Colorectal cancer represents a major health problem and an important economic burden in Puerto Rico. In the 1990's, the Commonwealth of Puerto Rico implemented a health care reform through the privatization of the public health system. The goal was to ensure access to health services, eliminate disparities for medically indigent citizens and provide special coverage for high-risk conditions such as cancer. This study estimates the 5-year relative survival rate of colorectal cancer and the relative excess risk of death in Puerto Rico for 2004–2005, by type of health insurance coverage; Government Health Plan vs. Non-Government Health Plan. Colorectal cancer in advanced stages was more common in Government Health Plan patients compared with Non-Government Health Plan patients . Government Health Plan patients in the 50–64  and ≥65  age-groups had the greater excess risk of death compared with Non-Government Health Plan patients. Further studies evaluating the interplay of access to health services and the barriers affecting the Government Health Plan population are warranted. Colorectal cancer (CRC) is the second most commonly diagnosed cancer among males and females, and is the overall leading cause of cancer death in Puerto Rico It has been shown that for people with cancer, an early diagnosis and appropriate treatment may greatly enhance their chances of survival patient delay, from first symptom to first contact with the primary care physicians (PCPs); doctor delay, from the first contact with the PCPs to initiation of investigation of cancer-related symptoms; and, system delay, from the initiation of investigation of cancer-related symptoms, referral to secondary health care, first visit, and diagnosis/referral to treatment and initiation of the treatment Aspects related to delay in cancer diagnosis and treatment could explain, in part, health system performance. Delay in cancer diagnosis and treatment can be categorized into three different types: Prior to 1993, the Commonwealth of Puerto Rico, a territory of the United States, had a regionalized public health system with primary, secondary, tertiary, and supra-tertiary patient care levels. All health care facilities and human resources were owned and financed by the government Reforma. The government employed two strategies to facilitate the transition. First, it contracted the management of access for the care of the medically indigent population to private health insurance companies. This contracting process was based on capitation arrangements. Second, it sold the majority of public healthcare facilities to private investors and providers, including most hospitals and primary care Centers for Diagnosis and Treatment The focus of this investigation is the first period of implementation of the GHP, which lasted until 2009. At the time, the GHP was locally known as Through the GHP, PCPs assumed the responsibility for coordinating the care of 1.6 million covered lives (40% of the Island's population) The goal of the1990's GHP reform was to ensure access to health services and eliminate disparities for medically indigent citizens and provide special coverage for high-risk conditions such as cancer. Among its services, the GHP has a special coverage provision that includes cancer, among others illnesses requiring specialized services. The purpose of this coverage is to facilitate the effective management of the insured population with special health conditions. Cancer coverage under this provision begins upon the confirmation of a cancer diagnosis. A confirmation is obtained through pathology results and/or procedures performed.Access to health insurance is known to influence the amount and quality of health care received, and thus, the type of insurance may be important to the cancer patient survival Data for patients diagnosed with CRC were provided by the Puerto Rico Central Cancer Registry (PRCCR). The PRCCR is one of the oldest population-based cancer registries in the world, collecting information since 1951 th (ICD-O-3) site codes C180-C209, excluding lymphomas, leukemia, and sarcomas This study included all invasive CRC patients diagnosed with primary cancer from January 2004 to December 2005. Primary site and histology type of invasive CRC were coded according to the International Classification of Diseases for Oncology 3The Puerto Rico Health Insurance Administration provided claims related with patients diagnosed with cancer to the PRCCR for 2004–2005 to identify and corroborate GHP patients. After obtaining analytical incident cases of CRC, the PRCCR conducted a probabilistic match to determine which patients were GHP patients. CRC patients in the PRCCR database which were not identified as Puerto Rico Health Insurance Administration beneficiaries were classified as NGHP patients. Similar to the proportion of people who's had GHP in Puerto Rico, 39.15% of CRC patient corresponded to GHP.The study was reviewed and approved by the institutional review board of the University of Puerto Rico, Medical Sciences Campus, San Juan, Puerto Rico. The study involved a secondary data-analysis of the databases of the PRCCR. All data obtained by the PRCCR from patients are held in strict confidence and patient records de-identified prior to analysis.In order to evaluate the difference in demographic characteristics and stage at diagnosis a Chi-square or Fisher's exact test were used when appropriate. Five-year maximum relative survival rate was calculated using the cohort method and using a maximum likelihood algorithm in STATA Software In addition to calculating survival, we modelled the effect of health insurance coverage type categories on relative cancer survival rate, while stratifying by stage and age group; and adjusting for sex and year of follow-up, using a Poisson regression model for excess deaths. The reference insurance plan group in the RER of death estimation was NGHP. The likelihood ratio test statistic was used to assess the significance of interaction terms.A total of 2,728 CRC patients were eligible for analyses. The distribution of cases by type of health insurance coverage is given in The likelihood ratio statistical test showed a significant interaction between the main predictor variable  and both the covariate age group at diagnosis (p<0.05) and stage at diagnosis (p<0.05). Thus, the Poisson model was stratified by age and stage at diagnosis.RER of death for colorectal cancer are illustrated in Among CRC patients with regional stage, a significant higher risk of death was observed for GHP patients ages 50–64 years, these having 66%  higher risk of death within five years of diagnosis (p<0.05). Nonetheless, GHP patients with ages younger than 50 years had marginal significant differences in the risk of death compared with the NGHP (p = 0.08). On the other hand, no statistical difference (p>0.05) was observed between GHP and NGHP patients aged 65 years or older.Furthermore, among CRC patients with distant stage, only a marginal difference in the RER of death was observed between GHP and NGHP patients for the age group 50–64 years. In this group the GHP patients had 52% higher risk of death  within five years compared with the NGHP patients. Meanwhile, among CRC patients with unknown stage, although the estimates have a similar pattern, no significant difference was observed between GHP and NGHP patients for all age groups.The analysis of health outcomes across different sectors of society provides an effective way to determine the impact of health care policies and measure the effectiveness of its implementations. Providing policy makers with evidence-based research allows for the corresponding corrective actions to take place and health policies to be redirected, in order to meet the population needs. It has been stated that cancer survival is a key measure of health system performance This study confirms that CRC patients who had GHP are diagnosed at an advanced stage and had a lower relative survival compared with NGHP patients, which highlights a health disparity that warrants further research. These results are relevant as patients diagnosed in later stages tend to have a lower survival rate, because they are more difficult to treat successfully. Another interesting finding was that GHP patients were diagnosed at younger ages (<65 years). Nevertheless, although GHP patients have a younger age at diagnosis, they have a more advance stage at diagnosis than NGHP patients. Thus, future studies should assess the potential risk factor differences between these groups, as well as the social and/or biological determinants of health that may be influencing these patterns.In addition, GHP patients from all age-groups diagnosed early , had a higher risk of dying within five years, compared to NGHP. Furthermore, even though the proportion of CRC patients <50 years was similar in both GHP and NGHP groups, an excess risk of death was observed in this youngest population of GHP patients  when compared to NGHP. This excess risk of CRC in patients younger than 50 years, in which CRC screening practices are not recommended, supports the potential role of other risk factors in Hispanics that needs to be better understood to develop appropriate intervention strategies, to reduce health disparities within this group. Meanwhile, differences were not that big among GHP and NGHP patients with regional/distant disease, supporting the fact that when disease is advanced, the outcomes are not different between these groups, a result that could be explained by the fact that receiving or not receiving the best treatment does not significantly change the survivorship among individuals with distant/advance stage disease in this population. Again, this highlights the fact that beyond an appropriate screening, GHP patients may have problems with access and quality of health services once diagnosed that impacts localized stage patients more strongly, in which appropriate treatment may have a better result on the disease outcome. This is relevant, as delay in treatment may be a sign of failures in the implementation of the reform of the GHP.Delay in cancer diagnosis of GHP patients warrant further research to better understand parts of these results. It is important to study the different factors that pertain to the patient delay, such as social conditions, co-morbidities, educational background, knowledge, attitudes, and behavior, among others. Mandelblatt and colleagues Despite these factors, the healthcare PCP's delay has been shown as an important factor that could have an influence on the delay of diagnosis Others system barriers that could have an influence on the delay of diagnosis and treatment in cancer patients include organizational and structural factors, reimbursement and financial forces, quality measurement, and regional resources Platino  In addition, another relevant fact evidenced by our study is that GHP patients in the 50–64 age group had the greater excess risk of death within five years of diagnosis, while the other age groups had a lower excess risk. A potential explanation of the difference in the RER of CRC by age group, could be related to the fact that approximately 81% of the population older than 64 years in Puerto Rico are covered by Medicare; either Traditional (Fee for Service) Medicare Advantage or Medicare It is important to highlight that GHP cancer patients have a comprehensive coverage with the Special Coverage provision that seeks to facilitate the effective management of this condition. Nonetheless, disparities in CRC outcomes exist, as has been described in the present study. Factors that should be evaluated in Puerto Rico include the supply of specialists (gastroenterologists) who accept the GHP and the difficulty to obtain the referral to a gastroenterologist among GHP patients, as these could help explain the disparity observed in our study between GHP and NGHP patients. Another aspect that needs further investigation is whether there is a difference in the quality of care between these groups. For example, if the established treatment guidelines are being followed, and if limitations regarding access to oncologic therapy, chemotherapeutic agents or surveillance exist. The fragmentation of services and poor coordination could be playing an important role.Reforma) was active. Thus, our results may not reflect current survival outcomes of CRC patients in Puerto Rico, as the government in 2010 implemented additional changes to the GHP, known locally from this date forward as Mi Salud. With this implementation, GHP  brought a set of new changes to improve the delivery of health care services to the Medicaid population in Puerto Rico The current analysis is focused on the study period of 2004–2005, in which the first period of implementation of the GHP . Another limitation is that the percentage of the NGHP group without insurance is unknown. Consequently, this could lead to an underestimation of the survival for this group. In addition, the use of maximum survival may result in an overestimate of the true survival rate The goal of the changes in the GHP in the 1990's was to ensure access to health services and eliminate disparities for medically indigent citizens and was intended to improve the quality and cost effectiveness of health services in Puerto Rico Access to health services by itself is not a guarantee of better health and better quality of life for a society. GHP's population may have some characteristics that must be taken into account when providing health services. For example, GHP patients may have differences in lifestyles, co-morbidities, family and social support, and socio-demographics factors that may influence the access to health services, as well as geographical challenges that may limit transportation and nearby access to certain specialists. These characteristics require creating an adequate health model to provide effective and timely health services to this population. It is necessary to study different health care delivery approaches and investigate what model of health care is the most cost effective for this population. A key issue is to build better polices and institutions with measurable results and principles of accountability.Health systems are complex systems; hence their results are the consequences of many multi-casual determinants. It is therefore essential to understand the different determinants that affect the health in a society. This way, policymakers can implement effective public policies and ensure suitable allocation of funds to address various health problems in society.


