The epidemiology and ecology of West Nile virus (WNV) have not yet been completely described. In particular, the specific roles of climate and water in the landscape in the occurrence of human WNV cases remain unknown. This study used Poisson regression to describe the relationships between WNV cases and temperature, precipitation, and the hydrogeography of the landscape in New York State from 2000 to 2010. Fully adjusted models showed that hydrogeographic area was significantly inversely associated with WNV cases (incidence rate ratio (IRR) = 0.99; 95% C.I. = 0.98–0.997, p = 0.04), such that each one square kilometer increase in hydrogeographic area was associated with a 1% decrease in WNV incidence. This association was independent of both temperature, which was also associated with WNV incidence , and precipitation, which was not . While the results are only suggestive due to the county-level aggregated data, these findings do identify a potentially important surveillance signal in the landscape epidemiology of WNV infection. Culex mosquitoes and passerine birds have been fairly well established as the primary vectors and reservoir hosts, respectively Culex vectors are different east and west of the Mississippi River, with Culex pipiens being the primary vector in the east, and C. tarsalis being the primary vector in the west C. pipiens in the east and C. tarsalis in the west C. pipiens. As such, these birds are fundamental to the disease ecology of WNV in the northeastern part of North America West Nile virus (WNV) was introduced into the United States during the summer season of 1999 in New York City. The virus was able to establish itself in each of the 48 contiguous states by 2005. Indeed, all the contiguous states other than Oregon and Washington were reporting human cases by the 2003 season All incident cases of WNV in humans were obtained from the New York State Department of Health by county for each of the years from 2000 through 2010 Climate data were obtained from a monthly surface data product from the National Climate Data Center, which manages meteorologic data products for the National Oceanic and Atmospheric Administration Mean monthly temperatures were also recorded for each of the 11 years from 2000 through 2010. Given the obvious problem of temperature variation by month, but the potential residual impact of higher temperatures overall throughout the WNV season, this study took a unique approach to quantifying temperature. Rather than creating discrete panel temperature data for each month, a monthly-weighted cumulative measure of temperature was used to represent the mosquito and WNV seasons as a whole from May through October. The mean temperature for each month from May through October was multiplied by its weighting factor, which consisted of the proportion (ranging from 0 to 1) of that month's temperature's estimated contribution to the overall occurrence of WNV in humans throughout the season. The relative importance of each month's temperature to the collective season's WNV occurrence was determined by the average distribution of heat across each month from May through October. Hotter months were weighted higher because of their relative importance for mosquito development and for WNV transmission. The specific weighting is as follows: the mean temperature for May was multiplied by 0.05, the mean temperature for June was multiplied by 0.15, and July, August, September, and October mean temperatures were multiplied by 0.3, 0.3, 0.15, and 0.05, respectively, and are depicted in the equation below:Hydrogeography data were obtained from the United States Geological Survey National Hydrology Dataset i. Moreover, panel data allow for both a temporal and spatial designation of the observations, thus they are fundamentally multidimensional data. With the application of random effects models, each case at time i and space j can be considered as the outcome of a random process. Poisson regression models count data, which are assumed to follow a Poisson distribution. This is a probability distribution of events observable in discrete intervals of time and space. In the current study, the Poisson regression is modeling the annual counts of human infections per the total county population, and therefore estimates the incidence rate. As such, incident rate ratios are reported in the results. Total seasonal precipitation, seasonal temperature, and hydrogeographic area all demonstrated bivariate associations with WNV cases and were subsequently included in an adjusted Poisson model as independent variables. The number of WNV-infected dead birds each year was also associated with the number of human infections per county. An additional aim of this study was to explore whether the associations between climate and hydrogeography factors and human WNV cases may be mediated by the extent of bird infections per year. Mediation cannot be adequately assessed simply by adding the purported mediator to a regression model and examining the change in regression coefficients of the model predictors whose effects are hypothesized to be mediated. To more appropriately assess the potential mediation of climate and hydrogeography by bird infection, instrumental variable regression was applied with hydrogeographic area and precipitation as the specified instruments, once again in regression analysis that accounted for the county and time panels inherent in the data.Random effects models were fit using Poisson regression for panel data and the results used to identify the associations between the hydrogeography and climate factors and human WNV infection per county across the 11 years of WNV surveillance. These panel data are longitudinal data, wherein instances of observations can be conceptualized as discrete time points at each time, Finally a map was constructed to show the spatial fit of hydrogeography and climate factors as predictors of WNV cases. A simple approach was adopted by adding just two layers to the map. The first layer is a monochrome choropleth of the predicted cumulative incidence of WNV from 2000 to 2010. The second layer overlays the choropleth with graduated symbols representing the actual number of observed cases per county over the same 11 year period.xtpoisson and xtivreg command procedures, respectively .ArcGIS was used for all mapping procedures and for calculating the Moran's Index to identify whether spatial clustering of the residuals was present (ESRI), and STATA v.11 was used for the Poisson and instrumental variable regression modeling, both specific to panel data, with the During the 11 year period from 2000 to 2010, 457 human cases of WNV occurred across the state of New York. These cases were distributed across just 29 of 62 counties (47%), ranging from 1 to 128 cumulative incident cases per county. New York State has a cumulative surface water area of 2619 square kilometers. The median hydrogeographic area across all counties is 40 square kilometers, but these counties also demonstrated considerable hydrogeographic variability, ranging from less than two square kilometers to 421 square kilometers.When these relationships were considered together in the adjusted Poisson model, the associations remained between WNV and hydrogeographic area and between WNV and temperature, but not between WNV and precipitation . For eveThis report found strong independent associations between WNV cases and both climatic and hydrogeographic factors across 11 years of observance in New York State. Specifically, increasing precipitation was significantly associated with decreasing WNV cases, but not after considering the amount of surface water in the landscape and temperature. Conversely, increasing hydrogeographic area was significantly associated with decreasing WNV cases independently of both precipitation and temperature. Temperature was consistently positively associated with WNV cases having adjusted for both precipitation and hydrogeography. Moreover, the association between water in the environment and human WNV infection may be mediated by birds during the same years. It should be stressed that these findings cannot be interpreted as causal, but they do suggest the possibility for an important relationship between hydrogeography and climate in the complex epidemiology of WNV infection.Culex mosquitoes transmit WNV in North America. Culex pipiens is the most important WNV vector in the northeastern United States in general, and in New York in particular. This mosquito, as with all mosquito vectors, requires water to complete its life cycle, and it prefers standing water containing organic material. The pregnant female ovipositions on the water's surface, and the larvae feed and develop under the water's surface. Subsequently they pupate and eventually emerge as adults C. pipiens' preferred hosts: passerine birds. These birds also require abundant water in the landscape for their survival. Because the passerine birds are the preferred hosts of the mosquito vectors in the northeast, the vectors do not typically pursue human hosts when these birds are present in adequate numbers C. pipiens with an adequate natural host population. On the other hand, those landscapes with less hydrogeographic area may be more sensitive to local precipitation. As such, periods of low precipitation may correspond to reduced (i.e. dispersed) bird populations, because there is less water in the landscape when there is less precipitation, and thus the need for C. pipiens to seek alternative hosts. This report cannot, however, support or refute this specific ecology as an important etiologic pathway in the landscape epidemiology of WNV. Nevertheless, this report does agree with the two studies that have shown hydrogeographic features to be important in determining C. pipiens abundance in the landscape and its capacity for West Nile transmission The inverse relationship identified in this report between precipitation and WNV in humans has been documented before. Outbreaks are being increasingly identified in concert with dry seasons of low precipitation Culex and birds species, and the physical landscape, may converge toward very different disease ecologies in the western US This study has some important limitations. The outcome and explanatory variables are all aggregated at the county level. As such, the specificity of the described associations is diminished and the resolution of the ecologic and epidemiologic picture is necessarily coarse. Undoubtedly, more localized, microgeographic phenomena with respect to water in the landscape will influence the transmission of human WNV, as well as modify the influence of birds as described above. Since this report did not address such localized features, the results are only suggestive, not conclusive. Furthermore, any direct causal claims would require a controlled experimental design involving randomized selection of mosquito and bird species georeferenced precisely with the hydrogeography of the landscape, and in close observation with the intra- and interseasonal variation in temperature and precipitation. Moreover, human cases of infection would also need to be georeferenceed in the same way such that the microgeographic covariation between these variables and human WNV infections may be better qualified to capture the true influence of these factors on human infection. Finally, the results described in this report are limited to the northeastern United States. It has been suggested that the virus, the relevant In conclusion, this study identified a unique association between WNV occurrence and the hydrogeographic area of the landscape that is independent of precipitation and temperature. This is the first time this association has been documented as a potential component of the landscape epidemiology of WNV in the northeastern United States. This epidemiologic feature may result from aspects of bird ecology that affect mosquito host-seeking behavior, however, the data in the current study are too limited to posit a bird mediator in the causal pathway. In addition, given the nature of the county aggregated data, this investigator is wary of drawing any causal conclusions with respect to water in the landscape. Instead, this study serves as a surveillance instrument that has been used to identify a potentially important signal with respect to the hydrogeography and landscape epidemiology of WNV transmission. This report does not purport to define etiologic pathways in this transmission, but rather suggests follow-up surveys of mosquito and bird populations, and human WNV cases, in areas both proximal and distal to large bodies of water in the landscape.


