Adenoid hypertrophy (AH) is an extremely common condition in the pediatric and adolescent populations that can lead to various medical conditions, including acute rhinosusitis, with a percentage of these progressing to chronic rhinosinusitis (CRS). The relationship between AH and pediatric CRS has been extensively studied over the past few years and clinical consensus on the treatment has now been reached, allowing this treatment to become the preferred clinical practice. The purpose of this study is to review existing literature and data on the relationship between AH and CRS and the options for treatment. A systematic literature review was performed using a search line for “(Adenoiditis or Adenoid Hypertrophy) and Sinusitis and (Pediatric or Children)”. At the end of the evaluation, 36 complete texts were analyzed, 17 of which were considered eligible for the final study, dating from 1997 to 2018. The total population of children assessed in the various studies was of 2371. The studies were categorized as surgical-observational, microbiological, genetic-immunological, and radiological. The analysis of the studies confirms the relationship between AH and CRS and supports the existing consensus on medical and surgical therapy. Furthermore, these studies underline the necessity to adapt medical and surgical treatment considering age, comorbidities including asthma and, if present, the Computed Tomography (CT) score. Adenoid hypertrophy (AH) is an extremely common condition in the pediatric and adolescent population, due to chronic inflammation that leads to the proliferation of adenoid lymphoid tissue , and is This is the therapeutic approach justified by the relationship existing between AH and pediatric CRS and the objective of this study is to perform a systematic review of the literature and data on this relationship.A systematic literature review was carried out in June 2019 through Web of Science, PubMed, and Scopus databases, using a search line for “(Adenoiditis OR Adenoid Hypertrophy) AND Sinusitis AND (Pediatric OR Children)”. After completion of all searches, duplicates were eliminated. In vivo and in vitro studies were included based on the causal relationship between adenoiditis or AH and pediatric CRS, regardless of whether they were prospective or retrospective. Both anatomical, observational, therapeutic, and microbiological studies were considered eligible for the study. Two of the authors (AB and CP) independently screened the retrieved studies based on the title, keywords, and abstract to exclude non-relevant and non-English written studies. Both retrospective and prospective studies were included, while small series and case reports were excluded due to their intrinsic lower level of evidence (the minimum number of patients was arbitrarily set to 10). Published reviews and textbooks on the subject were excluded, but their reference list was reviewed to identify possible additional studies. Studies whose main purpose was the relationship between AH and acute rhinosinusitis were excluded, as were studies where AH and CRS were considered but not compared (for example the impact of AH and CRS separately on asthma). Studies that did not meet the inclusion criteria were discarded during the initial review. When uncertainty existed in the abstract evaluation, the full text of the document was retrieved and assessed. A manual search in the reference lists of these articles was performed to identify potentially relevant papers missed during the database search. Differing opinions were resolved by consensus between the two authors. Data extracted and analyzed for the study included mainly the statistically-significant relationship between AH and CRS.At the end of the evaluation, 36 complete texts were analyzed, 17 of which were considered eligible for the final study; the 17 texts contained the results of 18 studies. The search results are shown in the PRISMA chart . The 17 Five out of 6 observational surgical studies demonstrate a statistically significant relationship between adenoid pathology and CRS, the only one that does not demonstrate a link  investigates the relationship between simple adenoid size and CRS.H. pylori and did not demonstrate the colonization of H. pylori strains in either adenoids or in sinuses. Seven out of 8 studies focusing on the assessment of common colonization/bacterial infection of adenoids and paranasal sinuses demonstrate a significant presence of the same bacterial strains on both adenoids and paranasal sinuses, underlining the significant relationship between adenoid disease and CRS. One study  had the objective of identifying All three of the genetic/immunological studies have shown alterations in the expression of different genes and factors of the inflammatory pathway in children with adenoiditis and CRS; the expression of all factors is instead normal in the absence of CRS. The radiologic study shows the frequent coexistence of AH and CRS and the greater therapeutic challenge compared to a simple CRS.AH is a widespread condition in the pediatric age ,4 The poAs explained previously, adenoidectomy is considered the first surgical treatment to be performed for pediatric CRS. This indication derives from several studies focused on the beneficial effect of adenoidectomy both for obstruction and bacterial reservoirs removal. One of the first studies has been published in 1997 by Wang and colleagues  and asseWhile Wang’s group focused only on simple AH and the consequent nasal stenosis, in 2003 Ungkanot and colleagues  investigIn 2007 Ramadan and colleagues analyzed 143 children that had adenoidectomy for CRS and observed that around 50% required a subsequent ESS because of symptom persistence at an average of 24 months after surgery, especially in children who had asthma and were of a younger age (7 years old or less)  This mayHaemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis were the most frequent bacterial strains isolated, while Staphylococcus aureus was excluded in consideration of the high rate of nasal colonization. In 2008 Shin and colleagues [Haemophilus influenza, Streptococcus pneumonia) but also Streptococcus pyogenes and Staphylococcus aureus. They also analyzed preoperative paranasal X-ray and showed the bacterial isolation rate increased significantly with sinusitis grade, concluding that there is indeed a correlation between CRS severity and adenoids infection and that Staphylococcus aureus is not only a colonizing bacterium. Completely focused on this latter bacterium is the study by Lin and colleagues [Staphylococcus aureus in 21.2% of specimens from chronic adenoiditis, 35% of which were MRSA. They also demonstrated that Staphylococcus aureus was frequently a cause of AH and not just simply a colonization. All these studies helped define the bacterial strains that are commonly involved in adenoiditis, AH and consequently in pediatric CRS, that are Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Streptococcus pyogenes, and Staphylococcus aureus. This information is helpful to establish an empiric first line therapy to treat pediatric CRS. The studies which will be discussed below had the objective of understanding if the bacteria causing chronic adenoid infection was the same as that causing CRS. The study of the group of Bernstein and colleagues  is of palleagues  performeHaemophilus influenzae, Streptococcus pyogenes, and Staphylococcus aureus strains were susceptible to all these antibiotics, except for cotrimoxazole. Mild susceptibility and resistance to certain antibiotics was found for Streptococcus pneumoniae, and Moraxella catarrhalis isolates. Further consolidation of this therapeutic approach was provided by Davcheva-Chakar and colleagues  who testClamydophila pneumoniae, this uncommon infection can lead to CRS in the pediatric population, particularly in middle east countries [Clamydophila pneumoniae, and cause rhinosinusitis concomitant with AH. They suggested performing target antibiotic therapy before adenoidectomy, to increase the surgical success rate. The authors underlined that this type of infection is rare in other parts of the world, but the data is still of great interest considering modern world complex migration. A further study carried out by the Cedeño group [Helicobacter pylori at the nasal, sinus, and adenoid level, driven by the assumption that gastroesophageal reflux is a risk factor for AH and CRS, even if there is no consensus in literature regarding this relationship [Several research groups over the last 10 years focused on the identification of other bacterial strains that could shed new light on CRS etiology and on the relationship between AH and CRS. An interesting study by Nia and colleagues focused on ountries . The groño group  focused tionship . UnfortuIn recent years the attention of researchers has shifted from individual bacterial strains to biofilms, complex habitats where different bacteria organize and coexist within polysaccharide matrices that provide them with a solid defense against antibiotics and other external aggressions ,26. In 2Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, Streptococcus pyogenes, usually susceptible to common antibiotic, and Staphylococcus aureus, unfortunately often MRSA. Therefore, good clinical practice should include starting with a wide range empiric antibiotic therapy [Considering the previous data, it is possible to conclude that the most frequent bacterial strains are  therapy  and in cThe effectiveness of adenoidectomy ranges between 47% and 56%. It has been shown to be less effective in children who have asthma with CRS. Why adenoidectomy is more effective for certain children and less for others appears complex and at times mystifying ,36,37. ISome groups have focused on the analysis of immunological changes and inflammatory responses in children that have AH +/- CRS ,33,34 deA first study by Eun and colleagues  evaluateIn 2015, Qu and colleagues  investigAs described before, all these papers are to be considered preliminary studies and more research is necessary to improve the knowledge of this complex inflammatory pathway and the relation between their activation, CRS and AH. However, this data underlines when CRS is present, the adenoid samples show a decrease of immunity factors like IgA or antigen presenting protein cells that is probably the causing agent of bacterial strains proliferation and consequently of CRS. Furthermore, the proliferation of bacteria leads to the activation of an inflammation pathway that causes the adenoids to increase in volume (AH). All these conditions lead to the creation of a loop in which the occurrence of infections and inflammations increases and is associated to volume augmentation of the adenoids, defining the clinical presentation of a typical pediatric CRS patient. 6 and in clinical guidelines [Analysis of the above studies confirms the relationship between adenoid hypertrophy and CRS and confirms also that the medical and surgical therapy aimed at the treatment of the former is effective on the treatment of the latter. However, albeit not represented in the Clinical Consensus Statementidelines ,14,15, t


