Group-based early parenting interventions delivered through community-based services may be a potentially effective means of promoting infant and family health and wellbeing. Process evaluations of these complex interventions provide vital information on how they work, as well as the conditions which shape and influence outcomes. This information is critical to decision makers and service providers who wish to embed prevention and early interventions in usual care settings. In this paper, a process evaluation protocol for an early years parenting intervention, the Parent and Infant (PIN) program, is described. This program combines a range of developmentally-appropriate supports, delivered in a single intervention process, for parents and infants (0–2 years) and aimed at enhancing parental competence, strengthening parent-infant relationships and improving infant wellbeing and adjustment.The process evaluation is embedded within a controlled trial and accompanying cost-effectiveness evaluation. Building from extant frameworks and evaluation methods, this paper presents a systematic approach to the process evaluation of the PIN program and its underlying change principles, the implementation of the program, the context of implementation and the change mechanisms which influence and shape parent and infant outcomes. We will use a multi-method strategy, including semi-structured interviews and group discussions with key stakeholders, documentary analysis and survey methodology.The integration of innovations into existing early years systems and services is a challenging multifaceted undertaking. This process evaluation will make an important contribution to knowledge about the implementation of such programs, while also providing an example of how theory-based research can be embedded within the evaluation of community-based interventions. We discuss the strengths of the research, such as the adoption of a collaborative approach to data collection, while we also identify potential challenges, including capturing and assessing complex aspects of the intervention.ISRCTN17488830 (Date of registration: 27/11/15). This trial was retrospectively registered.The online version of this article (doi:10.1186/s12913-016-1737-3) contains supplementary material, which is available to authorized users. The nature of the caregiving environment experienced at an early age plays a pivotal role in child development. Several studies and meta-analyses have demonstrated that early childhood interventions implemented between pre-birth and 3 years can help to improve parent-infant relationships and parenting skills –3. ReseaRecent significant advances in the delivery and testing of early parenting programs, as well as the accumulation of results from controlled trials, provide an important evidence base for ‘what works’ for parents and children . DespiteThere is increasing recognition of the importance of effectively implementing prevention and early intervention programs in order to ensure positive outcomes , 14. Indwww.mhsru.com). The research program is being conducted over a 5 year period (2014–2019) [The dearth of process-oriented research means that decision makers and service providers are often unclear about how and when such programs may be effectively embedded within community-based early years services , 26. Thi14–2019) . This gr14–2019) .Develop a program theory: Document, in detail, the design and development of the PIN program and outline its change principles and underlying assumptions.Assess implementation: Outline the key resources involved in program implementation and the extent to which the program is implemented as intended (i.e. fidelity to the program model/change principles); examine patterns of participation within the program, including the role of program developers and implementers, as well as program reach, recruitment, and participants’ patterns of engagement and responses to the program; and identify implementation barriers/facilitators.Explore the context of program delivery: Examine the conditions in which the PIN program is delivered including the individual, interpersonal and organisational capacities which support implementation; and explore the circumstances or contextual factors which influence the experiences of key stakeholders.Identify mechanisms of impact: Identify patterns of interaction between the program, the stakeholders involved, and the context in which the program is delivered and explore the extent to which these shape, either positively or negatively, the implementation and impact of the program; and identify lessons for the development and implementation of other similar complex prevention and intervention programs.The overarching aims of this process evaluation are to gain an understanding of the active ingredients of the PIN program and to systematically evaluate the processes and conditions which influence program implementation and effectiveness. More specifically, the process evaluation will attempt to ‘unpack’ the program components in order to identify and describe the causal assumptions underpinning the program and, in turn, assess how those change principles are substantiated through implementation. The conditions/factors which influence or shape program implementation and responses to the intervention will also be examined. In this way, we will examine how the program works (or does not work) and whether there are facilitators and/or barriers to program implementation and effectiveness. The specific objectives  . The benThe analysis of PIN program implementation (objective 2) will be guided by the work of Baronowski and Stables  who deveThe service delivery context which will be conceptualised as incorporating the capacities of individuals , organisational infrastructures  and interpersonal relationships .The broader contextual factors which are external to the intervention and which may shape and/or influence participants’ responses to the intervention .There is increasing recognition that programs can influence different people in different ways, while the success of implementation strategies and/or processes is frequently mediated by conditional or contextual influences . TherefoWe will explore, in turn, the interplay between the PIN program and its components, persons and conditions in order to gain insights into the processes of change arising from the intervention (objective 4). Thus, we will draw on a realist evaluation perspective  to invesGiven the complexity of social interventions such as the PIN program, the program theory will be used to identify priority avenues for investigation in relation to the implementation and effectiveness of the intervention . We willThe PIN program combines a range of developmentally-appropriate parent and infant supports which are delivered in a single intervention process from birth to 2 years of age  program in Ireland . The ABCA detailed process evaluation is being conducted in conjunction with a large-scale, longitudinal controlled before-and-after impact evaluation to assess the effectiveness of the program. Parents from within the sites where the program is delivered are recruited to the PIN program by Public Health Nurses and/or local, community-based service providers. Parents who are recruited to the program will subsequently be invited to participate in the research. A comparison group of parents who receive services as usual (and no PIN intervention) will be recruited from neighbouring areas with a similar profile to the intervention areas. Usual services in the non-intervention area for parent-infant dyads involve: one home visit from a PHN in the first 6 weeks after birth, regular developmental check-ups with a GP/PHN and vaccinations.Prospective participants will be informed of the research verbally and by means of a brief brochure describing the research. Potential participants will then be asked to provide their written consent to be considered for inclusion in the research and for their details to be passed to the research team. If this consent is provided, names and telephone numbers are confidentially passed to the research team. Participants will then be contacted by the research team and furnished with a detailed information sheet. All participants must be aged 16 years or older and will provide written informed consent. A power calculation conducted on the basis of comparing the mean score of an intervention group on the Parenting Sense of Competence Scale (PSOC)  to that Baseline assessments will be conducted with parents when the infant is approximately 6 to 14 weeks old. Subsequent follow-up assessments will be carried out when the infant is approximately 8, 16 and 24 months of age. The impact of the program, when compared to services as usual, will be investigated by assessing parent competencies and wellbeing, parent-infant relationships, child development and socioemotional adjustment. The process evaluation will be vital to interpreting the outcomes of the PIN program, while it also forms part of a wider goal to contribute to our understanding and knowledge of the effective implementation of complex early parenting intervention programs, including the relationships between program components, implementation processes, contextual factors and program outcomes. The process evaluation is being conducted by a multi-disciplinary research team independent of program development, implementation and delivery.Study participants will include program developers and implementers, as well as parents who take part in the PIN program. This process evaluation will be based on both qualitative and quantitative methods. Data collection will be conducted in two focused phases. During the first  phase, data collection will focus on explicating the theory underlying the intervention, identifying the causal assumptions inherent in the program and outlining the activities, resources and factors which are assumed to be necessary to achieving program outcomes.The second phase of data collection will expand on early findings and focus on exploring the processes involved in program implementation, patterns of engagement with the program, as well as the context in which the program is situated. Both quantitative and qualitative data will be gathered to explore program delivery processes, uptake and coverage, responses to the intervention, barriers to effective implementation of the program (e.g. program reach and participant engagement) and competing programs. As the PIN program is already being implemented, quantitative data relevant to program implementation  will also be collected during phase one of data collection. An in-depth examination of program implementation and contextual factors will inform a critique of fidelity to the PIN program theory, while also highlighting adaptation/innovation and enabling the interpretation of findings from the impact evaluation. The data gathered throughout the process evaluation will be synthesised and analysed in order to identify the mechanisms through which the intervention activities produce intended or unintended effects.A wide range of data sources will be used to develop an in-depth understanding of the PIN program, the key activities, processes, inputs and outputs involved in, and conditions associated with, program delivery and implementation.Phase 1 data sourcesLiaison with PIN program developers and implementers: The evaluation team and program developers and implementers are in regular communication. This will provide important insights into program logic, the choices made in relation to program content, preparation and groundwork for delivery as well as the planning and management of implementation.Documentation: A documentary analysis will be carried out which will involve the review and critical analysis of a