Utilisation of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and guide sheath (EBUS-GS) for diagnosis and staging of lung cancer is gaining popularity, however, its impact on clinical practice is unclear. This study aimed to determine the impact of the introduction of endobronchial ultrasound-guided procedures (EBUS) on time to management decision for lung cancer patients, and on the utilisation of other invasive diagnostic modalities, including CT-guided trans-thoracic needle aspiration (CT-TTNA), bronchoscopy, and mediastinoscopy.Hospital records of new primary lung cancer patients presenting in 2007 and 2008 (Pre-EBUS cohort) and in 2010 and 2011 (Post-EBUS cohort) were reviewed retrospectively.p = 0.015 and p < 0.001 respectively). Of 162 CT-TTNAs, 59 (36 %) resulted in complications compared to 1 complication each for bronchoscopy and EBUS-GS, and no complications from EBUS-TBNA. Fewer complications occurred overall in the Post-EBUS cohort compared to the Pre-EBUS cohort (p = 0.0264). The median time to management decision was 17 days (IQR 24) for the Pre-EBUS and 13 days (IQR 21) for the Post-EBUS cohort (p = 0.07). Within the Post-EBUS cohort, median time to management decision was longer for the EBUS group (n = 90) than the Non-EBUS group (17 days (IQR 29) vs. 10 days (IQR 10), p < 0.001). For half of EBUS-TBNA patients  and EBUS-GS patients , EBUS alone provided sufficient diagnostic and/or staging information; these patients had median time to management decision of 10 days. Regression analysis revealed that the number of imaging events, inpatient, and outpatient visits were significant predictors of time to management decision of >28 days; EBUS was not a predictor of time to management decision.The Pre-EBUS cohort included 234 patients. Of the 326 patients in the Post-EBUS cohort, 90 had an EBUS procedure (EBUS-TBNA for 19.0 % and EBUS-GS for 10.4 % of cases). The number of CT-TTNAs and bronchoscopies decreased following the introduction of EBUS (The introduction of EBUS led to fewer CT-TTNAs and bronchoscopies and did not impact on the time to management decision. EBUS-TBNA or EBUS-GS alone provided sufficient information for diagnosis and/or regional staging in half of the lung cancer patients referred for this investigation. The management of lung cancer has changed considerably over the last 5 to 10 years, with the recognition that Non-Small Cell Lung Cancer (NSCLC) is a heterogeneous disease in terms of its histopathology, molecular pathology, clinical manifestation, and response to treatment . ChemothWhilst non-invasive procedures such as computed tomography (CT), positron emission tomography (PET), and PET-CT provide information about extra-thoracic spread of tumours, their sensitivity and specificity for staging localised and regional disease such as hilar or mediastinal lymph node involvement is relatively poor –7. MediaThe more recent advent of ultrasound-guided endoscopic procedures provides visualisation of structures on the outside of the lumen wall, thereby allowing more accurate sampling of tissue. Endobronchial ultrasound (EBUS) and oesophageal ultrasound (EUS) procedures utilise a linear probe which provides a fan-shaped ultrasound image in which the sampling needle can be seen in real time, thus allowing more accurate sampling of mediastinal and hilar lymph nodes. These procedures perform at least as well as mediastinoscopy . EBUS trOver the last several decades, there has been a shift in the histology of NSCLC from squamous cell carcinoma, which tends to involve more central airways, to adenocarcinoma that is often located in the lung periphery, where approximately 70 % of NSCLC is now found . In the Studies into the modalities used to diagnose lung cancer have shown a reduction in the number of CT-TTNAs following the introduction of EBUS-GS  and a reThis study aimed to compare the number and type of procedures undertaken to diagnose and stage lung cancer, the time between first presentation at the hospital and establishment of a management decision, and the incidence of complications arising from diagnostic procedures before and after the introduction of EBUS.We conducted a retrospective pre-post study of all new primary lung cancer cases presented to the lung cancer Multi-Disciplinary Team Meeting (MDM) at a tertiary hospital in Western Australia, between 1 January 2007 and 31 December 2008 (Pre-EBUS cohort) and between 1 January 2010 and 31 December 2011 (Post-EBUS cohort). EBUS was introduced at the hospital at the end of 2008 and this hospital was the only site in the state where EBUS procedures were performed at the time. Patients’ medical records and hospital data were reviewed. Patients were excluded if their case was not discussed at the lung cancer MDM. While cases with both initial investigation and treatment performed outside the hospital were excluded, patients were included if they had had some imaging and/or invasive procedures performed elsewhere but were presented to the lung cancer MDM for diagnosis and management.The following data were collected: demographic details; co-morbidities (Charlson Index) ; performth edition of TNM staging [th edition [Clinical stage of the Pre-EBUS cohort was based on the 6 staging , while t edition . When stIn most cases, patients were presented to our MDM after an initial CT of the thorax and upper abdomen, and in the majority of the cases results of a PET scan guided recommendations for an EBUS-TBNA investigation.EBUS procedures: Both EBUS-TBNA and -GS investigations were performed under general anaesthesia or moderate sedation. An on-site pathologist was present to provide rapid on-site evaluation (ROSE) on EBUS-TBNA procedures. The site and number of lymph node stations sampled and the number of passes per lymph node were determined by the operator. At least three needle passes were made per lymph node unless the diagnostic material was reported adequate on ROSE.All statistical analyses were undertaken using IBM SPSS Statistics 19 and STATA v 13. Pearson’s chi-squared analyses or Fisher’s exact tests were undertaken for between-group comparisons for categorical variables  <28 days for the Post-EBUS cohort and within the EBUS group). Medians were calculated for continuous variables and non-parametric tests (Mann–Whitney U tests) were undertaken to compare groups . Backwards stepwise logistic regression was used to determine significant predictors of the TMD within 28 days vs greater than 28 days, with demographic variables , referral source, Charlson index, ECOG-PS, EBUS procedure, number of other invasive procedures, number of inpatient and outpatient visits, number of imaging investigations and stage of cancer initially entered into the model as potential predictors.Date of first presentation at the hospital was considered to be the first lung cancer-related hospital presentation date as either an inpatient or an outpatient. Date of management decision was defined as the date of the lung cancer MDM when the diagnosis was established and/or the initial treatment decision was made. Time to management decision (TMD) was defined as time from first presentation at the hospital to date of MDM when management decision was made. Patients referred to our hospital for investigation of a lung mass were first seen in a fast track clinic, held once weekly. EBUS bronchoscopy sessions were approximately once weekly. Access to PET was usually within 7 to 10 days. MDMs at our institution are held on a weekly basis.Ethics approval was obtained from the Sir Charles Gairdner Group Human Research Ethics Committee (REF No.2012-121) and the University of Western Australia Ethics Committee (REF No. RA/4/1/5871). The need for informed consent was waived by the Sir Charles Gairdner Group Human Research Ethics Committee.Of 775 lung cancer patients presented to the lung cancer MDM, 571 met the inclusion criteria: 245 in the Pre-EBUS cohort and 326 in the Post-EBUS cohort ; EBUS was undertaken mainly for patients with better performance status (ECOG-PS of 0 and 1).Both Pre-EBUS and Post-EBUS cohorts had similar patient characteristics Table . Within p < 0.001) and a 10.2 % fall in the proportion of patients with CT-TTNA (p = 0.012) following the introduction of EBUS-TBNA and EBUS-GS. Mediastinoscopies were not routinely performed on lung cancer patients in either cohort; only one mediastinoscopy was performed in the Pre-EBUS cohort and three in the Post-EBUS cohort. In the Post-EBUS cohort, EBUS-TBNA was undertaken for 19.0 % of cases (n = 62) and EBUS-GS for 10.4 % of cases (n = 34) . One invasive procedure was sufficient to establish lung cancer diagnosis for 68 % of patients in both cohorts. Invasive procedures were not undertaken on 8.5 % of the patients in the Pre-EBUS cohort and 9.8 % in the Post-EBUS cohort, for whom a diagnosis of lung cancer was made on the basis of clinical presentation and imaging. Approximately 23 % of the patients in the Pre-EBUS cohort and 22 % of the Post-EBUS cohort had 2 or more invasive procedures.A median of one invasive procedure was performed per patient in both cohorts Table  (p = 0.8n = 14) of all EBUS-GS cases. One patient (2.9 %) had two EBUS-GS procedures, nine patients (26.5 %) underwent other invasive investigations following EBUS-GS, and four patients (11.8 %) had invasive procedures before EBUS-GS. The main reason for additional invasive investigations among EBUS-GS patients was inadequacy of the preceding investigation/s. One patient was referred for EBUS-CG for material for molecular testing following positive result from a bronchoscopy.Six patients underwent both EBUS-GS and EBUS-TBNA; five as part of a single procedure and in one case EBUS-GS was undertaken with diagnostic purpose and then followed up by EBUS-TBNA for staging. A single EBUS-GS investigation was sufficient to establish lung cancer diagnosis in 41.2 % (n = 28) also underwent additional invasive investigations, both prior to and following the EBUS procedure. Multiple procedures were required for a number of reasons, including: non-diagnostic results from initial invasive investigations ; non-diagnostic EBUS-TBNA results ; additional material required for molecular testing ; and EBUS-TBNA being conducted for staging purposes only, following positive diagnosis from CT-TTNAs and FBs .Approximately half of all patients undergoing EBUS-TBNA  and EBUS-GS (N = 34). EBUS-TBNA (N = 62) did not result in any complications. Significantly fewer complications occurred in the Post-EBUS cohort compared to the Pre-EBUS cohort .Across both cohorts, 36 % of CT-TTNAs resulted in complications. Of 162 CT-TTNAs, 57 resulted in a pneumothorax, one in pulmonary haemorrhage, and one in intra-parenchymal bleeding. While only nine cases with pneumothorax following CT-TTNA had chest tube inserted, 32 patients were admitted for observation overnight. Only one complication  occurred each as a result of bronchoscopy (p = 0.070)  and EBUS-GS patients  underwent EBUS before or after other invasive investigations. For