Undergraduate education focused on public health (UGPH) has burgeoned over the past decade , 2. WhilOur aim is to advance the field as more students, faculty, and universities explore how best to launch and integrate public health into the education of undergraduate college students. Moreover, we hope that those faculties and universities that have been engaged in public health undergraduate education for many years will recognize the contribution that they can make by documenting, disseminating, and re-examining their work. To the extent that we have become an evidence-driven society, the need for data is compelling. The academic enterprise would benefit from descriptive data that describe the landscape of the field as a basis for subsequent evaluation studies, research on pedagogy, and concrete information on career trajectories.We note three caveats about this compilation. First, we limited this collection of articles to those focused tightly on undergraduate education for the general public health degree in the US. We recognize that within the sub-specialty fields of public health , there are long-standing undergraduate, graduate, and post-graduate degree programs. We did not include these for a variety of reasons, including that many are driven by external licensing and credentialing criteria and distinct academic accrediting bodies. Such programs unquestionably have experience and examples that contribute to the issues raised by the papers in this volume.Second, we also recognize that public health can be taught as a secondary field of clinical disciplines, including medicine, nursing, veterinary medicine, and dentistry. This volume does not explore interrelated curricula or dual degree pedagogy. Finally, the methods by which public health is taught and practiced in the US may be quite different from how it is taught and practiced in other countries. We have left all of these expansive issues for future discussions.The articles comprising the eBook on UGPH are organized according to four themes.Theme I presents articles that describe the recent history and background of undergraduate education for public health.Riegelman, Albertine, and Wykoff, each of them a leader with direct experience in promoting UGPH, describe the initiatives that have led to the recent evolution of undergraduate education for public health in the US .With a nationwide perspective on emerging public health education, Albertine views the collaboration between academics and clinicians from across disciplines as positive . HoweverEvashwick, Tao, and Arnold present results of the search of literature on UGPH published in peer reviewed journals between 2004 and 2014, with a total of 24 articles appearing . They coTheme II contains descriptions of existing programs, their exemplary features, and “lessons learned.”Stoots and colleagues describe the undergraduate curriculum in public health that the University of East Tennessee has developed. As one of the oldest undergraduate public health programs in the US, it places particular emphasis on aligning the curriculum with the needs of the local workforce . White dGriffin, DiFulvio, and Gerber describe the use of undergraduate public health peer advisers for a fast-growing undergraduate public health program at the University of Massachusetts Amherst . Peer adYeatts explains the importance of utilizing active learning strategies in an undergraduate introductory public health course . CoverinNelson-Hurwitz and Tagorda describe a three-course capstone series that is a key component of the Bachelor of Arts in Public Health at the University of Hawaii at Manoa . Spread Riegelman and Wilson consider the contribution of community colleges in training future public health professionals . They reTheme III focuses on curriculum issues, including the relevancy of accreditation.The seven articles address broader curriculum design, including accreditation, employment opportunities, and articulation with graduate programs. The authors reflect varied perspectives on whether undergraduate public health degrees should focus on preparing students for further study or direct entry into the public health workforce. Regardless, the authors all agree that any program needs to carefully assess its student market and the goals for the program, whether preparation for the job market or for further professional or academic study.Friedman and Lee provide a framework for a baccalaureate curriculum in public health, including general education requirements as defined by the institution, core public health classes taken by all public health students, domain-specific classes if students can choose specific concentrations or courses offering more depth for a generalist degree, electives, and field experience . In the Lee and Friedman acknowledge that undergraduate public health programs are relatively unusual in that they have evolved after graduate programs in the same discipline, noting that this history has introduced challenges in the articulation between programs , 14. TheWykoff and colleagues present results from alumni and employer surveys at East Tennessee State University to support their view that baccalaureate degrees in public health should be developed as professional degrees preparing students for the workforce . About oHolsinger and colleagues reviewed 19 programs from 17 accredited schools of public health offering undergraduate degrees . Across From the perspective of lengthy experience with accreditation of graduate public health education, King and Petersen describe the development of accreditation criteria for baccalaureate programs not affiliated with accredited schools or programs of public health as a coordinated approach to assure quality in undergraduate public health education without restricting to professional or academic programs . InformiTarasenko and Lee examine three major college directories and the Association of Schools and Programs of Public Health website to identify undergraduate degrees in public health, and then compare the specifics of the curriculum with the universities’ catalogs . In contTheme IV offers insights into the relationship between formal academic training and careers in the public health or healthcare workforce.Tilson, Bender, and Kronstadt describe the new accreditation for state and local public health departments, their responsibilities for “maintaining a competent workforce,” and how UGPH can work with government public health departments to cultivate the workforce for the future . LearninMartin discusses how education in public health can be applied to careers in healthcare delivery settings . The autCareer Planning in Public Health, which identifies and examines 101 employment options within the sphere of public health (Lee reviews the book c health . The autWe would like to thank all of those who contributed to this Research Topic as authors, editors, review editors, and thoughtful colleagues. Practitioners, as well as academicians, participated in shaping the articles that are showcased here. Many others are working in the field as teachers, practitioners, public health leaders, and students. The need for additional data is evident; rigorous evaluation and research studies are needed. The ideas articulated here hopefully contribute to identifying the issues that warrant analysis. We are all striving to create a public health system and public health workforce that will enable the US to maximize the health status of its communities. We hope the information and ideas shared here will further this goal.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.