Nurses have a crucial role in patient education of children with type 1 diabetes, but they often exhibit lack of knowledge of the patient education process. This study aimed to describe an educational program to enhance empowering patient education process for the blood glucose monitoring education of school-age children and nurses’ perceptions of using empowering techniques.An empowering patient education process for the diabetes education of school-age children was developed. The researcher collected nurse’s perceptions of managing the educational program by semi-structured interviews. Ten nurses carried out the diabetes education, and 8 of them participated in the interview. Three nurses implemented the diabetes education twice and were interviewed twice. The data consisted of 11 descriptions of the blood glucose monitoring education. The interviewer analyzed the data deductively and inductively by content analysis.Nurses described successful managing of the empowering patient education process. The need assessment consisted of using multiple methods and clarifying the capabilities and challenges of children and their parents. Planning manifested itself in adequate preparation and multiple objectives stated together with the family. Implementation comprised the relevant content, and the use of suitable teaching materials and methods. Evaluation was performed with various methods and documented accurately. Nurses also faced some challenges related to management and leadership, ambivalence with traditional and empowering patient education, and families’ overall situation.An example of developing evidence-based patient education program is presented, but besides education other factors supporting changes in work practices should be considered in further development. Type 1, insulin-dependent diabetes is one of the most common chronic diseases in childhood. Diabetes management relies on self-management . TherefoThe education and treatment of children with diabetes is carried out by a multidisciplinary team ,6, but nA patient education process includes assessment, planning, implementation, and evaluation ,13. In tChildren’s patient education need to be based on development psychology to support their age-appropriate use of knowledge . As for Although no preferred diabetes education approach exists , it is iIn general, diabetes education is based on structured curricula comprising survival skills upon diagnosis and continuing education later on ,25. The Each topic of the diabetes curricula is taught in an educational session and thereafter it is trained in practice under the guidance of nurses. In this educational program, we focused on a module of the survival skills, the blood glucose monitoring education and the empowering way to provide it. The purpose of this article was to describe an educational program to enhance empowering patient education process for the blood glucose monitoring education of school-age children and nurses’ perceptions of using empowering techniques.This educational program is part of a project aiming to develop patient education in pediatric wards. The project team composed of research (N = 2), patient education (N = 2), pediatric nursing (N = 5), diabetes management (N = 2) experts, and the parents of children with a chronic illness (N = 2) representing patient associations. The project team assembled for monthly meetings to review the learning theories and empowering patient education theories that aided in the development. The educational program was based on the principles of teaching school-age children and on the patient education process conducted in an empowering way. The program was developed based on literature and prior research as well as two studies focusing on nurses’  and schoThe empowering patient education process for the blood glucose monitoring education of school-age children was carried out in a pediatric ward of a Finnish hospital. The ward provided care for children with diabetes or other pediatric diseases. In education workshops in February 2010, the educational program was presented to the ward nurses and the pediatric diabetes team of the hospital. During one day, the pediatric nurse teachers of the project team taught nurses to carry out the blood glucose monitoring education using an empowering method of teaching school-age children and their parents. Teaching was provided with interactive methods and by using practical case-solving. All nurses also received the educational material including a manual explaining how to proceed in each phase of the patient education process.After the nurses’ education, the first author worked in close cooperation with the nurses and motivated them to use empowering techniques when a school-age child received the diabetes diagnosis, and the blood glucose monitoring education was given to the child and parents. In addition, the key issues of the patient education program were repeated to the nurses in monthly workshops.The management of the hospital granted the study permission, and its research ethics committee approved the study. Altogether 10 nurses carried out the blood glucose monitoring education according to the program. Three of them did it twice and were interviewed twice. However, in two cases the interview could not be conducted, and thus the data comprised a total of 11 descriptions of the blood glucose monitoring education implemented by 8 nurses. All nurses gave a written consent for their participation. The nurses’ age varied from 25 to 55, and their working experience in the ward ranged between 6 months and 13 years.During the year following the nurses’ education, their perceptions of utilizing the empowering patient education were explored to further develop the educational program. The study aimed to describe (1) the nurses’ perceptions of successful empowering blood glucose monitoring education of school-age children, and (2) the challenges nurses faced in it.The first author collected the data by semi-structured interviews. Their themes were based on the various phases of the patient education process and interaction. After the nurse had taught blood glucose monitoring to a school-age child, the nurse was interviewed in a tranquil setting. The tape-recorded interviews lasted from 17 to 36 minutes and were transcribed verbatim by the interviewer.First, the data were analyzed by a deductive content analysis ,27. The The successful managing of the empowering patient education process consisted of 4 categories: need assessment, planning, implementation, and evaluation (see Table The nurses’ descriptions of the implementation comprised information on the content, teaching materials and methods. The content of patient education was based on the objectives and contained information related to blood glucose control and techniques for blood glucose testing. Teaching material was to meet the individual needs of the children and their parents. Different materials were used, such as equipment, demonstrative and written material. Patient education was implemented using different teaching methods: First, interactive education included creating friendly atmosphere, showing approval, encouraging the child and parents, and using verbal counseling combined with other methods. Second, child-centered approach focused on the patient and promoted his/her participation by respecting the child, utilizing the child’s natural curiosity, helping to overcome one’s fear, and using simple language as well as rewards. Third, family-centered approach supported parent participation by listening to them and answering questions, teaching all family members together, proceeding on their terms, and giving feedback.The evaluation consisted of various methods and documentation. The methods, such as observing, asking questions, asking to explain the learning, and discussing feelings, promoted patient participation. The documentation of patient education including the subject of the session, participants, level of learning and need for repetition, was completed in a patient education form and patient files.The challenges formed 3 categories Table . First, In this paper, we described an educational program aimed to enhance nurses’ competence in empowering diabetes education. We also reported the nurses’ perceptions of the empowering education process. In successful empowering patient education, the need assessment was conducted comprehensively by using multiple methods for collecting information. Further, planning was done adequately for individualized patient education and the objectives including cognitive, capability, experiential and attitude objectives were stated with the family. This is opposed to previous studies ,11 reveaThe principles of empowering patient education ,12,14 asThe patient education was evaluated appropriately by verifying the learning achievements with multiple methods, and the documentation of patient education was produced accurately. This is in contrast to earlier research ,11 obserThree types of challenges were met in managing empowering patient education. First, challenges were related to management and leadership: lack of information and expertise as well as lack of vital resources. These issues indicate that teaching as such is not enough when targeting changes in work practices. Contextual factors related to a social system as well as organisations’ management and leadership issues play a key role in development . The manSecond, the ambivalence with traditional and empowering patient education revealed that the empowering patient education approach was adopted intellectually. However, changing the old intrinsic patient education paradigm was difficult despite the need for change being recognized. This change does not occur at once but it takes time. A positive and safe atmosphere for development as well as reflective team activities can promote changes in work practices .Third, challenges of client’s situation emerged when the child was a passive participant, or the parents suffered from a shock. Factors impacting teaching included the stress of a chronic illness and anxiety as well as the negative influence of the hospital environment, resulting in loss of control . In thesThe interviewed nurses described successful management of the empowering patient education suggesting that this study produced a useful evidence-based patient education program for diabetes education. On one hand, the nurses’ interviews indicate that a checklist of the content of the empowering patient education process could help nurses to prepare for and focus on the critical issues in the blood glucose monitoring education. On the other hand, the challenges nurses faced in managing empowering patient education showed that teaching nurses as such is not enough when aiming at changes in nursing practices. Therefore, the challenges revealed in this study should be considered when new educational programs are planned and implemented.Our study has some limitations. The number of school-age children with a recent diabetes diagnosis remained smaller than was assumed, and the nurses had only a few possibilities to implement empowering patient education. Moreover, the nurses’ interview data were the only source of information. The data revealed nurses’ descriptions of empowering patient education, but additional data and methodological triangulation could have given a more comprehensive description of what really happened during the patient education process.This paper provides an example of developing an evidence-based patient education program that can be useful for those planning and carrying out improvements in nursing practices and for managers and leaders in nursing units. The study provides practical examples of empowering patient education beneficial for all health care professionals working with school-age children and their parents. The nurses’ manual can add a valuable asset when new colleagues and nursing students are instructed to use the methods and content of empowering diabetes education. In addition, the findings may be utilized in pediatric units to develop materials and distribute resources as well as increase nurses’ capabilities. The study describes the challenges that need to be considered when aiming to change work practices. Teaching nurses should be combined with other strategies for discerning possible barriers for implementing the educational program.A rather small number of nurses implemented the educational program for school-age children with diabetes, and research is needed to obtain a more credible picture of the program and to develop it further. We also need more research to understand the usefulness of the program. Thus, observing the patient education sessions would extend our knowledge of them. The evaluation of a patient education program should involve the children’s and their parents’ perspective, and it would be useful to collect information about their learning achievements.The authors declare that they have no competing interests.MK was responsible for the study design, carried out data collection and analysis and drafted the manuscript. EE and IE participated in the design of the study, reviewed the data analysis, were involved in the drafting of the manuscript and contributed to the critical revision of important intellectual content of the manuscript. All authors read and approved the final manuscript.


