre-pandemic), were evaluated using multivariate analysis. Logistic regression using the “enter” method was independently performed, adjusting for sex, age, witnessed arrest, bystander CPR, AED use, shockable rhythm, cause of arrest, and the period relative to the COVID-19 pandemic. p < 0.05 was considered statistically significant.The data were analyzed using Excel 2019  and R . Descriptive statistics were used to describe the baseline characteristics. For continuous variables, values are presented as the means ± standard deviations. Normally distributed variables were analyzed using Student’s n = 34) and those with insufficient data (n = 1035). After the exclusion of 1069 patients, 32,134 patients who suffered OHCAs in public places were finally included in the study . Meanwhile, the rate of bystander AED use remained similar from 2016 to 2021 . The rate of survival to discharge of patients with OHCA in public places was similar between 2016 and 2019, with a marginal decrease in 2020 and 2021  .Seven subcategories of public places were analyzed in detail. Roads or highways and commercial facilities were the most common places of occurrence of OHCAs . The occurrence of OHCAs caused by disease was low on roads or highways and at industrial facilities  and was >75% in other places. The rate of bystander AED use was 10.6% at terminals and only 0.3% on roads or highways. In addition, the rate of bystander AED use in commercial facilities was low 1.8%; .p < 0.001). The rate of OHCAs caused by disease during the pandemic was higher than that during the pre-pandemic period . Survival to discharge and favorable neurological outcomes significantly decreased during the pandemic   .p < 0.001), followed by cardiac arrest due to disease and use of bystander AED . The period to the COVID-19 pandemic was associated with low survival to discharge  , 10.12; 95% confidence interval (CI), 8.85–11.59, < 0.001) .This study provided a comprehensive epidemiological assessment of OHCAs that occurred in public places in South Korea from 2016 to 2021, exploring the factors associated with outcomes and analyzing the impact of bystander interventions. The findings highlighted the crucial role of bystanders in OHCA management, with the rate of bystander-performed CPR steadily increasing from 18.8% in 2016 to 29.2% by 2021. These figures highlighted the growing public awareness and intervention in cardiac emergencies. However, bystander use of AED remained low during the study period, indicating it as an area that requires further public health interventions. Upon the examination of the survival-to-discharge rates of patients who suffered OHCAs in public places, our data presented a marginal dip during the last 2 years of the study, which coincided with the COVID-19 pandemic period.Previous studies have shown that OHCAs occurring in public places are frequently witnessed and have a high chance of bystander intervention ,8. In coCompared to other public places in this study, OHCAs that occurred on roads and highways showed distinctive characteristics. Trauma and other non-disease-related causes of OHCAs were common, whereas bystander intervention was uncommon ; the survival-to-discharge rate was only 7.0%. In contrast, leisure facilities, public buildings, and terminals showed considerable levels of bystander intervention . There is an apparent association between effective basic life support training and the presence of competent bystanders in public buildings, which typically includes schools ,25. AEDsThe overall low implementation and usage rate of AEDs in various public places are problems requiring improvement. The rate of AED use for OHCAs occurring in public places is between 1.0% and 12.8% in other countries; however, it remains extremely low worldwide ,32,33,34The pandemic substantially impacted OHCA characteristics. Kim et al. reported that the pandemic led to an increase in OHCAs at home, a decrease in AED use, and an increase in EMS response time compared to the pre-pandemic period . This alThe clinical outcomes of OHCAs that occurred in public places was markedly affected by factors such as the use of a bystander AED and the period relative to the COVID-19 pandemic, with a shockable rhythm having a substantial impact on the survival rate, which is consistent with prior knowledge. Research suggests that cardiac arrests in public places may be more likely to arise from certain heart conditions that result in shockable rhythms, in contrast to those occurring at home, which may often be due to medical conditions leading to non-shockable rhythms ,7. As caThis study has some limitations. First, despite using a nationwide dataset, the study utilized data collected by healthcare providers in the field, which may have resulted in a high probability of missing data and bias. Second, combining distinct public places into one large category for analysis can reduce representative homogeneity. For example, convenience stores, which are commercial facilities interspersed with residential areas and operate 24 h a day, may exhibit characteristics distinct from those of other commercial facilities. However, interpreting them as a single category may not adequately reflect these distinctions. Third, the study did not accurately reflect hospital treatment processes for each individual. Owing to lack of access to this information, we were unable to analyze the effect of drug use and hospital events on treatment outcomes. Fourth, although the purpose of this research was to report the characteristics of South Korean data, it is difficult to generalize these findings. The application of South Korea’s emergency medical systems, the function and capabilities of paramedics, and urban characteristics in other countries can be complicated by differences in these aspects. Finally, because this was a retrospective study, there is a substantial possibility of selection bias and the occurrence of latent confounders, which could limit the findings.This study investigated the recent occurrence of OHCAs in public places in South Korea, offering insights into OHCAs occurring in these locations. The findings revealed a rising rate of bystander CPR implementation; however, AED use by bystanders remained low. Therefore, enhancing AED accessibility, boosting awareness, and adapting emergency systems are essential measures that need to be taken for improving outcomes for individuals who suffer OHCAs in public spaces.


Because of their overall complexity, we used a systems-level approach to generate comprehensive and far-reaching recommendations to address the difficulties currently experienced by the Greek organ donation and transplantation program.Greece has fallen far behind many comparable European countries in the field of organ donation and transplantation and has made little progress over the past decade. Despite efforts to improve its organ donation and transplantation program, systemic problems persist. In 2019, the Onassis Foundation commissioned a report to be prepared by the London School of Economics and Political Science that focused on the state of the Greek organ donation and transplantation program and proposed recommendations for its improvement. In this paper, we present our analysis of the Greek organ donation and transplantation program together with an overview of our specific recommendations. The analysis of the Greek program was undertaken in an iterative manner using a conceptual framework of best practices developed specifically for this project. Our findings were further developed   The fields of transplant medicine and surgery have experienced extraordinary advances over the past 50 years. Despite this progress, the process of establishing an efficient and effective organ donation and transplantation program remains a challenge for many countries. Given the extensive scope of the many processes involved, for example, the design of both consent policies and clinical protocols, efforts to develop a successful program that meets the needs of a specific population are by their nature complex and require ongoing commitment, investment, evaluation, and improvement. Given the magnitude of the returns, both in terms of economics and quality of life, the case for investing in a comprehensive organ donation and transplantation service is certainly indisputable.Chronic kidney disease accounts for most cases of organ failure that ultimately lead to transplantation. Greece has among the highest incidences of end-stage renal disease (ESRD) among high-income countries. This outcome is driven by high rates of smoking, obesity, and poor cardiovascular health , 2. As aper capita in Greece is somewhat below the European average , Embase (Ovid), Scopus, and Web of Science using several relevant search terms. We restricted our search to papers published between 1 January 1968, and 26 February 2021, that were written in either English or Greek, and included journal research articles, comments, editorials, and reviews. Following the initial compilation of the search results and removal of duplicate entries, we then excluded papers that focused on topics other than solid organ donation and transplantation. We ultimately identified 15 unique peer-reviewed papers that focused specifically on solid organ donation and transplantation in Greece See . A selecA series of hour-long telephone interviews were conducted with a panel of 25 expert stakeholders in the field of solid organ donation and transplantation. These individuals were asked to validate and provide information that was complementary to the conclusions drawn from the literature review. A combination of convenience and judgment sampling was used to select interviewees who were accessible and might have professional insight into the policy, clinical, ethical, political, media, and regulatory environment of solid organ donation and transplantation . The fulA semi-structured interview protocol was employed that covered all aspects of solid organ donation and transplantation in Greece, including regulations as well as current and prospective future policies. Time was also provided for unstructured dialog focused on relevant topics.via a structured iterative process. As part of the first step, the research team used the results of the gap analysis to develop a set of preliminary recommendations to provide Greece with a framework to address the gaps and achieve high performance in each area. The project co-chairs then reviewed these recommendations and made several suggestions and refinements. The views of the stakeholder panel were then sought, which generated additional feedback and suggestions. The objective was to elicit feedback from as many disciplines as possible; thus, broad categories of stakeholders consulted included representatives of the NTO, national transplant centers, intensive therapy units, scientific societies, professional bodies, patient associations, the national bioethics committee, national representatives to the World Health Organization (WHO), political authorities, and the press. The research team integrated this feedback with the initial set of recommendations and undertook an additional cycle of review and refinement. The resulting set of recommendations was shared with the international and Greek panels of experts who submitted written feedback and