Despite a proven association between the implementation of prevention guidelines for central line associated blood stream infections (CLABSI) and reduction in CLABSI rates, in practice there is poor adherence. Furthermore, current guidelines fail to address the multiple process on the care continuum. This research is based on the bottom-up "Positive Deviance" (PD) approach, through which multiple creative and safer solutions for central line (CL) insertion were identified that were not previously described in the guidelines. The aim of the study was to deconstruct CLABSI prevention guidelines ("during insertion" process only) through the PD approach, working with physicians to identify additional actions that, in practice, help maintain a sterile environment and contribute to patient safety.Our study included a qualitative ethnographic study involving 76 physicians, working in a division of internal medicine and two intensive care units (ICUs). We triangulated findings from a combination of data-collection methods: semi-structured interviews, focused observations, video documentation, Discovery & Action Dialogue (DAD), and simulations. Deconstruction analysis was performed. A total of 23 creative extensions and variations of CL insertion practices were identified.The PD approach enables the identification of vital nuggets of hidden wisdom missing from the formal explicit CLABSI guidelines, and therefore helps bridge the gap between theory and praxis. During the guideline's deconstruction process, through collaborative staff learning, the written procedure is transformed into a living, breathing and cooperative one. It can reduce hospital stays and save lives, and therefore needs careful attention of healthcare scholars and practitioners. Healthcare-associated infections (HAIs) acquired by patients during hospitalization are one of the most intractable and highly investigated global health problems. While HAIs are life-threating to hundreds of millions of people worldwide , 2, an eThe European Union reports approximately 4,544,100 infections  and the Central line associated blood stream infections (CLABSI) are the most common HAIs in intensive care units (ICUs), defined as a primary blood stream infection (BSI) in a patient who had a central line (CL) within the 48-hour period before development of the BSI, and when the BSI was not secondary to an infection at another site . CLABSI'Strategies to prevent CLABSI in acute care settings were first outlined in 2008 by a group of endorsing and supporting organizations, and then updated in 2014 . The latThere is a significant association between implementation of CL insertion and maintenance bundles, and reduction in the incidence of CLABSIs in ICU settings. Nonetheless, more data is needed to determine which components of the maintenance bundle are essential in reducing infection risk , 13. IstThe National Healthcare Safety Network (NHSN) of the CDC has, since 2009, closely tracked US progress in reducing HAIs. The 2016 CDC progress report, based on 2014 data, indicated that CLABSI in acute care hospitals decreased 50 percent between 2008 and 2014 , 18. DesIn Israel, a decision was taken in 2014 to include CLABSI rates as part of quality of care indicators in hospitals . HoweverGurses et al.  analyzedOne of the creative solutions found to address these gray areas is the use of the "Positive Deviance Approach" (PD), which has been employed for nearly three decades in over 50 countries to address a wide variety of complex social problems, including the reduction of HAIs in the US, Colombia, and other countries –27. The The PD approach differs from common approaches to problem-solving, as it seeks to identify and streamline existing resources derived from the staff within a setting, rather than import external "best practices." These people and their behaviors are ordinarily “invisible” to others in their community . The appSinghal and Svenkerud  proposedThe present article seeks to deconstruct the processes associated with the guidelines for CL insertion and focuses on the insertion phase done by the physicians only, and not on the maintenance phase done by the nurses. Deconstruction is defined as a method that examines the relationship between a text and its meaning through decomposing, disassembling, and reassembling it . AccordiThis qualitative ethnographic research method used several tools: semi-structured interviews, observations, video documentation, Discovery & Action Dialogue (DAD) , and simThe study was conducted during 2018–2019, in the General ICU (GICU), Medical ICU (MICU), and Division of Internal Medicine, of the Hadassah Ein-Kerem Hospital, Jerusalem, Israel.The general research population included 76 physicians: 35 from two ICUs and 41 from the Division of Internal Medicine. During the sampling stages which were conducted in the two ICUs, we identified four physicians as PDs, as detailed below.In the first stage, purposive sampling, a nonrandom technique to identify and select individuals or groups proficient and well-informed with a phenomenon of interest [interest  was emplinterest .In the second stage, snowball sampling [sampling  was emplFor Step 1 (data collection), we used the following tools:Interviews: A total of 35 ICUs physicians were interviewed , data from the interviews, observations, and video documentation that informed the positive practices were presented to the Unit for Infection Prevention and Control team (two senior physicians and one nurse) for approval. We presented to them, in several sessions, the 23 practices through both written text and video clips. Initially, they discussed the practices and were asked to assess whether the PD practices were anticipated to reduce infections or cause harm, or whether there was a controversy. They then held an internal discussion and reached expert consensus. This phase was crucial for obtaining scientific approval on the implementation of the practices, before the diffusion phase.For Step 3 (diffusion of the CL insertion practices through multiple platforms) we performed the following tasks:Simulations [ulations , 32: ThrDiscovery & Action Dialogue (DAD) meetings: Two meetings were held with 41staff members comprising of junior and senior physicians , from the Division of Internal Medicine. The recorded videos were played, questions answered, and based on the DAD guidelines, a discussion opened on the viability of disseminating these extraordinary recommended practices among other physicians [ysicians .Editing and spreading the videos through WhatsApp application: After collecting and videotaping all the positive practices associated with the insertion of the CL identified among the four physicians, the videos were combined into one edited video  that combined all desired practices, demonstrating all the stages for dissemination to all ICU physicians via the WhatsApp application.Israel PD conference: Approximately 300 healthcare professionals took part in a unique professional conference dedicated to the PD approach and its implementation in Israel. The edited video of CL insertion was center stage. In addition, the PD approach, and procedures for receiving scientific approval and diffusing of PD practices were presented.PD Israel Facebook: We opened a Facebook page entitled "Positive Deviance Israel" with the goal of creating a community and a scientific social network of public health professionals interested in the approach, and to serve as a platform for raising awareness, dissemination and exchanging information. The page contains professional content: publications, lectures, videos (including the CL insertion video), and encourages professional collaborations and engagement in the field. The page received over 1580 views in the first month (May 2019).We triangulated the data obtained from different sources to bolster the study’s validity: face-to-face semi-structured interviews, observations, video documentation, and simulations . InterviAnalysis of the data was conducted as follows:Guidelines presentation–We integrated the three main guidelines in the literature  –15, in owe integrated and categorized texts from the three guidelines  into an index of “order of actions” to be taken during CL insertion –15.Content analysis and integration–we conducted a thematic analysis  of the tComparisons–we compared the CLABSI guidelines index to the additional PD practices identified.Deconstruction–we completed the analytical process by deconstruction, through which a common CL insertion narrative was created that contained the extension and additions to the index of current guidelines .This research was approved by the ethics committee of The Faculty of Social Welfare and Health Sciences at the University of Haifa, Haifa, Israel (confirmation number 392/17).A total of 23 practices were identified that were carried out on the continuum of CL insertion orders by four physicians who were identified as PD. The current guidelines to prevent CLABSI includes steps to be taken –15 withoThe first challenge to patient safety is how to comply with the guidelines in a dynamic moment with a complex set of variables at play. The literature shows that staff members find it difficult to follow the guidelines and thus compliance rates are low [second challenge is staff members’ different interpretations and implementations of the guidelines, which can often lead to failure to maintain good hygiene on the care continuum [third challenge is the missing parts in the guidelines that we coined as "gray areas" in our previous article [Since the literature shows a direct association between failure to maintain a hygienic environment and acquired infections in hospitals , 42, inf are low , 45. Oth are low , some by are low . The secontinuum , 47. The article . The gre article .In this study we found that the second and third challenges to patient safety can be addressed by identifying and detailing the PD physicians’ practices to the current CL insertion guidelines. We argue that the actions of the PD physicians are deconstructionist actions of disassembly and reassembly. Accordingly, the guidelines are analogous to the text and the PD physicians are the readers. The PD physicians’ encounter with the daily reality at their hospital, generated their creative and renewed deconstructive analysis of the current guidelines. When the PD physicians attempted to perform CL insertions, they often remained with unanswered questions. Therefore, on the ground, while performing the medical procedure, they transacted an intimate and closer reading of the text, examining the texture of the guidelines and adding the creative layers that were hidden and missing from the previously explicit text. In this sense, the deconstruction and reassembly processes brought forth the hidden wisdom and made it explicit .It is important to clarify in this context that our use of the word "de-construct", is not intended to refute or subvert the currentguidelines, as the philosopher Derrida explains in his writings . On the In our article the deconstruction analysis of the guidelines was done using simulation-based training . The sigIn our case, the simulation gave the PDs the opportunity to connect between the visualization of their thought and its rationalization. During the practical demonstration, the PDs explained to the audience their thoughts and the logic behind their actions, so that the act of inserting the CL, accompanied by words and visual cues, became an analytical process. The physician audience became active participants in the learning process, asking questions and sharing their experiences, thus significantly increasing the potential for storing and incorporating the information in their memory, rather than learning from reading literature and guidelines only , 53. ThiKahneman and Tversky , 56 arguThe dissemination of the PD practices flipped the tenets of the classical diffusion of innovation theory on its head. As Singhal and Svenkerud  argue, iDisseminating the novelty of our study through different platforms  expanded the likelihood that these analytical "human-centered” guidelines  would disseminate to wider circles of professionals beyond the hospital where we conducted the study. In fact, this approach provides a tool aimed at encouraging physicians to find solutions to a variety of medical conditions on the care continuum that have not been addressed by the official guidelines, and thus reduces the number of "professional falls" . This stLimitations of this study relate to not examining its long-term impact, that is, behavioral change and a reduction in CLABSI rates. As is known from the extensive literature in the field, significant changes such as declines in infection rates can be revealed through long-term monitoring. Nevertheless, our main goal was to examine the input rather than the impact: the way the PD physicians added new practices to the current guidelines (deconstruction). Furthermore, our study focused on CL insertion only, and did not address maintenance, which is also considered a significant strategy to prevent CLABSI and is usually within the responsibility of nurses . FurtherIn conclusion, the PD approach is a versatile tool that provides a solution for including the missing part from the formal explicit guidelines, and therefore helps bridge the gaps between theory and praxis. During the guideline deconstruction process through collaborative staff learning, the written procedure is transformed into a living, breathing and cooperative one. It can reduce hospital stays and save lives, and therefore needs careful attention from healthcare scholars and practitioners , 34, 58.