wide range of relevant documentation including: meeting minutes; organisational reports and publications; online material; brochures; program proposals and descriptions; program manuals and written materials; official policy documents and demographic data; publications, reports, and journal articles. This data will contribute to refining ideas and identifying the conceptual foundations of the PIN program.Interviews: Program developers and implementers will be interviewed to explore the developmental origins of the PIN program, factors which influenced intervention design, development, and content, as well as related motivations, attitudes, perceptions and beliefs.Phase 2 data sourcesLiaison with PIN implementers: Regular contact/meetings between the PIN program Project Coordinators (in both Site 1 and 2) and the evaluation team will be held to provide updates on: the development and implementation of program components; choices made in relation to program content and implementation; participant recruitment; the timing, delivery and implementation of intervention components; implementation and operational activities; as well as any planned and/or unplanned or forced changes to the program components and its delivery. Regular contact will also enable the evaluation team to monitor how operational and implementation activities evolve over time.Records and documentation: Records of recruitment procedures will be taken, including the number of prospective participants invited to participate in the program. Recruitment protocols, implementation manuals and other relevant documents (e.g. meeting minutes) will also be included in a documentary analysis. Demographic data, as well as routine documentation maintained by participating organisations (e.g. PHNs) including area birth rates, will be used to critique program reach.Impact evaluation data: Participant demographic data collected through the impact evaluation baseline assessments will be used to examine the characteristics of parents who engage with, and continue to participate in, the program. This data will be used to assess program reach and the maintenance of participant engagement. All parents who take part in the trial will also be asked, by means of a follow-up questionnaire administered by the evaluation team, to report uptake of services and supports which are external to the PIN intervention. In addition, parents in the control group will asked if they have accessed any of the treatment components (e.g. Baby Massage). This will enable the research team to examine if, and to what extent, contamination is occurring, thereby facilitating the accurate interpretation of program outcomes.Attendance checklists: Parent participants attendance for each program component will be routinely recorded by program facilitators. The number of sessions per component which individual parents attend, as well as the attendance of partners (if applicable), will also be recorded. Reasons for parental absence/non-attendance will be documented if available.Parent participant feedback forms: Parent feedback forms will be administered following the completion of each program component. These questionnaires will measure participant satisfaction as well as the perceived utility of the content of each program component, and facilitator effectiveness ; as well as highlighting any deviations from program content/protocols  and organisational capacity building processes (e.g. availability of training and/or other supports for program implementers)  Parent participants will be interviewed to explore issues pertaining to parenthood, including the experience of becoming a parent, parental expectations and the experiences and challenges/difficulties of parenting during infancy. These interviews will also focus on: parents’ experiences of taking part in the program; the extent to which they use the parenting skills, strategies, materials and information specified in the program; whether they continue to use such skills, strategies, material and information over time; barriers to program engagement/attendance; and factors which influence parenting experiences. A small number of partners of participating parents may also be invited to take part in qualitative interviews.Interview/group discussion procedure and participant sampling. All interviews and group discussions will be audio-recorded with consent and guided using a schedule of open-ended questions. Interview/group discussion questions will be altered to reflect stakeholders’ experiences in relation the PIN and stages of program implementation (e.g. to explore emergent issues in implementation and/or participation in the PIN program). A purposive sampling method will be used to identify and recruit participants. Selection and recruitment will be designed to include as wide and diverse a range of perspectives as possible and to access participants’ expertise in relation to the key research questions. Key inclusion/selection criteria include the participants’ role within the development and/or delivery of the PIN program and their ability to provide insight into the key issues influencing, and affected by, program development and implementation. Parent participants will be selected from the overarching intervention group recruited to take part in the PIN program and the effectiveness evaluation (n = 100 approximately). Key demographic variables , program delivery cycle and level of program engagement (e.g. no. of sessions attended) will be used to recruit parents to the process evaluation. Care will be taken to ensure diversity and balance throughout the sampling process.It is anticipated that approximately 40 key stakeholders will be invited to take part in interviews/group discussions. A responsive approach to sampling will be adopted; thus, as the research and data collection process progresses, potential participants will be identified and recruited on the basis of emergent findings. During the later stages of data collection, a small number of key informants will be re-interviewed or invited to take part in groups discussions in order to assess any potential changes over time in program implementation and delivery context, as well participants’ experiences, attitudes and beliefs.All qualitative data will be retained as written electronic files including document summaries and interview and group discussion transcripts. Interviews and group discussions will be recorded (with consent) and transcribed verbatim. Audio-files will be destroyed after transcription and all qualitative data will be stored securely on a password protected computer. All transcripts will be anonymised and any potentially identifiable data removed.A thematic analysis will be used to systematically analyse all qualitative data . This anQuantitative data from implementer and participant feedback forms, attendance checklists and questionnaires will be entered into a password protected database and will be analysed in SPSS using appropriate descriptive and inferential statistics. Analysis of the stakeholder survey will focus on variability across groups, while the extent to which the intervention is delivered as intended will be examined by exploring the proportion of the essential material which was reported as delivered. Variability in the extent to which the program is delivered as intended across facilitators/parent groups and change over time will also be examined. In addition, the proportion of parent participants who report high levels of satisfaction with, and high perceived utility of, the PIN program and its sub-components will be reported. We will also explore whether there are any significant differences in satisfaction and perceived utility across parent participant sub-groups (e.g. primiparous and multiparous mothers). Program reach will be assessed by examining the proportion of the mothers who have given birth in the treatment areas and who are recruited to, and engage with, the program. Dosage will be analysed by determining the average number of program sessions attended by parent participants. Systematic differences between those who attend a high percentage of sessions and those who fail to engage/attend a low number of sessions will also be assessed.The blending of findings from different and multiple data sources will be an important step in refining the interpretations of program outcomes, understanding the context of program delivery and, in particular, identifying mechanisms of impact. For example, narrative accounts of implementation (e.g. transcribed interviews) will be triangulated with findings from the stakeholder survey and implementer/participant feedback forms, as well as outcome data from the impact evaluation. At this stage of analysis, data will be interrogated in order to identify patterns of interactions between the PIN program theory and its implementation, participant responses and contextual factors. Thus, the data will be appraised in order to understand how the PIN program works and, in turn, to identify key mechanisms which are critical to program success or, conversely, where program and/or implementation failures are likely to occur.This process evaluation will be carried out by a small team of experienced researchers from different backgrounds with considerable experience both of mixed methods and of undertaking large-scale community-based evaluations. A number of steps will be undertaken to ensure a rigorous approach to data collection and analysis including: (i) a purposive and responsive sampling method to ensure a broad and diverse participant sample and, in turn, good conceptual generalisability; (ii) a systematic approach to data collection and analysis and drawing on a rich range of data sources including quantitative and qualitative data; (iii) triangulation of findings across multiple sources of data; (iv) respondent validation via reiterative sampling and transcript reviews; (v) reflexively assessing the role and input of the researcher(s) with respect to data generation and data analysis; and (vi) ‘sensitivity to context’, including reference to appropriate literature and theory, as well recognising and examining differing perspectives and the context in which data and findings are generated . Thus, pIn this paper we provide a detailed protocol for a process evaluation nested within a controlled trial of an early parenting intervention program aimed at improving parental competencies and infant wellbeing in the earliest years of life. It is increasingly recognised that implementation is vital to the effectiveness of prevention and early intervention programs . New proThis evaluation will adopt a comprehensive and rigorous, approach to the evaluation of the structures, processes and causal mechanisms inherent in the implementation of the PIN program. Nuanced information regarding the attitudes, characteristics and skills of program implementers, as well as interpersonal interactions, resources and circumstances around program implementation, will be collected using a broad range of quantitative and qualitative research methods.This research will also be conducted by an experienced, multidisciplinary team of researchers who are working in close collaboration with a range of community-based stakeholders involved in program delivery and implementation. Positive working relationships between the evaluation team and program developers and implementers have already been developed and are being closely monitored and maintained. This will be important in supporting the process evaluation in a number of ways. For example, regular positive communication between the research team and stakeholders will ensure that the evaluators are notified and informed about any planned phases of implementation. Challenges and changes to program content and delivery can also