ACTS secondary to amyloidosis is a very rare situation in the literature, and here, we present a unique case of ACTS secondary to amyloidosis.  A 61-year-old male patient was admitted to our hospital with complaints of numbness in the lateral half of his 1, 2, 3, and 4 fingers of his right hand. These complaints started acutely, and the patient did not have a history of trauma. His clinical examination was suitable for acute carpal tunnel syndrome.  Carpal tunnel syndrome, as well as acute carpal tunnel syndrome, may occur based on different causes. ACTS is very rare, especially when it is not caused by a trauma. Here, we presented a unique case of ACTS based on amyloidosis.  It should be kept in mind when ACTS may occur in patients with the diagnosis of amyloidosis. Amyloidosis is known to be associated with carpal tunnel syndrome (CTS) . AmyloidA 61-year-old male patient was admitted to our hospital with complaints of numbness in the lateral half of the 1, 2, 3, and 4 fingers of the right hand and decreased range of motion which started 1 day earlier and increased in severity. With the in-depth analysis of the patient's, he did not have any similar complaints before. An immunohistochemical examination of the biopsy material obtained from the mass on the right shoulder 1 month before the patient's numbness in his fingers was consistent with secondary amyloidosis.In the physical examination of the patient, active and passive flexions of the fingers were found to be limited and numbness was noticed in the 1st, 2nd, 3rd, and 4th lateral half of the fingers, which is the innervation area of the median nerve. Even though no atrophy was seen in the thenar muscles, it was observed that the palm of the effected hand was hypertrophic compared to the other palm, and the Tinel and Phalen tests were both positive.Because the direct radiographs of the patient were interpreted as normal, MRI was requested for further examination. MRI revealed excessive fluid collection and intense synovitis in the intercarpal, radioulnar, and ulnocarpal joints and surrounding para-articular soft tissue planes at the wrist level. The findings were thought to be compatible with amyloidosis, but rheumatologic diseases could also be compatible with the same findings. Because of this, further investigation has been done with clinical examination and laboratory findings. No rheumatologic diseases has been diagnosed after the investigation.In the patient's EMG, the following are found: (1) The compound muscle action potential of the right median nerve was found to be low amplitude, and the amplitude of the muscle action potential combined with wrist stimulation decreased by more than 50 compared to palm stimulation . Motor transmission speed was low in the palm-wrist segment. Motor conduction studies of the other nerves of both upper and lower extremities were found to be normal. (2) Sensory action potential of the right median nerve could not be obtained. In conclusion, these findings were consistent with acute carpal tunnel syndrome causing axon and myelin damage on the right upper extremity.The patient underwent surgery the day after he presented to our outpatient clinic. Incision has been done in the volar side of the right hand following the palmar crisis, and the transverse carpal ligament was loosened completely; afterwards, biopsy was taken for pathology. The median nerve appear to be swelled. It was assured that the nerve was completely decompressed distally and proximally. Neurolysis was performed after the median nerve was loosened. Diffuse synovial thickening has been observed around the flexor tendons which were hypertrophic . SynovecAccording to the results of the pathology samples sent during surgery, AA-type amyloidosis was detected in the samples taken from the median nerve sheath and from the synovial tissue on the flexor tendons Figures  and 4.The Tinel and Phalen tests were found to be negative, and numbness in the fingers disappeared and finger flexion movements were more comfortable after the operation.The carpal tunnel, which has a constant volume of 5 ml, is surrounded by carpal bones from 3 sides and surrounded by flexor retinaculum from the volar side. The problems occur in the structures passing through this small gap further narrowing the volume, leaving a minimal space for any expansion within the carpal tunnel .Carpal tunnel syndrome develops due to the prolonged and intensive use of the wrist and some systemic diseases such as rheumatologic diseases, diabetes, and amyloidosis. CTS is the most common chronic compressive neuropathy . There aACTS is characterized by continuous pain and numbness along the median nerve track due to the sudden and rapid increase in pressure in the carpal tunnel. The patient complains numbness in the first 3 fingers on the affected side and in the lateral half of the 4th finger.In the rapid process of ACTS, it is very important to make the diagnosis quickly and to plan the intervention early. The sooner the intervention is performed, the likelihood of undesirable conditions such as neural dysfunction, limitation of movement, disruption of microcirculation, and chronic pain is reduced .Local amyloid deposits have been held responsible in CTS cases developing on the basis of amyloidosis, and this is not uncommon. According to Kyle et al., 1500 patients have been operated for carpal tunnel release and 124 of them had local amyloid deposits . In anotThere are currently no guidelines for diagnosing ACTS or managing this process. But we know that early surgery and carpal tunnel loosening are the only ways to achieve good results. In one study, it was shown that patients who underwent surgery within 40 hours after the onset of ACTS symptoms have completely regained normal nerve function from day 4 postoperatively .ACTS is less common than CTS. ACTS usually occurs due to trauma and begins to show serious symptoms within days to hours. Carpal tunnel decompression is always the first-line treatment in ACTS cases, whether trauma-induced or based on another etiology. As in our case, it should be remembered that acute CTS may develop while expecting chronic CTS in a previously diagnosed patient with amyloidosis.


