Excess dietary sodium is a global public health priority, particularly in low- and middle-income countries where rates of hypertension and cardiovascular disease are high. The International Development Research Centre funded a research consortium of five Latin American countries (LAC) to inform public health policy for dietary sodium reduction (2016–2020). The objective of this study was to determine the outcomes of this funding on short-term  and intermediary outcomes . A summative program evaluation was conducted, using a logic model and multiple data sources including document review, surveys and interviews. Researchers from Argentina, Costa Rica, Brazil, Peru and Paraguay produced a significant amount of scientific evidence to guide decision making on sodium policy related to its content in foods, consumer behaviors , and the health and economic benefits of dietary reduction. A substantive number of knowledge translation products were produced. The funding enabled training opportunities for researchers who developed skills that can be scaled-up to other critical nutrients and health issues. It was unexpected that intermediary policy changes would occur, however several countries demonstrated early policy improvements derived from this research. A funded research consortium of LAC is a practical approach to invoke policy innovations. Low-and middle-income countries (LMIC) are disproportionately impacted by non-communicable diseases (NCD). Globally, two thirds of deaths annually are attributed to NCDs; while LMICs experience four-fifths of these deaths predominantly due to cardiovascular diseases (CVDs) . NCDs haExcess dietary sodium is a leading risk factor for NCDs, including hypertension, CVDs, stroke and kidney disease ,6. GlobaThe WHO set global targets to address NCD risk factors, which included a 30% relative reduction in mean population sodium intake by 2025 . Not surIn Latin American countries (LAC), policy development and implementation are complex and often challenging. Up-to-date national-level data that is high quality is frequently unavailable. This includes key data to drive sodium policy such as on the health and economic benefits of sodium reduction policies, the sodium content of foods consumed nationally and the factors influencing dietary sodium behaviors. A recent qualitative study demonstrated that the limited availability of sodium research in LAC is often due to a lack of funding, and limited human resources and infrastructure available to researchers . ResearcThe creation of scientific evidence and innovations across multiple research program objectives that can be scaled-up to produce policy changes across multiple LAC;The formation of multi-sectoral and multi-disciplinary partnerships;The formation of equitable, diverse and inclusive partnerships;The enhancement of consortium researchers’ confidence, capacity, and scientific abilities in conducting research to address public health nutrition issues in LACs.In 2015, the International Development Research Centre (IDRC), a Crown corporation of the Canadian federal government, created a “Food, Environment and Health” research funding program. The funds were in support of research on healthy food systems in LMICs, with an aim of reducing the health, social and economic burdens of diet-related NCDs. Under this program the IDRC funded a five country Latin American consortium to conduct research to inform public health policy innovations for dietary sodium reduction (IDRC Grant 108167). The consortium was led by the Costa Rican Institute of Research and Teaching in Nutrition and Health  with support from the University of Toronto and Ontario Tech University. The consortium included numerous researchers from Argentina, Brazil, Paraguay and Peru and stakeholders from non-governmental organizations across the region . MultiplThe program evaluation also assessed intermediate program outcomes which were defined as sodium reduction policy and program changes ; however it was unexpected that would occur over the relatively short 3.5-year funding period.A summative program evaluation took place at the end of the consortium funding period. The evaluation took a multiple method approach using quantitative and qualitative data from diverse sources consisting of a document review, program evaluation survey, team meetings and qualitative interviews. The program evaluation was guided by a logic model  developeProgram outcomes were evaluated with multiple methods. This data added a variety of insights to the evaluation, including social, cultural, and historical contexts on the research landscape in a country.Document Review. Several types of documents were reviewed, including the original grant application, interim progress reports, a compendium of knowledge translation activities conducted, meeting notes, memos, and country-level data on existing programs and policies from the PAHO  objective”. Furthermore, consortium researchers expressed a deeper appreciation for the social marketing research experience beyond training and knowledge creation, which included the formation of meaningful collaborations and a sense of community. A partnership with the Association Latin Americana de Mercadeo Social, further supported the development of social marketing skills and stimulated collaborations with other LAC social marketing researchers.Knowledge translation skills. The evaluation survey found that 90.9% of researchers reported a significant improvement in their knowledge and skills related to KT principles, concepts and their application [lication . For a mThe researchers’ dedication enabled them to achieve several intermediate outcomes, defined by the logic model , which wNational commitments to support and fund the implementation of social marketing program were achieved. In Paraguay, municipal governments used the qualitative research to inform a social marketing plan focused on banning saltshakers in food service establishments. Costa Rica obtained funding from Resolve to Save Lives to adapt the regional social marketing plan to their national context. Finally, the resources, training and outputs by the consortium researchers were leveraged to address other nutrition topics of public health concern and stimulated partnerships and collaborations. A six-month grant extension from the IDRC enabled researchers to conduct analyses on other nutrients associated with non-communicable diseases. This included the analysis of already nutrient data collected with FLIP-LAC. Analyses related to nutrients , the overall nutritional quality of packaged foods, and use of low sodium claims on the front of package were condcuted. Finally, the Organization for Economic Co-operation and Development invited the Principal Investigator to participate in a case study focused on best practices to reduce excess sodium consumption to mitigate CVD. This was a major achievement for future research in Costa Rica as the country did not have collaborations with civil society.This program evaluation demonstrated that a funded research consortium was an impactful way to build capacity and collaboration, and to generate evidence to inform population wide public health policies and programs for dietary sodium reduction. Specifically, this program evaluation demonstrated that all consortium level objectives were achieved for the duration of the program. With the IDRC’s investment in a funded research consortium, a significant amount of country and regionally specific evidence was generated from the five Latin American country participants. Policy change is rarely based on a single empirical research study ; howeverActions to reduce population-wide sodium intakes require multiple interventions that work synergistically, if countries are to achieve the WHO global target of 30% sodium reduction by 2025 . At leasThe funded consortium examined in this program evaluation allowed researchers and policy decision makers to form a community of practice with a shared focus on sodium reduction public health policies. This was a strength of the funded consortium as the community of practice that was created fostered learning interactions, shared knowledge, training and development efforts. It also created a rich environment to understand and make sense of new knowledge and training efforts, outcomes observed when communities of practices have strong and mutually respectful relationships. In other fields, a community of practice model has been utilized to promote practice changes in the clinical settings  and to iThe funded consortium integrated KT training and strategies for all the research program objectives, which is one factor leading to consortium success. Funding agencies can provide mechanisms to promote knowledge exchange through agency mandates on KT. One study found that 18 of 23 national and international funding agencies described some aspect of KT in their mandate . It is wThe use of a logic model framework was a strength of the program, which guided consortium actions and supported this evaluation. Only a few published studies have used a program evaluation framework, where most evaluations relied on observation designs . ExistinThis program evaluation illustrates the benefits of collaborative work in research—carried out by a consortium of LMIC countries in Latin America, with the support of international technical assistance—to facilitate the development and implementation of dietary sodium reduction policies, with an ultimate goal of reducing the burden of hypertension and cardiovascular disease. The dedicated efforts of the multidisciplinary team generated local and regionally scientific evidence for decision-making in sodium reduction policies and programs, innovations in food systems, using innovative technological and methodological approaches. The consortium is a model for other public health interventions that require new techniques for food policy analysis and consumer behavior, as well as the dissemination of key findings. The findings of this evaluation can be applied to the development of future consortium research partnerships and activities designed to address the burden of NCDs in the region.