Background: Disease assessment based on measurements of size and anatomic involvement have historically been central to surgical strategy. We propose this to be an outdated concept, which should be replaced by a deeper understanding of tumor biology and careful treatment planning.Report of case: A 34-year-old male was diagnosed with a Siewert Type 3 locally advanced cancer of the gastroesophageal junction, involving the coeliac axis and the superior mesenteric artery (SMA). He was treated with neoadjuvant chemotherapy, followed by chemoradiation, and then proceeded to surgery, at which time the tumor was judged unresectable. After extensive planning, a further surgery was attempted - an extended gastrectomy with distal esophagectomy, left hepatectomy, and splenectomy were performed. Additionally, the coeliac axis and the SMA were excised, followed by reconstruction of the hepatic artery and the SMA with grafts. Adjuvant chemotherapy was administered, and the patient is recurrence-free after five years follow-up.Conclusion: This case highlights the importance of the distinction between resectability and operability, and that patient treatment should be tailored and individualised based on the response to treatment, comorbidities, and underlying tumor biology. Over the past few decades, there has been a dramatic rise in the incidence of adenocarcinoma of the gastroesophageal junction (GEJ) in Western countries, including the UK . RadicalResectability is determined on a purely technical basis and will depend on the skill and experience of the surgeon. On the other hand, operability will, in addition to resectability, require a consideration of the benefits and risks to the patient, taking into account the age and comorbidities, as to whether a major surgical procedure with its attendant morbidity is justified. We illustrate the difference between unresectability and inoperability by presenting the case of a patient with adenocarcinoma of GEJ, which was initially considered inoperable.Informed patient consent was obtained at the time of treatment. No identifying patient information is contained in this paper.A 34-year-old physically fit male with no comorbidities or family history of cancer presented with resistant dyspepsia and was diagnosed with a locally advanced Type III GEJ cancer extending from 37 cm from the incisors, down onto the lesser curve of the stomach at the level of the incisura. Pathology was a moderately to poorly differentiated adenocarcinoma, HER2 negative. The patient's tumor was considered unresectable at presentation, and he underwent five cycles of neoadjuvant EOX chemotherapy  resulting in RECIST stable disease on CT. Extended neoadjuvant therapy was administered due to the locally advanced nature of the tumor. As it was still considered inoperable, consolidation radical chemoradiation to a dose of 50 Gy in 25 fractions with concomitant cisplatin and 5FU was subsequently delivered to the lower esophagus and proximal stomach, leading to significant regression demonstrable at diagnostic laparoscopy. Thereafter, an attempted resection was performed. However, at laparotomy, he was found to have gross disease invading the whole lesser omentum up towards the porta hepatis, with encasement of the left gastric artery and the origin of the coeliac axis as well as extensive serosal disease within the lesser sac and SMA origin. The dimensions of the portion of tumor involving the descending aorta were 3.6 x 2.8 cm.The patient underwent further surgical assessment as, a year after initial diagnosis and six months following completion of chemoradiotherapy, there was no evidence of metastatic disease and the tumor had remained stable on imaging, thereby demonstrating a more indolent tumor biology Figures -5. Six mA left thoracoabdominal incision was performed with a division of the diaphragm down to the aortic hiatus. The tumor was localized to the GEJ, invading the esophageal hiatus and left crus of the diaphragm. The left lateral segment of the liver was adherent to the stomach and could not be separated, with the tumor extending posteriorly and inferiorly toward the coeliac axis and SMA. The mid-thoracic and abdominal aorta were skeletonized and the visceral arterial branches exposed. The resection included an en-bloc excision of the lower part of the esophagus, the entire stomach, greater omentum, spleen, and the connective tissue of the lesser curve as well as a total bursectomy, including the anterior capsule of the pancreas and the left lateral segment of the liver in order to ensure tumor-free margins. After administration of bolus intravenous heparin, the coeliac axis, and the SMA were ligated at the origin and excised with the adjacent tissue specimen. The hepatic artery and the SMA were revascularised with a bifurcated Dacron graft. Gastrointestinal continuity was restored with a Roux-en-Y esophagojejunal stapled anastomosis at the level of the tracheal bifurcation. Fiducial markers were placed in the tumor bed at sites felt most likely to have a positive margin, in order to guide potential stereotactic radiotherapy in the postoperative period. Histopathologic examination of the surgical specimen confirmed a poorly differentiated mucinous adenocarcinoma of the stomach with signet-ring morphology arising from the GEJ. There was a very good response to chemoradiation (Mandard Tumour Regression Grade 3). Esophageal and gastric resection margins were clear of viable tumor, and two of 26 lymph nodes contained small deposits of adenocarcinoma. Furthermore, multiple coeliac lymph nodes, as well as the No 12 lymph node, showed no evidence of metastatic disease. Over 90% of the tumor was necrotic as a consequence of the chemoradiation and no evidence of malignancy was identified in the liver or the spleen. The postoperative course was uneventful, and the patient was discharged 13 days postoperatively. No further radiotherapy treatment was deemed necessary. In the following months, he received four cycles of DCF  chemotherapy and experienced problems with nutritional support, neutropenic sepsis, diarrhea, and intestinal bacterial overgrowth, all of which were controlled medically. A taxane-based regimen was selected based upon the relatively poor response to neoadjuvant oxaliplatin and capecitabine. Follow-up CT scans and tumor markers were performed at three-month intervals for three years, and at six-month intervals for a further two years. All showed graft patency and no local recurrence or metastatic disease. The patient is alive and well 5.5 years postoperatively with no evidence of recurrent disease; his weight is stable, and he returned to work and normal activities of daily life six months postoperatively.Currently, the Union for International Cancer Control (UICC) TNM classification is the main tool for defining the operability of a cancer patient, however, only from a purely anatomical point of view . The terAlthough the TNM classification is of value in determining the extent of a tumor and is therefore a guide to resectability, it does not take into account the ‘immune score’; namely, the role of adaptive and innate immunity in determining the tumor microenvironment . There iThere is no clear definition of standard therapy, but in the UK, it usually consists of perioperative chemotherapy and surgical resection based upon the MAGIC trial data, with chemoradiotherapy usually added postoperatively for adverse histopathologic features and patients with a high-risk of local recurrence  , 7. IncrAnother important factor in defining operability and resectability is the encasement of major vascular structures, such as the coeliac, common hepatic, or splenic arteries. En bloc resection of the coeliac trunk, along with the coeliac nervous plexus and lymph nodes for advanced gastric cancer, has been technically possible over the last 60 years, and several revascularization strategies have been subsequently described , 8. HoweThe value of pathologic response to neoadjuvant therapy in different types of cancer has been investigated. In particular, pathologic response in patients with esophageal cancer, who received preoperative chemotherapy or chemoradiation, was shown to play an important role in predicting survival outcomes. However, there is a need for additional surrogate markers for reliably predicting the biological behavior of the tumor. Recent and ongoing developments in proteomics, miRNA, and cDNA microarray technology may well have a role to play in the future in accurately determining therapeutic responses, whilst more sensitive and detailed molecular analysis of pathologic and immunologic responses could assist in predicting survival more accurately.It has been shown that downstaging of tumors can be achieved with neoadjuvant therapy, i.e., initially unresectable colorectal liver metastases . In the As regards to our patient, the tumor was aggressive in terms of its local behaviour but less so in terms of metastatic potential, with the patient having stable disease a year following initial diagnosis and with this being a key feature in the disease being considered potentially operable.In this case report, we address the complex issue of inoperability versus unresectability, as well as the important issue of patient selection for a multi-modality “off protocol” approach to complex tumors. Biological behavior and response of a tumor to chemotherapy and/or chemoradiation, along with the ability of the surgical team to undertake a potentially curative resection, even when technically very challenging, should all be taken into consideration. The word ‘inoperable’ should be used only in instances in which surgery could likely lead to the "on the table" death of the patient or to unacceptable postoperative morbidity or mortality. In other cases, they should be considered “potentially resectable” with the question being asked whether surgery would confer a clinical advantage and what potential benefits could justify the risk involved.Previously, surgical resection has been determined by tumor size and location, lymph node involvement, and the presence of metastatic disease. Although useful in actuarial terms, this is far from individualization in the world of “personalized medicine”. The personal selection by tumor biological behavior and response to neoadjuvant therapy, in addition to these other factors, would be more sophisticated and take into account additional factors, such as comorbidities, performance status, and immunology.


