Despite the evidence of the adverse consequences of immobility during hospitalization, patients spend most of the time in bed. Although physical activity is a modifiable factor that can prevent in-hospital functional decline, bed rest is deeply rooted in the hospital culture. To attack this, a multidimensional approach is needed. Therefore, Hospital in Motion, a multidimensional implementation project, was designed to improve physical behavior during hospitalization.The primary objective of this study is to investigate the effectiveness of Hospital in Motion on inpatient physical behavior. Secondary objectives are to investigate the effectiveness on length of hospital stay and immobility-related complications of patients during hospitalization and to monitor the implementation process.For this study, Hospital in Motion will be implemented within 4 wards  in a Dutch University Medical Center. Per ward, multidisciplinary teams will be composed who follow a step-by-step multidimensional implementation approach including the development and implementation of tailored action plans with multiple interventions to stimulate physical activity in daily care. A prepost observational study design will be used to evaluate the difference in physical behavior before and 1 year after the start of the project, including 40 patients per time point per ward . The primary outcome measure is the percentage of time spent lying, measured with the behavioral mapping method. In addition, a process evaluation will be performed per ward using caregivers’ and patient surveys and semistructured interviews with patients and caregivers.This study is ongoing. The first participant was enrolled in October 2017 for the premeasurement. The postmeasurements are planned for the end of 2018. The first results are expected to be submitted for publication in autumn 2019.This study will provide information about the effectiveness of the Hospital in Motion project on physical behavior and about the procedures of the followed implementation process aimed to incorporate physical activity in usual care. These insights will be useful for others interested in changing physical behavior during hospitalization.Netherlands Trial Register NTR7109; https://www.trialregister.nl/trial/6914 (Archived by WebCite at http://www.webcitation.org/76dyhdjdd)DERR1-10.2196/11341 More than 2 million patients are admitted to Dutch hospitals yearly, with a mean admission time of 7 days . AlthougNevertheless, patients are reflexively put into pajamas, transferred into bed , and speThe primary objective of this study is to investigate the effectiveness of Hospital in Motion on physical behavior within 4 wards .Secondary objectives are to investigate the effectiveness on length of hospital stay and immobility-related complications of patients during hospitalization and to monitor the implementation process.In November 2015, the project Hospital in Motion was started at the University Medical Center Utrecht (UMC Utrecht). Hospital in Motion is a complex multidimensional project primarily designed to improve physical behavior during hospital stay, defined as a decrease in patients’ sedentary behavior (lying) and increase in physical activity . This project follows 2 approaches. The first approach focusses on creating a hospital-wide awareness of the high amount of sedentary behavior during the hospital stay and the known associated adverse effects, and the necessity to incorporate physical activity in usual care. The second approach includes the development and implementation of tailored action plans for each clinical ward. In 2016 and 2017, a pilot study was performed on the geriatric department. Preliminary results and gained experiences during this pilot form the basis of this study protocol.This study will be conducted within 4 wards  of the UMC Utrecht, the Netherlands. Per ward, a tailored action plan will be implemented. The study protocol was assessed and approved by the medical ethics committee of the UMC Utrecht (study protocol number 16-250). Verbally informed consent was obtained from all patients.An observational study with a prepost design will be used to evaluate the effectiveness of Hospital in Motion on physical behavior. In addition, the implementation process will be evaluated by using a qualitative approach. Data will be collected before and after implementation. The duration of the implementation project is planned for 10 months, starting in January 2018 .Hospital in Motion will be implemented following the step-by-step model of Grol and Wensing  23]. St. St23]. Education: Education is an important cornerstone for increasing awareness on the importance of physical activity ,24, for Physical activity as part of usual care: For successful implementation, physical activity needs to be incorporated in usual care and all caregivers with direct patient contact need to be involved ,25, for Involving third parties: Involving the social environment  to improve inpatient physical behavior, for example, family and visit leaflets with information about the importance of physical activity during hospitalization and tips to improve patients’ physical activity ,27.Stimulating environment: Currently, hospital wards are not stimulating environments for performing physical activity . ChangesMobilization milestones: Daily mobilization goals are successful in increasing walking distance, ADL activities, and number of mobilization moments out of bed . The useTechnology support: Implementing technological applications such as cycle ergometers with interactive screens, activity trackers, or mobile apps to support, stimulate, and measure physical activity .In total, 160 patients will be included during a period of 2 months (40 patients per ward). Each patient admitted in the specific ward is eligible to participate in this study. Exclusion criteria for participating in this study were delirium and other cognitive impairments, whereby patients who were not able to provide informed consent were excluded. Patients receiving terminal care were also excluded.Physical behavior will be measured with the behavioral mapping method  and willPhysical behavior is defined as the percentage of the total observed time that a patient spent in a specific body position. A distinction will be made between lying, sitting (bedside or chair), and moving . The primary outcome in this study is the percentage of time spent lying.Secondary outcomes are the percentages of time spent sitting and moving, LOS, and the incidence of immobility-related complications  . LOS andDemographic characteristics that will be documented are gender, age, admission reason, specialism, the use of mobilization tools , urine catheter (yes/no), infusion (yes/no), and main perceived limitations during physical activity . In addition, the health perception and physical functioning of patients will be assessed.The subjective believed health questionnaire is used to obtain the health perception, defined as “individual’s experience of physical and mental functioning while living his life the way he wants to, within the actual constraints and limitations of individual existence” . The queThe Activity Measure for Post-Acute Care (AM-PAC) is a validated measurement instrument based on the activity limitation domain of the International Classification of Functioning, Disability and Health. In this study, the AM-PAC “6-Clicks” measures of basic mobility and daily activity in acute care will be used. These short forms have shown to be valid for assessing patients’ activity limitations in acute care settings ,35. HandIn this study, per ward 40 patients will be included per time point. This number is based on earlier studies evaluating physical behavior with the behavioral mapping method . PatientProcess evaluations are advised to monitor implementation processes of complex interventions and to evaluate factors of influence on the implementation. In this study, the framework of the medical research council guideline 2008 is followed to guide the process evaluation . The 3 kFor the caregivers’ survey, questions are formulated focusing on the willingness to change and motivation of the caregivers to help improve patients’ physical behavior. In addition, questions are included to investigate the current state of the 6 topics of the action plan. The scoring of the questions is based on the visual analog scale; a score between 0% and 100% agreement can be given per question. The survey will be sent to all caregivers of the included wards before and after the implementation period.For the patient survey, the level of encouragement patients perceived from care providers and the environment to be physically active in the past 2 days will be investigated using 6 statements with a 5-point scale. This patient survey will be performed before and after the implementation period. After the implementation, the survey will be supplemented with questions to investigate the success of the implementation of the action plans per ward.Semistructured interviews with patients and caregivers: After the implementation, semistructured interviews with both patients and caregivers will be undertaken. The interviews will be guided with a topic list based on the 3 key functions of process evaluation as described before .All statistical analyses will be conducted using IBM SPSS statistics software 25. All outcome variables will be tested on normality with the Kolmogorov-Smirnov test. Patients’ characteristics will be described using descriptive statistics and tested with the Chi-square test, Mann Whitney test, or independent samples t test. Physical behavior is defined as the percentages of the total observed time that a patient spent lying, sitting, and moving. For both the primary outcome (the percentage of time spent lying) and the secondary outcomes (percentage of time sitting and moving), the changes in percentages after implementation will be analyzed. In addition, between-group analyses will be performed per ward. The differences between pre- and postmeasurements will be analyzed with an analysis of covariance, whereby the covariate(s) include baseline variables that may differ between pre- and postmeasurements. If data are not normally distributed, log transformation will be executed before testing.The process evaluation will be based on the caregivers’ survey, patient survey, and semistructured interviews. Categorical data will be analyzed using Chi-square test and continuous data by using the Mann Whitney test or independent sample t test. To correct for multiple testing, a post hoc multiple comparison test will be performed. The semistructured interviews will be audio recorded and transcribed. Data analysis will follow 3 steps: coding, categorizing, and selecting themes, which will be performed in NVivo 11.This study is ongoing. The first participant was enrolled in October 2017 for the premeasurement. The postmeasurements are planned for the end of 2018. The first results are expected to be submitted for publication in autumn 2019.Despite the evidence about the negative consequences of low levels of physical activity, patients still spend most of the day in bed, leading to unnecessary functional decline and new disabilities in ADL ,3. PreviThe Hospital in Motion study has the strength that it contains multiple interventions tailored per ward, developed by a multidisciplinary project team. In addition, it is one of the first known large projects using a multidimensional approach, focusing on the physical environment, caregivers, and patients, instead of only 1 element, to improve physical behavior during hospitalization. Another strength of the Hospital in Motion study is the primary outcome of physical activity. As previous studies mostly included medical outcomes , levels of physical functioning or frequency of mobilization and the actual amount and change of physical activity have not been evaluated ,19,20,42Diverse factors could influence the success of the implementation of Hospital in Motion. The action plan is a multidimensional package of interventions aimed to improve physical behavior. It contains multiple interventions aimed to incorporate physical activity in usual care procedures, targeting the whole care system. This strength is a challenge at the same time. Many factors may affect the implementation process, such as the functioning of the project team, caregivers’ motivation and willingness to change, available time, and perceived workload. The appropriate study design has been discussed extensively within the research team because of the possible influence of confounding factors. As this study primarily aims to integrate physical activity in daily hospital care, more classic research designs  are less suitable. By following a step-by-step implementation process and by performing a process evaluation, the authors will provide useful insights into the changes in usual care and the successful and unsuccessful elements of the implementation process.