Accessory anatomical structures in the ankle and foot usually represent incidental imaging findings; however, they may also eventually represent a source of pathology, such as painful syndromes, degenerative changes, be the subject of overuse and trauma or appear as masses and cause compression syndromes or impingement.This review aims to describe and illustrate the imaging findings related to the presence of accessory ossicles and muscles in the ankle and hindfoot through different techniques, with special attention to those variants that associate factors of clinical relevance or that trigger challenges in the differential diagnosis. Accessory anatomical structures in the ankle and hindfoot are a common incidental finding.Anatomical variants may trigger challenges in the differential diagnosisAnatomical variants may be a source of pathologyA number of anatomical variations can be found in the ankle and hindfoot. These include accessory ossicles, additional sesamoid bones, variations in number and configuration of sesamoid bones, coalitions, bipartitions and variants in the soft tissues, such as accessory muscles.Most of them represent developmental abnormalities that constitute incidental radiographic findings .Accessory ossicles in most cases are a result of unfused ossification centres. They are seen as subdivisions of existing bones or free elements in the vicinity of the normal bone structures. Sesamoid bones have a different anatomical nature. They functionally represent components of a gliding mechanism and are at least partially embedded in tendons, reducing friction and protecting the tendon structure , 2.The most common accessory ossicles in the ankle and foot are the os trigonum, the accessory navicular  and the os intermetatarseum, in this order. With respect to accessory sesamoid bones, the os peroneum is the most frequently found .Accessory muscles are also generally asymptomatic and discovered incidentally on imaging studies. Occasionally, they will manifest clinically, presenting as mass lesions or causing compression syndromes such as tarsal tunnel syndrome, chronic pain or impingement.Our aim with this review is to illustrate the imaging findings related to the presence of accessory ossicles and muscles in the ankle and hindfoot through different techniques, with special attention to those variants that associate factors of clinical relevance or, in the case of the ossicles, that would pose a challenge in the differential with fractures.Bone coalitions, given their complexity and frequent clinical implications, deserve separate analysis and will not be the object of this review.Ossicles Fig.  Table 11The os trigonum is one of the most common accessory ossicles in the ankle and foot. Its prevalence is estimated in between 1 and 25% [Initially, this was interpreted as a non-united fracture. Currently, this is viewed as a developmental skeletal variation, likely resulting from failure of fusion of a secondary lateral tubercle ossification centre that forms at about 7–13 years of age, and normally fuses at about 14 years of age . It is cThe os trigonum is normally an incidental finding, with no associated pathology. Os trigoni may have a round, oval or triangular morphology .A single traumatic episode of forced plantar flexion or repetitive forced plantar flexion may result in degeneration or tear of the synchondrosis Fig. . RepetitSymptoms of os trigonum syndrome may result from all the situations mentioned above and consist of chronic or recurrent pain with stiffness, soft tissue swelling and tenderness to palpation in the postero-lateral aspect . The os Radiographs can detect the presence of an os trigonum; however, their sensitivity is limited in the assessment of early bone changes occurring with the development of pathology. The posterior impingement view has been shown to be more sensitive than the lateral view in the detection of an os trigonum .Computed tomography (CT) and magnetic resonance imaging (MRI) are able to detect the associated bone and soft tissue abnormalities.On CT images, irregularity and sclerosis, or changes related to degenerative change on the articular surfaces of the synchondrosis, may be present as a result of chronic stress and abnormal movement .On MRI images, the presence of bone marrow oedema in both aspects of the synchondrosis, fluid within or joint effusion, or signs of soft tissue involvement, such as oedema in surrounding structures or tenosynovitis of the flexor hallucis longus, will be indicative of os trigonum syndrome  Fig. 3)3).Fig. 3Increased technetium-99m intake is another typical feature linking symptoms to the presence of an os trigonum , althougOther possible causes of posterior impingement are related to the morphology of the lateral tubercle of posterior process of the talus . When this is markedly prominent, the same mechanism of plantar flexion described above , 11 causThe differential diagnosis of an os trigonum comprises fractures of the lateral or medial tubercles of the posterior process of the talus. These represent Shepherd’s or Cedell’s fractures, respectively , 12. TheIn the case of Cedell’s fracture, pain will be located postero-medially and, in some occasions, a lump will be palpated , 14.Fragments are usually non-displaced and resemble os trigonum. In the cases of fracture, besides from the background of trauma that may suggest it, on CT or MRI assessment, the edges will be irregular, not corticated and comminution is possible . FracturThese fractures can sometimes be missed, and they need fixation; otherwise, they may result in pseudoarthrosis. If fragments are very small, they can be excised. In cases when non-union has occurred, the fragments are usually resected .The os sustentaculi represents a very rare skeletal variant of the ankle and foot region, with a prevalence that has been estimated in 0.3–0.4% , 3. ThisA variant of the os has been called the assimilated os sustentaculi. This represents an accessory joint between the bony projections at the sustentaculum tali and the adjacent talus. It has been speculated that the os may incorporate to the sustentaculum when growth finishes, and this represents a fused variant of the condition , 16. A tIn a recent retrospective study by Yun et al., it was found that coexisting intraarticular talocalcaneal coalition was observed in 11 of 13 patients with extraarticular talocalcaneal coalition with os sustentaculi, suggesting that the os sustentaculi is a component of extraarticular talocalcaneal coalitions and thus related to the presence of symptoms .This os can become symptomatic in cases of chronic abnormal mobility (shearing), in which degenerative changes across the synchondrosis occur. Typical findings on CT images will be irregularity of the synchondrosis surfaces, with sclerosis and subchondral cyst formation. On MRI, there will be subchondral bone marrow oedema and fluid .Differential diagnosis includes fractures of the sustentaculum tali, which are also rare. These occur when there is a direct impact on a supinated foot and are frequently seen in association with severely comminute intraarticular calcaneal fractures, although they can also be found isolated. Pain and tenderness along the medial aspect of the foot will be the main clinical symptoms .Besides from the background of trauma, typical features of a fracture such as irregular interfaces and no cortication help to establish the diagnosis on radiographs and CT. Associated bone marrow and soft tissue oedema typically associated to the presence of fractures will be seen on MRI .The os calcaneus secundarius is a rare accessory ossicle of the foot, estimated to have a prevalence between 0.6 and 7% , 3. It cThis normally represents an incidental finding, which can easily be missed on conventional AP and lateral radiographic projections. Oblique views will demonstrate its presence.The os calcaneus secundarius is sometimes very difficult to distinguish from a fracture of the anterosuperior calcaneal process , which uIf one of these fractures is suspected, CT or MRI should be performed to fully characterise, given the implications for treatment  Fig. 7)7).Fig. 7Just as with the previously seen ossicles, the diagnosis can be established with the clinical background, and the typical irregularity of margins of fracture and no cortication described . The preThe os subtibiale is rare, with an estimated prevalence of 0.9% , and is The true os subtibiale derives from a persisting accessory centre of ossification and is different from an unfused secondary ossification centre. Secondary ossification centres normally fuse at around 7 years of age. If they do not assimilate to the tibial epiphysis, they appear as a separated medial malleolus . This isThe main differential of an os tibiale is avulsion fractures, which are common in the context of ankle trauma. Because ankle trauma is the most common indication for radiological examination of the ankle, the accessory ossicle can be mistaken by a fracture .Avulsion fractures are so much more common than the presence of an os subtibiale that in the context of a symptomatic patient after ankle trauma, the finding of an osseous structure below the medial malleolus should be considered and treated as a fracture .The os subfibulare has an estimated prevalence of 2.1% . SimilarThe os subfibulare can be found distal to the tip of the lateral malleolus, with round or comma-shaped morphology, and is asymptomatic .The main differential is avulsion fractures of the distal fibula. These are typical of inversion injuries of the ankle. Clinically, in these cases, there will be swelling, effusion and pain. Instability may be present, which can be a