Cardiovascular disease is the leading cause of mortality worldwide, accounting for 13%-15% of all deaths. Cardiac rehabilitation has poor compliance and adherence. Telerehabilitation has been introduced to increase patients’ participation, access, and adherence with the help of digital technologies. The target group is patients with heart failure. A telerehabilitation program called “Future Patient” has been developed and consists of three phases: (1) titration of medicine (0-3 months), (2) implementation of the telerehabilitation protocols (3 months), and (3) follow-up with rehabilitation in everyday life (6 months). Patients in the Future Patient program measure their blood pressure, pulse, weight, number of steps taken, sleep, and respiration and answer questions online regarding their well-being. All data are transmitted and accessed in the HeartPortal by patients and health care professionals.The aim of this paper is to describe the research design, outcome measures, and data collection techniques in the clinical test of the Future Patient Telerehabilitation Program for patients with heart failure.A randomized controlled study will be performed. The intervention group will follow the Future Patient Telerehabilitation program, and the control group will follow the traditional cardiac rehabilitation program. The primary outcome is quality of life measured by the Kansas City Cardiomyopathy Questionnaire. Secondary outcomes are development of clinical data; illness perception; motivation; anxiety and depression; health and electronic health literacy; qualitative exploration of patients’, spouses’, and health care professionals’ experiences of participating in the telerehabilitation program; and a health economy evaluation of the program. Outcomes were assessed using questionnaires and through the data generated by digital technologies.Data collection began in December 2016 and will be completed in October 2019. The study results will be published in peer-reviewed journals and presented at international conferences. Results from the Future Patient Telerehabilitation program are expected to be published by the spring of 2020.The expected outcomes are increased quality of life, increased motivation and illness perception, reduced anxiety and depressions, improved electronic health literacy, and health economics benefits. We expect the study to have a clinical impact for future telerehabilitation of patients with heart failure.ClinicalTrials.gov NCT03388918; https://clinicaltrials.gov/ct2/show/NCT03388918DERR1-10.2196/14517 Cardiovascular disease is the leading cause of mortality -4, accouTo date, telehealth and telerehabilitation in heart failure has focused on systems that use hemodynamic measurements , respiration, weight, and subjective questions to assess the risks of worsening heart failure. The responses are sent to health care providers, who then act on these data. Generally, patients do not see their own data. Instead, they wait for a health care provider to communicate to them on whether their heart failure has worsened . A reviePatients’ preferences and their choice of smart technology in telemonitoring have been assessed in a transatlantic multisite study . PatientThe overall purpose of the FPT study is to develop a telerehabilitation program that helps increase the quality of life of patients with heart failure and educate them to perform individualized monitoring in order to detect worsening of their own symptoms, thereby avoiding rehospitalization. The FPT will be implemented and evaluated in a clinical trial. The aim of this paper is to describe the research design, outcome measures, and data collection techniques used in the Future Patient research project.The FPT consist of three phases: (1) titration of medicine (0-3 months), (2) participation in the FPT at a health care center or call center (3 months), and (3) follow-up with rehabilitation in everyday life (6 months). The three phases of the telerehabilitation program are illustrated in The HeartPortal is a digital toolbox that functions as an interactive learning module; the setup is illustrated in An interactive information site for patient education, containing information on rehabilitation issues, presented in the form of text and short videos (1-1.5 minutes) with patients and relatives describing their experiences with heart failure, symptoms, living an everyday life with heart failure, etc.A communication platform enabling patients to communicate directly with health care professionals. The HeartPortal may be used by health care professionals and patients to collaborate on setting goals and activities, and the patients also have the opportunity to keep an online diary and define their own goals for rehabilitation.Visualization of measured values .Patient-reported outcomes (PRO) data . Every sAs part of the telerehabilitation program, there is continuous monitoring of the patient’s vital signs using technology-enabled devices/equipment. A list of the equipment used is provided below:Blood pressure  is measured every day during phase I.Weight scale  is used only in phase I of the FPT; in phases II and III, patients use their own weight scale. Patients with heart failure measure their weight every day during all three phases of the FPT.Data transmitter  to help transfer data such as blood pressure, day pulse, and weight in a secure form from the devices and to the HeartPortal.Step counters . Patients with heart failure can decide what kind of stepcounter they want to use. Steps are measured every day and transmitted to the HeartPortal.Sleep sensor  measures the numbers of hours of sleep, night pulse, and respiration.A tablet .The patients receive instructions on evaluating their own values and how to react if these values are abnormal. A telerehabilitation coordinator observes all the measured values as well, and during phase 1, the coordinator also acts as a coach, helping patients learn to observe and act on any abnormal readings or worsening of symptoms to avoid possible hospitalization. During phase II, health care professionals also view the data. All health care professionals from the hospital and health care centers have access to the data.There is a strong focus on data and network security in the Future Patient project due to the project’s complexity and the environment where data are generated from both the health system (pulled data) and the patients (pushed data). Based on different endpoints in the setup , the technology used, and the classification of information, the formation of metadata will be addressed via reliable integration encryption and infrastructure reliability.The target group in this study consists of patients diagnosed with heart failure according to the New York Heart Association (NYHA) class I-IV . PatientThe FPT will be tested in a multicenter randomized controlled trial (RCT) using a mixed method  approachThe sample size was defined based on a power calculation. The aim of this project is to increase the quality of life (QoL) using telerehabilitation compared to usual rehabilitation. Based on the official KCCQ guidelines , the powThe FTP program was designed using the self-determination theory (SDT) as a theoretical starting point. With the goal of increasing the effectiveness of behavior change interventions , SDT offThe Future Patient project has been approved by the Regional Ethics Committee (N-20160055) and the Danish Data Protection Agency. The study is listed in listed in ClinicalTrials.gov (NCT03388918). The study is being carried out in accordance with the Helsinki Declaration, and all participants have signed an informed consent form prior to enrollment in the study.Baseline data on demographics, clinical status, primary and secondary diagnosis, NYHA class, and actual prescribed medicines are being collected for both the intervention and control groups . QuestioPrimary and secondary outcome measures as well as the dates when they the data will be collected are shown in QoL is the primary outcome, which is measured using the KCCQ . KCCQ isAll measured clinical data including weight, blood pressure, pulse (day/night), steps, sleep, and respiration in the intervention group will be collected and analyzed.Changes in illness perceptions are being evaluated for both groups using the Brief Illness Perception Questionnaire (Brief IPQ) . The BriChanges in the type of motivation are measured using the Health Climate Change Questionnaire (HCCQ) . The HCCSymptoms of anxiety and depression are measured using the Hospital Anxiety and Depression Scale (HADS) questionnaire . HADS isPatients’ health and electronic health  literacy skills are measured using a Danish validated version of the eHealth literacy assessment toolkit (eHLA)  and the Qualitative exploration of patients’, their relatives’, and health care professionals’ experiences using the HeartPortal will be conducted. Semistructured interviews inspired by Brinkman and Kvale  will be A cost-effectiveness analysis will be based on the guidelines for economic evaluation by Drummond et al . EstimatAll demographic data are being stored in the Future Patient database (FPD). Data from questionnaires are stored in Research Electronic Data Capture software [computer software]  and used for quantitative analysis.All adverse events, including deaths, dropouts, or withdrawals from the study will be recorded and documented. If the patients no longer want to participate in the study, they can withdraw their consent at any time, and the reason for withdrawal will be documented. In this case, the project team will collect the equipment upon request. Patients who do not participate actively in the intervention will still be included in the study and analyzed according to the intention-to-treat approach. These patients will be allowed to retain use of the project equipment for as long as they want. Technical problems with the equipment will be recorded and documented.At baseline, descriptive statistics  will be The analysis of change in QoL, anxiety and depression, self-determination, illness perception, type of motivation, and health and eHealth literacy tests will be performed using data acquired through questionnaires. Comparison of incidence rates will be used to investigate the differences between the intervention and control groups. Two-sided tests and a significance level of 0.05 will be used.P<.05 will be considered significant for all tests.All events from the day after randomization to patient exit will be included, while any other evident outcomes will be measured as changes from baseline to all assessment time points. Changes in the other evident outcomes will be tested using linear mixed models. Linear mixed models allow repeated measures to be collected in a longitudinal design and are superior when dealing with dropouts compared to other methods used for repeated measures. Hence, it will not be necessary to use imputation techniques on missing data. Statistical analyses will be performed using SPSS [computer software] , and values of All interviews will be transcribed into text files by a research assistant. The data will be coded in NVivo [computer software] , with inspiration from the SDT theoretical framework and based on methods developed by Brinkman and Kvale . Two resResults from the RCT will be analyzed in the fall of 2019 and be published in peer-reviewed journals in the fields of telerehabilitation, clinical cardiology, and health economics and be presented at international conferences.The evaluation of the Future Patient Telerehabilitation program includes the clinical data recorded by the patient and psychosocial, health literacy, and eHealth literacy through questionnaires. Qualitative exploration of the perspectives of patients with heart failure, relatives, and health care professionals as well as a health economic evaluation will be conducted. The results from the RCT will be analyzed, and the results are expected to be published by spring 2020.The aim of the Future Patient study is to test, implement, and evaluate a telerehabilitation program for patients with heart failure. The RCT was divided into three phases in the intervention group: a posthospitalization phase, a rehabilitation phase, and daily life adjustment 6 months after rehabilitation. A more holistic approach to patient rehabilitation is introduced on the basis of user-driven innovation, to accommodate the needs of the end user. This was just the first step toward engaging the patient in self-management. The uniqueness of this study lies in two areas: the use of a variety of self-monitoring methods and the use of SDT within a telerehabilitation context. The measurements include activity, pulse, and sleep trackers, which automatically transmit the monitored data to the HeartPortal. The HeartPortal has the potential to facilitate and educate patients in self-managing their disease. In this way, patients can become more engaged in their disease progression. The patient has the option of sharing their data, thus providing the patient’s relatives the opportunity to monitor the progress of the patient through the HeartPortal, which, in turn, enables the relatives to motivate and support the patient according to their progression. The PRO data is a new tool that we will be tested, and we have not identified other studies that are working with PRO data for patients with heart failure.The expected benefit of the health economy evaluation for the telerehabilitation group compared with the control group is increased quality of life, reduced contacts to outpatient clinics at the hospital, and a reduction in admissions to hospitals.The HeartPortal is also designed to enable the patients to improve their eHealth literacy through a combined information platform. In addition, a communication platform has been incorporated into the HeartPortal, from which the patient and his/her relative can communicate with health care professionals, psychologists, and technical personnel. As such, the relative is an important member in this study, as studies have found that support from family and friends benefits patients with heart failure by improving patients’ quality of life and reducing rehospitalizations . AdditioThis study had three limitations that should be considered. First, a subject group consisting of patients with heart failure is highly sensitive to death, as this group is dominated by the elderly . Second,The expected outcomes are increased quality of life, increased motivation and illness perception, reduced anxiety and depressions, improved eHealth literacy, and health economics benefits. We expect the study to have a clinical impact for future telerehabilitation of patients with heart failure.


The ambition of universal health coverage entails estimation of the number, type and distribution of health workers required to meet the population need for health services. The demography of the population, including anticipated or estimated changes, is a factor in determining the ‘universal’ needs for health and well-being. Demography is concerned with the size, breakdown, age and gender structure and dynamics of a population. The same science, and its robust methodologies, is equally applicable to the demography of the health workforce itself. For example, a large percentage of the workforce close to retirement will impact availability, a geographically mobile workforce has implications for health coverage, and gender distribution in occupations may have implications for workforce acceptability and equity of opportunity. In a world with an overall shortage of health workers, and the expectation of increasing need as a result of both population growth in the global south and population ageing in the global north, studying and understanding demographic characteristics of the workforce can help with future planning. This paper discusses the dimensions of health worker demography and considers how demographic tools and techniques can be applied to the analysis of the health labour market. A conceptual framework is introduced as a step towards the application of demographic principles and techniques to health workforce analysis and planning exercises as countries work towards universal health coverage, the reduction of inequities and national development targets. Some illustrative data from Nepal and Finland are shown to illustrate the potential of this framework as a simple and effective contribution to health workforce planning. An adequate, well-distributed and motivated health workforce is central to the achievement of universal health coverage (UHC), and many of the Sustainable Development Goals (SDGs), including health (SDG3), decent work and economic growth (SDG8), gender equality (SDG5) and migration SDG10) [0 [1]. AcDespite the recent growth of the health sector, many countries have insufficient human resources for health (HRH). A supply-based shortage occurs when insufficient HRH are produced (or imported) and retained. A demand-based shortage occurs when a country cannot pay the recurrent costs of meeting the demand for HRH. In many low- and middle-income settings, both supply and economic demand fall short of population needs. It can be challenging to identify suitable methods for understanding the scale and characteristics of a shortage and therefore to devise appropriate policies for addressing it.Demography is the study of the profile and habits of populations, e.g. their age, gender, ethnicity, fertility, mortality and migration patterns . In thisWhile there are a few recent examples of using demographic techniques to study HRH , the conDemographic transition explains the decline from high to low rates of