these patients, median TMD was longer compared to patients with EBUS only: 45 days for EBUS-GS (p = 0.001) and 26.5 days for EBUS-TBNA (p < 0.001) (Table p = 0.018) (Table The median TMD was 17 days for the Pre-EBUS cohort and 13 days for the Post-EBUS cohort (0) Table . In the 0) Table . Howevernts n = 1, 50.0 % p = 0.020), outpatient visits  or imaging investigations . Conversely, patients with Stage III  or Stage IV  NSCLC had increased odds of TMD within 28 days compared to those with Stage I NSCLC. Patients with Limited  or Extensive  SCLC had increased odds of TMD within 28 days compared to those with Stage I NSCLC. EBUS was not an independent predictor of TMD within 28 days.A multiple logistic regression identified predictors of TMD within 28 days. The total number of inpatient visits, outpatient visits and imaging investigations Table  predicteTo assess change in practice patterns between the Pre- and Post-EBUS cohort, we evaluated all NSCLC patients with Stage I, II and III disease who had surgical resection Table . A higheThe introduction of new diagnostic procedures has the potential to prolong the diagnostic process and contribute to a delay in management decisions. However, this retrospective pre/post study demonstrated that introduction of EBUS-GS and EBUS-TBNA for the diagnosis of lung cancer at a tertiary teaching hospital in Western Australia led to a decrease in the number of bronchoscopies and CT-TTNAs and did not affect the TMD. The Post-EBUS cohort had fewer complications, which may be attributed to the decrease in the number of CT-TTNAs, as no change in the proportion of complications resulting from CT-TTNAs was observed.In our study, only one mediastinoscopy was performed in the Pre-EBUS cohort and three in the Post-EBUS cohort. Mediastinoscopies were not routinely performed as frequently as guidelines and their “gold standard” status would recommend , 8, 20; Our results show that diagnosis and staging of lung cancer in the Pre-EBUS cohort was a two stage process, with sampling of the peripheral lung mass by CT-TTNA or FB, and staging of the mediastinum by PET scanning, despite its limitations. Whilst mediastinoscopy was rarely performed at our hospital, previous studies of patients with NSCLC have reported that evaluation of the mediastinum by mediastinoscopy was infrequently performed 27 %) in patients undergoing surgery  % in pat. In addiWith regard to EBUS-TBNA staging of N2 nodes, there were no false negative cases discovered at surgery. A higher proportion of patients with clinical Stage II (N1 involvement) in the Post-EBUS cohort proceeded to surgery, compared with the Pre-EBUS cohort Table . FollowiSurgery is indicated for patients with Stage I or II disease and good performance status; hence, accurate staging is essential to exclude mediastinal involvement. Patients with an ECOG-PS of 3 or 4 are less suitable for radical treatment and thus fewer patients would be referred for EBUS-TBNA, as mediastinal staging is less critical. Consistent with these recommendations, almost all EBUS patients in our study had ECOG-PS of 0, 1, or 2.Radical chemo-radiotherapy with curative intent is indicated for Stage III disease. Our findings show that a higher proportion of Stage III NSCLC cases underwent EBUS-TBNA when compared to the other stages. As these patients are more likely to present with enlarged lymph nodes on CT or PET imaging, EBUS-TBNA would be the preferred invasive procedure, providing both diagnostic and staging information simultaneously with a lower risk of complication. EBUS-TBNA was undertaken in almost half of the patients with limited SCLC; such cases often have enlarged hilar or mediastinal lymph nodes, so EBUS-TBNA provides diagnostic material.Recommended timelines for diagnosis and start of treatment for lung cancer have been included in several guidelines , 24 and This study demonstrated that the median time from initial presentation to management decision for lung cancer patients decreased from 17 days for the Pre-EBUS cohort to 13 days for the Post-EBUS cohort; however, this difference was not statistically significant. It is important to emphasise that patients with suspected lung cancer presented at the hospital via different pathways, although referral source was not a predictor for the time taken from first presentation to final diagnosis and treatment recommendations. A small number of patients with suspicious pulmonary lesions on imaging, required extensive work-up and long follow-up before a definitive diagnosis was established. This may be reflected in the regression analysis, which indicated that a greater number of imaging investigations and inpatient and outpatient visits were associated with TMD >28 days. Furthermore, patients with Stage III and Stage IV NSCLC and patients with SCLC had higher odds of TMD of ≤28 days when compared to Stage I NSCLC. This finding is consistent with the overall clinical management of patients with advanced lung cancer, who are less likely to be suitable for radical treatment and require less rigorous investigations to guide management decisions, and hence, take less time to decide on a management plan.A recent multicentre, pragmatic, RCT showed that routine use of EBUS-TBNA after a staging CT for suspected lung cancer resulted in faster management decisions with fewer investigations when compared with conventional diagnosis and staging methods . Our stuOur results also showed that in the Post-EBUS cohort, for patients who had only a single EBUS (TBNA or GS) investigation, median TMD was comparable to those who had conventional invasive diagnostic and staging investigations. EBUS-TBNA alone provided diagnosis and intra-thoracic regional staging in 50 % of cases and a single EBUS-GS investigation was sufficient to establish lung cancer diagnosis in 50 % of cases undergoing the respective procedure.For half of the EBUS cases, additional invasive diagnostic procedures were conducted to obtain a definitive diagnosis and/or staging; these patients had a longer TMD. This may be explained by the finding that greater numbers of imaging procedures and occasions of service were both predictors of increased TMD in the regression analysis, and points toward the potential complexity of some cases referred for EBUS.While EBUS-GS provides diagnostic information only, EBUS-TBNA may fulfil both diagnostic and staging purposes, particularly in patients with suspected mediastinal lymph node involvement, where evidence-based guidelines recommend sampling of the mediastinum as the most appropriate first invasive test . MultiplIn this study, EBUS procedures were undertaken in 28 % of newly diagnosed lung cancer patients, with EBUS more likely to be undertaken in diagnostically challenging cases. As experience with EBUS has developed, there has subsequently been an increase in its use, such that EBUS is now performed in approximately 74 % of lung cancer patients at the hospital (unpublished results) for the purposes of tissue acquisition and more accurate staging.We recognise that our study has several limitations. This was a single-centre retrospective study in one of the largest tertiary hospitals in Western Australia that services a diverse population of patients, some of whom were referred from long distances and private practices because it was the only site in Western Australia to perform EBUS at the time. As such, our study cohort may not be representative of other practice. However, the diversity of referrals and the large geographic catchment area of the patients included in the study support our assumption that local variations are less likely to contribute to the reported findings, and that our results may be generalisable to other institutions providing similar care. Some may argue that the small number of mediastinoscopies performed over both cohorts limits the study’s generalisability. While we agree that mediastinoscopy has traditionally been considered the “gold standard” for lymph node sampling in patients with suspected lung cancer and mediastinal adenopathy, previous studies have reported that mediastinoscopy has been widely underused , 8 and mOur study shows that the introduction of EBUS to diagnose lung cancer was associated with a reduction in CT-TTNAs, bronchoscopies, and complications resulting from the invasive procedures. Furthermore, the institution of EBUS did not extend TMD, which remains well within current guidelines. In addition, EBUS alone provided sufficient diagnostic and/or regional staging information in 50 % of both EBUS-TBNA and EBUS-GS cases.


Current GINA guidelines emphasize the challenge of asthma care programs to meet local needs in various countries. We aimed to asses outcomes of a one-year capacitating program on asthma for non-specialists working in the Public Health System in Brazil.A group of 16 allergists/immunologists developed a capacitating program in 11 Public Health Units in the city of Ribeirão Preto, Brazil. The program comprised lectures on asthma and hands-on training on spirometry and use of inhalation devices; production of didactic material; and development of a protocol on management of asthma. Spacers and spirometry were provided. Each researcher visited one Health Unit 2-4 times a month, to accompany the non-specialist on patients' visits to the clinic, perform case discussions, and deliver short lectures to the health professionals. Records of asthma medications provided to patients upon physicians' prescription in the North Region were compared to those from three other Regions with no intervention.During the year prior to the capacitation program, inhaled Beclomethasone was delivered to 2,876 patients upon physician's prescription. At the end of the one-year capacitating program, there was an increase in deliver of inhaled Beclomethasone to 3,526 patients. Similarly, inhaled Albuterol, recommended as the rescue medication on the protocol, was delivered to 3,205 patients upon physician's prescription on the prior year, with increase at the end of the program to 4,850 patients. No such increase was observed in the South, Central and East Regions, where no capacitating program was conducted. Comparable number of prescriptions filled for inhaled Beclomethasone in the periods analyzed was: 1,210 and 1,074 for the East Region; 1,882 and 1,468 for the Central Region; and 1,347 and 1,244 for the South region, respectively. For inhaled Albuterol, the numbers were: 1,736 and 1,813 for the East; 2,602 and 2,662 for the Central; and 1,535 and 1,795 for the South Region, respectively. The number of prescriptions filled for Albuterol tablets and Aminophyline tablets decreased in most regions, whereas prescriptions filled for Albuterol syrup remained unchanged, with high prescription rates during the fall and winter months.A systematic capacitating program was successful in changing asthma prescription profiles among non-specialist doctors, with increasing delivery of inhaled Albuterol and inhaled Beclomethasone to patients with asthma.