To use intensive care unit (ICU) facilities efficiently and ensure high quality of care, an optimal patient flow is necessary. Discharging patients relieves the pressure on ICU beds but the risk of premature discharge must be managed carefully. Suboptimal patient discharge may result in ICU readmissions and in patients’ death.The aim of this study is to obtain insight into the safety and efficiency of current ICU discharge practices and into barriers and facilitators to the implementation of effective ICU discharge interventions, and to develop an implementation strategy tailored to the barriers and facilitators identified.This study exists of five phases. Phase A: analysis of routinely registered data on variation in ICU readmissions and hospital mortality after ICU discharge of all ICUs participating in the Dutch National Intensive Care Evaluation registry (n = 83). Phase B: systematic review of effective interventions aiming to improve the efficiency and safety of the ICU discharge process. Phase C: assessing the intervention adherence with a questionnaire survey among all Dutch ICUs (n = 90). Phase D: assessing barriers and facilitators to the implementation of effective ICU discharge interventions with a questionnaire survey among all Dutch intensivists (n = 700). The questionnaire will be based on barriers and facilitators identified by focus groups (n = 4) and individual interviews with professionals of ICUs and general wards and adult discharged ICU patients (n = 25 to 30). Phase E: systematic development of an implementation strategy based on the sampled data in phase A to D, and effective implementation strategies from the literature using the intervention mapping method.Using theory and empirical data, an implementation strategy will be developed to improve the safety and efficiency of the ICU discharge process. The developed strategy will be evaluated in a subsequent study. The knowledge obtained in this study should be used for further implementation of ICU discharge interventions, and can be used for implementation of handover interventions in other healthcare transition settings. The intensive care unit (ICU) is an essential component of most large hospitals, providing critically ill patients with high quality care. In addition, patients undergoing major surgery often require ICU admission postoperatively . TherefoAn optimal patient flow is critical to use ICU facilities efficiently and to ensure high quality of care. Discharging patients is one way of relieving the pressure on ICU beds but clearly, the risk of premature discharge must be managed carefully . The incICU readmission rates and hospital mortality after ICU discharge vary. Hospital mortality after ICU discharge is 12.4% in the United Kingdom, of which 39% is related to premature ICU discharge . Other sICU readmissions are an important cost driver. The mean unit price of an ICU day in the Netherlands is €2,183 . AccordiThe question is: How to prevent ICU readmissions and mortality after an ICU stay? What are available effective improvement interventions and are they used in daily practice? In addition to existing guidelines -21, liteThe aim of the pICUp (Patient Handover Intensive Care Unit Improvement) study is to obtain insight into current ICU discharge practice, an overview of effective ICU discharge interventions and into the factors that hinder and facilitate the implementation of these interventions (barriers and facilitators), with the final aim to develop a tailored implementation strategy. A better understanding of the barriers and facilitators and a tailored strategy will enhance the implementation of interventions in daily practice and will improve the quality of the ICU discharge process, leading to fewer adverse patient outcomes, such as fewer ICU readmissions and reduced hospital mortality after ICU discharge.The following research questions are formulated to address this aim:1. What is the variation in ICU readmissions and hospital mortality after ICU discharge between ICUs?2. What are effective ICU discharge interventions to prevent ICU readmissions and hospital mortality after ICU discharge?3. What is the adherence to these interventions?4. What are the barriers and facilitators to the implementation of these ICU discharge interventions?5. What is an appropriate strategy to improve the implementation of these ICU discharge interventions?et al.[et al.[To answer the research questions and structure the analysis, we developed a framework that provides insight into the process of the implementation of scientific evidence, and factors influencing this process Figure . This fret al.; and thel.[et al..The gray boxes reflect the temporal sequence of the implementation process from scientific evidence to improved patient outcomes: I) scientific research results in evidence about effective interventions that are recommended in clinical practice guidelines, II) the evidence should be tailored to local circumstances in local protocols, III) implementation efforts, such as a detailed and feasible implementation plan, and engaging stakeholders in an early stage, will improve the implementation process, leading to IV) improved behaviour and adherence to the intervention of stakeholders, and ultimately resulting in V) improved patient outcomes.e.g., interpersonal, interdepartmental and interinstitutional relationships); 6) professional characteristics; and 7) patient characteristics. Subcategories of these main domains are presented in Table Several factors influence the implementation process and could explain why effective and evidence-based interventions are not (fully) implemented. Based on literature, barriers and facilitators to implementation can be categorized in seven main domains -29,31, rExamples of influencing factors related to the intervention are the feasibility to actually incorporate the intervention in daily practice, the credibility of evidence behind the intervention, and the advantages for the healthcare workers or the patients. Societal factors are whether an intervention is reimbursed by healthcare insurers, political climate, policies, and regulations. Factors related to the implementation characteristics are, for example, the availability of an implementation plan, adequate education of professionals, and the degree of exposure of the professionals to the implementation efforts. Influencing institutional factors are for example organizational structure and resource availability. Social interactions within a team or within the network of a healthcare provider may also be of influence; collaboration between care providers or between wards, leadership, and (safety) culture are important factors. Main professional factors are knowledge (such as familiarity with guideline) and attitude  . PatientCurrently, 30% to 40% of all patients do not receive care according to actual scientific knowledge . We haveThe pICUp study is a descriptive, explorative study using a mixed method design. Quantitative methods are analysis of registered clinical data and questionnaire surveys, while qualitative methods  study variation in patient outcomes, current ICU discharge practice, guideline and intervention adherence, and the barriers and facilitators to implementation. Based on these findings a tailor-made implementation strategy will be developed.According to the research questions, the study is divided into five phases Figure :A. Analysis of the variation in ICU readmissions and hospital mortality after ICU discharge between ICUs,B. Systematic review of evidence-based interventions for improving handover of patients from the ICU to general wards,C. Analysis of guideline and intervention adherence and the association between adherence and patient outcomes,D. Analysis of barriers and facilitators to the implementation of ICU discharge guidelines and interventions and the relevance of these factors to professionals,E. Development of an implementation strategy tailored to the barriers and facilitators found.Below, we describe the study methods, population, analysis, and outcome measures per study phase. An overview of the research questions, methods and outcomes is given in Table The aim of this phase is to analyze the variation in ICU readmissions and hospital mortality after ICU discharge between ICUs, and the degree of variation not explained by patient mix.Data about the quality indicators related to suboptimal ICU discharge are derived from the Dutch NICE registry. Since 1996, demographic, physiological, and clinical data of patients admitted to Dutch ICUs are collected. All participating ICUs are obliged to attend training in accurate collection of data to ensure the quality of the registry. At each individual ICU and centrally, data are automatically checked for range and consistency. In addition, quality audits are carried out to ensure the validity of the registration ,34. DataThe variation in patient outcomes will be analyzed using ICU quality indicators related to suboptimal ICU discharge ,36. The The secondary patient outcome measure is hospital mortality after ICU discharge, which is defined as the percentage of ICU patients discharged alive from the ICU who died on a general ward.In addition, the association between patient’s outcomes and discharge time will be analyzed, because we know from previous studies that patients discharged at night experience a greater risk of mortality than patients discharged during the day ,6,39.e.g., age, APACHE IV score, co-morbidity at admission, diagnosis at admission, reason for discharge) and organizational factors  using multi level analysis. The remaining variance indicates room for improvement [Descriptive statistics will be used to characterize the study sample and to report the