In recent years, significant progress has been made in the field of liver machine perfusion. Many large transplant centers have implemented machine perfusion strategies in their clinical routine. Normothermic machine perfusion (NMP) is primarily used to determine the quality of extended criteria donor (ECD) organs and for logistical reasons. The vast majority of studies, which assessed the viability of perfused grafts, focused on hepatocellular injury. However, biliary complications are still a leading cause of post-transplant morbidity and the need for re-transplantation. To evaluate the extent of biliary injury during NMP, reliable criteria that consider cholangiocellular damage are needed. In this review, different approaches to assess damage to the biliary tree and the current literature on the possible effects of NMP on the biliary system and biliary injury have been summarized. Additionally, it provides an overview of novel biomarkers and therapeutic strategies that are currently being investigated. Although expectations of NMP to adequately assess biliary injury are high, scant literature is available. There are several biomarkers that can be measured in bile that have been associated with outcomes after transplantation, mainly including pH and electrolytes. However, proper validation of those and other novel markers and investigation of the pathophysiological effect of NMP on the biliary tree is still warranted. Due to demographic change, there is a greater need for organs and the proportion of organs from older or unhealthier donors in the donor pool is growing. This leads to an aggravation of the already existing organ shortage and amplifies the need to use organs from so-called extended criteria donors (ECD). ECD include, for example, elderly donors, livers with steatosis, or donors with other comorbidities. Organs from a donation after circulatory death (DCD) donor are categorized as ECD since organs experience a harmful period of warm ischemia prior to explantation and enter the cold storage period already with an energy debt . A limitThe diverse cells of the liver are all in different ways susceptible to one or all phases of IRI. The sinusoidal endothelial cells (SECs) in the liver for example are especially susceptible to cold ischemia . During The biliary tree is a complex and delicate system, damage to one part or one cell population often results in reactive changes or excessive proliferation of another. Therefore, biliary wound healing is a complex process . Deep woDuctular reaction (DR) is a form of intrahepatic wound repair mechanism . DR can A summary of studies that consider biliary injury in the context of NMP can be seen in bile and reduced GGT and LDH in the bile of the NMP group (n = 30) to compare hypothermic oxygenated perfusion (HOPE), sub-normothermic machine perfusion, and controlled oxygenated rewarming (COR) to SCS. All treatment groups showed an overall better outcome, lower levels of liver injury markers in perfusate, and better mitochondrial function. Furthermore, they showed higher bile production, bicarbonate secretion, and pHbile. Biliary injury was reduced, indicated by lower GGT and LDH in bile and by histological analysis  and ITBL in the NMP group . Only the NMP group received routine magnetic resonance cholangiopancreatography (MRCP) imaging. However, NMP was not able to prevent the development of ITBL in high-risk DCD grafts  have been published:n = 121) vs. SCS (n = 101). The NMP group showed 50% reduced graft injury measured by perfusate liver transaminases (p ≤ 0.001). Furthermore, a 50% lower organ discard rate (p = 0.008), resulting in a 20% increase of transplanted livers in the NMP group was observed. The reduction in MRCP diagnosed ITBL  was statistically non-significant . NMP grafts showed a reduction of EAD  and histopathologic evidence of IRI after reperfusion . NMP resulted in higher utilization of DCD livers initially accepted with 51% of transplanted grafts compared to 26% in the SCS group (p = 0.007). Despite the higher use of DCD organs in the NMP group, the incidence of ischemic biliary complications was reduced after 6 months  and 12 months . Ischemic biliary complications were defined as ITBL or bile leaks, which were confirmed either endoscopically or by magnetic resonance cholangiopancreatography. They did not mention if all patients or only symptomatic patients were examined  to describe the bile duct injury (BDI) score. The score ranges between 0–7 and was developed in 23 human livers subjected to NMP but not transplanted, a cut-off of 4.75 was empirically defined using the median of the histological scores. The authors investigated their results prospectively in a subsequent clinical study during NMP of 6 livers of which 4 were transplanted . HoweverThe histological scoring systems discussed above can be considered useful tools if they are interpreted with the knowledge of their insufficient validation for the prediction of clinical outcomes in mind.Furthermore, biomarkers that were identified with histological scoring systems as a surrogate endpoint for ITBL development should only translate into clinical decision-making after proper validation to prevent possibly transplantable livers from being discarded.The accuracy of the described histologic scoring systems in predicting ITBL should be treated with caution but they offer at least a certain degree of objectivity and enable comparison of results.Studies that focused on the assessment of biliary parameters during NMP are summarized in Two animal studies focused on predictive biliary markers during NMP for liver grafts that experienced different periods of warm and cold ischemia , 35. Thebile) was one of the most used biliary markers. Proposed cut-off values were >7.48  and Glut-1  alone and others in combination with clinical symptoms and/or cholestatic laboratory parameters. As for sample collection, a comprehensive description of methods helps to put results into context. In some cases, pHrability , 33. NevCurrently available evidence on biliary injury from experimental and clinical studies looks very promising. First clinical machine perfusion trials reported increased graft utilization, with comparable clinical outcomes. Just recently, the benefit of NMP regarding biliary complications was highlighted in a large randomized control trial , furtherHowever, machine perfusion has its limits and cannot yet undo extensive damage to the organ that has already occurred . Notably, it does offer the opportunity for therapeutic interventions. Only future studies will determine if therapeutic options such as organoids, mesenchymal stem cells, and novel targeted therapeutic agents can be used to further increase organ utilization.In conclusion, normothermic machine perfusion is a thrilling opportunity to treat the organ. Each step towards the extension of the donor pool needs to be accompanied by careful graft assessment to ensure patient safety. Every additional organ available for transplantation is a gain and with further improvement in already promising biliary viability assessment, liver transplantation in the future, without its Achilles’ heel, seems within reach.


Toxoplasma gondii acute infection was first attempted by detection of specific IgM antibodies, as for other infectious diseases. However, it was noted that this immunoglobulin declines slowly and may last for months or even years. Apart from the diagnostic problem imposed on clinical management, this phenomenon called our attention due to the underlying phenomena that may be causing it. We performed a systematic comparison of reports studying IgM antibody kinetics, and the data from the papers were used to construct comparative plots and other graph types. It became clear that this phenomenon is quite generalized, and it may also occur in animals. Moreover, this is not a technical issue, although some tests make more evident the prolonged IgM decay than others. We further investigated biological reasons for its occurrence, i.e., infection dynamics , parasite strain relevance, as well as host innate, natural B cell responses and Ig class-switch problems inflicted by the parasite. The outcomes of these inquiries are presented and discussed herein.Diagnosis of  Toxoplasma gondii is an obligate intracellular parasite distributed globally in warm-blooded animals, including humans, with variable incidence depending on climatic conditions, being higher in tropical areas than in cold or dry regions  negative) [In a recent study with C57BL6 "bumble" mice, deficient in the transcription factor Nfkbid on which B-2 and B-1 cells depend for class switch and development, respectively, do not produce IgM antibodies and succumb to a secondary infection by egative) .Important specific features of congenital toxoplasmosis are the route of infection , the stage of the infecting parasite (tachyzoite) and the maturity of the immune system ,4,115. TAmong the possible phenomena that underline the chronicity of IgM are the decrease in the number of B-2 or Th lymphocytes and the alteration of the transduction signals important for the Ig class switch.T. gondii tachyzoites spread throughout the body, and the number of T and B lymphocytes decreases by 50% in the blood and the bone marrow (BM); this was demonstrated in adult mice experimentally infected with the virulent RH strain [T. gondii may induce long-term immune disturbances associated with impaired thymic function.There is evidence supporting both phenomena in toxoplasmosis, although we have not been able to find any studies that specifically address the effect on IgM levels derived from B-1, MZB or B-2 cells. When a host is infected, H strain . Since tH strain . This beH strain ; the autT. gondii-infected B and T cells had a smaller rough endoplasmic reticulum as well as a decreased level of cytokine secretion, respectively [T. gondii increased PI3K in EL4 cells, a tumor cell line used to explore T cell transcriptional regulation [Besides numeric declines, functional alterations may also explain the augmentation or permanence of IgM. It is worth remembering that two types of stimuli in B-2 and CD4+Th cells must occur for successful class-switching DNA recombination (CSR); these are BCR–antigen, CD40–CD40L (CD154) and TLR–ligand interactions, which directly or indirectly cross the PI3K route inhibiting it, to unblock the nuclear activating factor κB (NF-κB) and its translocation to the nucleus, where it provokes the synthesis of the activation-induced cytidine deaminase  and other genes related to this complex phenomenon ,119,120.ectively . In a stectively . This megulation . PI3K pagulation ,119,120.T. gondii on CD40 in B-2 lymphocytes is unknown, but an increase in CD40 expression has been seen in macrophages of C57BL/6 mice infected with type 2 but not type 1 or 3 strains [CD40 is another primary stimulus that, together with the TLR, decreases the expression of the enzyme PI3K, in this way stimulating Protein kinase B (known as AKT) and FOXO, and favoring class switching. The effect of  strains . It is k strains .Although the studies mentioned above were performed with macrophages or cell lines, these phenomena may be occurring in normal T or B lymphocytes, as they have similar receptors and signals that drive their functions. If true, the communication between T and B lymphocytes would be decreased, causing an inhibition of Ig class switch, either by alteration of primary or secondary stimuli or both .T. gondii IgM antibodies can be confirmed from the data of several works, depicted together in this review. Despite some diagnostic tests, such as the ISAGA, making IgM look more chronic than others, such as IFAT, it seems that high titers prevail when the avidity is low, but the latter does not always reflect the tachyzoite menace to the host in terms of symptoms or vertical transmission.The chronicity of the anti-We believe that there is more than one mechanism to explain the long-lasting IgM response, but some are less probable than others. For example, there is evidence that gestational sexual hormones can prolong the acute infection; nevertheless, this phenomenon is not exclusive of pregnant women; it also occurs in the acquired form of the disease and even in children with congenital infection. Likewise, reinfections could explain some but not most cases of persistent IgM, because they would provoke waves, not the slow decline observed. On the other hand, reactivation is not related to IgM, but to IgG raising, as in HIV patients or graft recipients.T. gondii could continuously induce IgM at low levels, but for long periods. Some strains could be more prone to provoke this stimulation, such as those of low virulence; the data from animals support this notion, although as far as we know, no long-lasting kinetic studies of IgM antibodies in experimental models have been performed.Here, we propose various mechanisms that could better explain “chronic IgM”, although there is direct evidence of none. Among them, micro-reactivation (excystment)–encystment cycles of T. gondii-reactive Rheumatoid Factor in humans and IgM anti-HSP70 in rodents, the latter produced by B-1 cells. The recent work with “bumble mice” showed strong evidence of the role of B-1 cells, although this was proven in reinfections.Other mechanisms we think may cause IgM chronicity include B-1 cell-derived natural antibodies, since there is evidence of Ig class-switch alterations caused by the parasite or by altering receptors, cytokines or signaling molecules are likely, since interference with them by the parasite has been shown. Nevertheless, these results have been obtained with other cell lineages that are activated by the same molecules and means, but not in T or B cells directly.T. gondii antibodies decline slowly after infection. The biological and clinical relevance of this phenomenon is unclear, since it has been observed in asymptomatic pregnant women and congenitally infected babies, as well as in symptomatic cases of the acquired form. The underlying mechanisms are variable, and all or some may be occurring under different circumstances.It is clear that IgM anti-