participated in online round-table meetings to provide further comments. These comments were incorporated into a final set of recommendations.This case study differs from the others in this series as it includes an additional focus on policy recommendations that might be used to improve the Greek national organ donation and transplantation program. Consensus on the recommendations for the reform and development of the Greek program was reached Greece has a long history of solid organ transplantation. The information shown below in The following sections provide an overview of the main areas in which the organ donation and transplantation program in Greece currently falls short of internationally-recognized standards and highlight areas with the greatest potential for improvement. These results are presented in Political commitment and support for the Greek organ donation and transplantation program have always been inconsistent. The structural reforms of the early 2000s, including the foundation of the NTO and the launch of the ODC program, resulted in significant improvements in the donation and transplantation services available in Greece . UnfortuThe 2008 national financial crisis disproportionally affected organ donation and transplantation activity in Greece . The ausIn addition to adequate and consistent funding, political support designed to provide a consistent strategy for improvement will also be needed. In contrast to the roles and responsibilities of NTOs in many European countries , the Greek NTO can play only an advisory role with respect to policy development –10. TranGreece has developed extensive legislation focused on the definition and diagnosis of brain death. However, there is no separate legislation regarding the definition of brain death as distinct from its relationship with organ donation. This may ultimately create the false impression that a diagnosis of brain death is generated primarily to facilitate organ donation and transplantation. There is also ambiguity as to when to initiate this diagnostic process; the role of ancillary testing to confirm brain death is also poorly defined –37.Greek law allows for organ donation after brain death (DBD) from adult and pediatric patients and for living donation (LD) from adult donors only –37. PediThere have also been several poorly-planned changes in consent policy that have been introduced over the past decade. In 2011, the Greek government introduced an “opt-out” consent policy and provided 2 years for public information campaigns to take effect –42. HowePublic trust in the Greek National Organ Donation and Transplantation Program is limited compared to that enjoyed by its European neighbors. While 55% and 53% of Europeans agree in principle to personal or family-member organ donation, only 43% and 41% of Greeks agree with these principles, respectively. One of every two Greek citizens identifies distrust in the system as the primary reason for non-consent , the NTOs are independent bodies with the capacity to enact change without the need for legislative recourse –10.The organizational structure of the Greek NTO includes a president, a managing director, and three departments that are responsible for transplant coordination, management and finances, tissue storage, and histocompatibility testing . This stFurthermore, the Greek NTO is severely short-staffed and under-resourced. National law sets a minimum staffing requirement of eight temporary and 15 permanent employees, all of whom must have appropriate qualifications . At the On paper, the defined national and international responsibilities cover all the essential functions of an NTO that are identified by the conceptual framework . HoweverThere are five accredited transplant centers in Greece. A sixth facility, the Onassis National Transplant Center (ONTRC), is currently under construction with an expected completion date of 2024. However, there is little to no quantitative and qualitative data that address the human resources and infrastructure capacity of either Greek or other European transplant centers. To gain a better understanding of the resources available in these different settings, the research team surveyed all existing transplant centers in Greece as well as major transplant units in Croatia, Italy, Portugal, Spain, and the UK . Our resCreating financial incentives and ensuring that all parties involved (including staff and facilities) are adequately reimbursed and compensated for their work is a key feature of a successful transplantation system -10, 29. Although the Greek NTO manages an organ donor registry, a non-donor registry, a DBD donor registry, and the national waiting lists, the lack of a centralized IT system is a key weakness as there is no mechanism in place that facilitates the timely and efficient exchange of information between the components of the donation and transplantation program.National legislation has defined a series of quality standards that must be met prior to the authorization and licensing of transplant units . SimilarA few quality indicators are monitored by the NTO and included in annual reports –24. WhilGreece has not adopted any public health programs designed to promote healthy diets , increased physical activity, limiting alcohol consumption, or smoking cessation. Greece has not promoted interventions designed to reduce the risk of hepatitis  or to improve health literacy. High-risk populations are not screened for heart, lung, liver, and/or kidney disease. However, prompt access to tertiary prevention, most notably dialysis care, has been established . The quaInadequate coordination of the donation process is one of the most important policy gaps identified in this report. The role of Organ Donation Coordinator (ODC) was first introduced in 1999 as a result of national legislation in Greece . The coma priori prioritization of living donors on any transplant waiting list (in case of future need). These factors have all been enshrined in legislation to promote living donation , all of whom are based at the NTO headquarters in Athens, and are responsible for the coordination of all transplant procedures in the entire country. Because of the small number of TRCs, transplant coordination services are not available at all times.With respect to operative and peri-operative care, feedback from the interviewees suggested that the lack of physical capacity  and human resources  limits timely access to transplant procedures. There are no standardized national peri-operative care protocols in Greece.There are also no national guidelines that direct follow-up care of transplanted patients . Transplant recipients receive routine follow-ups from multidisciplinary teams in transplant units. There is no established system that permits local health centers to provide care. Thus, some patients need to travel long distances for routine follow-up appointments. This is a source of significant stress and unnecessary expense. Furthermore, mid-to long-term outcome data are not systematically collected or monitored –24.In the early 2000s, the NTO initiated a training program for ODCs, that was undertaken in part with cooperation with the Transplant Procurement Management-Donation and Transplantation Institute (TPM-DTI) in Barcelona . The traAt the present time, Greece offers no official training programs (fellowships) for transplant surgeons and physicians. Individuals typically gain experience in transplantation during their subspecialty training  or independent practice . Greece offers no official training in organ donation and transplantation for intensivists, anesthetists, or nurses.Transplantation research in Greece is not a priority; the resources allocated to medical research and development are below the European average . Since 1The national scientific societies  and the professional bodies  are not engaged in the development of national transplantation policy and at present have no institutional or advisory roles.The full set of recommendations for reform of the Greek organ donation and transplantation program can be found in the Report for a New National Solid Organ Donation and Transplantation Plan in Greece . Due to The key recommendations which must be implemented if Greece hopes to improve its organ donation and transplantation program are outlined in the following sections. These sections reflect specific domains of the framework and the gaps identified in our analysis.Long-term support from the central government will be needed to promote reform. Sustainable funding sources will need to be identified, and the NTO should be relaunched as an independent body with the authority to enact change.Legislative reform will also be required to move toward a “soft opt-out” consent policy. This legislation must be complemented by public awareness campaigns and appropriate training of transplant professionals. Changes will be needed to separate the legislation focused on the neurological diagnosis of death and the principles of (DBD). Clinicians must receive regular training on the diagnosis of brain death, and the NTO must take the lead in establishing legislative provisions for DCD. A Pilot DCD program should be established in selected centers that already have the appropriate expertise and infrastructure.Policies aimed at reducing the need for transplantation must be developed. Primary, secondary, and tertiary preventative strategies must be devised and implemented.Greece needs to build and maintain public support and trust in the transplant system by focusing on organ donation as a critical component of an altruistic society. Achieving this goal will require adherence to the strictest ethical standards, implementation of rolling public awareness and educational campaigns, and maintaining good relations with the media.The re-launched, independent NTO must be appropriately staffed and provided with adequate funding. The recommendations provide clear and specific guidance for the governance, structure, and funding of the NTO and include recommendations for the establishment of a dedicated leadership team. A key responsibility of the relaunched Greek NTO will be to establish and maintain a national IT system with associated databases that can be used to improve the efficiency and effectiveness of the donation and transplantation program.There is an urgent need to expand operating theater capacity (for both donation and transplantation procedures) and to improve access to imaging and other diagnostic services, for example, endoscopy. The KEN-DRG system must be revised to ensure that all activities related to organ donation and transplantation are adequately reimbursed, including the efforts of staff, participating units, and supporting services.Transplant recipients (as well as their families and loved ones) and live donors must be the central focus of the national donation and transplantation program in Greece. Policies and procedures must be developed that promote collaborative engagement with patients, families, and caregivers, not only with respect to their own cases but also in all aspects of system planning and development.The existing donation and transplantation workforce needs to be expanded. There is a particular need to increase the number of specially-trained ODCs who will then be appointed to every unit participating