The Health Information Technology for Economic and Clinical Health Act (HITECH) allocated $19.2 billion to incentivize adoption of the electronic health record (EHR). Since 2009, Meaningful Use Criteria have dominated information technology (IT) strategy. Health care organizations have struggled to meet expectations and avoid penalties to reimbursements from the Center for Medicare and Medicaid Services (CMS). Organizational theories attempt to explain factors that influence organizational change, and many theories address changes in organizational strategy. However, due to the complexities of the health care industry, existing organizational theories fall short of demonstrating association with significant health care IT implementations. There is no organizational theory for health care that identifies, groups, and analyzes both internal and external factors of influence for large health care IT implementations like adoption of the EHR.The purpose of this systematic review is to identify a full-spectrum of both internal organizational and external environmental factors associated with the adoption of health information technology (HIT), specifically the EHR. The result is a conceptual model that is commensurate with the complexity of with the health care sector.We performed a systematic literature search in PubMed (restricted to English), EBSCO Host, and Google Scholar for both empirical studies and theory-based writing from 1993-2013 that demonstrated association between influential factors and three modes of HIT: EHR, electronic medical record (EMR), and computerized provider order entry (CPOE). We also looked at published books on organizational theories. We made notes and noted trends on adoption factors. These factors were grouped as adoption factors associated with various versions of EHR adoption.The resulting conceptual model summarizes the diversity of independent variables (IVs) and dependent variables (DVs) used in articles, editorials, books, as well as quantitative and qualitative studies (n=83). As of 2009, only 16.30% (815/4999) of nonfederal, acute-care hospitals had adopted a fully interoperable EHR. From the 83 articles reviewed in this study, 16/83 (19%) identified internal organizational factors and 9/83 (11%) identified external environmental factors associated with adoption of the EHR, EMR, or CPOE. The conceptual model for EHR adoption associates each variable with the work that identified it.Commonalities exist in the literature for internal organizational and external environmental factors associated with the adoption of the EHR and/or CPOE. The conceptual model for EHR adoption associates internal and external factors, specific to the health care industry, associated with adoption of the EHR. It becomes apparent that these factors have some level of association, but the association is not consistently calculated individually or in combination. To better understand effective adoption strategies, empirical studies should be performed from this conceptual model to quantify the positive or negative effect of each factor. The US Government passed the Health Information Technology for Economic and Clinical Health (HITECH) act  to incenAdoption of the EHR is a significant goal. International vernacular for the EHR varies; for example, electronic patient record, computerized patient records, electronic medical records (EMRs), and digital medical record. The defining difference, as defined by the Institute of Medicine, the health arm of the US National Academy of Sciences, focuses on the longitudinal and interoperable nature of the electronic patient record . WithoutStudies estimate that adoption of the EHR could eventually save more than $813 billion annually, prevent 200,000 adverse drug events, and enhance the doctor-patient relationship through increased communication . UnfortuThe environment of health care is unique in a competitive environment. The health care organization develops an organizational strategy based on the local environment. To increase an organization’s ability to compete, its strategy might also include cost reduction, and EHR adoption runs counter to this goal in the SR. The health care environment faces many sources of influence, including a reluctance to accept technology.There has been a tremendous amount of research dedicated to the study of acceptance of technology, specifically the Technology Acceptance Model (TAM) . More reOrganizational theories address influence, but none adequately addresses the complexity of the health care organization. Payers, providers, and patients all control resources that exert influence. The nature of the competitive environment will also exert influence on decisions. External influence from those who control resources can be explained through resource dependence theory ,10. InteExternal Control of Organizations, [According to resource dependence theory, health care organizations with the greatest level of dependence on other organizations that control the resources will feel the greatest level of environmental influence on its decisions . The Reszations, , which izations, . As orgainnovation, is communicated through channels over time among members of a social system” [. These factors are sorted into three categories of a predictive model for EHR adoption: innovation determinants, organizational determinants, and environmental determinants [Similar to Resource Dependence, the Diffusion of Innovation Theory describes a social system that influences through communication channels -13. Diffrminants . The nexThe concept of compatibility  goes beyThe concept of complexity  is approThe concept of trialability  applies The concept of observability  is also Relative advantage is a multifaceted concept for this study. In health care, the most important factor is provision of health, as well as the treatment and prevention of disease. If adoption of the EHR speaks directly to the health care organization’s primary purpose, then it might provide relative advantage over competitors that have not adopted it. Another concept is that of social prestige . Unless health care organizations manage their organizational processes and deal with their environments in order to select a portfolio of activities and find appropriate position in the health care industry . It follows that adoption of an EHR would alter how a health care organization manages its organizational processes, so this definition of strategy is a good fit for the health care industry. However, two significant considerations in the health care environment are the level of local competiveness, and how health care organizations compete [Strategy can be a multifaceted concept, and organizations around the world hire strategy experts to help identify and focus on a market forces. An operational definition of strategy is borrowed from education  and is a compete .Studies have shown that decision making in the health care industry is often based on how the organization competes, whether in a single-market or multimarket environment . In eithAsh and Bates  studied Factors that influence health information system (HIS) adoption in US hospitals have been studied by others as well (n=1441) . ResultsA knowledge-based taxonomy of critical factors for adopting an EHR was developed from a systematic literature review . The resAlternative measures of EHR adoption among hospitals have been studied . AuthorsOthers have studied the relationship between hospital financial position and the adoption of the EHR . ThroughBecause commonly used elements of organizational strategy are difficult to change, several of the variables were categorized as internal organizational factors. Research has assessed variables of hospital influence in five categories: (1) capacity as measured by number of beds in groupings by intervals of 100, (2) management, or ownership, (3) organizational focus, or teaching status, (4) competitive location and alternatives, and (5) state regulatory pressures .Although resources have been consumed to study factors associated with adoption of HIT, there is a gap in the literature that provides a conceptual model to guide the design of empirical models. It may seem backward to design a conceptual model after so many studies have already been conducted, but the gap remains. The aim of this study was to develop a conceptual model from a systematic literature review that associates both internal and external factors associated with adoption of the EHR. The intent of the conceptual model is to enable future empirical models.Search terms were selected based on the experience of the authors in the field of health care administration. The time frame of 1993-2013 was selected as convenience. It was assumed that 2 decades would be sufficient to capture trends.The 83 records were reviewed for content and evidence. After discarding 58 articles for lack of evidence, three additional references were added because they were key concepts upon which other studies were based. Of the remaining 25 articles, a list of factors was identified as IVs. Some factors were grouped under a similar category for the purposes of simplification of the conceptual model. The dependent variable (DV) started as adoption of the EHR, but the studies from those chosen were not as specific. From personal experience, many studies seem to discuss the EHR, but call it something else: most commonly the EMR. That is why EMR was included in the search. Because so few ERHs exist without some form of CPOE, the latter term was included in the search criteria.Our study combines the influences highlighted by previous work and examines determinants of EHR adoption. Examining EHR adoption at the health care organization level will demonstrate validity between this study and others that have used the hospital as the unit of analysis.Several influences in the environment exert pressure on the health care organization to adopt EHR. Influences range from incentives from the federal government to the nature of local competitive community. US federal incentives provide a heavy influence for EHR implementation, under specific conditions, and imposes penalties for a lack of EHR implementation.The internal politics of one organization serve as one source of influence. A hospital is part of a community, which serves as an external influence. Further, if a hospital is also part of a larger multihospital system (MHS), then the politics of the broad MHS will also exert influence on local decisions.The patient is external to the organization, and for our study, the patient primarily serves as an external influence. Although some employees of the health care organization might also be patients, and this relationship could create a small internal influence, this study considers those few stake holders in the internal organizational factor of users. The providers are internal to the organization, and for our study, providers serve as an internal organizational influence. The payer is a significant influence , and theThe premise for an EHR adoption conceptual model is that that environmental influences affect organizational strategy of the health care organizations that adopt the EHR ,22,24,25Elements of organizational strategy are not variables that can be easily changed ; therefoResource Dependence Theory explains environmental influences and the external interdependence of organizations . The autDisparate stakeholders have different interests with reference to different components of the EHR. These interests may be different in the SR interests versus the LR interests. SR interests are those that are immediate, such as current year expenditures. LR interests are further out when all inputs are variable. The SR interests of cost can often compete with the LR potential of cost savings and greater safety. Both the SR and LR interests are affected by the external environment .In a highly competitive environment, SR cost implications could often win over any long-term savings. The number of patients in a market is fixed in the SR, and a highly competitive market will affect each competitor’s share of that market. The SR costs of EHR implementation might be insurmountable by an organization in this market because it could not afford to lose ground without significant capital reserves or the ability to borrow cheaply . HoweverExternal stakeholders that control resources important to the health care organization can exert significant influence. For instance, a health care organization that receives a significant amount of revenue from the CMS will be influenced more by incentives provided by the CMS than an organization that receives a significant cash flow from private third parties. The relative influence of various external stakeholders may be captured by an analysis of the structure of the market in which a health care organization operates.Stakeholders have varying interests with regard to the capabilities and effects of EHR components depending upon their relationship with the health care organization. Private payers have both SR and LR interests in the EHR. In the SR, their focus is on minimizing expenditures. Because the health care organization would pass on the implementation costs through higher contract costs, payers would not be equal in the SR. In addition, the disruption of EHR implementation could potentially affect care processes and therefore increase claims. Payers would be interested in the LR benefits of the EHR: potential cost savings, better disease management, and increased safety. However, the SR interests of the private payers might overshadow the LR benefits of the EHR. Public payers enable care of the indigent and elderly. As part of the