The Match in emergency medicine (EM) is historically competitive for applicants; however, the 2022 residency Match had a large number of unfilled positions. We sought to characterize the impact of and response to the Match on programs and determine programs’ needs for successful recruitment strategies.We conducted a web-based survey of EM residency program leadership during March–April 2022. Program characteristics were generated from publicly available data, and descriptive statistics were generated. We analyzed free-text responses thematically.There were 133/277 (48%) categorical EM residency programs that responded. Of those, 53.8% (70/130) reported a negative impression of their Match results; 17.7% (23/130) positive; and the remainder neutral . Three- and four-year programs did not differ in their risk of unfilled status. Hybrid programs had a higher likelihood of going unfilled  vs community  or university programs . Unfilled programs were geographically concentrated. The quality of applicants was perceived the same as previous years and did not differ between filled and unfilled programs. Respondents worried the expansion of EM residency positions and perceptions of the EM job market were major factors influencing the Match. They expressed interest in introducing changes to the interview process, including caps on applications and interviews, as well as a need for more structural support for programs and the specialty.This survey identifies impacts of the changed match environment on a broad range of programs and identifies specific needs. Future work should be directed toward a deeper understanding of the factors contributing to changes in the specialty and the development of evidence-based interventions. The National Resident Matching Program (NRMP) (the Match) in emergency medicine (EM) is historically considered competitive for applicants. By 2021, EM grew to comprise up to 8.1% of positions in the Match with nearly 100% program match rates.2The application and matching environment for EM has evolved over the past decade. The number of Accreditation Council for Graduate Medical Education (ACGME)-accredited EM training programs and associated training slots increased dramatically since 2016. Of the 95 new programs accredited by the ACGME since 2016, 41 were previously accredited by the American Osteopathic Association (AOA) and received ACGME-accreditation through the single accreditation system moving their positions and applicants into the Match.We sought to understand the needs and perceptions of the specialty’s residency training programs. The Council of Residency Directors in EM (CORD) conducted a survey to characterize the impact and response of programs to the 2022 EM Match. We hypothesized that the impact of the 2022 Match extended beyond the unfilled programs and that we could identify common needs to tailor future support interventions for all our programs.We conducted a survey of residency training program leadership  using a web-based survey distributed by Qualtrics  during the CORD Academic Assembly in March 2022 in San Diego, CA. Participation in the survey was solicited using QR codes during conference presentations, and the survey was also sent on the organization’s PD listserv during and after the conference to elicit responses from individuals who did not attend the conference.The survey included program demographic information and respondent’s role. Participants were also asked to indicate whether their program filled in the Match and whether it filled at, below, or above the expected level on their rank list. They were also asked to rank factors they believed may have contributed to the outcome. We created the survey based on knowledge of the literature and current conversations within the specialty. We all have significant expertise in residency administration with more than 50 cumulative years in residency leadership and ongoing involvement with EM education. The survey was pilot-tested with an expanded group of expert volunteers consisting of four current and former PDs, all of whom have experience with survey design. We refined the survey on their feedback prior to distribution. The survey is included as an We analyzed the data using Microsoft Excel 365  to calculate descriptive statistics and an online calculator for odds ratios (OR) and confidence intervals (CI).4What do we already know about this issue?The 2022 residency Match in emergency medicine had a large number of unfilled positions. No previous research has been published to explain the sudden change in the Match outcome.What was the research question?What was the impact of the 2022 Match on EM residency programs? What needs do programs have for the future?What was the major finding of the study?Perceived worsened Match results were mainly attributed to increased slots and the future job market. Application and interview processes were a major concern.How does this improve population health?These findings will help the specialty in developing program-level resources that will address future needs.To avoid over-weighting perspectives from a single program, data were sorted to select a single response per program. We used the following order of consideration to select responses when more than one was available per program: residency PD; residency coordinator; vice (or associate) chair or chair; APD; residency core faculty member; general faculty member. No questions were required in the survey. We used the American Medical Association’s publicly available portions of their Fellowship and Residency Electronic Interactive Database (FREIDA) of residency programs for self-reported demographic descriptions, and the Emergency Medicine Residents Association Match for training format.Of an initial 169 responses, 133 represented unique programs for a 48% (133/277) response rate of EM residency programs. Unique respondents for programs included 103 PDs (77.4%); 18 APDs 13.5%); four chairs including vice and associate (3.0%); four coordinators (3.0%); three clerkship leadership (2.3%); and one other (<1%). We compared demographics of responding programs with those of EM residency programs as a whole in %; four cOf the 69 unfilled programs, 26 responded to this survey (37.6%). Unfilled programs in our study were predominantly concentrated in four geographic divisions: Mid-Atlantic, East North Central, South Atlantic, and West South Central . The postgraduate year (PGY) 1–3 format programs were not more affected than PGY 1–4 . Programs self-described as community/university-affiliated (hybrid) programs had a much higher odds ratio at 4.52 (CI 1.7–12.4) of going unfilled in our sample than university  or community programs . Programs overall viewed their match outcome negatively with 70/130 (53.8%) responding that the overall quality of their match was a little or substantially worse than typical. Even when only filled programs were considered, 51/105 (48.6%) reported that their match outcome was worse than in previous years. A minority reported a better than usual perceived match outcome (23/130 (17.7%) all respondents; 23/105 (22.0%) filled programs only). Programs perceived the quality of applicants as similar to previous years. This did not significantly differ between filled and unfilled programs.P=0.7, ns). Neither did filled and unfilled programs differ significantly in the number of candidates they interviewed but elected not to place on their rank lists. Programs largely indicated that they would continue to interview about the same number of applicants in the next year , although unfilled programs were more likely than filled programs to indicate plans to expand the size of their interview pool .In general, programs reported interviewing an average of 14.2 candidates per residency position available . Unfilled programs averaged 13.9 applicants per residency position  with filled programs averaging 14.3 , which did not reflect a significant difference , with 75% (20/25 responding) reporting they were either extremely or somewhat satisfied with the quality of candidates in the SOAP. Programs averaged 3.2 open positions entering into the SOAP (range 1–10) with an average intern class size of 10 (range 6–16). Fifteen of 25 (60%) had more than one open position in the SOAP. Program needs regarding the SOAP largely centered on rapidly learning an unfamiliar process and the need for guidance and support.Respondents focused on the expansion of EM residency slots in both new (23.9%) and existing (19.4%) programs, as well as student perceptions of the future job market within EM (21.7%), as the major factors they felt influenced the 2022 Match. The unfilled programs focused on perceptions of future job prospects in EM (48.0%) and the virtual interview format (28.0%) as their major concerns.). The majority of the responses indicated a desire for structural changes in the interview process including placing caps on the number of programs that students may apply to as well as the number of interviews they may attend. Thirty-five programs  indicated that the number of interviews per applicant should be capped. There was also a significant interest in an in-person component to interviews .Programs identified their greatest needs for the future and resources from the CORD organization in free-text responses. These were grouped into themes . The majWe report data on program perceptions and experiences in the 2022 EM Match. Overall, we identified significant program-level concerns associated with the unprecedented number of unfilled residency positions and the need to unexpectedly use the SOAP. Recognizing that the depth of the rank order list (ROL) is not the same as true applicant quality, programs broadly reported that they went deeper into their ROLs than in previous years. This trend affected both filled and unfilled programs, which suggests that the changes in the Match environment itself are responsible rather than individual program factors. We did not identify a clear difference in numbers interviewed between filled and unfilled programs to account for different outcomes in the Match.One potential risk factor, which is suggested by our data, is the influence of geography on program outcomes. Our dataset, as well as the general NRMP data, show that the unfilled positions in EM were higher in certain geographic areas.Challenges with the application and interview processes were a major concern among our respondents. Programs expressed a desire for changes including interest in the implementation of program signaling, interview control (capping applications and interviews), and allowing an in-person component to the interview day . CurrentThere are undoubtedly external factors that may have influenced how students view the specialty including the dramatically tight job market in 2020 that was precipitated by the financial crisis with COVID-19.19This is somewhat reminiscent of anesthesiology’s challenges in the 1990s in which a major surplus was predicted.This was a voluntary survey subject to selection bias focused on organizational involvement with CORD. However, our 48% response rate is composed of a broad geographic and program-format sampling, which provides support for its conclusions. It is important to note that there are response biases in our sample with overrepresentation of filled programs and some geographic regions, which may have biased results. In addition, the issues around a successful Match are tied to program reputation, and responses may be impacted by social desirability bias given the identified nature of the data. While we recognize that disclosure and discussion of information by specific programs may be sensitive, this information is publicly available through NRMP reports.We present data from a survey of EM residency program leadership in the wake of the 2022 EM residency match, which identifies broad-based effects extending beyond the historic number of unfilled EM residency programs. In addition, the unfilled programs have needs for support including effective use of the SOAP program. Interventions at the specialty level will include a research agenda and development of program-level resources that will address these needs. Future work should be directed toward a deeper understanding of the factors contributing to these changes and the development of evidence-based policy interventions.