in organ donation. All processes along the clinical pathway, including patient follow-up, need to be subject to nationally agreed-upon protocols that are consistent with internationally-defined best practices. The NTO, alongside a panel of experts with organ-specific expertise, should be fully involved in generating this guidance.Living donation (LD) is currently underutilized and should ultimately become a cornerstone of the donation and transplantation program in Greece. Pre-emptive renal transplantation from a living donor should become the treatment of choice for ESRD. Dialysis assessments must always involve discussions regarding the feasibility of transplantation and the possibility of identifying a living donor.The existing national system of quality assurance should be strengthened and expanded to include pre-transplant care. Existing quality indicators on donation and transplantation should be broadened and updated regularly. The NTO should develop additional capacity to support healthcare facilities seeking to reach compliance with regular audits based on key performance indicators conducted by the Body of Inspectors for Health and Welfare Services (SEYYP).Professional organizations and scientific societies must be consulted at all stages of this programmatic expansion. The board of the NTO should include representatives from relevant organizations. These representatives should play pivotal roles in developing and ratifying guidelines, protocols, regulatory standards, and training programs for use throughout Greece.Greece must develop a national strategy that provides tailored and continuous training for healthcare professionals in all areas that are relevant for organ donation and transplantation. Dedicated training modules that follow existing guidelines created by the European Union of Medical Specialists should be available for use.Improving the performance of the organ donation and transplantation system requires an innovative research and development program. All units and staff must be actively supported and encouraged to participate in research activities at local, national, and international levels.The implementation of the preceding recommendations will be a complex and time-consuming task. Thus, we recommend the establishment of an implementation task force that will be chaired by the permanent secretary of the Ministry of Health. We recommend the establishment of a 7–10-person task force that includes representatives from key interests. Annual reports focused on overall progress should be submitted for review.This is the first comprehensive, systems-level study of the Greek organ donation and transplantation program published to date, and the first attempt to provide comprehensive recommendations for reform. Our findings were evaluated using a novel conceptual framework that takes a wide view of the field and attempts to capture all factors which might influence the success of a national donation and transplantation program. Thus, this study captures aspects of the Greek program that had not been considered in previous evaluations of Greece’s comparatively poor performance. Our study was also based on existing published and unpublished literature on solid organ donation and transplantation and was further informed by extensive rounds of interviews with numerous global, national, and local policy stakeholders in the field.One limitation of this study was that the analysis was not designed to capture data focused on all aspects of a donation and transplant program . We also recognize that the subjective views of the authors may have influenced the narrative review of the literature. Furthermore, we are aware that the views expressed by the interviewees may not be fully representative of all those working in the field of organ donation and transplantation in Greece.Our study has highlighted numerous policy gaps with a significant impact on the national solid organ donation and transplantation program in Greece. A national reform program designed to address these policy gaps and implement the required policy changes should become a national priority. The recommendations provided represent a comprehensive set of potential policy priorities that can be used to strengthen the Greek national organ donation and transplantation system. Implementing these recommendations may accelerate Greece’s progress toward a national organ donation and transplantation program with performance metrics that are comparable to successful programs that have been developed in other European countries. This would deliver immeasurable improvements to the quality of life of thousands of individuals as well as their families.As with all major policy reforms, the success of these efforts will rely on the manner of their implementation. One frequently observes a gap between policy plans and their implementation. Because of the extensive nature of the recommendations, coordination of the reforms will be a complex process. An implementation task force may play a crucial role in this endeavor and thus should have a formal mandate from the government to lead the policy design process and oversee the implementation of these reforms. The task force should also be provided with the responsibility of preparing the legislation needed to support the reform program as well as establishing a clear roadmap with due regard for the phasing of and interdependencies between the various programmatic elements. This roadmap should include clear targets and milestones that will ensure appropriate sequencing, for example, making certain that the capacity of the donation and transplantation workforce and infrastructure increases in concert with the coordination capacity of the system as well as increased rates of consent and availability of organs for transplant.Finally, the task force should commit itself to rigor and transparency. For example, the task force might publish an annual report that highlights progress and identifies the gaps remaining to be addressed. Transparency will also be needed to support efforts to strengthen public support for organ donation and transplantation which will also be critical to the program’s success.


The coronavirus disease-19 (COVID-19) pandemic restricts rapid implementation of in-person delivery of cardiac rehabilitation (CR) at the center for coronary artery disease (CAD) patients undergoing percutaneous coronary intervention (PCI), thus enabling a cohort comparison of in-person vs. remote CR program. This study aims to investigate outcomes of exercise capacity, health-related quality of life (HRQL), mental health, and family burden of stable CAD patients undergoing PCI in low-to-moderate risk after different delivery models of CR program.2max) and the respiratory anaerobic threshold (VO2AT) before discharge, at the end of the 8-week and 12-week in-person or remote CR program after discharge.The study included a cohort of stable CAD patients undergoing PCI who had experienced two naturally occurring modes of CR program after hospital discharge at two time periods, January 2019 to December 2019 (in-person CR program) and May 2020 to May 2021 (remote CR program). The exercise capacity was assessed by means of 6-min walk test (6MWT), maximal oxygen uptake (VO2max after 8-week and 12-week CR program whether in-person or remote model (p < 0.05). The distance walked in 6 min was longer and the maximal oxygen uptake (VO2max) was higher at the end of the 12-week in-person or remote CR program than 8-week in-person or remote CR program (p < 0.05). The respiratory anaerobic threshold (VO2AT) of CAD patients was decreased after 8-week CR program whether in-person or remote model (p < 0.05). CAD patients receiving remote CR program exhibited higher HRQL scores in domains of vitality (p = 0.048), role emotional (p = 0.039), mental health (p = 0.014), and the summary score of the mental composite (p = 0.048) compared to in-person CR program after 8 weeks. The anxiety and depression scores of CAD patients undergoing PCI were decreased after 8-week CR program whether in-person or remote model (p < 0.05). The CAD patients receiving remote delivery showed lower anxiety and depression scores compared to those receiving in-person delivery at the end of the 8-week CR program (p < 0.05). It was found that the family burden scores of CAD patients undergoing PCI were reduced after 8-week and 12-week CR program whether in-person or remote model (p < 0.05). The CAD patients receiving remote CR program showed lower family burden scores than those receiving in-person CR program after whether 8 weeks or 12 weeks (p < 0.05).No adverse events occurred during the CR period. CAD patients had a longer distance walked in 6 min with a higher VOThese data indicate that a properly designed and monitored remote delivery represents a feasible and safe model for low-to-moderate-risk, stable CAD patients undergoing PCI inaccessible to in-person CR during the COVID-19 pandemic. Coronary artery disease (CAD) is one of the most common cardiovascular diseases and becomes the major cause of morbidity and mortality worldwide until 2040 , 2. PercOn January 30, 2020, the World Health Organization declared the outbreak of a new Corona virus, SARS-CoV-2 which spread very rapidly throughout the world and impinged on economic, social, and health systems . The susThe study included a cohort of stable CAD patients undergoing PCI who had experienced two naturally occurring modes of CR program after hospital discharge at two time periods, January 2019 to December 2019 (in-person CR program) and May 2020 to May 2021 (remote CR program). To ensure individualized exercise prescription, the patients were given a comprehensive assessment for CR program during the 2–4 weeks after hospital discharge, including review of medical history, risk factor profiling, exercise and lifestyle behaviors, anxiety and depression evaluation, and digital health literacy . AfterwaParticipants were deemed eligible if they fulfilled the following inclusion criteria: an age of ≤ 75 years; a cardiologist-confirmed final diagnosis of stable CAD with low-to-moderate risk (< 15% five-year risk of major adverse cardiovascular event) according to the clinical practice guidelines updated 2019 of the American College of Cardiology/American Heart Association Task Force ; undergoParticipants were excluded from the study if they had high risk of CR, recent onset of acute myocardial infarctions within three weeks, malignant arrhythmias, uncontrolled ventricular rhythm disorders, unstable angina, poorly controlled hypertension, exercise-induced ischemia, associated valvular heart disease, COVID-19 vaccination, or infected with COVID-19. Pacemakers or implantable cardioverter defibrillator and cardiac resynchronization therapy (CRT-ICD) carriers, those with severe cognitive impairment or lack of digital literacy, and those failing to walk for long periods of time due to respiratory or musculoskeletal conditions were also excluded.Patients who were required to receive in-person CR program attended the CR center of our hospital three times per week  to perform the exercise program including 10–15 min of warm-up, 40–60 min of combined aerobic exercise  at 50-80% of their peak heart rate, and a final 15 min of stretching and cool down. In addition to physical training, the