variation in hospital mortality rates after ICU discharge and ICU readmission rates. To attribute variation to suboptimal care, the rates will be corrected for patient mix , Cinahl, PsychInfo, the Cochrane Library, and EMBASE. The inclusion criteria will be: studies with experimental study designs; that include patients undergoing and/or healthcare providers involved in the transition from ICU to ward; that have an intervention explicitly describing one or more components aiming to improve the handover from ICU to ward; and that have ICU readmission rate or hospital mortality rate after ICU admission as an outcome measure.First, studies that do not meet the inclusion criteria will be eliminated based on their title and/or abstract. Full-text copies of studies identified as potentially relevant will be retrieved and reviewed for the final inclusion. The methodological quality of the included studies will be assessed and data such as a description of objectives, design, participants, intervention, and effect measures will be extracted.The study outcomes will be presented in tabular form, and a qualitative assessment will be made based on the methodological quality, sample size, intervention characteristics, outcome, statistical significance, and effect size.The aim of this phase is to assess the adherence to the Dutch national guideline  and inteThe intervention adherence will be studied using a questionnaire survey, which includes questions about local policies, organization, and procedures regarding the ICU discharge process and the application of ICU discharge interventions. Questions from the questionnaire of the Dutch Healthcare Inspectorate (IGZ) and the visitation questionnaire of the Dutch Society of Intensive Care (NVIC) will be used ,36. MoreThe association between intervention adherence (questionnaire) and patient outcomes (Phase B) will be analyzed to determine whether adherence leads to better patient outcomes.Descriptive statistics will be used to characterize the study sample and to report the adherence to the guideline and interventions. Regression analysis will be performed to analyze the association between adherence and patient outcomes. Adherence to each discharge intervention will be dichotomised, resulting in one adherence score.The aim of this phase is to explore the factors influencing the implementation of the ICU discharge guideline  and inteA combination of qualitative and quantitative methods will be used to identify and quantify barriers and facilitators to ICU discharge guideline and intervention adherence.First, semi-structured interviews will be conducted to explore all relevant barriers and facilitators to guideline and intervention adherence and opportunities for improvement. The interview questions will be based on a loose structure consisting of open-ended questions that define the area to be explored.Second, focus group interviews will be conducted to gain broader insight into the barriers and facilitators. For both the individual interviews and the focus groups, an interview guideline will be formulated with a series of open-ended questions to explore barriers and facilitators to inappropriate ICU discharge processes and regarding the implementation of the ICU discharge interventions.Third, a questionnaire will be developed to quantify the barriers and facilitators identified in the individual and focus group interviews. The questionnaire will contain questions about demographic characteristics, and statements concerning barriers and facilitators regarding the implementation of ICU discharge guideline and interventions identified.Approximately 25 to 30 individual interviews will be carried out with managers and healthcare professionals from ICUs and receiving general wards, including intensivists, ICU nurses, and physicians and nurses of general wards. They will be recruited from six hospitals: two general, two teaching, and two academic hospitals.Furthermore, patients will be interviewed together with a relative, because many post-ICU patients do not remember the ICU admission and the period immediately afterward. The amount of interviews depends on the point of saturation: when no new analytical constructs can be identified in interviews and focus groups .Four focus group interviews (moderated group discussions with six to ten persons) will be performed with intensivists, ICU nurses, physicians of general wards, and nurses of general wards. They will be recruited from several ICUs, ensuring a representative sample in terms of ICU size.The questionnaire will be sent to all intensivists in the Netherlands registered with the Dutch Society of Intensive Care (NVIC) to quantify barriers and facilitators identified in the individual and focus group interviews.The individual and focus group interviews will be recorded and transcribed verbatim according to a standardized format. The transcripts will be analyzed and coded by a researcher with qualitative data analysis software (Atlas.ti). The barriers and facilitators will be classified according to analytical categories, based on the framework described in section ‘theoretical framework’.Descriptive statistics will be used to characterize the study sample and to report the results of the interviews, focus groups, and questionnaires. Variance in outcomes from the questionnaire between different types of hospitals  and demographic characters  will be analyzed.The aim of this phase is to develop a tailored implementation strategy to improve the handover process between the ICU and the general ward.To develop the implementation strategy, a complete and detailed plan to change the current way of working and improve quality, the Intervention Mapping (IM) method of Bartholomew will be used. IM is a systematic, iterative six-step process to develop an intervention program, based on theoretical, empirical and practical information . Resultse.g., stage of behavioural change) . In step two, specific and feasible goals and change objectives  are set. In step three, interventions from literature (phase B) are selected that correspond to the change objectives formulated in step two. Step four is the development of a tailored intervention program and pilot testing this program. In step five, the total implementation strategy is developed, including methods and tools for implementation. To evaluate the effects of the developed intervention program and implementation strategy, an effect and process evaluation is conducted in step six [The first step is conducting a problem analysis to describe the healthcare problem, barriers and facilitators to change and the target population . They declared ethical approval was not required under Dutch National Law.The goal of this study is to obtain more insight into current ICU discharge practices, and into the barriers and facilitators to the implementation of effective ICU discharge interventions. Analysis of the variation between ICU readmission rates and hospital mortality after ICU discharge reveals room for improvement. Improvement may be found in better adherence to effective ICU discharge interventions. In this study, a tailored implementation strategy will be developed based on theoretical and empirical information gathered. Insight into barriers and facilitators to the implementation of ICU discharge interventions is essential in deciding what kinds of activities should be developed to prevent suboptimal ICU discharges resulting in ICU readmissions and mortality. The knowledge obtained in this study should be used for the further implementation of ICU discharge interventions and can be used for implementation of handover interventions in other healthcare transition settings, such as operating theatre to ICU, operation theatre to general ward, hospital to hospital, or hospital to primary care interface.This study uses a mixed methods approach, combining qualitative and quantitative research methods, to answer the research questions . TherefoThe definitions of the patients outcome measures in this study, ICU readmissions and hospital mortality after ICU discharge, are commonly used ,37. TherIn phase C, information about adherence is obtained by sending a questionnaire to all Dutch ICUs. A possible limitation of this method is response bias, which will be minimized by sending reminders by e-mail and follow-up calls. In addition, self-reporting adherence may result in overestimation. During the development of the questionnaire, questions that may invite socially desirable answers will be avoided.The individual interviews and focus groups in phase D might raise questions about generalizability of the results. Therefore, the results of the interviews and focus groups will be quantified by a questionnaire sent to the entire Dutch intensivist population. The results of the questionnaire may also be subject to response bias, which also will be minimized by sending reminders.The Intervention Mapping method used in phase E has not yet been proven more effective in comparison to other improvement methods. However, it is generally accepted that systematic development of tailored implementation strategies is preferred over intuitively selecting strategies .Based on the results of this study, a tailor-made implementation strategy will be developed to improve the implementation of effective ICU discharge interventions in daily practice. In a subsequent study the cost effectiveness of the developed implementation strategy should be tested.The authors have no competing interests to declare.MZ and HW contributed to the study design and coordination. NS en MZ drafted the manuscript. HW, JGH and GW revised the manuscript critically for important intellectual content. All authors read and approved the final manuscript.


