Five to 25 percent of residents in aged care settings have a combined hearing and visual sensory impairment. Usual care is generally restricted to single sensory impairment, neglecting the consequences of dual sensory impairment on social participation and autonomy. The aim of this study is to evaluate the effectiveness of a self-management program for seniors who acquired dual sensory impairment at old age.In a cluster randomized, single-blind controlled trial, with aged care settings as the unit of randomization, the effectiveness of a self-management program will be compared to usual care. A minimum of 14 and maximum of 20 settings will be randomized to either the intervention cluster or the control cluster, aiming to include a total of 132 seniors with dual sensory impairment. Each senior will be linked to a licensed practical nurse working at the setting. During a five to six month intervention period, nurses at the intervention clusters will be trained in a self-management program to support and empower seniors to use self-management strategies. In two separate diaries, nurses keep track of the interviews with the seniors and their reflections on their own learning process. Nurses of the control clusters offer care as usual. At senior level, the primary outcome is the social participation of the seniors measured using the Hearing Handicap Questionnaire and the Activity Card Sort, and secondary outcomes are mood, autonomy and quality of life. At nurse level, the outcome is job satisfaction. Effectiveness will be evaluated using linear mixed model analysis.The results of this study will provide evidence for the effectiveness of the Self-Management Program for seniors with dual sensory impairment living in aged care settings. The findings are expected to contribute to the knowledge on the program’s potential to enhance social participation and autonomy of the seniors, as well as increasing the job satisfaction of the licensed practical nurses. Furthermore, an extensive process evaluation will take place which will offer insight in the quality and feasibility of the sampling and intervention process. If it is shown to be effective and feasible, this Self-Management Program could be widely disseminated.NCT01217502.ClinicalTrials.gov,  As people age, the increasing chance of acquiring a combined hearing and visual impairment adds to the risk of dependency on informal and professional care. In the Dutch population of people aged 80 and over, 5 to 25 percent have a dual sensory impairment (DSI) acquired at old age; the highest percentages were found among seniors living in residential care settings .People with DSI experience barriers in communication, mobility, and information access ,3, and DUsual care for seniors with DSI aims to reduce the effects of single sensory impairment, for example by providing technical devices, in some cases supplemented by communication strategies for hearing-impaired seniors, or by training in reading and daily living skills of visually impaired seniors. In some West European countries , home-dwelling seniors with DSI have access to services designed for deafblind adults who acquired dual sensory impairment at an earlier stage in life. These services offer support from social workers and interpreters to address the participation restrictions. In contrast, DSI seniors living in residential care settings are often deprived of special support. Health-care settings are found to be environments where there is limited awareness of the hearing and visual impairment of the patients, leading to a lack of supportive measures in the social and physical environment ,13. HearBased on what we know from the limited number of available trials, self-management strategies can be expected to be beneficial for sensory-impaired seniors , with a This trial aims to evaluate the effectiveness of a self-management intervention for DSI seniors living in aged care settings. We chose cluster randomization in order to avoid contamination resulting from the effects of possible exchange of information by nurses within the age care setting. We hypothesize that the intervention group will have a more favorable development in social participation, and in nurses’ job satisfaction than the control group. In addition, we hypothesize that seniors suffering from depressive feelings will benefit more from the intervention, and that intervention outcomes at both the level of the seniors and of the nurses will be associated with the adherence of the nurses to the program.The study is designed as a cluster randomized, single-blind controlled trial Figure . A clustThe study sample will consist of age care settings where DSI seniors live. The inclusion criteria for the aged care settings are (1) care organizations offering residential care to seniors, (2) with nursing teams assigned to one setting or location. The inclusion criteria for the care professionals are (1) provision of regular direct daily care (at least twice a week) to the participating senior, (2) qualified as a licensed practical nurse, that is, a three-year basic nursing vocational training at secondary level, and (3) consent given to participate. The inclusion criteria for the seniors are (1) aged 55 or over, (2) a hearing loss of PTA ≥40 dB , (3) a vTo assess cognitive functioning, we will use the DSM IV criteria for capacities in executive functioning: planning, organizing, sequencing and abstracting . These cDSM IV criteria, capacities for executive functioning:–planning–organizing–sequencing–abstractingStep 1. Create valid communication conditionsa. Adapt your output to the auditory and visual needs of the DSI personAdapt your articulation, face orientation, rhythm and tempo of your speech, and adapt conditions such as lighting, distance, height, and exclude glare and environment noise. If provided, ask the senior to use his/her familiar (hearing) devicesb. If the person does not understand your speech, switch to writingAdapt size, color and contrast of your writing, adapt paper and pencil typec. Structure your informationDivide your information into clear parts, avoid sentences with multiple clauses, and pause between each sentence to give the older person time to absorb and comprehend the informationStep 2. Observe cognitive functioninga. Find proof that the person comprehends your introductionIs he aware who you are?Does he comprehend that you want to provide information about a research project?Does he concentrate on you or your information?Is he trying to understand and comprehend?Or does he repeatedly ask who you are, and what you want? Does he persist in talking about his/her own issues or in continuing with own activities?b. Induce the senior in cognitive planning and reasoningAsk the persons’ help or preference in planning your next visit; invite him to choose between two or three alternatives (planning)Invite the person to talk about his experiences with his hearing and vision, and the adaptations he has already established Invite the person to tell you what a normal day looks like Invite the person to tell you what a weekend day looks like Observe the contribution of the senior during this conversation: are his reactions adequate answers to your questions? Are his answers coherent?We will start recruitment of the