Resident satisfaction is an important aspect of nursing home quality. Despite this, few studies have systematically investigated what aspects of nursing home care are most strongly associated with satisfaction. In Sweden, a large number of processual and structural measures are collected to describe the quality of nursing home care, though the impact of these measures on outcomes including resident satisfaction is poorly understood.A cross-sectional analysis of data collected in two nationally representative surveys of Swedish eldercare quality using multi-level models to account for geographic differences.Of the factors examined, nursing home size was found to be the most important predictor of resident satisfaction, followed by the amount of exercise and activities offered by the nursing home. Measures of individualized care processes, ownership status, staffing ratios, and staff education levels were also weakly associated with resident satisfaction. Contrary to previous research, we found no clear differences between processual and structural variables in terms of their association with resident satisfaction.The results suggest that of the investigated aspects of nursing home care, the size of the nursing home and the amount activities offered to residents were the strongest predictors of satisfaction. Investigation of the mechanisms behind the higher levels of satisfaction found at smaller nursing homes may be a fruitful avenue for further research. The increasingly elderly population in many western countries has created an increased demand for high quality medical and social care services. This includes nursing home (NH) care, referring to facilities providing 24-h functional support and care for persons who require assistance with activities of daily living and who often have complex healthcare needs . AchieviA particular challenge in regulating quality in NH care is that it is in many regards a ‘soft’ service in which the individual experiences of the NH residents is an important dimension of quality. While many aspects of quality  must be considered in order to achieve a well-rounded assessment of the care provided at a given nursing home, some scholars have argued that resident satisfaction may be the most appropriate assessment of quality in NH care , 5. In hstructure – process – outcome model [Structural factors refer to the physical attributes of the setting in which care is provided, including the number and qualifications of staff, equipment, and physical facilities [Processual factors denote the manner in which the care services are delivered, e.g. whether care routines follow set guidelines, and the extent to which residents are involved in decisions about their care. Quality outcomes can be measured in many ways, both objectively in the form of health status or subjectively in the form of patient/resident satisfaction [Given that the satisfaction of residents is an important dimension of quality in NH care, the question becomes how this is achieved. That is to say, what factors are most important to focus on when seeking to improve the satisfaction of NH residents? The most commonly used analytical framework for understanding how quality is generated in health and social care is Donabedian’s me model , 13. A csfaction . A centrThe literature on medical quality in NH care in terms of, for instance, mortality and adverse event rates, has investigated numerous explanatory factors including staffing, ownership, care routines, and the size of facilities –17. SuchIn Sweden, several public investigations have pointed to quality deficiencies, and a lack of systematic knowledge about factors leading to improved quality , 25. TheIn Sweden, there is good availability of data on various aspects of NH care due to comprehensive data collection efforts by the Swedish National Board of Health and Welfare (NBHW). Annual surveys measuring satisfaction are sent by the NBHW to all NH residents, and surveys assessing processual and structural measures of quality are sent to every NH in Sweden. So far however, the use of these data for research has been limited. One exception is a study by Kajonius and Kazemi  which inIn this study, we aim to evaluate which structural and processual measures of quality have the strongest associations with overall NH resident satisfaction. In doing so, we hope to provide policymakers and researchers with a broader picture of the determinants of resident satisfaction as NHs than has previously been available.In Sweden, all citizens have access to publicly funded NH services at heavily subsidized rates. The eldercare system in Sweden is decentralized, with responsibility for service provision resting with the nation’s 290 municipalities. Municipalities are obliged to offer NH care to those determined to have a need for such care based on national criteria. The municipality may provide services themselves, or contract out service provision to private entities  living iBrukarundersökningen, or user survey) distributed yearly to all individuals over 65 years of age receiving elder care services including NH care. This survey consists of 27 separate items to be rated on a five-point Likert scale, relating to their satisfaction with a variety of aspects of elder care services, as well as their health status. Among those living in NHs the survey had a response rate of 56% in 2016, resulting in a total of 40,371 responses [Two nationally representative surveys conducted in 2016, both developed and administered by the NBHW, serve as the primary sources of data. The first survey is a user satisfaction survey  is completed by administrative staff at each NH, and had a response rate of 93% in 2016, resulting in 2153 responses [The second data source is a survey sent directly to all NHs in Sweden by the NBHW, which assesses a number of processual and structural measures of quality. This survey , and was a poor candidate for approaches based on extraction of distinct latent variables. As such, we chose to extract a single composite measure of satisfaction from the user survey for use as the dependent variable, consisting of questions 5–19, 21–25, and 27. To generate a composite measure for use as the dependent variable, the percent of residents at a nursing home responding positively to a given survey question was normalized by subtracting the average percentage of patients responding positively to that question in the population, and dividing by the standard deviation of the population, resulting in a standardized z-score. Z-scores were then averaged across all included survey items to result in a composite score with equal weights for each question.The NBHW divided the unit survey into 12 conceptual categories. A factor analysis showed that the individual questions generally loaded well onto the categories proposed by the NBHW and it was therefore chosen, with a few exceptions, to retain this categorization as the basis for the independent variables used in the analysis. Based on the Donabedian model, the independent variables were divided into “structural” and “processual” variables.The first seven variables related to different processual factors, such as meal-related routines or physical or social activities.Participation in resident councils.Questions 1 and 1a in the unit survey related to the ability of residents to participate in “resident councils” where residents regularly meet to voice concerns in the NH. Issues raised during resident councils may for instance include the planning of common activities or menus for the coming weeks. These were aggregated and reported as the variable Individualized action plans.Questions 2 and 3 in the unit survey concerned the existence of-, and the residents participation in, the creation of “action plans” concerning the care needs and wishes of the resident. These action plans contain information about how various care activities are to be carried out and should be updated every 6 months. The questions were combined into the variable Meal-related routines and plans.Questions 4 and 5 addressed the existence of meal-related routines, and the documentation of meal preferences in the residents’ action plans. Such meal routines are to be based on the Five Aspects Meal Model (FAMM) proposed by Gustafsson et al. , and shoPatient safety routines.Questions 6a-c in the survey related to the existence of formal routines for handling resident safety issues such as threats, violence, and addiction. While the NBHW grouped question 7 (routines for cooperation with relatives) into this category, it did not load well onto a common factor and is conceptually quite distinct, and was therefore excluded. The remaining questions were combined into the variable Availability of exercise and social activity.Questions 8 and 8a-b in the unit survey related to facilities for-, and availability of, exercise and social activities. We excluded question 8 , which had a weak-to-moderate factor loading, so as to interpret this variable as a purely process-related measure. The remaining questions were combined into the variable Care coordination routines and Medication review routines, respectively.Questions 9 and 10 related to the existence of routines for planning care in cooperation with other healthcare providers, and whether resident’s involvement was documented. Similarly, questions 11 and 12 related to routines for medication reviews and whether resident participation is documented in the medical record. We reported these as the variables Nurses per resident, Staff per resident, and Staff with adequate education respectively, and weekday and weekend staffing levels were weighted at a 5:2 ratio to represent average daily staffing levels. While staffing ratios are fairly straightforward to calculate, the definition of what constitutes an “adequate education” is more complex. Adequacy is determined by the amount of healthcare-related training completed by non-nurse staff based on a point scale established by the NBHW [The structural variables included indicators of staffing, ownership and size. Three factors relating to staffing from the unit survey, including the ratio of nurses per resident (questions 13 and 14), non-nurse staff per resident (questions 15 and 16), and the portion of staff with an “adequate education” for their position (questions 17 & 18) were identified. These are reported as the variables the NBHW .Size of nursing home. The NH’s ownership status, i.e. whether it was run by a private or a public provider, was reported as the variable Private ownership.The number of beds available at each NH was reported as Several variables were included in the analysis to control for population health differences between the NHs included in this study. Self-rated health has been found to be an excellent predictor of clinical outcomes , 41, andIt was further deemed necessary to control for demographic factors for which data was only available at the municipal level. This refers to different demographic, economical, and political conditions which may vary significantly between the 290 municipalities. A set of controls were adapted from previous studies , 42, 43 As the large number of quality measures made available by the NBHW was unsuited to direct inclusion in a regression-modelling framework, an initial exploratory factor analysis was performed to reduce the dimensionality of the dataset as described above. Data from the user satisfaction survey and the unit survey were aggregated at the NH level. We sought to minimize bias in the estimation of the effects of the investigated quality measures by drawing upon the approach to causal modelling first described by Pearl , using trms R package [lme4 R package [The aggregated variables were first analyzed in a classical ordinary least squares regression framework using the Huber-White sandwich estimator to account for heteroscedasticity and clustering as implemented in the  package . Hierarc package , as impl package . ConfideIn this analysis, we report our results in terms of standardized regression coefficients. While this allows for direct comparison of the importance of each independent variable in predicting resident satisfaction, it makes interpretation in terms of absolute effects cumbersome. Given the low rates of missing data at the unit level, multiple imputation was not deemed to be necessary, and cases with missing values were deleted list-wise in the relevant models. All statistical analyses were performed using R version 3.5.0, and a reproducible accounting of our reported findings is included as Additional file Data from both surveys (the user survey and the unit survey) were aggregated at the NH level, resulting in 1921 records in the user survey, and 2189 records in the unit survey. 