Two online self-management programs for patients with atopic dermatitis (AD) or food allergy (FA) were developed with the aim of helping patients cope with their condition, follow the prescribed treatment regimen, and deal with the consequences of their illness in daily life. Both programs consist of several modules containing information, personal stories by fellow patients, videos, and exercises with feedback. Health care professionals can refer their patients to the programs. However, the use of the program in daily practice is unknown.The aim of this study was to explore the use and characteristics of users of the online self-management programs “Living with eczema,” and “Living with food allergy,” and to investigate factors related to the use of the trainings.A cross-sectional design was carried out in which the outcome parameters were the number of log-ins by patients, the number of hits on the system’s core features, disease severity, quality of life, and domains of self-management. Descriptive statistics were used to summarize sample characteristics and to describe number of log-ins and hits per module and per functionality. Correlation and regression analyses were used to explore the relation between the number of log-ins and patient characteristics.P=.002) and .26 (P=.05), respectively, and an R2 of .23. Two hundred fourteen adult FA patients were referred to the online FA training, 124 logged in for at least one occasion and data from 45 patients were available for analysis. Mean number of log-ins was 3.0 (range 1-11). Linear regression with the number of log-ins as dependent variable revealed that adding the self-management domain “social integration and support” to the model led to an R2 of .13. The modules with information about the disease, diagnosis, and treatment were most visited. Most hits were on the information parts of the modules (55-58%), followed by exercises (30-32%).Since the start, 299 adult patients have been referred to the online AD program; 173 logged in for at least one occasion. Data from 75 AD patients were available for analyses. Mean number of log-ins was 3.1 (range 1-11). Linear regression with the number of log-ins as dependent variable showed that age and quality of life contributed most to the model, with betas of .35 ( The online self-management programs “Living with eczema” and “Living with food allergy” were used by patients in addition to the usual face-to-face care. Almost 60% of all referred patients logged in, with an average of three log-ins. All modules seemed to be relevant, but there is room for improvement in the use of the training. Age, quality of life, and lower social integration and support were related to the use of the training, but only part of the variance in use could be explained by these variables. Atopy refers to the genetic tendency to develop allergic diseases such as atopic dermatitis (AD), allergic rhinitis, asthma or food allergy (FA). Allergic diseases are common in children in the age group up to twelve years; a study showed that at twelve years 58% of the children had AD, asthma, and/or rhinitis at some time . The preTechnological self-management systems for patients with chronic diseases can help them to understand and monitor their condition, and support patients in achieving behavioral change . Self-maWe previously developed two online self-management programs based on scientific guidelines and professional experience for patients with AD or FA. The programs were aimed at helping patients cope with their condition, follow the prescribed treatment and deal with the consequences of their illness in daily life. Both programs “Living with eczema” , and “LiIn 2010, a feasibility study of the self-management programs for adults took place to explore the usefulness and ease of use of the training. This was based on the Technology Acceptance Model (TAM) developed by Davis . AccordiTherefore, the primary objective of this study was to explore the use and characteristics of adult visitors to the online self-management program “Living with eczema” and “Living with food allergy” in order to increase and optimize the use of the program in daily practice. The secondary objective was to investigate the factors related to the use of the program.A cross-sectional research design was used to explore the use of two online self-management programs among patients with AD or FA. The measure of usage was the total number of log-ins in the study period. Data of usage was obtained during the patient’s use of the program and was embedded into the program design. Patients had access to the program for a three month period. The number of log-ins was measured for all participants of both programs, and the number of hits on the system’s core features was measured only among the participants who provided informed consent. To explore the patients’ characteristics a questionnaire-based online survey was conducted on a convenience sample of patients attending the online self-management programs. All patients who provided informed consent were included, and the questionnaires were incorporated at the start of the program.Study population consisted of adult patients with FA or with AD who received an account for one of the online programs. To investigate patient characteristics, all patients who provided informed consent since the start of the programs were included. The gender of each patient and the health care provider who enrolled them in the program were registered, and from the start of the program the number of visits to the site was counted. To examine the usage of the program, patients were recruited from the participants of both online self-management programs between October 2012 and November 2013, because since October 2012 it has been possible to measure the number of hits on the system’s core features.Eligible patients were at least 18 years old, Dutch speaking, and had a clinical diagnosis of AD or FA. Patients were referred to the online programs by GPs, specialists, dieticians or nurses. After referral, they received an account from which they were given access to the training. The account was valid for a period of three months in which patients could complete the program, but this period could be extended at the request of the participant. Informed consent was asked at the start of the online program through a specific letter and was incorporated as a link in the webpage of the program. Their reply was registered and they received a copy via email. A flowchart of the study can be found in The Medical Ethics Review Committee of UMC Utrecht confirmed that the Medical Research Involving Human Subjects Act did not apply to this study.Measurement of the demographic variables (age and gender) was incorporated in the initial questionnaire.Disease severity of AD was measured using the extent+ severity part of the Impact of Chronic Skin Disease on Daily Life (ISDL) questionnaire . Extent Disease severity characteristics of FA were measured by two questions: (1) which food caused an allergic reaction; and (2) whether the patient had been prescribed an adrenaline auto injector.Quality of life (QoL) was measured using the Dermatology Life Quality Index (DLQI) for patients with AD. The DLQI is a self-administered general dermatology QoL instrument and consists of ten questions with a 4-point Likert scale ranging from 0  to 3 (very much). The DLQQoL of patients with FA was measured using the Food Allergy Quality of Life Questionnaire-Adult Form (FAQLQ-AF). FAQLQ-AF contains 29 items and 4 domains about allergen avoidance & dietary restrictions, emotional impact, risk of accidental exposure, food allergy related health. The total FAQLQ score is the sum of all the items divided by the number of items and ranges from 1 ) to 7  .Self-management in patients with both conditions was measured using the health education impact Questionnaire (heiQ) version 3.0 . The heiNumber of log-ins and hits per module and per functionality  were automatically registered in the web system of the online program. This functionality has been available since October 2012.Statistical analyses were performed using SPSS Statistics 20.0 . Standard descriptive statistics were used to summarize sample characteristics and to describe numbers of log-ins and hits per module and per functionality.The total score on the DLQI, FAQLQ-AF and the sum scores on the eight different domains of the heiQ are at interval/ratio level measurements, and correlations with the number of log-ins were calculated using Pearson’s product-moment correlation. The correlation between the extent + severity part of the ISDL, and usage was also calculated using Pearson’s product moment.For the analysis of factors associated with number of log-ins into the online program, multiple linear regression was used. Variables related to the number of log-ins with a significance level of ≤ 0.1 were included in the model. Categorical variables were converted into dummy variables to perform the regression analysis. Prior to each regression analysis, data were checked for linearity and normality by performing a residual analysis, and checked for multicollinearity.Since the start of both programs, a total of 513 patients received an account for the online program by their physician, nurse or dietician: 299 patients for AD and 214 for FA . Of the Of the 299 AD patients referred to the online program, 173 logged in on at least one occasion and 95 gave informed consent for the use of their data. Eighty-one patients filled in questionnaires, but 6 were excluded because they were under 18 years of age (n=4) or age was unknown (n=2). Reasons for not using the program or no informed consent were not given, because patients were asked to give their informed consent (yes or no) online when first visiting the program.Data of 75 patients was available for analysis . Of themP=.001), and between number of log-ins and quality of life . Correlations between number of log-ins and domains of self-management, such as emotional well-being and skills and techniques were .2 (P=.09) and -.19 (P=.1), respectively. No correlation was shown between number of log-ins and sex or with other domains of self-management. Linear regression with number of log-ins as dependent variable and entering age, quality of life, and two domains of self-management, namely emotional well-being and skills and techniques, led to an R2of .23. Age and quality of life contributed the most to the model, with betas of .35 (P=.002) and .26 (P=.05), respectively. Two of the self-management domains, emotional well-being, and skills and techniques did not significantly contribute to the model.A low, but significant correlation was shown between the number of log-ins and age . No correlation was shown between number of log-ins and sex, age, possession of adrenaline pen, aspects of quality of life, and other domains of self-management. Linear regression with number of log-ins as dependent variable and entering “social integration and support” led to an R2of .13.A low, but significant negative correlation was shown between the number of log-ins and the domain of self-management “social integration and support”  were on the informational parts of the modules (55-58%), followed by exercises (30-32%). Ten percent or less of all hits were on videos and patient narratives .The online self-management programs “Living with eczema” and “Living with food allergy” were mostly used by patients of our university center. Of all referred patients, 58% logged in for at least one occasion. Patients