Shared decision-making is not widely implemented in healthcare. We aimed to set a research agenda about promoting shared decision-making through continuing professional development.Thirty-six participants met for two days.Participants suggested ways to improve an environmental scan that had inventoried 53 shared decision-making training programs from 14 countries. Their proposed research agenda included reaching an international consensus on shared decision-making competencies and creating a framework for accrediting continuing professional development initiatives in shared decision-making.Variability in shared decision-making training programs showcases the need for quality assurance frameworks. Shared decision-making (SDM) is an interactive process during which patients and practitioners collaborate in choosing healthcare. SDM is the crux of patient-centered care . SDM is Continuing professional development (CPD) is an important means by which health professionals keep abreast of the latest advances in healthcare . Given tAs planned in our protocol , we orgaThe workshop had two main components  of the United Kingdom's recent stipulation that SDM would become the norm--the "No decision about me without me" campaign . The NHSe.g., Switzerland).Representatives of Canada, Germany, Switzerland, and the United States explained particularities regarding SDM in their healthcare systems. In the United Kingdom, for example, physicians deliver care based on evidence of effectiveness, including cost effectiveness, while in Switzerland, the pharmaceutical industry wields substantial influence at all levels. Some representatives spoke of barriers to the practice of SDM: In the United States, implementing SDM is made more difficult by the fact that healthcare is delivered by independent groups. Participants also reported on the implementation of decision aids, on prevention and health-promotion measures, and on current research initiatives for developing and implementing SDM. Participants reported more training activities in SDM for health professionals since 2007 -36 and ti.e., set of activities), published or unpublished, in whatever language, that targeted SDM. Because our search strategy favored sensitivity over specificity, we considered all SDM training programs, including those in clinical settings other than primary care. We also included stand-alone activities when the full program material was not available to us. Once we had identified the programs, reviewers extracted each program's main characteristics: the program name, the nature of the material available and extracted, author contact information, the creation or publication date, the country of origin, and the languages in which the program was available. We also extracted information about the programs' educational features: their conceptual underpinnings; the rationale for developing the program; the sources that informed the program; the healthcare professionals targeted; the clinical context; the program's objectives and duration; its components and activities ; essential elements of SDM covered by the program [i.e., participants' reaction, their degree of learning, changes in their behavior, and changes in patient outcomes) [Our aim for the meeting was to present the preliminary results of the scan and to explore how to improve and complete this part of our protocol . Briefly program ; and infutcomes) .e.g., a PowerPoint presentation, a class syllabus, trainer and trainee manuals, a DVD, an auto-tutorial), which made it difficult to compare programs, since the information contained in a PowerPoint presentation, for example, is not as extensive as that contained in a trainer's manual. We specified to workshop participants that each program had only been extracted by one person and that we had not assessed the programs' quality but that we intended to use workshop participants' feedback to improve the scanning process after the workshop. We also mentioned that in future work of this genre, we intended to solicit the feedback of patient representatives as well as that of academics and managers.At the group meeting, the team explained the data-extraction process and presented its findings: detailed information about 53 programs from 14 countries, published in 9 languages. Because six programs were identified late, the team only extracted the data from 47 programs. Of these, 34 programs targeted licensed health professionals and were retained as CPD programs. The clients of those programs were mostly physicians (n = 34) and/or nurses (n = 13). Most programs mentioned primary care (n = 37). There was considerable heterogeneity in the programs' duration (three hours or less to more than three days) and in their teaching methods, which included large group sessions (n = 32), small group sessions (n = 25), auto-tutorials (n = 15), the dissemination of printed educational material (n = 16), audit and feedback (n = 13), case discussions (n = 26), simulations (n = 23), and self-evaluations (n = 12). More programs took place in cancer (n = 7) than in any other clinical area, but cardiovascular diseases, diabetes, chronic pain, prenatal screening, and other areas were represented as well. Most programs covered the nine essential elements of SDM identified in the integrated SDM model developed by Makoul and Clayman (2006). We also discussed an important limitation of our scan; namely, that we included SDM training programs and stand-alone activities independent of the formats in which they were available to us . This meant that we extracted data from diverse formats . They found that the SDM-CPD programs identified in the scan showed great variety and suggested pursuing the search for programs or performing a systematic review instead of an environmental scan. They also suggested extracting more information about the programs, such as the type of conceptual model used ; stating whether the program hailed from a unit devoted to SDM or patient participation or a similar topic, or whether it came under the umbrella of a more generic CPD institution; and specifying the types of learning activities practiced  and each program's core objectives. They also asked that the programs be appraised in light of accreditation standards and suggested asking the program developers to validate the data extracted from their program (member checking). They suggested performing subgroup analysis  or focusing solely on postlicensure programs .We held two small group discussions. For each one, we divided the participants into four groups of eight people from diverse backgrounds. In each group, one person took detailed notes and a second reported back during the plenary sessions. Additional File With regard to the research agenda, citing the International Patient Decision Aid Standards research group -41, partAt the end of the workshop, we collected 18 evaluation sheets. The mean scores for the 10 items  ranged from 4.3  to 4.8 (for "Were the discussion sessions useful?" and "Did the speakers and moderator encourage the audience's involvement?"). Participants also identified weaknesses, proposed improvements, and suggested next steps  explore the feasibility and acceptability of participants' suggestion to establish an international consensus on core SDM competencies for SDM-CPD programs, (b) seek consensus on ways to evaluate CPD interventions, (c) create an evaluation framework based on accreditation standards, and (d) construct a grid or checklist for accrediting SDM-CPD programs based on the framework mentioned. Finally, we will consider applying for grants to develop and pilot SDM-CPD programs across healthcare professions and countries.The authors declare that they have no competing interests.All authors have made substantial contributions to the conception and design of this study and to the acquisition of data for the environmental scan. All authors attended the workshop. FL and RD drafted the manuscript. All authors revised it critically for important intellectual content and all approved the final version submitted.Appendix 1. Workshop AgendaClick here for fileAppendix 2. List of Speakers and ParticipantsClick here for fileAppendix 3. Questions and Answers for the Small Group DiscussionsClick here for fileAppendix 4. Workshop EvaluationClick here for file


PRAME gene transcription in leukaemic cell lines is rapidly induced by exposure of cells to bacterial PAMPs (pathogen associated molecular patterns) in combination with type 2 interferon (IFNγ). Treatment of HL60 cells with lipopolysaccharide or peptidoglycan in combination with IFNγ resulted in a rapid and transient induction of PRAME transcription, and increased association of PRAME transcripts with polysomes. Moreover, treatment with PAMPs/IFNγ also modulated the subcellular localisation of PRAME proteins in HL60 and U937 cells, resulting in targeting of cytoplasmic PRAME to the Golgi. Affinity purification studies revealed that PRAME associates with Elongin B and Elongin C, components of Cullin E3 ubiquitin ligase complexes. This occurs via direct interaction of PRAME with Elongin C, and PRAME colocalises with Elongins in the Golgi after PAMP/IFNγ treatment. PRAME was also found to co-immunoprecipitate core histones, consistent with its partial localisation to the nucleus, and was found to bind directly to histone H3 in vitro. Thus, PRAME is upregulated by signalling pathways that are activated in response to infection/inflammation, and its product may have dual functions as a histone-binding protein, and in directing ubiquitylation of target proteins for processing in the Golgi.Preferentially expressed antigen in melanoma (PRAME) has been described as a cancer-testis antigen and is associated with leukaemias and solid tumours. Here we show that  PRAME gene shows low level expression in other normal tissues including endometrium, ovary and placenta PRAME in normal tissues and its overexpression in tumours renders it a useful marker of minimal residual disease after chemotherapy, and an attractive target for immunotherapy, particularly in acute myeloid leukaemia (AML) and chronic myeloid leukaemia (CML) PRAME-negative leukaemias the gene can be induced by demethylating agents PRAME expression.PRAME/MAPE/OIP4 is an atypical cancer-testis antigen whose expression is associated with leukaemias and a large proportion of solid tumours  protein sharing structural similarity with Toll-like receptors PRAME and other cancer testis antigen genes is suggestive of roles in chemosensing, reproduction or immunity PRAME multigene family in humans NALP) gene family PRAME might be regulated by signalling pathways activated in proinflammatory responses. We therefore set out to investigate whether PRAME expression is modulated by signalling molecules such as IFNγ or microbial PAMPs. We also endeavoured to isolate PRAME-interacting proteins, to provide further insight into its cellular functions.PRAME expression in leukaemic