The Democratic Republic of the Congo (DRC) has a high measles incidence despite elimination efforts and has yet to introduce rubella vaccine. We evaluated the performance of a prototype rapid digital microfluidics powered (DMF) enzyme-linked immunoassay (ELISA) assessing measles and rubella infection, by testing for immunoglobulin M (IgM), and immunity from natural infection or vaccine, by testing immunoglobulin G (IgG), in outbreak settings. Field evaluations were conducted during September 2017, in Kinshasa province, DRC. Blood specimens were collected during an outbreak investigation of suspected measles cases and tested for measles and rubella IgM and IgG using the DMF-ELISA in the field. Simultaneously, a household serosurvey for measles and rubella IgG was conducted in a recently confirmed measles outbreak area. DMF-ELISA results were compared with reference ELISA results tested at DRC’s National Public Health Laboratory and the US Centers for Disease Control and Prevention. Of 157 suspected measles cases, rubella IgM was detected in 54% while measles IgM was detected in 13%. Measles IgG-positive cases were higher among vaccinated persons (87%) than unvaccinated persons (72%). In the recent measles outbreak area, measles IgG seroprevalence was 93% overall, while rubella seroprevalence was lower for children (77%) than women (98%). Compared with reference ELISA, DMF-ELISA sensitivity and specificity were 82% and 78% for measles IgG; 88% and 89% for measles IgM; 85% and 85% for rubella IgG; and 81% and 83% for rubella IgM, respectively. Rubella infection was detected in more than half of persons meeting the suspected measles case definition during a presumed measles outbreak, suggesting substantial unrecognized rubella incidence, and highlighting the need for rubella vaccine introduction into the national schedule. The performance of the DMF-ELISA suggested that this technology can be used to develop rapid diagnostic tests for measles and rubella. Measles and rubella (MR) cause a substantial public health burden and have been targeted for regional elimination. Measles caused an estimated 9.8 million cases globally in 2019, a 65% decrease from 2000 .The Global MR Elimination Strategic Plan 2012–2020 outlined recommended strategies including high coverage with two doses of MR-containing vaccines, effective disease surveillance, outbreak preparedness and rapid response, and research and development of improved diagnostic tools . ChallenThe Democratic Republic of the Congo (DRC) is a key country for measles elimination efforts in Africa because of its large population and geographic area, and central location with nine international borders . In DRC,Laboratory support for MR surveillance is provided by the WHO Global MR Laboratory Network  which suFor the evaluation of DMF-powered immunoassay as a surveillance tool in a suspected outbreak setting, a team comprised of members from DRC’s Institut National de Recherche Biomedical (INRB), U.S. Centers for Disease Control and Prevention (CDC), and University of Toronto (U-Toronto), supported measles surveillance field investigations in Kinshasa province 30 August–23 September 2017. Members reviewed weekly district-level reports from Integrated Disease Surveillance and Response with the Directorate General for Disease Control and direct notifications through case-based surveillance. The team visited all facilities in Kinshasa health districts reporting suspected measles cases, defined as fever and maculopapular (non-vesicular) rash and either cough, coryza, or conjunctivitis, or an illness a health-care worker suspected to be measles . FacilitWe conducted a household serosurvey 30 August–18 September 2017 in Biyela health zone, Kinshasa province, where a measles outbreak was confirmed in July 2017. The study area included an area surrounding the household of a confirmed measles case from the outbreak. Prior to the survey, a census of the study area was conducted 28–29 August 2017, in which all households with at least one eligible study participant (child aged 5–14 years or woman aged 15–49 years) were mapped and enumerated using tablets with EpiSample . A household was defined as individuals who slept under the same roof the night before the visit. Compounds with multiple structures and heads of household were treated as separate households. Sample size was based on an estimated 60% rubella IgG seroprevalence with desired precision of +/- 8% separately for children aged 5–14 years and women aged 15–49 years. To have a 90% probability of obtaining desired precision, final sample sizes for each group were 100 children and 100 women, or 200 total individuals.Using EpiSample, a random sample of 120 households (estimated number required to identify 100 children and 100 women) was selected from enumerated households in the study area; an additional 30 households were selected as backup if the sample size was not achieved from initial selection. Field team members used EpiSample to navigate to selected households. Three attempts were made to visit the 120 selected households before teams began visiting backup households. Any household with an eligible person was attempted for enrollment; where present within the same household, one woman and one child were randomly selected from among eligible women and children for enrollment.Field teams, comprised of a medical epidemiologist with training in phlebotomy, an epidemiologist, and a local community health agent, visited households. For each household, a questionnaire was administered to each participant after obtaining informed consent (or from the responsible adult for a child) including name, address, phone number, age, sex, pregnancy status, any symptoms at time of data collection or in the previous 28 days, prior measles diagnosis, vaccination history, and contact history. Vaccination history was verified by vaccination card, if available. GPS coordinates were recorded for each household. A blood specimen was collected by venous puncture from each consenting individual and transported to the field lab for processing. All questionnaires, enrollment forms and blood specimens were labeled with unique barcodes to ensure lab results matched correctly with each participants’ data. This study received ethical approval from the DRC’s University of Kinshasa School of Public Health Ethical Committee. The Office of the Associate Director for Science at the Center for Global Health, U.S. Centers for Disease Control and Prevention (CDC) determined the evaluation not to be human subjects’ research and approved it as a public health program evaluation activity, according to U.S. Department of Health and Human Services Human Subjects regulations and procedures. Because the evaluation was not human subjects’ research, a consent procedure was approved where verbal consent was obtained from participants at the beginning of the survey as part of a standard script, and refusal was documented on forms by survey teams.Surveillance specimens were tested for MR IgG and IgM antibodies, while serosurvey specimens were tested for MR IgG only. U-Toronto team members tested all surveillance and serosurvey specimens on the same day as collection if possible, or within 48 hours, by DMF-ELISA in the field lab which was erected outdoors each day in the affected health district. The field lab consisted of DMF instruments (MR Box 2) and cartridges, portable tables and chairs, and a canopy to cover the work area from sun. A sample of whole blood was aliquoted for testing by DMF-ELISA, while the remainder of the blood specimen was separated into serum using a portable centrifuge. Sera were stored and transported to a centralized lab for testing using Siemens Enzygnost MR IgM ELISA kits  at INRB in Kinshasa, DRC and Zeus MR IgG ELISA kits  at the CDC in Atlanta, USA; results were interpreted based on manufacturer specifications. Specimens sent to CDC for IgM testing were assessed using a Diamedix kit  for rubella IgM and a previously described CDC in-house measles IgM capture test .Magnetic-bead based immunoassays for four analytes (measles IgG and IgM and rubella IgG and IgM) and the MR Box 2 control system were designed and optimized in the laboratory in Toronto. Four MR Box 2 instruments and 1,000 cartridges were manufactured at U-Toronto and carried to DRC for the field trial. Positive and negative controls were included in each assay run and runs not meeting defined quality control criteria were excluded. DMF-ELISA results were normalized to account for differences in instrument, temperature, and humidity. Additional details are included in the Survey responses were collected on paper forms and entered in Epi Info version 7 . Double data entry was performed, and data discrepancies reconciled by reviewing the paper forms. All analyses were conducted using STATA v15, Microsoft Excel 2013, Prism 8, and Python. Descriptive analyses were conducted, including proportions, means, and standard deviations, using reference ELISA results from INRB and CDC. Vaccine effectiveness (VE) during active surveillance was calculated as (1—[Odds cases vaccinated/ odds cases unvaccinated]). Performance of DMF-ELISA was assessed in comparison to reference ELISA, including receiver operating characteristic (ROC) analysis and calculation of sensitivity, specificity, and overall agreement of MR IgG and IgM results. Specimens collected from both surveillance and serosurvey were included in this comparison.A total of 157 suspected measles cases were included in the surveillance study: among these, 86 (55%) occurred in female participants, and 90 (57%) in those aged <5 years. Measles IgM was detected in 20 (13%) cases; among these, 17 (85%) were <5 years of age, and three (15%) were 5–14 years. The proportion of suspected cases with detected measles IgM was highest among children aged <5 years (19%), compared with children aged 5–14 years (5%) and people aged ≥15 years (0%). Among 157 suspected cases, rubella IgM was detected in 84 (54%) cases; of which, 44 (52%) were among persons aged <5 years, 36 (43%) were 5–14 years, and four (5%) were ≥15 years. Proportions of suspected cases with detected rubella IgM were slightly higher in the age groups for ≥15 years (66%) and 5–14 years (59%), followed by <5 years (49%) .