birth and death . CountriCountries in different stages of transition exhibit different patterns of health and health workforce needs and demand. LMICs in pre- and early transition experience high infant, child and maternal mortality  and haveCountries in late transition or post-transition have ageing populations and high rates of chronic and noncommunicable diseases including diabetes and cancer. They require a health workforce with varied specialisms, skilled in the use of technology, and a high level of elderly care. An ageing population—and within it, an ageing workforce—brings with it concerns about the future supply of HRH and their capacity to perform physically demanding work . The gloA commonly used and easily understood demographic analysis tool is the population pyramid, which is a graphical representation of the age and sex composition of a population. Pyramids can help to generate hypotheses about something that changed in the past . They can also contribute to forecasts of how population size and structure might change in the future, e.g. a broad base predicts population growth and a narrow base indicates contraction. This predictive ability can be useful for future planning.Figure The principles of population demography can be applied to the health workforce. The health workforce is a sub-population within the general population, and parallels can be drawn between key demographic events in these two populations. For example, the rate of production of HRH is to the health worker population what the fertility rate is to the general population. Similarly, the rate at which HRH leave the workforce permanently is like the rate at which people die in the general population, and the rate at which health workers join or leave the population temporarily is like the rate of migration in the general population. Age, gender and ethnic or geographic imbalances in the health workforce can bring about challenges in the same way that such imbalances in the general population do.Figure Demographic trends can have direct implications for labour markets through three primary channels: labour supply, productivity and demand . While lIn this section, HRH pyramids for physicians, nurses and midwives in Nepal and Finland are used to illustrate contrasting health workforce demographics. The data sources for the two countries use different age groupings, so a direct comparison is not possible, however, then can be easily compared against the national pyramids Fig. . Also, tCreating population pyramids requires robust data for each health worker category , their gender and their age/age group. HRH disaggregation should also take into account disaggregation by sector, employment patterns (e.g. full time vs part time) and geographical distribution. In this study, the Nepal data were derived from the Ministry of Health’s Human Resource Development Information System (HuRDIS). HuRDIS is a digital record of public sector HRH distribution. A 2012 HRH assessment identified over 50 000 health workers of whom 46% were female . The totThe Finland data are derived from Statistics Finland’s open database of employment statistics  and descn = 1200) and ayurvedic (n = 47) physicians. Allopathic physicians include medical officers, consultants and anaesthetists. Ayurvedic physicians include those educated to a degree level (a 5.5-year Bachelor of Ayurvedic Medicine and Surgery programme). In Finland, this includes all physicians with a current contract of employment (n = 20 121).Using population pyramids, Figs. Several patterns may be observed in Figs. Second, the overall shape of the Finland pyramid indicates a stationary population which is unlikely to change significantly in size in the foreseeable future. By contrast, the Nepal pyramid has a wide base, predicting growth (assuming young physicians remain in the workforce), perhaps due to the recent expansion in capacity for medical education , 17. HowThird, there are small ‘dents’ in the Nepal pyramid: there are relatively few men aged 31–35 and 46–55 and relatively few women in their 30s. It is of course possible that these are due to the incomplete dataset. However, if a country shows such patterns, it is possible to speculate about possible reasons. For example, in Nepal, younger physicians tend to be more attracted to the private sector, which accounts for approximately 40% of health workers , which wFigures Observations can again be made, most notably the gender imbalance, with these occupations consisting mostly or completely of women. The lack of men in Nepal reflects the fact that only women can be ANMs and that, although men may train as nurses, they tend not to. As of 2018, official policy is that 15% of nursing education places are reserved for men . In a world with a shortage of health workers, such losses and constraints represent a significant waste of resources.Given the feminisation of the health workforce, investing increasing resources in HRH can potentially catalyse women’s empowerment and equity and address the gender issues above. To realise these gains, we must first understand the context-specific composition of the health worker population at both national and sub-national levels, using demographic analysis techniques such as those described in this paper.Global Code of Practice [The international mobility of health workers is increasing . Future Practice  shows a A third cross-cutting issue is the ageing of the health workforce. As in many countries, the general population is ageing, so too is the sub-population of health workers. Understanding of the demographics and age distribution of the health workforce is needed to plan future needs, supply and demand, taking into consideration health workforce ageing and retirement. Where empirical data is sparse, demographic methods for estimating entries and exits to a population could be a useful addition to the toolkit. As health workers approach retirement, adequate numbers of new HRH need to be educated, recruited and retained, and early retirements minimised by reinvesting in mature health workers via supportive policies and practices.The study of populations is crucial for health planning. While the existing literature provides evidence regarding populations, their health status and changing health needs and demands, the scientific response to examining the demography of health workers has not yet caught up with the need to understand this evolving and diverse sub-population. This paper aims to contribute to furthering this understanding by suggesting a conceptual framework for studying health worker demography, using data from Nepal and Finland to illustrate the potential of this approach. It complements the existing literature on the socioeconomic impacts of investments in HRH and underlines the need to link these studies with demographic assessments of health worker populations.Simple demographic techniques such as population pyramids do not require extensive statistical expertise but can enhance understanding of the health workforce and thus help examine what policy issues need to be addressed. For example, a drop in numbers among women in their early 30s may suggest a need for policies to address the retention of women with young families. These techniques can also help with medium-term forecasting without the need for complex models, because the shape of the pyramid predicts growth or contraction in workforce size and gives pointers on important issues such as outflows from the workforce in specific age and gender groups. However, these techniques are dependent on reliable data, which are not always easily available.Due to data limitations, our sample pyramids focused on public sector only and did not account for informal workers providing home care. Also, local appointments and graduates on government bonded service are not generally included. Further studies including this disaggregation as well as looking at issues of formally retired (but still active) HRH might be useful to shed further light on the dynamics of health worker demography.Consolidating studies on health worker migration, ageing and gender would also stimulate a critical policy agenda. Policy change on HRH has far-reaching and long-term effects on the health sector, population health and sustainable development. Information on health workforce demography is a cornerstone of health planning and policy, enabling more efficient and effective delivery of health interventions to populations, as well as to global priorities related to the creation of jobs, gender equality and international migration. Using simple analytical approaches, like the one presented in this study, would help public health professionals and development planners to formulate more effective evidence-based strategies as well as creating specific planning tools to implement policies.