who participated in the online program had an average of three log-ins and mostly visited the modules with information about the disease (AD or FA) and its treatment. Most hits were on the informational sections of the modules and on exercises. It seemed that higher age and lower quality of life influenced use of the AD program, while the lower scores on “social integration and support” influenced use of the FA program. However, explained variance of use was low.The feasibility evaluations of both online programs, carried out previously, showed that usefulness and usability of the programs were well-appreciated. According to the TAM model , this coBesides the factors related to the online program itself, patient characteristics may also influence the use of the program. We concluded that higher age and lower quality of life were associated with use of the “Living with AD” program, but the explained variance was 23%. The mean age of users of the AD program was 34 years. It is possible that relatively older patients more often took the opportunity to visit the program than young adults. Usage of eHealth interventions has also been studied in patients with other chronic diseases. For example, users of a health weight assistant  and a Wethe ability to seek, find, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem” [Because of the low explained variance in the use of both programs, other factors than demographics, disease severity, quality of life, and self-management may be of influence. We expect that eHealth literacy is such a factor. eHealth literacy is defined as “problem” . eHealthproblem” . The eHeThere is no doubt about the importance of patient education and self-management support for patients with AD  or FA 3. HoweverA limitation of the study was that disease severity, quality of life, and self-management were only measured at the start of the program; as a result, effects of the program on these clinical outcomes are unknown and it is not possible to analyze which patients will benefit most from the program. Further research with a longitudinal design will give additional insight into the effects of the programs. Moreover, most patients were referred by a university center. In this center specialized nurses or dieticians already support patients with information and education The actual need for information in this university center may be lower in than in less specialized or general hospitals. Implementation of the program at regional hospitals or in community care would probably increase the use of the programs and extend it to a more diverse patient group. Knowledge about use and factors influencing use of specific self-management programs can contribute to optimal usage of these programs, which in turn will increase the intended effects on clinical outcomes. However, generalizability of the findings of this study is limited due to the small sample size and specific adult patient group.Physicians, dieticians, and nurses, mostly from a university center, regularly referred their patients to the online programs “Living with food allergy” or “Living with eczema” for online self-management training, in addition to the usual face-to-face care. Nearly 60% of all referred patients logged in. All modules seemed to be relevant, but there is room for improvement in use of the program. Age, quality of life, and lower social integration and support were related to use of the program, but only a part of variance in use could be explained. Further research is needed into predictors of use related to the program and characteristics of users, as well as further research into the effects of the program on clinical outcomes.


Atención Integral a la Niñez en la Comunidad (AIN-C).Factors that influence performance of community health workers (CHWs) delivering health services are not well understood. A recent logic model proposed categories of support from both health sector and communities that influence CHW performance and program outcomes. This logic model has been used to review a growth monitoring program delivered by CHWs in Honduras, known as A retrospective review of AIN-C was conducted through a document desk review and supplemented with in-depth interviews. Documents were systematically coded using the categories from the logic model, and gaps were addressed through interviews. Authors reviewed coded data for each category to analyze program details and outcomes as well as identify potential issues and gaps in the logic model.Categories from the logic model were inconsistently represented, with more information available for health sector than community. Context and input activities were not well documented. Information on health sector systems-level activities was available for governance but limited for other categories, while not much was found for community systems-level activities. Most available information focused on program-level activities with substantial data on technical support. Output, outcome, and impact data were drawn from various resources and suggest mixed results of AIN-C on indicators of interest.Assessing CHW performance through a desk review left gaps that could not be addressed about the relationship of activities and performance. There were critical characteristics of program design that made it contextually appropriate; however, it was difficult to identify clear links between AIN-C and malnutrition indicators. Regarding the logic model, several categories were too broad  and some aspects of AIN-C did not fit neatly in logic model categories . The CHW performance logic model has potential as a tool for program planning and evaluation but would benefit from additional supporting tools and materials to facilitate and operationalize its use.The online version of this article (doi:10.1186/s12960-016-0115-x) contains supplementary material, which is available to authorized users. Given the existing and increasing efforts to deliver health services through community health workers (CHWs), critical questions remain about their performance and how to improve it to reach the greatest health gains possible. Many studies on CHW performance have focused on aspects of service delivery or health outcomes –3, but nCommunity and health system support activities with potential to influence performance identified at the Summit, such as local health committees, community participation, drug availability, and support from government entities, reflect those under study elsewhere –7. In faBuilding on the work from the Summit , NaimoliAtención Integral a la Niñez en la Comunidad or Integrated Child Health Program in the Community (AIN-C), which is described in detail below.The objective of this study was to conduct a retrospective review of a CHW program using the generic logic model for CHW performance and identify the factors contributing to the program’s success in improving health outcomes. The program under review is a national community-based health and nutrition program focused on growth monitoring in Honduras known as In the late 1980s/early 1990s, the Ministry of Health (MOH) in Honduras suspected that persistent malnutrition was a key factor in static mortality rates and developed the Integrated Care of the Child (AIN) program to detect growth faltering in health facilities. A review conducted in 1994 suggested that services should be taken beyond the facility level , 11. A cmonitoras who conducted community-based growth monitoring program (GMP) to detect faltering early and promote feeding strategies. Monitoras were selected by the community. The program had an unusual design in that it employed teams of monitoras to share responsibilities in each community at any given time [monitoras on a team varied between two and five, but three was the average [AIN-C was targeted at children under five and was supported by volunteer CHWs known as ven time . The num average , and teamonitoras provided monthly monitoring for children under two and followed up with households that missed monthly monitoring appointments [monitoras were allowed to hold growth monitoring sessions in the format most suitable to their community . The program was also designed to encourage active community participation and evidence-based decisions with monitora teams engaging communities in discussion about key issues that had implications for the nutrition and health status of local children [The intments , 13. Theintments , 12, 13.monitoras to trigger dialogue with caregivers and inform individualized counseling with counseling cards, (ii) by the community to measure progress and identify impediments to growth, and (iii) by health system actors to measure outcomes and improve the program [Monitoring sessions involved weighing each child, tracking their growth on a simple ledger, and counseling caregivers as needed. The data collected were to be used (i) by the  program .Monitoras were supervised directly by the health center nurse auxiliary during growth monitoring sessions, and as monitoras built knowledge and skills, they were given increased independence and responsibility. Health sector nurse supervisors also visited but more infrequently. Further, monthly meetings were held at the health center with other community volunteers to review progress, receive training, and restock medicines and supplies [supplies .AIN-C was designed to roll out to 60 communities per year, with all communities covered nationwide within 6 years . Six disA midterm evaluation by BASICS in 2000 suggested that AIN-C communities were more likely to know about the program, participate in growth monitoring, and attend weighing sessions consistently than control communities . High raThis study was conducted as a retrospective documentary review, which was complemented by in-depth interviews with knowledgeable respondents. A total of 30 documents were obtained, including World Bank and USAID reports, MOH documents and policies, national health surveys, and presentations .Four in-depth interviews were conducted with individuals intimately familiar with the development and implementation of the AIN-C program, including former MOH officials, USAID personnel, and contractors. The first interviewee was identified by contacts at USAID, and she then suggested additional interviewees to contact. One interview was conducted face-to-face and three were telephone-based. Interviews lasted between 30 and 60 min. The telephone interviews were recorded, but not transcribed, and extensive notes were taken for all interviews. The interviews were unstructured and were used to fill gaps in knowledge from the document review and confirm preliminary analyses. Of the total 30 documents reviewed, seven were provided by interviewees.Analysis was iterative. Coded output was reviewed by code and across logic model categories to identify factors contributing to the success of the AIN-C program as well as critical areas that presented challenges. Gaps in timeline or understanding as well as issues of clarity were explored with respondents, and analyses were subsequently refined.No ethics review was sought for this project as it was a desk review from existing documentation, with interviewees reflecting on prior work experiences.Most of the available evidence focused on the period during which BASICS supported the AIN-C program, with minimal publicly available information about the current status of AIN-C. Current policy documents from the MOH –18 mentiPrior to AIN-C, there had been limited improvements in human development in Honduras. Gains had been made in