reliable tool to confirm avulsion fracture, and rule out os subfibulare. Avulsion fractures are more typical of older subjects and normally involve the insertion of the anterior talofibular ligament Fig. . In a loGiven the much higher prevalence of distal fibular injuries due to inversion trauma, some authors actually blanket any ossified structure adjacent to the lateral malleolus as the result of an avulsion fracture, which might have happened remotely in time , 29.Other ossicles, such as the os supratalare or os talotibiale, are rare and not associated to painful conditions. The main differential in these cases has to be done with a fracture. Lack of history of trauma, clinical symptoms and absence of a potential site of origin for a fracture fragment in the adjacent bones would favour the existence of an ossicle  Fig. 9)9).Fig. 9Several rare accessory bones in the hindfoot have been described, such as an accessory calcaneus, by Krause and Rouse , and bipAccessory tali are extremely rare, with only a few case reports . These ab.Soft tissues of the ankle and hindfoot. Accessory Muscles Table .Other rare ossicles have been described, such as an “ankle patella”, a large accessory bone anterior to the tibiotalar joint  and a smThe peroneal muscles are two, the peroneus longus and peroneus brevis.They run posteriorly to the lateral malleolus, the brevis more anterior than the longus.A third peroneus can be found with a prevalence of up to 95% in cadaveric studies . The musThere are a number of other accessory peroneal muscles, with names such as peroneus accessorius, peroneocalcaneus externum, peroneus digiti minimis and peroneus quartus. This last term is the one generally used for accessory peroneal muscles in the postero-lateral aspect of the leg .Prevalence is difficult to set. In general, cadaveric and radiological studies demonstrate similar prevalence, approximately 10% on MRI  and 22% It is more commonly bilateral and seen in males.In most cases, the peroneus quartus arises from the peroneus brevis, but it can arise from the peroneus longus and fibula as well. The tendon is medial and posterior to the brevis and longus peroneal tendons.The insertion is very variable and will determine the different given names. The most common insertion is on the calcaneus, known as peroneocalcaneus externum, with a prevalence of 79–91% .The peroneus accessorius arises from the peroneus brevis to insert onto the peroneus longus, and the peroneus digiti minimi arises from the peroneus brevis and inserts onto the head of the fifth metatarsal and base of the first phalanx , 40. InsThe peroneus quartus is a pronator. It is normally asymptomatic, but in some cases, it can cause crowding in the retinaculum, leading to subluxation of the peroneal tendons or tears due to friction.A peroneus quartus can be removed in the cases in which it is causing pathology. A very interesting feature of this accessory muscle is that it can be used on ankle surgery to repair retinaculum injuries .Finally, the peroneus quartus can result in imaging pitfalls. The accessory tendon of the peroneus quartus, separated by a tissue plane from the other peroneal tendons, can be mistaken for a tear, but distinguishing it becomes easy by following the tendon to its own independent muscle belly .The flexor digitorum longus arises from the tibial surface, below the origin of the soleus. The tendon courses posterior to the medial malleolus and splits into four different tendons that insert on the distal phalanxes of the second to fifth toes.Prevalence of the flexor digitorum accessorius longus has been set in 6–8% . It is mThe flexor digitorum accessorius longus can arise from any structure in the posterior compartment but is seen to arise more frequently from the medial margin of the tibia or from the lateral aspect of the fibula distal to the origin of the flexor hallucis longus. The tendon courses beneath the flexor retinaculum, through the tarsal tunnel, superficial to the neurovascular bundle . It typically inserts onto the quadratus plantae or flexor digitorum longus  Fig. 1111.Fig. 1In the tarsal tunnel, the tendon or low-lying fibres of the muscle can create a compromise of space, and so the presence of a flexor digitorum accessorius longus has been linked to tarsal tunnel syndrome . One surThe presence of this accessory muscle has also been associated to flexor hallucis longus tenosynovitis .The peroneocalcaneus internus muscle is a rare accessory muscle. In a series of asymptomatic volunteers, its prevalence was estimated on 1% . In one The peroneocalcaneus arises from the internal aspect of the fibula, below the origin of the flexor hallucis longus, and descends posterior to this displacing it anteriorly and medially, with the tendons running parallel. This configuration has the potential to cause crowding in the tarsal tunnel , 51. TheThe presence of the muscle is normally asymptomatic, given it is not directly related to the neurovascular bundle. Only in very rare cases in which the peroneocalcaneus internus displaces the flexor hallucis longus medially a tarsal tunnel syndrome has been reported . OccasioIt can be mistaken with a flexor digitorum accessorius longus, but its location posterior to the flexor hallucis longus, as opposed to the neurovascular bundle, and its insertion on the calcaneus, as opposed to the flexor digitorum longus or quadratus plantae, help on distinction .A rare associated problem with the presence of a peroneocalcaneus internus is the possibility to fail to recognise this separately from the flexor hallucis longus in arthroscopy , which may lead to an altered surgical approach, and potential injury to the neurovascular bundle. The flexor hallucis longus is used as a landmark for the medial margin of safety in arthroscopic surgery .The soleus is located in the deep posterior compartment and arises from the proximal fibula, the posterior  and medial tibia and a fibrous line bridge in between tibia and fibula. Its tendon normally joins the Achilles tendon.Accessory solei have a prevalence of 0.7–5.5% according to cadaveric studies .The accessory soleus normally arises from the anterior surface of the soleus, partially sharing the soleus origin, and descends antero-medially to the Achilles, superficial to the flexor retinaculum, to insert on either the Achilles or the calcaneus, on the superior or medial surface, with a tendinous or a fleshy insertion. The different types of insertion define the different types of classified accessory soleus  Fig. 1313.Fig. 1An accessory soleus may present as a soft tissue mass in the postero-medial aspect of the ankle. It tends to be noted if there is an increase in muscle mass and activity, and sometimes, there is associated pain, triggered by exercise, that could be explained by the increase of intrafascial pressure or insufficient blood supply , 53. In Accessory solei may be evident on radiographs, as partial obliteration of the Kager fat pad. MRI and CT are more sensitive and specific, and in the case of MRI, intrinsic muscular changes and relations with adjacent structures can be evaluated to investigate the aforementioned associated pathologies , 53.The tibiocalcaneus is a rare accessory muscle, with only a few radiology reports , 54.It has been described arising from the medial tibia and inserting on the medial calcaneus, similarly to a subtype of accessory soleus, with the difference that the tibiocalcaneus is located deep in the flexor retinaculum. As a difference from the flexor digitorum accessorius longus, the tibiocalcaneus inserts onto the calcaneus and not the flexor digitorum longus or quadratus plantae.Given the deep location in the flexor retinaculum, this accessory muscle can potentially cause tarsal tunnel syndrome .A third peroneus muscle and tendon located in the anterior compartment is a common finding that can be found with a prevalence of up to 95% in cadaveric studies . The musThe extensor hallucis capsularis tendon has been estimated to have a prevalence of 14% in the population. The tendon arises from the extensor hallucis longus tendon or muscle, in most of the cases, and inserts onto the first metatarsophalangeal joint capsule. This tendon may be useful in the cases in which grafting is needed for reconstruction, especially in cases of hallux dysfunction .Other rare accessory muscles have been described in the anterior compartment of the leg, with tendons parallel to the extensors, such as the anterior fibulocalcaneus , which oThe tibioastragalus anticus of Gruber’s muscle is another rare accessory muscle in the anterior compartment of the leg. The muscle arises from the lower third of the anterolateral tibia and interosseous membrane and inserts onto the anterolateral aspect of the neck of the talus. The tendon is deep to the tibialis anterior and extensor hallucis longus tendon . This acThis review has illustrated the imaging findings related to the presence of accessory ossicles and muscles in the ankle and foot through different techniques and the potential clinical implications related to their existence, highlighting the importance of each technique in the diagnosis and assessment of related pathology.Most accessory ossicles will represent an incidental finding on radiographs. Accessory muscles can occasionally represent an incidental finding on radiographs, but are mainly incidentally noted on MRI and CT.In cases where pathology in relation to the presence of these structures is suspected, detailed clinical correlation and careful assessment with MRI and CT plays a very important role.It is useful for the radiologist to be familiar with the characteristics of these anatomical variants to avoid misdiagnosis.