cells such as HL60 might be modulated by exposure to lipopolysaccharide (LPS) and IFNγ, either as single inducing agents or in combination. HL60 leukaemic cells have low levels of PRAME transcripts PRAME (as determined by RT-qPCR – data not shown). However, as shown in PRAME transcript levels was observed within 1 hour of combined treatment with LPS and IFNγ. This increase was transient as PRAME levels were lower at 4 hours post-treatment, and restored to background levels within 24 hours, suggesting that turnover of PRAME mRNA may be relatively rapid. The induction of PRAME by LPS/IFNγ was inhibited by pre-treating cells with actinomycin D for one hour prior to addition of LPS/IFNγ  LPS/IFNγ , indicatPRAME transcripts, polysome gradients were prepared from extracts of HL60 cells treated or untreated with LPS and IFNγ. As shown in PRAME transcripts were substantially enriched in polysome fractions, as confirmed by densitometry (lower panels). In contrast, a control transcript (β-actin) showed little change. These results indicate that upregulation of PRAME gene expression by LPS/IFNγ in HL60 cells may be achieved not only through increased transcription, but also effects on translation of PRAME transcripts.To examine whether LPS/IFNγ results in increased translation of PRAME expression could be induced by other microbial PAMPs in addition to LPS. As shown in PRAME expression. In contrast, peptidoglycan (PGN) in combination with IFNγ substantially increased PRAME expression, similar to the LPS/IFNγ response. Induction of PRAME by PGN/IFNγ was also transient, with peak levels observed within 1 hour post-treatment  was used to allow for expression of PRAME proteins in the cells. As shown in trans Golgi network, and staining of HL60 cells with the 58K Golgi marker confirmed that these structures appear to be linked to the Golgi network and show considerable colocalisation with PRAME , but not ELB , its re-activation in tumours might facilitate their targeting by immunotherapeutics.In addition to the observed effects on cription , treatmeolysomes . This suEndogenous and overexpressed PRAME proteins were observed in both the nucleus and cytoplasmic compartments in different cancer cell lines . In addiDue to poor performance of available PRAME antibodies in detecting endogenous proteins by western blotting, we were unable to reliably detect an increase in intracellular levels of soluble PRAME in HL60 cells following IFN/LPS induction. It is possible that the detection of endogenous PRAME in cell-free extracts might also be hampered by its retention in the insoluble fraction of cell lysates, due to increased localisation to Golgi/ER macromolecular structures.et al. Using an affinity purification approach to explore the functions of PRAME through its molecular partners, we identified an interaction of PRAME with the Elongin/Cullin E3 ubiquitin ligase complex as confirmed in a range of binding assays and co-purification experiments . Co-immuElongins have both nuclear and cytoplasmic functions, having roles in protein ubiquitylation and gene transcription Our affinity purification experiment also identified a novel interaction of PRAME with core histones . Direct In conclusion, our study provides novel insights into the functions and regulation of PRAME, as summarised in 2 incubator. Cell cultures were split 24 hrs prior to treatment with 100U/ml interferon-gamma , 50 ng/ml Salmonella minnesota lipopolysaccharide , 5 μg/ml Bacillus subtilis peptidoglycan , 10 μg/ml muramyl dipeptide , 100 μg/ml zymosan A  or 10 μg/ml mannan . Actinomycin D  was applied to cells 1 hr prior to other treatments.HL60, U937, U2OS, MCF-7 and HEK293 cell lines were purchased from the European Collection of Cell Cultures (ECACC). HL60 and U937 leukaemic cell lines were maintained in RPMI-1640. HEK293, U2OS and MCF-7 cells were maintained in Dulbecco's modified Eagle medium. Culture medium was supplemented with 10% foetal bovine serum, 2 mM glutamine, 100units/ml penicillin and 100 µg/ml streptomycin and cells were maintained at 37°C in a 5% COTM mammalian transfection kit (Clontech).U2OS and HEK293 cells were seeded onto coverslips 16 hrs prior to transient transfection using CalPhosC.elegans CUL2, ELB, ELC, ELC mutant (L47D/L49D/Y88D/Y91D) and human ELC PRAME coding sequence was generated from pCMV-Sport6-PRAME (Geneservice) using the following primers: 5′-atggaacgaaggcgtttg-3′ and 5′-ctagttaggcatgaaacagggg-3′. The fragment was subcloned into SmaI digested pBSKSII, to generate pBSKSII-PRAME. pBSKSII-PRAME was digested with BamHI and XhoI and the insert fragment was subcloned into pGEX4T1, to generate GST-PRAME. This fragment was also subcloned into pBTM116mod and pASV3mod BamHI and XhoI sites in pcDNA3.1(+).PRAME-EGFP and PRAME-FLAG expression vectors 32P-labelled probes for full-length PRAME and actin. Activity was visualised using a Storm825 phosphorimager  and ImageQuantTL software .After cycloheximide treatment of HL60 cells and preparation of cell lysates TM total RNA kit I (Omega Bio-Tek). RNA was reverse transcribed using oligo(dT)12-18 and Superscript III (Invitrogen) according to the manufacturer's instructions. RTqPCR was performed using Brilliant II SYBR green qPCR mix (Stratagene) and primers: PRAME: 5′-tgctgatgaagggacaac at-3′ and 5′-cag cacttgaagtttccacct-3′; GAPDH: 5′-aggtgaaggtcggagtcaac-3′ and 5′-gatgacaagcttcccgttct-3′. PCR was conducted using Mx3005P real-time PCR system (Stratagene) with the following conditions: hot start activation at 95°C for 10 mins followed by 40 cycles of 95°C for 30 secs, 59°C for 1 min. PCR reactions were performed in triplicate for each sample. The threshold cycle number of PRAME was normalised to that of GAPDH. Fold increase was calculated using the comparative (ΔΔCt) method, as previously described RNA was extracted using EZNAProteins were resolved on standard SDS-PAGE gels and transferred to nitrocellulose membranes. Membranes were preblocked in 3% non-fat milk in PBS prior to addition of primary antibodies. For Western blotting, coimmunoprecipitations, and immunofluorescence, the following antibodies were used: anti-PRAME , anti-FLAG M2 , anti-Golgi 58K , anti-His , anti-ELB , anti-ELC , anti-CUL2 , anti-HA , anti-H2A , anti-H2B , anti-H3 , anti-H4 , anti-GST , anti-GFP (ab6556 Abcam WB 1∶500). The following horse radish peroxidise-linked secondary antibodies were used for Western blotting and co-immunoprecipitations at 1∶5000: chicken anti-mouse , donkey anti-goat , goat anti-rabbit . For immunofluorescence, the following secondary antibodies were used at 1∶500: alexa fluor chicken anti-mouse 488 (A21200), alexa fluor chicken anti-goat 594 (A21468) and alexa fluor chicken anti-rabbit 594 (A21442) Invitrogen. Y2H fusion proteins in yeast cell-free extracts were detected using anti-LexA  or anti-HA .Immunofluorescence staining and image capture was performed using a Leica LSM510 confocal microscope essentially as described previously E.coli Rosetta cells and selected on LB plates containing ampicillin. Single colonies were cultured to exponential phase in LB ampicillin broth at 37°C, and GST protein expression was induced by addition of, 0.5 mM isopropyl β-D-1-thiogalactopyranoside (Merck) for 16 hrs at 20°C. Bacterial pellets were resuspended in NTN , sonicated and then centrifuged at 15000rpm for 40 mins at 4°C. The supernatant was added to prewashed glutathione sepharose beads  that had been blocked with 0.5% milk and incubated for 16 hrs at 4°C with rotation. The beads were washed extensively in NTN buffer. Affinity capture was performed using 1 mg whole cell extract or 15 μg purified core histones (Sigma H9250). GST, GST-PRAME and other proteins bound to beads were resolved by SDS-PAGE and revealed by western blotting using the antibodies described above.Preparation of whole cell extracts of mammalian cells was performed by using freeze thaw cycles in cell lysis buffer with protease inhibitors as described previously After protein separation by SDS-PAGE, gels were fixed with 2 washes in 40% methanol/10% acetic acid, sensitized in 30% methanol, 0.2% sodium thiosulphate, 6.8% sodium acetate, impregnated with 0.25% silver nitrate and developed in 2.5% sodium carbonate, 0.15% formaldehyde, 0.003% sodium thiosulphate. The staining reaction was stopped in 1.46% EDTA.Bands of interest were excised and analysed by the Cambridge Centre for Proteomics. This involved overnight trypsin digestion of the proteins in the gel bands followed by reverse phase liquid-chromatography and then high mass accuracy mass spectrometry. For identification of proteins, the MS/MS fragmentation data were used to search the human National Centre Biological Information database using the MASCOT search engine. Probability-based Mowse scores were used for evaluating peptide identifications Yeast transformations, yeast two-hybrid reporter assays, yeast cell-free extract preparations for western blotting were performed essentially as described previously


Hadenoecus cumberlandicus Hubble & Norton (Orthoptera: Rhaphidophoridae), is vital to the cave community, making this cricket a true keystone species. Bioassays conducted on cave walls and in the laboratory show that clustering in H. cumberlandicus is guided by a pheromone, presumably excreta. This aggregation pheromone was demonstrated by using filter paper discs that had previous adult H. cumberlandicus exposure, resulting in > 70% response by either nymphs or adults, prompting attraction , followed by reduced mobility (arrestment) on treated surfaces. Adults were similarly responsive to pheromone from nymphs, agreeing with mixed stage composition of clusters in the cave. Effects of [0.001M – 0.1M] uric acid (insect excreta's principle component) on H. cumberlandicus behavior were inconsistent. This pheromone is not a host cue (kairomone) and is not used as a repellent  as noted through lack of responses to natural H. cumberlandicus pheromone and uric acid concentrations by a co-occurring predatory cave orb weaver spider, Meta ovalis Gertsch (Araneae: Tetragnathidae). This pheromone is not serving as a sex pheromone because nymphs were affected by it and because this population of H. cumberlandicus is parthenogenic. The conclusion of this study is that the biological value of the aggregation pheromone is to concentrate H. cumberlandicus in sheltered sites in the cave conducive for minimizing water stress. Rather than signaling H. cumberlandicus presence and quality, the reduced mobility expressed as a result of contacting this pheromone conceivably may act as a defense tactic (antipredator behavior) against M. ovalis, which shares this favored habitat site.Food input by the cave cricket,  Meta ovalis Gertsch (Araneae: Tetragnathidae), is frequently observed coinciding with the presence of large roosting aggregations of the cave cricket, Hadenoecus cumberlandicus Hubble & Norton (Orthoptera: Rhaphidophoridae). In addition, H. cumberlandicus and