We evaluated a newly designed electronic portfolio (e-Portfolio) that provided quantitative evaluation of surgical skills. Medical students at the University of Seville used the e-Portfolio on a voluntary basis for evaluation of their performance in undergraduate surgical subjects.Our new web-based e-Portfolio was designed to evaluate surgical practical knowledge and skills targets. Students recorded each activity on a form, attached evidence, and added their reflections. Students self-assessed their practical knowledge using qualitative criteria (yes/no), and graded their skills according to complexity (basic/advanced) and participation (observer/assistant/independent). A numerical value was assigned to each activity, and the values of all activities were summated to obtain the total score. The application automatically displayed quantitative feedback. We performed qualitative evaluation of the perceived usefulness of the e-Portfolio and quantitative evaluation of the targets achieved.Thirty-seven of 112 students (33%) used the e-Portfolio, of which 87% reported that they understood the methodology of the portfolio. All students reported an improved understanding of their learning objectives resulting from the numerical visualization of progress, all students reported that the quantitative feedback encouraged their learning, and 79% of students felt that their teachers were more available because they were using the e-Portfolio. Only 51.3% of students reported that the reflective aspects of learning were useful. Individual students achieved a maximum of 65% of the total targets and 87% of the skills targets. The mean total score was 345 ± 38 points. For basic skills, 92% of students achieved the maximum score for participation as an independent operator, and all achieved the maximum scores for participation as an observer and assistant. For complex skills, 62% of students achieved the maximum score for participation as an independent operator, and 98% achieved the maximum scores for participation as an observer or assistant.Medical students reported that use of an electronic portfolio that provided quantitative feedback on their progress was useful when the number and complexity of targets were appropriate, but not when the portfolio offered only formative evaluations based on reflection. Students felt that use of the e-Portfolio guided their learning process by indicating knowledge gaps to themselves and teachers. Portfolio-based assessment tool is at the apex of Miller’s pyramid, because it provides performance-based assessment in real context by analysis of actions ,2. PortfBuckley et al.  reportedThere is ongoing debate regarding the relative learning impacts of electronic portfolios versus paper-based portfolios . ElectroMost of the currently used portfolios are designed primarily for formative assessment and focused on the learning process. They present students with information about their strengths and weaknesses, and help to formulate plans for improvement . These phttp://www.portfolioelectronico.com/cirugiayorlsevilla). The application was simple and intuitive, and was designed for users with a low to medium level of experience with information and communication technologies. Access to the application was by individual username and password. Pilot studies of the e-Portfolio exceeded the requirements for robustness proposed by Barrett [The new e-Portfolio was used to evaluate students taking undergraduate surgical courses at the University of Seville. The e-Portfolio was web-based and was available online via all standard web browsers . The dat Barrett , and didPractical knowledge and skills targets were selected from the University of Seville Undergraduate Otorhinolaryngology Programme, and were adapted to meet the requirements of the European Space for Higher Education . This prThe e-Portfolio included 32 knowledge targets, including knowledge about outpatient units (9 targets), knowledge about hospitalized patients (13 targets), and knowledge about operating rooms (10 targets). Prior to software conversion, these targets were displayed in the first column of a table. The second column showed whether each objective had been achieved . A cumulative score of at least 26 points (>80%) was required before students were considered to have sufficient knowledge. The Department of Surgery set this cutoff figure to ensure that future physicians would be competent in most of the targeted objectives.The e-Portfolio also included 20 skills targets, which were divided into basic abilities (8 targets) and advanced abilities (12 targets). Each skills target could be achieved by different degrees of participation as an observer, assistant, or independent operator. The skills were taught in clinical settings, and performance was directly observed by the teachers  formats. The e-Portfolio also provided a summary of each student’s training and learning progress on a page that allowed students to upload a personal photograph. The visibility of the photograph increased as the student progressed through the learning targets. Students were also able to print their portfolio in Excel® file format.The e-Portfolio was described to the 112 medical students who were trained in the Otorhinolaryngology Department at Virgen Macarena University Hospital, Seville, Spain during 2010–2011. Use of the e-Portfolio was voluntary. We evaluated the usefulness of the portfolio to students at the end of the academic year using a structured questionnaire, and by randomly selecting 16 students for semi-structured interviews that followed the same structure as the questionnaire. We evaluated students’ understanding of the portfolio methodology, understanding of the learning targets, ease of use of the e-Portfolio, interest in learning surgical subjects, and perceived usefulness of the e-Portfolio in terms of learning outcomes. The roles of clinical teachers were reduced to teaching skills in clinical settings, to allow students to guide their own learning and evaluations. Data were analyzed using the triangulation technique. The usefulness of the e-Portfolio was evaluated by measuring the proportions of learning targets achieved.Of the 112 students, 37 (33%) agreed to use the e-Portfolio to register their learning activities, using a variety of electronic devices. When asked about their understanding of the methodology of the portfolio, 87% of students said they understood the methodology and 12% were able to explain the methodology precisely when questioned. Many students (79%) reported that the teachers were more willing to help them achieve the learning targets after they were made aware of the learning model of the e-Portfolio. All students who used the e-Portfolio reported that they gained a better understanding of the objectives of the course by focusing on the target activities. They appreciated the reduction of the vast field of possible diagnoses and operations to a small number of targets that seemed achievable. The focus on a manageable number of targets allowed them to determine what they needed to learn during the course.Nineteen students (51.3%) reported that reflective writing in the free text fields was useful, but that they had not written much because they did not know what to write. Another 13 students (35.1%) reported that they had written something because they expected that the teacher would take this into account, but they thought it was a waste of time. Five students (13.5%) reported that they considered written observations to be useless. Seventeen students (46%) asked their teachers to focus on the targets listed in the portfolio, thereby reducing more general teaching and teaching of material that was not included as a target.Seventeen students (46%) reported that they had initially worked eagerly on the e-Portfolio because they had found it an interesting initiative, but eventually felt disenchanted because other students and some teachers did not show much interest. These students also felt that because the e-Portfolio was a temporary and voluntary activity, it would not be useful for longer term evaluations.All students agreed that the quantification of their performance using numerical feedback was the most valuable aspect of the e-Portfolio. They felt that the e-Portfolio model was more useful for learning practical skills than the previous model that simply required students to be present in clinical settings and then tested them later.Individual students achieved a maximum of 65% of the overall targets and 87% of the skills targets. The mean total score was 345 ± 38 points. For basic skills, 92% of students achieved the maximum score for participation as an independent operator, and all achieved the maximum scores for participation as an observer and assistant. For complex skills, 62% of students achieved the maximum score for participation as an independent operator, and 98% achieved the maximum scores for participation as an observer or assistant.The evidence provided by students consisted mainly of photographs and videos recorded during activities by their classmates using their smartphones, and the files were uploaded to the e-Portfolio using their laptops later.The portfolio model remains relatively unknown among clinical teachers and students. Disappointing experiences reported by students  and teachers  have hindered the implementation of this model . AwareneIt is likely that so few students in this study chose to use the e-Portfolio because of a lack of knowledge and experience regarding this learning model. Although the methodology was well understood when explained, few students (12%) were able to describe it precisely when questioned. The voluntary nature of inclusion in the study also reduced participation, as some students perform only mandatory activities, or activities that will be reviewed and evaluated. The current educational culture discourages written self-assessment of learning, resulting in a widespread resistance and lack of interest in producing written observations. The electronic portfolio model that was developed by Virgen Macarena University Hospital was probably particularly useful by combining into a single portfolio information that is usually found in separate portfolios . Our modConsidering current technology, access to an electronic portfolio via the internet should be considered standard . Many deThe most important feature of the e-Portfolio was the requirement for students to complete a predetermined number of target activities. Students were able to improve their skills by repeating activities with their clinical teachers in ways that paid attention to specific aspects of the tasks. All activities were assigned a numerical value, and the values of all activities were summated to obtain the total score. Observation of the progress of the total score increased interest in completing complex activities. Progress was recorded without testing, so that formative assessment was integrated with the numerical evaluation, without being punitive.The e-Portfolio allowed students to understand their learning objectives using specific targets, rather than using the previous generic objectives . StudentReflective portfolios do not usually provide quantitative evaluations of activities and are teacher-dependent tools that require teacher assessments as well as student observations . The e-PNumerical scores may give some students a false sense of security that they will pass the course, without encouraging identification of their shortcomings . HoweverStudents generally preferred to complete the skills targets than the knowledge targets. This may be because they were interested in the new teaching and learning experiences and the feedback provided by the e-Portfolio. Both students and teachers were encouraged to increase the roles of students in achieving their learning targets. This was a remarkable difference compared with the rejection of purely reflective portfolios.The limitations of this first version of the e-Portfolio include its primary focus on achieving skills targets, rather than on a more comprehensive assessment of competence including communication skills, knowledge, technical skills, clinical reasoning skills, emotional skills, values, and observations that would benefit patients as well as society ,35. HoweMedical students found that use of an electronic portfolio that provided both quantitative feedback on their progress and formative evaluations stimulated their learning. The students felt that use of the e-Portfolio provided valuable guidance to their learning process by indicating their progress towards achievement of the skills targets, and that this motivated both them and their teachers to focus more clearly on the learning objectives. Identification of an appropriate number and complexity of learning targets helped the students and their teachers to evaluate progress and outstanding objectives.The Authors declare that they have no competing interests. The Electronic Portfolio of the Faculty of Medicine was supported by a financial fund from the 2009 Innovation and Teaching Enhancing Programme, University of Seville, Spain. The manuscript processing charges were financed by the Andalusian Association for Medical Education in Otorhinolaryngology.SSG conceived of the study, participated in study design and coordination, drafted the manuscript, and performed the statistical analyses. JMOB and EMCO participated in study design, helped to analyze the results, and helped to draft the manuscript. All authors read and approved the final manuscript.