United States Department of Health and Human Services (HHS), the CMS is highly interested in disease management, public health, safety, and research, and it may value these LR capabilities of the EHR more than the SR costs. The CMS, as part of HHS, would also favor the EHR because it supports the Presidential directive to promote the establishment of the Nationwide Health Information Network that links electronic patient records through health information exchanges.Providers and patients value face time with each other. During EHR implementation, providers might spend less time in communication with patients. Providers must adapt their processes and clinic-to-administrative schedules. Any disruption or action that is perceived as deleterious to this relationship could result in a negative reaction to EHR implementation. As a result, physicians might oppose EHR adoption, or they might simply support the EHR solution with the shortest implementation time or least administrative burden. Patients might not like the reduced face time with the provider, but they might be attracted to EHR components such as e-prescribing, e-results, personal health records, and email access to the provider. These desirable features are available to the patient when the health care organization chooses to adopt various portions of the CPOE component to the EHR.The articles chosen for final inclusion were read once more to make a list of variables. The variables from the studies were listed as internal and external. There were significant commonalities in the variables used, so they were combined in the model.As depicted in The dependent variable was not consistent: seven references used EHR adoption ,30,31,33As depicted in As previously stated, there was overlap between the sources/theories. There were four internal forces and seven external forces identified through multiple works by three authors -14,22. HThis framework captures both internal and external factors that influence the adoption of the EHR. The positive (+) and negative (−) signs in the model describe the relationship identified by the associated authors. For instance, Gin et al  identifiThe main findings of this study were that nine studies identified external factors and 16 studies identified internal factors associated with the adoption of EHR. These factors were depicted in a conceptual model to describe relationships to EHR adoption.The conceptual model for EHR adoption illustrates a framework within which both administrators and policy makers can work to understand the levers that exert significant influence in the adoption of EHR. The extensive literature review conducted by this study builds a unique model from which empirical studies can be designed.Identifying relationships between the adoption factors and adoption of the EHR becomes significant because it identifies levers that will produce a desired action. For instance, if a hospital has a majority of senior providers, perhaps from the Baby Boom generation, the administrators become aware of the additional effort that needs to go into user acceptance. A hospital that has a majority of new providers will not need to expend the resources on user acceptance, because studies already show a penchant for technology in younger generations. Similar inferences on other factors of adoption could be made, and some would require additional study.For instance, the literature on workflow impact is split. There seems to be evidence that the presence of the EHR both enhances and complicates the providers’ workflow. This observation clearly begs additional questions. Were subjects for the data in different phases of adoption of the EHR? Was the hospital that responded negatively in the middle of an EHR implementation? Logically, a large implementation of any technology will become disruptive to the organization. Several studies could emerge from this relationship alone.Empirical models could easily be designed to further investigate specific relationships between the IVs and DVs. The set of studies on CPOE was interesting. Although there were some overlaps with adoption of the EHR, there were also studies that only looked at CPOE. There does not seem to be an abundance of evidence in the literature about CPOE, and yet the AHA regularly collects data on six different versions of CPOE: laboratory, radiology, pharmacy, nursing, physician notes, and consults. There was no data to be found about the use or efficacy on CPOE consults. It might be interesting to determine the reason for this paucity of data.The EHR adoption conceptual model associates internal and external factors with the adoption of the EHR, but it is primarily based on an extensive literature review. So far, it is not empirically tested. However, data are available to test the theory. Because the findings of our study are descriptive in nature, we do not opine on appropriate medical use of the information.Caution should be identified with the interaction of variables. Some variables will most likely confound or mask the effects of others. For instance, is there a direct relationship between the number of beds of a hospital and the number of full-time equivalents? There are staffing models that would most likely answer that question. If there is a similar relationship, then one of these variables should be eliminated in favor of the stronger one. Otherwise, the effects of the weaker variable will be masked by the other. A false conclusion could easily be identified concerning the masked variable.A majority of references for this study were from the United States, with one exception from Hong Kong. The internal validity of this study is strongest within the US health care sector. The conceptual model might be limited outside the United States because of the nature of competition between hospitals. The analysis of 83 articles identified studies that used similar methods: survey or secondary data analysis. Many authors analyzed data from the AHA, a well-established data set in the United States. These data are self-reported, which comes with limited bias.This study also identified overlap between studies in terms of variables. One interpretation of this overlap could be that the variables and associated studies are highly reliable. The key word/phrase searches described in the Methods section identifies the databases queried and results given. Other researchers should be able to duplicate or update this conceptual model going forward.


Teaching physiology, a complex and constantly evolving subject, is not a simple task. A considerable body of knowledge about cognitive processes and teaching and learning methods has accumulated over the years, helping teachers to determine the most efficient way to teach, and highlighting student’s active participation as a means to improve learning outcomes. In this context, this paper describes and qualitatively analyzes an experience of a student-centered teaching-learning methodology based on the construction of physiological-physical models, focusing on their possible application in the practice of teaching physiology.After having Physiology classes and revising the literature, students, divided in small groups, built physiological-physical models predominantly using low-cost materials, for studying different topics in Physiology. Groups were followed by monitors and guided by teachers during the whole process, finally presenting the results in a Symposium on Integrative Physiology.Along the proposed activities, students were capable of efficiently creating physiological-physical models  highly representative of different physiological processes. The implementation of the proposal indicated that students successfully achieved active learning and meaningful learning in Physiology while addressing multiple learning styles.The proposed method has proved to be an attractive, accessible and relatively simple approach to facilitate the physiology teaching-learning process, while facing difficulties imposed by recent requirements, especially those relating to the use of experimental animals and professional training guidelines. Finally, students’ active participation in the production of knowledge may result in a holistic education, and possibly, better professional practices. Taking into account that innovation in medical education is not an easy task , a consiSome of these methodologies are particularly suitable when physiology teacher’s focus is on fostering the rational use of experimental animals , 17 and In Brazil, the intrinsic difficulties in implementing more efficient ways to teach physiology were recently augmented by new demands of the National Curriculum Guidelines for health professionals, and by ethical restrictions imposed on the use of experimental animals , 17. To This paper describes the process of teaching and learning physiology through the construction and presentation of physiological-physical models (PPMs), focusing on their potential use in the practice of teaching physiology. What makes our experience different is that students represent the core of the process, not passively receiving a proposal for constructing a PPM, but creating it instead, and that all the PPMs are presented in a Symposium on Integrative Physiology (SIP), an academic event especially created for this purpose.After applying the proposed methodology, students were able to develop PPMs that effectively represented different types of physiological processes. The closure of activities took place in an event designed specifically for the integration of knowledge in physiology (the SIP) through the presentation of 8–23 different Physiology models in each edition. In fact, it was a consensus among the evaluators that all the PPMs presented up to the last SIP met the evaluation criteria of uniqueness, creativity and representativeness of the physiological topic in question, and most of the models were rated very good or excellent .th Brazilian Congress of Medical Education (COBEM), and one proposal for patent , a student and teacher body dedicated to improve learning outcomes in Human Physiology Figure .Table 1Table This article describes a teaching and learning active methodology based on the use of physical models as tools in medical physiology. The fact that, at the end of the process, students were capable of successfully creating their own PPMs with great representativeness of physiological phenomena presents itself as the main finding of the reported experience.Concerning the effectiveness of the methodology described when it comes to the models used as learning tools, the integrative character of the proposal allowed to transpose physiological concepts from theory to an immediate and practical application. As shown in Figure Despite such variations in the degree of complexity for building the PPMs, our results indicate that, under favorable conditions, students are perfectly capable of designing and building models based on Physiology-related topics on their own, suggesting that the method could be reproducible in other schools. As for the PPMs themselves, all of them were built predominantly using recycled materials, which are cheap and readily available almost everywhere in the world. The use of such tool can be considered a valuable alternative, in view of the ethical and legal barriers imposed on animal experimentation in Brazil and elsewhere. Although sophisticated industrial simulators are available for use in practical Physiology classes, many medical schools in developing countries cannot afford them; hence, their students would benefit from using such handmade models. The PPMs developed by our undergraduates and presented at the SIP were considered highly representative of their respective physiological topics, encouraging discussions about the theme and promoting student-student and student-teacher interactions. This could be attributed to the interactive nature of the models, whose colors, movements, sounds and even smells and tastes captivated the audience, creating an enjoyable atmosphere of excitement and passion for learning during the SIP, as observed in experiences described by other groups , 22.The feedback from students about the approach used was excellent, with an overwhelming majority of students reporting positive results and that the creation of the PPMs helped them learn. In addition, students were also asked to give their verbal feedback, and all the groups stated that the protocol in which they participated helped them to learn and fostered the development of certain skills. The challenge of creating a new, original teaching model of a physiological process is an unusual situation for undergraduate Physiology students, which leads them to find a solution not available in articles or textbooks, thus firing their creativity.Another important point is the fact that the teamwork was supported from the initial stages of our methodology. In this regard, the fact that students were always working in groups is of particular note, since it is already described that individuals are likely to learn more effectively when they learn with others than when working alone , 7. In oIn consonance with these observations, since teamwork is not possible in the absence of communication , 24, theSince the integrated curriculum has recently emerged and presents itself as a current trend in medical education, one could wonder where the proposed methodology would fit, considering the strict timetables available for Physiology classes. In this regard, once the proposal described herein is based on an integrative perspective, we do believe it could be applied not only to the field of Physiology, but also to combine different disciplines in