be highlighted. In addition, PIN program implementers will assist with data collection (e.g. maintaining and providing participant feedback forms) and are also committed to monitoring fidelity and implementation processes. While this will help to reduce the costs of data collection and participant burden, facilitator self-assessment of fidelity and distribution of participant evaluation forms may bias implementation and/or result in Hawthorne effects. However, similar procedures for implementation fidelity monitoring have been reported elsewhere , 58. FurPotential challenges must also be noted. Firstly, the evaluation team will not communicate emerging findings from the process evaluation to key stakeholders in order to avoid any interference in the implementation process. However, the PIN program theory will be developed in collaboration with key stakeholders, whilst an interim evaluation report will also be made available prior to the completion of this study. There may also be instances where it is ethically imperative to communicate findings of the process evaluation to program developers/implementers (e.g. evidence of harm). It is possible that such interactions between the evaluation team and program developers/implementers may influence the development of the program and/or implementation activities. Secondly, the team of researchers with responsibility for conducting this process evaluation are also involved in conducting the outcome evaluation and cost-effectiveness analysis. This integration will be important in facilitating data sharing and in minimising participant burden; however, data collectors cannot be blind to program allocation and, therefore, some potential for bias in the interpretation of program functioning and outcomes may arise. For this reason, a reflexive approach to data collection and analysis will be adopted in order to minimise any bias and improve the reliability and validity of the findings. Analyses of program effectiveness will be conducted by the research team’s Data Manager who is blind to group allocation and not involved in any way in data collection.Finally, the complex nature of the PIN program presents challenges. For example, the program consists of multiple interrelated and interdependent components, as well as multiple stakeholders. Some elements of the program are manualised (e.g. IY programs), while other components are not. Additionally, there are differences in program content and implementation processes across sites, while there is also likely to be adaptation and learning by those implementing and those receiving the intervention as delivery proceeds , 60. TheThere remain significant barriers to ensuring that vulnerable children and families receive high-quality early intervention and prevention services and supports . It is i


Improvisation is an articulated multidimensional activity based on an extemporaneous creative performance. Practicing improvisation, participants expand sophisticated skills such as sensory and perceptual encoding, memory storage and recall, motor control, and performance monitoring. Improvisation abilities have been developed following several methodologies mainly with a product-oriented perspective. A model framed under the socio-cultural theory of learning for designing didactic activities on processes instead of outcomes is presented in the current paper. The challenge is to overcome the mere instructional dimension of some practices of teaching improvisation by designing activities that stimulate self-regulated learning strategies in the students. In the article the present thesis is declined in three ways, concerning the following three possible areas of application: (1) high-level musical learning, (2) musical pedagogy with children, (3) general pedagogy. The applications in the music field focusing mainly on an expert's use of improvisation are discussed. The last section considers how these ideas should transcend music studies, presenting the benefits and the implications of improvisation activities for general learning. Moreover, the application of music education to the following cognitive processes are discussed: anticipation, use of repertoire, emotive communication, feedback and flow. These characteristics could be used to outline a pedagogical method for teaching music improvisation based on the development of reflection, reasoning, and meta-cognition. Music improvisation could be defined as the real-time creative performance of novel music and consists of inventing music extemporaneously. Improvisation is a discovery act that goes beyond the application of a preexisting technique and aims to delineate an original framework. Improvisation could be considered one of the most articulated expressions of creative behavior as stated by Beaty , p. 109:Improvisation also has a versatile and interactive nature: a performance can be modeled and adapted to different circumstances. The adjustments involve feedback processes which consist of real-time answers to situational events: the musical improvisations are modified and adjusted in relation to the conditions of the performance. The cognitive components are developed in a social context: improvisation is an interpersonal action that is developed among people cooperating to create a musical piece extemporaneously Monson, . The socImprovisation can also be a teaching technique to innovate the current methods bringing new challenges to education Santi, . Improvi“Whereas at one time teaching and learning was information being passed, memorized, and repeated, students can now find their own knowledge. Learning now consists of using information in creative ways and requires a shift in how students are taught. This is quite similar to what occurred in music over a hundred years ago when jazz was introduced to the culture. Music moved from musicians playing what the composer wrote, to creating their own music within a structure. This shift is an apt metaphor for the changes being felt in twenty-first century teaching and learning. The processes of learning and creating jazz provide a way to illustrate new teaching methods that allow students to discover new knowledge through their own creative interests and to develop self-efficacy with the material.” Luquet, , p. 60.For these reasons jazz (and improvisation) could be considered as a model of teaching. The current article aims to propose an educational approach for the development of processes rather than products Monk, , focusinThe educational benefits that improvisational activities could have on the students is an increasingly discussed issue in the field of music education. Aspects such as historical significance, the position of improvisation in music education, stimulated musical abilities and the activation of transfer processes were considered Azzara, .Improvisation has been an essential component of musical expression and several forms have been used throughout history. The analysis of improvisation techniques occurring at different times shows the relevance of historical and stylistic variables. In the nineteenth century, improvisation was abandoned with the use of scores. Until this period, improvisation was used for educating several complex musical abilities  during musical improvisation. This repertoire of licks is stored in the long-term memory and is learned through listening and studying the improvisations of eminent musicians. The use of the repertoire is based on memorization of patterns that could be used during improvisation and involve several levels. The aim is to expand both the long-term memory archive of patterns and licks and the schemes for managing them during improvisation. The challenge is to provide students not only the basic material (the licks), but also the strategies for properly selecting the licks (the grammar). The selection of licks has to be framed respecting the characteristics of the context of the improvisation. For this reason a proper method of education must provide strategies not only for the memorization of licks, but also for the correct use and for the re-elaboration and adaptation of licks to a specific situation.The KEY CONCEPT 2Utilizing repertoire formulas such as clichés or licks during improvisation.Several activities could be proposed for expanding the students' repertoire of licks such as listening and analysis of solos of famous musicians in different musical styles. The educational approach consists of learning by ear and the aim is to stimulate the students to repeat and memorize the solo, then to sing the solo and finally to play the solo with an instrument. The practice could involve the analysis of previous solos, the identification of relevant parts and of the strategies used for developing the solo. A reflective thinking approach has to be promoted in the students, stimulating their reasoning on how to make the licks meaningful in specific situations. In addition, creativity principles also have to be introduced, by asking students to create variations and their personal adaptations of licks.Emotive communication regards the induction and transmission of affective and emotional feelings during musical improvisation. The reference for musical communication is the musical grammar and the stylistic principles, which are used as a set of rules for developing the piece. During emotive communication the melodic, harmonic, timbre, dynamic and rhythmic elements are modulated and idea generation is mediated by emotions and inner feelings (Jordanous and Keller, KEY CONCEPT 3Communicating emotions through improvisation.Several educational activities could be used for developing emotive communication such as inviting pupils to improvise on a specific emotive state. In this activity students have to find the proper sound for expressing their inner feelings activating a process of introspection. In addition, a verbalization task of the experience could be included, in which students are asked to reflect on the sound produced and whether the sounds matched their inner feelings. This verbalization activity leads students to reflect upon the process of sound selection and production and to define the variables of emotive communication in music. The objective is to stimulate self-reflection and an approach to improvisation based on reasoning rendering the implicit process of emotive communication a conscious one. Activities on emotive communication imply switching one's focus from the formal aspects to the dynamic and expressiveness of the music providing students with a more motivating and significant field of work than traditional approaches.Feedback regards the skills to reply to events by producing real-time adaptations to advance an improvisation. These modifications are made for rendering the improvisation more reliable and logical. Feedback involves different monitoring processes according to the features of the music, the group dynamics and the context. Several strategies for managing feedback are used by performers, and several kinds of feedback have been described, such as external and internal feedback (Biasutti and Frezza, KEY CONCEPT 4Making real-time changes to synchronize or improve an improvisation using monitoring processes.The educational activities on feedback aim to increase students' skills to respond promptly to the external inputs during an improvisation. While improvising, several unexpected events could happen and performers must be educated on how to manage these issues. Feedback activities could involve tasks such as proposing musical events which change suddenly, requesting participants to react to these modifications while performing. Another activity could involve a dialog with musical questions and answers, focusing on aspects of music such as melody, harmony, timbre, and rhythm. These