Although public-private partnerships have become common in the health sector, the evidence supporting their effectiveness is limited, and when the products or services provided by the private partner are harmful to health inherent conflicts of interest may be difficult to overcome. The objective of this study is to appraise the evidence describing process or effectiveness of public-private partnerships (PPPs) that aim to promote population health, and analyse how characteristics such as independence or competing interests influence the results of their evaluation.We carried out a systematic search of Medline and Web of Science to identify scientific reports evaluating the process or effectiveness of PPPs that aim to promote population health. Two reviewers applied inclusion criteria, extracted and evaluated study quality. We classified PPPs according to the health problem tackled, the independence of the evaluation, and the potential for competition between business interests of the private partner and health promotion activity undertaken. We classified the conclusions of the evaluation as positive (supportive/tentatively supportive) or negative .We identified 36 studies evaluating 25 PPPs. Evaluations that were favourable to the use of PPPs in health promotion were more frequently classed as “not independent” and of poor quality. On the other hand, negative evaluations were more common when the PPP involved a private partner with a high potential for competition between the health promotion activity undertaken and their financial interests. PPPs that sought to prevent non-communicable diseases were more frequently negatively evaluated compared to PPPs tackling infectious disease or other types of health problem. Almost all of the evaluations evaluated process, with only 2 papers reporting quantitative health related outcomes.There is still a lack of sound evidence supporting the effectiveness of public-private partnerships in health promotion, and the evidence base is skewed by non-independent evaluations. Public health actors should abstain from engaging in agreements with industries whose business interests have a high potential for competition with the health promotion activity undertaken. Public-private interactions have become common in the health sector. Governments, multilateral institutions and industries are applying these arrangements to address diverse health related issues. The origins and reach of the so called public-private partnerships (PPPs) have been thoroughly described at the global level –3 and haHowever, criticism has also arisen regarding PPPs in the health sector. Authors argue that alliances between public health and private sector have inherent conflicts of interest that cannot be reconciled when the products or services provided by the private partner are harmful to health , 12. ColWhile many public-private interactions are used in developing, financing and providing public health infrastructure and service delivery or in providing drugs, vaccines or other products, significant criticism has arisen when it comes to agreements between governments and industries that are negatively associated with health, especially in the area of health promotion . There iSome authors call for precaution when entering in partnerships for health promotion with companies that market products negatively affecting health, at least while there is no evidence of their effectiveness. Moodie R et al. suggest there is no evidence that the partnership of alcohol and ultra-processed food and drink industries is safe or effective, unless driven by the threat of government regulation . Galea aBeyond the need to establish criteria for engaging with private partners to implement health promotion programs, scientific evidence on the effectiveness of these partnerships becomes the key issue. Ideally evaluations should address whether or not the partnership is able to produce a real and durable improvement in population health. While it may be challenging to demonstrate changes using health indicators, intermediate proxy indicators established prior to carrying out the evaluation can be useful to indicate that the initiative is having the desired effect. The difficulty to evaluate public-private interactions, and the frequency of potential conflicts of interest could explain the scarcity of evaluations, particularly in health promotion . So far,We carried out a systematic search of the Medline database using Pubmed and Web of Science (WoS) on 27th June 2018 combining the text words “public private partnerships” OR “public private partnership” to identify studies that evaluated PPPs in health promotion. Two reviewers independently screened the titles and abstracts of all potential articles and reviewed the full text of preselected abstract for final inclusion in the study. We also reviewed the references of included papers to identify potentially relevant studies.We selected studies based on the following criteria: Scientific articles published in a peer-reviewed journal that evaluated the role of a local, national or multi-national Public-Private Partnership in health promotion, understood as the process of enabling people to increase control over and improve their health. We did not include initiatives that focused solely on the provision of health care such as pharmaceuticals, vaccinations, nutritional supplements, or provision of clinical services. Furthermore, we chose to exclude initiatives where the private partner was the tobacco industry as it is already widely accepted that undue influences from the tobacco industry prevent them from having a legitimate role in health promotion. PPPs were only eligible for inclusion if they included at least one public partner and one private partner, defined as for profit companies or organizations, or foundations funded by private companies although not necessarily for profit. Initiatives were considered to be PPPs when the interaction between private and public partners was established for the specific purpose of implementing or driving forwards a health promotion program with a shared goal, thus excluding other types of interaction such as dialogue preceding regulation. Quantitative and qualitative evaluations were included if they empirically analysed either the process and/or effectiveness of PPPs in health promotion. We resolved discrepancies in the screening of abstracts by arbitration with a third reviewer. Figure Two researchers independently extracted the characteristics of each evaluation from the articles. We classified each study as quantitative, qualitative or mixed; and whether it addressed process or impact. Furthermore, we classified each article according to the independence of the evaluation. Evaluations were considered to be independent only if all author affiliations and funding sources were unrelated to the partners involved in the PPP. Government workers were considered independent as long as they did not work directly in the area of the PPP, and authors working in publicly funded evaluations units were considered unbiased, thus independent. We categorised the private partner(s) of the PPP according to whether the business interests were likely to be in conflict with the health promotion activity undertaken by the PPP. This question was not always straightforward. For example, while fresh fruit and vegetable producers have no conflict with health promotion activities focussing on healthy weight, and junk food restaurants have a clear conflict, other types of food producers such as the meat and dairy industry, large supermarket chains or unspecified restaurants are more difficult to classify. For this reason, we classified the PPPs according to three categories Table .Table 1Finally, we recorded word for word the conclusion of the evaluation according to the abstract or discussion of the paper, and classified it as critical, semi-critical, tentatively supportive or supportive.We developed a simple tool to gage study quality which incorporated dimensions from existing guidelines –25. We jWhen there were numerous studies on the same PPP, we combined the findings of the evaluations for analysis. In the case of the UK Public Health Responsibility Deal, which entails voluntary partnerships with industry in four dimensions , we classed each dimension as a separate PPP, thereby combining the evidence provided of evaluations only when they evaluated the same dimension. The Australian Food and Health Dialogue, which later changed its name to the Healthy Food Partnership in 2015, was classed as one PPP. If the combined evaluations were from different years, we noted the year of the most recent evaluation. If there was a discrepancy among key variables, including the grading of the conclusions of the evaluation , we used the information from the paper with highest quality. When quality was equal, we kept the conclusions of the most independent evaluation. We carried out a univariate analysis to assess the relationship between the conclusions of the evaluation  and key characteristics of the PPP or of the evaluation. We assessed statistical association using Fisher’s exact test.Of the thirty-six studies analysed, eleven (30.6%) were evaluating PPPs in the United Kingdom ((UK), of which nine evaluated the Public Health Responsibility Deal). Nine (25%) evaluated PPPs in the United States of America (USA), 5(13.9%) in Australia , and 3(8.3%) in Tanzania . The remaining studies were carried out in Argentina, Botswana, Canada, Malaysia, Nigeria, Sri Lanka, Zambia and one study included multiple partnerships from various countries. Less than half of the papers were deemed to be of high quality providing strong evidence , while 12 studies (33.3%) were moderate quality and 7(19.4%) were poor quality. Almost all of the papers were published on or after 2012 . The earliest evaluation was published in 1999, and was the KINET  .Thirty-six papers analysed 25 different public-private partnerships  and deemed to be of poor quality  supported the application in health promotion of the PPP evaluated. Evaluations were more frequently critical if the PPP sought to prevent non-communicable diseases . Conversely, for PPPs tackling NCDs, a significant proportion of the evaluations were critical of partnership with private sectors for health promotion. Positive evaluations were rarely observed in independent evaluations, and the majority of partnerships with industries that have commercial interests competing with the health promotion activity, did not support PPPs in this area.These findings are important because NCDs continue to rise globally, particularly in low and middle-income countries (LMIC) where globalization has increased availability of tobacco, alcohol and unhealthy foods, and industry activities tend to be poorly regulated . These sOur results show that there is limited evidence proving the effectiveness of PPPs for health promotion, at least in the area of NCDs, and supports the idea that governments should air on the side of caution. Applying this precautionary principle could avoid confusion considering that goal 17 of the United Nations Sustainable Development Goals for 2030 actively advocates for countries to “Encourage and promote effective public, public-private and civil society partnerships, building on the experience and resourcing strategies of partnerships” . EffectiThe proportion of non-independent evaluations was high, and non-independent evaluations more frequently described success of the PPP under evaluation. For example, one paper that explicitly sought to document the effectiveness of PPPs in the area of childhood obesity was funded entirely by the Mondaléz foundation, which includes numerous chocolate and confectionary producers and which also made a payment directly to one of the senior authors for writing the paper . We alsoWe limited the review to material published in scientific peer-reviewed journals, and there are likely to be other relevant documents in grey literature  that evaluate PPPs but they were not included here. Furthermore, there may be numerous initiatives that have been evaluated ad hoc and are never formally reported. We limited our review to peer-reviewed scientific journals assuming these are more likely to be independent, methodologically sound evaluations. Nevertheless, a significant proportion of the studies evaluated were methodologically poor and more than half were written by people related to one of the partners involved in the PPP. Internally-evaluated initiatives, publishing detailed and critical evaluations of the implementation process or monitoring of public-private partnerships may be useful for making operational improvements to new or existing initiatives, but it is clear that a partner who has dedicated time and resources to implementation, is likely to have an interest in demonstrating their worth. Although they can be useful for some endeavours, they cannot substitute the requirement for un-biased independent evaluations that measure indicators related to the effectiveness of the health promotion activity undertaken as it was initially set out.The evaluation of study quality was challenging because the studies used different designs and methodologies. We developed a simple tool that incorporated dimensions from existing guidelines –25, but Regarding the search strategy, we systematically searched two databases using the search term “public private partnerships” OR “public private partnership”. Although it is possible that authors of relevant evaluations may have used different terms , after numerous pilot searches with different terms prior to choosing this strategy, and after reviewing the references of all included articles, we deemed the strategy used to be sufficiently sensitive to identify a large proportion of relevant evaluations. We acknowledge that some papers evaluating PPPs as defined here are likely to have been missed because they used different terminology. This limitation is unlikely to introduce significant selection bias into the study because the terminology used by the authors of evaluations is not likely to be related to their independence, or other characteristics analysed. Therefore, it is unlikely to detract from the main message of the paper related to the lack of independent, unbiased evaluations of the effectiveness of PPPs for health promotion.Lastly, inclusion of grey-literature or unpublished evaluations, would likely increase the proportion of non-independent, poor quality studies but is unlikely to change the conclusion, that there is a lack of sound evidence showing health improvements due to government partnerships with industry for health promotion.In conclusion, there is a lot of activity around the PPPs, and they appear to be widely accepted in spite of the lack of sound evidence , 30. EveAdditional file 1: Text S1. Tool to evaluate the quality of the studies included in the review.Additional file 2: Text S2. List of 36 studies evaluating PPPs included in the review.Additional file 3: Table S1. Details and classification of the 25 PPPs evaluated.Additional file 4: Table S2. Analysis of quality of the 36 studies evaluating PPPs included in the review.Additional file 5: Table S3. Conclusions regarding the public-private partnerships (PPP) for health promotion according to characteristics of the PPP or the evaluation, stratified by health problem.