aged care settings by sending an invitational email and an information brochure to the board and the scientific committees of aged care organizations, followed by a personal visit to those organizations interested in participating. Nurses at the participating settings will screen seniors using the Severe Dual Sensory Loss screening tool (SDSL), a questionnaire validated for the Dutch population for DSI . If the Cluster randomization occurs after inclusion of seniors in the trial. Settings where no senior participates are therefore not included in the randomization.The study will be single-blinded, which means that seniors, nurses and trainers will be aware of the allocation arm but will be blinded to the results of any previous assessments. The outcome assessors will be blinded to allocation of the aged care setting of the seniors and the nurses.In this study, the self-management program aims to empower and enable seniors to develop confidence and motivation in the use of their own skills, using resources to participate in a good, safe and emotionally satisfying life in the context of their dual sensory impairment. The SMP-DSI focuses on three self-management tasks to help DSI seniors regain autonomy in their daily lives: 1) to take care of the medical and rehabilitation aspects of the disease ; (2) to carry out normal activities to sustain social participation (role management); and (3) to manage emotional changes as a consequence of being chronically ill  . The pro to take Nurses in the intervention group will be trained to support the seniors using the SMP-DSI program. The training program consists of nine meetings over a five to six month period, totaling about 18 hours, divided into three rounds; each round consists of a three-hour training session, a 1-hour coaching on the job session, and a one and a half hour supervision session. An interval of two to three weeks is planned between each meeting to give the senior-nurse pairs the opportunity to practice the SMP-DSI in daily care situations.Training. The training sessions provide nurses with the background and theory of the SMP-DSI, and focus on the conversational and supporting interview methods needed to assist senior clients in their process of self-management. Each training session involves clearly defined goals and home assignments.1. Coaching on the job. Individual coaching sessions are held to address nurses’ individual experiences regarding the application of the SMP-DSI in practice. Nurses reflect on the process and results of their professional performance.2. Supervision. Participating nurses from different intervention clusters share their experiences using the SMP-DSI and discuss any issues.3. Training and supervision sessions are group meetings attended by nurses from one or more settings and led by a trainer. The on-the-job coaching is conducted in individual sessions between the nurse and trainer. Nurses keep two semi-structured diaries: a diary on the interviews with their senior, and a diary with their own learning experiences and consecutive learning goals. Five qualified nurses with long experience of supporting dual sensory impaired seniors will be coached to deliver the SMP-DSI training program to the participating nurses.Seniors in the control group will receive care as usual, mostly using personal technical devices.At senior level, the primary outcome measure is social participation, as measured by the Hearing Handicap Questionnaire (HHQ) ,26 and tAt nurse level, the outcome measure is job satisfaction, as measured by the Maastricht Job Satisfaction Scale for Healthcare (MJSSH) , a questIn addition, at senior level we will collect at baseline sociodemographic, personality and communication characteristics. The following variables will be recorded: age, marital status, highest completed education, profession (before retirement), preferred communication modality , use of hearing or visual devices. Data on functional status will be collected by administering the basic activities of daily living relevant for the target group  and the Two research assistants will collect the data from both seniors and nurses at baseline, and at five to six weeks after the end of the intervention. The research assistants will be blinded for group allocation, and each participant will be followed up by the same assessor. All data from the seniors will be obtained during one-to-one interviews at the senior home environment; data from nurses will be obtained using a written questionnaire. Nurses who meet the participation requirements of 80% will receive a participation certificate from Radboud University Nijmegen and the Kalorama Foundation.For practical reasons, we expect to be able to include 14 to 20 aged care settings, with a maximum of 132 DSI seniors and their nurses. Improvement in either one of the two social participation scales , is considered a success; study success is defined as a statistically significant difference on either HHQ or ACS. The enrolment of 14 to 20 settings will enable us to detect an effect size of 0.7 or larger with 80% power on either HHQ or ACS  of 0.36 standard deviation (SD)), based on the following reasoning: (1) Randomization is at the level of the aged care setting to avoid contamination that may arise should control group nurses come into contact with DSI senior nurses in the intervention group. (2) Uncorrected for clustering, a sample size of 32 per group is needed for the mentioned effect size and power . (3) Given a prevalence of 20% and accounting for low participation rates as found in most studies of very aged and medically compromised seniors, and an average size of a setting (100 to 200 seniors), we expect to recruit five to ten DSI seniors per setting. Typically, a nurse at each setting will coach one to two seniors, so that five nurses from one setting will be involved. Thus, seniors are nested within nurses within aged care settings. To account for this clustering (assuming an intra-nurse correlation between seniors of at most 0.3 and an intra- setting correlation between nurses of at most 0.10), the sample size has to be increased by a factor between 1.12 (if each setting has five nurses each with one senior) and 1.54 (if each setting has five nurses each with two seniors) . In ordeDescriptive statistics (mean standard deviation or median and interquartile range) will be used to describe the baseline characteristics of the aged care setting and of the seniors. We will use a linear mixed model to analyze the outcomes and to account for clustering of seniors within nurses within the settings and for repeated measurements. The influence of relevant/prognostic characteristics of aged care setting/seniors on the outcomes will also be investigated by including these as covariates.The analysis will be based on all the resulting data using the intention-to-treat principle. Moreover, a per protocol analysis and a regression analysis with the adherence to intervention protocol (see below) will be performed to assess the influence of compliance. For all tests, significance will be tested using two-sided tests with an alpha level of .05.In order to assess the internal and external validity of the study, we will evaluate process data on sampling quality  and on intervention quality . The data