an integrated curriculum. Furthermore, counting on the students’ commitment in performing the activities out of the classroom, at specific moments previously defined (such as observed in the SIP), it would be possible to conduct the methodology smoothly, provided that it does not compromise the curricular activities.The models envisioned by the groups were designed and tested several times and most of them had several trial versions before reaching the final version. Thus, it becomes plausible to suggest that when students were building a particular model, giving it a physical body and testing it, they were actually testing their mental models of the Physiology topic on which they were working , 12, 19.Still considering the presentations at the SIP, it should be kept in mind that it was a moment when each student was required to express himself about his group’s model, the physiological process that the model purportedly represented, and how the model reproduced the physiological process Table . In addiIn summary, our teaching-learning methodology produced good learning outcomes. The proposal presented herein has proved to be an attractive and useful approach to facilitate the Physiology teaching-learning process. Furthermore, the method is an accessible and relatively easy way to foster meaningful learning and active learning while concomitantly addressing multiple learning styles.While assessing this proposal as a whole, some aspects should be considered, as observed in other suggested implementations , 15. FirHaving successfully achieved and implemented the proposed approach, we intend to extend this methodology in the near future to other health sciences courses by inviting other teachers to become regular participants. This would allow us to establish an integrated symposium for all the biological and biomedical courses in our University. Based on this invitation, a pilot project was implemented at our institution in previous semesters, with the participation of the Nutrition course. By this means, we intend to ensure that other undergraduate health sciences courses will benefit from our approach, sharing new experiences and learning together, as should be the case in professional environments after graduation. Furthermore, a suggestion for another feedback tool is already being elaborated by our group.a) no requirement for the use of experimental animals; b) encouragement of active learning; c) promotion of meaningful learning; d) meet the needs of as many students as possible in terms of different learning styles; and e) stimulate the development of skills and competencies essential for health professionals.The development of this teaching and learning strategy was guided by our country’s curriculum guidelines for health professional training  and our During the whole semesters, activities in which students engaged were carefully documented on activities logs, filled by the Physiology teacher and/or Physiology Monitors (PMs). At the end of each semester, data were descriptively analyzed, in search for any signs of active learning and meaningful learning , 10. Fig512 undergraduate students who participated in this proposal were all studying Human Physiology. In order to organize the implementation of the proposal, a Committee for the SIP was defined. The latter consisted of four students who participated in the first edition, and became PMs in the following editions, after receiving specific training in the teaching and learning methodology. Four guest teachers were invited to evaluated students and their work, together with the Physiology teacher.The activities conducted with undergraduate students of Human Physiology  in the period between 2007 and 2010 were exempted from the submission to the Institutional Ethical Committee. The exemption is justified because all the methodological procedures applied along the proposal, the latter based on the development of PPMS, are in accordance with the institution’s Pedagogical Policy Plan  for the undergraduate medical course.Theoretical background: Students took classical classes in Physiology and received continuous guidance about the construction of the PPMs. Two-hour meetings with teachers, PMs and postgraduate students were scheduled once a week  Originality, depending whether similar apparatus were previously described, and how similar they were to the model under evaluation; 2) Reproducibility, depending on how cheap and available the components of the model were and how simple was its construction; 3) Representativeness, related to the capacity to represent a physiological process, explain and transmit the concepts involved. The assessment of the models was coupled with the ones of the oral presentation and posters, as well as the answers to evaluators’ questions (Figure All authors took responsibility for analyzing the data. Initially, the models which received higher scores after being presented in the SIP were selected as potential standards to represent the topics exposed at the end of activities. Finally, for choosing the models shown in Table A previously designed questionnaire was sent to every participant of this proposal. It was composed of three questions (See Figure


This study examined the causal model of relation between marital relation-ship status, happiness, and mental health in infertile individuals.In this descriptive study, 155 subjects (men: 52 and women:78), who had been visited in one of the infertility Centers, voluntarily participated in aself-evaluation. Golombok Rust Inventory of Marital Status, Oxford Happiness Ques-tionnaire, and General Health Questionnaire were used as instruments of the study. Datawas analyzed by SPSS17 and Amos 5 software using descriptive statistics, independentsample t test, and path analysis.Disregarding the gender factor, marital relationship status was directly related tohappiness (p<0.05) and happiness was directly related to mental health, (p<0.05). Also,indirect relation between marital relationship status and mental health was significant(p<0.05). These results were confirmed in women participants but in men participantsonly the direct relation between happiness and mental health was significant (p<0.05).Based on goodness of model fit in fitness indexes, happiness had a mediatorrole in relation between marital relationship status and mental health in infertile individu-als disregarding the gender factor. Also, considering the gender factor, only in infertilewomen, marital relationship status can directly and indirectly affect happiness and mentalhealth. Infertility is defined as 1 year unprotected intercoursewithout pregnancy . AlthougStresses of infertility and its treatment procedurecan damage the quality of relationships in infertile couples. If the couples cannot appropriately cope with these stresses, those may lead to several psychological problems for each partner that can considerably affect their marital relationship with each other. Such stressful relationships per se can intensify stresses and distresses related to infertility. Thus, in this position a vicious circle develops that can negatively affect couple’s mental health mutually. Moreover, it has been argued that the diagnosis of infertility may magnify and intensify the disappointments and conflicts that have been previously existed in couple’s relationships with each other .Although mental health of couples may be damaged by the diagnosis of infertility and couples are usually confused about the ways of handling this condition, infertility per se does not necessarily damage couple’s mental health or quality of their relationship with each other . Even soHappiness, which is as essential dimension of life and related to functioning and success , generalBased on several studies and theoretical discussion, it is clear that there are significant relationships between marital relationship status with mental health -27, mariBased on several studies, that mentioned, it seems that infertile individuals may be more at risk for mental health problems, compared with fertile individuals, because they experience many social, cultural, and psychological stresses related to infertility . So it iAccording to our knowledge, so far no study investigated the mediator role of happiness in relationship between marital relationship status and mental health in infertile individuals through a causal model. Thus, the purpose of this study was to investigate the causal model of relation between marital relationship status, happiness, and mental health in infertile individuals. The theoretical path model for the relation between marital relationship status, happiness, and mental health is presented in the The research method of this study was descriptive. The study population included all infertile men and women visited in the Isfahan Fertility and Infertility Center between August and September 2012. The sample of this study were 155 subjects (men: 52 and women: 78) whom had been visited in the Fertility and Infertility Center and selected by convenience sampling [a type of sampling in which members of the population are chosen based on their relative ease of access. This kind of sampling is common to use when applying other sampling methods accompanied by some difficulties. But in this kind of sampling there are limitations to generalization of data ]. Two psThe Oxford Happiness Questionnaire (OHQ) is a self-report instrument with 29 items designed to measure intensity of happiness . It was The General Health Questionnaire (GHQ-28) is a self-report instrument with 28 items designed to measure mental health . Each itIn this study, Cranach’s alpha values for the three instruments were computed. In the GRIMS, Cranach’s alpha was assessed as 0.935, in OHQ, as 0.934, and in GHQ-28, Cranach’s alpha as 0.563.Data was analyzed by SPSS17 and Amos 5 software using descriptive statistics and path analysis.Ethical considerations in this study concluded:each of subjects who not volunteer to participate in the research was disregarded for this study.The information related to each participant was secret and no organization or person with the exception of the authors reaches to these data.Mean, standard deviation, and independent sample t test of all participants' scores in variables of the study are presented in the According to To analysis of the causal model of relation between marital relationship status, happiness, and mental health, path analysis was used. The result of path analysis for all participants (including men and women) is presented in the Based on the Based on the results of Also, the model of the study separately investigated men and women. The result of path analysis for women is presented in the Based on the Based on the results of the Based on the Based on the results of Although the main purpose of this study was not to compare infertile men and women in dependant variables of the study but the results showed significant differences in infertile men’s and women’s mental health. These findings of this study were in the line of studies showed that infertile women demonstrated more health impairment, compared with infertile men , 41. AlsThe findings of this study confirmed the causal model of relationship between marital relationship status, happiness, and mental health in infertile individuals without consideration the gender factor. This model also was confirmed in women participants but not confirmed in men participants. Based on this model in infertile women, marital relationship status directly is effective on mental health with mediation of happiness. Also the results showed that in both infertile men and women, happiness has the direct effect on mental health. The findings are the line of several studies that have showed significant relationships between these three variables , 24-27 bIn psychological theories and studies about close relationships, it has repeatedly reminded that happiness cannot be understood without understanding close relationships. Very studies in the field of well-being have confirmed that happy people have satisfying relationships. Based on these studies, satisfaction of marital relationships is a strong predictor of happiness . Even inThe findings of this study revealed the importance of attention to psychological health of infertile individuals, especially in infertile women. Also, the findings suggest that it is useful to enter some components of marital relationship status that can improve and enhance the experience of happiness in infertile couple’s relationships to mental health in these individuals. So, in the field of psychotherapy and counseling with infertile individuals probably couple therapy or couple counseling is better and more appropriate than individual therapy or counseling. Moreover, the authors suggest that psychological interventions by psychologist or counselors integrate and accompany with medical treatments presented by professional infertility centers.To generalize these findings to Iranian population, we suggest further researches to assess the model of this study in other population of infertile couples and individuals. One of the most important limitations of this study was disregarding demographic components and personal characteristics such as highest group of age, duration of infertility, type of treatment, main reason of infertility belong to which gender. Most of these limitations were limitation of sufficient number of professional examiner to interview with subjects and invite them to participate in the study. The examiners of this research were only two psychologists, so in spite of considerable time spent for the sampling, the sample size of the study was not completely sufficient.