patients were also required to receive a health education session and a weekly group psychotherapy session, once a week for each, at the hospital. The aim of a health education session was to extend patients’ knowledge and understanding of cardiac anatomy and function, risk profiling of cardiovascular diseases, medication, diet, exercise, erectile dysfunction and return to work. A group psychotherapy session was carried out to handle patients’ confusions and problems about postoperative complications, social function, medication compliance, as well as economic burden. The in-person CR protocols are described in Fig. An expert team specific for implementing the remote CR program was established including a chief physician of CR as a leader, 2 rehabilitation therapists responsible for individualized exercise plans and exercise intensity, 3 nurses in charge, and 3 nurses responsible for health education, psychotherapy session, and data collection via a telephone follow-up every Monday and a home visit every Thursday. Besides, the Xiaomi MI Band 5  was used as a rehabilitation tool to monitor patients’ heart rate (HR) during exercise and the fitness data of patients can be collected by the mobile app named Xiaomi Sports issued by Xiaomi. In brief, patients who were required to receive remote CR program were instructed to connect their smartphones with the Xiaomi MI Band 5 via the mobile app recording the basic information of patients, including age, height, body mass index (BMI), and exercise plans before discharge. Before home exercise, the wristband app and HR sensor were checked and validated with the aid of the family member and the nursing staff. The patients were requested to do home exercise every two days per week and the excise plans were same as in-person CR program, although they were encouraged to exercise every day. When taking exercise, the patients should wear the Xiaomi band on their wrists and be accompanied by their family members. Before discharge, the heart rate, blood pressure, and metabolic equivalent monitored by the wristband app and HR sensor should be adjusted with the data measured by cardiopulmonary exercise data at the hospital to ensure the accuracy of the Xiaomi band detection. The patients’ heart rate, blood pressure, metabolic equivalent and records of movement track were monitored by the Xiaomi band in real time, and the corresponding data were transmitted to the mobile phone application through Bluetooth intelligent technology during movement. If arrhythmia occurs on the electrocardiogram during exercise, the system will remind the patient to stop exercise, and upload the data to the data center in real time. The expert team group will analyze the data and adjust the exercise plan according to the change of the patient’s heart rate and physical condition during exercise. In addition to home exercise, the members in the expert team group performed a telephone follow-up at 5:00 p.m. every Monday and a home visit at 6:00 to 8:00 p.m. every Thursday. The patients’ medication, diet, mental health, and exercise plan were recorded. During each visit, the team members performed health education, addressed the patients’ doubts or problems from the following four aspects: postoperative complications, economic burden, social function limitation and medication compliance, and helped them to manipulate a detailed and feasible solution. At the same time, the family members were encouraged by the team members to give appropriate response to the onset of disease and to guide the patients to develop a healthy lifestyle. The remote CR program was also performed three times per week . The remote CR protocols are described in Fig. 2max) and the respiratory anaerobic threshold (VO2AT) before discharge, after 8-week CR program, and after 12-week CR program. The 6MWT was conducted following the previously standard guidelines [2max, VO2AT measurement was also performed for objectiveness and good reproducibility [2max and VO2AT.The exercise capacity was assessed by means of 6-min walk test (6MWT), maximal oxygen uptake  which comprises 36 items in total covering the physical composite scores including physical functioning, role physical, bodily pain, general health, and the mental composite scores including vitality, social functioning, role emotional, and mental health . The scaAssessment of anxiety symptoms and depressive disorders applied the Chinese versions of the Zung’s Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) both of which cover psychological and somatic symptoms and can intuitively reflect respondents’ subjective feelings for nearly a week . Each scAssessment of family burden applied a Chinese version of the family burden scale of disease (FBS) which encompasses 24 items referring to six domains: economic burden, impact on daily activities, impact on social life, impact on free time, impact on physical health, and impact on mental health . Each itA sample of 80 patients was required for the study after sample size power analysis using the PASS software, with a of 0.05, power (1-β) of 80%, and predicted loss rate of follow-up = 10%. The outcomes were described using mean ± standard deviation for measurement variables, using counts and percentages for categorical variables. Fisher’s exact test and Student’s t-test were used to compare the baseline characteristics of the groups, and the repeated measures analysis of variance was used to compare before discharge, after 8-week CR program, and after 12-week CR program. The significant difference was set at p < 0.05 for all tests. Descriptive analyses were performed by GraphPad prism 8.0 .A total of 49 stable CAD patients undergoing PCI and requested to receive CR program from January 2019 to December 2019 were prospectively recruited, among which 4 patients failed to completed the in-person CR program for unexplained reasons. Finally, 45 patients (91.84%) completed the in-person CR program were included into this analysis as the in-person CR group. From May 2020 to May 2021, due to the COVID-19 pandemic, 55 patients were requested to receive remote CR program and prospectively invited to participate in the study as the remote CR group. Among 55 patients, 3 patients declined to participate in the study, 2 patients refused owing to their own habits of exercise, and 3 patients failed to complete the remote CR program and withdrew due to difficulty in use of the equipment and other personal reasons. Finally, 47 patients (85.45%) complete the exercise intervention and were included into this analysis as the remote CR group. Figure 2max and VO2AT at the baseline (p > 0.05). As shown in Table 2max of the patients was enhanced after 8-week and 12-week CR program whether in-person or remote model, and the VO2max was increased at the end of 12-week CR program compared to 8-week CR program (p < 0.05). The VO2AT of CAD patients was decreased after 8-week CR program whether in-person or remote model (p < 0.05). These data indicated that in-person CR program could be replaced by remote CR program for stable CAD patients undergoing PCI during the COVID-19 pandemic.Before undergoing either in-person or remote CR program, two groups of stable CAD patients did not differ with regard to 6MWT, VOAs depicted in Table p < 0.05). These data suggest that remote CR program could effectively alleviate the depression and anxiety of patients requested to receive CR program during the COVID-19 pandemic.Next, we analyzed the anxiety symptoms and depressive disorders of stable CAD patients undergoing PCI after in-person CR and remote CR models by using Zung’s SAS and SDS questionnaires. As listed in Table p < 0.05). These data suggest that stable CAD patients undergoing PCI requested to receive CR program may cause less family burden during the COVID-19 pandemic.The family burden of stable CAD patients undergoing PCI after in-person CR and remote CR models was assessed by using the FBS scale Table . It was This study examined the exercise capacity, quality of life, mental health, and family burden of stable CAD patients undergoing PCI requested to receive in-person CR program compared to remote CR program. The main findings of this work support remote delivery as a feasible and safe model for stable CAD patients undergoing PCI inaccessible to in-person CR during the COVID-19 pandemic.Exercise capacity is considered as a predictor of cardiovascular death in patients with CAD , 24. SomFollowing 8-week and 12-week CR program whether in-person or remote model, the HRQL scores were increased in all domains of physical and mental composites both, indicating the overall equivalence in HRQL between groups was expected, concurring with other previous reports , 30. SimFor stable CAD patients undergoing PCI, depression and anxiety are associated not only with a poorer prognosis and increased long-term mortality, but also with reduced productivity owing to evidently increased disability rates in the working population and increased medical care costs . After PAfter PCI, patients suffered from in stent restenosis repeatedly, and the high medical costs brought a heavy economic burden to patients’ families. The economic burden has a negative impact on the physiological health and emotional functions of the caregivers, especially during the COVID-19 pandemic . Remote There are several limitations of this study that should be noted. Although the remote CR program was delivered in a fixed format, there is no fidelity test to ensure that the curriculum was delivered exactly as it should be. In the in-person CR group, the participants voluntarily attended the drop-in center, but their family members did not receive any assistance from the drop-in center, unlike the experimental group families who received family psychoeducation. Thus, the benefit of remote CR program may be due to the potential Hawthorne effects, because services offered to the remote CR group were more intensive. Besides, the patient recruitment occurred at two different time points, January 2019 to December 2019 and May 2020 to May 2021 due to the COVID-19 pandemic, creates a critical need for further prospective studies investigating the outcomes after two delivery models of CR program at the same period to validate the remote delivery as an alternative delivery model for CR program.In conclusion, our study demonstrates that both in-person or remote CR programs could effectively improve exercise capacity, quality of life, mental health, and reduced the family burden of low-to-moderate-risk, stable CAD patients undergoing PCI who were requested to receive CR program. This investigation showed that CR by a remote delivery might become a relevant alternative to conventional center-based CR. This innovative healthcare delivery method appears to be a feasible, tolerable, safe, cost-effective solution, and is likely to facilitate the continuity of care for people who encounter geographical or social accessibility difficulties. In future research, this study should be replicated with a larger sample size, validation of the curriculum, and a comparable intervention intensity control group. For the outcome assessments, areas such as employment, community functioning, personal empowerment, and sense of purpose should be included rather than merely focusing on symptom management and social functioning.