will be performed alongside the SMP-DSI study, and the process evaluation will be executed prior to the effect analysis. Quantitative and qualitative data will be collected from the research database, the intervention diaries and the coaching diaries of the nurses, the semi-standardized records of the trainers, the assessors, the research assistants and the researcher.To evaluate sampling quality, recruitment and randomization will be defined by description of the recruitment and randomization procedure for the aged care settings; the informed consent and allocation procedure of the seniors; and by description of the barriers and facilitators to the recruiting of the aged care settings, nurses and seniors. Reach will be determined by the proportion of the seniors participating in the SMP-DSI and the number of nurses involved in the intervention.To evaluate the intervention quality, we will analyze adherence and treatment delivery using data on the frequency and extent to which the SMP-DSI was performed by each pair of senior and nurse, and data on attendance of nurses in the training program. We will also describe the reasons for refusal before the start or during the intervention by aged care setting, nurse and senior. Relevance and feasibility will be defined by the nurses’ diaries and learning goals, the trainers’ training and coaching evaluations, and opinions of the seniors, nurses and trainers about the program. Incentives and barriers toward treatment delivery at the level of aged care settings, nurses and seniors will be classified using the Grol and Wensing framework .In accordance with the Dutch Medical Research Involving Human Subjects Act (WMO), this study has been approved by the Committee on Research involving Human Subjects of the Arnhem-Nijmegen region, ABR 26192.091.08.All participating seniors will be requested to sign a consent form prior to data collection.In this paper we describe the study design for a Self-Management Program for seniors with a Dual Sensory Impairment (SMP-DSI) living in aged care settings, with the aim of improving social participation and autonomy in seniors and job satisfaction in nurses.This study adds to usual care by expanding the role of the professional caregivers who offer daily care to seniors whose autonomy is threatened. For reasons of feasibility, we only included licensed practical nurses as they are the professional caregivers who offer the majority of the daily care in aged care settings in the Netherlands, but the SMP-DSI could also be used by healthcare assistants or nurse assistants. In the Netherlands, licensed practical nurses and nurse assistants are specially trained in the provision of somatic care and in responding to challenging behavior, but little attention is given to methods aiming at improving seniors’ autonomy and self-management. A strength of this study is that the consecutive coaching sessions offer the professional caregivers solid opportunities to get acquainted with the intervention. However, the long training period increases the risk of drop-out among the aged and vulnerable seniors.Some specific issues on assessment and outcome measures need to be discussed. First, the assessment of hearing and visual impairment necessary to identify eligible seniors may contribute to the awareness among seniors and nurses of the presence of a DSI, and may influence usual care, resulting in a decrease of the potential effect. Second, we assess cognitive functioning using the DSM IV criteria in relation to the performances needed when executing self-management strategies. Third, we had to tackle a methodological difficulty concerning the selection of outcome measures. As no validated outcome measures on social participation were available for the dual sensory impaired senior population, we selected two outcome measures: one validated for hearing impaired seniors, and one validated in a number of samples of older adults, and adapted for visually impaired seniors. In addition, we included several secondary outcome measures that each captures one or more aspects related to the consequences of a dual sensory impairment, such as mood, autonomy and functional decline . Moreover, as depressive feelings may impact the results, mood will be considered as an effect modifier for the analysis.Finally, as recruitment for trials in residential settings and logistic planning is often a challenge, in the research team we will include special members who have access to an extensive network of care providers for seniors, and we will organize the training sessions in the region of the intervention clusters, adopting flexible schedules for the aged care settings. If the SMP-DSI proves effective in the aged care setting, wider implementation will be recommended in order to improve the social participation and autonomy of the seniors.The trial is currently recruiting aged care settings.The authors declare that they have no competing interests. None of the funding agencies had any role in preparing, reviewing or approving the manuscript. They will not be involved in the collection, analysis or interpretation of the data.MVD developed the project and obtained funding. LRM is the investigator, has developed the materials for the study, and drafted the manuscript. MVD, GK, MG, SZ and PH contributed to the conception and design of the study, and reviewed and commented on drafts of the manuscript. ST wrote the statistical methods and reviewed drafts of the manuscript. All authors read and approved the final manuscript.


We followed up a series of 23 Parkinson's disease (PD) patients who had performed an immersive virtual reality (VR) protocol eight years before. On that occasion, six patients incidentally described visual hallucinations (VH) with occurrences of images not included in the virtual environment. Curiously, in the following years, only these patients reported the appearance of VH later in their clinical history, while the rest of the group did not. Even considering the limited sample size, we may argue that VR immersive systems can induce unpleasant effects in PD patients who are predisposed to a cognitive impairment. Nowadays, there is an increasing emphasis on the application of technology in the assessment and rehabilitation of neurological diseases and one of these technologies is Virtual Reality (VR). While the literature is limited, there are research programs studying this application specifically in Parkinson's disease (PD). As such, understanding the usefulness, the limitations, and the considerations in the application of the technology is important to both scientific and clinical communities.In the past few years, strong scientific production has sustained the role played by external cues, such as visual ones, in the multisensory rehabilitative approach to PD .VR technologies combined with treadmill training have been successfully used to ameliorate gait in PD –4 by meaAn occasional negative impact of immersive VR systems on PD patients has been preliminarily reported also for the postural control .We previously , 9 reporThese observations generate the need to find a clinical reason that may explain the unpleasant effects of VR immersion and help us better understand where the positive effects of VR technology end and the