©). This is a nationwide electronic portfolio for formative and summative assessment of all Spanish otorhinolaryngology residents. The portfolio was presented at An International Association for Medical Education (AMEE) 2010 in Glasgow, Scotland, and at the First Congress of the Iberoamerican Academy of Otorhinolaryngology 2011 in Cancun, Mexico. SSG is a member of the Spanish National Committee of Otorhinolaryngology, which is responsible for the National Programme of Otorhinolaryngology. SSG is also President of the Andalusian Foundation for Research and Knowledge Management in Otorhinolaryngology, President of the Andalusian Association for Medical Education in Otorhinolaryngology, and Secretary of the Andalusian Association for Health Sciences Education.SSG participated in conceiving, coordinating, and implementing the Electronic Portfolio of the Spanish Society of Otorhinolaryngology and Cervical-Facial Pathology (named FORMIRSSG, JMOB, and EMCO received grants from the University of Seville through several Learning Innovation projects including Electronic Portfolios, Problem Based Learning, and Learning Research.No ethical approval was required for this study according to Spanish laws. However, the Faculty of Medicine at the University of Seville reviewed and approved the study protocol and carefully considered the related ethical issues. Anonymity of participants was guaranteed, and no potential harm to participants was identified.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/13/65/prepub


Musculoskeletal symptoms are common in the neck, back, and upper limbs amongst musicians. Playing-related musculoskeletal disorders have been found to range from 32% to 87% with a tendency for female musicians to have more problems than males. Studies of musculoskeletal problems in instrumentalists have generally involved pre-professional musicians or populations comprising musicians of different levels. The objective of this study was therefore to investigate the prevalence, duration and consequences of musculoskeletal symptoms in professional symphony orchestra musicians.A cross-sectional questionnaire study. The study population comprised of 441 musicians from six Danish symphony orchestras; 342 (78%) completed the questionnaire.During the last year 97% of the women and 83% of the men experienced symptoms in at least one of nine anatomic regions . 86% of the women and 67% of the men experienced symptoms for more than seven days, while 63% of the women and 49% of the men had symptoms for more than 30 days. Woodwind players had a lower risk for musculoskeletal symptoms and a lower risk for the consequences. Among consequences were changed way of playing, reported by 73% of the musicians, difficulty in daily activities at home, reported by 55%, and difficulty in sleeping, reported by 49%. Their health behaviour included taking paracetamol as the most used analgesic, while physiotherapists and general practitioners were reported as the most consulted health care professionals concerning musculoskeletal problems.Results regarding symptoms in six anatomic regions were compared to results for a sample of the general Danish workforce. Symptoms were more frequent in musicians and lasted longer than in the general workforce. This applied to both genders.Within the last year most symphony orchestra musicians experienced musculoskeletal symptoms in the neck, back or upper extremities. The symptoms impacted on their level of function in and outside work and were reflected in their health behaviour. Generally women had a higher risk than men and woodwind players a lower risk than other instrumentalists. Finally, symptoms were more frequent and lasted longer in the musicians than in the general workforce. Across countries and continents, many professional classical musicians are employed in symphony orchestras that are generally comparable in instrumentation and in the hierarchical organization of their different instrument groups ,2. The eIn the scientifically biomedical literature, professional symphony orchestra musicians are poorly described, as most studies of musculoskeletal problems in musicians have been done with populations involving pre-professional musicians, or mixed populations with different types of musicians, and thereby mixed exposures ,4. The rSymphony orchestra musicians are often music conservatorium graduates and have practiced for hours every day to reach the elite level. This level can be achieved only through effort and discipline and with the will to improve their techniques all the time ,10. TheyThe aim of this study was to investigate the prevalence and consequences of perceived musculoskeletal symptoms in the highly selected occupational group of symphony orchestra musicians.This research involved a cross-sectional questionnaire study of professional symphony orchestra musicians in Denmark.All seven professional symphony orchestras in Denmark were asked to participate in the study. They were included orchestra by orchestra to ensure that all employed musicians could receive information and participate in the survey at their workplace. One orchestra was not able to participate due to administrative reasons and was not included. In the remaining orchestras, four musicians on long-term leave could not be contacted and were not included. Nobody was excluded from the study. The study population was thus 441 musicians from the six participating symphony orchestras, with 342 (78%) answering the questionnaire, in total 208 men and 134 women. The respondents, as well as the study population, were comprised of 61% men and 39% women.Results from the symphony orchestra musicians were compared to results from The Danish Working Environment Cohort, a study performed by The National Research Centre for Work Environment and Health, Denmark, who provided the data concerning the cohort for reference use in the current study. The Danish Working Environment Cohort Study is a sample-based, multi-topic survey of work environment and health among the Danish workforce . The samData were collected from January 2007 to June 2008. All contacts with the participants took place at the musicians' workplace. The orchestras were visited one at a time. An introductory meeting was held, after which the questionnaires were distributed to each musician. The questionnaires were completed during work-time and collected less than two hours later. The few musicians who could not attend the introductory meeting received an information letter and a questionnaire, both delivered to their private mailbox at work.Gender, age, orchestra of employment and instrument information were obtained for all participants in the study population as baseline data from employment lists in the participating orchestras.In accordance with the aim of study, the main outcomes were information about musculoskeletal symptoms and consequences of the symptoms. The musculoskeletal symptoms were measured as 1) period prevalences: the 7 days' and 12 months' prevalence, and 2) symptoms duration: symptoms for more than 7 days and for more than 30 days. The consequences were measured as 1) impact on level of function on work: impaired or changed way of playing, 2) impact on level of function outside work: difficulty in daily activities at home, difficulty in leisure time activities, or difficulty in sleep, and 3) behavioural consequences: pausing from practicing alone, pausing from rehearsals, not playing at concerts, taking sick-leave, using painkillers, or consulting health care providers.Work-related questions included playing exposure, music education and current employment.The questionnaire was constructed on the basis of interviews with classically trained musicians. Questions regarding musculoskeletal symptoms were adapted from the Nordic Musculoskeletal Questionnaire -26. The The face validity of the draft questionnaire was tested with help from music conservatory students from the Carl Nielsen Academy of Music, Odense, Denmark, who filled in the questionnaire and commented on the comprehensibility of the questionnaire, any disambiguity of questions, and the relevance of the topics. The face validity of the final questionnaire was tested by an expert panel consisting of professionals from the Danish music industry and from the musicians' union.In the descriptive analysis, all crude prevalence calculations were based on the total group of respondents by gender, the denominator always being 208 for men and 134 for women. The used prevalence calculations for the reference group were likewise based on the total group by gender. Test for equality of proportions was used for calculating the level of significance of different results in comparable groups, e.g. between genders or between the musicians and the general workforce. Associations between the binary main health outcomes and instrument groups were estimated using logistic regression with robust standard error adjusting for gender, age, number of playing years on the main instrument, and using orchestra of employment as the cluster variable. The high string group accounted for the largest instrument group and was chosen as reference in the analysis. Likewise associations between health outcomes and gender were estimated using robust logistic regression adjusted for age, instrument group, number of playing years on the main instrument, and with orchestra of employment as the cluster option; being the largest group, men were chosen as reference. Exactly the same method was used to estimate associations between the consequences of the musculoskeletal symptoms and gender and instrument groups. Prevalence odds ratios were calculated with 95% confidence intervals. The level of significance was defined as p < 0.05. Statistical analysis was performed using Stata 10.0 .Approval for this study was obtained from the Danish Data Protection Agency  and the Research Ethics Committee (project ID VF-20060086). Written information about the study was provided to all participants and meetings were held to provide oral information. Participation was voluntary.Most of the musicians have played music, and often their main instrument, since childhood, see Table The prevalence of reported musculoskeletal symptoms in nine anatomic regions are shown by gender in Figure Prevalence odds ratios with 95% confidence intervals for the different anatomic regions are listed by gender in Table The prevalence odds ratios of symptoms were also calculated by instrument group, see Table Also regarding the duration of symptoms there was generally little statistically significant association between the instrument played and the reported symptoms, see Table Impaired level of function at work, expressed as a changed or impaired way of playing due to symptoms in the neck, back, or upper extremities, was reported by 73%. Regarding impaired level of function outside work due to the musculoskeletal symptoms, 55% reported difficulty in daily activities at home, 53% difficulty in leisure time activities, while 49% had experienced difficulty in sleeping. The prevalence was significantly higher for women regarding changed or impaired playing, difficulty in daily activities at home, and difficulty in sleep.For impact on leisure time activities, there was no significant gender difference. But according to the adjusted