Demand for training life scientists in bioinformatics skills led to the development of a train-the-trainer collaboration between the European Molecular Biology Laboratory–European Bioinformatics Institute (EMBL-EBI) and 2 Australian organisations, Bioplatforms Australia and Commonwealth Scientific and Industrial Research Organisation (CSIRO) in 2012. The goal of the collaboration was to establish a group of trained instructors who could develop and deliver short bioinformatics courses nationally. A train-the-trainer course introduces instructors to aspects of andragogy and evidence-based learning principles to help them better design, develop, and deliver high-quality training. Since then, both the number of trainers in the network and the course portfolio have grown. Best practises have been developed and shared between the Australian cohort and EMBL-EBI to address common challenges in bioinformatics training. The Australian trainer cohort undertook a train-the-trainer instructor course, again with EMBL-EBI, and subsequently successfully delivered train-the-trainer courses to interested bioinformatics trainers within Australia. We conclude that a train-the-trainer approach can help build national capacity and maintain a critical mass of trained instructors. PLOS Computational Biology Education paper.This is a In recent years, there has been an inexorable increase in the growth of data production in the life sciences, which has led to a shift in the practise of life science research itself. Applied bioinformatics skills are now essential to the successful analysis of data from high-throughput ‘omics instrumentation. Despite the demonstrated need for bioinformatics skills, bioinformatics seldom occupies a core part of undergraduate life science degree courses. Yet productive life scientists need some degree of familiarity with bioinformatics concepts, tools, resources, and approaches to design and execute their experiments appropriately. This leads many researchers, at all career stages, to seek out point-of-need courses: when the need arises, they seek training in that particular topic to enable them to perform their immediate data analysis tasks.Bioinformatics itself is a rapidly evolving multidisciplinary science that requires biological, statistical, and computational expertise. Technological advances in instrumentation often necessitate the development of new tools and methods. This creates an ongoing need for bioinformatics skills development for bioinformaticians and experimental biologists alike, who need to constantly adapt and learn new skills. The level of demand for bioinformatics training has been increasing in recent years ,2,3.In 2012, despite the high demand for bioinformatics training, there was a shortage of courses and trainers in Australia. Surveys undertaken within institutions confirmed the need for training in a wide variety of topics, driven by the availability of increasing volumes of data . To addrThe TtT programme instructed active bioinformatics researchers in aspects of educational theory and assisted them with the design and subsequent delivery of a course in Australia, using EMBL-EBI training material as a foundation. This work has been previously described .Since this initial TtT workshop, over 30 bioinformatics training workshops have been delivered by the cohort of TtT attendees to 930 researchers in 13 institutions in 8 cities around Australia . Over 20This paper describes the components of the TtT programme and how the collaboration expanded beyond the initial Introduction to Next-Generation Sequencing (NGS) workshop in 2012. The overall success of this programme has led to outcomes beyond the original scope of this programme. In the intervening period, there has been shared learning by all partners in this collaboration. This paper discusses what we have learned and shared with each other and demonstrates how national bioinformatics training capacity was sustainably increased using this model.The TtT model used by this programme incorporated several components: observation and participation in an established workshop; instruction on training theories and methodologies; collaborative content development and delivery; and, importantly, coaching and mentoring from experienced trainers with peer-to-peer support . With thIn March 2012, a group of 8 Australian bioinformatics researchers with an interest in bioinformatics training were selected from Bioplatforms Australia and CSIRO facilities to participate in the TtT programme. The participants were geographically dispersed with varying research interests but were all experienced in the analysis of NGS data. The group attended an established 3-day introductory course at EMBL-EBI on NGS data analysis, where they participated actively and observed experienced trainers delivering the course.The cohort then attended a 2-day TtT workshop, designed by EMBL-EBI, which offered practical guidance on course development and delivery based on educational principles. Many in the Australian group were first-time trainers or had no prior exposure to training theories. As such, it was important to introduce a range of communication and training methods, as well as concepts around different learning styles and preferences. During the TtT workshop, the new trainers reflected on and discussed their experiences from the EMBL-EBI NGS workshop from an attendee’s perspective. The group discussed the elements that contributed to good or bad training sessions, drawing attention to their own learning preferences and how these could influence their training styles.The TtT workshop also addressed practicalities around course design, including defining the target audience and learning objectives, accommodating different learning styles, programme design, and gathering and assessing feedback from attendees. The workshop highlighted how these tools and methodologies could help focus the development and refinement of training content. These lessons were put into practise on day 2 of the course, when the Australian cohort, with EMBL-EBI’s input, developed an outline for an NGS workshop to be delivered upon their return home.The Australian cohort selected core modules, or subsets of topics, from the EMBL-EBI NGS workshop that, from their experience, met the needs of researchers in their own institutes. They then developed a set of learning objectives for the new course, identifying infrastructure requirements and data sources. By the end of the TtT workshop, the Australian cohort and EMBL-EBI faculty had developed an outline for a 2-day Introduction to NGS workshop, using the EMBL-EBI content as a foundation.To maintain momentum, a fixed time frame of 4 months after the EMBL-EBI workshop was set for the first delivery of the new Australian course. The course outline and material were refined and prepared with the aid of regular Skype meetings between EMBL-EBI trainers and the Australian cohort. The course outline was expanded to document which EMBL-EBI material  would be reused to meet the learning objectives of the course, to what extent they would be adapted, and also to develop any new material as needed.As the project involved multiple contributors in different geographical locations, Google Docs was used to share course material and documentation, enabling multiple users to contribute and track changes. With the success of the workshop series and the growth of the volunteer trainer base, in subsequent years a robust reproducible framework for developing, maintaining, and delivering material using GitHub was developed and adopted by the group .As the workshop would be run in several locations across the country, a mode of delivery that would minimise reliance on information technology (IT) staff also needed to be found. As earlier described, a cloud-based solution was chosen .This first Australian course was delivered in July 2012 in Sydney and Melbourne, with the majority of the content being delivered by the EMBL-EBI faculty and the Australian cohort assisting as trainers or as helpers. After these first 2 courses, the Australian cohort reviewed feedback from the EMBL-EBI faculty and the trainees. They reflected on their own experience of having participated as training assistants and determined how to further adapt the material for the local audience. This led to alterations to the course before it was run next, later in 2012. Most notably, this included the addition of an introductory command line session. Continual evaluation of the feedback from later workshops led to the course growing from the initial 2-day workshop to a 3-day workshop.The TtT programme was fundamental to the successful development and delivery of the Australian Introduction to NGS course. The programme taught