negative ones start.A relationship between VH and cognitive impairment in PD has been tentatively established: PD patients with VH show a prolonged choice reaction and a stimulus discrimination deficit , as wellAim of the present study was to study retrospectively after eight years all the 23 cases who participated in the first VR study , in ordeIn the 2005 study , 9, the PD patients performed their virtual actions worse than the controls in terms of time of execution, exploration, pointing, and precision in avoiding obstacles. None of the controls complained of any disturbances, such as minor transient effects (nausea or vertigo) or visual abnormalities.Although none of the participants reported ever having experienced VH, during the off-state virtual session, six PD patients incidentally reported an occurrence of images not included in the virtual environment .The “object” of VH was the same for all patients. According to their descriptions, it seems that in all cases the patient preserved the insight that the hallucinated image was inappropriate at that point of virtual navigation, but they did not appear surprised or worried about this visual experience.We reviewed the clinical history of all six patients who experienced VH: none had previously reported anything similar to illusions or sensations of presence or passage.In 2013, we tried to follow up all 23 PD patients of the previous study. According to an agreement between the Local Association of Patients and the Division of Neurology and Neurorehabilitation of the Istituto Auxologico Italiano Piancavallo (Verbania), Italy, all patients may be visited at least once per year. The visits included a clinical update via a neurological exam (UPDRS motor part)  and a nePatients were retrospectively divided into two groups according to the results of the first study: with VH  and without VH .In the VRVH group, one patient had died and one had undergone deep brain stimulation surgery (but was still included in the follow-up); in the second group (WVRVH), four patients had died and two patients could not be found. Thus, 5 of the 6 patients in the VRVH group and 11 of the 17 patients in the WVRVH group completed the follow-up .While none of the patients in the WVRVH group presented any hallucination in their clinical history, all six patients of the VRVH group reported the appearance of VH during the course of their disease. Curiously, the dead patient in the first group developed VH during their clinical course, while the four dead patients of the second group did not.Demographics and clinical characteristics of the groups at baseline and eight years later at the follow-up are shown in  a priori, highlighting that only VR was able to make a prediction in this sense. In fact, according to neuropsychological tests, the logistic regression forecasted that no patients would report VH; however, during VR six patients incidentally described VH confirmed eight years later. This result makes how VR highlighted a phenomenon that cannot be predicted with standard neuropsychological tests evident.In Even with the limited sample size in this study, we reported a correlation between complaining of VH during a VR immersion and further appearance of VH in the clinical picture.This finding leads us to two relevant observations concerning VR technology: (1) it can potentially induce unwanted effects in PD patients; and (2) there are questions about its usefulness in predicting further development of VH in PD.To our knowledge, in the literature there are no reports of unwanted effects concerning VR sessions for PD patients; our findings seem to be in contrast with the increasing claims of usefulness of VR in the rehabilitation approach of these patients –4, 16.One explanation is that most VR methodologies used in rehabilitation programs for PD are not immersive or projected-based systems that strongly reduce the sense of presence, which may be considered a trigger for unwanted effects, especially those regarding the visual system.VR experiences are pooled by a common step-simulation by the interaction . One of This feeling of presence, which in adult subjects is modulated by the prefrontal cortex-visual system loop , is striVarious pathogenic models have been considered to explain VH in PD, such as the hypersensitivity of mesolimbic receptors due to dopaminergic denervation during a dopaminergic treatment , the derVH are one of the most typical symptoms among the behavioural disturbances observed in PD, affecting about one-quarter of patients. Several descriptions reported the presence of formed images as inanimate objects or indefinite/not fully formed images, sensation of presence (persons-guardian angel), or simply illusions consisting of the misinterpretation of images, with the overlap of humanoid or animal tracts on animated objects .Curiously, VH can also include the feeling of an abnormal “presence” (a vague and erroneous perception that another person or threat is present) or “passage” hallucinations  .The presence of VH during VR immersion is an interesting and unexpected finding, as few side effects following immersion in VR have been previously reported in literature. Research conducted on a group of healthy individuals evidenced transient reduced binocular vision after wearing a head-mounted display for just ten minutes , which wVH in VR navigation show similarities with VH usually evoked in the clinical history of PD patients, such as preserved awareness, only a moderate impact of stress, and the incidence of images resembling animals (three of six patients in the present study).The VH shown by our patients always occurred only during “off-medication” periods.Other authors  reportedWe can argue that a reduced dopaminergic state is correlated with an altered sense of presence, such as that observed in children whose immature prefrontal brain structure would lead them to an increased susceptibility for the experience of presence . Thus, aVarious prospective studies , 32, 33 In the present study, the comparison between the two groups shows that the L-dopa eq/die of the WVHVR patients is substantially lower at the baseline than in the follow-up, so that the Hoehn/Yahar stage and UPDRS part III score. These data would support the assumption that visual hallucinations, cognitive impairment, and motor scores seem to run in the same direction , 11.However, our findings can only raise and not solve the question of whether VR technology can potentially be considered a useful tool to predict who could further develop VH.Indeed, our study is limited by the restricted number of cases and by the fact that a repetition of the VR session was not included in the clinical follow-up. Moreover, as the VH were an unexpected side effect at that time, visual performances (such as color discrimination and contrast perception) of all patients have not been investigated.In consideration of the growing use of VR in PD treatment, the first intent of this paper is to alert the scientific community about the possibility of unwanted effects when immersive systems are used.Moreover, we describe a link between past and further occurrence of VH in VR and clinical history, respectively, but only further controlled studies with larger numbers of cases will lead to the answers.