education and health with little progress in malnutrition . In an eOther broader contextual factors fed into the development of the program. First, Honduras had a history of volunteerism, especially for health, which provided a backbone for establishing a volunteer cadre of health workers . Second,The right to health and food had been established in the constitution of Honduras, providing a legal expectation for supporting health and well-being . Policy governance, the MOH was committed to increasing coverage and quality of care, and empowering and incentivizing communities towards social control of nutrition programs [monitoras  o In-country formative research  o Pilot testingThere was an emphasis on strengthening initial training protocols, but investments in sustained training were unclearSupervision was operationalized to be standard throughout MOH facilities, but NGO implementers provided more supportive supervisionMost of the documentary sources were focused on program design and implementation. They highlighted several important features:monitoras or the community in their decision-making.There was limited information about the ongoing monitoring and evaluation of the program. Few, if any, health centers used growth monitoring data to support There was no substantive information about technical support activities from the beneficiary communities.monitoras and AIN-C into the health system, including defining roles and responsibilities [monitoras and other networks that could have supported them and AIN-C.AIN-C was designed to focus on the community’s capacity and responsibility to ensure that its children are fed and growing . Variousbilities . Howevermonitoras, and communities were given ownership over AIN-C materials (INT 07.30.14). It is not clear how well the quarterly community meetings were implemented, though, as noted above, there was anecdotal evidence of participatory decision-making leading to community actions [In order to ensure community involvement and support, communities were advised that they needed to show their commitment by agreeing to join AIN-C and vest themselves in the program. This process was facilitated by engaging in conversations with communities and elders . Further actions .monitoras, so health system incentives were planned for and operationalized [Program planners did not want to exceed the limits of the inherent volunteerism of onalized . Incentionalized .monitoras garnered stature and respect in the community due to their role, but this was not widely documented [monitoras became community leaders and advocates, especially after Hurricane Mitch when they helped mobilize communities to identify their needs and advocate to have them met .There was some evidence that cumented . Anecdotmonitora performance indicated that:17 % were making regular classifications errors20 % were not counseling children with inadequate growth60 % provided counseling with quality errors. Of these, 50 % were not using counseling cards correctly or at allAn implementation review was conducted by BASICS after five full years of implementation . ResultsMonitoras were giving several, general recommendations to improve feeding practices instead of one or two targeted messages. Table monitora performance.Challenges for counseling centered on correctly identifying specific problems linked to growth faltering and providing tailored advice. A midterm evaluation of the AIN-C program was conducted in 2000 through a household survey that compared AIN-C communities with control communities served by the same health facilities . A finalAt midterm, caregivers in AIN-C communities showed improvements in their knowledge and practice despite poorer living conditions overall . ParticiNational rates of malnutrition were already declining prior to the initiation of AIN-C, but the trend becomes more marked after its introduction Fig. . Howevermonitoras were providing effective counseling, but issues around classification errors, missed opportunities for counseling, and challenges in counseling quality were identified. In terms of health outcomes, evaluations of AIN-C found improvements in knowledge and caregiving practices and, most importantly, in malnutrition for children exposed to GMP with regular participation. However, due to the limitations of data available during this review, we were unable to draw direct linkages between components of the AIN-C program and positive health outcomes as intended. Below, we explore characteristics of AIN-C design that allowed the program to be contextually appropriate, reflect on the logic model itself, and raise considerations for future applications of the model.This article describes a GMP delivered by CHWs in Honduras through the categories of the CHW performance logic model described by Naimoli et al. . ResultsIn Table Monitoras were established as a team to allow CHWs to share the workload and reduce the likelihood of program collapse due to turnover. In order to avoid over-relying on the inherent volunteerism of community members, health sector incentives for monitoras were established. Further, flexibility in implementation and plans for information sharing allowed AIN-C delivery to be responsive to community needs.First, in terms of content, evidence was used by program planners to design AIN-C to avoid earlier pitfalls. The intervention was designed to focus on limited information per visit, with regular follow-up of participants. Second, there are several design characteristics related to the delivery of AIN-C worth noting. AIN-C was targeted at the communities who were the worst-off in order to realize the most gains and address equity. monitoras, and holding community meetings. CHWs were linked with the health system through training, supervision, monitoring, and health referrals. Further, the strong government commitment to the overall efforts to address equity and improve health and well-being suggest high-level commitment to AIN-C’s goals.Lastly, characteristics around supportive mechanisms covered both community and broader systems supports. On the community side, AIN-C communities had to agree to three main responsibilities: agreeing to become an AIN-C site, selecting First, we reflect on the ease of use of the CHW performance logic model and potential improvements to consider based on our experience and then address the potential uses suggested by the logic model’s authors.Most monitoring and evaluation (M&E) efforts assessing CHW programs are not designed to assess CHW performance at the core of their activities or as a driver for the program’s theory of change. The CHW performance logic model is useful in helping reorient M&E approaches to focus more clearly on the intersection between CHW performance and program- and system-level activities. Consequently, our most important learning from using this logic model to evaluate AIN-C is that it is critical to start any evaluation with evidence on CHW performance as a way to provide a more focused approach to reviewing the program. While we were able to use the logic model to identify critical components of the program’s design, we were unable to identify factors contributing to programmatic success as we had originally intended.Also, we identified several issues regarding the current composition of the logic model to consider for future iterations. First, the model as represented makes it appear that each component is equally weighted, when in reality this may be context-specific, which the authors acknowledge. Second, the technical support category is very broad and encompasses activities for multiple programmatic stages , both for the health sector and community, resulting in a complex category that is unwieldy. Smaller categories would help clarify the potential roles of different actors to identify and address gaps, and strengthen the program. Similarly, the inputs and context categories are broad and include many complex components, such as policies, funding, organizations, which have likely implications for program success. In fact, a recent review proposed an approach stressing the critical pathways through which contextual factors influence CHW performance . Third, The logic model authors suggested four potential uses for the CHW performance logic model, each with their own considerations, which we address in turn. For planning, the logic model may be too comprehensive with many components to focus on, which could overwhelm policymakers. It would be helpful to identify which are the key categories to focus on at the outset of planning a program, or provide guidance for a facilitated planning process with the logic model as its basis. For practical purposes, the logic model could be used to (i) assess the current programmatic landscape and the potential contributions of a new intervention delivered by CHWs, (ii) explore how program- and system-level activities may support or hinder the CHW program and meeting its goals, and (iii) for careful reflection on community contributions.For consensus building, the logic model can be used through guided discussions aiming for a coordinated approach; the caveat above about the number and complexity of categories would also be a concern here. For program implementation, the model could be used to inform discussions around prioritizing investments and problem solving. However, it could be difficult to tease out specific areas to address without targeted and regular monitoring data. As for evaluation, the model identifies all the potential categories necessary to develop a comprehensive evaluation design. In fact, we believe that Honduras would benefit greatly from an on-the-ground evaluation of the AIN-C program using the CHW performance logic model to identify and address program challenges.Lastly, we stress an important consideration for these strategies: communities. A clear role for communities would need to be identified a priori when using the logic model for these strategies to ensure that programs are planned, built, implemented, and evaluated in a representative, transparent, and responsive manner.There are several limitations to this review. First, there was limited documented information about AIN-C available in the public domain. Most of the available evidence focused on the period of BASICS and USAID support, and minimal publicly available information on the current status of AIN-C. We attempted to address this limitation by conducting additional literature review searches through databases of published research as well as general web searches, but few additional documents were identified. Second, for interviewees, there had been a lag of about 10 years between their participation in AIN-C and their interview for this project, which may have limited their recall of details on the program. Lastly, in terms of the application of the logic model itself, the core documents about AIN-C contain little discussion about the community component of the program making it difficult to ascertain its contributions despite the intentions in the design and original rollout. We are unsure whether the lack of a documented community role in AIN-C represents poor community involvement or uneven documentation.This retrospective desk review explored a GMP in Honduras delivered by CHWs through the lens of a CHW performance logic model. It identifies lessons to be learned from the program’s design as well as from the potential of the logic model itself, which provides a comprehensive basis for understanding, planning, and evaluating CHW programs into the future.