Frontiers series “Effective delivery of integrated interventions in early childhood: innovations in evidence use, monitoring, evaluation, and learning.” The 31 contributions to the series reflect the breadth and depth of complexity that characterizes ECD, including global geographic spread, with studies from Asia, Europe, Africa, and Latin America and the Caribbean. Our synthesis finds that integrating MEL processes and systems into the fabric of a program or policy initiative can broaden the underlying value proposition. Specifically, ECD organizations sought to design their MEL systems to ensure programs fit the values, goals, experiences and conceptual frameworks of diverse stakeholders, so that participating makes sense to all. For example, formative, exploratory research identified the priorities and needs of the target population and frontline service providers, and informed the content and delivery of an intervention. ECD organizations also designed their MEL systems to support a shift of accountability toward broader ownership: They included delivery agents and program participants alike as subjects rather than objects, through active participation in data collection, and by providing opportunities for equitable discussion of results and decision-making. Programs collected data to respond to specialized characteristics, priorities and needs, embedding program activities into existing day-to-day routines. Further, papers pointed to the importance of intentionally involving a variety of stakeholders in national and international dialogues to ensure that diverse ECD data collection efforts are aligned and multiple perspectives are considered in the development of national ECD policies. And, several papers illustrate the value of creative methods and measurement tools to integrate MEL into a program or policy initiative. Finally, our synthesis concludes that these findings align with the five aspirations that were formulated as part of the Measurement for Change dialogue, which motivated the launch of the series.In this review paper, we explore how on-the-ground Early Childhood Development (ECD) innovators are using monitoring, evaluation, and learning (MEL) systems to guide the design and implementation of ECD programs, as well as how MEL systems can influence policy and support the achievement of impact at scale. We reflect on articles in the  Frontiers in Public Health launched the series: “Effective delivery of integrated interventions in early childhood: innovations in evidence use, monitoring, evaluation, and learning.” This provided a forum for ECD implementers to explore the practical solutions they are generating as they integrate MEL systems into the cycle of program design, redesign, implementation, adaptation, and scaling. Altogether, 31 articles were accepted for publication.Recent influential series on Early Childhood Development (ECD), in 2016, 2018, and 2019,Frontiers series built on a year-long (2019–2020) dialogue among ECD practitioners, researchers and MEL specialists working in low-resource settings across the world. The outcome of this dialogue is described in detail in Krapels et al. , Europe , Africa , and Latin America and the Caribbean , with some countries hosting multiple studies . In terms of ECD intervention areas, some papers focused primarily on health, with programs addressing, for example, anemia, nutrition, oral hygiene, and a public mHealth system. Two papers were concerned with assessment instruments for child development in general, and language in particular. Other papers featured parenting programs as the main, or an important, intervention focus. A major theme across papers was the value placed upon community engagement. With families and education being at the center of these narratives, the age of the children involved ranged from the prenatal period through to the age of six, the full ECD period.The geographic spread of the 31 contributions in the Our reflections begin with a group of papers that illustrate how MEL supported program design and implementation, creation of novel approaches, or adaptation to new contexts. We then discuss papers that describe specific MEL techniques or methods, which the developers have also used to support a cycle of review and reflection. The third group of papers report on the use of existing implementation science frameworks to guide the implementation process and its evaluation. We next consider papers that report experiences using MEL systems and data more broadly, to support scaling efforts and policy change. Finally, we discuss papers that describe strategies to consolidate information, at national or international levels, to guide decision-making in policy and practice.The papers considered in this section describe how MEL systems collected information to guide the development and delivery of specific interventions, with an eye to process, quality and in some cases impact. The results support the longer-term goal of building a delivery system for an intervention to achieve sustainable impact at scale.Krishna et al.  uses twomothers from the beginning, and the MEL system tracked related dynamics. This serves as an example of Measurement for Change, as the authors observe that “[t]hough mothers initially served as barriers and gatekeepers in the way of father-child bonding, they eventually became enablers in the process” .UK Medical Research Council Guidance on Developing and Evaluating Complex Interventions , a project initiated in 2018 by USAID and the ECD Measure Group at the University of Nebraska Medical Center. The project convened multi-disciplinary and multi-stakeholder teams in four countries—Ethiopia, Liberia, Rwanda, and South Africa—comprising government officials, local university researchers, early childhood education (ECE) practitioners from civil society, and USAID education officers. A Data for Impact framework and toolkit was developed, which guided the country teams to build data-driven ECE systems. The authors highlight the importance of: attending to the composition and perspectives of the teams expected to use these data for decision-making; aligning the scope of the data collected with national ECD priority areas; and covering not only child outcomes, but also processes for achieving and maintaining high-quality program delivery. They suggest that national data dashboards, like the National Early Childhood Development Program's dashboard in Rwanda, could help achieve national alignment.Related, the paper by Raikes et al.  illustraagreed that M&E was necessary to guide structured data collection and ensure transparency. Yet interviewees reported that data collection in ECD projects was often seen as intended solely for scientific publications, and of little use for project improvement or addressing implementation challenges” . zation” [ advocateMeasurement for Change not as a checklist, but as stimulus for reflection in developing MEL systems that truly support the effective delivery of interventions. MEL becomes a constant process of intentional inquiry, nudging program implementers to slow down, reflect, and course correct when necessary, thereby paving the way for meaningful change in the lives of families and communities.Taken together, the papers in this series show that it is helpful to view the five aspirations of JL led on writing and editing, but substantial written contributions were provided by PH, JR, LH, WS, JK, MH, AR, AS, and CD. All authors contributed equally to the development of the ideas presented in this review. All authors contributed to the article and approved the submitted version.