Increased tooth loss is associated with age and number of risk factors including diabetes, tobacco use, IL1+, and cardiovascular disease. Conclusion: These trends suggest that older patients and those with more risk factors should seek further preventive care to reduce future tooth loss.Background: Certain risk factors such as tobacco use, diabetes, genetic variations on the IL1 gene, and other inflammatory conditions are hypothesized to predict tooth loss in patients treated in a large medical center. Tooth loss trends are hypothesized to be greater in patients with more risk factors. Methods: DNA samples for 881 individuals were taken from the Dental Registry and DNA Repository at University of Pittsburgh School of Dental Medicine. Clinical data for all 4137 subjects in the registry were also available. SNP genotyping was performed on the samples for IL1α (rs1800587) and IL1β (rs1143634). IL1 positive status was determined as having one or more of the recessive alleles for either SNP. Tooth loss status was determined based on dental records and data gathered for age, sex, ethnicity, and self-reported medical history. Various statistical analyses were performed on the data including genetic association analysis by the PLINK software, chi-square, Mann-Whitney U, and ANOVA tests to determine significance. Results: Tooth loss averages increased with age by all risk factors (smoking, diabetes, hypertension, and interleukin genotypes;  In dentistry, the traditional claims of “everyone should go to the dentist twice a year” and/or “everyone should brush their teeth three times a day” are actually not based on evidence. They are supported by common sense and the perception that these guidelines appear to be right for most of people. The selection of an appropriate recall interval for patients is quite difficult  since thRecent years have brought a renewed interest in the impact of oral health on overall health. Gum inflammation  has been linked to a number of adult diseases, which include cardiovascular conditions and premature births. The two common bacteria-mediated diseases of the mouth, dental caries and periodontal diseases, continue to be highly prevalent and are the leading causes for tooth loss. Tooth loss is associated with poorer quality of life. Evidence shows that 80% of the burden of these diseases is confined to 25% of the population. So it would be most beneficial to focus public health efforts in identifying and implementing more aggressive preventive strategies for the segment of the population which needs the most care .Pittsburgh is the largest city adjacent to one of the poorest areas in the USA, Appalachia. The Appalachian mountain range extends across 13 states in the United States from New York to Mississippi. Positive core values associated with the region include strong sense of community, strong family support systems and social ties, religious affiliation, pride in self and family, independent self-reliance, the importance of justice, loyalty, religion, faith in god, strong work ethic, trustworthiness, and a feeling of belonging in the mountains. More problematic stereotypes and/or cultural norms are also associated with the region, such as fatalistic outlook, distrust of outsiders, and distrust of formalized medical systems. Independent from these data, quantitative data clearly show socio-economic indicators are much worse for the communities in the Appalachian region compared to those in the rest of the United States (reviewed in ). In regAn analysis of the self-reported medical history adjusted by sex, age, and ethnic background indicated that individuals who smoked, had diabetes, or cardiovascular diseases had statistically more tooth loss . TherefoPittsburgh is the largest city in the Appalachian region of the United States, and one of the poorest in the country. Pittsburgh has had fluoridated water since 1953; however, nearly half of the children in Pittsburgh between six and eight have had cavities according to a 2002 State Department of Health report . More thThe most common reasons for tooth loss are dental caries and periodontal diseases. In our sample, particularly for the group under 50 years of age, dental caries is the main reason individuals lost their teeth. Interleukin 1 composite genotypes have been investigated for a role in periodontitis, both looking at the progression of disease, as well as treatment outcomes, but results are inconclusive and the suggestion of performing systematic genetic testing for periodontitis has been challenged (reviewed by ). Our daIn aggregate, these data indicate a model of personalized dentistry in which individuals receive a customized schedule for their periodic dental visits is warranted. A portion of the population that “tests” positive for a higher risk for tooth loss based on smoking and diabetes status, blood pressure levels, and interleukin 1 genotypes should visit the dentist more often, as much as four to six times per year. Individuals can potentially be tested as early as adolescence since the pathological processes and risk factors associated with the development of cardiovascular diseases have been shown to begin in childhood, and similarly, the incidence of type 2 diabetes reported in children has increased substantially (reviewed in ). In con® chemistry as described previously [At the time of these analyses, 4137 subjects from the University of Pittsburgh School of Dental Medicine Dental Registry and DNA Repository  approval #0606091) were available for study. Starting in September of 2006, all individuals that seek treatment at the University of Pittsburgh School of Dental Medicine have been invited to be part of the registry. These individuals give written informed consent authorizing the extraction of information from their dental records. Tooth loss was defined as the total number of teeth extracted due to caries or periodontal disease. Teeth extracted due to orthodontic reasons, trauma, or congenitally missing did not contribute to the total count per subject. Longitudinal data to estimate tooth loss overtime was not available for all individuals in the population and tooth loss was defined according to the most recent visit to our clinics. The average age of the population is 48 years and we decided to analyze further the data based on individuals younger and older than 50 years of age with the assumption that individuals younger than 50 years are less impacted by periodontal diseases and most of their tooth losses can be attributed to dental caries. Further stratification did not provide additional insight [eviously . The mareviously , chi-squIndividuals with hypertension, diabetes, those who smoke, or have certain interleukin 1 genotypes have higher frequency of tooth loss. Tooth loss is more dramatic in individuals that accumulate more than one of these risk factors.


Disease prognosis is very poor in patients with brain tumors. Cognitive deficits due to disease or due to its treatment have an important weight on the quality of life of patients and caregivers. Studies often take into account quality of life as a fundamental element in the management of disease and interventions have been developed for cognitive rehabilitation of neuropsychological deficits with the aim of improving the quality of life and daily-life autonomy of patients. In this literature review, we will consider the published studies of cognitive rehabilitation over the past 20 years. Brain tumors represent 2% of the total incidence of cancer. They can occur at any age but they are more common in the elderly. The primary adult tumors include meningiomas, schwannomas, primary CNS lymphomas, and gliomas of the cerebral hemispheres .High-grade gliomas (HGG), WHO grade III or grade IV , 2, are Given the poor prognosis of many brain tumors, the primary objectives of the therapy are to reduce morbidity and restore or preserve neurologic functions and the capacity to perform daily activities as long as possible.It is widely accepted that brain tumors and related treatments can impair cognitive function across many domains and can have an impact on patients' quality of life. Cognitive deficits in patients with brain tumors can be caused by the tumor itself, by tumor-related epilepsy, by treatment , and by psychological distress . Cognitin = 13, 16.25%), memory , attention , logical-executive functions , and visuospatial abilities .In 139 patients with brain tumor, Tucha et al.  found thA recent review of the literature by Gehrke et al.  indicateCognitive rehabilitation in glioma patients may have an important role achieving both an improvement in neurocognitive functions and a better quality of life after treatment . CognitiStudies assessing results of cognitive rehabilitation in brain tumor have appeared only recently in the literature.Cognitive remediation/rehabilitation therapy is based on the principles of neural plasticity of the brain. It is a type of rehabilitation that offers exercises aimed at improving various domains of cognition such as attention, memory, language, and executive/control functions. The expected result is an indirect positive impact on functional deficits affecting everyday