actions could be performed even with eyes closed to enhance a deeper concentration on elements of the sound events. Additional feedback activities could propose events from other perceptive modalities such as visual and kinesthetic stimuli, asking students to provide a musical interpretation of these stimuli. To enhance interaction among performers risk-taking tasks (Wopereis et al., Flow is an intense state of consciousness including physiological, cognitive and affective aspects during musical improvisation. Flow is linked to optimal experience (Csikszentmihalyi, KEY CONCEPT 5A state of mind of intense absorption during improvisation, including cognitive, affective and physiological aspects, linked to optimal experience.Teaching flow directly is demanding and educational activities are based on promoting a performance setting that facilitates flow. Several actions could be considered for these purposes so as to set-up clear objectives that can be verified in a direct way. The activities could be based on the concept of zone of proximal development considering the distance between the current development level and potential level of development that can be achieved by students (Vygotsky, In the present paper, a pedagogical approach on the development of processes was discussed analyzing the following elements: anticipation, use of repertoire, emotive communication, feedback and flow. These features could be used to outline a pedagogical method based on reasoning, to teach music improvisation stimulating meta-cognition Luquet, . The aimThe surrounding paradigm is the socio-cultural theory of learning and the student-centered approach as applied in music where pupils are active rather than passive learners elaborating their knowledge in a transformative way (Vygotsky, Regarding curriculum planning, teaching improvisation is a very time-consuming and demanding activity. Teachers who use improvisation as a teaching technique must carefully plan all the variables of the activities instead of improvising their actions. The teachers of improvisation are more prepared, more able to handle the unexpected and the unpredictable, and more willing to take risks than traditional teachers. Teaching improvisation involves designing, monitoring and evaluating (Biasutti, Designing the activities, teachers should provide a unified plan for process development. In addition, a conscious expression of aesthetic features of the musical productions has to be considered. Teachers have to reinforce the students' intrinsic motivation to music achievement which is directly connected to self-regulated learning. The teaching approach should focus on the learning process rather than on products stimulating pupils' elaboration of musical knowledge in an independent way (Biasutti, The current study has limitations. First, there was little space to discuss other improvisation theories and to compare them. Second, the focus was only on the five dimensions of music improvisation according to Biasutti and Frezza  without The theoretical framework of the current essay is based on music with the idea to transfer these principles to other areas (Harrison and Pound, Improvisation could be considered an adaptive behavior to a real-time unpredicted event, based on creativity and divergent skills, providing a wide scale set of stimuli. Improvisation enhances the transfer of learning mechanisms allowing the application of such skills in other domains as well (Harrison and Pound, In conclusion, improvisation is a teaching technique that could give input for renovating current educational methods. Improvisation could open new perspectives regarding teaching and learning, proposing a model based on creativity development and a process oriented teaching approach.The author confirms being the sole contributor of this work and approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To investigate the prevalence of difficulties in adopting initial breastfeeding techniques and their association with breast disorders in postpartum women. The cross-sectional study was carried out with 276 randomly selected mother-baby pairs in rooming-in in 3 hospitals in a city of Minas Gerais State (southeast Brazil). An assessment protocol was established to evaluate the breastfeeding technique used. The association between the variables studied and breast disorders was determined by the chi-square test followed by logistic regression, with significance level set at 0.05.p=0.003); maternal schooling ≤8 years ; and supplement provision to the newborn at the hospital . Mothers working outside the household  served as as protective factor on the multivariate model. The main factors indicating difficulties to initiate the breastfeeding techniques were inadequate attachment of the baby to the breast (25%), baby response to the contact with the breast (26.1%) and breast disorders (28.3%). Variables associated with postparturm breast disorders were: adolescent mothers (OR 3.35; 95%CI 1.51-7.44;  The main difficulties in initial breastfeeding were associated with breast disorders, and the factors associated with this problem included demographic and social, variables, as well as others related to the care routine adopted by maternity hospitals. It is believed that a poor technique would make it difficult for the newborn to suck and empty the breast, thus affecting the dynamics of milk production. As a consequence, the mother can introduce other foods early, causing the weaning.,,,There are some very relevant aspects in the process of sucking that should be carefully assessed by health professionals in the activities for education and promotion of breastfeeding. Some behaviors observed during breastfeeding in the maternity hospital are not desirable, and seen as risk factors for weaning.,,WHO, together with the United Nation’s Children Fund (Unicef), recommend the use of a “sucking evaluation file” as a strategy to monitor and identify these initial difficulties involving the breastfeeding technique.This is a cross-sectional, observational and analytical study, which assessed mother-baby pairs, selected randomly, in the first 18 to 48 hours postpartum. The study was conducted in three hospitals, all named “Hospital Amigo da Criança”, in the north of Minas Gerais. The city where the study was conducted has about 390 thousand residents, and is a macro-regional reference for several sectors of the regional economy, as well as in the health field. Sample selection was random, restricted to mother-baby pairs assisted by the Unified Health System (SUS), who stayed in a collective accommodation after postpartum care and presented with conditions for being discharged from the hospital together.Sample calculation was conducted to define the minimum number of pairs analyzed in the study, considering a population of 3,000 mothers thorughout a six-month period, with prevalence of initial problems involving the breast of 20%,The following inclusion criteria were considered: mothers who received postpartum care in one of the three hospitals in the city, with term pregnancy, who were in good health conditions, according to clinical records, to respond to the initial survey. Regarding newborns, the inclusion criteria were: good health conditions, according to clinical records, with possibility for hospital discharge and being exclusively fed with breast milk at the moment of discharge . Exclusion criteria were: mothers who have not received immediate postpartum care (home parturition), mothers pregnant with twins and those whose did not stay in the group accommodation. The pairs were assessed at a hospital environment (accommodation), when considered to have conditions for hospital discharge. The evaluation was conducted from 18 to 48 hours postpartum.The allocation of pairs was conducted by random selection on days and shifts for visits in each hospital, including all mothers who met the inclusion criteria and who accepted to participate. The allocation of the binomials for the study was conducted according to the proportion of births in the six months prior to the beginning of data collection in each hospital. The interviews were conducted by a previously trained and calibrated team, using the consensus technique by an obstetric nurse with experience in maternal breastfeeding and who is a monitor of the training course in Hospital Amigo da Criança in Counseling for Maternal Breastfeeding.The data collection instrument included the sucking evaluation file,p<0.2) were assessed by the binary logistic regression, using the Backward Wald method. In this last stage, the Odds Ratio (OR) were calculated with the respective 95%CI. For the final model, only the variables associated up to a 5% level  were considered.The Statistical Package for the Social Sciences (SPSS), version 18  was used for data analysis. The variables were assessed in a descriptive manner, by presenting absolute and relative frequencies. For the analytical stage of the analysis, problems with the breasts  were analyzed and defined as a single outcome variable (dependent). The associated variables were identified among the other characteristics that were investigated (independent), based on the chi-square test. The variables associated to a 20% level , and the use of supplements for the child in the maternity hospital was reported by 25.0% of the mothers (t6).The observation of the sucking allowed identifying conditions that indicated initial difficulties with the techniques in all the assessed aspects, especially inadequate handle (25.0%), response to the contact with the breast (26.1%), and problems with the breast (28.3%) .p<0.2) were assessed together and remained in the final multivariate model as variable associated with breast problems: the fact of being a teenage mother , schooling equal to or lower than 8 years , the fact of having received supplements at the maternity hospital  and the fact of working outside the household, which was a protective factor  in the final logistic regression model.,,,The results obtained in the study show high prevalence of conditions indicating initial difficulties with the breastfeeding technique. Even though there are few studies described in the literature with the same approach, other authors also revealed high prevalence of initial breastfeeding difficulties by applying the sucking evaluation file from Unicef.Carvalhaes et al., in a study conducted in a public maternity hospital working on low-risk childbirth, assessed 50 mother-baby binomials and showed that 18 to 34% of the pairs presented difficulties with the initial breastfeeding period, in at least one of the aspects of sucking that were observed.Traditionally, the most prevalent problems with puerperal breasts, that is, mammary ingurgitation and mammillary lesions, are attributed to the inadequate position for breastfeeding and/or the baby’s handle.Breast problems may compromise the success of maternal breastfeeding. A national study identified a high incidence of mammillary lesions in the maternity hospital, of 43.6%.,,In this study, the authors chose to assess, specifically, the factors associated with the presence of brast problems in mothers in the first 24 hours postpartum, still inside the maternity hospitals, because the changes could be identified more easily, with minor chances of subjective assessment by the evaluators. Therefore, the variables associated with breastfeeding difficulties were mother’s age and schooling, the fact that the newborn received supplements in a hospital environment and the report that the mother worked outside the household, being the later a protective factor. Literature did not show studies associating the mother’s age with breastfeeding problems. There are, however, records that teenage mothers provide less breast milk to their