A 7.0-magnitude earthquake hit Lushan County in China’s Sichuan province on April 20, 2013, resulting in 196 deaths and 11,470 injured. This study was designed to analyze the characteristics of the injuries and the treatment of the seismic victims.After the earthquake, an epidemiological survey of injured patients was conducted by the Health Department of Sichuan Province. Epidemiological survey tools included paper-and-pencil questionnaires and a data management system based on the Access Database. Questionnaires were completed based on the medical records of inpatients with earthquake-related injuries. Outpatients or non-seismic injured inpatients were excluded. A total of 2010 patients from 140 hospitals were included.The most common type of injuries involved bone fractures (58.3%). Children younger than 10 years of age suffered fewer fractures and chest injuries, but more skin and soft -tissue injuries. Patients older than 80 years were more likely to suffer hip and thigh fractures, pelvis fractures, and chest injuries, whereas adult patients suffered more ankle and foot fractures. A total of 207 cases of calcaneal fracture were due to high falling injuries related to extreme panic. The most common type of infection in hospitalized patients was pulmonary infections. A total of 70.5% patients had limb dysfunction, and 60.1% of this group received rehabilitation. Most patients received rehabilitation within 1 week, and the median duration of rehabilitation was 3 weeks. The cause of death of all seven hospitalized patients who died was severe traumatic brain injuries; five of this group died within 24 h after the earthquake.Injuries varied as a function of the age of the victim. As more injuries were indirectly caused by the Lushan earthquake, disaster education is urgently needed to avoid secondary injuries. China is an earthquake-prone country. Three earthquakes with magnitudes above 7.0 have occurred in China in the past 5 years: the Wenchuan, Yushu, and Lushan earthquakes Based on the experience gained from the 2008 Wenchuan earthquake, the Chinese government and various departments responded quickly to this earthquake. Eighteen minutes after the quake hit, the Chengdu Military Region organized the earthquake relief headquarters, and the China Earthquake Administration immediately launched a first-grade emergency response to the earthquake One week after the earthquake, the expert team developed a questionnaire and a data management system to epidemiologically survey inpatients with injuries related to the Lushan earthquake. This study was conducted to comprehensively analyze earthquake-related injuries, examine the status of rescue personnel and material support, and provide data to assist planning for future earthquake disaster relief.The study protocol was approved by the Ethics Committee of the Chinese PLA General Hospital, and the need for informed consent was waived. Patient records/information were anonymized and de-identified prior to analysis.After the Lushan earthquake, the Health Department of Sichuan Province ordered all its subordinate municipal Health Administrative Departments to conduct an epidemiological investigation of all injured hospitalized patients. The epidemiological survey tools included paper-and-pencil questionnaires and a data management system based on the Access Database. All questionnaires and the Access database were designed by the expert team, and all investigators were trained. The primary data for the investigation included the hospital records of the injured patients, laboratory test results, and related rehabilitation records. The survey included all patients hospitalized for injuries caused by the Lushan earthquake; all outpatients and inpatients injured by other causes were excluded. The questionnaire consisted of seven parts. Part 1 contained general questions. Part 2 presented questions about overall treatment. Part 3 related to injuries and treatment. Part 4 covered rehabilitation. Part 5 included questions about infections during hospitalization and antimicrobial drugs used. Part 6 addressed complications experienced by patients during hospitalization. Part 7 examined laboratory results. The investigation was conducted from May 9, 2013 to July 9, 2013. All data entry was completed by August 14, 2013. All data are stored at the Information Center of the Health Department of Sichuan Province.Critically ill: Victims in a hemodynamically unstable condition with life-threatening organ dysfunction or/and severe infection who met ICU admission criteria.Seriously ill: Victims with a potential risk of organ dysfunction or critical illness who required close observation All data collected via the questionnaires were entered into the Access database and then converted into Excel files for processing. A total of 2010 patients were drawn from 140 hospitals. 155 patients were transferred, 141 of whom were hospitalized twice, and 14 of whom were hospitalized three times. To avoid repetition, duplicate records were combined. All data were checked by the two authors independently.χ2 tests. All P values were two-tailed, and values <0.05 were considered to indicate statistical significance. The SPSS software 13.0  was used for statistical analysis.Descriptive statistics for all numerical variables, including the means, standard deviations, and percentages of all categorical variables, were calculated. The Kolmogorov-Smirnov test was used to determine the normality of the distribution of continuous variables. Continuous variables with normal distributions were expressed as means ± standard deviations, otherwise, medians and interquartile ranges (IQRs) were used. Categorical variables were expressed as absolute values and percentages. Patients were divided into nine groups according to age: ≤10, 11–20, 21–30, 31–40, 41–50, 51–60, 61–70, 71–80, and 81–94. Categorical variables were compared using The mean age of the 2010 earthquake victims was 44.2±21.3 years, and 1129 (56.2%) were male. Children younger than 15 years accounted for 8.2% and those older than 60 years accounted for 25.2% of the victims . The meaLushan County in Ya’an City contained the largest number of injured  and severely injured  victims; this was followed by Mingshan District, Yucheng District, Baoxing County, and Tianquan .Of the 2010 patients admitted to hospitals, 1172 (58.3%) injuries involved fractures or crush injuries. The causes of injuries were jumping , smashing , falling , and crushing/cutting/unknown . Age-stratified profile of injuries and deaths are provided in Infection sites were recorded for 143 patients during hospitalization . Lung inA total of 81 patients received blood transfusion therapy. The most common blood transfusion therapy involved red blood cells; this was followed by plasma transfusion. Seventy-five patients received a median transfusion of 3.5 units (2.0–6.0) of red blood cells. Forty patients received a median transfusion of 4.0 units (3.0–8.0) of plasma. Nine patients received transfusions of whole blood or platelets. Thirty-six patients received ventilator-assisted breathing therapy. Regarding the treatment of crush injuries, fasciotomies were performed in 25 cases, six of which were performed in affected hospitals and 19 of which were performed in backup hospitals. Amputations were performed in 12 cases, four of which occurred in affected hospitals and eight of which occurred in backup hospitals. No patient received renal replacement therapy.A total of 1418 (70.5%) patients had limb dysfunction, and rehabilitation records were found for 852 (60.1%) of this group . The medOf the 2010 patients, 93 were critically ill, and 240 were seriously ill. A total of seven patients died during hospitalization, and their mean age was 45.3±14.4 years . The age distribution of deceased individuals is presented in This is the first epidemiological study, which was organized by the Health Administrative Department, adopted a systematic approach to understanding the earthquake-related injuries and treatment of all hospitalized seismic patients. These data can make an important contribution to the efforts of governments and aid organizations to treat and organize the treatment of future earthquake-related injuries. These data on the Lushan earthquake differ from data on previous earthquakes in several respects. First, the treatment of all critically injured patients was centralized, and the rescue of earthquake survivors was effective. Second, we found more jumping injuries and fewer crush injuries. Third, hospital infection control and rehabilitation specialists participated during the early phase of the response.Three earthquakes with magnitudes over 7.0 on the Richter scale have occurred in China in the past 5 years. Due the massive number of injured individuals and the inadequacy of the treatment available in local areas, most people injured in the Wenchuan and Yushu earthquakes were transported to other areas The rescue operation following the earthquake rested on the four centralization principles Similar to the previous earthquakes Post-earthquake infections are common and associated with a high mortality rate As the magnitude of the Lushan earthquake was significantly lower than that of the Wenchuan earthquake, the numbers of patients requiring amputation and suffering from paraplegia as a result of their wounds were relatively small, 12 and 20, respectively. However, many patients who suffered fractures and peripheral nerve injuries required rehabilitation The treatment of injured children after disasters requires improvement The injuries of some patients were indirectly caused by the earthquake. Due to the severe trauma caused by the Wenchuan earthquake, the local residents reacted with great fear to the Lushan earthquake. Many residents who were not in the epicenter of the earthquake jumped from tall buildings, and 371 patients were injured as a result; this group included 17 (13.4%) and 61 (22.5%) of those who were critically and severely injured, respectively. Sichuan Agricultural University is the only university in Ya’an. Although the earthquake fractured the building of the university, it did not collapse, and more than 100 students were slightly injured while escaping. Seven were injured by jumping from the building and were sent to Ya’an People’s Hospital The situation of each earthquake is unique. Yet, knowledge about the injuries caused by each disaster and how to treat them can improve the organization, treatment, and rehabilitation available for future disasters. Moreover, improving disaster-related education should also reduce secondary injuries.