1711 records could be automatically linked based on municipality and NH names, and an additional 87 records could be matched through manual review, resulting in a dataset containing 1798 NHs. An analysis of non-matched records may be found in Additional file Descriptive statistics were generated for each of the variables included in the analysis, and are presented in Table With regard to municipality level statistics, we see that about 21% of Swedes are over the age of 65, 4% of whom live in NHs, where the average age of residents is 83. The average annual per-resident cost for the municipality is 838 thousand SEK (around 80 thousand EUR), while average per capita taxable income is 188 thousand SEK  suggesting that healthier residents reported considerably higher levels of satisfaction. Among the municipality level controls, average NH resident age had a positive correlation with satisfaction, and average per capita taxable income had a negative correlation with satisfaction. Interestingly, no significant relationship between the amount spent per resident and satisfaction was identified. Full model summaries, along with a table reporting the data upon which Fig. Size of a NH  had the greatest impact on resident satisfaction, followed by the processual measure Availability of exercise and social activities. The processual variables concerning Individualized care and the structural Staffing and Private ownership all had similar, weakly positive, effects on resident satisfaction. The processual Safe care variables had no significant effect on resident satisfaction. We found no clear differences in terms of effect sizes between processual and structural variables. Below, we discuss these findings in order of the effect size identified in our results.In this study, we investigated a total of 12 variables representing different aspects of care quality reported in the NBHW unit survey. Of these, seven were considered to represent process-related quality, and five to represent structural quality. Our main findings were that the size was the best predictor of resident satisfaction suggests that smaller NHs in Sweden had more satisfied residents than their larger counterparts. A recent literature review surveying studies examining the impact of NH size on quality outcomes showed size to be an important predictor of quality, with smaller homes generally having better quality outcomes [The fact that NH outcomes . None ofoutcomes  and loweoutcomes . NH qualWhile size may be an important predictor of satisfaction in and of itself, it is also likely that there are causal mechanisms behind this association which mediate the effect of size. Previous research has for instance indicated that staff turnover may be lower  and stafvailability of exercise and social activities was found to have the strongest association with resident satisfaction among the processual variables. Previous research has found that physical activity-related interventions can improve the subjective health status of NH residents [The Aesidents , althougesidents . Our resIndividualized care, Private ownership, and Staffing. The Individualized care variables included participation in resident councils, the use of individualized care plans and the use of meal routines. We identified no previous research regarding the impact of resident councils or the use of individualized care plans on satisfaction in the literature, though Lucas et al., [Three other variable groups had weaker effects with regards to resident satisfaction:  et al.,  did iden et al., , 57, andstaffing had effect sizes similar to those found among the processual individualized care measures. Staffing as a determinant of care quality has been well researched. In a review of 70 articles, Castle [The structural measures related to , Castle  found a , Castle , Hyer et, Castle , and Shi, Castle  point toRegarding the effect of ownership, the main results suggest a higher level of resident satisfaction among privately operated NHs after controlling for municipal level covariates. That is to say, while there was no overall difference in absolute levels of satisfaction, a difference was identified upon taking into account that public and private NHs are not evenly distributed across Sweden, and that when the effects of this non-uniform distribution was accounted for (in effect comparing NHs within the same county), a difference could be identified. The somewhat counter-intuitive effect could, at least in part, be explained by the tendency of private care providers in Sweden to establish themselves in municipalities with higher income levels, where resident expectations may be higher. This supposition is supported by the finding that average per capita income had a significant negative association with resident satisfaction  are not immediately visible to residents, and are thus less likely to influence satisfaction. Studies investigating the impact of these measures on clinical outcomes may well find that they do have an effect with regards to quality in that respect.While we found no association between measures of and processual variables including individualized care and activities play a role in determining resident satisfaction. The difference in results between the two studies could be explained by the fact that the processual and outcome variables in the Kajonius and Kazemi study were both drawn from the resident survey , while the structural variables they were compared with were drawn from a separate statistical database lacking this overall correlation. It is thus likely that the differential effects identified by Kajonius and Kazemi are an artefact of how the authors chose to operationalize the processual and structural measures. Furthermore, in the study data was aggregated at the municipal level, thereby investigating only differences in resident satisfaction between municipalities, which we found to account for only 10% of the total variation in satisfaction between NHs.Taken together, the findings of this study indicate that NH residents are more satisfied in smaller NHs, and NHs with frequent opportunities for physical and social activity. Only weak effects were identified with regards to processual individualized care measures, private nursing home ownership, and staffing levels. Formal routines had no effect on the satisfaction of residents. Another contribution of the study is the comparison of the effect of structural and processual variables on satisfaction. In contrast to a previous study on Swedish NH care , this stThis study was a secondary analysis of two nationally representative surveys collected for quality improvement purposes. A strength of the study is thus that the results are likely to generalize well to other contexts similar to that of Sweden, and the wide scope of these surveys allowed us to investigate and compare a broad range of factors. A limitation of the study was that the validity and reliability of these surveys has not been established in the publicly available literature, although the NHBW has analyzed the impact of loss to follow-up in the user survey , and perAmong other simplifying statistical assumptions including those of additivity and linear effects, we assumed that each question in the survey was equally important to residents in generating the composite measure used as the dependent in our analysis. Weighting each question equally would seem to be a reasonable assumption to make in the absence evidence regarding resident preferences, and the main findings regarding nursing home size and availability of activities were robust to a range of sensitivity analyses and alternate survey question weights.It was common for the satisfaction surveys to be completed with the assistance of third parties, which could potentially influence reported outcomes, and while the rate of missing data was too high to include this variable in the formal analysis, a sub group analysis of homes reporting data on this variable may be found in Additional file Of the quality factors investigated, NH size had the most prominent association with satisfaction, followed by the availability of exercise and social activities. Processual measures relating to individualized care, such as participation in resident councils and the formulation of individualized action plans had a weak association with resident satisfaction, as did other structural factors such as staffing ratios and staff education. The results also suggested that privately managed NHs had a slightly higher level of resident satisfaction, though the effect was similarly weak and appeared only after adjusting for municipality-level covariates. The results in this study suggest that both structural and processual quality factors matter in determining resident satisfaction, with NH size and the availability of exercise and activities having the greatest impact.While the findings in this study suggest a direct link between offering more activities and a higher rate of satisfaction, more research is needed to determine why residents appear more satisfied at smaller homes. It may be that the proximal causes of satisfaction at smaller NHs could be replicated at their larger counterparts, for instance by improving staff continuity and turnover. If so, this could be a cost-effective alternative to building smaller nursing homes. Qualitative studies using methods such as interviews and participant observation may be most appropriate to investigate such effects in more depth. Another policy implication is that activities for residents should be a priority in NH care, and in cases where NHs care is contracted out, offering physical and social activities should be a requirement.Additional file 1. Analysis_notebook. This document provides additional details regarding the factor analysis undertaken to reduce the dimensionality of the data prior to regression analysis, additional details regarding the main analysis, and a number of post-hoc analyses undertaken to evaluate the sensitivity of the findings, and investigate a number of interesting findings suitable for pursuit in further research.Additional file 2. Survey_questions. This document details the specific questions from the two NHBW surveys constituting the aggregate variables included as independent variables in the regression analysis reported in this manuscript.