Cognitive impairments after stroke are not always given sufficient attention despite the critical limitations they impose on activities of daily living (ADLs). Although there is substantial evidence on cognitive rehabilitation benefits, its implementation is limited because of time and human resource’s demands. Moreover, many cognitive rehabilitation interventions lack a robust theoretical framework in the selection of paper-and-pencil tasks by the clinicians. In this endeavor, it would be useful to have a tool that could generate standardized paper-and-pencil tasks, parameterized according to patients' needs.In this study, we aimed to present a framework for the creation of personalized cognitive rehabilitation tasks based on a participatory design strategy.We selected 11 paper-and-pencil tasks from standard clinical practice and parameterized them with multiple configurations. A total of 67 tasks were assessed according to their cognitive demands  and overall difficulty by 20 rehabilitation professionals.alpha values from .918 to .997—we identified the parameters that significantly affected cognitive functions and proposed specific models for each task. Through computational modeling, we operationalized the tasks into their intrinsic parameters and developed a Web tool that generates personalized paper-and-pencil tasks—the Task Generator (TG).After assessing the internal consistency of the data—that is, Our framework proposes an objective and quantitative personalization strategy tailored to each patient in multiple cognitive domains  derived from expert knowledge and materialized in the TG app, a cognitive rehabilitation Web tool. Stroke is one of the most common causes of adult disability, and because of the aging of the population, the number of people having a stroke continues to rise. According to the 2015 Global Burden of Disease study, the total number of stroke events in Europe is predicted to increase by 34% between 2015 and 2035. This increasing number of people living with the effects of stroke results in a growing burden on families, societies, and health care systems. Reducing the long-term disability will help to bring down these costs [Poststroke impairments impact the individual’s ability to safely and independently carry out activities of daily living (ADLs) and to restart prestroke personal, social, and vocational activities. Stroke survivors often express that they feel like a different person, not because of the typical motor sequels but because of changes they suffer in cognitive functions underlying their capacity for language, attention, executive functions, and memory .Currently, rehabilitation following stroke routinely takes a bottom-up approach, with the primary focus placed on motor gait retraining, followed by upper limb rehabilitation and speech and language therapy . ConsequIn a recent James Lind Alliance study, 799 stroke survivors were interviewed about their unmet needs following a stroke, and they reported problems with concentration (45%), memory (43%), and reading (23%) . A high Rehabilitation refers to the act of relearning a previously learned behavior that has been disrupted by brain damage. It involves re-establishing connection weights or synapses within the network, diverting the information by building new connection weights or synapses or activating the neurons that were not previously used . Ben-YisAlthough paper-and-pencil tasks are reliable tools to assess multiple domains of cognitive functioning  , there aThe American Congress of Rehabilitation Medicine conducted systematic reviews on a total of 370 studies about cognitive rehabilitation for people with traumatic brain injury (TBI) or stroke, published from 1971 through 2008 ,22,18. CThe primary difficulty in determining the impact of cognitive interventions on the everyday functioning of healthy older adults is that most trials do not include functional outcome measures ,25. A reOver the past few years, several computer-based solutions have been proposed to increase the availability and quality of cognitive training, flooding the marketplace with commercial brain exercise programs that claim to improve cognition and have diagnostic abilities  such as Despite the proliferation of information and communication technologies (ICTs) in cognitive rehabilitation, only 5% to 15% of people with disabilities have access to technological devices that can assist in the rehabilitation process . In addiTo maximize the benefits of ICTs and to address the above-stated limitations, we developed a new Web-based tool, the Task Generator (TG). This Web tool capitalizes on the solid aspects of existing computerized training protocols for cognitive rehabilitation ,32,39 anThe objective of this research was to propose a systematic and objective design framework that can guide us on the methodology for the development of training tasks capable of addressing multiple domains of cognitive functioning, yet delivering a highly adaptive training program to each patient’s assessed deficits, and showcase its use in a Web-based app for cognitive rehabilitation.We have based our methodology on a participatory design strategy involving rehabilitation experts interworking with the research and development team through interviews, meetings, and questionnaires. In As a first step toward the creation of a repertoire of cognitive training tasks, 3 rehabilitation experts (2 neuropsychologists with experience in cognitive assessment and interventions in stroke and dementia and an experienced rehabilitation technology researcher) documented the currently used methodologies in clinical rehabilitation settings  and collected the most commonly used training tasks, some of them being available as published training material . Of thisAs stated previously, no clear or comprehensive cognitive rehabilitation framework can provide us with general guidelines for cognitive training task selection. In the education field, however, there are multiple frameworks, the Bloom Taxonomy is one of the most relevant ones . Hence, Knowledge (lower level): memory of stories; cancellation; questions of general knowledge; find locations; image pairsComprehension: differences between similar scenarios; categorization; synonyms and antonyms; associationApplication: mazes; problem resolution; tangram; numeric sequences; navigationAnalysis: action sequencing; visual memory; puzzles; word searchEvaluation (higher level): differentiation between coherent and incoherent situations; comprehension of contextsTask Selection process, according to the learning objective’s representativeness and the relevance for ADLs performance, resulted in the selection of the following 11 tasks: word search, problem resolution, numeric sequences, action sequencing, association, cancellation, categorization, comprehension of contexts, image pairs, mazes, and memory of stories.After the identification and organization of the 20 tasks according to their learning objectives, the 3 rehabilitation experts proceeded to a ranking of the 20 available cognitive tasks according to its relevance in the successful performance of ADLs. This It is necessary to identify the relevant tasks to train a specific cognitive deficit (such as attention and memory) to define a proper rehabilitation program, but that is not sufficient. It is imperative also to consider the learner characteristics to design adapted training capable of providing as best as possible a personalized rehabilitation. In our case, the learners are stroke patients with different deficits that need to be rehabilitated through intensive and continuous training. There is then, no one-fits-all training program. There should be a uniquely adapted rehabilitation program for patients according to their assessment of the multiple domains of cognitive functioning. Currently, this adaptation process is generated through tacit knowledge based on the clinicians’ subjective experience—which is essential and results from years of training—but there is no explicit formulation of such knowledge. This implicit knowledge is valid and necessary; however, to generalize, we should be able to transform it in a set of objective guidelines that support the personalization of training to the characteristics of each patient. To obtain such a set of guidelines and an objective way of operationalizing the adaptation in the different cognitive tasks, we followed a participatory design strategy with the main stakeholders.This step had as primary objective to break down each of the 11 previously selected cognitive training tasks and identify their main parameters or variables to quantify their effects regarding demands in different domains of cognitive functioning. For that, we operationalized all tasks into their task parameters  to study their demands in 4 cognitive domains  and for their overall difficulty . The breakdown of the tasks is as follows and is summarized in number of words to find and the existence of clues provided to identify words .Word search: A predetermined number of words can be found up, down, forward, or diagonally in a pool of randomized letters. Words can overlap so that a letter can be part of 2 or more words. This task was operationalized according to the ypes of problems are presented, numeric calculations or calculations based on a textual description of daily activities. Problems vary according to the number of operations involved and the use of numbers with ones or tens.Problem resolution: Here, 2 tmissing numbers  in the sequence, their position in the sequence, and the step size between numbers.Numeric sequences: A numeric sequence is given as a finite sequence of numbers, and the subject must come up with the missing numbers. The task can be operationalized according to the number of number of steps to be ordered and whether the goal of the task is explicitly mentioned or must be guessed.Action sequencing: In this task, a list of randomized steps needed for the execution of several ADLs is presented. The task can be defined by the number of randomized pairs of items. These items need to be paired correctly according to a logical relationship between them.Association: The task comprehends a type of stimulus , the pool size, and their arrangement (randomly organized or in a grid structure).Cancellation: The purpose of cancellation tasks is to find predetermined target stimulus in a pool of distractor stimulus. Thus, we operationalized this task according to the number of categories and the number of items.Categorization: This task consists of organizing different items into their underlying categories. The names of the categories are not given, it must be guessed from the item’s or object’s relationships. The task can be defined according to the some descriptions, with some being incorrect descriptions.Comprehension of contexts: In this task, some images are given with a number of pairs of images are presented to be memorized. They are recalled after 30 min.Image pairs: In this task, size.Mazes: The task consists of a labyrinth type of puzzle through which one must find the way out. The task can be operationalized according to the maze type) and can have several descriptive elements (size) and a variable number of questions.Memory of stories: The task consists of recalling information about a read story or a pictorial scenario by answering questions about it. Stories can be textual or pictorial , task parameters were selected and combined according to what was feasible to implement and could be mathematically modeled. Subsequently, we further involved in this study a total of 20 external rehabilitation experts  from the private and public sectors in the autonomous region of Madeira and mainland Portugal. None of them was involved in the previous steps of the design process. The age range of participants was from 26 to 56 years , and the experts’ experience range was from 2 to 32 years . Participants were 85% (17/20) female.Each of the 20 study participants rated each of the 67 task variants in a 1 to 10 Likert scale according to their assessment of the tasks’ demands on attention, memory, language, executive functions domains, and difficulty. Participants were provided with the questionnaires to be completed within a week and the order in which participants rated the variants, and the amount of time required to complete the 67 of them was not controlled.Cronbach alpha, which reported consistency in the experts’ responses for all tasks , through the multilevel analysis package, which provides tools to estimate a wide variety of within-group agreement and reliability measures and provides data manipulation functions to facilitate multilevel analyses such as the one presented here [Statistical Package for the Social Sciences 20 (IBM SPSS Statistics 20).An analysis of the ratings of the 20 rehabilitation experts’ answers was performed to proceed to the identification of the relevant task parameters and the quantification of their impact regarding cognitive demands via a computational modeling approach. We have used this computational approach because traditional multiple regression techniques treat the units of analysis as independent observations, which is not the case in our study. The computational modeling was performed with the ted here . A descrBy assessing the minimum and maximum ratings per task variant in each domain, we can create a profile for every task, which is graphically represented in The above-reported ranges correspond to the ranges of the tested task variants, which are limited to the parameters described in DV=intercept+C1∗IV1+C2∗IV2+...