M. ovalis can be found out in the open, at wall/ceiling junctures. This cave cricket-spider cooccurrence is so regular, in fact, that the presence of one typically is used to indicate the presence of the other in survey work; the large, easily noticed M. ovalis, in particular, is especially useful in this regard as a landmark for pointing out large aggregations of H. cumberlandicus (mixed stages) that would otherwise be concealed in expanded ceiling fractures or joints overhead. This codistribution between H. cumberlandicus and M. ovalis is not only observed in many of the caves in northeastern Kentucky (Carter County), USA, but also throughout the majority of cave systems in North America where cave crickets (Hadenoecus spp.) and M. ovalis are found  to an array of springtails, beetles, flies, and millipedes that thrive below the Hadenoecus roost on the cave floor , supported by previous work on crickets . It is not uncommon for a predator to use excretory products of prey as a potential signal of healthy prey and their abundance  in Carter Cave State Resort Park  from August to October, 2003–2007. The study site was in a dry, phreatic, 280 m long passage that was situated above a lower active vadose stream level. Laurel Cave is a multi-entrance cave system developed in Mississippian limestone . This area is a horizontal, tubular paleo-trunk conduit ranging in height from 1–4 m that intersects the lower stream passage approximately 4.5 m above the stream and about 200 m northwest of a 1 m high × 4 m wide entrance . There aabundant .H. cumberlandicus exists in Laurel Cave  and were consistent with measurements recorded in this region of the cave as reported by Hill  and was diluted with HPLC grade acetone (Sigma); acetone also served as a control. All preparation and application of solutions were done using glass . Filter paper was No. 3 Whatman (www.whatman.com) with an internal diameter of 9 cm. These filter paper discs served as targets in the attraction bioassays. All materials were handled using gloves and forceps to avoid contact with human skin oils. Any labeling on the filter paper disc was done with a graphite pencil .Uric acid was purchased commercially  containing a filter paper disc for 48 h, modified from aggregation pheromone collection by Nagel and Cade (H. cumberlandicus (10 from adults and 10 from nymphs).Natural aggregation pheromone was collected by placing and Cade  and McFaand Cade . CollectTo prepare the filter paper discs of uric acid, each dilution, [0.1M], [0.01M] and [0.001M] uric acid, was tested separately and applied  at the center of the 9 cm filter paper disc and then allowed to air dry, making a spot application that did not exceed 3 cm in diameter. Three different sets of uric acid dilutions were prepared, and a fresh filter paper disc was used for each experiment. Control filter paper discs were those treated with 200 µl acetone, as well as untreated filter paper discs. Only one dilution of uric acid was tested at a time.www.amefird.com) on the walls of the cave (securing the ends of the thread with poster putty) and on the outside of a clear plexiglass chamber (described below) in the laboratory tests. Each 50 cm × 50 cm quadrant was subdivided into four quadrants and the filter paper disc was placed at the center of the point of intersection (25 cm from the sides of each quadrant). The filter paper discs were placed in the study arena such that they alternated between quadrants: control (quadrant 1), test (quadrant 2), control (quadrant 3), test (quadrant 4). Therefore, a test quadrant was in between two control quadrants.Experiments focused on a two-choice bioassay set up, providing a choice between two control filter paper discs (untreated or acetone) and two test filter paper discs  in a statistically valid four-quadrant block design  with the filter paper discs secured on the floor of the chamber that was then inverted so that the crickets were in an upside down position like they are in the cave; discs were at least 15 cm away from the walls of the chamber. Counts of H. cumberlandicus in the various quadrants  were made at 1 h and again at 6 h in both cave and laboratory settings. Filter paper discs were secured using nontoxic, unscented poster putty .H. cumberlandicus each; thus 10 H. cumberlandicus per replicate, n = 4. In the experiments where M. ovalis was used, total sample size was 15 for each observation; thus, 3 M. ovalis per replicate, n = 5. Data were expressed as percentage of H. cumberlandicus or M. ovalis that were counted in the test quadrants. Untreated filter paper discs were used for comparison and to rule out potential directional left/right bias. Percentage data were arcsin transformed and analyzed using chi-square (χ2) statistics using 50% (20 H. cumberlandicus) or 47%  as the expected (E) value, a = 0.05, d.f. = 1  and 78%) (31/40 H. cumberlandicus), respectively . Similar results were observed if adults were introduced to filter paper discs that had been exposed to nymphs and nymphs responded similarly to discs that had been exposed to adults, yielding high percentage attraction values ranging from 73% (29/40) - 83% (33/40). In all cases, H. cumberlandicus crawled directly to odor sources and stayed there. There was little movement between quadrants during the 6 h test period; in most cases, H. cumberlandicus made direct contact with the filter paper disc, with other individuals clustering around. The results to discs treated with uric acid produced significant attraction at [0.1M] uric acid at 1 h, but this was not significant at 6 h; and there was a significant response after 6 h at [0.001M] uric acid that was not significant at 1 h. Response to [0.01M] uric acid did not produce any significant stimulatory effect  to filter paper discs treated with uric acid. Filter paper discs that had been exposed to female adults were detected by nymphs, and filter paper discs that had been exposed to nymphs were attractive to female adults, with 78% (31/40) and 73% (29/40) attraction and arrestment, respectively, after 6 h . There seemed to be stronger recruitment at 6 h than at 1 h in the cave with the natural H. cumberlandicus aggregation pheromone  and 88% of heromone . In bothM. ovalis in control quadrants (untreated and acetoneonly) was similar to values for M. ovalis that were counted in quadrants containing test attractants  averaged 31% at 1 h and 47% at 6 h, and this was similar to control resultsH. ventured into the test quadrant. There was no dose effect to increasing uric acid concentration, and the number of ractants . Percent.In laboratory bioassays, filter paper discs that had been defecated upon by female adult H. cumberlandicus-contacted filter paper discs elicited no significant attraction activity to M. ovalis at 1 h or at 6 h . Uric acid-treated discs produced significant attraction by M. ovalis at [0.1M] uric acid at 1 h and at [0.001M] uric acid at 6 h, and repellency at [0.001M] uric acid at 6 h  on treated areas, leading to collections of numerous individuals, occasionally in direct contact with each other . The response is not stage-specific, because nymphs react to excreta from female adults and female adults react to excreta from nymphs, which rules out classification of this chemical cue as a sex pheromone . Although speculative, the apparent derivation of aggregation pheromone from feces agrees with the abdominal origin of aggregation pheromone in the house cricket, Acheta domesticus , based upon related studies, it is conceivable that the active components are phenolic-based or organic acids derived from resident gut bacteria  to M. ovalis; therefore, H. cumberlandicus excreta (i.e. guano accumulation) apparently fails to be detected by M. ovalis as a signal of H. cumberlandicus prey quality , presence, or abundance. There is also no evidence that H. cumberlandicus aggregation pheromone contains any kind of repellent to M. ovalis, because no blatant avoidance behavior was displayed by M. ovalis when introduced to the H. cumberlandicus aggregation pheromone. Often when spiders are predators, the spider's excreta is detected and modifies the behavior of potential prey by stillness and reduced movements to go undetected, as though proceeding cautiously, described as a novel form of antipredator behavior . In the present study, however, nymphs and female adults of H. cumberlandicus were shown to exhibit reduced activity (arrestment-retaining effect of aggregation pheromone) in response to their own excreta, thus it seems reasonable to suggest that the H. cumberlandicus aggregation pheromone similarly adds a useful defense function against predation by M. ovalis residing close to the H. cumberlandicus roost.Cave orb weaver spiders, behavior ; prey  rates of individuals are greatly suppressed by nearly two-fold, leading to a group effect that facilitates water conservation  habitat site selection within the cave, satisfying an absolute moisturerequirement, presumably with access to outside food; (2) regulation of water balance via a resultant group effect; and, (3) perhaps defense against the predatory M. ovalis by antipredator behavior featuring reduced movement.Cave crickets and cave spiders are characterized by losing water rapidly and drying out quickly , and, aservation . Taken t


Existing infection control(IC) programs in hospitals are not effective due to lack of coordinated educational modules for stake holders in health care environment. We highlight our experience on a new knowledge management program which aims to educate and update information regarding IC practices to all Health Care Practitioners (HCP).A working core group was formed comprising of Heads of all clinical departments and Microbiology. Three members of the core group initiated a program at departmental level to identify their needs & issues, and to find out areas of constraints & possible remedial measures. The self generated team (BLUE BOARD) interacted through electronic media. A common platform was created so that different units could revise existing policies considering guidelines & feasibility of implementing the revised ones. Achievements were assessed by indicators viz., infection rate and antimicrobial usage. Data was analysed by simple descriptive statistics.They met at regular intervals & utilized learning materials, guidelines & other scientific data from authorized resources. They contributed to revise the program based on feedback from members. This continuous on-going education cum training programme blended with computer technology, interactive discussions & role plays brought down infection rates (25%) and reduction in the use of antimicrobials (17%).“Blue Board” has streamlined IC practices, improved the attitude of HCPs. Based on the confidence gained, BLUE BOARD system extended their services to other hospitals within the locality, disseminated knowledge gained and maintained uniformity in IC practices.None declared.