Virtual Patients (VPs) may improve cognitive and behavioral skills better than traditional methods do. The aim of this paper was to investigate challenges faced by teachers and students in order to effectively implement VPs across undergraduate and postgraduate curricula. In addition, differences in student and teacher perceptions that could impact curricular integration of VPs were explored.A two-phase descriptive study was performed: 1) evaluation of the VP design process and curricular integration, conducted upon academic medical teachers; 2) evaluation of learning and clinical reasoning experiences with VPs, from the students’ perspective.n = 252).VPs seem to fulfill most needs as set by course directors, while they satisfy student needs and create perceptions of improved knowledge and clinical skills reasoning.The results of this study document high acceptance of VPs by both medical teachers and students (Medical educators have encountered educational challenges upon transforming the curriculum. To develop VPs, academic institutions have to pay equal attention to the needs of potential adopters and VP authors. Strategic development and use of VPs may motivate more widespread integration of VPs and lead to a high quality medical education system. Even though the rapid increase in medical information and the expectations for quality health care during the last decades have enhanced the complexity of medical decision-making, there has been a reduction of time for education  and stroThe rapid development of new reliable information technologies enabled the creation of contemporary learning activities that could not be previously achieved. These can now enhance effectively medical education and training . Under tThese opportunities that VPs provide in modern medical education , in assowww.meducator.net) [http://vp.med.auth.gr/ariadne), which resulted in the development of a considerably extensive and open VP repository; the latter aimed at training students in applied knowledge, clinical reasoning and professional attitude, and led to the full incorporation of these newly created educational objects in Problem Based Learning (PBL) sessions in the medical curriculum, both undergraduate and postgraduate. Following the procedure of creation, implementation and incorporation of the VP cases in the curriculum, an effort for a comprehensive evaluation of various parameters of the VP design, use and integration process, from both educators’ and students’ perspective, aimed to add meaningful knowledge considering the full adoption of VPs.The Medical School of Aristotle University of Thessaloniki (AUTH) has made remarkable efforts to improve medical education in the last few years, trying to assimilate new trends and modernize the curriculum. Part of this effort was initiated in the mEducator project (tor.net) , 18 onlyThus, the aim of this paper was to perform a both quantitative a qualitative research for the VP use and implementation across the medical curriculum. Concerning the quantitative approach, the purposes of the study was a) to measure the propensity of medical teachers and students toward the use of VPs in the medical curriculum and b) to measure the preferences of medical teachers and students concerning the way VPs should be utilized across their studies. At the same time, the qualitative evaluation performed in this study aimed to a) describe advantages and disadvantages in VP integration into the medical curriculum and b) to describe the experiences of both medical educators and students in adopting VP resources in their learning and training across the medical curriculum. This bilateral perspective could help in shaping new strategies to effectively integrate this unique type of educational resources in medical education, while addressing important questions on the optimal design and use of VPs. A well-designed curriculum integration of VPs will have the potential to generate medical students with professional knowledge, experiential learning and critical thinking.medphys.med.auth.gr/mei) research team who, apart from the technical support of the system, undertook the responsibility of “training the trainers” or teacher training with respect to technical knowledge and skills required for VP authoring. The outcome of this effort was the creation of a repository of the first 35 VP cases in the Greek academia as well as the local Medical School. These VP cases were implemented through OpenLabyrinth, an open source on line activity modeling system that allows the design and implementation of interactive “game informed” educational activities [The ARIADNE project team consisted of 34medical teachers , in collaboration with 5 members of the mEducator project and the Medical Education Informatics . In the second phase, 219 participants have arisen from a random selection of medical students  .The on line questionnaire data were entered into a database and then imported into IBM SPSS Version 19.0  for descriptive statistical analysis.As far as the qualitative data of the study are concerned, the SRQR guidelines were followed, so as the results of the qualitative part of the study to be more easily accessible to readers when critically appraising, applying, and synthesizing study findings.Data analysis took place at the same time with data collection. Identifiers were omitted to maintain anonymity and confidentiality. Transcripts were analysed using content analysis. A coding sheet was created following a discussion among the primary investigator and supervisors (PB and CH.). Transcripts were read carefully and a summary of meaning units was generated and reduced into codes. Codes were then transferred to the coding sheet, and similar codes were gathered under sub-categories. A category scheme was then developed to group similar sub-categories together. Finally, themes that connect the various categories were identified.Credibility was enhanced by the heterogeneous sample and by performing member check, and using field notes. Dependability was established by having the primary investigator and two experienced researchers review the coding process and agree on the analysis. Confirmability was addressed through constant dialogue among the researchers. Finally, authenticity was ensured by using icebreakers to establish a trusting relationship with the participants and get them to openly discuss their experiences.The vast majority of participants 83.3%) approved that educational activities based on VPs are more interesting than traditional ones. Medical teachers in a rate of 60% agreed that the design process of a VP increased their research interest for the clinical condition related to the case. However, some 63% of them responded that the educational experience with VPs cannot be considered equivalent to a real clinical contact, but all of them (100%) agreed that it can contribute to the development of clinical skills through practice in clinical decision making Table . Finally.3% approThe results of the medical teachers’ questionnaire analysis also contained qualitative data. Medical teachers identified 14 pairs of positive and negative experiences related to virtual patient use. Positive and negative experiences were categorized into two major themes: (1) Educational aspects of VP use and (2) Communication aspects of VP use. Within the two major themes, we identified five subthemes: (1a) Clinical Care of patient , (1b) Learning effect of the VP, (1c) Information Access, (1d) Quality of the educational Resource, (2a) Students engagement and (2b) Student collaboration. Representative medical teacher quotes are provided in Table An important feature that helps in increasing motivation was reported to be the part of media resources, since they add extra value and interactivity to the clinical cases, resulting in more attractive and interesting learning scenarios to trainees. For example it was mentioned “These media files will make the VP very attractive to trainees! They will feel like playing a game with avatars”. Besides, multimedia material was mentioned to add realism to VPs and contribute to a more thorough presentation of clinical cases, leading to better memorization of the diagnostic process. Thus, the optimal use of media adds authenticity and better memorization of clinical conditions.Another important issue that was highlighted on top of that, however, was that VP design is time and effort consuming and needs, even basic, IT knowledge and support. It was also sporadically mentioned were that VPs as educational objects lack the ability for real contact between instructor and learner and, as far as the design process is concerned, there is a need for a stock of media material for the proper VP creation, thereby indicating the need for VP repurposing and reusing.The medical student population included both male (61.20%) and female (38.80%) participants.In a first phase, results of the overall evaluation from all participants were obtained, regardless of sex, age and year of study Fig. . Most meMoreover, the vast majority of participants answered positively to the question of VPs’ integration in the medical curriculum (in a percentage over 98%), something that shows high acceptance of VPs’ incorporation in the curriculum Table .Table 5Furthermore, male participants of the first 2 years of study rated their educational experience with VPs with a mean of 5.55 in a scale 1–6, while female students of the same years of study rated their educational experience with a mean of 3.08 in the same scale. Moreover, male and female postgraduate and PhD students rated their educational experience with about the same value that slightly exceeds 5.13. Similarly, males aged under 25 evaluated their experience with a mean of 5.33 and females aged under 25 with a mean of 3.86. These lead to the conclusion that male young students of the pre-clinical years of study show a significant preference in VPs as learning objects, in comparison to their female mates.Going a step further, it can be easily seen from the results of all participants Table  that stuIn Table With the increasingly widespread adoption of VPs, there exist potential pedagogic synergies to allow trainees the opportunity to practice in realistic and safe learning environments. The results of this study are consistent with findings from other studies of VP adoption  and evenConsidering the likelihood that technology will grow increasingly sophisticated and costly, we have to be thoughtful about how limited, available resources are used, and we should strive in unison towards improving the education of our future physicians . The proIn the light of our results concerning the VP design, medical teachers seem to be able to develop and edit highly interactive VP cases with comparatively little assistance from computer specialists. Additionally, the process of VP design and development itself provides them the opportunity of further deepening in clinical knowledge and clinical reasoning. The VP creation and implementation process in medical curriculum can also serve as a means for collaboration between medical teachers of the same or different medical specialties and contribute to sharing understanding in health care education.In terms of the research questions of this study, as far as the propensity of medical teachers