odds ratio, females had a significantly higher risk for experiencing impact on all levels of function due to musculoskeletal symptoms than men, see Table Regarding the instrument groups the odds ratios for difficulty in playing (impaired or changed way of playing), in daily activities at home, and in doing leisure activities were all statistically significantly lower for the woodwind players compared to the high string players, see Table In the previous 12 months, 42% had paused from practicing at home/alone as a consequence of musculoskeletal symptoms. For both genders, this was significantly more frequent than pausing from rehearsals with colleagues, as reported by 16%, and more frequent than not playing at concerts, as reported by 20%. Sick-leave due to neck, back or upper extremity problems was reported by 24%. Use of painkillers due to these symptoms was reported by 49%, neck problems being the most frequently reported cause, and 64% had been examined or treated by a health care professional, see Figure Looking into the consumption of medicine, whatever the reason, 13% of the women and 12% of the men reported taking mild painkillers such as paracetamol once or more per week, while 44% of the women and 26% of the men reported taking them once or more times per month, making this the most commonly used kind of analgesic. Use of NSAIDs once or more per week was reported by 11% of the women and 8% of the men, while use of NSAIDs once or more per month was reported by 13% of the women and 9% of the men. Regular use of opioids on at least a monthly basis was reported by only 2% of the musicians, sedatives by 6%, and hypnotics by 4%.The most frequently consulted health care professional for musculoskeletal problems was the physiotherapist, by whom 52% of the women and 39% of the men had been examined or treated. Furthermore, 30% of the women and 31% of the men reported having been examined or treated by their general practitioner, 22% of the women and 16% of the men had been examined or treated by a specialist doctor, and 20% of the women and 26% of the men had consulted a chiropractor. In addition, 33% of the women and 15% of the men reported having consulted other kinds of treatment providers of conventional or alternative medicine. The most frequently reported reasons for being examined or treated for musculoskeletal problems were symptoms in the neck, upper and lower back.According to Table The comparison of musculoskeletal problems in the symphony orchestra musicians with those in the general workforce in Denmark is illustrated in Figures Musicians of both genders had significantly more symptoms in the right shoulder within the last week and within the last year, and more had symptoms for at least 7 days, than seen in the general workforce. Significantly more female musicians also had right shoulder symptoms for more than 30 days. Regarding the right hand, significantly more female musicians than other female workers had symptoms within the last week and within the last year or had symptoms for at least 7 days. Also the male musicians had significantly more right hand and wrist symptoms within the last week than men in the general workforce, and significantly more male musicians than men in the workforce sample had right hand symptoms for more than 30 days within a year.Lower back problems were less overrepresented in the musicians and were for both genders only significantly higher within the last seven days.The main findings of this study were the very high prevalence of musculoskeletal symptoms in the neck, back, and upper extremities among professional symphony orchestra musicians and the considerable impact the symptoms had on the musicians' level of function in work with changed or impaired way of playing as well as outside work in both domestic and leisure time activities, and in sleep.There was barely any statistically significant risk difference between the instrument groups, except that the woodwind players turned out to have a significantly lower risk for experiencing musculoskeletal problems and a significantly lower risk for consequences - such as impact on level of function - from musculoskeletal symptoms. In contrast there was a significant gender difference: Compared to the men, the females had a significantly higher risk for having symptoms, having the symptoms for more days, and females were also more affected by the consequences.A comparison of the results for the musicians to the results for the general workforce showed that symptoms were significantly more frequent in more anatomic regions in musicians than in the general workforce.There was a pronounced gender difference with female musicians having a higher prevalence of complaints than males. A similar gender difference was found in the general workforce. However, compared to the general workforce both genders of symphony orchestra musicians had a higher prevalence of musculoskeletal complaints; not only more symptoms but also symptoms lasting for more days, see Figure The musicians reported changed or impaired way of playing, difficulties in daily activities at home, in leisure time activities and in sleep as common consequences of musculoskeletal symptoms. That significantly more women experienced impaired playing, difficulties in daily activities at home and in sleep than men might be caused by biological gender differences such as strength, size, hormonal status, or be an expression of culturally different roles between the genders, e.g. women in Denmark taking a greater share of the housework than men -32. WhatBetween the instrument groups there was a remarkably little difference in risk for perceived symptoms as well as for experiencing consequences due to the symptoms. Especially when looking at the self-perceived symptoms, the woodwind players were the only group that stood out. The woodwinds had, however, a lower risk for musculoskeletal symptoms in different anatomic regions and a lower risk for consequences as well. The most remarkable might not be the woodwinds showing a lower risk for perceived musculoskeletal symptoms. More remarkable might be the fact that the majority of instrumentalists seemed so homogenous a group that they - compared to the high string players - barely showed any significant difference in symptoms risk amongst the instrument groups.Taking into account the many analyses made on instrument group level, see Table To understand the musician as a patient it is important to look at the behavioural consequences as different ways of coping with musculoskeletal symptoms or even physically impairment or loss of function. This research demonstrated, that due to musculoskeletal symptoms significantly more musicians of both genders reported having paused from practicing at home/alone than having paused from rehearsals, cancelled playing at concerts or taking sick-leave. This behaviour pattern is consistent with the cultural discipline inherent in the occupation, which is based on a deep appreciation of the necessity for each instrument to contribute to a musical piece, and a pronounced understanding of being an integral member of one orchestra when performing, leading to a natural hierarchical order of importance of playing situations, with concert performances and orchestral rehearsals being the most important. A less idealistic reason would be that the musicians due to the competitive work environment felt forced to play despite there symptoms motivated by a concern for reprisal or dismissal. So despite their symptoms, the professional musicians will therefore be inclined to perform at rehearsals and concerts, and play less when practicing alone, where reducing their effort can aid their recovery without compromising their colleagues. Consumption of analgesics, presumably to avoid, reduce or delay the sensation of symptoms and their consequences, is another behavioural strategy. A similar behaviour is seen in athletes with exercise-induced muscle injury ,34. The As most symphony orchestra musicians have played their main instrument since childhood starting out playing it as a leisure time activity that later became a way of life; as they compete in an environment occupied by audition winners; as they always play with the same physical exposure to the instrument and many eventually acquire musculoskeletal problems; and as they often play despite their symptoms, the musicians could be considered comparable to elite sportsmen. Their musculoskeletal symptoms have also been suggested comparable to the overuse injuries experienced among athletes indicating a very high degree of strain and injury ,36. But The cross-sectional study design was the chosen method for collecting data to reveal the extent of certain health and working conditions among professional musicians and to facilitate comparison of data with a follow-up investigation. Early interviews ensured that topics included in the questionnaire were of relevance to the musicians and not just of interest to the research group. Questions on musculoskeletal problems were mainly built on known questionnaires in order to have standardised results which could be compared to other groups ,25,27. ARespondents were representative of the study population with respect to gender, age, and instrument groups. Despite the very satisfactory response rate of 78%, a possible selection bias risk was an over-representation of symptoms among the respondents in respect to non-respondents. Another selection bias risk could be the healthy worker selection, as symphony orchestra musicians are a highly selected group .Mastering the instrument with rhythmic timing and perfect sound is a prerequisite for winning a position in an orchestra. This is the result of playing the main instrument for many years, of often having a music conservatory education, and of playing 6 or 7 days a week in order to maintain the level. The selection of the fittest must take into account the musician's psychological, audiological and musculoskeletal health, because performance anxiety, hearing disorders or musculoskeletal problems could necessitate giving up the dream of a place in a professional symphony orchestra -39. ThusThe group of respondents in the current study was representative of the whole occupational group in Denmark regarding participation by gender and by instrument group, two variables known for all members of the occupational group. Symphony orchestras are very similar worldwide with approximately the same instrumentation, the same hierarchical organization in the instrument groups, and the same way in which the instruments are played. The results are therefore indicative of the level of musculoskeletal problems of this occupational group world-wide, including the likelihood of a higher occurrence of musculoskeletal symptoms amongst female musicians. That the population of symphony orchestra musicians in this study was characterized by fewer and younger women than men was not caused by a drop-out of women from the orchestras but reflects what has largely been a male dominated profession in Denmark until about two decades ago, and which it still is in many countries.Comparable to professional athletes or even soldiers, professional symphony orchestra musicians are an elite occupational group with specific physical demands in their work including the necessity to practice for long periods to maintain a high level of performance. Recommendations for systematic research sequences to prevent injuries in sportsmen and soldiers could therefore be expected to be transferred to professional symphony orchestra musicians successfully -42. ApplWithin the last year most symphony orchestra musicians had experienced musculoskeletal symptoms in the neck, back or upper extremities. The symptoms impacted on their level of function in and outside work and were reflected in their health behaviour: Impact on playing, sick-leave, difficulty in daily activities at home, in leisure time, or in sleep, as well as use of analgesics and use of health care providers were all common consequences of the musculoskeletal symptoms in the occupational group of symphony orchestra musicians.Compared to the high strings players the woodwinds had a significantly lower risk, assessed as odds ratio, for perceiving musculoskeletal problems as well as for experiencing consequences due to the musculoskeletal problems. Finally the woodwind players also had a lower risk for pausing music playing activities as well as for taking sick-leave due to musculoskeletal problems. The group of low string players showed the tendency for having symptoms for more days. Brass players showed a statistically significant lower risk for pausing from practising, rehearsals, or not playing at concerts.Compared to a sample of the general workforce, symphony orchestra musicians of both genders had a higher prevalence of musculoskeletal symptoms, and the musicians also had more days of symptoms. Compared to the general workforce sample the distribution and frequency of symptoms in the symphony orchestra musicians would be indicative of their symptoms being work-related. Professional symphony orchestra musicians are a highly selected group and should be considered an elite occupation with a high risk of acquiring musculoskeletal symptoms.The authors declare that they have no competing interests.Conception and design of the study: HMP, JB, JWH. Data collection: HMP. Data analysis: HMP, JB, NW. Interpretation of data: CM, HMP, JB, JWH, NW. Writing the article: HMP, NW. Design of figures: CM, JB, HMP. Revising the article critically: CM, HMP, JB, JWH, NW. Final approval of the version to be published: CM, HMP, JB, JWH, NW. Guarantor of the paper: HMP, NW.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2474/12/223/prepub