For the Public’s Health series of reports from the Institute of Medicine.  The summary measures comprise 3 components: current health, sustainability of health, and well-being. The measure of current health is disability-adjusted life years (DALYs) calculated from health care claims and death records. The sustainability of health measure comprises member reporting of 6 behaviors associated with health plus a clinical preventive services index that indicates adherence to evidence-based preventive care guidelines. Life satisfaction represents the summary measure of subjective well-being.Health plans and accountable care organizations measure many indicators of patient health, with standard metrics that track factors such as patient experience and cost. They lack, however, a summary measure of the third leg of the Triple Aim, population health. In response, HealthPartners has developed summary measures that align with the recommendations of the HealthPartners will use the summary measures to identify and address conditions and factors that have the greatest impact on the health and well-being of its patients, members, and community. The method could easily be implemented by other institutions and organizations in the United States, helping to address a persistent need in population health measurement for improvement. Editor’s Note: This article is a joint publication initiative between Preventing Chronic Disease and the National Academy of Medicine.For the Public’s Health: The Role of Measurement in Action and Accountability. When aggregated across health plans, the measures would be applicable regionally and nationally, because nearly 90% of Americans are now registered with a health plan . The ACG system aggregates medical care claims data into 267 Expanded Diagnosis Clusters, which are in turn aggregated into 27 Major Expanded Diagnosis Clusters. The HealthPartners framework calculates a YLD score for each health plan member using the highest-weight condition in each Major Expanded Diagnosis Cluster using a 100% sample of claims data. As with YLL, YLD is a period prevalence calculation.The Global Burden of Disease nomenclature for YLD is not used, however, by HealthPartners and other US health plans. Therefore, HealthPartners created a crosswalk between the weights for the 220 YLD conditions defined by the Global Burden of Disease project and the Johns Hopkins Adjusted Clinical Groups (ACG) system  6|18 program . The goaAlthough the registration of deaths in the United States is complete, the cause of death listed on the death certificate is not always specific, individuals may be misidentified, and the lag time to obtain death records from a state health department or the CDC is 15 months from the end of a particular year. Even with those considerations, however, overall death rates and causes of death can be considered to be adequately reliable.The estimation of YLD from claims data are potentially biased by the inability of individuals to access care or a low propensity to seek care. Discrepancies between self-reported health and estimates of the burden of disease based on claims data, if they exist, suggest that patients are having difficulty accessing care.The depth of information that HealthPartners can collect from its members through surveys is limited; all survey response rates are falling, and the US population is fatigued from the ubiquity of surveys. Despite best efforts, challenges remain in identifying alternative methods for obtaining survey responses that preserve the unique opportunities for understanding the relationships between behavior and disease that are created when survey responses can be linked with data on health care use at the individual level.Because of its brevity, the survey must be seen only as a screening instrument, with collection of more detailed data needed if deficits or problems are identified. Data collected through surveys can also be subject to response bias, both because of the differential propensity for some individuals or subpopulations to complete surveys and because the manner in which they respond to particular survey items may differ. Although statistical adjustment and careful attention to key variables that confound the results can mitigate these shortcomings, concern about residual bias will always exist. Limiting comparisons to situations that are known to be appropriate will also mitigate shortcomings in the data.These limitations must be weighed against the fact that action must be taken and policy must be made whether or not data are available. HealthPartners believes that policy is best when it is informed by data, even if those data are not perfect.HealthPartners will use the County Health Rankings framework to assess the elements in the social, economic, and physical environments that affect health . The socHealthPartners recognizes especially the value of assessing the health and well-being of infants, children, and adolescents. It also recognizes that the health and well-being measures that apply to these groups are not the same as those that apply to adults; the goal of health and well-being promotion for infants, children, and adolescents is to maximize an upward trajectory of development, while the goal for adults is to maintain functioning. HealthPartners expects to develop summary measures of health and well-being for children and adolescents over the next 3 to 5 years.HealthPartners also recognizes the importance of assessing the health and well-being of individuals with limited English proficiency. The 4 languages spoken most frequently by the population the organization serves, other than English, are Spanish, Somali, Hmong, and Vietnamese. Starting with Hmong, the survey will be translated, tested, and fielded in 1 additional language each year between 2016 and 2019.HealthPartners has developed summary measures of health and well-being that the organization will use to identify and address the conditions that create the highest burden of disease and greatest impact on the health and well-being of its patients and members. It will also use the measures to guide its community-directed initiatives. The method could be implemented by any US health plan.Crossing the Quality Chasm, Plsek advised the reader who wants to design a health system for the 21st century, “[R]ather than agonizing over plans . . . generate a ‘good enough plan’ and begin to observe what happens” (In an appendix to happens” . HealthPhappens” , HealthP


The biobank was created as an infrastructure to support the activities of the Fiorgen Foundation (http://www.fiorgen.net/), a nonprofit organization that promotes research in the field of pharmacogenomics and personalized medicine. The way operating procedures concerning samples and data have been developed at daVEB largely stems from the strong metabolomics connotation of Fiorgen and from the involvement of the scientific collaborators of the foundation in international/European projects aimed to tackle the standardization of pre-analytical procedures and the promotion of data standards in metabolomics.We present here the organization of the recently-constituted da Vinci European BioBank (daVEB,  These infrastructures can generally be reconducted to one of the following formats: Population-based biobanks, disease-oriented biobanks, case-control biobanks, biospecimen specific biobanks . daVEB is a partner biobank in BBMRI-ERIC  and its Italian hub BBMRI.it. In 2011, daVEB obtained quality certification according to UNI EN ISO 9001:2008 for “Collection, storage and distribution of biological samples and the associated data for scientific research” ; the certification has been renewed in 2014. Procedures and standards adopted at daVEB originate from the strong links with scientists of the University of Florence and their involvement in several EC projects in related fields.Here, we present the establishment of a methodology-driven biobank, which aims at  the collection of samples and data for future metabolomics analyses and develops protocols and standards that can assure optimal outputs from the use of this analytical methodology. The present case history concerns the creation of the da Vinci European BioBank (daVEB) , a smallIn this article, after a brief presentation of the key aspects of metabolomics in the frame of biobanks, we will review the actions undertaken at daVEB to develop validated procedures for the collection, handling and storage of samples, to provide adequate data sets for the interpretation of metabolomics data through statistical approaches and, last but not least, to facilitate the distribution of the information deriving from metabolomics analyses within the biomedical research community.Metabolomics is the study of the complete pool of small molecules forming the metabolome of a biological sample . The human metabolome composition accounts for several thousands of small molecules <2000 Da) produced by the genome of the host organism and by the genomes of its microflora or deriving from the interaction with the environment [000 Da prThe two main analytical methodologies used in metabolomics are mass spectrometry (MS) and nuclear magnetic resonance (NMR). MS-based technologies, which are generally coupled to chromatographic separations, identify the metabolome components based on their charge-to-mass ratio, have high sensitivity and therefore provide a comprehensive overview of the metabolome. As a drawback, they suffer for reproducibility problems especially in quantitative analyses and require specific approaches for chemically different classes of compounds. In NMR-based metabolomics, only the signals of all metabolites present in a given sample above a certain concentration threshold are observable, but they are all simultaneously measured in a single monodimensional spectrum. The information about the chemical identity of many of the observed molecules can be retrieved by matching the spectral patterns to those in available databases. At variance with MS, NMR demands little sample preparation and is rapid and quantitative, but has lower sensitivity .www.instruct-fp7.eu) that has been defined by the European Strategy Forum for Research Infrastructure (ESFRI). During the last decade and in collaboration with the Fiorgen Foundation, CERM has established a metabolomics research unit/group and hosts NMR spectrometers that are fully dedicated to metabolomics analyses. Collaborative projects have led to the metabolomics characterization of several pathological states  [CERM, which hosts the daVEB infrastructure, is the Magnetic Resonance Center of the University of Florence and has a long-standing tradition in NMR of biological systems. Since 1994 CERM has been funded by EC to provide transnational European access to its NMR resources; since 2007 it is one of the core labs of the European Research Infrastructure for Integrated Structural Biology  ,16,17,18iseases) .There is an obvious link between metabolomics and biobanking activities: Metabolomics profiling and biomarker discovery rely on the comparison of data acquired on large ensembles of samples from different groups of donors. The subsequent analysis allows researchers to assess group-wise differences with statistical approaches that are mainly adapted from earlier emerged omics technologies. Biobanks are obvious providers of samples for large-scale studies and, as such, are a much-needed resource in metabolomics, adding capacity and creating value for the research community.in vivo” metabolome. However, during the entire pre-analytical phase  the concentrations of several metabolites can change due to residual enzymatic activities in the samples and chemical reactions, e.g., induced by exposure to air and/or light. The collaboration between CERM and daVEB has led to the development of metabolomics as an analytical tool to evaluate the effect of different pre-analytical procedures on the sample metabolome [http://www.spidia.eu/) and have led to development of evidence-based standard operating procedures, now implemented at daVEB, which cover the pre-analytical steps for urine, serum and plasma samples [The biomedical significance of metabolic analyses requires that the metabolome of the sample to be studied represents as closest as possible the original “tabolome ,23,24. S samples ,24. In p samples ,24. Anal samples . For thewww.excemet.org) [For the close links between metabolomics and biobanks, researchers at CERM have promoted the foundation of consortium called EXCEMET  , aimed aThe biomaterial available at daVEB includes different types of samples, as summarized in The availability of gender and age-matched controls is an