and students to use VPs and moreover the implementation and formal integration in the medical curriculum, current VPs seem to fulfill most needs from course directors and teachers from various educational disciplines and medical specialties, while they seem to satisfy student needs and perceptions of improved knowledge and clinical skills reasoning. At the same time, concerning the preferences of VP utilization, the virtual clinical encounters used in this study appear to be particularly well suited for learning and assessment purposes for medical students, who have had limited or no significant clinical contact. Therefore, medical teachers and students, as well, propose a strategic development and use of VPs in underrepresented topics, especially in pre-clinical medical education, since they may motivate a more widespread integration of VPs into medical education .As far as the exploitation of the advantages and disadvantages of VP integration and user experience, the results of this study suggested that the VP learning effect, the contribution to the better clinical care, the better access and the quality of the education resources seem all to support the formal integration of these learning objects to the medical curriculum.We have to mention that in our case, VP scenarios were not part of the core curriculum, but were actually used as supplementary materials to the formal curriculum. Maybe they would be regarded differently by faculty and learners if they were considered part of the core curriculum.The creation of additional clinical competency cases for both preclinical and clinical years of study including questions and explanations tailored to the critical-thinking that would allow learners the opportunity to explore the consequences of clinical decisions are highly recommended from both medical teachers and students. In addition, wider development of VPs in other disciplines, such as acute care and surgery, would result in a comprehensive body of cases to complement the entire clinical curriculum. Such a development of the VP instruction model would encompass the progression dimension across a whole medical curriculum, where VPs are present in all curricular semesters in an effort to aid the integration of theory and practice aligned by findings in others studies .This study indicates issues that are deemed highly important for the exploration of the VP usefulness in medical education when issues of development and implementation of VPs are considered. Medical educators are usually encountered with a plethora of educational challenges when asked to transform curricula, or develop PBL cases and courses, or promote independent and active learning. As new technology becomes more widely available for educational purposes, medical educators often take existing training material and simply transcribe it into the new technological medium , 29, witEfficient educational strategies including current trends in technology and curricula that improve the quality of the medical education system should be widely developed and thoroughly adopted, according to both medical teacher and student perceptions. This will be a very rewarding experience both for those who deliver these educational courses, as well as, for the recipients of such training. Effective teaching using VPs would be beneficial to be set and formally embedded in the medical curriculum. At the same time, a number of remaining issues regarding VPs design, authenticity and implementation need to be fulfilled, in order to reach the potential educational goals of such applications. That way, VPs’ integration in the medical schools, along the lines of innovation and continuous quality improvement and extensive use of analytics , are likA part of this study included qualitative description. Qualitative description is often criticized for lacking rigour. For this reason, a number of strategies were employed to enhance trustworthiness. Moreover, sampling from a heterogeneous pool of participants  increases the risk for selection bias and makes the comparison of findings difficult.We present the results of a combined evaluation of transforming the medical curriculum with VPs’ adoption from both medical teachers’ and students’ perspective. In the face of compelling evidence , 32, 33,The results of this study document high acceptance of VPs by both medical teachers and students, since it is evident that they perceive VPs as an excellent learning tool in undergraduate and postgraduate curriculum. The content of these VP cases has already been repurposed and shared in different educational contexts aiming at a wider adoption of VPs’ integration in medical education .At the same time, important questions that remain on the optimal design, use and integration of VPs should be addressed in order to adequately inform future development. Potential variations in VP design are practically limitless and more research is needed to inform instructional design and curricular integration, so as VPs to be effectively adapted to the needs of potential users and instructors . Future During the last few years, VPs have become more widely available and easier to create, driven both by student and teacher interest and by recognition of their pedagogic value . Under t


We thank Crezee et al. for their opinion article concerning the impact of the time interval between radiotherapy (RT) and hyperthermia (HT), elicited by our recent publication showing no effect of the time interval on clinical outcome . We welcWe regret the feeling of insufficient caution in our conclusions. In fact, we and our referring radiation oncologists took the results of the study of van Leeuwen very seriously. It initiated an intense discussion as to whether the treatment procedure for RT+HT should be offered only if both treatments could be delivered in the same institution to maintain a short treatment interval between the therapies. After all, the international standard for locally advanced cervix cancer consists of combined radiotherapy and platinum-based chemotherapy . HoweverA limitation of both our studies, besides the retrospective nature, is the long inclusion period; 1999–2014 for van Leeuwen et al. and 1996–2016 for our cohort. This makes both our analyses subject to confounding factors, because of changes in interval times in different time periods. For example, in our cohort we observed longer waiting times between RT and HT in earlier years vs. more recent years. Given the larger number of patients in our cohort, we were able to analyze the effect of the time interval per time period of 4–5 years, showing no effect of the time interval for all time periods (p = 0.624)  . These r= 0.624) .in vivo studies regarding the exact working mechanisms of hyperthermia in patients, not in models, are highly needed. We feel that the Overgaard paper is an important paper, but it represents only a single experimental setup in one tumor model, and can thus not be generalized to the clinic .MK: drafting of the manuscript. HM and MF: critical review of the manuscript. GR: drafting of the manuscript and critical review of the manuscript.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.


Although the adverse effects of trans fat consumption are well documented, industrially-produced trans fats are still used in a variety of food products. Our objective was to investigate the presence of trans fat information on the nutrition facts panel, in the list of ingredients, and the use of trans fat claims in packaged food and beverages marketed in Brazil. This was a cross-sectional study that used data from packaged food and beverages available in the five supermarket chains with the largest market share in Brazil. Of the 11,434 products that were analyzed, 81.3% did not present a source of trans fats in the list of ingredients. The percentages of products with specific (hydrogenated fats or oils) and unspecific trans fat terms  in the list of ingredients were 4.1% and 14.6%, respectively. Bakery products, cookies and crackers, candies and desserts, snacks, and convenience foods had the highest percentages of trans fat claims. We also found claims in products with ingredients that are sources of trans fats. In conclusion, trans fat ingredients were found in almost one-fifth of the Brazilian packaged foods. The current Brazilian legislation is not sufficient to inform consumers about the content of trans fats in packaged foods. Along with measures to restrict the use of industrially-produced trans fats, improvements in nutritional labeling are also needed. Trans fats are unsaturated fatty acids with at least one double bond in the trans configuration. They occur naturally at low levels in meat and dairy products from ruminants and are industrially produced by the partial hydrogenation of vegetable oils . Trans fThe adverse health effects of trans fat consumption, particularly the association with increased risk of coronary heart disease (CHD), are well documented in the literature ,6,7. AltOver the past decades, voluntary and regulatory measures to lower the content of industrially-produced trans fats, including improvements in food labeling, food reformulation, and restrictions in use, have been adopted around the world . The mosIn 2003, the Brazilian Health Regulatory Agency  included the information regarding the content of trans fats as a mandatory item on the nutrition facts panel of packaged foods and beverages labels in the country. However, the current legislation fails to provide clear and adequate information related to the content and presence of trans fats in packaged foods and beverages. First, trans fat content below 0.2 g per serving is considered insignificant and must be declared as zero on the nutrition facts panel . Still, A review that investigated the consumption of trans fats in 29 countries worldwide found that in the majority of the studied countries, the trans fat intake is under the limit of 1% of total energy intake, and the main source of the trans fats consumed is from animal products . HoweverConsidering the challenges of developing and implementing effective regulatory measures for the prevention and control of NCDs related to unhealthy diets in Brazil, the objective of the present study was to evaluate the presence of trans fat information and claims regarding trans fats in packaged foods and beverages marketed in Brazil.This cross-sectional study used data from a sample of packaged foods and beverages that are sold in Brazilian supermarkets. Supermarkets were selected as the source for the data collection because they are the main places in which food is purchased in the country . The fivTrained fieldworkers photographed all sides of the packages of the products available in the stores between April and July 2017, according to the methods proposed by Kanter et al. (2017) . We inclWe excluded duplicate records, products available in more than one package size, multipacks with different items, products without a nutrition facts panel, products without a list of ingredients, and products with missing values for portion size and/or calories. The final database was composed of 11,434 products. All products were included in the analysis of the nutrition facts panel and the list of ingredients.n = 3491). This was the first project aimed to