children in relation to the others, and also have more difficulties to initiate the practice of breastfeeding.,It was not possible to identify scientific articles that associate the use of food supplement still in the hospital with breast problems, even though an association has been observed with worse scores in the breastfeeding file.,As to the association between breast problems and maternal schooling, other studies have indicated an intrinsic relationship between the practice of breastfeeding and schooling.This study showed that the maternal report of working outside the household functions as a protective factor for the occurrence of problems with the puerperal breast. Even though we did not find other studies approaching this subject, the circumstance observed may be explained by the fact that working mothers have more opportunities to access positive information about breast care outside the household.According to Roig et al., the information related to breast care and breastfeeding provided by health professionals during prenatal care are closely related with the success in maternal breastfeeding, as well as with the presence of positive previous experiences with breastfeeding.The results of this study including some limitations, such as the fact that information regarding previous lactation experiences were not considered. This fact could be related to the lower prevalence of initial difficulties among multigravid women, but this data was not measured alone. Another limitation is that only women assisted in the Unified Health System were assessed, even if many of them have received prenatal care in the private system, or both. Therefore, the prevalence of initial difficulties may have been measured only in the lower social strata of the population, and the results of this study, therefore, may not be extrapolated for binomials assisted by the private health system.The evaluation of difficulties in sucking techniques, still in the hospital environment, is a simple, economic measure that does not require a specialized professional. Therefore, it can be incorporated to the criteria of hospital discharge, in order to identify and assist the binomials that present some sort of problem regarding the breastfeeding process, providing the adequate orientation to solve these difficulties and to strengthen the mother-baby connection.As a future perspective, the determination of the impact of initial difficulties with the sucking technique on the duration of exclusive maternal breastfeeding should be assessed by the longitudinal observation of the mother-baby pair, and that may show exactly which are the factors related with the sucking technique that can be related with early weaning.


The nuclear bomb testing conducted at the Semipalatinsk nuclear test site in Kazakhstan is of great importance for today’s radiation protection research, particularly in the area of low dose exposures. This type of radiation is of particular interest due to the lack of research in this field and how it impacts population health. In order to understand the possible health effects of nuclear bomb testing, it is important to determine what studies have been conducted on the effects of low dose exposure and dosimetry, and evaluate new epidemiologic data and biological material collected from populations living in proximity to the test site. With time, new epidemiological data has been made available, and it is possible that these data may be linked to biological samples. Next to linking existing and newly available data to examine health effects, the existing dosimetry system needs to be expanded and further developed to include residential areas, which have not yet been taken into account. The aim of this paper is to provide an overview of previous studies evaluating the health effects of nuclear testing, including some information on dosimetry efforts, and pointing out directions for future epidemiologic studies. The STS was a major site for nuclear weapons testing by the former Soviet Union, and it was where the former Soviet Union conducted their first nuclear test on August 29, 1949. Afterwards, 456 nuclear explosions were carried out between 1949 and 1989, including 111 atmospheric events (86 air events and 25 surface events) between 1949 and 1962.3The Semipalatinsk nuclear test site (STS) is located in the present East-Kazakhstan Oblast (or administrative division) of Kazakhstan, a country that was previously a part of the Soviet Union. The test site is named after the city of Semipalatinsk (in Kazakh: Semey) and is located approximately 150 km west of the city. The test site covers an area of 18,500 kmThe test site had three major testing areas. Atmospheric bomb tests were performed at Ground Zero. Over 200 underground nuclear tests were performed in the Degelen Mountains. 123 underground nuclear tests were conducted in the Balapan area, one of which led to the formation of Lake Chagan , which is sometimes called ‘Atomic Lake’ due to the current radioactive environment.Previous analyses made by several institutes from different countries might provide insight into the health effects from low dose radiation exposure, as defined by the European low-dose initiative MELODI.The 111 atmospheric events conducted between 1949 and 1962 caused the primary source of radioactive contamination of the environment and the majority of the radiation exposure of the public. The most damaging tests, in terms of exposure, were those conducted on August 29, 1949 (with a yield of 22 kilotons (kt) TNT equivalent), September 24, 1951 (38 kt), August 12, 1953 (400 kt), and August 24, 1956 (27 kt). Most of the other explosions led to exposures that affected only the test ground, not the vicinity of the test site.The population living closest to the test site was exposed to relatively high levels of radiation. Settlements affected by the 1949 test were located north-east of the test site (e.g. Dolon and Cheremushka), but traces from this test have also been documented in residents living further away in the Altai region in Russia.Both, external and internal exposures need to be considered when estimating the individual doses to which residents have been exposed. External exposure was caused by the radioactive clouds and submersion, whereas internal exposure is caused by the consumption of contaminated foods. Food consumption varied between the different ethnic groups living in the contaminated areas, such as Kazakhs, Russians, and Germans. The first effort to evaluate both external and internal exposure was attempted in Kazakhstan and published in 2000.18The first studies on health effects associated with nuclear bomb testing were of a descriptive nature. One of the first published reports focused on the increased age-specific incidence rates of malignant tumors in the Semipalatinsk Oblast compared to the general population of the Soviet Union and Kazakhstan populations.Based on data that were collected from 1960 to 1991 by the National Research Institute of Radiation Medicine and Ecology of Kazakhstan, a cohort was established which became known as the “historical” cohort. This cohort was comprised of approximately 20,000 individuals. Half of these individuals came from exposed villages and the other half came from a comparison (unexposed) area. The first analyses were based on the dosimetry system developed by Kurakina et al.The dosimetry system was based on a joint U.S./Russian dose reconstruction methodology that combined the experience of dose-reconstruction scientists in Russia and the U.S.A cross-sectional study of the prevalence of thyroid diseases was conducted using 2,994 residents from eight villages. The study involved ultrasound screening, and malignancy status was confirmed by cytopathology evaluation. In terms of excess relative risk per unit dose, the dose-response findings for nodule prevalence were compatible with those from populations exposed to medical X-rays and atomic bomb survivors.27Two studies looked into possible radiation effects in the offspring of exposed individuals. The first study focused on investigating whether the exposures led to a significant change in the sex ratio of newborns. Based on 11,464 single births from 3,992 mothers exposed to radiation during 1949–1956, the overall sex ratio was 1.07 (e.g. 107 boys per 100 girls), which was comparable to the sex ratio in Kazakhstan in the mid-2000s (1.06).8To our knowledge, no additional studies have been conducted on mental disability or congenital malformation.Several databases and registries have been developed over the past few decades, which need to be further explored for risk analyses. One of these resources is the previously mentioned historical cohort.Biological samples from individuals living in the affected areas have been collected in numerous studies;32This review demonstrates that different datasets are available for investigating health effects of radiation among the population living in proximity to the Semipalatinsk nuclear testing site. The EU-funded project SEMI-NUC aims to evaluate to what extent the different data sets can be linked and whether there is a possibility to use this data for a future prospective cohort study. To that end, possible follow-up mechanisms are going to be tested, including monitoring of incidence and mortality data, where the outcomes of interest are cancer and non-cancerous diseases. Avenues of ascertainment of vital statistics and cause of death have yet to be identified and validated. Thus, available sources of information must be defined . Methodologies that were used to calculate doses for existing cohorts have to be reviewed and compared, including identifying potential discrepancies and reasons for the discrepancies. Furthermore, it will be important to evaluate the quality and the content of existing biomaterials. Such evaluations will need to look at how samples were processed and stored, which types of equipment was used for DNA extraction, methods of evaluation of previous cytogentic analyses, and the condition of stored tissue samples. In addition, there will be evaluations of the possible use for modern technology analysis. For the latter, validated SOPs have already been developed and are available on the internet.However, there are other interesting options for future research on the effects of low to intermediate doses. The large data sets independently developed by Katayama et al.Although research on the health effects of low to medium exposures from the nuclear testing is of high public health relevance, a major limitation is that studies mentioned in this paper are not well connected with each other. This makes an overall joint evaluation difficult. Additionally, epidemiological research in the area close to the test site faces a number of difficulties. One of the problems is that exposures are dominated by the radioactive plumes , but for some health endpoints, internal exposures are of a higher relevance. Since exposure estimates have been carried out many years after actual events, this introduces another source of bias. Another limitation is that biological materials from the affected population were not always properly stored and labeled. It is difficult to link available biological material to individuals included in the epidemiological studies and their demographic data.Despite the fact that difficulties exist, studies of individuals affected by atomic bomb testing have the potential to contribute to a better understanding of radiation exposure risk, particularly because the population is not a randomly selected one (e.g. nuclear workers have much fewer and lower exposures in comparison to atomic bomb survivors).In summary, data are available for more than 100,000 persons forming a large cohort which needs to be further investigated.