life. Proper treatment with these therapies can help enhance the social and professional integration of patients.Two main types of exercises are used for this treatment: compensation and retraining. In retraining, we retrain brain functions with regularly repeated exercises specific for the deficient aspect of a cognitive function. This is referred to as restoring the deficient function. Another rehabilitation technique is to work with the preserved cognitive functions by compensation techniques. In this case, the patient will be encouraged to develop alternative means to achieve goals. New strategies can include the use of planners, checklists, or memory notebooks. These two forms of training work together: restorative processes help to develop compensatory strategies and vice versa. The final goal is to increase functionality of patients .The purpose of this concise literature review is to analyze the research carried out with the specific aim of rehabilitating cognitive function in patients with cerebral tumor.We also wanted to ascertain whether any real benefit is associated with these neuropsychological training interventions and the difficulties related to the specific research protocols in this field.An online literature search was performed in PubMed, Medline, and Web of Science for articles published between January 1995 and December 2015. In addition, the reference list of all identified publications was checked. The following search terms were used: brain tumor, glioma, cognitive therapy, exercise therapy, cognitive rehabilitation; cognitive remediation therapy, and neurocognitive training.Studies were included if all of the following criteria were met: adult patients aged ≥18, primitive brain tumors including gliomas, and studies written in English. Randomized control trials, clinical trials, observational trials, and retrospective trials were included. In total, 42 articles were found, 6 were excluded because they were duplicates, and 21 because they were either congress abstracts or were not written in English.We found 15 publications regarding cognitive rehabilitation ; 7 were The study population includes patients with primary brain tumor and, in particular, patients with high-grade glioma (HGG) and low-grade glioma (LGG) and their caregivers in nonpharmacological cognitive rehabilitative intervention studies. One publication included both patients and caregivers  and two Taking into account the instruments used for the assessment of cognitive functions before and after training, we can see that, in selected studies, various data collection methodologies are employed see . If we tYang et al.  investigIn their study, Zucchella et al.  proposedGehring et al.  evaluateIn the study by Locke et al. , researcHassler et al.  assessedIn the observational study carried out by Maschio et al. , patientSherer et al.  retrospeAlso, with regard to the rehabilitation training programs used in the studies taken into account, we can find various types of training programs administered. Each program also included a different number of training sessions and follow-up sessions .The rehabilitation program used by Yang et al.  used virIn Zucchella et al.'s  program The study by Gehring et al.  aimed toIn the study by Locke et al. , the rehRegarding the Hassler et al.  study, tMaschio et al.'s  study aiIn Sherer et al. , the goaYang et al. , in inteIn the study by Zucchella et al. , at the Gehring et al.  found thIn the study by Locke et al. , at the In Hessler et al. , the evaMaschio et al.'s  cognitivResults of the study by Sherer et al.  demonstrIntact cognitive function is necessary for patients with brain tumor to have good quality of survival and independence in everyday life.Usually, cognitive rehabilitation is rarely offered to patients with brain tumor because they are not seen as potential clients due to their poor prognosis.Rehabilitation training typically used with patients with brain tumors is borrowed from studies of cognitive rehabilitation in patients with other acquired brain injuries. It is possible that rehabilitation training used in patients with other brain injuries has not had the same results in patients with brain tumor. This type of patients has different cognitive deficits because they usually have no site specific deficits  but more global cognitive deficits.A methodological limit of some of the studies considered is that they did not have a control group , 16, 19.Among the studies taken into account, none included a placebo group. This would be the best condition of study to be taken into account. A study without a placebo group cannot state with certainty that the changes of the study group are only due to the effect of training , 39.In most studies, however, to include a placebo group is considered unethical and impractical.One way to cope with this problem is to create a control group that does not initially benefit from the treatment, being inserted onto the so-called waiting list as Gehring et al.  did in tAnother problem was the different type of brain tumors analyzed in the studies. For example, in the largest and very important study of Gehring et al. , there wAnother critical point is that these patients were studied at different times during the treatment: one study  enrolledIn the studies taken into account for this review, we have seen that different tests were used to assess cognitive functions. In a noteworthy retrospective study , the tesYet, the training programs used in the various studies were different and not comparable. Indeed, some authors principally used computer programs –15, whilThis implies that even though they measured the same domains of specific functions, it cannot always be possible to compare the results of various tests, because they measure different specific aspects of a particular cognitive domain.It is not clear what the best timing of assessment and training is and what intensity should be used. To date, no guidelines exist indicating when and in what kind of patients an intervention with cognitive rehabilitation may be useful. The study by Gehring et al.  has a trIt seems to be important to train patients early before surgery. In this period, cognitive reserve of patients can be used to try to recover cognitive functions before starting other treatments . AnotherAs reported by various studies, the residual cognitive deficits have a major impact on perceived quality of life of patients. Considering this, it is understandable how important it is to also include in the evaluation of patients a detection of the quality of life at the beginning and the end of the treatment, to see if a real positive effect was achieved also from this point of view.Unfortunately, not all studies considered QOL assessment , 18.IDH1 and IDH2 gene status and MGMT gene promoter methylation could be important in order to program neurocognitive rehabilitation. Indeed, those genes are important prognostic factors in glioma patients; in particular, IDH1 and IDH2 can be mutated in low-grade and anaplastic glioma, as well; in fact, mutations of IDH1 and IDH2 genes are found in 70% of grades II and III gliomas and secondary glioblastomas [Recently, various studies showed that, in addition to the different types of treatments carried out, a number of specific molecular features linked to cancer may affect the presence of cognitive deficits in patients with brain tumors . InvestiRegarding ApoE gene, Correa et al.  found thIt is very difficult to draw firm conclusions on the basis of the studies considered. In the reported studies, research designs are different, as well as the number of patients, the disease diagnosis, the tests used, and the adopted rehabilitation training.As shown by the various studies, a cognitive rehabilitation program involves a large commitment in terms of time and compliance of both patient and relatives who accompany him. Because of this, many patients often cannot participate because of the long distance from the treatment center or because no one can accompany them or because they tire of the program over time. Despite these problems and those arising from differences in the assessment of cognitive functions and implementation of the rehabilitation program, the reviewed studies reach the conclusion that a rehabilitation intervention can be very useful in patients with glioma and, more generally, in patients with other brain tumors , 10. MorIn conclusion, it seems that the studies conducted up to now bring back the encouraging results on the application of rehabilitation techniques on deficit in cognitive function in patients with cerebral tumor. Patients and family members seem to be satisfied with the results and it seems that patients benefit from greater autonomy in everyday life and that family members have a lesser burden. It is important that future studies in exploring this topic be structured in an appropriate manner, by providing a control group and a randomized selection of patients in the groups. Knowledge of specific genetic mutations involved in the development of cognitive deficits may be directed to personalized cognitive rehabilitation programs and to minimizing the appearance of deficit.