identify the prevalence of nutrition claims in Brazil, so we guaranteed that our sample size was large enough to estimate even a small prevalence (p = 0.01) and its 95% confidence intervals (CI), considering a precision of 0.005  idenRegarding nutrition claims, as mentioned previously, the current Brazilian rules permit the use of messages that claim that the product is free of trans fats on products with trans fat content below 0.1 g per serving . HoweverImposing limits on the use of industrially-produced trans fats is the measure that has had the greatest impact on trans fat consumption in many countries , and it In 2008, the Pan American Health Organization (PAHO) launched the “Trans Fat Free Americas”, which recommended a limit of 5% of total fats from trans fats in industrialized food products and pointed to the need for legislative measures . CountriImplementing policies that aim to restrict trans fats in the food supply results in the need for product reformulation, and the employed substitutes can be concerning as trans fats could be replaced with saturated fats to maintain the required or preferred solid fat content. However, a study conducted in 14 countries that aimed to compare foods with high and low content of trans fats showed that french fries, cookies, cakes, and microwave popcorn with low content of trans fatty acids had a higher content of saturated fats but also higher content of monounsaturated and polyunsaturated fatty acids . The resIt is important to highlight that, initially, trans fat use by the food industry was considered a healthier option in relation to animal fat, due to the presence of unsaturation and its vegetable origin, but it is currently known that its consumption negatively impacts lipid metabolism, causing detrimental effects on the heart health . The useThis study has some limitations. Our data source was the labels of food products marketed in the country and, to classify the product by the presence of trans fats, we used the information available in the list of ingredients and on the nutrition facts panel without conducting laboratory analyses, which may have introduced bias in our findings. Another limitation was the use of a random subsample to evaluate nutrition claims. Nonetheless, we were cautious in selecting our subsample, we included a large number of products, and we did not find any statistically significant differences in the proportion of foods in each food category or on the average content of nutrients, including trans fats, when we compared our subsample with the total sample of the assessed Brazilian packaged foods (data not shown). As a strength, we attempted to include all available packaged foods and beverages in the five largest food retailer chains in the country. We also took advantage of the INFORMAS claims taxonomy, which was developed to standardize the classification of the different health-related labeling components in different countries, to assess the presence of claims .In conclusion, despite advances in recent years regarding the use of trans fats in Brazil, important issues concerning the presence and information about trans fats remain. In food labeling, there is a possibility that products are declared as trans fat free even with the presence of ingredients that are sources of trans fats. Another related issue is the deficiency of standardized terms in the list of ingredients. The lack of accurate information on packages can misinform consumers and lead to excessive consumption of trans fats without knowing. Food labeling with clear and adequate messages is a citizen’s right, as was established by the Brazilian Consumer Defense Code (Código de Defesa do Consumidor) . In the


The activity of arthropods on corpses has been largely investigated, since they can produce information to reconstruct the peri-mortem events. However, the feeding/movement activity of insects around the crime scene, among the clothes and on the body, can also cause some alterations that can lead to wrong reconstruction and misinterpretations. This article summarises all the post-mortem arthropods artefacts related to the scene (i.e. fly artefacts and floor stripes) and the body  that can mislead the forensic pathologist, discussing macroscopic and microscopic findings derived from forensic casework and from experimental laboratory studies, in order to provide a useful instrument to avoid misinterpretations and evaluation errors. Finally, some procedural notes for the documentation and the interpretation of findings are proposed. Arthropods, including insects, arachnids, scorpions and crustaceans, are the largest and most numerous zoological taxon on Earth. Arthropods are present in a wide variety of locations commonly used by humans, and they have been reported also from crime scenes.During the last three decades, the utility of forensic entomology in death investigation has been largely documented in Europe, America, Australia, and Asia by several case studies  and expeIt is worth mentioning that such cases and experiments show the potentiality of this discipline in the forensic pathology investigation field not only in post-mortem interval (PMI) estimation but also in drug detection, cadaver transfer and victim identification . TherefoDespite being highly informative, arthropods have the potential to strongly alter and modify the crime scene and the victim’s body.Therefore, given the complexity of crime scene investigations and the necessity to respond to the six W questions  and to understand the dynamics of violent crimes, the forensic entomological knowledge is of utmost importance, and the forensic pathologists should be aware of the damage that arthropods can cause, together with the useful information they can provide.The aim of this work is to analyse the scientific literature dealing with all the post-mortem artefacts, caused by arthropods, of the scene and the body in order to provide forensic pathologists with a useful instrument to avoid misinterpretations and evaluation errors.In fact, a summary overview of these lesions in a single paper has never been done until now and this article can be considered as a consultative tool for forensic pathologists and crime scene investigators, during a crime scene investigation and the autopsy.description of post-mortem artefacts in death scene;presentation of post-mortem cases investigated through (at least) an autopsy with or without histology analyses;critical discussion on issues related to the identification or misinterpretation of post-mortem artefacts.A literature search in the electronic databases Pubmed, Scopus and Web of Science was conducted using a combination of free text protocols  individually combined through the Boolean operator “AND”. At the same time, filters such as full-text, publication date from January 2000 to September 2016, and English language were activated resulting in more than 100 articles, which were submitted to the following criteria of inclusion (one at least):Moreover, entomological books and forensic entomology and pathology manuals –12, whicSubsequently, the selected papers were analysed in full text together with the chapters of the selected books and manuals.Forty-one papers dealing with post-mortem artefacts due to arthropods that fulfilled the inclusion criteria were included in the investigation. Among these, 7 were case reports –19, 3 caAs previously mentioned, insects from a crime scene and/or a cadaver can provide useful information; however, their feeding and locomotor activity through the crime scene, among the clothes and on/in the body, can also cause some alterations resulting, if wrongly interpreted, to misinterpretations and wrong investigative reconstructions.The analysis of the literature shows that several authors described the alterations and modifications of the crime scene and the post-mortem injuries caused by different animals: vertebrates and invertebrates. The following paragraphs describe and discuss the alterations of the crime scene, clothes and body generated by the feeding and locomotor activity of invertebrates, saprophagous arthropods, associated with the cadaver decomposition. These alterations can be grouped as “crime scene entomological alterations”  and “entomological body artefacts” .Bloodstain pattern analysis (BPA) has a key role during crime scene investigation, providing crucial information about the physical events that led to the bloodstain deposition . The infSince bloodstains are not static and can be altered after formation, in particular during the liquid phase, some alterations after deposition should be considered as part of the BPA , and they could allow the reconstruction of the criminal acts , 48, 51.Morphological alterations of bloodstain pattern due to insect activity are described in several entomological textbooks –9, but, FAs were described for the first time by Lassaigne in 1856 , who defThe differentiation between FAs and bloodstains and the confounding factors affecting their shapes and characteristics have been widely discussed in forensic literature . BeneckeThe same authors  also proEven if there are not universal rules that can be used to differentiate FAs from bloodstains, Table In addition to macroscopic observations, immunological and molecular tests have to be applied for the correct identification of suspect spots .On the other side, flyspecks can be a further source of human DNA useful for victim identification if the body is removed from the crime scene before the investigators’ arrival. From this point of view, flies can be considered as a vehicle for the spreading of the victims DNA. Human DNA can be extracted from FAs in sufficient quantities to provide a full profile of the donor , 34, 41.Calliphora spp., Lucilia spp., etc) disperse to find an adequate place for pupariation and then pupation  whereas a minority remain on the corpse or in the clothes (e.g. Phormia regina and Protophormia terraenovae). This phase of wandering larva is called “postfeeding” because at this stage, larvae stop feeding and empty the digestive system from any food remains [Diptera larvae, called maggots, in the families Calliphoridae, Sarcophagidae and Muscidae are the primary consumers of animal organic matter. After completing their feeding phase, the majority of the larvae , especially in degraded and dirty environments, little information is reported about their activity on the bodies.Ants are one of the world’s dominant insect groups with important ecological roles. Their part in the faunal succession varies from predator of eggs and larvae of other insects to early scavenger on the flesh or exudates from the corpse itself. Their activity was documented both in outdoor and indoor cases .On a body, ants feed off keratin in eyelashes, eyebrows, lips and knuckles and superficial layers of skin. Their feeding pattern is confined and characterised by multifocal areas of skin loss with small linear trails bordering the primary erosion points. The resultant thinning of the epidermis leads to an increased fluid loss with the development of irregular, serpiginous and scalloped areas of superficial skin loss known as “parchmenting” . In addiPost-mortem injuries caused by Formicidae , 36 can As insects feed mainly on the uncovered areas of the body, ant bites are frequently located