Superior cava venous obstruction use to show a typical clinical presentation and a CT scan or even an ultrasonography can be sufficient to achieve an accurate diagnosis, but in this case, to obtain the final diagnosis, a multimodal assessment is needed. This case report shows a multidisciplinary approach which helped diagnose a complicated case, where conventional diagnostic methods were not enough. Superior vena cava syndrome (SVCS) is very unusual and associated with thyroid cancer; the most common tumors related to this syndrome are lung cancer, lymphoma, and mediastinal metastases. Only a few cases have been described in the literature . We founAn 80-year-old woman presented to medical emergency with two days' history of edema in the left arm.As relevant medical history, she was diagnosed with a follicular thyroid cancer in 2003. A total thyroidectomy was performed, and she needed to be given two ablative doses of I131 . She hasAt this moment, she was admitted in the medical emergency because of the increasing edema in the left upper limb. She also refers to 15 days' history of palpebral edema. She denied worsening of basal dyspnea, chest pain, or recent episodes of hemoptysis. On examination, she was eupneic, and there was evidence of fullness of the head, with remarkable palpebral edema, a collar of stokes and notable edema of the entire left superior member and left breast. Collateral circulation and telangiectasia in the left pectoral were also noticed.An eco-Doppler was performed by the vascular surgery service with an inadequate exploration of the subclavian vein because of the edema, but it was evidence of permeable veins of the rest of the left upper limb. A contrast-enhanced CT was recommended which was performed with focus on the cervical, thoracic, and axillary area. There were no signs of compressive masses or intravascular filling defects. One week before, an evaluation CT scan for thyroid cancer was performed, and when reviewed at that moment, it was not showing compressive masses or filling defects either.Despite no proof of SVCS in imaging test, corticosteroids (dexamethasone 4 mg each 8 hours) and low molecular weight heparin at anticoagulant doses were started by the clinical suspicion. The patient was asymptomatic, so she was discharged with a close follow-up in the oncology consultation.After a slight improvement, the patient worsened again and was admitted to the hospital for further examination. On reexamination at this moment, there was notable edema of the head, upper chest, and both upper limbs. However, a clear asymmetry persisted and left upper limb and the left side of the chest were more edematous. During the hospitalization, a PET was performed showing increased activity in the already known lung metastasis and a new image with also increased activity that extended from the thoracic inlet to the anterior mediastinum . The PETThe case was reviewed by the vascular surgery team which decided on the implantation of two stents to resolve the SVCS. After the extraction of a tissue sample from the SVC invasion, one XL stent was placed in SVC, and another stent was implanted in the left subclavian vein without acute complications.The patient condition improved within days, and she was released from the hospital. Unfortunately, a few days later, the patient was readmitted to the hospital because of a nosocomial pneumonia which resulted fatally.The SVCS is the clinical expression of external compression or intrinsic obstruction of the SVC. Malignant conditions remain the leading cause of the SVCS even though in the more recent reviews  benign eSVCS encompasses various signs and symptoms. The most typical is the swelling of the neck and dyspnea. The edema of the neck is accompanied by a substantial number of cases with facial and upper chest edema and with prominent superficial vessels in this area and jugular venous distention.The diagnosis of SVC syndrome is made clinically with an accurate clinical history and physical examination, focusing on the duration and the speed of symptoms onset and the history of previous invasive procedures or malignant diseases. After a clinical diagnosis, contrast-enhanced CT is the key examination to find the abnormality underlying the SVCS and its characteristics to plan the best therapeutic strategy in each case . Other iThe case we present in this paper represents an unusual physiopathology of an SVCS which made the diagnosis confirmation by image a challenge. However, in atypical cases like this, where there are signs not usually associated  and the CT does not show any justifiable cause for an SVCS, a multimodal assessment can be necessary. In this case, the implications of the vascular surgery team and the Radiology and the Nuclear Medicine Departments allowed not only an accurate diagnosis but also an effective treatment.