± 2.3). Compared with confirmed rubella, a higher proportion of persons with measles IgM reported having fever , runny nose (86% and 100%), cough (73% and 100%), or red eyes (67% and 90%) currently or within the previous 28 days; compared with confirmed measles, a higher proportion of persons with rubella IgM reported a history of swollen glands .Twenty-two (16%) persons reported a rash onset 0–3 days prior to sample collection; of these, three (14%) tested positive for measles IgM, and 11 (50%) tested positive for rubella IgM. One hundred six (76%) persons reported a rash onset 4–28 days prior to sample collection; of these, 12 (11%) tested positive for measles IgM and 59 (56%) tested positive for rubella IgM. Mean number of days reported since rash onset was 23  were seropositive for measles IgG, and 110 (70%) were seropositive for rubella IgG. All 20 persons among whom measles IgM was detected were also seropositive for measles IgG, and 82 (98%) persons among whom measles IgM was detected were also seropositive for rubella IgG. Children with MR IgG detected were higher among ages 5–14 years (92% measles IgG and 85% rubella IgG) than <5 years (80% measles IgG and 58% rubella IgG); 100% of suspected cases among persons aged ≥15 years had detectable MR IgG, but the number of suspected cases in this group was small (n = 6). Persons with detectable rubella IgG were higher among females (76%) than males (63%), while persons with detectable measles IgG were similar by sex (85% and 86%).Of 157 suspected measles cases, 118 (75%) reported having received MCV; however, only 15 (13%) had documented vaccination status. Among 118 persons with reported MCV, measles IgM was detected in eight (7%), while measles IgM was detected in 12 of 29 (41%) reported unvaccinated persons . Twelve A total of 427 households were enumerated in the survey area with a recent confirmed measles outbreak, and 145 households were visited for consent and enrollment. Of these, 125 (86%) consented to participate, eight (6%) refused, and 12 (8%) were absent . A totalThe MR Box 2 instrument, method, and cartridges featured a long list of advances relative to what was previously described , includiIn the comparison of specimens tested on-site using the MR Box 2 with reference testing at INRB and CDC, a total of 14.5% of test specimens  were excluded for not meeting quality control standards. For measles IgG specimens (n = 305), the area under the curve (AUC) for ROC analysis was 0.86. Compared with reference ELISA, sensitivity of the measles IgG DMF-ELISA was 82% , specificity was 78% , and overall agreement was 81% . For measles IgM specimens (n = 129), the AUC was 0.93, and sensitivity, specificity, and agreement were 88% , 89% , and 88% , respectively .For rubella IgG specimens (n = 308), the AUC was 0.91, sensitivity was 86% , specificity was 85% , and overall agreement was 86%  . For rubThis study in DRC found that upon serologic confirmation of suspected measles cases, most infections were caused by rubella, similar to previous reports . WithoutConfirmed measles cases with detectable measles IgM were more likely to be young (85% aged <5 years) and unvaccinated against measles (60%), indicating gaps in DRC’s vaccination program. Previous assessments in DRC identified suboptimal measles protection and observed deficiencies in routine immunization, including failure to vaccinate and reduced VE –16. VE iSeroprevalence for measles was 93% for both children and women, which was likely a combination of both protection from vaccination and natural infection related to the recently confirmed measles outbreak in the area. While only 83% of children and 62% of women reported vaccination against measles, it is difficult to precisely determine the contribution of immunization to high measles seroprevalence, as recall of vaccination status is generally unreliable , especiaAmong those in whom rubella IgM and IgG were detected during active surveillance, a majority  were female, and nearly half (48%) of those with detected rubella IgM were aged >5 years. A difference in rubella IgG seroprevalence was observed between children  and adult women  during the serosurvey. With a lack of rubella vaccination and a high proportion of persons with rubella IgM detected among older ages groups, young women reaching adulthood in DRC may be left at higher risk of infection during pregnancy and higher CRS risk for their infants . This fuad-hoc for use with different assay configurations based on need.The first use of the prototype DMF-ELISA for MR IgG testing in Kakuma Kenya during 2016 demonstrated a potential role for the diagnostic tool in remote areas with limited access to centralized laboratories . FollowiThis study had some limitations. First, the serosurvey excluded children aged <5 years due to challenges with collecting blood intravenously from small children; this would have been a valuable age group to assess for measles seroprevalence. Second, DMF-ELISA testing was performed by expert users, and results were not available in real time due to the need for subsequent adjustment and interpretation of results; the ELISA results used in the investigation and presented here were not impacted by this limitation. Third, participant recall was relied upon for history of vaccination and clinical symptoms, but accurate recall likely varied with time from the event.A high percentage of people with suspected measles in in this outbreak setting were found to have rubella (54%), highlighting the unrecognized burden of rubella in this community and the need for better diagnostics to investigate outbreaks of rash illness. Additionally, lower rubella IgG seroprevalence occurred in older children, and a high proportion of cases with detectable rubella IgM occurred in older age groups, raising concerns around CRS risk for young women. The Kinshasa outbreak investigation documented high VE against measles among suspected measles cases, confirming that gaps in vaccination were the likely outbreak cause. The serosurvey documented high measles seroprevalence in a community that had recently experienced a measles outbreak. Findings from our field investigation in Kinshasa supported the need for introduction of RCV in DRC and further assessments in other countries that have not introduced RCV and have frequent outbreaks of suspected measles.S1 File(PDF)Click here for additional data file.


The Age Friendly University (AFU) initiative provides a vision to inspire institutions of higher education to respond to the interests and needs of an aging population to promote well-being and quality of life. At Central Connecticut State University (CCSU), we have utilized multiple strategies to engage collaborators within our university and our community to further age-inclusive efforts. The purpose of this presentation is to describe the ongoing collaboration, through the Matter of Balance program, with the Connecticut Healthy Living Collective, an emerging hub of state, regional and local agencies and organizations dedicated to healthy aging in communities throughout our state. The Matter of Balance program is an empirically supported community-based treatment to reduce fear of falling among older adults. We will first discuss the pilot internship program offered within the Department of Psychological Science that trained students as program facilitators which was cut short in Spring 2020 due to COVID 19. We will then describe “Version 2.0” of the collaboration which was offered in the Spring 2022 semester. This time, it was grounded in a gerontology internship course that expanded to include research, faculty, and student collaboration with the Department of Physical Education and Human Performance. In addition to providing these overall descriptions, the presenters will review the strengths and challenges of each approach, share results about the students’ experiences, and highlight the multidimensional value this intentional effort offers.