on the arms and the legs , 45. TheTherefore, the final diagnosis can be only confirmed at the autopsy by gross and microscopic analysis.Histologically, the level of skin damage inflicted by the feeding action of ants is often represented by the absence of the epidermis only  without haemorrhage from the skin and the subcutaneous tissues.Ant injuries may be of some utility in recording the presence of clothing and the position of the body after death since ant injuries can mark the perimeter of clothing and outline the junction between the body and the surface that it was laying on, due to their inability to gain access to skin beneath elasticized clothing or parts of the body pressed against the floor or ground. This information may be important especially if clothing has been removed prior to autopsy or if lividity is minimal .Skin (Dermestidae), chequered (Cleridae), clown (Histeridae) and burying (Silphidae) beetles can appear on a body during the late decomposition phases as body feeders or since the early stages as predators of other species. Beetles cause alterations that can be confused with lesions that could actually cause the victim’s death . It has Cadavers collected from water often show post-mortem lesions caused by water turbulence, contact with the bottom of the river but as well as by the feeding activity of fluvial and marine scavengers, the latter including cookiecutter sharks, small size fish, deep sea crabs and mollusks –64.Post-mortem injuries caused by aquatic animals  need to The crustacean scavenging action is mentioned in many forensic textbooks but the aspect of these injuries is not described in detail in the literature, probably because of the difficulties in attributing the observed wounds to a specific species, with a few exceptions .The post-mortem damage of the body in freshwater can include the loss of soft tissues mainly on the face and in cervical area. The haemorrhagic aspect of extensive but superficial wounds predominantly on the face can gave rise to suspicion of criminal assault Fig. . After dSuch a particular macroscopic aspect of these can to lead to the erroneous diagnosis of chemical or deep second-degree burns .Literature reports that cockroach feeding activity on remains can be misinterpreted as burn since they left small (< 0.6 cm), round physical artefacts on the skin .Notiothauma reedi (Mecoptera: Eomeropidae). No record of this kind of lesions were reported from human cases.Some round lesions of the epidermis and part of the superficial dermis, approximately 3–5 mm in diameter, with an alopecic border were reported on the skin of pigs used for decomposition studies in South America . The cenA variety of insect taxa can modify bones with their mandibles, including the larvae and adults of some beetles , moths (Tineidae), wasps  and termites  , as obseIn particular, terrestrial invertebrates, which have an osteophagic behaviour, can colonise the burial place and influence the taphonomic processes  even in Hairs are the most resistant structures in the human body after teeth and bones and nails and can be collected from a crime scene several years after a victim’s death. However, they can be altered by different organisms, such as fungi and arthopods, mainly insects in the orders Coleoptera and Lepidoptera. A general classification of damage has indicated that insect feeding activity only produces concave lesions caused by their “gnawing” activity, whereas fungal alteration leads to transversal tunnelling inside the hair structure. Studies of trauma on hair are extremely rare but a pilot study highlighted that the effect of the entomological components involved seems to be clearly distinguishable (thanks to the “gnawing” pattern) from sharp force trauma .The crime scene, as well as the body, which can be considered itself as a crime scene, must be analysed and scrutinised with attention and precision, also taking in consideration the possibility of the post-mortem alterations due to the activity of arthropods and other organisms .On this point, the analysis of the literature has shown that among the 15 papers dealing with the issue of post-mortem arthropod body injuries, histological analysis were performed only in three cases in order to confirm post-mortem nature of the injuries while in the remaining 12 papers, the macroscopic findings were not microscopically confirmed.Therefore, in order to reduce the risk of misinterpretation, some procedural notes to be followed in case of potential alterations due to the insect activity are suggested here. These notes take into account the two phases of a violent crime investigation: the crime scene investigation and the autopsy, and they can be applied also in a broader context when other animals or environmental factors could affect the integrity of the body.Perform complete and detailed description and photographic documentation with a proper camera of the crime scene, including body position, clothes position, potential FAs and floor stripes position that may be present, at the discovery moment.Pictures have to be collected using the principles of forensic photography, since commercial smartphones and tablet do not have the appropriate resolution. All the detail photos have to be done with and without an appropriate scale and an optimization of the light.Windows, doors and lights positions have to be reported on the documentation in order to identify any entry/exit point for insects and other animals. In indoor cases, particular attention has also to be paid not only to the room where the body lays but as well to the contiguous spaces, under the carpet or any object on the floor potentially used as a shelter by the insects.Collect all the arthropods present on or near the body or in the crime scene , 38 and Search and collect insects present on the body, clothes, body bag or coffin after transport from the crime scene to the morgue.Perform an accurate external examination on clothes and on the body, describing and photographing all the injuries with and without an appropriate scale and an optimization of the light.Compare the position in which the body was found and the clothes with the site of injuries.Perform an incision into each lesion area, and underlying tissues should be observed and sampled for further histological analyses.In case of suspicion of lesions being produced by arthropods, a histological analysis of the samples has to be performed, in order to confirm the post-mortem nature of the lesions, characterised by the absence of vital reaction, such as congestion, fibrin deposit or inflammatory reaction.Entomological artefacts represent an important issue for forensic pathologists, since they can lead to wrong investigative reconstruction and misinterpretations, both during body examination at the crime scene and during the autopsy.Therefore, in order to avoid misinterpretations and evaluation errors in the discrimination between ante-mortem injuries and post-mortem insect artefacts, the correct training in forensic pathology should include expertise regarding post-mortem artefacts produced by arthropods and other organisms. Moreover, during the different phases of a violent crime investigation (i.e. crime investigation and autopsy), the potential existence of alterations due to insect activity, animals or environmental factors that can affect the integrity of the body must be considered in order to take the necessary operational and procedural attentions, for example, following the tips in Table In conclusion, a multi-disciplinary approach is recommended in death investigation , 44, 65,


This book describes the Mediterranean diet (MD), explored its nutritional constituents and its beneficial health effects. It explains in detail how consumption of MD helps to prevent cardiovascular diseases. It also delineates how much wrong diet contributes to development and progression of heart diseases.In this book, MD was defined as a healthy eating model, dating back to early 1960s and observed in Greece and Southern Italy. It was also described as a traditional diet obtained from Mediterranean countries, consisting of foods such as grains, vegetables, fruits, olive oil, nuts, fish, dairy products, eggs, meat, herbs, and spices.The book is made up of 12 chapters which gave in-depth explanation of what MD is. The composition as well as methods with which to achieve and adapt to MD, with the aim of preventing cardiovascular diseases, were highlighted.The introductory chapter talks about the traditional healthy MD pyramid, the biological and epidemiological evidences regarding the benefits of MD. This chapter discusses the several clinical trials and results involving the adherence to MD together with how it has impacted on the risk of cardiovascular diseases. The authors described the positive results from several clinical trials and mentioned that the significant PREDIMED trial showed ~30% decrease in cardiovascular disease risk factors. They also highlighted the fact that other lifestyle-related factors could be affecting the potential effect of MD on the improvement of cardiovascular health.Chapters 3 to 8 revealed the importance of major components of MD; fats, oil, mixed nuts, fruits and vegetables, cereals and legumes, fish and meats. Chapter 9 highlights the benefits of moderate consumption of red wine to the body. Chapter 10 lays emphasis on the relationship between high life expectancy rates, low mortality rates and Mediterranean countries with regards to adopting a social lifestyle. Chapter 10 also elaborates on how climate conditions can impact on cardiovascular health and stresses the importance of mental well-being in maintaining a healthy lifestyle. Chapter 11 covers healthy diet and effect of MD on heart and brain function and lists different studies (between 2006 and 2017) which have attempted to show association between MD and improvement of cognitive function.The 12th Chapter which is the concluding chapter provides details of 30 short and simple recipes containing the different classes of food in MD.Each chapter contained illustrations, in form of figures and tables highlighting more details about the subject. For instance, the Mediterranean Diet pyramid which showed details of types of foods and the amount to be consumed. This is helpful for readers who understand better with visuals.In this book, some of the illustrated figures appeared blur due to low image quality. We also observed that the pattern in each chapter was slightly different which could be due to the different contributing authors. However, all chapters included references which would be very helpful for anyone interested in researching more about the Mediterranean Diet.In summary, this book emphasized the fact that MD is a highly recommended eating model to be adopted toward the prevention of cardiovascular diseases. We do recommend this text for students, physicians, and researchers in areas such as cardiovascular and nutritional sciences. It contains guidelines on dietary patterns that can help improve the health of susceptible and healthy individuals, aiming to maintain a healthy lifestyle.EA and CO read the book and drafted the review summary together. EA typed the manuscript and edited. CO proofread and made final corrections.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.