Nature and Science, may signify the epitome of successful interdisciplinary integration of research knowledge and cross-disciplinary dissemination of findings. But how interdisciplinary are they? The journals are multidisciplinary, but do the individual articles themselves draw upon multiple fields of knowledge and does their influence span disciplines? This research compares articles in three fields  published in a leading disciplinary journal in each field to those published in Nature and Science. We find comparable degrees of interdisciplinary integration and only modest differences in cross-disciplinary diffusion. That said, though the rate of out-of-field diffusion might be comparable, the sheer reach of Nature and Science, indicated by their potent Journal Impact Factors, means that the diffusion of knowledge therein can far exceed that of leading disciplinary journals in some fields .Interest in cross-disciplinary research knowledge interchange runs high. Review processes at funding agencies, such as the U.S. National Science Foundation, consider plans to disseminate research across disciplinary bounds. Publication in the leading multidisciplinary journals,  Interest in cross-disciplinary research knowledge interchange runs high. US funding agencies, including the National Science Foundation and the National Institutes of Health, as well as the National Academies of Science –4, promoFacilitating Interdisciplinary Research:Elsewhere we have explored interdisciplinary research counterposed against other forms of research, expressly disciplinary and multidisciplinary, with note of the potential of developing future fields via transdisciplinarity to go beyond previous fields –8. Colle“Interdisciplinary research (IDR) is a mode of research by teams or individuals that integrates information, data, techniques, tools, perspectives, concepts, and/or theories from two or more disciplines or bodies of specialized knowledge to advance fundamental understanding or to solve problems whose solutions are beyond the scope of a single discipline or area of research practice” p. 188) [88 [1].integration of knowledge . A key distinction arises between interdisciplinary–as reflecting a greater degree of integration–and multidisciplinary–as more reflecting juxtaposition [The essence here is the requirement of position , 9.Nature or Science  signified in itself the successful interdisciplinary integration and diffusion of findings.In recognition of the promise that interdisciplinary research holds for addressing complex scientific problems with societal implications, the National Science Foundation (NSF) directs grant reviewers to consider a proposal’s plan to disseminate findings across disciplinary bounds in order to have a broader impact. One of us (GS), a program director at NSF, has frequently heard panelists reviewing grant proposals, program directors reviewing progress reports, and external evaluators reviewing the impact of funding programs comment as if publication in Nature and Science? Articles in them are explicitly chosen not only because they move their specific literatures in important ways, but also because of their potential to interest–and to influence–multiple segments of the scientific community. To be sure, one has merely to pick up an issue at random to see authors from a wide range of scientific departments and institutions, questions pursued using a wide range of methods, and references drawn from a wide range of literatures. In our investigation, we recognize that Nature and Science are surely multidisciplinary, but here we explore the extent to which their content (their articles) are interdisciplinary.But does it? How interdisciplinary are What does multidisciplinarity at the level of the journals indicate about the integration and diffusion of knowledge at the level of individual articles? Researchers can appear to be promiscuously interdisciplinary, publishing with multiple collaborators in multiple fields, when at the individual project level they are serially monodisciplinary, each publication hewing closely to a particular literature. Similarly, the goal of many funding programs is the creation of a multidisciplinary portfolio of research projects. When evaluated at the level of the portfolio, they appear successfully interdisciplinary, but when evaluated at the level of individual funded projects they can look decidedly monodisciplinary . Level oNature and Science articles to those appearing in prominent disciplinary journals in those selected fields. Our focal questions: Are Nature and Science papers more interdisciplinary? And do Nature and Science papers diffuse strikingly more widely?Our overarching research questions concern patterns of research knowledge transfer across fields, motivated by the hypothesis that interdisciplinary research offers compelling promise in advancing science and solving complex societal problems. We translate these interests to examine empirical evidence on citation patterns across scientific fields, comparing Nature and Science because they are the two leading multidisciplinary journals–based on reputation, explicit editorial policy, Web of Science Subject Category , and prestige–fortified by their very high Journal Impact Factors (JIF). Though JIF tells a limited story [Nature’s and Science’s high JIFs do indicate that their articles are read and cited. A lot. Using JIFs from the 2010 Journal Citation Reports, we find Nature at JIF = 36.1 and Science at JIF = 31.4. We utilize Web of Science (WoS) as a leading database indexing fundamental research published in over 12,000 journals.We chose ed story –14, NatuData challenges led us to limit our exploration to select fields, mainly because collection and cleaning of sets of citing records is extremely expensive, both in terms of time and funding. Articles typically cite 30 or more references, resulting in a huge multiplier. Furthermore, articles in the top multidisciplinary journals–of special interest to us–accrue many citations. For example, one compilation of 545 publications we examined drew 60,425 cites.Nature and Science, we focused on a sample of articles that appeared in a single year, 2009, in each of three fields–a life science (Cell Biology), a physical science , and a behavioral science (Cognitive Science). These choices resulted from discussions with NSF colleagues about candidate fields in terms of coherence and mainstream interest, and empirical forays regarding journal coverage. We observed that any given issue of Nature or Science might have multiple articles on Cell Biology, whereas it might have none on Physical Chemistry or Cognitive Science.In order to address questions of the interdisciplinarity of We then sought to identify a comparison set of top