Having advanced cancer presents many challenges for patients and family caregivers. The FOCUS program is a psychoeducational nurse-led intervention, developed in the USA, to support dyads of patients with cancer and their family caregivers to live with the illness. The program includes a conversation manual and information resources for dyads. We aimed to develop a version of the program for dyads facing advanced cancer in six European countries.The Participatory and Iterative Process Framework for Language Adaptation (PIPFLA) was used to guide the translation of the program to the local contexts of Belgium, Denmark, Ireland, Italy, the Netherlands, and the UK. In several rounds, potential program users  and researchers from all six countries reviewed program materials and advised on adaptations.The PIPFLA process resulted in one European version of the program in different languages (FOCUS +). The FOCUS + conversation manual is uniform across all countries. The main adaptations included additional attention to both family caregiver and patient needs; more emphasis on self-management, advance care planning, and shared responsibilities; discussing the dyad’s outlook rather than optimism; addressing the role of nurses as educational rather than therapeutic; and more suggestions to refer dyads to health care professionals for specific care needs. The information resources for dyads were adapted to fit with local contexts.The PIPFLA methodology is an efficient and effective framework to thoroughly translate and culturally adapt a complex USA-based program for use in six European countries in collaboration with end users.The online version contains supplementary material available at 10.1007/s00520-022-07391-x. Advanced cancer substantially affects the lives of patients and their relatives, with many relatives taking up a role as informal family caregiver , 2. FamiSeveral interventions have been developed to jointly support persons with advanced cancer and their family caregivers –15. One Since the program’s start in 2002, it has been delivered to dyads in different regions in the USA facing different types and stages of cancer . The program has been tested extensively with positive outcomes for both patients and their caregivers . These pThe translation and adaptation of the FOCUS program was part of the DIAdIC project, a research program to evaluate Dyadic Psychoeducational Interventions for People with Advanced Cancer and their Informal Caregivers in an international randomized controlled trial. The countries involved in this study are Belgium, Denmark, Ireland, Italy, the Netherlands, and the UK (Northern Ireland and England). We used the Participatory and Iterative Process Framework for Language Adaptation (PIPFLA) to linguistically and culturally adapt the FOCUS program 23). PIPFLA was originally developed to translate and adapt an American-English intervention into an American-Hispanic intervention, using input from the perspectives of the intended users  and the perspectives of outsiders, such as researchers or politicians . The PIPFLA consists of multiple steps: (1) preparation, (2) forward translation, (3) backward translation, (4) review of backward translation, (5) harmonizing, (6) review by reference group (emic perspective), (7) harmonizing, (8) review by reference group (etic perspective), (9) harmonizing, (10) proofreading, and (11) final language adaptation [. PIPFLA Whereas the original PIPFLA approach assumes that a program is in principle suitable for the new context and starts with its linguistic translation, we started with a general assessment of the suitability of the program in each of the countries Table . We exteAll steps of the translation and adaptation process were followed as planned, resulting in an adapted version of the FOCUS program: the FOCUS + program. The FOCUS + conversation manual for nurses is uniform across all countries, with country-specific aspects in terms of language. For sensitive topics, such as the end of life and sexuality, slight deviations from the original wording were allowed if these were considered more appropriate. The additional information materials and resources for the dyads are largely country-specific and adapted to national healthcare systems and regulations.Needs and wishes of the family caregiverIn the original FOCUS program, the family caregiver seems primarily positioned as a person supporting the patient. Reference groups of researchers and users advised putting more emphasis on the impact of the patient’s illness on family caregivers themselves. In FOCUS + , the values and needs of both individuals within the dyad are addressed equally. Questions about family concerns were added, and questions focusing primarily on the patient in the original FOCUS program were revised and directed towards the dyad.Self-managementSeveral items in the original FOCUS program were considered to be too normative or prescriptive in the local culture of the six countries, such as the sentence instructing the nurse to “teach (the dyad) about benefits of active versus passive coping strategies.” Furthermore, a normative or prescriptive approach was considered not to comply with current views on the enhancement of self-management. Members of reference groups in several countries suggested that, whereas self-management at the beginning of this century focused on treatment compliance, it is nowadays, and in the context of advanced cancer, seen as more comprehensively “managing the physical, psychosocial and existential consequences of living with a progressive and life-threatening disease and its treatment” . As a reThe concept of optimismThe emphasis on “optimism” as the preferred mindset in the FOCUS program was considered too normative in the context of advanced cancer by most of the reference groups. According to the reference groups, the original approach seemed to suggest that it is best for dyads to be optimistic, where it may also be beneficial to acknowledge and discuss negative or pessimistic feelings of the patient, the family caregiver, or both. Therefore, the reference groups recommended the use of a more neutral approach to give dyads the opportunity to discuss both positive and negative feelings. “Outlook” was considered to be a more neutral term and a better fit with the European context. Therefore, the term “Optimism” in the original FOCUS program was changed to “Outlook” in the European FOCUS + program. The item “optimism assessment” was changed into “assess the dyad’s outlook about their situation.”The supportive and educational character of the programAccording to several reference groups, some wording in the original FOCUS manual seemed to have “therapeutic” or psychological care-oriented intentions. Psychological interventions were considered not to be a formal responsibility of nurses in the European countries involved, which may be different from the role of (oncology) nurses in the USA. A consensus was reached that the goal of the FOCUS + program should be framed as improving the dyad’s self-management and self-efficacy by providing information and psychoeducation. Adaptations were made to emphasize the supportive and educational nature of the nursing intervention.The order of topicThe reference groups recommended changes in the order of the topics in the manual. For example, discussing concerns about children was part of the third session of the original FOCUS program. This topic was moved to the first session in the FOCUS + program, because reference groups stated that it is a priority for many patients and family caregivers. Another example is the topic of intimacy and sexuality. In the original FOCUS program, this topic is discussed in the second meeting, which is conducted by telephone. Discussing a potentially sensitive topic such as intimacy and sexuality over the phone was considered inappropriate. In the European program, this topic is therefore discussed in the second face-to-face meeting at the patient’s home.Referral to health care professionalsAdaptations to the original FOCUS manual address seven themes or areas. Specific examples of adaptations are included in Table Both FOCUS and FOCUS + include referrals to additional information resources where this may be helpful. In case a dyad has specific questions about the diagnosis and treatment options, the intervention nurse is expected to provide such information in the original program. In FOCUS + , dyads are referred to their attending health care professionals. This decision was made because the complexity of current individualized and targeted therapies in oncology treatment may exceed the knowledge and competencies on FOCUS + intervention nurses.In addition to the manual for nurses, the original FOCUS program includes a wide collection of additional information resources, such as leaflets about therapies, booklets on physical, social, psychosocial, or spiritual consequences of cancer, and websites to various American guidelines and resources. Because each country was expected to have many equivalents of the materials, translation of all original materials was judged not to be necessary. In addition, original American materials often did not comply with the diversity of healthcare services and support in Europe.Therefore, each country selected national equivalents of the original USA leaflets and booklets, with an even wider range than the original FOCUS materials in terms of content, format, and application level, varying from hospital-based to national guidelines. During the evaluation of the national equivalent materials, some of them were updated because of the availability of new treatment or new communication options.The project management team recommended integrating all information resources into one booklet. This booklet was developed by the project management team and follows the structure and content of the conversation manual so that it can serve as a reference book for dyads in all stages of the intervention and beyond. The booklet was tailored to the dyad, e.g., by including exercises about dyadic communication.This paper presents the systematic translation and cultural adaptation of a psychoeducational program, originally developed and evaluated in the USA for dyads of cancer patients and family caregivers, to a European dyadic program for patients with advanced cancer and family caregivers. The main themes of adaptations of the FOCUS + manual for nurses were the needs and wishes of the family caregiver; self-management; the concept of optimism; the supportive and educational character of the program; the order of topics; and referral to health care professionals. The additional information resources for dyads were adapted to local contexts.The PIPFLA was found to be a useful framework to develop a program that fits into the living context and treatment of the target group while remaining faithful to the original program. The main feature of PIPFLA is the structured participation of various stakeholders in the translation process, ensuring input from the perspectives of potential end users (“emic”) and scientific experts (“etic”). Using these perspectives together may cause tension, for instance, when negotiation is needed to resolve differences between end users’ preferences and scientific guidelines. This usually does not outweigh the benefit of incorporating both perspectives . In our As the six European countries differ in language, culture, and the organization of healthcare, the translation and adaptation process took time, negotiation, and compromise. For example, addressing “end of life” issues requires nurses to take a careful and empathetic approach with dyads. Both patients’ and family caregivers’ perspectives in each country made a meaningful contribution to discussions about this item. In their opinion, it is important that the nurse gives dyads the opportunity to talk about the end of life and that the nurse would do this sensitively using a more indirect approach. Nurses from each country would use local terminology which is appropriate for this sensitive approach. There were also topics on which all reference groups agreed, such as replacing the concept of optimism to outlook. This example took less time to discuss.The PIPFLA aligns with ADAPT guidance on adapting interventions to new contexts. ADAPT is an update of the well-known Medical Research Council guidance, published in November 2020 . The ADAThe European FOCUS + program will be evaluated in an international randomized controlled trial. Studying the effectiveness of a complex psychoeducational intervention requires standardization. However, complex interventions may work best when tailored to local circumstances rather than being completely standardized , 28. We,Although nurses are increasingly aware of the needs of patients and their relatives, their approach to identifying and discussing those needs is typically unstructured with supportive tools lacking , 30. TheTransforming the American nurse-led FOCUS program for persons with advanced cancer and their family caregivers to a European FOCUS + version to be implemented in six countries  required a series of country-specific adaptations. Our study shows that the PIPFLA methodology provided an efficient and effective framework for the translation and adaption of such a complex psychoeducational intervention. PIPFLA enabled us to make cultural and linguistic adjustments together with the end users, while staying close to the original program.Supplementary file1 (DOCX 20.1 KB)Below is the link to the electronic supplementary material.


This symposium reports evaluation findings from the Right Care, Right Place, Right Time (R3) program. The initiative is designed to integrate housing, health, and supportive care to residents of affordable senior housing using a wellness team . The embedded team works directly with residents to address health-related, educational, and informational needs and access to services - focusing on proactive outreach and prevention, coordination with providers, constant contact with residents, and targeting high-risk residents. The initiative aims to create a replicable, scalable, and sustainable model of housing with supportive services that enables independent living while reducing health care costs. Two wellness teams served approximately 400 participants at seven Boston-area buildings. The R3 program was implemented in two phases. The 18-month pre-intervention period was January 2016-March 2017, while the 18-month Phase 1 intervention period was July 2017-December 2018. The 21-month Phase 2 implementation period (known R32), which introduced a targeting strategy to identify high risk residents, was January 2019-September 2020. Evaluation activities included quantitative and qualitative components. Program participants and non-participants at intervention and comparison sites were surveyed on program-related experiences. Program, housing, and community partners were interviewed. Key performance indicators were tracked. Medicare claims data were analyzed using comparison groups. Focus groups were completed with payers, housing providers, and community stakeholders. The purpose of this symposium is to identify the experiences of program participants and key stakeholders with the R3 program, and to assess program impact. Edward Miller and Marc Cohen will serve as chair and co-chair, respectively.