practical aspects of course design and delivery whilst giving the new trainers access to established training materials. It introduced formal training methodologies and allowed trainers to put their learning into practise within a short time frame, with expert support. The additional postcourse coaching and mentoring also reinforced the concepts that they had learned, providing them with the confidence to deliver the material themselves.Feedback from the Introduction to NGS workshops indicated that there was considerable demand for workshops in other bioinformatics analysis topics. However, with only 8 volunteer trainers, the network was underresourced to fulfil this demand. To deliver a bioinformatics workshop, trainers were required to take time from their research to travel and teach, attend preworkshop teleconferences to discuss required updates, and assist with the maintenance of the material and training platforms. Therefore, to meet the community's needs, the Bioplatforms–CSIRO training portfolio and network was expanded through TtT programmes at EMBL-EBI and The Genome Analysis Centre  .As with the initial NGS workshop, subsequent courses were adapted from existing workshops to meet Australian researchers’ needs and a broader audience. As such, introductory content was often expanded, and complex or specific exercises were removed. The trainers also added datasets relevant to the Australian research context and materials from their own training portfolio.Following these 4 TtT courses, the course portfolio had expanded to 7  in respoAs the Bioplatforms/CSIRO training portfolio and network grew, the EMBL-EBI and Australian teams continued to engage in practical, technological, and evaluation strategies to support both the training programme and the trainers. EMBL-EBI shared further in-house processes for trainee selection and expectation management and impact evaluation, including gathering long-term feedback. Similarly, the Australian cohort shared their own training experiences, feedback, and observations with EMBL-EBI so that they in turn could assess the impact of their TtT courses and inject new ideas into current course offerings.It became apparent that there are common issues associated with delivering bioinformatics training courses to diverse audiences in different contexts. These included inspiring, enthusing, and keeping participants engaged; gaining useful feedback on whether learning is taking place; and defining methods that actually work for training delivery. In this collaboration, we shared efforts to meet and overcome these challenges through development and solidification of best practises. These issues are common among trainers worldwide. Working with EMBL-EBI raised awareness among the trainers from Australia of international initiatives to address common challenges in bioinformatics training. This led them to participate in and directly influence international bioinformatics training initiatives including the Global Organisation for Bioinformatics Learning, Education, and Training (GOBLET ), the InIn addition to drawing on EMBL-EBI’s expertise and training support, the Australian team adapted or developed practises required to run their workshops in a local context, which were constantly reviewed to ensure that they met the needs of the trainers and trainees. Ultimately, these also influenced how EMBL-EBI delivers its own training. For example, some tutorial example datasets used in the Australian workshops were shared with EMBL-EBI and subsequently used in EMBL-EBI workshops.The road show format of the workshops and the distributed trainer network necessitated the development of innovative solutions for sharing course material, developing it collaboratively, and delivering courses with minimal overhead for host institutions ,6. The ABioinformatics training courses require sufficient compute resources, successful installation of multiple tools, and availability of reference data. A cloud-based training platform was developed that served a number of purposes: it addressed the need to minimise preparation for IT administrators at host institutions, provided a consistent software environment for all trainees, provided a storage solution for reference and test datasets, and enabled course participants to access a virtual machine (VM) on the cloud after the course, thereby enabling them to reinforce their learning.Furthermore, early experiences with the Australian NGS course indicated that there was demand for a stand-alone RNA-Seq course using several components of the NGS course . Modularising the course into discrete topics, such as alignment and RNA-Seq, meant that it was possible to design bespoke courses from the content that had already been developed by the team. Each module was further broken down into 4 components necessary to rerun a workshop reproducibly: tools, data, manual, and presentation material. This modularisation allowed a ‘mix-and-match’ approach, allowing trainers to select short or longer courses depending on local training needs .Bioinformatics training courses are not static and need updating with technological advances. With some courses that were run less frequently , EMBL-EBI trainers shared updated materials and their latest example datasets before each new iteration of the course.The development of the TtT programme with the Australian bioinformatics community was EMBL-EBI’s first move towards developing a formal TtT programme for both an external and an internal audience. The programme has developed significantly since its initiation in 2012 on the basis of feedback from the organisers and participants of the initial courses, allowing greater emphasis to be placed on certain elements of the training and how best to deliver to, and inspire confidence in, the new trainers.www.cabana.online) is building bioinformatics training capacity throughout Latin America, using a modification of the TtT model initially developed for Australia.Since this collaboration started, TtT courses have been delivered with a number of communities who were looking to further develop training capacity, enabling a focus on specific subjects as the start point for that development. For example, the Capacity Building for Bioinformatics in Latin America (CABANA) project .In May 2016, a community survey by the Australian Bioinformatics and Computational Biology Society (ABACBS) education subcommittee found a strong interest in participating in a TtT workshop as part of the ABACBS/GOBLET Best Practices in Bioinformatics Training workshop, which was being held in conjunction with the GOBLET Annual General Meeting (AGM) 2016 and the ABACBS 2016 national conference (https://carpentries.org/). The 6 sessions covered (1) an introductory session explaining the approach to the TtTI course and course structure and addressing trainee questions; (2) the elements of good versus bad training and trainers; (3) reviewing how people learn; (4) defining learning objectives and using them to design sessions and courses; (5) assessment and gathering feedback; and (6) a final wrap-up session to address any questions or clarifications arising from the course.A TtT instructor (TtTI) course was initiated, developed, and delivered by EMBL-EBI, with members of the Bioplatforms/CSIRO network of trainers as instructors in training. Eight members of the training network volunteered to participate in a TtTI course. Participants were coached remotely to deliver existing TtT material through a series of 6 webinar sessions in September and October 2016. This training material was based on the ELIXIR EXCELERATE TtT programme , which iTo maximise the coaching time, materials were shared beforehand so that the instructors in training had an opportunity to review them and prepare questions. Additional background material was provided for greater understanding of the theoretical background behind the presentation material. In the coaching sessions, the presentation material was reviewed, and activities for instructors to facilitate discussion of these concepts to trainees were explored. Approximately 30 minutes of each session was dedicated to questions and answers, which gave instructors in training the opportunity to delve deeper into the material with the coach.The support and experience of EMBL-EBI was of considerable benefit to the instructors in training, who drew on this knowledge during the formal coaching sessions. Prior to the TtT course delivery day and having reviewed the training material, an additional coaching question-and-answer session was held to boost trainers’ confidence and to clarify any further questions from the instructor trainers. Whilst the instructors in training still felt some trepidation, they felt well prepared to