Since the development of endobronchial ultrasound-guided real-time needle aspiration (EBUS-rt-TBNA) no false positive (FP) cases have been described. We present the first FP case for EBUS-rt-TBNA secondary to a carcinoma in situ (CIS) in the bronchial point of puncture. A 66-years-old male was referred to our Institution because of a mass in left lower lobe. The bronchoscopy did not show any endobronchial lesion. The cytology of the washing confirmed an unspecified non-small cell lung cancer. An EBUS-rt-TBNA for staging was carried out. No mediastinal nodes over 5 mm length were found but one single left hilar node at station 11 L was sampled. The cytology of the TBNA showed lymphocytes and neoplastic squamous cells. The patient underwent thoracotomy. On the surgical specimen no metastasis on any of the nodes resected were detected but a CIS on the bronchial resection margin was described. A bronchial biopsy confirmed CIS on the bronchial stump. The reported case depicts an unusual situation, we consider EBUS-rt-TBNA an accurate technique if minimal requirements are met Endobronchial ultrasound-guided real-time transbronchial needle aspiration (EBUS-rt-TBNA) is a relatively novel technique that has proven useful in lung cancer diagnosis and staging. EBUS-rt-TBNA can be performed under conscious sedation in an outpatient setting. Several studies have demonstrated that EBUS-rt-TBNA is an accurate procedure alternative to surgical staging, with fewer complications and similar figures for sensitivity and specificity. While an average false-negative rate of 10 % represents a handicap for this procedure, no false-positive (FP) cases have been described. We present the first FP case of EBUS-rt-TBNA.A 66-year-old male, with a 40 pack-year smoking history, consulted his general practitioner because of persistent cough lasting for 3 months. A chest x-ray was performed and a mass on left lower lobe (LLL) was detected. The patient was then referred to our Institution. The thoracic CT-scan confirmed the presence of a peripheral mass on LLL (4x3 cm), without evidence of nodal enlargement Figure . A whiteSince the development of transbronchial needle aspiration (TBNA) for flexible bronchoscopy for lung cancer staging in the eighties, false-positives (FP) have been rarely reported. A case is considered as FP when tumor cells are identified on transbronchial lymph node aspiration but tumor metastases are not found in nodes obtained by thoracotomy or mediastinoscopy. Probably the exceptionality of FP in TBNA sampling is an accurate estimation but not all the studies confirmed positive TBNA results with further invasive procedures. When the technique was first described  it was rCropp  and colsWith the emergence of echo-probes for radial EBUS the accuracy of TBNA procedures increased and only one case of FP was registered in a series of Okamoto et al.  Since thEBUS allows real time guidance of the puncture avoiding incidental sampling of masses. The needle used for EBUS-rt-TBNA incorporates a stylet in the inner channel that prevents contamination. The only potential scenario for FP results of EBUS-rt-TBNA is the use of a single needle to sample more than one node after a positive result.To our knowledge, the present case is the first FP documented for EBUS-rt-TBNA and is the first attributed to needle contamination by neoplastic cells from a bronchial CIS on the puncture point. As a mechanism similar to that suggested by Cropp and cols, probably malignant squamous cells from the CIS were introduced during the puncture and then aspirated. During the procedure the syringe suction was always attached and released just when the needle was inside the lymph node. Consequently, we do not consider incidental suction of the bronchial wall as a possible explanation for this case. Fortunately, in our patient the FP had no consequences on the staging that could change the choice of treatment. CIS are frequent in smoking patients with lung neoplasm, may be multicentric and difficult to identify with white light bronchoscopy .The present case represents a fortuitous coincidence that might be considered when obtained results are contradictory in patients with squamous lung carcinoma. EBUS-rt-TBNA is a highly specific technique with a very low risk of contamination if minimal requirements are met.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.The authors claim no conflict of interest to declare.JS-S: performed EBUS and wrote the manuscript. FA: performed EBUS. PS: performed autofluorescence bronchoscopy and attended the patient. ML: performed pathological examination. EC: performed pathological examination. JA: perfomed surgery on the patient. EM: performed EBUS and revised the manuscript. JR-M: revised the manuscript. All authors read and approved the final manuscript.This paper has been published with funds from a grant from the Spanish Government (FIS 09/01612).


DHAV-1 FJ1220 has high homology of up to 99.6% to the DHAV-1 strain Du/CH/LGD/111238 but relatively low homology to strains FFZ05 and FZ05. An amino acid hypervariable region in the VP1 protein of FJ1220 has the motif  Avihepatovirus, of the family Picornaviridae, and designated duck hepatitis A virus 1 (DHAV-1). Two viruses associated by genotype and serotype with DHAV-1, now designated DHAV-2 and DHAV-3, have been identified separately in Taiwan and South Korea (Astroviridae and designated duck astrovirus type I (DAstV-I) and DAstV-II, respectively (Duck hepatitis (DH) is a highly fatal contagious infection in ducklings, characterized primarily by liver necrosis and hemorrhage, and it is caused mainly by three known types of duck hepatitis virus  . Then the amplified products were purified and cloned into pMD18-T vectors  and sequenced with an ABI 3730 XL DNA analyzer. Sequences were assembled and analyzed by Lasergene v7.0 .The full genomic length of DHAV-1 FJ1220 is 7,691 nucleotides (nt), excluding a 17-nt poly(A) tail at the 3′ end. A single large open reading frame (ORF), which is flanked by a 627-nt 5′ untranslated region (UTR) and a 315-nt 3′ UTR, is 6,750 nt in size. The single large ORF, which initiates from the optimal Kozak context at nt 626, encodes a putative polyprotein precursor of 2,249 amino acids. A total of 11 cleavage sites have been found in the polyprotein, contributing to generate 12 proteins  by the cleavage process. The 2A protein comprises three unrelated proteins, 2A1, 2A2, and 2A3. Among them, 2A1 has an NPG↓P cleavage site signal, 2A2 is an AIG1-like protein containing a GXXGXGKS nucleoside triphosphate (NTP)-binding motif, and 2A3, similar to the 2A proteins of parechoviruses, kobuviruses, and tremoviruses, has a special H-NC box.180TPSGR184 motif of FFZ05 and FZ05 has been replaced by 180ALSRG184 in FJ1220. The genome data for strain FJ1220, isolated from a dead pigeon in eastern China and reported in our study, will be helpful for understanding the epidemiology and evolution of DHAV-1.Comparative genomic analysis showed that FJ1220 has high nucleotide similarity (99.6%) to DHAV-1 strain Du/CH/LGD/111238, which was collected in 2011. However, relatively low nucleotide homology (93.5%) occurs between FJ1220 and two strains, FFZ05 and FZ05, collected in the same place as FJ1220 in 2005. Amino acid sequence analysis revealed that a hypervariable region of DHAV-1 is located at amino acids (aa) 180 to 219 in capsid protein VP1, confirming the findings by Xu et al. . In the KC904272.The complete genome sequence of the DHAV-1 strain FJ1220 has been deposited in GenBank under the accession no.