The NIH National Center for Advancing Translational Science (NCATS) was established to support translational research that spans the entire TS Continuum, with the goal of bridging the gap between preclinical biomedical research and real-world applications to advance treatments to patients more quickly. In 2018, the Translational Science Training (TST) TL1 Program at the University of Texas Health Science Center at San Antonio implemented new strategies to better include and encourage research more broadly across the TS Continuum, including the addition of postdoctoral scientists and a clinically trained Program Co-Director, expansion of team science and community engagement programming, and targeted trainee recruitment from schools of nursing, dentistry, and allied health, in addition to medicine. The objective of this bibliometric analysis was to determine if the program exhibited a more diverse mix of T-types after the adjustments made in 2018. The TST/TL1 Program experienced a shift in T-type, from mostly T0  to more T3/T4  research, after new strategies were implemented. This supports the conclusion that strategic programmatic adjustments by an NCATS-funded predoctoral training program resulted in outcomes that better align with NCATS priorities to develop Trainees who contribute across the entire TS Continuum. NIH’s National Center for Advancing Translational Science (NCATS) aims “to turn biomedical research discoveries into health solutions…through the application of translational science (TS) .” NCATS The Translational Science Training (TST) TL1 Program at the University of Texas Health San Antonio was established in 2009 in affiliation with the Institute for the Integration of Medicine and Science – home for the institution’s CTSA – and offers TL1 support for multidisciplinary research and education for predoctoral and postdoctoral scientists.In 2018, the TST/TL1 Program implemented several new strategies to better include and encourage research more broadly across the TS Continuum, including the addition of postdoctoral scientists and a clinically trained Program Co-Director, expansion of team science and community engagement programing, and targeted trainee recruitment from schools of nursing, dentistry, and allied health, in addition to medicine. The objective of this bibliometric analysis was to categorize publications of TST/TL1 trainees according to Surkis’ TS “T-types” T0–T4) [ [4] and et al [Bibliometric information was gathered for all TST/TL1 trainees who participated in the program from 7/1/2009 to 12/31/2021 using PubMed, Scopus, and Google Scholar searches. Original research articles qualified for inclusion in this analysis when a TST/TL1 trainee was listed as a coauthor in any position and when the work was published after they were appointed to the TL1 training grant. Editorials, commentaries, and errata were excluded. One trained investigator independently reviewed the title and abstract for each published article and classified the article based on the T-type criteria outlined by Surkis et al . T-typesPublications were subsequently divided into pre- (2009–2017) and post- (2018–2021) periods to assess differences in T-types before and after the program modifications. Groups were compared using chi-square and Fisher’s exact statistical tests.p < 0.01), the percentage of T1/T2 was similar in both periods , and the percentage of T3/T4 publications was higher in the post-period .Overall, 494 publications from 77 TST/TL1 trainees were included in this analysis. In 2010, 100% of publications by trainees were T0; however, by 2021, over half of the publications by trainees were other T-types /TL1 Program experienced a shift in T-type, from mostly T0  to more T3/T4  research, after new strategies were implemented. A 2019 survey of TL1 programs by Sancheznieto et al  reportedThe findings of this analysis suggest that strategic programmatic adjustments, such as the inclusion of postdoctoral trainees, were associated with a more diverse mix of TS activity in the post-period, thereby helping the TST/TL1 Program at the University of Texas Health Science Center at San Antonio to better reflect research along the TS Continuum.


The program was feasible to deliver, acceptable to participants and seemed beneficial for health. Access to similar programs may assist in secondary stroke prevention.Healthy lifestyles including exercise and diet can reduce stroke risk, but stroke survivors often lack guidance to modify their lifestyles after hospital discharge. We evaluated the implementation of a new, secondary stroke prevention program involving supervised exercise, multidisciplinary education and coaching to address modifiable risk factors. The group-based program involved face-to-face and telehealth sessions. The primary outcomes were feasibility, examined via service information , and participant acceptability (satisfaction and attendance). Secondary outcomes examined self-reported changes in lifestyle factors and pre–post scores on standardized clinical tests ). We ran seven programs in 12 months, and 37 people participated. Attendance for education sessions was 79%, and 30/37 participants completed the full program. No adverse events occurred. Participant satisfaction was high for ‘relevance’ (100%), ‘felt safe to exercise’ (96%) and ‘intend to continue’ (96%). Most participants (88%) changed (on average) 2.5 lifestyle factors . Changes in clinical outcomes seemed promising, with some being statistically significant, e.g., 6MWT (MD 59 m, 95% CI 38 m to 80,159 m,  Stroke is an episodic condition and a leading cause of disability and death worldwide ,2,3,4. IThe long-term risk and rate of recurrent stroke has been described as unacceptably high ,7, especModels of community care may support secondary stroke prevention ,6, with Our primary aim was to evaluate the implementation of a secondary stroke prevention program provided within a Community Rehabilitation Service to see if it was feasible to deliver and acceptable for participants. The secondary aim was to evaluate if participation contributed to clinical outcomes that may help mitigate the risk of stroke. During the design and evaluation phase, we sought stakeholder, consumer and participant guidance to help ensure that the program met the needs of the participants. We hypothesised that we could design, deliver and implement a group-based program involving multidisciplinary education, supervised exercise and coaching to support people with mild stroke or TIA to modify lifestyle factors known to increase risk of further stroke. In addition, we hypothesized the program would be acceptable for participants.The study was an observational study that evaluated the implementation of a newly designed secondary stroke prevention program . The program was delivered within a community multidisciplinary rehabilitation setting, from the Health Independence Program at Austin Health, in Melbourne, Australia. Austin Health is a large metropolitan tertiary public health organization affiliated with universities for research and the teaching of medical, nursing and allied health. Austin Health admits around 500 people with a stroke event per year. Our stroke care includes an emergency department, an acute stroke unit, subacute inpatient and community rehabilitation and outpatient medical clinics. The project had ethical approval granted by the Austin Health Office for Research (reference number 20210118).People with mild stroke or TIA were invited to participate with the support of written participant information, discussion and opt-in consent. To be eligible, people needed to be community dwelling, over 18 years of age, within 4 months post stroke event, able to walk independently with or without an assistive device and living within the geographical area. Participants needed to be medically stable and have modifiable lifestyle risk factors for stroke. There were no additional exclusion criteria. People were referred to the program by allied health professionals, stroke liaison nurses or medical staff working in stroke care at Austin Health. This included acute wards, outpatient clinics (TIA and stroke prevention and rehabilitation physicians) and community rehabilitation. Eligibility and informed consent were confirmed via a triage process involving telephone contact with each person referred.The program was based on current guidelines ,14,19 anPhase 1  delivered in a group telehealth format (synchronous video using the Microsoft 365 Teams platform) by the multidisciplinary team from Austin Health’s Community Rehabilitation Service or Stroke Service . All prePhase 2 , participant demographics and costs (staff time and wages). Participant acceptability was measured by participant uptake, attendance (number of sessions and proportion who completed the program) and satisfaction with the program. To determine satisfaction, we custom designed an online survey to enable participants to provide anonymous feedback about the program (using Microsoft 365 Forms). The survey focused on relevance, format , perceived safety and support and whether the program supported the ability to address lifestyle risk factors, as outlined by behaviour-change principles . Survey Blood pressure: measured using an automated machine (OMRON HEM-7203) with an inflatable cuff around the upper arm. For those with a stroke or TIA, blood pressures lower than 130/80 mmHg are recommended to reduce risk of recurrent stroke .Waist circumference (centimetres): measured at the level of the umbilicus with a tape measure being loose enough to fit one finger between the tape and participant. The Australian Heart Foundation recommends waist circumference less than 94 cm for males and less than 80 cm for females .Six-Minute Walk Test (6MWT): a widely used measure of functional walking endurance with high test–retest reliability, validity and established normative data for age and sex ,32. The Thirty-Second Sit to Stand Test: a practical test of functional leg strength and endurance with excellent test and retest reliability and validity. Scores reflect the number of times a person can complete sit to stand in 30 s from a 43 cm chair. Normative values in community-dwelling healthy adults aged 60–64 range from 12 to 17 for women and 14 to 19 for men .International Physical Activity Questionnaire (IPAQ) : we usedThe Stroke Self-Efficacy Questionnaire (SSEQ) : a self-Fatigue Severity Scale (FSS) : a validStroke Exercise Preference Inventory (SEPI) : a standOur secondary outcomes involved clinical tests and patient-reported outcomes measured before commencing the program and at 12 weeks (discharge). The series of standardized clinical tests and validated questionnaires used are listed below. All clinical outcomes and questionnaires (with the exception