A number of cognitive interventions have been developed to enhance cognitive functioning in the growing population of the elderly. We describe the Mindfulness-Based Cognitive Approach for Seniors (MBCAS), a new training program designed especially for seniors. It was conceived in the context of self-development for seniors who wish to enhance their relationship with their inner and outer selves in order to navigate their aging process more easily and fluently. Physical and psychosocial problems related to aging, as well as some temporal issues, were taken into account in developing this program. Unlike clinically oriented mindfulness-based programs, which are generally delivered during an 8-week period, the MBCAS training program is presented over a period of 8 months. The main objectives of this program are to teach seniors to observe current experiences with nonjudgmental awareness, to identify automatic behaviors or reactions to current experiences that are potentially nonadaptive, and to enhance and reinforce positive coping with typical difficulties that they face in their daily lives. Details of the program development and initial implementation are presented, with suggestions for evaluating the program's effectiveness. The world's population is aging, with more elderly people alive than ever before, and their proportion of the world's population is increasing. For example, in Switzerland during 1990 to 2011, the proportion of people over 65 rose from 5.8 to 17.2 % and those over 79 from 0.5 to 4.8 % . A secondary purpose is to discuss its implementation, some initial findings, and considerations about its effectiveness.The MBCAS program is based on the MBSR, Mindfulness-Based Cognitive Therapy  to stimulate awareness of automatic responses; (b) to exercise self-observation of mental and emotional events which trigger automatic reactions; (c) to encourage more adaptive responses, as an alternative to automatic reactions; and (d) to develop acceptance of and compassion toward one's own internal and external events. In addition, MBCAS includes specific objectives for seniors, including (a) to stimulate verbal skills related to the consciousness of inner experiences; (b) to move mindfully in the context of one's physical limitations; (c) to experience feelings of losing control, without nurturing other thoughts such as the risk of losing autonomy; (d) to disentangle oneself from negative thoughts specific to aged people   the underpinning of the program is self-development of seniors and this takes time—a lot more time, given their age and potential for decreasing cognitive abilities; (b) healthy seniors are generally not eager to follow an intensive 8-week program because there is no clinical urgency; (c) healthy seniors have a need to feel competent and thus are not eager to be closely guided; (d) healthy seniors have a need to exercise and explore new learning within their own rhythm of life and a longer intervention period gives more time to practice alone, with regular guidance and group meetings; (e) a longer intervention period provides more opportunities to engage in meditation practice under “real-life conditions” and permits the ritualization of the practice; and (f) with a more relaxed training pace and an enhanced opportunity to really practice, the instructor becomes less important than the participant's experience.The temporal design of MBCAS is a monthly 2-h session in a closed group, followed 2 weeks later by a 1-h practice session, in an open group that includes current participants, seniors who previously attended the program, students, and academic colleagues. While the number of group sessions, training hours, and cost are similar to other standard mindfulness-based interventions, the opportunities for individual practice during the MBCAS program are four times greater. It would be interesting to assess whether the regularity of daily practice and attendance at the monthly sessions are affected by this particular temporal design.MBCAS uses group training, a format well suited to seniors. As many seniors live alone at home, group training provides an opportunity for social interaction in the local community. The format enables the acquisition of new behaviors through observational learning and modeling what has worked for other group members Bandura . FurtherThe mindfulness training was conceived as a group process, where participants and instructors meet regularly to learn and practice. The core of any mindfulness program takes place during these practice sessions, where each participant exercises the connection to his or her inner world at the same time as others practicing in the same room, and sharing with others, moment-by-moment. Thus, each participant could report on his or her unique inner experience, which has been knitted with the shared common moment . Moreover, people are generally seated in a circle, which enables subtle and inherent information to pass within the group: “When one sits in a circle with others, everyone is equal and linked… Because everyone is interrelated and derives meaning through the relationship of the circle, each person's vision is transformed as the circle takes form”  Who controls my life: my habits or my consciousness? (2) How does my mind work? (3) Breathing as an anchor to the present moment. (4) Developing awareness of my moods. (5) Dealing with uncomfortable situations. (6) How about my future? (7) What can I do: adapt or resist? and (8) Taking care of myself, day after day.To develop the participant's mindfulness, two kinds of exercises were used: (a) focusing on something specific during meditation, an excellent training to reduce distraction and loss of focus and to increase concentration, and (b) simply “being,” that is, without selecting or avoiding anything that could emerge during a meditation session, which is standard training for cultivating presence and openness moment-by-moment. The progression of the exercises starts with the very tangible bodily sensations and moves toward the less tangible inner experiences . The meditation and cognitive exercises in MBCAS are similar to those used in other programs but adapted to the needs of the seniors. At the end of each session, the participants receive audio CDs, written material, and home practice exercises.The basis of mindfulness practice is to cultivate disidentification from one's experience of internal events. For example, the participants are taught, “I am not what I feel or think,” in order to understand that feeling anxious or having negative ideas at one moment does not mean that they are that inner feeling or thought. They learn to observe their thoughts, feelings, and emotions as transient events that pass through their mind but to not hold on to them as being true or descriptive of them . The MBCAS program provides the opportunity to be more mindful of upper body tensions and movements, allowing better understanding of one's bodily sensations. The participants are invited to practice all eight movements every day.The walking exercise permits rediscovering a certain quality of openness to and acceptance of the present moment. Participants are encouraged to explore walking at various speeds in order to rediscover their safe balance. They may also try the walking exercise with a small rice bag on top of their head, to practice the feeling of having or losing control, and cultivate their kinesthetic sense of verticality. Even though it is not an objective per se, in time, practicing conscious verticality stimulates deep musculature and frees the head. This results in an enhanced physical presence that inspires dignity.Six months prior to implementing the program, a free introductory session was announced in the local newspaper. During this 2-h session, the mindfulness approach and the MBCAS program with the title of each of the eight sessions were presented, along with two typical exercises. At the end of the session, people could complete a form to preregister for the program or they could think about it and contact the instructor later, within a specified deadline. Writing the title and dates of each of the eight sessions on the flyers was a key point for many participants in deciding to enroll in the program, with many commenting, “This program is written for me.”One month before the program began, all potential participants were individually interviewed and invited to set private goals for the particular aspects of themselves they wanted to be more aware of. These personal goals often give clues about how the participants perceive themselves. During the interview, some informal questions were asked regarding health, aches and pains, and important psychosocial events that the participant might have encountered. The French versions of the following assessment instruments were administered: the Geriatric Depression Scale . On average, participants attended 12.6 of the 15 meetings. The percentage of participants who dropped out was low , and 10 % of enrolled participants had to postpone their training for personal reasons to the next time the MBCAS program was run. Periodically, we monitored the frequency and duration of home practice through a random poll. We found that, on average, participants practiced for about 27 min every 1 to 2 days. This is a level of practice that is slightly higher than the usual 15 to 20 min reported in the literature . Most also reported an improved quality of life and also specific personal outcomes such as joy and satisfaction during the 8 months, traversing periods of low motivation without giving up, feeling of release at the realization that thoughts are just thoughts, better insight into one's automatic pilot, enhanced linking to the present moment, self-dignity, better connection to self, and better acceptance of the process . Some also reported that, during the training period, they acquired new behaviors that they considered to be efficient. These included, “I recover faster from emotional events,” “When I lock the door, I no longer need to check it again,” “I try to do less, but try to complete what I start,” and “I have discovered a way of exploring who I am and I am eager to continue this exploration.”If a participant is reasonably healthy, there is virtually no age limit to developing mindfulness and to finding the energy to mobilize one's inner resources. The MBCAS program provides a context for developing mindfulness in seniors. As there is no clinical motivation to engage in such a program in an intensive way, it provides a low intensity and relaxed approach to developing mindfulness over an 8-month period. One possible obstacle to this program duration could be that the long intersession intervals might be uncomfortable for instructors who are used to providing this type of training in a medical or psychosocial context over 8 weeks. Nevertheless, it might challenge their ability to let go of the process and to truly rely upon the resources that healthy participants are proud to discover and activate. In our experience, the longer time facilitates the emergence of the true nature of each participant.The 8-month program appears to be well adapted to healthy seniors who wish to invest in a mindfulness-based approach to life. The temporal aspects of the design are realistic and comfortable, allowing participation in the mindfulness program to go beyond learning tricks to feel better. Many of the aged participants in the MBCAS program had previously tried several things, had attended various self-development seminars, engaged in one or more psychotherapies, and had read numerous self-help books. With MBCAS, most participants expressed appreciation for having time to truly learn and practice different ways of being rather than doing. They had spent a lifetime in the doing mode, and they relished learning how to connect with the present moment , to acknowledge things as they are , and acquiring a sense of openness to life .Many participants experienced “off” periods, during which it was difficult to practice, and “on” periods when it was easier. They had time to test, try and apply the recommended exercises, give up, try again, find their own rhythm, lose, and once more find the link to their breathing. This was an important point to learn. When the program was over, participants were not surprised if they encountered variations in their motivation or obstacles that momentarily prevented them from maintaining their practice. Through the 8-month program, they appreciated having time to think in detail about mindfulness practice and having opportunities to share these experiences within the group. For the participants, the choice to engage in the MBCAS program and do the daily exercises was an important decision as it had to be maintained over 8 months. In itself, this process built self-esteem.Much socialization took place during the 8-month program. Some developed strong relationships with other participants in the course of the training. Others did not build special relationships but really enjoyed the group activity in sessions spaced over time, without feeling stressed by an obligation to be close to others. Almost all participants reconsidered their relationship to solitude by letting their negative representations of solitude dissolve.Our preliminary quantitative and qualitative data suggest that the MBCAS program may be successful in enabling seniors to activate more constructive and creative responses to the challenges and difficulties in their daily life and to travel on a path of acceptance of the ups and downs of life itself. They appear to be able to observe and respond to what is going on in their lives in a more mindful manner instead of automatically reacting to it. Research studies of MBCAS should focus on evaluating the effectiveness of the program across a broad spectrum of variables that include life satisfaction, role functioning, and self-rated emotional and physical health.While mindfulness meditation is essentially an experiential and individual practice, verbal communication within the group is an essential component of the MBCAS program because it assists the participants to make sense of these experiences by intertwining the consciousness of one's inner world with the shared outer world. For example, during a breathing exercise each participant may hear a specific song in a particular way and later, through language, share the experience. However, linguists have shown that language is not transparent and, with aging, communication may be physically impaired due to a number of auditory and visual changes (Zellner Keller Group discussions offered a number of opportunities to clarify this instability and opacity in verbal communication. Time and tools may also have contributed to this learning. The seniors often complained about how hard home writing tasks were. Some even felt bad about having difficulties in writing due to bad school memories or feelings of incompetence. It took time to learn how to put inner experiences in words. The 8-month program favored this particular kind of language acquisition, developing patience and perseverance. Discussions around the flipchart contributed to the sharing of experiences and drawings were often helpful. For example, the use of smiley faces was very useful in the naming of different moods. Finally, suggested readings and booklets were helpful to anchor this ongoing learning process at home.Seniors in the MBCAS program are generally older than the instructors. The ways in which the seniors connect to past events reflect how they navigate back and forth through their life course. For example, our MBCAS participants were mostly retired, their children were adults, and the parents had an empty nest, and they often believed that their affective relationships had been largely explored. Former obstacles could still be very vivid, while others might have been almost forgotten. Sometimes the core of all these difficulties was roughly the same: a similar problem had been faced many times, at different ages, in different situations. For example, a number of participants reported that they had been marginally depressed most of their adult life. Sometimes, their problems required different resources as they had been exposed to largely different experiences. In other words, each participant arrived with an extensive portfolio of memories, stored strategies, and failures. These materials could resurface during the exercises and the discussions in the MBCAS program, revealing that the relationships with these memories could still be emotionally raw. Learning how to relate to these raw memories in a nonjudgmental manner helped them to achieve equanimity in life.Indeed, some participants may have felt overwhelmed or troubled by their mental activity, ruminating, and feeling stuck in old memories. The proposed "exit" from this entanglement was the voice of their body: the physical sensations were the interface to inner experiences. In MBCAS, the participants were invited to cultivate a deep-rooted consciousness of those bodily responses.The core of any mindfulness approach is to train participants to concentrate and listen to their bodily sensations, for physical sensations only occur in the present moment. For seniors, this training is assumed to permit a “rereading of one's past with new glasses,” where the past becomes an interesting and constructive living resource. The past is always explored in the present moment, and any projection of the present on memories is understood as not being “the past.” Thus, exploring past events from the present sensations is expected to stimulate the cognitive training of the disidentification process—the capacity to observe oneself without judgment.Compared to other mindfulness-based programs, the specifics of MBCAS are mainly qualitative adaptations for seniors. Aging can bring about many disturbances in one's life, and the MBCAS is designed to assist seniors in navigating life in a more fluent manner. The art of fluency consists of making things go smoothly, in an easy and effortless manner Zellner . PracticIn summary, the MBCAS appears to be a promising program in the areas of mood, acceptance and adaptation to aging, with a more compassionate attitude toward one's body. Engaging seniors in a mindfulness-based approach to life is a realistic objective. Moreover, reasonably healthy seniors are well suited to embark on an 8-month training program. Studies on the short- and long-term effects of MBCAS for reducing the risk of mental and physical aging diseases should be the next step in the development of this program.