Sichuan is a province in China with an extensive history of earthquakes. Recent earthquakes, including the Lushan earthquake in 2013, have resulted in thousands of people losing their homes and their families. However, there is a research gap on the efficiency of government support policies. Therefore, this study develops a new perspective to study the health of earthquake survivors, based on the effect of post-earthquake rescue policies on health-related quality of life (HRQOL) of survivors of the Sichuan earthquake.This study uses data from a survey conducted in five hard-hit counties  in Sichuan in 2013. A total of 2,000 questionnaires were distributed, and 1,672 were returned; the response rate was 83.6%.Results of the rescue policies scale and Medical Outcomes Study Short Form 36 (SF-36) scale passed the reliability test. The confirmatory factor analysis model showed that the physical component summary (PCS) directly affected the mental component summary (MCS). The results of structural equation model regarding the effects of rescue policies on HRQOL showed that the path coefficients of six policies  to the PCS of survivors were all positive and passed the test of significance. Finally, although only the path coefficient of the educational rescue policy to the MCS of survivors was positive and passed the test of significance, the other five policies affected the MCS indirectly through the PCS.The general HRQOL of survivors is not ideal; the survivors showed a low satisfaction with the post-earthquake rescue policies. Further, the six post-earthquake rescue policies significantly improved the HRQOL of survivors and directly affected the promotion of the PCS of survivors. Aside from the educational rescue policy, all other policies affected the MCS indirectly through the PCS. This finding indicates relatively large differences in the effects of different post-earthquake rescue policies on the HRQOL of survivors. On 12 May 2008, an earthquake with a magnitude of 8.0 on the Richter scale hit Wenchuan. This earthquake was the most devastating since the founding of New China. The earthquake also resulted in 5,335 students presumed dead or missing, more than 7,000 people becoming disabled, 152 million losing their jobs and lands, and 1,449 victims becoming lone people [National Master Plan on Post-Disaster Restoration and Reconstruction of Wenchuan Earthquake.” The plan proposed 1 trillion yuan for the completion of reconstruction of hard-hit areas in Sichuan, Gansu, and Shaanxi within three years. The plan aims to make the basic living conditions and economic social development levels of survivors reach or exceed pre-disaster levels. The plan covers fiscal, tax, financial, land, industrial, and aid policies and counterpart support. For education, employment, poverty alleviation, and other aspects that urgently needed protection and support from the government, the plan particularly proposed rescue policies in education, orphans, employment, poverty, legal, and social security[Post-disaster reconstruction has become the government’s top priority task. On 23 September 2008, less than half a year after the Wenchuan earthquake, the General Office of the State Council released the document “security.However, specific studies regarding post-earthquake rescue policies are weak and there is a research gap on the effect of government support policies. Recovery and reconstruction comprise a complicated systematic project, which can be divided into transition and overall periods. First, The health condition of earthquake survivors is a controversial issue. However, many studies on survivors’ health have focused on the prevalence rate of mental disorders and their risk factors. It was found that 22.6% of the adolescent respondents were depressed, whereas 10.6% were reported to have suicidal ideation one month after the earthquake. Three mStudies assessing HRQOL include one focused on children, indicating that the HRQOL of children with PTSD rapidly declined. TherefoSpecifically, we will develop a new perspective on the study of the health of earthquake survivors by assessing the effect of post-earthquake rescue policies on survivors’ HRQOL. In particular, we address the following questions. What is the current state of the survivors’ HRQOL? The government has given much support to the hard-hit areas; however, has the HRQOL of survivors improved? In the reconstruction, post-earthquake rescue policies play an important role. The government has rich resources to guide social forces to effectively perform reconstruction work; nevertheless, is the implementation of post-earthquake rescue policies effective? Can these policies improve the HRQOL of survivors? Are there any differences among the effects of different post-earthquake rescue policies on the reconstruction? To summarize the effects of reconstruction policies and assess the effects on the HRQOL of survivors, we need to know the answers to the questions above.The post-earthquake rescue policies can significantly improve the HRQOL of survivors.Can the post-earthquake rescue policies affect the HRQOL of earthquake survivors? A previous study found that the HRQOL of survivors has generally improved after receiving social support over time. Thus, wCan different post-earthquake rescue policies affect the HRQOL of survivors to the same degree? The degree of damage in all social areas caused by the earthquake differs. When the government develops these policies, they will follow the actual situation and make targeted policies. However, the government cannot guarantee the generation of similar strong effects. Thus, we propose the second hypothesis;The effects of different post-earthquake rescue policies on the HRQOL of survivors have significant differences.Hypothesis 2: We divided the HRQOL of survivors into two dimensions, namely physical component summary (PCS) and MCS. Is the degree of the effects of post-earthquake rescue policies on the two dimensions the same? What, then, is the degree of the impact of the mechanism? Thus, we propose the third hypothesis in this study;The post-earthquake rescue policies directly affect the HRQOL of survivors. The effect mechanism on the MCS is mainly achieved by improving the PCS.Hypothesis 3: Frequent earthquakes have constantly reminded us to pay more attention to the hard-hit disaster areas. The effect of policy implementation and the HRQOL of survivors need urgent attention. Based on these needs and research gaps, we have used the Medical Outcomes Study Short Form 36 (SF-36) to measure the HRQOL. Moreover, we measure the effects of the implementation of post-earthquake rescue policies for education, orphans, employment, poverty, legal, and social in five hard-hit disaster areas in Sichuan on the HRQOL of survivors. The study presents data on the effects of policy implementation and the HRQOL of survivors, analyzes the effects of different post-earthquake rescue policies on the HRQOL of survivors, and provides suggestions on how to improve the effects of reconstruction and the HRQOL of survivors for the government and non-governmental organizations.Data were obtained through a survey in five counties in Sichuan in 2013 using a multi-stage sampling method. First, we selected five cities  from 39 hard-hit disaster areas by using simple random sampling. Based on the same method, we then selected a county  in each city as well as 400 randomly selected survivors in each county. Guided by investigators, each participant independently completed the questionnaire. A total of 2,000 questionnaires were distributed, and 1,672 were returned; the response rate was 83.6%.The questionnaire asks about the post-earthquake rescue policies, cognition of survivors, and HRQOL of survivors. In this study, the measurements include the SF-36 scale and post-disaster rescue policy scale.The SF-36 scale or the Medical Outcomes Study Short Form includes 36 items that measure eight domains and one self-assessed domain on health changes. In this study, the SF-36 measured the HRQOL of survivors after the earthquake and studied the effect of post-earthquake rescue policies on the HRQOL of survivors.National Master Plan on Post-Disaster Restoration and Reconstruction of Wenchuan Earthquake” and other governmental policies, the post-disaster rescue policy scale consisted of the following six metrics:According to the “Educational rescue policy1. The absorption of students in secondary vocational schools in disaster areas to the local school is encouraged. Local governments should expeditiously implement the policy that involves the education of the children of migrant workers into the public education system. The support of primary and secondary teachers’ allocation and training, especially for special education, should be increased. Financial assistance to students from economically disadvantaged families should be extended. University admission plans in disaster areas should also be expanded.Orphan rescue policy2. The construction of facilities for social welfare, social relief, rehabilitation, etc., should be implemented. New public service sites should be configured for disabled facilities. Enterprises, social groups, and individuals are encouraged to offer a variety of support to orphans and disabled people.Employment rescue policy3. People with employment difficulties due to disasters should be involved in the employment rescue coverage to ensure that each family has at least one earning member. Companies are encouraged to recruit urban workers unemployed due to disasters and for individual business operators to rise in the planned areas. The unemployment insurance rate of companies in the planned areas should be reduced as required. Social security subsidies, micro-lending, and other measures should promote employment.Poverty rescue policy4. Investment should be increased in rural social security. The involvement of people who experience poverty due to disasters should receive at least a minimum living security system as required. Funds from the Rehabilitation Fund should be allocated for the reconstruction of the poor villages. Rehabilitation projects in ethnic minority areas and poor areas should not require the provincial local government to provide matching funds.Legal rescue policy5. Legal rescue institutions at all levels should provide the survivors with legal advice, representation, criminal defense and other free legal services. Bar associations should provide necessary rescue for legal aid work. Judicial, administrative departments should oversee legal aid work.Social security policy6. This policy should ensure that the work injury insurance of insured persons has been paid. Injured workers who are not insured should be assisted through public donations and the rescue system. The basic pension for enterprise retirees in the disaster areas should be paid. Companies that stopped production due to the disaster should not be penalized for holding social security payments. Unpaid pension insurance of the bankrupt enterprises after repayment could be written-off after approval.Reliability refers to the consistency, stability, and reliability of survey results and indicates the