+Ci∗IViwhere Ci indicates the contribution of each IV to the DV. These models considered a linear relationship with the order that the tasks were analyzed, allowed the slopes of these relationships to randomly vary, and incorporated an autoregressive structure with serial correlations in the error structures.The basic procedure started by examining the nature of the outcome (task difficulty or cognitive load). First, we estimated the intraclass correlation coefficient and determined whether the outcome or DV (task difficulty or cognitive load) did not randomly vary among rehabilitation professionals. Thereafter, we considered only the significant IVs of the model. Second, we examined the form of the relationship between the order of the rated cognitive tasks and the outcome task difficulty or cognitive load. We wanted to know whether there was an order effect of the task’s rating. Third, we attempted to determine whether the relationship between the task order and the outcome or DVs is constant among individuals or whether it varies on an individual-by-individual basis. Fourth, we modeled the error structures such as autocorrelation .P values. AIC is an estimate of a constant plus the relative distance between the unknown true likelihood function of the data and the fitted likelihood function of the model so that a lower AIC means a model is considered to be closer to the truth. AIC does not provide a test of a model in the sense of testing a null hypothesis; therefore, it can tell nothing about the quality of the model in an absolute sense. BIC is an estimate of a function of the posterior probability of a model being true, under a specific Bayesian setup, so that a lower BIC means that a model is more likely to be the true model. Both criteria are based on various assumptions and asymptotic approximations. Hence, AIC and BIC provide a means for model selection. Each, despite its heuristic usefulness, has also been criticized as having questionable validity for real-world data. Our modeling process stopped at the step where the best model was generated according to AIC.The model quality was quantified, after each iteration, through the Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), and (Order) and fourth (AutoCorr) steps of the modeling process.Through the computational analysis, we quantified how the manipulation of the IV impacted the DV. In some tasks and for some specific cognitive domains, it was not possible to model the relationship between IV and DV, which means that some parameter manipulations had no significant effects on the DV. In those cases, the mean rating is assumed in that domain. Task parameters that do not have a significant contribution to either of the cognitive domains or overall difficulty are omitted in the guidelines below. In the following, we present the detailed guidelines for the customization of training. Through raising the number of words, it is possible to increase overall difficulty, memory, attention, and executive functions’ demands. In addition, if clues are given in images, it is more difficult and demanding for memory, attention, and executive functions .The task allows the training of language by presenting the problems through real daily living situations. A higher number of operations and number of digits increase the general difficulty of this task  and 4.The higher the demands for training memory, attention, executive functions, and language, the more the missing numbers, and yet higher if they are omitted at the beginning of the sequence. Concerning overall difficulty, the task is more laborious if the sequence is in descending order and the higher the step size between the sequence numbers is .A higher number of steps are needed to increase the cognitive demands. Also, it is possible to make the training more demanding for attention and language if the task goal is not explicitly mentioned .Augmenting the number of pairs will increase the difficulty as well as the training of memory, attention, executive functions, and language .Memory and attention demands can be increased by using symbols and letters instead of numbers and by having more distractors and targets. For training in the language domain, we should use symbols and increase the number of distractors. By increasing both targets and distractors and using symbols, the task gets more difficult and more demanding in executive functions .Augmenting the number of categories will increase the difficulty of the task as well as the training of memory, executive functions, and language. Concerning attention, besides augmenting the number of categories, we need to have more items per category .The higher the number of descriptions per context, the higher the demands for executive functions, language, and difficulty  and 6.Increasing the number of images to pair will increase the difficulty of the task and the training of memory, attention, executive functions, and language .They can be used to train memory, attention, executive functions, and language. By augmenting the size of the mazes, the cognitive demands and general difficulty are increased .To increase demands for memory, attention, and general difficulty, we need to increase the length of the story and the number of questions about it. To train executive functions and language, increasing the story length is enough .The above modeling effort of the selected cognitive training tasks—selected for their high impact in the realization of ADLs—enables us to create a cognitive rehabilitation program that is precisely adjusted to each individual cognitive domain depending on the specific profile of each patient in terms of memory, attention, executive functions, language demands, and overall difficulty. Our computational approach, thus, captures the implicit rehabilitation experts’ experience and knowledge quantitatively; thus, providing us with explicit models to create an adaptation engine capable of personalizing cognitive training.Still today, paper-and-pencil tasks are the most widely used means of cognitive rehabilitation  because Tasks can be created either individually by directly specifying the values of their parameters  or as a When the patient finishes a set of tasks, the clinician may use one of these 2 procedures:From training session to training session: By scoring the TG task’s performance using a 0% to 100% scale and computing the mean performance of the whole task’s set. If the mean performance is higher than a specific threshold , the clAfter a progress evaluation point: By performing a new assessment of the patient profile. A new set of training tasks is generated with the new assessment following the same procedure stated in the Cognitive Training Program Generation section.Attention parameter can be defined from MoCA’s attention component score (0-6); the delayed recall and orientation scores (0-11) can be used to parameterize memory; executive functions can be parameterized through the sum of the visuospatial, executive, and abstraction MoCA subscores (0-7); MoCA’s naming and the language scores (0-6) can be used to parameterize language; and the total score (0-30) can be used to parameterize the overall difficulty. After the characterization of a patient, through the normalization of these assessment results on a 1 to 0 scale, a full training program is generated by pressing the Generate Training button and then can be downloaded as a PDF file by pressing the Download PDF button. In addition, there is an optional check box in the patient profile page that when selected only generates tasks closely matching the chosen profile. Tasks that would differ substantially from the selected profile can then be filtered out as they can represent nonoptimal task parameter choices. Nonetheless, the user can disable this feature by unchecking the selection box and the TG will generate the complete set of 11 tasks, with the best possible personalization allowed by their parameters.Once a patient is assessed, and the patient’s deficits and cognitive profile are known, the clinician’s challenge is that of adapting the available training tasks to this patient. TG solves that problem by allowing clinicians to quickly generate a complete cognitive training program, containing the whole set of 11 tasks by simply specifying the cognitive profile for a patient in 4 cognitive domains , and the overall task difficulty in a 1 to 10 scale. This can be easily done through the characterization of the patient with validated instruments such as the Montreal Cognitive Assessment (MoCA) . The TG We developed a design framework where we borrowed concepts from educational psychology and a participatory design strategy with stakeholders to support the development process. Through this process, we were able to identify a representative group of well-established standard paper-and-pencil tasks currently used for cognitive rehabilitation, and we operationalized them with respect to their parameters. To that end, the expert knowledge of 20 rehabilitation experts was used to model each task for its difficulty and impact on cognitive functions. The task models obtained provide us with valuable guidelines toward the development of personalized cognitive rehabilitation tools. Furthermore, we demonstrated the proposed methodology with an example case: a Web-based tool for the generation of customized paper-and-pencil cognitive training tasks, the TG. We believe that the TG contributes toward the definition of objective procedures for the application of adaptive cognitive rehabilitation through the use of ICTs. The use of TG has virtually zero cost associated, and it is available in English, Portuguese, and Italian.Recent technological advances have allowed improved apps for cognitive rehabilitation, and it has been shown that they can be effective rehabilitation tools for health professionals . HoweverThe app here presented guidelines in a Web-based tool as the TG also addresses the accessibility limitations because it can be widely deployed at health care centers and home. This new approach does not interfere with current clinical practices because it produces printable paper-and-pencil tasks. By enabling the adaptation of task parameters and difficulty levels according to patient performance, this tool provides a comprehensive and highly personalized cognitive training.Despite the valuable guidelines obtained, via computational modeling, from our participatory design strategy, some limitations of our study must be considered. First, there is a considerable variety of paper-and-pencil tasks being used in cognitive rehabilitation and stimulation practice, and we have selected a small subset of 11 tasks to be possible to parameterize and present them in a questionnaire; however, we are aware it is a small number. Second, concerning the sample of rehabilitation experts, 20 participants can be considered a small number although we managed to include different professionals: physicians, psychologists, and therapists. Third and last, our participatory design strategy was limited in the sense that we did not include subjective and qualitative feedback from the rehabilitation experts, except for one of the physiatrists who was involved in the task selection phase.Although paper-and-pencil tasks are widely used in cognitive rehabilitation, these tools mostly focus on isolated components of cognitive functioning, which have been reported to disagree with everyday life tasks ,48. It hCurrently, we are running a 1-month longitudinal randomized controlled trial comparing both TG and Reh@City v2.0 interventions. This study entails a comprehensive neuropsychological assessment not only pre- and post intervention but also at follow-up, with the aim of comparing the impact of a personalized paper-and-pencil program (TG), a personalized and integrative VR-based program (Reh@City v2.0), and conventional therapy. The main objective of this study was to assess the neuropsychological and functional impact of a paper-and-pencil task and a VR intervention, having the same tasks and parameterization guidelines for comparison. In addition, in this study, we are also addressing the usability of the tool through interviews and questionnaires so that we can improve both tools regarding the patients’ perspective.Many health care providers are unfamiliar with ICTs and, as a consequence, a very small percentage of people with disabilities have access to technological devices that can assist them in the rehabilitation process. To mitigate this issue, it would be valuable to improve the usability of both the TG and the Reh@City by interviewing the health care providers after using them as complementary tools for their work.Moreover, as future work, we are also planning to upgrade the TG app by creating a tablet version that allows remote monitoring by the health care providers and automatic personalization through artificial intelligence and machine learning algorithms.