Fatigue is an unavoidable part of a basketball game, which may affect an athlete’s performance. The aim of this study was to investigate the effect of upper extremity fatigue on grip strength and passing accuracy in basketball, and ascertain if the effects of different fatigue protocols on grip strength and passing accuracy are the same. Twenty-four juniors under 18 years old  volunteered to participate in the study, and were divided into two groups. After a warm-up, both groups performed the basketball passing test and grip strength was recorded for each group under three different testing conditions: rest, 70% and 90% exercise intensity. The protocol used for the first group was the chest press, and for the second group the wrist curls. Results show that after the upper extremity fatigue protocol all parameters of the study (grip strength and passing accuracy) showed a significant decrease, and there was no significant difference between both groups regarding grip strength and passing accuracy. The study suggested that in order to avoid upper extremity fatigue, basketball trainers and coaches need to include upper extremity conditioning exercises into their training sessions. Basketball is a game of continuously changing tempo, requiring speed, acceleration, explosive movements such as rebounding, passing, jump shooting, fast breaks and high speed play. The game also involves skills that must be applied dynamically, explosively and repeatedly . HandgrUpper extremity muscle strength and grip strength are the primary factors affecting passing accuracy. Grip strength is correlated with the strength of the upper extremity, general strength of the body and some anthropometric measurements . Grip pMuscle fatigue occurs with prolonged or repetitive use of a muscle group. The mechanism of fatigue is multifactorial and not fully understood, but it involves the central nervous system, peripheral nervous system, muscle units and individual muscle fibers. At the level of muscle cells, depletion of energy stores may be a significant factor . FatiguFatigue is especially important in a sporting context and in a team game such as basketball, fatigue may be the determining factor between winning and losing. The study of fatigue relative to performance of different skills has long been a subject of practical and scientific interest to strength and conditioning professionals, trainers, coaches and sport scientists. Research to date however, has provided conflicting and often contradictory findings, partly due to the inconsistent experimental designs and procedures used. According to the best of the researcher's knowledge, there is no study that has examined the effect of upper extremity fatigue on grip strength, and passing accuracy in basketball. Therefore, we decided to conduct this research because of the importance of grip strength and passing accuracy in basketball, which will seek to contribute to the lack of scientific information, Consequently the two main aims of this study were (1) to investigate the effects of upper extremity fatigue on grip strength and passing accuracy in basketball, and (2) to ascertain if the effects of different fatigue protocols on grip strength and passing accuracy have the same effect.Twenty-four male junior basketball players from 2 teams  volunteered to participate in this study. They were divided into two equally sized experimental groups. Before applying the fatigue protocols the researcher compared the two experimental groups in pre-test for grip strength and passing accuracy. No significant differences between the two groups were observed.Body height and body mass were measured with subjects in training clothes and barefoot. Body height was measured using a stadiometer, accurate to within 1 cm . Body mass was measured using a digital medical scale, accurate to within 0.1 kg .A portable digital hand dynamometer  was used to measure grip strength. Participants were evaluated in a standing position, arms at their side, not touching their body, elbows bent slightly. The participants were asked to squeeze the dynamometer three times with each hand. There was a one minute rest period between each trial in order to avoid the effects of muscle fatigue. The result of each trial was recorded to the nearest kilogram. The mean value of three squeezes was taken into account .This test was chosen because it is an appropriate test for assessing basketball passing skills. The test was validated by the American Alliance for Health, Physical Education, Recreation and Dance in 1984 using senior high school students. The test-retest approach computed reliability coefficients of 0.84 to 0.97 so the test is both valid and reliable.The test also required participants to pass the ball quickly and accurately, two elements fundamental to passing in basketball . The teTwo points were awarded for each chest pass that hit the target or on the target lines.One point was awarded for every pass that hit between the targets.No point was awarded if a player’s foot was on or over the restraining line, or if a pass other than a chest pass was used.The player stood behind the 8-foot restraining line, holding a basketball and facing the far left wall target (A). Then, an assistant played the CD, which emitted a three-beep countdown, and the fourth beep signaled the start of the test. Following the fourth beep, each player performed a chest pass to the first target square (A), recovered the ball while moving to the second target square (B), performed a chest pass to the second target (B). The player then continued this action until he reached the last target (F). While at the last target (F), they threw two chest passes then repeated the sequence by moving to the left, passing at targets E, D, C and so on. The only modification to the test was that it continued for just thirty seconds. Only chest passes were allowed. The scoring of the test was as follows:The test result was obtained by totaling all the points scored over 30 s.Participants lay flat on a bench with feet on the floor, arms extended upward, holding dumbbells with an overhand grip. They lowered the dumbbells to the chest level, bending elbows and rotating forearms to bring their hands into pronation , and exhaled to press dumbbells back up until arms were straight. After that, they slowly lowered the weight in a controlled fashion down to starting position. They repeated the movement for a desired number of repetitions. During the exercise protocol, each participant kept spine in a neutral position, and kept the head on the bench. The muscles engaged in this exercise were chest, shoulders and triceps .p< 0.05.All analyses were executed in SPSS for windows version 16.0 . Values were expressed as mean and standard deviation (SD). The independent samples t-test was used to determine the mean differences in grip strength and passing accuracy between the two experimental groups following upper extremity fatigue protocols. The paired samples t-test was used to compare the effect of upper extremity fatigue on grip strength and passing accuracy for each group. The level of significance was set at The present study was conducted to investigate the effect of upper extremity fatigue on grip strength and passing accuracy in basketball, and to ascertain if the effects of different fatigue protocols on grip strength and passing accuracy are similar. The results from this study showed that there were significant differences (p<0.05) in the performance between pre-test, post-test for group 1 which used the dumbbell chest press as a fatigue protocol. The paired samples t-test was used to examine the mean difference in the performance at rest and the performance under the influence of exercise intensity of 70% of RM in the dominant hand grip, non-dominant hand grip and passing accuracy for group 1. It showed that there was a significant difference (p<0.05) in the results between the performance at rest and the performance following moderate intensity exercise. The same t-test was used to examine the mean difference in the performance at rest and the performance under the influence of exercise at intensity of 90% of RM, in the dominant hand grip, non-dominant hand grip and passing accuracy. The results showed that there was a significant difference (p<0.05) in the performance between the performance at rest and that following high intensity exercise. The paired samples t-test was used to examine the rate of decline or the change in the dominant hand grip, non-dominant hand grip and passing accuracy for group 2 from the rest to exercise of intensity 70% of RM. Results showed that there was a significant difference (p<0.05) in the performance between the performance at rest and that following moderate intensity exercise. The same t-test was used to examine the mean difference in the performance at rest and the performance under the influence of exercise at intensity of 90% of RM, in the dominant hand grip, non dominant hand grip and passing accuracy. Results showed that there was a significant difference (p<0.05) in the results between the performance at rest and that following high intensity exercise. The independent sample t-test was used to test the difference in performance at exercise intensity of 70% of 1 RM between the two groups in the dominant hand grip, non-dominant hand grip and passing accuracy. The same t-test was used to test the difference in performance at exercise of intensity of 90% of 1 RM between the two groups in the same variables. Results showed no significant difference (p>0.05) in the performance between both groups. This means that the two fatigue protocols which were used had the same effect on grip strength and passing accuracy in basketball. Upper extremity muscle strength and grip strength is one of the factors affecting the accuracy of the passing and the grip strength is correlated with the strength of the upper extremity . From tTrying to identify the physiological mechanisms underlying fatigue effects on performance in this study is both challenging and highly complex. Additionally, mechanisms of fatigue are still not understood . The faThe major conclusion drawn from this study according to the results was that upper extremity fatigue with exercise intensity of 70% of 1 RM, and exercise intensity of 90% of 1 RM, had a significantly negative effect on grip strength, and passing accuracy in junior basketball players. There was no significant difference between the two groups in post-test for grip strength and passing accuracy. This means the two fatigue protocols used had a similar effect. This indicates that trainers and coaches in basketball should avoid upper extremity fatigue, which may affect the level of performance. Therefore, they need to include upper extremity exercise into their training sessions. In the future it would be noteworthy to study whether and how fatigue impacts on some other skills in basketball, which were not discussed in this study. Most of all, it would be interesting to find out whether fatigue causes quantitative and qualitative changes in the passing technique, and to analyse these changes.