degree of consistency of the results obtained by repeatedly measuring the same objects with the same methods. Reliability indicators are always indicated by correlation coefficients, which can be broadly divided into three categories: stability coefficients (cross-time consistency), equivalent coefficients (cross-form consistency), and internal consistency coefficients (cross-item consistency). Among them, the internal consistency coefficient is often used to measure the reliability of attitudes, opinions, and questionnaires. The internal consistency coefficient, that is, the Cronbach’s alpha coefficient, measures reliability by calculating the variance of each item and the total variance of all items.The SF-36 scales and post-disaster assistance policy scales determine the HRQOL of survivors and their satisfaction with the policies, respectively. The questionnaires employed in this study utilize the aforementioned scales. In this study, we use the internal consistency coefficient to measure the homogeneity of items in the scales to measure the reliability of the questionnaire.The confirmatory factor analysis (CFA) model starts from the concept model, fits with the observation data and concept models, and tests the degree of support of the observation data to the concept model. The biggest advantage of the model is that it allows the testing of the relationship between observation variable and latent, and the latent variables under the situation in which there are measurement errors. Thus, the test effect is higher, and commonly used to study the model of social and psychological structures and their relationships.The structural equation model (SEM) is a linear statistical modeling technique that combines econometrics, sociology, psychology, and other statistical analysis measurement methods. It covers several original multivariate data analysis methods and applies nominal, ordinal, interval, and ratio variables. In empirical studies in management and social sciences, SEM is a major multivariate data analysis method along with multiple regression analysis method. SEM is used to explain the relationship between multiple variables and concepts. Statistically, by looking for some variables that can be observed as a potential variable “identity,” we could analyze the relationships between the “latent variables”.In this study, we identified the internal relationships between the latent variables with the CFA model and established a suitable SEM based on it to study the effects of different policies on the HRQOL of survivors.Table In the eight domains of HRQOL, the mean value was lower than 50, which means the HRQOL of survivors is not good. Among them, physical functioning (PF), the mean values of four items in role physical (RP), role emotional (RE), and social functioning (SF) were relatively low. This finding indicates the HRQOL on these four domains was worse. The mean values of six items on the satisfaction with post-earthquake rescue policies were lower than 2, which reflect the low satisfaction of survivors regarding the policies. Thus, the post-earthquake rescue policies need to be further improved.The total Cronbach’s alpha coefficient of the SF-36 scale is 0.913. The general evaluation criterion of reliability is the range scale of reliability of over 5.0. When the Cronbach’s alpha coefficient is over 0.70, the total reliability is very good. In other words, the survey topics had strong internal consistency. Table χ2), chi-square value/degrees of freedom (χ2/df), and goodness-of-fit index (GFI), among others, are utilized in this model. Second, the added goodness of fit is used to compare the theoretical model and virtual model. The increasing fit index (IFI) is an example of indices used in this model.We established the corresponding CFA models and discussed their validity. Considering the actual needs, the CFA results often require overall model fitting to evaluate the fitting degree between model and data. Overall model fitting employs several aspects. First, the absolute goodness of fit is used to predict to what extent the model can determine the covariance matrix and relevant matrix. Chi-square value  are relatively fit indices; their values lie between 0 and 1. Theoretically, these indices can produce meaningless negative values. If their value is close to 1, then the model has a good fit. The model is acceptable if the value of these indices is greater than 0.90. The closer their value is to 1, the better the fit of the model.The The SF-36 scale consists of eight domains, which represent the PCS and MCS. Hence, we established a CFA model to study the interrelationship between the MCS and PCS  The post-earthquake rescue policies can significantly improve the HRQOL of survivors. The six policies have direct effects on promoting the PCS of survivors. The first hypothesis was mainly supported.ii) The impact mechanism of the six policies on the MCS of survivors is basically the same. Aside from the educational rescue policy, other policies affected the MCS indirectly through the PCS. The third hypothesis was mainly supported. In other words, the post-earthquake rescue policies directly affected the PCS of survivors. The policies affected the MCS indirectly through the PCS.iii) Differences between the path coefficients in the model are relatively large, which means the differences in the effects of the policies on the HRQOL of survivors are relatively large. Among them, the legal rescue and social security policies are most effective on the HRQOL of survivors. The education, orphan, employment, and poverty rescue policies have relatively weak effects on the recovery of the HRQOL of survivors. The second hypothesis was mainly supported.The government plays the crucial roles of being a leader and a guide. The implementation of reasonable policies can positively affect the promotion of the reconstruction effort. Among them, the government has provided different medical services in various phases of the reconstruction. Before 31 December 2008, the individuals who were injured because of the earthquake received free medical aid. The normal health care system has been made appropriate to the survivors in the hard-hit disaster areas. In fact, the survivors had high satisfaction with the medical services arranged by the government. The surShortly after the earthquake, the most pressing needs of survivors included housing, employment, and education. However, firstly, with the reconstruction moving forward, legal and social security issues may become more important. Because of land requisition, the number of farmers who lost their land increased. In terms of land use, they need urgent legal services. Secondly, while the current level of compensation for land requisition in China is low, the way to rehouse the survivors is simple and straightforward, without securing their long-term livelihoods. The lanThis finding prompts us to propose that post-earthquake rescue policies should be adjusted to ensure a better reconstruction effect. Government services should uphold the “people-oriented” concept and should help citizens to articulate and achieve common interests. The HRQOL of survivors has improved, but they have greater needs, such as a better social security system and more professional legal services. Therefore, our government should ensure the implementation of all six policies that can favor legal rescue and social security policies. During policy implementation, a good implementation of mechanisms in monitoring, effect assessment, and feedback should be established among survivors, policy makers, and implementers to ensure full exchange and communication. Some duplicated or rigid policies should be terminated or adjusted timely.Surely, this study has some limitations. First, we selected only five prefecture-level cities in the Sichuan province in our sample. Sichuan earthquakes not only affected cities of the Sichuan province but also villages of nearby provinces, such as Gansu and Shaanxi; future studies should be extended to cover the said areas. Second, this study focused only on post-earthquake rescue policies. Other policies may also affect the HRQOL of survivors. Future studies could focus on other post-disaster reconstruction policies of the government. Lastly, concern on the HRQOL of survivors should last. Future studies can do follow-up investigation on the HRQOL of survivors.Many studies on the health of earthquake survivors have focused on the prevalence rate of mental disorders and their risk factors. By contrast, the present study investigates the health of earthquake survivors from the perspective of HRQOL. Among the few studies about HRQOL, most have focused the positive effect of social support on survivors’ HRQOL. Furthermore, there is a research gap on the effect of government support policies. Therefore, we developed a new perspective to study the health of survivors. We provide an assessment of post-disaster rescue policies by survivors in hard-hit disaster areas and renew interest in the HRQOL of these survivors, as well as the effect of post-earthquake rescue policies on the survivors’ HRQOL. Our main findings are as follows:1. As the basic statistics of policy and SF-36 scales show, the general HRQOL of survivors is not good; they have low satisfaction with the post-earthquake rescue policies.2. The post-earthquake rescue policies can significantly improve the HRQOL of survivors. The six policies have a direct effect on promoting the PCS of survivors.3. The impact mechanism of the six policies on the MCS of survivors is basically the same. Aside from the educational rescue policy, other policies affect the MCS indirectly through the PCS.4. Differences between the path coefficients in the model are relatively large. This finding indicates relatively large differences in the effects of different policies on the HRQOL of survivors. Among these policies, legal and social security are the most effective on the HRQOL of survivors. The education, orphan, employment, and poverty rescue policies have relatively weak effects on the recovery of the HRQOL of survivors.We finally know the effect of post-earthquake rescue policies on the HRQOL of survivors. To enhance the positive effect, the implementation of policies should be changed and adjusted to the actual needs of survivors. A related medical rescue policy should focus more on the mental health of survivors.aThis photo was taken in Guangyuan, one of the sites where the questionnaires were distributed.BP: Bodily pain; CFA: Confirmatory factor analysis; GH: General health; HRQOL: Health-related quality of life; MCS: Medical component summary; MH: Mental health; PCS: Physical component summary; PF: Physical functioning; SE: Standard error; SEM: Structural equation model; SF: Social functioning; SF-36: Medical Outcomes Study Short Form 36; RE: Role emotional; RP: Role physical; VT: Vitality.The authors declare that they have no competing interests.YL wrote and revised the manuscript, was responsible for the design of the study, and performed the statistical analysis. XW participated in the statistical analysis. Both authors read and approved the final manuscript.