The need for memory specialists is increasing as the incidence of dementia rapidly rises across the globe. In rural areas, demand for these specialists far outstrips supply. It is increasingly difficulty for patients to receive care in a timely manner. In this paper, we document our experience using videoconference telemedicine to bring a multidisciplinary model of care to a rural retirement community in Southern California. To our knowledge, we are one of the first to integrate telemedicine into dementia care on this large a scale. Given the relatively remote location, patients and neurologists have previously had to travel great distances and bear with long wait times. With neurological consultation by telemedicine and a local team consisting of a geriatrician, a neuropsychologist, and a case manager, we have been able to provide comprehensive dementia care in this underserved area, comparable to university-affiliated California Alzheimer’s Disease Centers, typically found only in major metropolitan areas. We have shown that telemedicine can be very effective in improving access and quality of dementia care. Telemedicine, the use of telecommunication and information technology in clinical evaluation and treatment, has existed in various forms for over 100 years. Its evolution is intricately linked to the advancement of information technology . InteresPsychiatrists were among the first to widely adopt video-based telemedicine by initially capturing video to send to providers in what is known as “store-and forward” telemedicine . This adIn neurology, telemedicine has found wide acceptance in the area of stroke management. In 1999, Levine and Gorman proposed the use of telemedicine in the management of acute stroke and called it “telestroke” . Since tThis paper summarizes the current state of telemedicine in dementia care and documents our experience in using telemedicine to bring a multidisciplinary model of care to the Coachella Valley, a retirement community in Southern California.As life-expectancy rises across the globe, dementia has become a major public health concern. The number of people who are 65 years and older is expected to increase from 500 million globally to one billion by 2030 . Three tAlthough there is no effective therapy to stop the progression of AD, timely diagnosis might help lessen early anxiety and frustration associated with cognitive decline. For some patients, pharmacotherapy might temporarily stabilize cognitive decline and behavioral symptoms. Most importantly, early recognition of disease also allows patients and families to better plan for the future and makes informed decisions regarding their medical care and quality of life.Primary care physicians are often the first and only point of contact for older adults with memory concerns. Unfortunately, dementia remains undiagnosed by these providers in an estimated 50–67% of patients over 65 –27. In tvia telemedicine was not inferior to FTF assessment  opened in November of 2007 on the EMC campus in Rancho Mirage, California. In late 2012, an institutional agreement was made between EMC and the USC to develop a comprehensive and multidisciplinary model of care with referrals from a network of local primary care physicians and general neurologists and case management resources from the local chapter of the Alzheimer’s Association. The aims of the new model are to provide (1) timely diagnosis; (2) comprehensive management from diagnosis to social service referrals; and (3) accurate and up-to-date information regarding memory loss to the patients, their families, and the community. Below, we detail the demographics of the targeted service area, the new service model, and initial statistics.The Coachella Valley is located in Riverside County, one of the fastest growing counties in the US and the fourth largest county in the state of California. The Coachella Valley’s population grew by 40% from 1990 to 2000, by another 38% from 2000 to 2007, and is expected to grow an additional 30% from 2008 to 2016. Total population as of 2010 is 423,000. The county consists of eight regions with seniors disproportionately represented in the Western region.As Table The Alzheimer’s Association has predicted that the number of people living with AD in Riverside County will double by 2030. Among baby boomers in Riverside who reach the age of 55, one in six will develop dementia and one in eight with AD. These statistics have led the Alzheimer’s Association to call for improvement in community-based health services and to specifically address the need for a comprehensive memory assessments center in the Coachella Valley.Patients are typically referred to the MAC by local primary care physicians, general neurologists, or the Alzheimer’s Association. A small number of them come without referral, having learned about the MAC through local community outreach and publication. The team of specialists consists of a geriatrician, a neuropsychologist, a behavioral neurologist, and a case manager to fully address the needs of patients and their families. In this manner, patients receive the entirety of their care locally from diagnosis to treatment to social and support services. Central to this new model is access to behavioral neurology by telemedicine Figure .Patients are first registered by phone or in person where relevant demographic, financial, medical, and cognitive/behavioral information is gathered and entered into an electronic database. In the first visit, they meet with a geriatrician, who performs screening tests for cognition and mood, conducts a general physical and neurological exam, orders imaging and labs , and manages existing medical problems. The patient then sees a local neuropsychologist who assesses mental status and orientation, attention and concentration, short- and long-term memory, executive function, and depression/anxiety. All information is then shared with the behavioral neurologist on EMR by remote access for diagnosis and management by telemedicine. Using high-quality audio–video equipment, the neurologist takes additional history and performs focused cognitive and neurological assessments with the help of an onsite licensed vocational nurse (LVN). The management plan is then formulated and discussed promptly at the end of the telemedicine session, or if appropriate, in a subsequent family teleconference attended by the patient, family members, geriatrician, and case manager. The nurse works closely with the front office staff and the specialists to facilitate appointments, orders, and communication.Telemedicine has not been widely used as part of dementia care due to the intricate nature of the auditory and visual interaction between a patient and an examiner. However, with the availability of high-quality videoconferencing technology and secure high-speed internet, this is rapidly changing.Prior to 2013, the MAC was based on the conventional model of care. A neurologist from USC commuted every weekend from Los Angeles to Palm Desert  to assess and manage patients. Access to the neurologist was the limiting step in patient enrollment. Over time, it became apparent that this setup was not sustainable as clinic wait-time lengthened to 6+ months, and the demands of frequent travel weighed heavily on the neurologist.In 2013, with support from benefactors, EMC, USC, and the Alzheimer’s Association, we developed a new multidisciplinary model with integration of telemedicine. A key feature of the new service model is the use of telemedicine technology in cognitive and behavioral examination. In utilizing telemedicine, specialist care is made available to resource-scarce region. To our knowledge, we are one of the first to integrate telemedicine into dementia care on this large a scale.In our experience over the past 3 years, telemedicine poses no barrier to accurate evaluation and is as effective as a meeting in person. Accurate diagnosis in memory clinic requires detailed history from patients and families and demonstration of cognitive deficits and neurological findings in the office. With reliable and high-fidelity audio/video equipment, we have been able to obtain history and perform cognitive exam in the same manner as we would in person, with only occasional repetition of questions by the onsite staff. For neurological exam, the neurologist can rely on exam results from the initial visit with the geriatrician and perform a focused exam to demonstrate signs of cerebral degeneration, such as frontal release signs. When these signs cannot be demonstrated visually, such as the sign of cog-wheeling in arm/wrist, our nurse is trained to report tactile findings. After diagnoses are made, treatment and management locally by primary care physicians and case managers make the experience seamless for the patients and their families. Access to a behavioral neurologist is no longer the limiting factor in dementia care.From 2008 to 2012, there was a significant drop in number of new appointments, reflecting the failings of the conventional program  . They take place in a modified exam room in the MAC, next to the office of the geriatrician. A camera with remote-controlled zooming and turning (Lifesize Team 220 video conference codec) is installed on the wall with view of the entire exam room. Two computer monitors provide simultaneously videostreaming of the neurologist and the visual tools for cognitive examination. Fifteen minutes before each appointment, the neurologist at USC and the nurse at EMC test the audio–video system for optimal setting. For the appointment, the patient and their families are greeted and brought in by the nurse, who stays in the room during the entire session. Detailed history, focused neurological assessment, and cognitive exam are performed with the nurse’s assistance. Prior in-person instruction by the neurologist ensures that the nurse can appropriately follow instruction and report finding in a neurological exam. No special training in telemedicine is required for the neurologist.Setup of the telemedicine clinic requires purchase of videoconferencing equipment and training of qualified nurses to assist with the cognitive and neurological assessment. The cost of the equipment can range from a few thousand to tens of thousands of dollars depending on the availability of reliable and secure internet connection. At the MAC, equipment investment at EMC and USC added up to about $10,000. The professional fee for the telemedicine session is billed by the behavioral neurologist at USC, and technical fee is billed by EMC. Professional billing for telemedicine conducted through USC Care, Inc. was reimbursed similarly to FTF meeting at USC. Insurance reimbursement is comparable to an university-affiliated CADC, with 45% by private insurance, 50% by Medicare, and 5% by self-pay or scholarship.n = 33), a number similar to rates in comparable literature (Satisfaction data were collected by phone calls from 46% of the patients and/or their families (terature . PatientTelemedicine is a powerful tool to address the problem of access to care across medical specialties. In the USC–EMC MAC experience, we have demonstrated that comprehensive and seamless integration of telemedicine into dementia care is not only possible but also preferred by patient over long-distance travels. This model also allows for a solid relationship between providers that may be lost in a more traditional referral based model. The integration of telemedicine has effectively increased accessibility of behavioral neurologists to rural retirement communities of the Coachella Valley in Southern California. In the future, telemedicine is expected to become pervasive. The USC–EMC MAC serves as an efficient model for integration of telemedicine, allowing an underserved group of patients to experience multidisciplinary care within a single institution.JT, RF, and CL: drafting of manuscript, and acquisition and interpretation of data. HC and CL: critical revision of manuscript, and conception.