The recycling and reuse of construction waste have not only effectively protected natural resources but also promoted the sustainable development of the environment. Therefore, in this article, waterborne polyurethane (WPU) as a promising new polymer reinforcement material was proposed to reinforce the road demolition waste (RDW), and the mechanical performance of WPU-reinforced RDW (named PURD) was investigated using triaxial unconsolidated and undrained shear (UU) and Scanning Electron Microscope (SEM) tests. The results showed that under the same curing time and confining pressure, the shear strength of PURD increased with the increase in WPU content. When the WPU content was 6%, the WPU presented the best reinforcement effect on RA. The failure strain of PURD increased with the increase in confining pressure, but increased first and then reduced with the increase in WPU content. The specimens with 5% WPU content showed the best ductility. At the curing time of 7 and 28 days, the internal friction angle and cohesion of PURD increased with the increase in WPU content, and they reached a maximum when the WPU content was 6%. The internal friction angle barely budged, but the cohesion increased obviously. The enhancement effect of WPU was attributed to the spatial reticular membrane structure produced by wrapping and bonding particles with the WPU film. Microscopic analysis showed that with the increase in WPU content, the internal pore and crack size of PURD gradually decreased. As the WPU content increased, the WPU film became increasingly thicker, which increased the adhesion between WPU and RA particles and made the structure of PURD become increasingly denser. Over the past few decades, infrastructure construction has flourished due to widespread urbanization, the world population soaring, and the changing economic landscape of the developing countries ,2. This In the process of pursuing sustainable development in the construction industry, cement production consumes a lot of energy and emits a large amount of greenhouse gases, and the total emission accounts for about 8% of the total global carbon dioxide emissions ,17,18. TCurrently, the high-molecular polymers have been applied in the reinforcement of building materials, among which polyurethane is particularly prominent in improving strength and stability ,28,29,30In summary, it is found that due to the pollution problems caused by the use of cement and the accumulation of construction waste, as well as the shortcomings of high energy consumption in the mining of construction materials, the current society urgently needs to find new environmental protection reinforcement materials and resource utilization methods of construction waste to alleviate the pressure on the environment and resources. At present, a large number of research works mainly focuses on natural building materials such as sand, marine clay, gravel, and concrete, while the research on recycled building materials is relatively rare. Therefore, using waterborne polyurethane as a new environmental protection reinforcing material to study its effect on the mechanical properties of recycled aggregate can realize the engineering recycling of building materials, to achieve the social benefits of protecting the environment and saving resources. Meanwhile, the abundant research work has only explored the compressive strength, flexural strength, shear modulus, and damping ratio of various building materials, and has not yet conducted in-depth research on shear strength.The objective of this paper was to explore the effect of WPU on the triaxial shear strength of RA by unconsolidated undrained shear (UU) tests on the WPU-reinforced RA (PURD) specimens under different ages, confining pressures, and contents of waterborne polyurethane. Meanwhile, the microstructure of PURD was characterized by scanning electron microscope (SEM) tests to explore the WPU reinforcement mechanism on RA.2 and CaCO3. The acquisition process of RA required for the test is shown in The RA was collected from the abandoned road section of Erhuan North Road, Shaoxing City, Zhejiang Province, which was the mixed gravel after the crushing of the roadbed base material. The main chemical components of RA are SiOThe RA was reinforced by WPU with four contents. The WPU solutions were diluted with water to a solution with a low content, and then the RA was mixed with WPU. The specific test scheme is shown in The WPU content in the test scheme is the mass ratio of WPU and RA, and the solid content of the solution needs to be considered. The moisture content of the specimen was set to 16%, the main purpose was to keep consistent with the natural moisture content of the RA, and the moisture contained in the WPU solution should be considered. The calculation process of the test mix proportion is shown in Equations (1) and (2).The preparation process of the UU test specimens in this study is divided into the following steps see  as per t(1)The RA was placed in a constant-temperature oven at 105 °C for 24 h to ensure that the moisture in the RA was completely dried, and then cooled to room temperature.(2)The corresponding qualities of the RA, WPU solution, and water were weighed according to the mix proportion set in (3)An amount of 154 g of the mixture stirred evenly was shaped in a cylindrical mold with a height of 80 mm and a diameter of 39.1 mm. It must be fully compacted with a jack and statically pressed for 10 min.(4)The specimens were demolded after being fully compacted. Then, the specimens were cured in a standard curing box for 7 and 28 days, respectively. The curing temperature was controlled at 20 ± 2 °C, and the relative humidity was >95%.The samples for the SEM test were from the dried sample blocks of broken sample in the UU test. A layer of conductive adhesive was pasted tightly on the sample with a thin rod, and then the specimen particle powder on the surface was blown away with a suction balloon to avoid polluting the instrument lens.The instrument used in the UU test was a fully automatic triaxial shearing instrument (TKA.TTS.3S) produced by Nanjing, China, TKA Technology Co., Ltd. The four confining pressures  were applied, and the loading rate was set to 1 mm/min. According to the relevant provisions of the Standard for geotechnical testing method (GB/T 50123-2019) , after tThe equipment used for the SEM test was a high- and low-vacuum scanning electron microscope (JSM-6360LV), which is produced by Tokyo, Japan, Electronics Co., Ltd. The specimens damaged from the UU test were placed in an oven for 24 h, and the test was performed after the specimen was dry. Finally, the SEM images were taken under different magnifications, and the magnifications of this study were selected as 500× and 2000×.According to the deviatoric stress q and the axial strain ε obtained from the test, the deviatoric stress–strain relationship curves of PURD specimens are drawn in qmax, kPa, which can reflect the shear strength of PURD. According to the deviatoric stress–strain curves of PURD from By further analyzing The curing time of cement-based materials has an important influence on the strength of the specimen. Cement usually completes almost all hydration reactions when curing for 28 days, and the strength of the specimen will increase significantly compared with that under the curing time of 7 days. Therefore, it is necessary to explore the effect of curing time on WPU-strengthening RA ,45. CompThe strain corresponding to the peak strength of PURD in the deviatoric stress–strain curve in According to Comparing the failure strain of PURD with different WPU contents, it can be found that the failure strain of PURD increases first and then decreases with the increase in WPU content under the curing time of 7 and 28 days. Under two curing times and four confining pressures, the failure strain of PURD-5 reaches the maximum value. Compared with PURD-3, the failure strain increases by 41%, 50%, 124%, and 99% at the curing time of 7 days, and increases by 61%, 37%, 31%, and 41% at the curing time of 28 days, respectively. The growth rate is relatively large. The above analysis shows that PURD-5 exhibits the best ductility, mainly because the increase in WPU content will make the cementation between the RA particles more obvious, and there will be a certain “pulling” effect between particles to prevent brittle failure . Howeverσ as the abscissa, the shear stress τ as the ordinate, (σ1f + σ3f)/2 as the center, and (σ1f − σ3f)/2 as the radius, the limit Mohr stress circle is drawn on the τ-σ stress plane diagram. Then, the common tangents of the Mohr circle under four different confining pressures are drawn, which are the shear strength envelopes of the limit Mohr stress circle, where σ1 represents the large principal stress, σ3 represents the small principal stress, and the subscript f represents the limit equilibrium state, that is, the molar stress circle is tangent to the shear strength envelope, which means that the shear stress on the τ-σ stress plane is equal to the shear strength. Based on this, the limit Mohr stress circles and shear strength envelopes of PURD with different WPU contents under 7 and 28 days of curing time were drawn, respectively WPU can obviously improve the shear strength of RA. The shear strength of PURD increases with the increase in WPU content. When the WPU content is 6%, the shear strength reaches the maximum value, which is nearly 30% higher than that of PURD-5. However, the curing time has little effect on the reinforcement effect of WPU, and the increase in shear strength can be ignored. Therefore, WPU can directly exert all strength effects in a short curing time, and is relatively flexible in engineering application, which is a very effective and promising new type of high-molecular polymer reinforcement material.(2)WPU has great influence on the ductility of RA. The failure strain of PURD increases with the increase in confining pressure, and first increases and then decreases with the increase in WPU content. The failure strain of PURD-5 reaches the maximum value. Compared with PURD-3, the failure strain of PURD-5 increases by 41%, 50%, 124%, and 99% at 7 days and 61%, 37%, 31%, and 41% at 28 days, respectively. The growth range is large, so PURD-5 shows the best ductility.(3)WPU can obviously increase the cohesion of RA. The internal friction angle and cohesion of PURD increase with the increase in WPU content, which is highly consistent with the change law of shear strength. However, the increase in internal friction angle is small, only about 5%, and the increase in cohesion is obvious. At the curing time of 7 days, the cohesion of PURD-6 increases by 144%, 142%, and 91%, respectively, compared with those of PURD-3, PURD-4, and PURD-5. At the curing time of 28 days, the cohesion of PURD-6 increases by 141%, 134%, and 77%, respectively, compared with those of PURD-3, PURD-4, and PURD-5.(4)The enhancement effect of the polymer can be attributed to the spatial reticular membrane structure produced by wrapping and bonding particles with the polymer film. With the increase in WPU content, the internal pore and crack size of PURD gradually decreases, and the number of them also decreases. Meanwhile, the polyurethane-wrapped RA particles gradually form agglomerates and finally produce a large number of polyurethane films. With the gradual increase in WPU content, the polyurethane film becomes increasingly thicker, which makes the bonding effect of the polyurethane on the RA particles become increasingly stronger, and the overall structure of the PURD becomes increasingly denser.(5)In this test, the mechanical strength of RA is obtained on the basis that the mud content is 20.5%. If different practical projects need to obtain higher mechanical parameters, it is necessary to reduce the mud content of RA. Similarly, if the engineering has low requirements for mechanical parameters, the requirements for mud content can be appropriately relaxed. Thus, the processing steps for RA can be appropriately reduced.To explore new environmentally friendly reinforcement materials and realize the recycling and utilization of construction waste, a new reinforcement method using PU to enhance RDW was proposed in this study, thus reducing the environmental pressure and resource shortage. The UU test and SEM test were conducted to investigate the reinforcement performance and mechanism of PU. The main conclusions are presented as follows:


The language was adjusted to ensure content accessibility and semantic and conceptual equivalence. Finally, references to several cultural aspects, such as habits, customs, and traditions, were adapted to fit the new cultural context. The UCLA program may be a promising tool to help alleviate the cognitive difficulties reported by cancer survivors in different cultural contexts. Future research is needed to confirm the feasibility, acceptability, and preliminary efficacy of its Portuguese version, “CanCOG®—Reabilitação Cognitiva no Cancro”.Cognitive difficulties are highly prevalent and negatively impact cancer survivors’ quality of life. The UCLA Cognitive Rehabilitation Intervention Program  is an evidence-based intervention developed and tested in the US to address the cognitive complaints of cancer survivors. Since there are no cognitive rehabilitation programs available for Portuguese cancer-related settings, this study aimed to culturally adapt the UCLA program to Portugal. Nine steps were implemented for this cultural adaptation: needs assessment, initial contacts, translation, cultural adaptation, independent review by a panel of experts (n = 6), focus group discussions with cancer survivors (n = 11), systematization of inputs and improvement of the final materials, fidelity check, and preliminary acceptability assessment. The findings suggested that changes to the original materials were needed. A Portuguese name, “CanCOG Some participants highlighted the positive effect of these approaches on returning to work after diagnosis in promoting greater acceptance and adaptation to new difficulties and demands. The potential contact with other cancer survivors was also reported as a benefit of participating in the intervention by enhancing the sharing and mutual validation of the difficulties and feelings experienced: “The symptoms we experience are not just us who have them, there are other people who have them too, and it’s normal, so we don’t get so worried.” .Regarding benefits, participants consistently reported that the intervention could contribute to recognizing and minimizing the negative impact of treatments on cognitive function  by providing useful “tips” and “tools” for daily routine: I got very affected in terms of memory, essentially. I feel a really big difference. And I am motivated by the fact that perhaps I can improve (…), the exercises make me improve.” . A major barrier anticipated to be an obstacle to participation was the time spent in the sessions and displacements and the consequent articulation with professional and family activities. For this reason, online interventions, identified as a preference for most participants, were perceived as an alternative to manage this limitation: “I think that online becomes simpler because of traveling and time, and we can, perhaps, do as much online at home as I can do at work, at the end of the day. I think it becomes easier for that.” .Among the main motivations for participating in a cognitive rehabilitation program, cancer survivors identified informational needs related to understanding the causal relationship between treatments and cognitive difficulties. A motivating factor for participation was also the perception of real difficulties at the memory level and the expectation of improvement through the intervention: ““I think so. Because some of these exercises are for memorization, well, for memorization… concentration… of sequences” (…) I think that in general, these exercises are transversal to most professions, some apply on one side, others apply on the other.” . However, for some participants, low levels of literacy and/or more limited intellectual and cognitive abilities were noted as potential barriers to performing exercises with greater complexity. The frequency and duration of the sessions  was also considered adequate, especially if they were held in an online environment with greater schedule flexibility. All participants recognized the importance of doing the exercises outside the sessions to complement the intervention and showed openness to fitting them into their daily routines.Regarding the appraisal of the content and structure of the program, all participants showed a high level of acceptability. Most survivors reported that the exercises included in the intervention proposal trained different cognitive abilities, were suitable for various audiences , and presented an appropriate degree of difficulty: Draft 2 version of the program. All adaptations were reported in a template created by the research team, similar to Final Version of the program was finally achieved. Future steps include implementing this version to test its acceptability, feasibility, and efficacy among Portuguese non-CNS cancer survivors.Contributions that emerged from the expert panel and target population appraisals were finally systematized through meeting discussions among the Portuguese research team. Together, these contributions provided important inputs to improve the text materials of the program. These steps resulted in the ®—Cognitive Rehabilitation in Cancer. As highlighted by initial data from the needs assessment  [Although cancer survivors reported positive feedback concerning the expected benefits of the program, potential challenges and barriers to a successful implementation of the intervention were also identified. Time spent in sessions, displacements, and consequent articulation with professional and family activities were pointed out as the main obstacles to participation. This is an important finding from this study since the literature is scarce regarding the experience and needs of cancer survivors with CRCI in cognitive rehabilitation intervention programs. An important qualitative study exploring the perceived facilitators and barriers to interventions found that ease of use, accessibility, and convenience are crucial to facilitate participation, while cost, time, intensiveness, and distance to travel hampered participation . These rer 2022) , which wer 2022) ), provider 2022)  noticed This paper adds to the literature in several ways: (1) this is the first experience of adapting the UCLA program to a different language and cultural context and, therefore, it can provide guidance for other researchers that propose to do the same; (2) this is the first attempt, to the best of the authors knowledge, of adapting a cognitive rehabilitation program to a different country, based on a proposed model that aggregates different international guidelines with strategies from both bottom-up and top-down approaches, including multiple stakeholders; thus, this model can be replicated in the future to adapt other cognitive rehabilitation programs for other populations; (3) as this study demonstrates, successful cultural adaptation of a cognitive rehabilitation intervention is a planned, organized, iterative, and collaborative process ; it is hhttps://www.ipaac.eu/res/file/outputs/wp4/practices-recommendations-cancer-cognitive-impairements.pdf accessed on 21 October 2022), where the CanCOG® program is indicated as one of the ongoing works to offer cognitive management in Europe. The study also highlights that CRCI should be a priority in multidisciplinary national and European cancer control programs. This is particularly important since CRCI has been under-addressed by oncology specialists, who are uncertain of potential management strategies [Finally, it should be noted that the adaptation of the UCLA program and development of a Portuguese version is highly relevant because it aligns with the aims of the European Consortium of Cancer and Cognition (ECCC), which states that post-cancer care cognitive intervention rehabilitation programs for CRCI should be promoted . As theirategies ,90, and rategies ,92.This paper describes the process of cultural adaptation of the UCLA Cognitive Rehabilitation Intervention Program to Portugal. The main changes introduced to the original program materials are presented and discussed. A specific cultural adaptation model of nine steps for cognitive rehabilitation programs was proposed to adapt the UCLA program to the Portuguese context, which others can find useful if they attempt to undertake similar projects. Analysis of the main differences between the participants in the original program implementation and potential Portuguese participants was important to inform and guide the necessary changes; furthermore, the dynamic collaboration among project researchers and stakeholders, namely experts and the target population, was paramount to the implementation of these changes. Future studies will include implementing the original face-to-face group format and an equivalent individual web-based format to confirm their acceptability, feasibility, and efficacy in Portuguese cancer survivors. This type of program is an essential clinical tool to alleviate CRCI among cancer survivors and help improve their QoL. In Portuguese cancer-related settings, this program is a valuable contribution considering the absence of specific cognitive rehabilitation interventions for this population.


Children that are `looked after' include those that are accommodated in foster, kinship and residential care placements, as well as those at home on compulsory supervision. They have poorer physical and mental health than their peers and there are concerns about the relatively high levels of untreated morbidity. Oral health and access to dental services among Looked After Children (LAC) has received limited attention to date. The objective of this study was to compare the oral health and access to dental services of children who are looked after by the state, with comparable children in the general population. School and Social Work datasets were able to be linked using the Scottish Exchange of Data (ScotXed) Unit. This in turn was linked with health data making use of the Scottish national record-linkage system provided by the NHS eDRIS team for the FARR Institute Scotland. All of the following datasets used in this study are complete national datasets for the time periods noted.School Pupil Census 2012: a census of children in local authority primary and secondary schools that provides each child’s age, sex and socioeconomic status as measured by the Scottish Index of Multiple Deprivation (SIMD). The other datasets cover the period 2008-2012: LAC- all children with social work referrals for various types of placement; registration with dentists; hospital discharge data for all episodes of tooth extraction; National Dental Inspection Programme (NDIP) data from Primary 1 and Primary 7 school years . The LAC group were compared to their peers by logistic regression adjusted by SIMD, using remote access to the National Safe Haven. There were 633204 subjects in the study group . Ages ranged from four to 17 years (mean 12 LAC and 10 nonLAC); with 53% male for LAC and 51% nonLAC; and 42% in the most deprived SIMD level for LAC and 21% for non-LAC. The subjects in the LAC group were more likely to have dental decay at Primary 1, odds-ratio (OR) 2.93 , and Primary 7, OR 1.81 . LAC subjects were less likely to be registered with a dentist, OR 0.50 , and more likely to have teeth extracted, OR 1.50 . All tests p<0.001.Looked after children are more likely to have dental problems and less likely to use dental services than their peers, after adjustment for socioeconomic status.