Specifically, studies with published data in the fields of environmental release, toxicity and ecotoxicity of ENMs were considered. For this Editorial, we, the guest editors, performed a brief review with the aim of setting the framework for the Special issue on the “Environmental Impacts of Nanomaterials”. We started with the DaNa web-based knowledge base  are a diverse group of materials that find application in a great variety of products ranging from cosmetics to paints, from sports equipment to electronics, and from soil remediation to nanomedicine . The NanThe environmental impact of ENMs is a broad field spanning not only the whole life cycle of nanomaterials, including the waste phase, but also many different environmental contexts with different prevailing conditions. Ultimately, ENM will also reach the technosphere, for example, waste water treatment or incineration plants. In addition to incidental release, there are several applications that imply the intentional release of ENM into water and soil, such as ENM employed in remediation techniques . www.nanoobjects.info [Considering the increasing use and application of ENMs, there has been growing concern about the environmental safety and impact of nanomaterials released to various environmental compartments. During the last decade tremendous effort has been put into scientifically addressing these concerns, resulting in an overwhelming number of studies. In 2009, the DaNa project was launched to summarize and aggregate the knowledge generated and aimed to provide impartial information on ENM with access for all. For this purpose, knowledge from the scientific literature, as well as other sources is condensed into a web-based knowledge base  was conducted for the 26 ENMs included in the DaNa knowledge base. The search strategy used the name of the respective ENM, “ENM” and “nano*” and either “environment”, “tox*”, or “ecotox*” as keywords. The results are shown in This rather simple evaluation of current nanotechnology related literature reveals discrepancies in the assessment of the safety of selected nanomaterials. In particular, current research on environmental safety tends to focus on whether applications have relevance in the environmental sector rather than assessment of actual release and distribution in different environmental settings. With regard to the latter, the literature search applying the additional term “environmental release” yielded either none or very few results. Most of the currently available data on this issue relies on modelling approaches e.g., ,12.In addition, many of the research gaps evident in the field of nanotechnology are due to insufficient, very time consuming and/or expensive methodology and analytical procedures. Detection and quantification of ENMs in complex environmental samples are particularly challenging ,14.As evidenced by the number of hits given in We hope that our brief literature review provides some inspiration to steer research into the impact of ENMs on the environment in a more appropriate direction. As discussed, there are specific data gaps in the area of environmental risk assessment. In order to improve the evaluation of the environmental risks of ENMs, we recommend generating more data of high quality and reliability on the actual environmental release and fate of ENMs. Furthermore, we consider it important to foster the publication of ecotoxicity studies that report on the non-toxicity of ENMs as reliable studies on this issue represent important building blocks for improved risk assessment. Finally, to add to the ever-growing knowledge base in general, and subsequently to the DaNa knowledge base, in this special issue we aimed at providing a platform for more detailed research into the environmental effects of ENM. We, the guest editor team, hope that this Special Issue of Materials is of interest to the scientific community and facilitates further discussion on the environmental fate and safety of ENMs.


This study focused on the relationship between job design and behavioural outcomes of employees in Agricultural Research Training, Ibadan, Oyo State, Nigeria. The study was quantitative and the items in the questionnaire were adapted from previous studies. A total of 227 respondents were surveyed and statistical regression models were used to examine the relationship between the independent variables (job design) and dependent variables . The findings showed that 14.4% of the variance in job design dimensions can explain the variance in employee behavioural outcome. The model revealed that task identity, sense of autonomy and skill variety had more statistical significance in predicting employee behavioural outcome, recording the highest beta value than other variables such as task significance and feedback mechanisms. The model indicates that the strength of regression weights of paths has a strong direction. Specification TableValue of data•The data can be used by government, private investors and other stakeholders to make decisions on how best to design and manage work activities and the impact of that on the work that people do.•The data can be used to highlight the importance of changes that new technology is bringing to influence work design and the overall productivity of the institute.•The data provides information on how different job designs dimensions can interact effectively to enhance positive behaviour and sustain greater commitment.•Generally, data acquired from this study would be significant for improving institutional framework, facilitating goal achievement, and designing motivating work which would in turn lead to sustainability of the institute.1The study is quantitative in nature and in an attempt to control for variability between companies , the scope of this study was limited to one research institute with multiple sections. The Job Characteristics Questionnaire (JCQ) developed by Hackman and Oldham was used to gather the core job characteristics data because it is the most validated and efficient means of accurately measuring job design.Of the 300 JCQ surveys that were sent to the institute, 227 of these staff participated in the survey, for a 76% response rate. To achieve this response rate, several follow-up attempts were made to increase participation in the research. These included personal phone calls, as well as sending follow-up emails to the leaders asking for participation. After all data was collected, organized, and codified, it was analysed using SPSS, version 21. The independent variable for the study was job design. Data for the independent variable were collected via the JCQ survey instrument from voluntary participants within the company. Job design were measured using 15 questions. As recommended by the JCQ, the five measures and scales were used to calculate the score for each individual. These measures were identified as skill variety [SV], task identity [TI], task significance [TS], sense of autonomy [SA] and feedback mechanism [FM]. Cronbach׳s Alpha for job design was .869, well within the limits of acceptable reliability. Responses were collapsed by first averaging all items within each scale (three items each), then by averaging the resulting scores across all five scales to yield a single number representative of the level of job design for each respondent. In this study, the dependent variable was employee behavioural outcome as measured by employee engagement, job satisfaction and involvement in decision making. Thus, descriptive statistics for the indicators used in this analysis were not reported. The dependent variable data meet the assumptions for normality test.During the data collection stage, demographic variables age, experience, and education were all coded, or scaled, so that the numbers shown do not reflect actual numbers. The scales used to code each of these variables is shown in 2The study is quantitative in nature and data were retrieved from staff and management of sampled institute. The decision to elicit information from the employees and the management group was based on the fact that while employees were often in the best position to describe their job contents; it is also crucial to investigate these practice from the perceptions of the managers. This shows that the samples were diverse and it can be concluded that non-response bias will not significantly affect the generalizability of the study findings. The use of bar chart was also carried out to describe the work characteristics in the sampled institute as presented in The study adopted the approach recommended by The results of CFA analysis suggest that the factor loadings for all major variables range between 0.704 and 0.761. The three conditions used to assess convergent validity as suggested and recommended Based on the results of the test, it has proven that the data are good in terms of convergent validity, construct reliability, and discriminant validity. Moreso, a model fit was evaluated to show the relationship between observed and unobserved variables by examining several fit indices which include: chi-square (χ2), chi-square/degree of freedom (χ2/df), Goodness-of-Fit Index (GFI), Comparative Fit Index (CFI), Standardized Root Mean Residual (SRMR) and Root Mean Square Error of Approximation (RMSEA). Having run the test, the SEM was obtained, and results of fit indices was shown in Results in 2=.144, which connotes that 14.4% of the variance in job design dimensions can explain the variance in employee behavioural outcome. This means that a unit increase in job design dimensions will lead to an increase in employee behavioural outcome. The model revealed that task identity, sense of autonomy and skill variety had more statistical significance in predicting employee behavioural outcome, recording the highest beta value than other variables such as task significance and feedback mechanisms. The model indicates that there are varying explanations for the dependent variables. Hence, it is seen that the strength of regression weights of paths has a strong direction.Before conducting the structural model, the data was tested for linearity, normality and multi-collinearity. All the basic assumptions were acceptable and prove that the data met the conditions of basic assumption in regression analysis. In this case, the R3Of 300 copies of questionnaire were distributed, only 227 responses were received resulting in a response rate of 76%. Data were gathered from directors, managers, assistant managers, scientists, field agents, and other categories of employees across the sampled institute with the aid of a researcher- made questionnaire based on the works of Inclusion criteria:•Participants had to be staff of the sampled Institute•Participants must have signed the consent form provided•Participants must have worked with the institute for a minimum period of 3 yearsHowever, the researchers ensured that respondents were well informed about the background and the purpose of this research and they were kept abreast with the participation process. Respondents were offered the opportunity to stay anonymous and their responses were treated confidentially.