High maternal mortality in India is a serious public health challenge. Demand side financing interventions have emerged as a strategy to promote access to emergency obstetric care. Two such state run programs, Janani Suraksha Yojana (JSY)and Chiranjeevi Yojana (CY), were designed and implemented to reduce financial access barriers that preclude women from obtaining emergency obstetric care. JSY, a conditional cash transfer, awards money directly to a woman who delivers in a public health facility. This will be studied in Madhya Pradesh province. CY, a voucher based program, empanels private obstetricians in Gujarat province, who are reimbursed by the government to perform deliveries of socioeconomically disadvantaged women. The programs have been in operation for the last seven years.The study outlined in this protocol will assess and compare the influence of the two programs on various aspects of maternal health care including trends in program uptake, institutional delivery rates, maternal and neonatal outcomes, quality of care, experiences of service providers and users, and cost effectiveness. The study will collect primary data using a combination of qualitative and quantitative methods, including facility level questionnaires, observations, a population based survey, in-depth interviews, and focus group discussions. Primary data will be collected in three districts of each province. The research will take place at three levels: the state health departments, obstetric facilities in the districts and among recently delivered mothers in the community.The protocol is a comprehensive assessment of the performance and impact of the programs and an economic analysis. It will fill existing evidence gaps in the scientific literature including access and quality to services, utilization, coverage and impact. The implementation of the protocol will also generate evidence to facilitate decision making among policy makers and program managers who currently work with or are planning similar programs in different contexts. The adoption of the Millennium Development Goals in 2001, specifically goal 5, renewed the global emphasis on reducing maternal mortality. This international commitment gained political attention; many low income countries prioritized improving women’s access to maternal health services [Between 1992 and 2006, the Indian Ministry of Health and Family Welfare focused on strengthening the health system infrastructure to better support emergency obstetric care (EmOC) services especially in the public sector. A concerted effort was made to increase capacity for institutional deliveries by upgrading facilities to improve access to skilled birth attendance and EmOC . Key strWhile it is extremely important to invest in EmOC facilities, developing strategies that increase the use of these services especially among the poor who suffer the largest burden of maternal deaths are equally significant . Most deUsing the platform of the NRHM, the government introduced demand-side financing initiatives for maternal health to reduce financial barriers that often preclude women from accessing skilled attendance at birth . Two larA traditional CCT provides a monetary incentive directly to the intended group on the condition the beneficiary satisfies a pre-defined set of requirements . India’sThis protocol describes the proposed comprehensive evaluation of two respective programs in Gujarat and Madhya Pradesh. The evaluation, called the MATIND project is a four year project supported under the EU FP7 framework. The proposal aims to study (i) trends in program uptake since inception(ii)the influence of the program on institutional delivery rates, maternal and neonatal outcomes, (iii) explore service providers’ experiences,(iv) emergency transportation systems for obstetric referrals,(v) characteristics of the facilities participating in the programs, (vi) quality of care administered, (vii)experiences of the beneficiaries and non-beneficiaries, (viii) the role of community health workers and (ix) the cost effectiveness of the programs.The program evaluation will be conducted at three different levels of the health system with specific objectives at each level: (i) the provincial (policy) level which includes secondary data from governments and other important stakeholders at the provincial level, (ii) the district level  which focuses on health facilities (iii) and the community level, in villages (sub-district), which includes mothers and local health workers.The objectives at each level of the study are listed below and summarized in Table 1. Provincial (policy) level:(i) Program Trends: To describe trends in program uptake for each program since inception and to study district level time series of program uptake data from 2004 to 2011. Further to examine the extent to which changes in the proportion of institutional deliveries have influenced maternal and neonatal outcomes over that period of time.(ii)Private Sector Participation: To describe trends in private sector  participation in each of the programs over time. Also, to study the characteristics of private sector participant facilities.With regard to the JSY program in MP, to explore the reasons for the decision to subsequently reduce the role of the private sector in the program. Also to explore among selected erstwhile participating private facilities, their experience with JSY and their perception on the state decision to exclude them from the scheme.With regard to the CY program, to explore experiences and motivations among selected private providers currently participating in the program, reasons for non-participation among a sample of those who were eligible but never participated and those who participated initially but have since left the program.(iii) Emergency transportation for obstetric care: To study two different emergency obstetric transportation models utilized in each of the programs with regards to coverage, equity in access, current utilization, and cost of the service. Further, to explore among a group of mothers their experience of gaining access to and using the transportation.(iv) Cost-effectiveness of the Programs: To develop and apply a model for assessment of the utility of the two maternal health programs and to perform a sensitivity analysis by testing alternative assumptions for a cost utility analysis.2. Facility Level (public and private facilities):(v) Facility Survey: To list all facilities in the study districts offering obstetric care and classify them as non-EmOC, basic or comprehensive emergency obstetric care (BEmOC or CEmOC) facilities. Further, to study the characteristics of these facilities with regard to ownership, accessibility, bed strength, human resources, training, referral communications and processes, availability of equipment, drugs and supplies and infection control procedures.(vi) Quality of Care: To study in EmOC facilities the quality of care through direct observation of normal deliveries, a review of case records and registers and assessments of provider competence. Further to study experiences and perceptions of quality of care of mothers who delivered under the respective programs, and to study key procedures they experienced. In cases of mothers who were referred into facilities, referral indications and transportation details will be studied.3. Community level (mothers in sampled study villages):(vii) Program beneficiaries and non-beneficiaries: To study and compare beneficiaries and eligible non-beneficiaries of the program in the community in terms of: socio-demographic characteristics, utilization of antenatal services, birth attendance, delivery outcome, birth weight, receipt of post natal care, immunization of the child and costs of care incurred. Reasons for participation/non participation and choice of place of delivery will be explored. Predictors of non-participation will also be studied.(viii) Equity in access to facilities (geographic): To estimate the influence of distance to facilities on place of delivery in comparison to other determinants of delivery service use.(ix) Role of community health workers in program uptake: To study the role played by the ASHA  and the traditional birth attendants (TBA) in the antenatal, delivery and postnatal periods of program mothers. Also to explore among ASHAs their motives for participation and long term professional aspirations within the NRHM. The dynamic between various community level workers, the TBA, the ASHA and the female health worker will be explored. Concerns on the potential duplication of roles between the latter two will be explored among policy makers.The study will take place in two provinces Figure  where thFor studies at the district level, we purposefully selected three districts from each province in collaboration with the provincial ministries of health. The selected districts include districts from different geographic areas of each province, varying human development indices and represent different population sub groups including disadvantaged groups like scheduled castes (SC) and tribes (ST).A range of methods will be utilized during the data collection phase. Document reviews, time series, surveys, in-depth interviews, exit interviews, focus group discussions, case record reviews, and structured observations will be used. These are described in greater detail in the section below.1. Provincial (policy) level:At this level we will collect secondary data on program related inputs, outputs and outcomes in each province. A time series analysis, consultations with key stakeholders, and review of relevant program documents will allow us to study program trends (objective i) and comment on the uptake of the programs since inception. A complete time series will be derived from maternal health data with regard to uptake (proportion of eligible women who participate), institutional delivery , district level ante-natal care (ANC) coverage (proportion of women completing >3 ANC visits), and maternal and neonatal deaths. The data will be obtained from multiple sources including the District Level Household Survey (DLHS), Annual Health Survey, Sample Registration System (SRS), Vital Registration and health department sources for the purpose of data triangulation and the development of robust estimates. A major challenge in the analysis is the lack of complete time series for the maternal mortality data. Instead of relying on a single source for information, statistical data fusion techniques will be applied to collate data from various sources. The data fusion techniques will borrow strengths across time and space from the existing data to derive a complete time series estimates for the variables of interest.A second study at the policy level will focus on trends in private sector participation (objective ii) in each of the programs over time. The role of private providers varies in each program. Private providers played a small part in the JSY program; however they are a large resource in Gujarat and thus the central focus in CY. Private facility characteristics will be studied through a cross-sectional facility review (see objective v). In MP, we will explore with NRHM program managers the experiences of collaborating with private providers and the perception of the role of the private sector in JSY, justification for criteria used for selection, and rationale for their inclusion in and subsequent exclusion from the program through in-depth interviews. Implementation issues and the overall benefits or disadvantages of participating in the program will also be explored with a selected group of private providers.In Gujarat, we will use qualitative methods to explore participation of the for-profit health sector in CY and understand the factors influencing private provider participation. The qualitative research will be conducted using an interpretive approach, and will seek to understand private providers motives for participation/non participation, appropriateness of payment amounts under the program, procedures for reimbursement and interfacing with government officials. In addition, the study will explore how the program affects/affected patient turnover, what proportion of their patients are/were CY, influence on human resources, changes made to the facility to incorporate the program and suggestions on how to improve the functionality of the program. An experienced researcher will interview a purposive sample of private providers who (i) are currently participating in the program, (ii) were part of the program but no longer participate and (iii) never participated. Thematic analysis using the framework approach will be applied.Difficulties accessing transportation to receive emergency obstetric care is one of the numerous barriers experienced by many rural women , and we A quantitative retrospective data analysis will be completed with data ascertained from call centers to determine utilization patterns and uptake of the respective transport systems. Socio-demographic characteristics of the beneficiaries and other outcomes will be collected in a cross-sectional questionnaire to study equity in use of the service.NRHM program officials and District Chief Medical & Health Officers (CMHOs) will be interviewed to gain insight into the structure under each model and the benefits and limitations of the respective decentralized and centralized emergency transportation services. The discussion will include perceptions on efficiency, geographical accessibility, functionality, sustainability, technical capacity, constraints and motivations of the human resources, and procedural limitations. In addition, costs associated with implementation and ongoing usage will be elicited.All interviews will be conducted in Hindi by a research assistant, transcribed and then translated into English. In-depth interview data will be analyzed thematically, using the framework approach. The analysis will draw out differences between the two schemes in terms of implementation, stakeholder views of the schemes and experiences of utilization. A cost effectiveness analysis between the two programs is also planned.A cost effectiveness of the two programs (objective iv) will be performed through two different methods. The first approach will be to compare the costs and outcomes of the two programs for matched groups of participants. The primary outcome will be the proportion of institutional delivery. Other outcomes to be analyzed will be the proportion of cesarean deliveries, antenatal check-ups and delivery outcomes . The costs will