deliver the TtT workshop by the end of the TtTI course. Although the TtTI course contains elements of educational theory, its main focus is on the practical elements of teaching people in a workshop setting. All the instructors in training had lots of experience, and that was as valuable as the basic theory. In essence, the TtT course focusses on individuals making practical changes to the way they do things.The GOBLET/ELIXIR TtT course was held on Nov 4, 2016, with 15 trainees, the majority of whom were already experienced trainers. As the focus of the TtT course is on sharing experiences and ideas, a group of this size easily allows these discussions to happen and be managed by the instructors.There was no selection process for the course, but all participants were sent a survey prior to the course to detail their experience of training to date and their expectations in attending. This enabled the instructors to gain a better overview of the prospective attendees and enable them to prepare to meet certain expectations. This exercise also helped the trainees prepare, getting them to think about the experiences and ideas they could share and what kind of support they were looking for within their own training practise.The course was delivered by 4 of the 8 TtT instructor trainees, with 1 trainer being responsible for each of the 4 main topics in the course.Directly after the course, an anonymous feedback survey was conducted about the organisation and content of the course, whether the trainees felt that they would use the material in their future training activities, open questions about best and worst parts of the course, and any requests for additional course content.Despite the fact that many attendees were active trainers themselves, the feedback was overwhelmingly positive, with all attendees indicating that they had gained something from the course. One hundred percent of attendees stated that they would use what they had learned in future courses and also indicated that they would recommend the course to others. Attendees in particular enjoyed the interactive and collaborative format of the course and learning from the experience of others.As a number of course attendees had some training experience and may naturally already be undertaking some of the recommendations in the TtT, the course content provided them with an opportunity to reflect on their own training practise and incorporate tips and tricks from other participants. Despite their experience, attendees commented on how the TtT course had made them look at how they train in a very different light. Knowing that they need to structure their lessons and exercises in different ways to cater to individuals’ different learning styles and considering how writing learning objectives would help them to communicate what a lesson or course will cover resonated strongly with them.Following the success of this course, a TtT workshop was again delivered at the ABACBS national conference in November 2017 to 5 attendees. To date, a total of 20 new Australian trainers have been trained by the Bioplatforms/CSIRO instructors, enabling further growth of the national cohort of trained bioinformatics trainers, bringing the total of Australian trainers who have been part of this programme, at EMBL-EBI or in Australia, to 42.Feedback on the benefit of the TtTI course from the new instructors who delivered the course indicated that the course provided them with a useful refresher on the TtT course content, a greater knowledge and appreciation of the course topics, a framework by which to share their experiences, and the confidence to deliver a TtT course . None ofTrainers also noted that when attending a TtT course as trainees, they focussed on the ‘how’: how to apply what they were learning to the course they would design and teach. They felt that the TtTI course focussed more on the ‘why’: why we teach these topics in a TtT course, why it matters to trainees, and ultimately why it makes a difference to the attendees of the courses they will deliver. This was similar to their own experiences teaching technical topics to bioscientists, such as quality control of NGS data. They know this topic well but don’t necessarily have either the need or the time to share all of that knowledge with attendees for the attendees to learn about this. However, without this deep subject matter knowledge, they felt that they would fall short on teaching the topic and that consequently the TtTI course provided that knowledge to them. In this context, the TtTI course provides attendees with the best way to impart their skills to attendees.There was also a greater appreciation among the new instructors of what the original TtT courses they undertook gave them. For example, the instructors remembered not particularly enjoying having to write intended learning outcomes for the course that they would create in their TtT course and found it a very difficult task. However, with course design, teaching, and TtTI experience behind them, they had a newfound appreciation for why this exercise is essential and now appreciate that it is fundamental in framing the scope and indeed the limits of the course based on the audience that you are aiming your course at.The TtT model, successfully developed in 2012 between an Australian trainer cohort and EMBL-EBI, has been expanded to increase the course portfolio and the network of trainers in Australia who have undertaken the TtT programme. The TtT model takes a group of bioinformaticians with subject matter expertise, enthusiasm, and ability to learn and trains them in aspects of andragogy and good course design, followed by subsequent mentoring and coaching and an opportunity to put what they have learned into practise shortly after completion of the TtT course. Twenty-two Australian trainers have been trained in this way by EMBL-EBI, and almost 1,000 trainees in Australia have attended a variety of courses, using EMBL-EBI training material as their foundation, delivered by this group over a 5-year period.On participating in a TtT workshop in Europe, the Australian trainers agreed to volunteer to deliver a minimum number of workshops nationally for the Bioplatforms/CSIRO programme. All 22 trainers met that requirement. In many cases, these trainers also participate in developing and delivering these or other workshops within their own institutions or local communities, as supported by their workplace. The TtTI initiative enabled another 20 Australian trainers, not associated with either Bioplatforms or CSIRO, to undertake a TtT workshop that they could then apply to their own training. Those trainers are, to our knowledge, still involved in training at their own institutions or in local communities.The TtT training and mentoring provided this cohort with confidence and assurance and also a streamlined guide to developing and updating material. Without the opportunity to attend an EMBL-EBI course and subsequent trainer training, it is highly unlikely that they would have come together to develop a course such as this without the focus that this opportunity gave them.Outcomes beyond the scope of the initial collaboration have been achieved . What beThe TtTI initiative enabled a new group of Australian trainers to benefit from a TtT course and in doing so enabled the Bioplatforms/CSIRO trainers to reinforce their own learning and reflect on their own practise. This allowed not only independent capacity building but also local community building in the Australian training network.With a TtT workshop delivered at the national bioinformatics conference in 2 consecutive years, the total number of Australian trainers who have benefited from this programme is 42 over 5 years, substantially increasing the national bioinformatics training capacity. Having a larger pool of trained trainers increases sustainability of training capability nationwide and minimises impacts from trainers moving on to new roles and being unavailable to train.Identifying common issues faced by trainers in delivering training to diverse audiences helped the collaboration become more of a shared best practises effort. Each group shared their solutions to particular challenges they faced in evaluation of learning, identification of suitable test datasets, training delivery, sharing content with other trainers, content maintenance and updating, and trainee engagement. This led to involvement with global professional bodies for bioinformatics training and engagement with other training consortia meant that both groups could contribute to initiatives to address these challenges.The demand for bioinformatics and data science training in the life sciences continues ,2,3, andS1 Table(DOCX)Click here for additional data file.