of the Stroke Exercise Preference Inventory) were completed at initial assessment (before commencing program), midway (week 6) and discharge (week 12). Participants also provided self-reported information about changes in their lifestyle risk factors for stroke via the online, anonymous survey at the completion of the program (via Microsoft 365 Forms). The tests and questionnaires used are as follows:t-test for interval data that were normally distributed and the Wilcoxon signed-rank test for non-parametric data or interval data that were not normally distributed. Statistical significance was set at 0.05. Paired comparisons were also reported as mean difference and 95% confidence intervals. Self-reported changes in lifestyle factors (provided in the online survey) were summarized descriptively outlining the proportion of participants who made lifestyle changes and the number of risk factors addressed. Data from the IPAQ  were also collated. Statistical analyses were performed using R Statistical Software . Online surveys and descriptive data were analysed using Microsoft 365 Forms and Excel. We did not undertake an intention-to-treat analysis, nor perform a priori sample size calculations.Service information  were collated to examine if the program was feasible to deliver. Participant acceptability was summarized by collating information such as participant uptake, attendance and satisfaction. Clinical outcomes for group data were summarized (pre and post) and then analysed statistically using paired comparisons. We used a paired-sample Over the evaluation period (intake October 2021 to October 2022), 90 referrals were received for the program. At triage, 37 people consented to participate, 10 were wait listed and 43 did not proceed with the program. The reasons for not participating were as follows: offered an alternative service such as 1:1 Exercise Physiology (28); medical (4); could not access telehealth (2); program was not indicated (3) and person’s choice (6). The 37 referrals that proceeded came from the acute ward (19), community rehabilitation (13), Better at Home (an inpatient bed substitution provided at home (3)), the Stroke Prevention Outpatient Clinic (1) and the external subacute rehabilitation setting (1).Of the 37 participants, 73% were male, and the average age was 62 years. Most participants had an ischaemic stroke event (86%) and were a first presentation for a stroke event (86%). At triage, the average time since stroke event was 56 days. One-quarter of participants only received the secondary stroke prevention program, while the remainder also had Community Rehabilitation Services. For more demographic and medical information, see During the evaluation period, we delivered seven intakes of the program. Given that each intake had the capacity for eight participants, the overall uptake of the program during the evaluation period was 66%, while the later intakes ran at full capacity. No adverse events occurred. Seven participants did not complete the full program  for the following reasons: medically unwell unrelated to stroke (three); moved overseas (one); exacerbation of back pain (one); contracted COVID-19 (one) and returned to work (one).We calculated that 122 staff hours were needed to deliver the 12-week program for eight participants to receive 24 occasions of service. These hours involved approximately 105 h of Exercise Physiology , with the remainder being for multidisciplinary education and administration. Based on 2023 award rates (including on-costs), the cost of the 12-week program was AUD 7760, and the cost per participant was AUD 970.At triage, 83% of referrals wanted to participate in the 12-week program or an alternative service, and only 7% of people referred declined a service. Participants attended 79% of the telehealth education sessions and 83% of the supervised exercise sessions. The majority of the planned telehealth coaching sessions were completed. As mentioned previously, 81% of the participants completed the full program.Twenty-four participants completed the online survey (65% response rate). The findings support that satisfaction was high (strongly agree and agree) for ‘relevance’ (100%), ‘would recommend to others’ (96%), ‘felt safe to exercise’ (96%) and ‘intend to continue’ (96%). See The secondary outcomes involved clinical tests and questionnaires. Paired comparisons for the group show improvements after participation that were statistically significant for waist circumference, walking endurance, functional lower limb strength and levels of physical activity and fatigue. The changes observed for self-efficacy and blood pressure showed a diverse range and were not statistically significant see .Most participants (89%) reported that they had changed a lifestyle risk factor for stroke since attending the program see . On averThe secondary stroke prevention program incorporating supervised exercise, multidisciplinary education and coaching was found to be feasible, safe and low cost to deliver. Participants found the program acceptable in terms of uptake, satisfaction and attendance. The clinical outcomes observed after participation also suggest possible benefits for addressing modifiable lifestyle factors associated with risk of recurrent stroke ,10,14,18Elements of our program that may have assisted in making the model feasible to deliver and acceptable to participants require mention. The education, support and coaching were guided by evidence and principles of behaviour change ,28. The In terms of feasibility, our program aimed to support people with mild stroke or TIA, as many of these people are not linked to health professionals for guidance to modify lifestyle risk factors for stroke, such as diet and exercise. Our referral data indicate that we captured 18% of the 500 people admitted annually to our health setting for stroke events. However, the low referral numbers for people with TIA or from the Stroke Prevention Outpatient Clinic highlights areas to target for referrals and service promotion. While our observation that few people (7%) declined a service for secondary stroke prevention may reflect a referral or selection bias, it seems that people want to improve their health outcomes and would benefit from the opportunity for support. Further, while the program ran at 66% capacity, it took time to promote a new service within our health setting and to establish clear referral pathways. At the end of the 12-month evaluation period, demand increased, and we now have a waiting list and continue to deliver the program as part of routine care.Given that low levels of physical activity ,12,17,18The potential cost benefits of our program to reduce healthcare costs seem promising. Our 12-week program for eight people was estimated to cost AUD 7760 and may have contributed to reducing the risk of recurrent stroke given the observed increase in physical activity, walking endurance and changes in lifestyle. In comparison, the Australian weighted-average inpatient separation for stroke in 2020 costed AUD 10,209  or reducSeveral limitations of this study need consideration when interpreting and attempting to generalize from our findings. The study involved a small convenience sample of people from one healthcare setting with an established stroke unit and was from a high-income country. The participants had a range of medical conditions but were clinically stable and living independently in the community. Given the clinical nature of the program, the rate of attrition in attendance due to unrelated illness, relocation and return to work was not surprising, and seemed unrelated to the program. The study was also undertaken in the context of a program evaluation and was not designed to investigate the effectiveness of the intervention. The study was not controlled was under powered, and outcome measures were not undertaken by independent assessors. Moreover, the participants were aware of the program evaluation, and their positive views about the program were a source of potential bias. Further, while our approach did aim to change behaviour, we do not follow up participants to see if the observed changes were sustained. Given these limitations, the gains observed in the secondary outcomes should be interpreted with caution. Future controlled research is needed to determine if the program is effective, leads to sustained changes in lifestyle and reduces risk of recurrent stroke.Our group-based program that combined supervised exercise, education and coaching to manage modifiable risk factors for stroke was feasible and low cost to deliver, acceptable to participants and may have supported beneficial clinical and health outcomes. This type of model of care has the scope to support people to address modifiable risk factors for stroke, and thus may assist in improving patient outcomes and optimizing the use of healthcare services. Further investigation of the program is needed to examine if it is effective and if changes in lifestyle are sustained.


Porcine epidemic diarrhea (PED) is a severe infectious disease that causes very high mortality in newborn piglets up to 2–3 weeks age. The main cause of repeated outbreaks of PED in infected farms is the continuing circulation of the PED virus (PEDV). Improper gilt management, including inappropriate gut feedback, commingling, and inadequate immunization, causes a prolonged virus circulation in breeding herds. Moreover, insufficient transfer of passive immunity through the colostrum to newborn piglets can also increase infection risk. Therefore, a gilt management program that controls infection should focus on infection monitoring and acclimatization. We investigated the source of recurrent PEDV outbreaks and examined how the effect of immunization methods, specifically using gut feedback mechanism and vaccination, can reduce PEDV circulation and improve immune responses in replacement gilts.The study site was a segregated commercial production farm with endemic PEDV. The acclimatization methods included gut feedback and vaccination. This longitudinal study evaluated two strategies of gilt acclimatization against PEDV: Program 1 (routine farm management) and Program 2 . Levels of PED RNA in fecal samples were measured using quantitative reverse transcription-polymerase chain reaction, and the PEDV S gene was sequenced. Porcine epidemic diarrhea-specific immune responses were assessed using enzyme-linked immunosorbent assay and the serum neutralization test.Porcine epidemic diarrhea outbreaks occurred in the farrowing, nursery, and finishing units and farrowed litters 5–10 days old were symptomatic of PED. Phylogenetic analyses of the S gene showed PEDV sequence divergence between PEDV field strains and vaccine strain, which may contribute to periodic