added value for the definition of the diseases signature in metabolomics profiles. The present capacity of the biobank is of about 265,000 vials  to be stored at −80 °C and 195,000 vials  to be stored in the vapor of liquid nitrogen, at temperatures below −170 °C. Considering the sample turnover due to sample distribution for research purposes, on average daVEB hosts about 10,000 samples.https://www.davincieuropeanbiobank.org/en/research/sample-search. Samples and the associated data, which are project specific, are available for research purposes to external users, according to the published accession criteria [The biobank catalogue can be browsed via the web: criteria .A minimum data set is required for a sample to be accepted in daVEB, which includes the following info: Phenotypic descriptions , demographic information , individual information .Information concerning the sample history is associated to each aliquot, in particular the processing SOP followed at collection, the temperature story (freeze chain) including transport and storage temperatures, and the freeze time, from transport date and duration, entry date in −80 °C mechanical freezers or tank for storage in the vapor phase of liquid nitrogen, to the registration and exit date.etc. These three characteristics made it necessary for the daVEB biobank to implement a flexible infrastructure permitting the management of different data types for different collections, both for clinical and for other biomedical information. Furthermore, the IT infrastructure allows each collection to be extended at a later moment to include new samples  or new data types to be associated to the current samples . A further need arising from the above is to implement an approach to search our database that allows users to compare collections with different content types and, sometimes, formats.The technology-driven nature of the da Vinci European BioBank raises the need for a very specific design of its IT infrastructure. In particular, the present design takes into account the following characteristics of the operations of daVEB: (a) the samples stored originate from different collections, which do not share a focus on a common disease nor a common sample type and are collected in different, multiple centers; (b) each collection is associated to a different organization and a different ensemble of clinical data; (c) besides clinical data, samples are associated to other biomedical information, which, in addition to metabolomics data (present for the large majority of samples), can include genetic data, various kinds of images, A paramount concern when dealing with biobanks is the secure access to the data and the confidentiality of personal data. The daVEB IT infrastructure has addressed this problem by consistently Open SSL/TSL standard protocols for data exchange and network communications. Furthermore, data are separately stored onto two different servers. All personal information is kept on a server that is not accessible from the public network, but only through a private network and with different credentials than the first server. All other data, which do not raise privacy issues, reside on a separate server reachable via the public network.http://www.obofoundry.org/) [For the practical implementation of the daVEB IT infrastructure, we decided to exploit as much as possible open standards and open source software. This should also facilitate the interaction, and eventually the exchange of information, with other biobanks at the European and global level. Our data models are thus available in the form of schemes stored as Open Document Format (ISO Standard) data sheets; as an example, this includes the specific formats and definitions adopted for the information concerning sample history. Regarding data vocabularies and semantics, we designed procedures that allow the daVEB staff to define relationships between different relevant ontologies. We centrally rely on the Open Biological and Biomedical Ontologies made available by the OBO foundry (ry.org/) . Howeverry.org/) . This mary.org/) . This shMore in detail, each collection corresponds to a specific data scheme. An example is shown for a collection of samples from coeliac patients as a table in etc.) that can be associated to each field  diet habit elements for healthy subjects in MET projectthat are not in(B) diet habit elements for pathologic subjects in COE projectWe can translate such a question into a nested SQL query using the data contained in metadata tables to capture common definitions for diet habit in the MET and COE projects, and use such information to determine the result set, defined as the difference A-B. The entire data extraction procedure is automated and entirely SQL driven. http://www.cosmos-fp7.eu/). The specific aim of COSMOS is to develop open standards for the exchange of metabolomics data and the associated metadata, together with a variety of tools to support capturing and management of such information. These tools interface to the software used for data acquisition, to commonly used programs for the analysis of metabolomics data, and to relevant databases, such as Metabolights (http://www.ebi.ac.uk/metabolights/) [http://nmrml.org) as on open mark-up language specifically designed for NMR data resulting from metabolomics applications has been a crucial achievement. Notably, it is not needed to store the experimental data in the nmrML format, as they can be directly imported at a later stage. On the other hand, the ontologies used within the daVEB data warehouse are compatible with the ISA software suite that is central to metadata management in COSMOS. COSMOS has been developing a controlled vocabulary for NMR experiments, called nmrCV, adopting the OWL  syntax. The OBO ontology used within the IT infrastructure of daVEB can be readily converted to the OWL format.As far as the development of standards for the inclusion of metabolomics data in the biobank database, the involvement of some of us in the FP7 project COSMOS has been particularly valuable. COSMOS is a collaborative project funded by the European Commission within the 7th Framework programme (lights/) . COSMOS Beyond the mere distribution of the metabolomics profiles associated with the various samples, the daVEB biobank provides support for the reuse of the derived biomedical and clinical information. For example, COSMOS provides a computational infrastructure to identify and quantitate specific metabolites within the entire profile. This information can be derived from the metabolomics data in the daVEB biobank through a variety of analytic approaches and its significance is defined on a statistical basis . HoweverThe rapid development of high-throughput technologies and computational frameworks enables the examination of biological systems in unprecedented detail, paving the way to significant advances in personalized and precision medicine. By providing tissues, cells, fluids, and raw data, biobanks have become the drivers of the translational research cycle, since they are the custodians of the biospecimens and related anonymized data. A deep knowledge of the requirements inherent to a specific omic analytical approach allows biobanks to foster the development of this discipline. The close collaboration between biobanks and analytical platforms becomes essential to create a new generation of biobanks acting as drivers of the development of new methodologies.


For over 20 years, SAVE Foundation has concerned itself with the conservation of European livestock breeds. Often, this work has occurred in small populations of cross-border breeds. Livestock has developed over centuries of selection by farmers. The selection has been based on the ecological, climatic, and economic conditions of the local environments. One of these factors, the economic, is affected by the political situation of the country. Country borders as well as human populations have changed many times over the centuries. In contrast, the ecological and climate conditions have generally remained more stable. This means that highly similar locally adapted breeds can often be found both sides of current political borders and are generally grouped within the geo-ecological regions they developed in Druml et al. .Progressive displacement crossing by highly selected cosmopolitan breeds caused additional fragmentation of locally well-adapted but, in current economic environments, less successful breeds. Remnants from these formerly large populations may not amount to enough stock to make up a nucleus herd for conservation breeding within each single country. However, together with highly similar strains in bordering countries, there may be enough animals to create a combined gene pool and to conserve the locally adapted breed. Up to now, strategies for implementing this conservation method have relied heavily on historical and phenotypical information. Many projects conducted by SAVE over the years have been based on research into historical literature and data, field trips and discussions with experts with local knowledge. The high cost of genotyping combined with the relatively low usefulness of the results has meant that many projects carried out by SAVE and its partners have not used genotyping as a basis for conservation. The advent of SNP genotyping has changed this situation. The relatively low cost for genome-wide genotyping led to a substantial new situation where a higher level of accuracy can be brought into projects without creating a massive financial burden.BushaLive project, funded under the “Funding Strategy for the Implementation of the Global Plan of Action for Animal Genetic Resources.” The BushaLive project targets the autochthonous Buša  cattle breed of the Balkans. This breed survives in small, highly endangered, sub-populations that are additionally separated from each other due to the break-up of Yugoslavia into smaller states. The Buša is the collective term for small and robust shorthorn (brachyceros) cattle of the Balkans. Residuals from this formerly large Population are currently present in Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Greece, KosovoAn example of this in action is the The Buša is hardy and well-adapted to extensive farming in challenging environments with low managerial input. The Buša, with their withers' height at around 100 cm, show high fertility and modest production in harsh environments , Montenegro, Serbia, and The Former Yugoslav Republic of Macedonia. A minimum of 20 samples of possibly unrelated animals per country and strain was requested for the study. To obtain unbiased estimates of the diversity parameters, the population history, genetic differentiation, and the degree of admixture in distinct Buša strains we performed the genome-wide SNP genotyping (the BovineSNP50 BeadChip). To assess admixture and diversity parameters, genotypes of eight reference populations have been included. These populations represent possible sources of admixture as well as having been subject to different levels of artificial selection. Four Buša strains sampled in former studies have also been included. These old samples complement the newly collected material (SAVE Foundation, Within the first phase of the The achieved results provide a framework of future breeding actions and decisions which will be discussed between stakeholders involved in the conservation programme of this fragmented metapopulation (Medugorac et al., http://agrobiodiversity.net/balkan/topic_network/Bushalive.asp.Additional to the genotyping further information on each of the sampled animals has been collected via a comprehensive survey targeting their phenotypic characteristics and husbandry systems, as well as the products and services that they provide. This information, together with the genetic data, will be used to provide a basis for the development of a regional strategy for the management of the breed, spanning all stakeholder levels from farmers to governments. The project will also explore the potential for more effective marketing of the breeds' products. The next steps will be the establishment of basic recording systems and support for the development of breeding organizations and common breeding goals. The project will close with a stakeholder workshop for people working at all levels in the conservation of the breed. The event will provide an opportunity to pass on the information gathered and the strategies developed during the project to those who will use them in the future. All the results and data will be published, as they become available, online on: 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.