There is sparse literature on whether training in endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) improves the diagnostic yield of conventional TBNA (cTBNA).The aim of this study was to evaluate the diagnostic yield of cTBNA before and after the introduction of EBUS.This was a retrospective analysis of patients who underwent cTBNA at our center. The study was divided into two periods, before and after the introduction of EBUS at our facility. The diagnostic yield of cTBNA was compared between the study periods. Rapid on-site cytological examination was not available.A total of 1,050 patients  underwent cTBNA during the study period . Sarcoidosis (n = 527) followed by bronchogenic carcinoma (n = 222) formed the most common indications for performing cTBNA. There was a significant increase in both the success of obtaining a representative sample (from 71% to 85%), and the diagnostic yield (from 33% to 49.5%) of cTBNA, after the introduction of EBUS. The increase in the diagnostic yield of cTBNA after introduction of EBUS remained significant even after adjusting for years of performing cTBNA and the type of anesthesia  on a multivariate analysis.The diagnostic yield of cTBNA at our facility increased after the introduction of EBUS-TBNA. However, given the retrospective nature of the study, prospective studies are required to confirm our findings. Conventional transbronchial needle aspiration (cTBNA) is a bronchoscopic procedure that samples accessible hilar and mediastinal lymph nodes with the help of bronchial anatomic landmarks, guided by computed tomography (CT). With theRecent evidence suggests that the diagnostic yield (and thus the training) of cTBNA may improve after acquisition of knowledge gained by performing EBUS-TBNA. Herein, st January 2006 and 1st April 2015, in the bronchoscopy suite of this Institute. We retrieved the following information from the bronchoscopy database: details of clinical evaluation, tuberculin skin test (TST), findings on chest radiograph and CT of the chest, cytology findings of the aspirate, and the final diagnosis. The study protocol was approved by the Institute Ethics Committee , and a consent waiver was given as this was use of anonymized retrospective patient data. However, a procedural consent was obtained from all patients. A part of this data has been published previously.[This was a retrospective analysis of consecutive adult (≥18 years) subjects who underwent cTBNA between 1eviously.–14cTBNA is being performed at our facility since 2006 while EBUS-TBNA was started in June 2011., 15 cTBNA flexible bronchoscope  was used to perform cTBNA, as described previously. Smears wAn experienced cytopathologist examined all the smears for adequacy of the samples and the definite diagnosis. TBNA samples were categorized as: (a) diagnostic: if cTBNA enabled a final diagnosis of tuberculosis, sarcoidosis, malignancy, lymphoma and other diagnosis; (b) representative: either by a diagnostic sample or by a preponderance of benign lymphocytes.Mycobacterium tuberculosis; and, (b) clinicoradiological response to anti-tuberculosis treatment.Cytologic samples containing malignant cells were considered diagnostic of malignancy. A final diagnosis of sarcoidosis was made on the presence of all the following criteria: (a) consistent clinical and radiological presentation; (b) demonstration of non-necrotizing granulomas on c-TBNA along with negative acid-fast bacilli and fungal stains; and no growth of mycobacteria on MGIT; and, (c) clinical and radiological response after treatment with glucocorticoids. A diagnosis of tuberculosis was based on the demonstration of all the following: (a) necrotizing granulomatous inflammation or presence of acid-fast bacilli (AFB) on microscopy or a positive culture for The study was divided into two periods: period I (before the introduction of EBUS) and period II (after the introduction of EBUS). The first 100 subjects who underwent c-TBNA after initiation of the EBUS facility were included in period I as these procedures were conducted in a period considered to be the learning curve of EBUS training. The yield of cTBNA technique was analyzed during the two periods with regards to representative sampling of lymph node and the diagnostic yield. We however, also reanalyzed the data by including the initial 100 cases done after introduction of EBUS period (‘learning curve’ cases) in period II.www.statsdirect.com). Data were expressed as mean ± standard deviation (SD), or number with percentage. Differences between continuous variables in the two groups were compared using Mann-Whitney U test while differences between categorical data were compared using the chi-square test or Fisher’s exact test. A multivariate logistic regression analysis was performed to study the effects of EBUS training, cTBNA experience and the type of anaesthesia on the diagnostic yield of cTBNA. A p value <0.05 was considered statistically significant.Statistical analysis was performed using the commercial statistical package StatsDirect  subjects while EBUS was done in 14.7%  of the subjects. There were 647 (61.6%) men with a mean (SD) age of 45.6 (11) years . Of the During period I, 849 patients underwent cTBNA while in period II, 201 patients underwent cTBNA. Presumed sarcoidosis as an indication for performing cTBNA increased from 47.6% to 61.2% from period I to period II. Diagnosis and staging of bronchogenic carcinoma and other conditions as indications showed a decreasing trend from 22.9% to 13.9% and 9.9% to 0.9%, respectively as an indication for performing cTBNA. The size of the lymph nodes (both station 4R and 7) and the time needed to perform the procedure were similar between the study periods. However, the median number of passes at station 4R was significantly higher in period I in comparison to period II.Of the total number of bronchoscopic procedures, the proportion of cTBNA performed reduced from 12.1% (849/7039) in period I to 4% (201/5005) in period II. The information on the yield of cTBNA yield was available in 1,048 patients . In two patients, the details of cytological examination were not available and hence they were excluded from the analysis for diagnostic yield. There was a significant increase in the diagnostic yield of cTBNA after the introduction of EBUS (p<0.0001), increasing from 33% to 49.5% . There wThe results of this study suggest that the diagnostic yield of cTBNA at our facility increased from 33% to 49.5% after the introduction of EBUS. The increase in diagnostic yield remained significant even after adjusting for the years of performing cTBNA and the type of anaesthesia  during bronchoscopy. The cTBNA procedure as a proportion of the total bronchoscopic procedures declined from 12% to 4%, after the introduction of EBUS-TBNA. This was also seen in another study where the number of cTBNA procedures declined by almost half from 11.75 cTBNA per month in pre-EBUS era to 6.03 cTBNA per month in the post-EBUS era.Although cTBNA is an easy and safe procedure to sample the mediastinal lymph nodes, it is underutilized due to the wide variations in the reported success rate and the unfounded fear of causing trauma to major blood vessels., 5 The cWhat are the clinical implications of this study? The results of this study suggest that cTBNA remains a useful technique in the diagnosis of mediastinal adenopathy with almost a 50% yield despite multiple operators with varying experience performing the procedure. This is especially important for the developing world, where EBUS-TBNA is not easily available due to constraints of cost while cTBNA can be readily introduced with no added costs. The results of the study do not imply that operators without EBUS misunderstand the mediastinal anatomy and are not correctly aspirating a lymph node station. Rather, the fellows undergoing training perform cTBNA procedures better, due to superior understanding of the mediastinal anatomy after watching and training on EBUS. Thus, if academic institutes acquire EBUS and train their fellows in both the TBNA techniques, it is likely that the yield of cTBNA would increase after performing EBUS-TBNA.Finally, the study has a few limitations. This is a retrospective time-series analysis, a study design fraught with confounders and bias. The increase in the diagnostic yield could also be due to several factors other than the introduction of EBUS. We implemented a strict cTBNA procedure protocol that was not in place prior to EBUS. Also, we meticulously observed and recorded the data of lymph node location and size for all patients undergoing TBNA , after the introduction of EBUS.–21 The iIn conclusion, introduction of EBUS-TBNA procedure at a bronchoscopy facility enhances the diagnostic yield of c-TBNA in patients with mediastinal lymphadenopathy. However, due to the retrospective nature of our study, prospective studies are required to confirm our study findings.