outbreaks and continued persistence of PEDV in the farm. After gut feedback and acclimatization, replacement gilts from Program 1 continued to shed PEDV before being introduced to sow herds, while those from Program 2 did not shed PEDV before being introduced to sow herds. However, the components of the immune response against PEDV in serum samples, including specific immunoglobulin (Ig)G, specific IgA, and neutralizing antibodies were lower in gilts of Program 2 than those in Program 1.We speculate that implementing the appropriate gilt acclimatization program can control PEDV circulation in farm. However, the acclimatization methods in Program 2 did not induce a strong and adequate immune response in replacement gilts. Therefore, maternal immunity levels and the degree of protection against PEDV require further study. In the past decade, porcine epidemic diarrhea (PED) has become one of the most severe infectious diseases that cause large-scale economic losses in pig production. Infections caused by the PED virus (PEDV) cause severe diarrhea, vomiting, and dehydration, leading to a very high mortality rate in suckling pigs. However, older pigs may develop only mild diarrhea and are often virus carriers, resulting in endemicity . Before The recurrent outbreaks of PED in infected herds are due to the continuous circulation of PEDV in the environment, which constitutes the main risk factor for this disease , 6. TherTherefore, to control PEDV circulation in the endemic herd, an appropriate gilt management program that focuses on acclimatization and immunity improvement is urgently needed.This study aimed to investigate how gut feedback mechanism and PEDV vaccination in gilt development unit can affect PEDV circulation and improve the immune response of replacement gilts.The study protocol was approved by the Animal Care and Use Committee, Kasetsart University (IACUC #ACKU65-VET-025), and the owner’s approval and agreement to participate in this study were obtained.The study was conducted from June 2020 to December 2021 in a commercial swine herd in Thailand that experienced recurrent outbreaks of PED. The samples were processed at the Kamphaeng Saen Veterinary Diagnostic Center, Faculty of Veterinary Medicine, Kasetsart University.® PT-100, ChoongAng Vaccine Laboratories Co., Ltd. (CAVAC), Daejeon, South Korea) and (ii) acclimatization using the intestinal contents from piglets with PED (gut feedback). The gilts were also vaccinated against porcine reproductive and respiratory syndrome virus, porcine circovirus type 2 viruses, foot-and-mouth disease virus, and classical swine fever virus, Aujeszky’s disease virus, porcine parvovirus, Erysipelothrix rhusiopathiae, leptospirosis, and Actinobacillus pleuropneumoniae.The study site was a P0-P1 segregated commercial production farm with endemic PEDV. The farm had approximately 5000 sows in four units (700–1200 sows in each unit). All replacement gilts (Large White × Landrace) were internally replaced at 12 weeks of age (20 pigs per pen). The replacement gilts were divided into three groups according to the phase of the gilt management program and were housed in three barns: The nursery to grower barn (G1), finisher barn (G2), and the replacement gilt barn (G3). All gilt management barns had an evaporative cooling system in the semi-isolated area. The G1 and G2 barns had 20 pens on both sides of the walkway, whereas the G3 barn had 100 individual stalls at the back of the barn. Incoming gilts were immunized against PED by two methods: (i) PEDV inactivated vaccine . In both methods, gilts were immunized against PEDV through gut feedback and vaccination. The experimental design of each program is illustrated in In “Program 2,” the acclimatization method involved implementation of PEDV gut feedback in the G1 barn when the gilts were 13 weeks old. These gilts then received intramuscular vaccinations against PEDV when they were 28 and 31 weeks old (both in the G2 barn). The 28-week-old vaccinated gilts were moved to individual stalls in the G3 barn for the cool-down period. In both programs, samples were collected using similar procedures, with minor differences. The statuses of their viral kinetics, and immune responses, were compared until gilt replacement. Moreover, porcine epidemic diarrhea virus infections among pigs were recorded, especially when animals exhibited clinical signs of PED. Porcine epidemic diarrhea virus S gene sequences were confirmed through quantitative reverse transcription-polymerase chain reaction (RT-qPCR).Five pigs from four pens (containing 20 immunized gilts) from each program were selected for serial sample collection. Sample collection started on the day of acclimatization and ended at replacement. Blood and fecal samples were collected at each acclimatization period: (i) Before immunization by gut feedback, (ii) 4 weeks after immunization, (iii) during the cool-down period, and (iv) during replacement. Samples were collected from Program 1 gilts at 24, 28, 31, and 35 weeks of age and from Program 2 gilts at 13, 17, 28, and 35 weeks of age. Blood samples (5 ml) were centrifuged at 8000x g for 5 min and the resulting sera were aliquoted into microcentrifuge tubes. Fecal samples were collected using cotton swabs, which were then transferred to 500 mL of D-solution . The solution and samples were mixed thoroughly by vortex mixing and stored at −80°C until testing.® probe  [Porcine epidemic diarrhea virus was detected by RT-qPCR using primers that targeted the PEDV M gene . Total Rhailand) . The RT-et al. [Nucleotide sequences of the partial spike gene from PEDV-positive samples were evaluated by first aligning them using BioEdit version 7.2.6.1  and MEGAet al. [50/well). The plates were incubated at 37°C for 1 h. The serum-virus mixtures were transferred into Vero cells and incubation at 37°C for 48 h. The SN titer was defined as the highest dilution of the serum that inhibited the cytopathic effects (CPE).All serum samples were submitted to the Kamphaeng Saen Veterinary Diagnostic Center, Faculty of Veterinary Medicine, Kasetsart University. The serum samples were analyzed using a whole-virus enzyme-linked immunosorbent assay designed to detect the levels of specific immunoglobulin (Ig)G and specific IgA of PEDV . An S/P et al. , with miStatistical analyses were performed using R Studio version 4.0.1 (https://posit.co/download/rstudio-desktop/). The viral titers, S/P ratios, and neutralizing antibodies associated with Program 1 and Program 2 were compared at each time point using independent t-tests. The frequencies of virus-positive animals were compared among the groups using Fisher’s exact test. p < 0.05 was considered statistically significant.The numbers of suckling piglets lost due to diarrhea and wasting from June 2020 to December 2021 are shown in The sequences of the partial S gene in five PEDV-positive samples collected from affected pigs were analyzed. Phylogenetic analysis showed the S gene sequences were clustered into two major groups: G1 and G2 . All PEDThe dynamics of PEDV shedding in the replacement gilts of Programs 1 and 2 are shown in The results of assays detecting specific IgG against PEDV are shown in The levels of PEDV IgA antibodies are shown in The levels of serum neutralization (SN) antibodies  show thaIn this study, we evaluated a PED outbreak using RT-qPCR and nucleotide sequencing methods to obtain genetic information about the virus. The results of the genetic analysis of PEDV indicate that all viruses identified in this study are 100% homologous. It should be noted that the PED outbreak in this farm might occur due to viral persistence in the farm. Then, the gilt acclimatization program was implemented in response to this outbreak and included monitoring PEDV shedding using RT-qPCR. Porcine epidemic diarrhea virus was detected before gut feedback in the gilts of both Programs, which can be explained by the possible exposure of the pigs to the virus circulating in wean-to-finish barns. Moreover, PEDV was detected continuously in Program 1 gilts, with some replacement gilts continuously transmitting PEDV during the replacement period. This PEDV strain was consistent with the same PEDV genetic results, and thus, it might have been the possible source of the circulation of PEDV in the breeding herd .In Program 2, disease transmission was controlled in the replacement gilts before they entered into the herd. The modified Program 2 method involved early gut feedback and gilt flow management adjusted to reduce the chances of PEDV transmission within the farm. Continuous farming is a system that has been adjusted by the application of all-in/all-out replacement gilts, stringent disinfection procedures, and the adoption of biosafety measures. All of these measures, applied in Program 2, have controlled PEDV infection . InteresIt is concerning that the immunity of replacement gilts can affect the lactogenic immunity that protects suckling piglets against PEDV and is conferred by maternal antibodies. Therefore, we compared the immune responses between the acclimatization methods in Programs 1 and 2. Some gilt in both programs developed a specific immune response to PED before immunization, which may be due to natural exposure to circulating PEDV before initiating gut feedback . The immOur results suggest that Program 2 is a suitable method to control PEDV circulation within the farm. However, the immunity level of the replacement gilts in Program 2 was lower than that of the replacement gilts in Program 1, and this may have been due to the implementation of an improper immunization method that failed to sufficiently immunize the pigs . Our resOur study demonstrated that it was difficult to eliminate PEDV on the farm by practicing gut feedback, which tended to become a source of virus circulation and reinfection. Thus, a suitable acclimatization protocol should be applied for gilt immunization. Moreover, gilts should be provided with an appropriate cool-down period, from gut feedback to replacement, lasting at least 10 weeks. Nevertheless, our results suggest that the immune responses following immunization with gut feedback and vaccines may not provide adequate immune protection at replacement. Therefore, a comprehensive and appropriate acclimatization protocol and successful biosecurity management are needed to prevent and control PED effectively.PS, AB, and YW: Conceptualized and designed the study and prepared the initial draft of the manuscript. PS, SP, AB, and YW: Performed the sample collection, experiments, and data analysis. PS, MS, WC, OB, and KW: Conducted the RT-qPCR, ELISA, neutralization test and sequencing analysis. PS and PJ: Statistical analysis. YW: Finalized the manuscript. All authors have read, reviewed, and approved the final manuscript.