European Union (EU) legislation states that the routine tail docking of pigs should not be carried out and that manipulable materials should be made available to all pigs to prevent tail biting and allow them to behave naturally. However, between 90 and 95% of pigs within the EU still have their tails docked to avoid the risk of tail biting. Farmers say they require information tailored to their particular production systems before they abandon this practice. In this study, four types of enrichment materials used in Spanish pig fattening production systems are compared. Most of these systems have fully slatted floors and high external temperatures for considerable periods of the year. The effects of chains (the control group), wood, paper or straw in a rack on the behaviour, health/physiology, performance and meat and carcass quality are evaluated. Straw in a rack was found to be the best material to meet the behavioural needs of pigs, whereas paper met the criteria of being manipulable, but only for a short period. To avoid the risk of blockages in the slurry system, there are some practical issues to consider and improvements to be made to the design of the rack for providing straw used in this study.P < 0.001). Skin lesions and redirected behaviour were lower for pigs with S . The pigs offered S presented lower CgA after no fasting than pigs with P or CH (P = 0.055). Lactate was higher in pigs with W and CH treatments, regardless of fasting (P < 0.05). The N:L ratio increased over time (P < 0.05). No other significant effects were found. Overall, straw in a rack was the enrichment material that enhanced pig inherent behaviour.Some positive effects regarding the use of enrichment material on the stimulation of pig exploration and a reduction in redirected behaviour was reported. This study aims to evaluate the effects of four enrichment materials on the behaviour, physiology/health, performance and carcass and meat quality in pigs kept in Spanish production conditions. Ninety-six male pigs (six pigs/pen) ranging from 70 to 170 days old were used. Chains were used for the control group (CH), and wooden logs (W), straw in a rack (S) or paper (P) were also used. The pigs were subjected to two pre-slaughter treatments: 0 or 12 h of fasting. Their behaviour was observed for 12 weeks using scan and focal sampling. Samples of the Neutrophil: Lymphocyte (N:L) ratio and lactate were obtained from the pigs at 66 and 170 days old. Saliva samples for Chromogranin-A (CgA) were obtained at 67, 128, 164 and 170 days old. The weight, skin lesions and feed intake of the pigs were recorded. S triggered more exploratory behaviour than W and CH ( Environmental enrichment has been defined as the improvement in the biological functioning of captive animals resulting from modifications to their environment . EnricheThe current European Union (EU) Directive for the protection of pigs  stipulatIt has been suggested that the availability of enrichment materials, especially straw, may increase the general activity, reduce stereotypes and increase the social interactions of the pigs ,13. MoreThe aim of this study is to evaluate the effect of four different types of enrichment material, feasible to implement in Spanish pig housing and climate conditions on: (1) behaviour; (2) physiology and health indicators; 3) productivity and (4) carcass and meat quality, in fattening docked pigs. The four criteria suggested by Van der Weerd and Day . However, in this study the enrichment was provided as point source objects and, therefore, small differences between the different types of material were expected in relation to the risk of disease dissemination. There were no differences found in the neutrophil/lymphocyte ratio between treatments, only a significant increase over time in all treatments. Several studies have shown that increasing corticosteroids because of stress results in a redistribution of white blood cells involved in the immunological response, such as an increase in neutrophils (N) and a decrease in lymphocytes (L) . For thiCgA is an acidic soluble protein stored and co-released with catecholamines to the blood from the vesicles of the adrenal medulla, the sympathetic nerve endings ad neuroendocrine tissues . SalivarThe pigs in this experiment were also subjected to different pre-slaughter fasting times (0 and 12 h). The lack of on farm fasting has been described as a stressor  and was ® assessment protocol and are said to be a proxy indicator of aggression [Body lesions are included as one of the parameters assessed for the criteria of ‘good health’ in the Welfare Qualitygression . An integression ,14,17. HIn this study, no differences were found in either the performance parameters or the quality of the carcass and meat between the four types of enrichment materials. Some objects like chains, balls, metal bars, nutritious objects or cloth strips have been reported to have no influence on productivity in grower finishing pigs, which is in keeping with our results ,36. On tOn the other hand, there were no major differences found in this study between the different enrichment materials when it came to carcass and meat quality, which concurs with previous investigations ,37. HoweRegarding the cost of the treatments, straw in a rack requires the highest investment and maintenance cost. It is estimated that a mean quantity of 30 g per day per pig of straw was used. This is higher than the quantity of 8.3 g per day per pig reported in a recent study for chopped straw . The samThe chain enrichment was chosen for the control group in this study (chain is not appropriate on its own) or because if proven to work, a combination could be easily implementable on Spanish pig farms. Of the four materials tested, paper seemed to trigger pigs’ interest, but only for a short time and providing paper more often would be time consuming for farmers. Another concern in relation to newspaper regards the potential toxicity of the ink. As paper is commonly used in some farms, it was used in this study to obtain more information and there appeared to be no detrimental effect on productivity. Chopped and pelleted newspaper has previously been considered safe as animal bedding . MoreoveStraw in a rack is the material found to enhance more species-specific behaviour, such as exploratory behaviour towards the enrichment. In addition, the pigs provided with straw presented with the lowest percentage of redirected behaviour. Chains presented a more pronounced reduction in pigs’ interest over time when compared with straw. Paper was only available for a short period after it was provided, and the percentage of redirected behaviour, either towards the pen or to other pen-mates as well the values of CgA in saliva tended to be higher. No major health problems could be attributed to any of the enrichment treatments. Pigs offered straw presented with a lower increase in CgA levels when subjected to a more stressful pre-slaughter treatment (no fasting) when compared with the pigs provided with chains and paper, potentially indicating a greater capacity to cope with this stressful condition. Lactate levels were found to be lower in the pigs in the straw and paper treatments, the ones in which pigs presented with higher levels of on farm activity, which may have allowed them to cope better with physical stress. Skin lesions were lower for the pigs in the straw treatment compared to pigs offered paper, who also had a higher percentage of negative social behaviour. The cost of providing any of the enrichments in this study was not that expensive, although the straw in a rack had a higher labour cost and management expenses. In this study, the economic benefits of providing any of the enrichment materials tested would have to be linked to the potential advantages for animal welfare, because no positive effects on performance or meat quality were found. To summarise, straw in a rack proved to be the best option from an animal welfare point of view. However, some design aspects need to be improved, such as adding a tray to collect the spare straw, to avoid the risk of blocking the slurry systems. It is important to note that the overall welfare status of the pigs in these experimental conditions was good which may have balanced out any differences between the enrichments provided.