This past November, over 1,000 nurse practitioners, PAs, pharmacists, clinical nurse specialists, and other oncology professionals gathered at the Gaylord National Hotel in National Harbor, Maryland, to participate in the JADPRO Live at APSHO conference. This meeting was the fourth annual JADPRO Live event addressing the unique educational and professional needs of the advanced practitioner in hematology and oncology. United in Practice, United in Care, recognized the importance of all members of the oncology care team. Taking place only a few miles from our nation’s capital, the conference presentations often featured a collaborative educational approach involving two or more speakers discussing practice-changing information. A frequent topic was the role of the advanced practitioner in providing high-quality and effective care. This role was often highlighted in the context of case studies presented by speakers to the audience. The theme of this JADPRO Live, Journal of the Advanced Practitioner in Oncology (JADPRO) could come together and share their expertise with other advanced practitioners. As Conference Chair of the live meeting and Editor-in-Chief of the journal, I’m very proud of the focused education we’ve been able to bring to the advanced practitioner, including sharing clinical updates and practical information, and the opportunities we provide to promote networking among other passionate attendees of the conference.The concept for JADPRO Live at APSHO came from a vision for a place where readers of the The JADPRO Live meeting also serves another purpose. It is the setting for the annual meeting for the Advanced Practitioner Society for Hematology and Oncology (APSHO). Along with 4 days of live presentations, members share APSHO society highlights and accomplishments of the past year. In addition, APSHO members who are involved in one of the three APSHO committees  convene to review, discuss, and plan the society’s educational offerings, membership opportunities, and communication strategies. At every meeting, members and attendees are encouraged to network and share important practice updates with each other in both relaxed and more formal settings throughout the conference. To disseminate much of the key meeting information to our readers, we’ve gathered the live meeting content in the print journal. In the pages of this very special issue of JADPRO, you’ll find summaries of the main presentations that were given in National Harbor. Our writers have distilled each presentation into its key elements, with the hope of bringing you an overall sense of the meeting. Whether or not you were able to attend the event in person, I think you will find value in this special issue. I hope you will enjoy exploring the critical issues addressing the advanced practitioner in oncology as you read the coverage here. advancedpractitioner.com/sessions) to access full-length presentations recorded at the conference. There you’ll see all of the different learning formats that you can download: full-length video presentations, podcasts, slides, and written transcripts. Choose your preferred format and enjoy the educational offering. Then, follow the instructions to complete a posttest and evaluation and earn your free CE/CME/CEU credits.If you find the following information useful, please visit the JADPRO website (This special issue of JADPRO gives an overview of the kind of educational content you’ll find at any of the JADPRO Live at APSHO conferences. But what you won’t necessarily see in these pages is the excitement and fun and passion that’s evident as you walk around the conference site, in the main session rooms, the preconference workshops, the exhibit hall, the poster sessions, the luncheons and receptions-—anywhere advanced practitioners gather and network with their peers. That energy comes from the feeling of being recognized, respected, and heard. And that’s what attendees tell us they feel at JADPRO Live. Precision Thinking, Practical Knowledge and will address many of the exciting updates in oncology care today. Visit jadprolive.com for more information as it becomes available. See you in Houston!Please join us this fall at the Marriott Marquis Hotel in Houston, from November 2 through 5, to participate in a truly unique educational experience and to network with your peers. This year’s theme is Pamela Hallquist Viale, RN, MS, CNS, ANP—Chair, JADPRO Live at APSHO


Plasmodium falciparum is most prevalent in the Pacific Coast, some regions of the Amazon Basin, and some regions of the Magdalena Basin. Plasmodium vivax is the most prevalent parasite in Colombia, particularly in the Northern Amazon Basin, the Caribbean, and municipalities of Sucre, Antioquia and Cordoba. We find an acute peak of malarial infection at 25 years of age. Indigenous and Afrocolombian populations experience endemic malaria (with household transmission). We find that Plasmodium vivax decreased in the most important hotspots, often with moderate urbanization rate, and was re-introduced to locations with moderate but sustained deforestation. Infection by Plasmodium falciparum, on the other hand, steadily increased in incidence in locations where it was introduced in the 2009-2010 generalized epidemic. Our findings suggest that Colombia is entering an unstable transmission state, where rapid decreases in one location of the country are interconnected with rapid increases in other parts of the country.Determining the distribution of disease prevalence among heterogeneous populations at the national scale is fundamental for epidemiology and public health. Here, we use a combination of methods  to study measurable differences in malaria intensity by regions and populations of Colombia. This study explores three main questions: What are the regions of Colombia where malaria is epidemic? What are the regions and populations in Colombia where malaria is endemic? What associations exist between epidemic outbreaks between regions in Colombia?  Malaria in Colombia has been studied from a variety of disciplines that describe disease patterns with dimensions such as the diversity of the vector , 2, charde novo emergence of human genetic resistance to malaria. On the contrary, the parasite appears to have developed resistance to treatment. Until recently, it was unknown whether observed pathogen resistance was the result of selection of adaptive mutant strains under drug pressure, or the spread of resistant strains , a, a77], aThe approach to test hypothesis is mainly based on the Bernoulli model of the Kulldorff Scan Statistic developed in  using thG of N by N was overlaid onto Colombia’s jurisdictional boundaries and then the set of possible outbreaks is limited to all the possible sub rectangles within the grid.Given the data aggregated by municipality for 2007-2015, each record is assigned to the centroid of the municipality. Because the set of possible outbreaks  is almost unlimited in terms of shape and size, a solution is to approximate this set. In this case, a grid m for each rectangle R contained in G, where m(R) corresponds to an integer and in our specific case, the number of individuals inside the given rectangle. This leads us to assume that there is a rectangle Z contained in G such that each individual inside Z has a probability p of being infected, while the individuals outside Z have a probability q. Let Rn be the number of observed malaria cases inside R, so by assuming a Bernoulli model and the following hypothesis for our unknown variables p and q:Now, under the Bernoulli model we consider a measurement we have these possible distributions:0H:Assuming 1H:Assuming 1H, we have that Z is a region with potential malaria outbreak.And hence, under ss) is defined as the highest density measurements for all subrectangles:Lastly, the third and final step is to establish a measure of density for each subrectangle, in this case the likelihood ratio. This measurement of density has desirable properties to compare different sized rectangles . So, 2525 derivess(R) can be interpreted as the likelihood that subrectangle R is an outbreak.The local measurement ss* under the null hypothesis. Finally, it assesses the value of ss* with the observed data. If p is not greater than 0.05 under the null model, 0H is rejected and we assume an outbreak.To test the hypothesis represented in The main objectives are to determine whether abnormal behaviors are related across municipalities and finding, if a relationship exists, groups of them that have a similar temporal patterns, independent of their geographical layout. To address these matters we turn to Topological Data Analysis (as mentioned in section 2.5).Mapper, introduced in PlasmodiuPlasmodium vivax, while epidemics of Plasmodium falciparum have been less intense, but more frequent (3 years). Control strategies should not only aim to adapt and mitigate to current burdens of malarial infection, but also be prepared for the re-introduction of malaria in locations where it was previously not endemic or epidemic. Such increases are to be expected in areas with sustained and moderate deforestation and without dense human occupation.Our findings also suggest that the epidemic changes of malarial infection in Colombia are complex, comprised of a multiplicity of interconnected trends by parasite and region. This is consistent with the unstable transmission pattern exhibited in countries with rapid reductions of malaria. We observe a 5 year period between peaks of transmission for Plasmodium falciparum was particularly acute among the Afrocolombian population of the Pacific region, while in the Cauca Basin, it constituted an isolated outbreak of the population with no ethnic denomination, while in the Pacific, the outbreak was dispersed among both the Afrocolombian and the indigenous populations.Our findings have potential implications for malarial infection control. First, we found that malaria in Colombia did present different, isolated pockets with distinctive epidemic characteristics. These hotspots play an important role in malaria transmission and when targeted, constitute an efficient way to reduce malaria intensity . FurtherDifferent parasite loads among ethnically and culturally distinct populations constitute the quintessential mechanism of selective pressures that are ideal for the evolution of parasites. The diversity of epidemic characteristics of malarial infection among the subpopulations of Colombia account for an ideal environment for parasite evolution, where plasmodia persist under different pressures of asymptomatic individuals, susceptible classes of ethnically distinct populations, and public health interventions using different anti-malarial strategies. Such diversity provides the necessary conditions, acting as isolated experiments, and then sharing “successful” results, for the emergence of resistant parasites.Second, the patterns of endemicity observed in these populations suggested that prevention efforts should be population specific, and vary according to the epidemic characteristics exhibited by the parasite in the targeted population. Demographic, social and population factors confound studies limited to environmental factors and are also excluded from many studies  and thusTherapeutic failures have been suggested to be correlated with high intestinal parasite loads . The effThird, prevention strategies focusing on populations with endemic malaria would yield a reduction of occupational hazard malaria, since both types of epidemic characteristics exist in the same clusters of malaria, and interact in ways that determine their spatio-temporal epidemic characteristics.Our study was constrained by data availability at the spatial and temporal resolutions we observed for the epidemiological data. We are aware that it would have been ideal to include variables that describe vector ecology, distribution and behavior, pathogen genetic information, climatic variation during the study period, and other sociodemographic information. Further research will show whether including these variables alters our findings. It is possible that such information will improve the ability of the model to correctly identify clusters, or more interestingly, the overlapping of clusters and variables may shed light into ongoing debates, such as vector displacement, for example. Our findings should be cautiously interpreted, but we are confident that they inform policy in a way that few other epidemiological studies currently advise, and furthermore, our findings are complementary to vector, pathogen and epidemic literature, to improve our understanding of malarial infection dynamics in Colombia at a national level, and the way in which such dynamics interact at a regional level.For completeness, we include the malaria incidence extracted from the data in