primarily be from the payer perspective, the state, but also costs to the patients will be collected and analyzed. The second approach will be to analyze each system separately from an equity perspective, i.e. how costs and access to services are distributed according to categories of socio-economic status. In view of the complexity and multi-dimensionality of both the interventions and the outcomes, we will not aim to comprise the analysis in a single index number.2. Facility Level:At the facility level we will collect primary data on the types of facilities that are administering obstetric care under the programs (objective v), and the quality of care received (objective vi). These facilities will be visited to study maternal health outcomes. Both quantitative and qualitative methods will be utilized to achieve these objectives.An initial list of all public and private facilities in the study districts will be obtained from government records. The list will be verified by site visits. Snowballing will then be utilized to identify any missing private facilities where obstetric care is provided. A modified Averting Maternal Death and Disability (AMDD) survey  will be A cross-sectional survey will provide additional information on how the facilities function under the respective programs as well as aspects of quality of care provided. The assessment will include variables on infrastructure, accessibility, human resources, functional equipment, accessibility to drugs and supplies, referral communications and processes, infection control procedures and service statistics. This survey will provide the current operating state of the facilities. Descriptive statistics will be calculated for the areas mentioned above. These will be compared between public and private facilities and between the two programs.Data on delivery outcomes for women admitted in the facility will also be collected over a five day period at each facility that had more than 10 deliveries in a month. A research assistant, assigned to the facility, will administer a short questionnaire to mothers who deliver within the defined time frame. Basic socio-demographic characteristics, pregnancy and delivery details, and indication for referral if appropriate will be elicited. More specific details of the same delivery will be obtained from the nurse in the labor ward. These will include type of delivery, presence of known pregnancy or delivery related complications, maternal and neonatal outcomes. This will provide information on the proportion of these events among program mothers. In the case of CY, it will allow a comparison with non-program mothers who deliver at the same time in the program hospitals. This study will provide a cross sectional snap shot of outcomes for program mothers. The proportion of program mothers who have complications, who undergo instrumental delivery, referred, who have adverse neonatal outcomes will be reported as will the number of maternal deaths during this period.The Hulton et al. Quality of Care framework will be used to assess the quality of care (objective vi) from both the provision of care (facility perspective) and the experience of care (user perspective) . ObservaNon-participant observation of normal deliveries will be performed on a sample of mothers in selected facilities. The observations will describe the technical care given during labor and delivery, infection control practices and the interaction between the staff and mother. A retrospective review of pre-defined indicators from a sample of case records will be performed in all study facilities to assess the quality of records maintained. The registers will also be assessed and the number of deliveries and procedures performed will be recorded. The competence of labor ward nurses providing obstetric care will be assessed utilizing case vignettes. The case vignettes will focus on normal labor and delivery. A short structured exit interview will be administered to all post-partum mothers enrolled in the study before discharge to determine which key procedures they underwent. The procedures included in the questionnaire will be based on common practices that may harm or benefit the mother during or after delivery, as described in the WHO evidence based practices ,15. A suFor the observations, content analysis will be used to conceptualize and classify events, behaviors and actions to obtain a rich understanding of quality of care and explanation of how women experience care at facilities . Basic d3. Community level (mothers in the study villages):At the community level we will collect primary data from recently delivered mothers to compare outcomes between eligible beneficiaries and non-beneficiaries (objective vii) for each of the programs. A cross-sectional study will be conducted with women residing in the selected study villages who delivered in the last year. JSY program participation is defined as an institutional delivery in any public health facility. Program non participation is defined as a home or private facility delivery. CY program participation is defined as a below poverty line (BPL) or tribal mother who delivers in a CY approved facility. Program non participation is defined as BPL or tribal mother who delivers outside of a CY approved facility.Stratified systematic random sample will be used to select the study villages in each district. The districts will first be stratified by blocks (administrative units) and then the villages in each block will be classified into two strata based on the size of the population. Villages will be randomly selected from each strata based on the population proportion. Given the different design of each program, the sample sizes will vary in each province.There will be three points of data collection; (i) when the woman delivers, (ii) 15 days and (iii) 28 days post-delivery. The ASHA will administer a simple symptom based checklist to all mothers regardless of place of delivery to ascertain maternal morbidity, complications associated with the pregnancy and delivery, at the three time points. To ensure quality data collection, a physician will administer a second checklist to 5% of all mothers which will be compared to the data collected by the ASHA.Socio-demographic details, history of previous pregnancies, receipt of comprehensive maternal health care , place of delivery, delivery type, birth weight, immunization of the child, indirect and direct costs associated with delivery, program participation and maternal and neonatal outcomes will be elicited post-delivery in the mother’s home by a trained research assistant. In addition, reasons for participation/non-participation in the program, reasons for their choice of facility and barriers (if any) to access of care will be collected. Data will also be collected on household amenities and assets. This will help create an indicator to assist in quantifying the degree of income related inequalities and how it influences the inequities in access to care. In the event of a maternal death, the head of the household will be requested to provide the information.Propensity score matching will be used to select a comparison group from the sample of non-participants closest in terms of observable characteristics to a sample of program participants. Comparisons of the outcome variables described above between the two groups (users and non-users) will be studied. Reasons for participation/non participation will be described. In a separate hierarchical model, the predictors of non-participation will be studied in each program. Costs incurred will be compared by place of delivery.The facilities identified in objective v will be mapped onto a Geographic Information System (GIS) (objective viii). Digitized GIS maps of the selected districts in both provinces will be created. The map will have basic layers of district and block boundaries, road and rail networks, and settlements. Global Positioning System (GPS) co-ordinates will be taken for all facilities and added to the map as a separate layer. The location of the mothers who participated or did not participate in the program (objective vii) will be added as an additional layer. Distance from the mothers’ village to the selected health center will be calculated from the GIS. The association between distance from a facility and program use will be studied. Level of care offered at the facility will also be used as a predictor in the model for choice of place of delivery. Suitable GIS software along with standard statistical software will be used. A regression model will be developed using the background predictors of place of delivery  as well as distance to the nearest facility.The last objective in this level will focus on the community health workers’ participation in the program (objective ix). The ASHA is a female resident of the village who is incentivized by the government to motivate women to deliver at facilities under the programs. The government has identified the ASHA as a pivotal role in the community success of the program . A purpoQualitative studies: Transcripts and recorded material will be stored in a locked location. The interviewee will be disassociated from the transcripts before analysis.Research Electronic Data Capture (REDCap) will be utilized as an online database. Data will be exported into appropriate statistical software for analysis. Both of the proposed programs are innovative demand side financing programs with an explicit focus on promoting institutional delivery. They are the first of their kind implemented on such a large scale. Several demand-side financing interventions have been previously deployed to create demand for different health services . Most ofIn this article we have outlined the protocol for an evaluation of the two large scale demand side financing programs for maternal health in India. There have been repeated calls in the scientific literature to study the effectiveness of such large demand side financing programs.Design of the evaluation: Habicht et al  emphasizperformance and impact[The current evaluation studies both nd impact of the pnd impact based onnd impact. This evperformance of the program. These will include quantitative analysis of secondary data, surveys of facilities, questionnaires to mothers, community based surveys of households, and spatial analyses to study access. Qualitative methods will also be employed. These will include in depth interviews with policy makers, program managers, healthcare providers and women. Focus groups with women who utilized the program will also be done. The project will contribute new knowledge in a number of areas which have not been studied before in the context of demand side financing programs; including spatial analysis to study access to EmOC, private sector collaboration in demand side programs, an assessment of potential models for emergency transport and quality of care under the programs.Multiple methodologies will be used in the evaluation to study the impact will be made from secondary and primary data. One measure of impact will be the influence of the programs on the final outcome i.e. maternal mortality. This will involve the construction of statistical estimates from secondary data sources as detailed on page 9. A second assessment of impact will be to study differences in outcomes among eligible beneficiaries and non-beneficiaries. While a randomized experimental study would have been the most robust design , this is not feasible for these specific large programs as they have been rolled out nationwide/statewide. Hence, there are no non-program groups from which a random sample can be drawn. Given that the two programs are implemented completely across the provinces under study and so preclude a randomized design for evaluation, we will generate the comparison groups  using matched comparisons. In this evaluation, propensity score matching [The assessment of matching  will be cost utility analysis of each of the programs from a payer (state) and patient perspective will be done. There have been no previous economic analyses of these programs.In addition to performance and impact of the two programs, a In summary, this paper describes a comprehensive evaluation protocol for two innovative demand side financing programs to promote maternal health in India. The protocol comprises an assessment of the performance and impact of the programs as well an economic analysis. The implementation of the protocol will generate evidence to facilitate decision making among policy makers and program managers who currently work with or are planning similar programs in different contexts. The evaluation also aims to fill existing evidence gaps in the scientific literature on the performance and impact of large scale demand side financing programs for maternal health. The results from the studies in this protocol will help support the design of efficient demand side financing programs in the future.The MATIND study has received ethical approval from institutional review boards at Karolinska Institutet, Liverpool School of Tropical Medicine, Public Health Foundation of India, and R.D. Gardi Medical College.ASHA, Accredited Social Health Activists; ANC, Antenatal Care; ANM, Auxiliary Nurse Midwife; AMDD, Averting Maternal Death and Disability; BEmOC, Basic Emergency Obstetric Care; CY, Chiranjeevi Yojana; CEmOC, Comprehensive Emergency Obstetric Care; CCT, Conditional Cash Transfer; DHIS, District Health Information System; DLHS, District Level Household & facility Survey; EmOC, Emergency Obstetric Care; GIS, Geographic Information System; GPS, Global Positioning System; ICDS, Integrated Child Development Services; JSY, Janani Suraksha Yojana; MP, Madhya Pradesh; NRHM, National Rural Health Mission; OR, Odds Ratio; SC, Scheduled Caste; ST, Scheduled Tribe; TBA, Traditional Birth Attendant.The authors declare that they have no competing interests.KS drafted the manuscript and all authors contributed subsequent drafts and revisions of the paper. ADC, DM, VD, RT, and HD were co-applicants on the original grant application and made substantial contributions to study design. The MATIND team worked with refining the protocol, development and testing of tools and the database. The MATIND study team includes: Lennart Bogg, Sarika Chaturvedi, Vinod Diwan, Hengjin Dong, Partha Ganguly, Veena Iyer, Kate Jehan, Rajesh Mehta, Rajesh Nair, Marie Ng, Santhi N.S., Parvathy Sankar Raman, Bharat Randive, Joanna Raven, Yogesh Sabde, and Rachel Tolhurst. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/699/prepub