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The receptionist is the focal point of the practice, undertaking an array of clinically orientated roles such as triaging patients for GP consultations or managing repeat prescribing. However, the full nature and extent of the receptionist’s clinical activities is unknown as are the implications for patients. The aim of the proposed review is to explore the nature of the receptionist’s clinical roles, their extent and their implications for patients. In doing so, we will highlight any gaps in the evidence base which future research may explore.The databases Medline/PubMed, Ovid, Cinahl, ASSIA, Cochrane, EMBASE and Science Direct will be searched for relevant literature. We will look at both qualitative and quantitative research on GP receptionists, based within primary care to explore their roles within the primary care team, the clinically relevant roles they undertake, the extent of these roles and any implications these roles might have. No limits are placed on the date or place of publication; however, only research published in English will be included. Screening, quality assessments and data extraction will be carried out by two reviewers, who are not blinded to study characteristics. Analysis follows a four-stage method, established by Whittemore and Knafl (2005).The review will explore existing research covering the clinically orientated roles of the GP receptionist. The findings of the review will be important for healthcare professionals and academics working within primary healthcare. It will highlight and for the first time synthesise research relating to the complex and essential work of the GP receptionist. Our findings will inform the direction and focus of further research, as gaps in the knowledge base will be uncovered.CRD42016048957.PROSPERO registration no: The online version of this article (10.1186/s13643-017-0612-6) contains supplementary material, which is available to authorized users. General practice receptionists are the first point of contact for patients. Their functions are varied and encompass administrative duties, such as filing, maintaining medical records and making appointments , 2. In aIn a 2013 survey, 18% of GP practices surveyed reported that reception staff have some involvement in telephone triaging. Though the authors do not define ‘involvement’, it is clear this task has clinical implications as the inaccurate assessment of symptoms can lead to a delay in consultation and diagnosis or patients being referred to inappropriate services . Though Receptionists also report clinical information to patients, for example, the reporting of blood test results. In this scenario, receptionists relay results, sometimes with the help of pre-prepared scripts. Frequently, they are unable to respond to further enquiries from patients leading some to question whether this is an appropriate role for the receptionist . Test reDespite the range of clinically orientated duties, no formal training is required or systematically delivered. Instead, receptionists new in post typically receive their training from existing reception staff for training , 16. FurThe receptionist is an essential feature of the primary care system, contributing to its smooth running and acting as point of contact and buffer, between patient, GP and other clinical staff. Primary care is under increasing pressure; the emphasis has shifted to prevention  and manaAn earlier scoping review (undertaken by the lead author MB) indicates that the receptionist is female, married and undertakes a visible role in the practice as well as a number of clinical relevant tasks. However, a more systematic, concentrated search of existing literature is needed to fully explore these issues, to access the extent of the receptionist’s clinical roles and to identify if possible what implications the receptionist undertaking these roles might have.The existing research is both qualitative and quantitative in nature and so our systematic review will be integrative. This will enable us to more fully explore all of the existing research and develop a comprehensive overview .What is the role of the GP receptionist within the primary care team?What clinically orientated roles does the GP receptionist undertake?What is the extent of these clinically orientated roles and the effects on the patient and patient care?This review will summarise past research, draw conclusions and highlight unresolved issues and direct future research, in accordance with Whittemore and Knafl (2005). To do this, the review will explore the receptionist’s roles within the primary care team. It will also explore the literature around the clinically orientated roles of the GP receptionist, to identify the type and extent of the roles that these individuals undertake. The review will ask three questions:The protocol has been prepared in line with the Systematic Review and Meta-analysis Protocols or PRISMA-P . The PRIhttp://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016048957The systematic review will explore existing literature according to best practice in systematic review methodology . The iniThe eligibility criteria used in the study are in accordance with the SPIDER search strategy . SPIDER The research will include GP receptionists or medical secretaries, these are individuals tasked with providing administrative support to the practice  and support for patients seeking medical care . In addition, they should be based in general practice, within primary care. This is operationalised as general practice based in the community offering care for minor or chronic/long term illness and providing referrals to specific services for more serious illness care.The research included will cover the clinical and general roles of the receptionist as well as any potential implications for or effects on patients.The research will include interviews, focus groups, ethnographic observations, case series and surveys.The review will explore attitudes, beliefs, satisfaction and medical outcomes.Including qualitative, quantitative and mixed methodologies, only empirical research will be included. No limits are placed on the date of publication.Research will not be excluded by country of origin. Though there may be differences in the structure, funding and support of medical systems around the world, research conducted within other healthcare models can still provide valuable information on the contrasting roles of the GP receptionist. However, research will only be included from outside the UK, where it is produced in English or a good quality translation is available.We will use multiple search strategies to obtain a representative sample . Search See Additional file Individual journals will be hand searched for relevant articles; these will include but not be limited to journals covering primary care research and healthcare research such as the British Journal of General Practice, The British Medical Journal (Open), The Journal for Health Care Quality and BMJ Quality and Safety, in addition to hand searching of the reference lists of included research. Finally, the review will include conference proceedings and National Health Service (NHS) or healthcare policy documents sourced from websites published by the NHS.Literature searching will be undertaken by the lead author (MB) and search results will be extracted to Endnote X7.3.1 . After tTwo reviewers will undertake the full-text review. Microsoft Excel will be employed to facilitate this process. Quality assessment will be undertaken on each of the remaining papers; quality will be assessed using the CASP resource for qualitative research , the QuaAs discussed, the reviewers will employ EndNote X7.3.1  to facilFinally, a PRISMA diagram  will be Publication information ,Study characteristics ,Participant information ,Outcomes .Data will be extracted independently by the lead author (MB) and a second reviewer. Data extraction will be based on the supplementary guidance chapter 5 to the Cochrane handbook . This te(i)Data reductionData analysis will follow the four-stage procedure detailed by Whittemore and Knafl (2005):Qualitative research: including interviews, focus groups and ethnographic observations.Case seriesSurveys Mixed methods Analysis begins with the process of data reduction. Included studies will be divided into groups based on the research design; as such, there will likely be four subcategories:This process provides a systematic framework for the analysis.(ii)Data displayData reduction continues with each primary source being coded, employing a priori codes relevant to the review questions . From each of the studies included, a master file is created. This master file contains all of the codes derived from each study and is the basis for the continued analysis, enabling easier and more systematic comparison and integration of data on specific issues such as sample characteristics, surgery type, receptionist workload/roles or other variables.(iii)Data comparisonThe individual master files for each of the selected articles will be combined into a single Excel database for each subcategory defined in the reduction stage. At this stage, the process of reconstructing the data begins and within each of the sub categories, the individual codes are drawn together and grouped by similarity. For example, codes showing a clinical aspect can be grouped together as ‘clinical roles’ at this stage. The process of data display facilitates the recognition of patterns and relationships in the data and enables the development of early broad codes. These will in turn inform the direction of the analysis and the emerging themes.(iv)Conclusion drawing and verificationThis iterative stage of the analysis employs the data displays to compare the selected articles across all of the categories and subcategories. This allows for the identification of patterns, themes and relationships that may be present in the data to be uncovered and for the emerging core themes to be realised and then saturated. For example, a number of studies may discuss a number of clinically relevant duties that the receptionist has, each of these could then be coded across the whole dataset and result in codes for each of the different clinical activities, triage, clinical information provision and repeat prescribing, for example. NVivo v11  will be The codes developed across the dataset will be further integrated with each other to form higher level descriptive codes/themes. As in the example given, each of the codes relating to triage, clinical information provision and repeat prescribing are conceptually related as different aspects of clinical work and so could be integrated into a single theme.This review will produce a comprehensive account of the existing literature covering the clinically orientated roles of the GP receptionist. The review’s findings will highlight the limitations and gaps in the existing literature and will in turn inform the authors’ ongoing research  which isThe findings of this review will also be important for healthcare professionals and academics working within the primary healthcare field. The review aims to clarify the roles that the receptionist undertakes, issues around training and any potential implications of the receptionist taking on clinically orientated roles. Furthermore it will highlight the potentially problematic ad hoc adoption of clinically orientated roles by untrained staff or on the contrary highlight this as a continuation of roles that the receptionist has been undertaking for decades.The review will explore the need for any additional training for the GP receptionist. It will raise awareness of the need for closer attention to the roles they undertake and the support that is available in practice for this. The GP 5-year forward view details 45 million pounds of funding for the training of receptionists to undertake two discrete roles: managing clinical correspondence and active signposting (care navigating) . There iFinally, the review will highlight the importance of the receptionist as a focal point of general practice, a role that has been potentially overlooked by the research community and in practice.Additional file 1:PRISMA-P 2015 checklist. (DOCX 36 kb)Additional file 2:Medline search strategy. (DOCX 15 kb)