disciplinary journals. As a starting place, we used the Web of Science Subject Categories (WCs) to identify the set of journals in each field covered by WoS. We then considered journals with relatively high JIFs for their fields (one indicator of impact), looked to whether they were the flagship journals of the major professional societies in the fields, and again consulted with NSF colleagues on prestige and reputation. We selected the following:Cell (JIF = 32.4)Journal of Physical Chemistry A (JIF = 2.8)Cognitive Science (JIF = 2.3)Nature and Science articles to disciplinary articles and refrain from field-to-field comparisons.We recognize that the wide range in impact of the journals affects the relative diffusion of research knowledge across disciplines. As the above JIFs attest, citation practices vary greatly by field . JIF infNature and Science and the disciplinary journals, while taking best advantage of the articles available for 2009. We did not include in our sample articles that had fewer than four references to WoS journals as that would have rendered the interdisciplinarity metrics unreliable. Using these criteria, we gathered a sample of 1643 Nature and Science articles published in 2009.Number of publications to assess was another consideration. Obtaining sufficient publications factored into our field, journal, and temporal (one year) selections. We decided that looking at publications appearing in 2009 would support conclusions that are reasonably current, yet allow sufficient time (5 years) for papers to accrue citations; we note that there are many issues in tracking citation over time [Cognitive Science is considered by definition to be a Cognitive Science article. But how to categorize Nature and Science articles? We considered various ways to classify articles, including assignment based on review of titles, keywords, or abstracts by disciplinary experts. The greater subjectivity of such judgments, combined with the sheer numbers of papers to be examined, rendered the approach less attractive (though not inappropriate). We also considered coding authors’ disciplines based on departmental affiliation. That would have proven problematic. First, it is not clear who the lead author of an article is. In some fields, the first author can be assumed to be the lead, in others it is the last. Moreover, Nature and Science do not always show departmental affiliation. And even when they do, the specificity of our fields does not always satisfactorily match the available information–“Physical Chemistry” would not usually be the name of a department or center. Furthermore, affiliation information gleaned from WoS records is inconsistent and deciding on field boundaries is tricky. Further ambiguity arises with multiple authors who reside in different departments or even individual authors with multiple departmental affiliations.A key challenge was to determine what constitutes an article in a target field. For the three disciplinary journals, we took publication in the chosen journal as the selection criterion–that is, an article appearing in Nature or Science article’s cited references as a viable, reproducible, and somewhat more objective indicator of field ties. We follow Schunn [Nature and Science and include all of those for which 25% of the references are in a particular field. We recognize that this approach tiptoes toward tautology, but we reasoned that if, for example, at least 25% of an article’s references were not to articles appearing in Cell Biology journals, it would be difficult to consider the article to be a Cell Biology article. As a further check, we sampled entire issues of Nature and Science from our dataset and found that for every article there was at least one field that accounted for at least 25% of its references. This is not to say this need be true for the entire dataset, but our inclusion criterion would not appear to have biased our dataset in a systematic fashion.We shifted to examination of a w Schunn  whose coVantagePoint software [Nature and Science article selection requires consideration of multiple factors. Reflecting on our selection of “disciplines” to study regarding multidisciplinary knowledge transfer patterns, we are using WCs. The names suggest the tendency of fields of study to intersect and integrate over time. Again, in consultation with disciplinary experts and scope provided by professional societies, we include the following WCs for our fields:To perform the categorization, we apply a thesaurus in software  to standCell Biology: CELL BIOLOGY; BIOCHEMISTRY & MOLECULAR BIOLOGYPhysical Chemistry: CHEMISTRY, PHYSICAL; PHYSCIS, ATOMIC, MOLECULAR & CHEMICALCognitive Science: BEHAVIORAL SCIENCES; COMPUTER SCIENCE, ARTIFICIAL INTELLIGENCE; LINGUISTICS; PSYCHOLOGY; PSYCHOLOGY, APPLIED; PSYCHOLOGY, DEVELOPMENTAL; PSYCHOLOGY, EDUCATIONAL; PSYCHOLOGY, EXPERIMENTAL; PSYCHOLOGY, MATHEMATICAL; PSYCHOLOGY, MULTIDISCIPLINARY; PSYCHOLOGY, SOCIALNature and Science in 2009, our search, using the WC-based operationalization described above, yielded 339 Cell Biology articles, 61 Physical Chemistry articles, and 34 Cognitive Science articles. All of the selected Nature and Science articles are in only one of the three field categories; that is, there is no overlap. Preliminary analyses on the metrics described below showed no significant differences between articles in a given field appearing in Nature as opposed to those appearing in Science. Therefore, because the numbers of articles in Physical Chemistry and Cognitive Science appearing in Nature and Science were relatively low, and those in Cell Biology so high, the articles appearing in the two journals were pooled. As the pooled number of Cell Biology articles was so great, we randomly selected 50 articles from Science and 50 from Nature. Finally, we randomly sampled 50 articles appearing in 2009 from each of the three disciplinary journals  for inclusion in our dataset as the foil to the Nature and Science articles.Of the 1643 articles appearing in Measuring interdisciplinarity remains a challenge . IntegraIntegration scores reflect distance among WCs based on the relative degree to which one WC’s journals cite those of the other 223 WCs in a given year of WoS –26. For pi is the proportion of references citing the WC i in a given paper. The summation is taken over the cells of the WC x WC matrix. sij is the cosine measure of similarity between WCs i and j—based on cross-citation among WoS journals in a given year (we use 2010 here). We report findings in terms of means, though we recognize that citation distributions are generally non-normal. For reporting purposes, use of means appears reasonable in that our focus is on scores that are constrained to a range from 0 to 1. That said, the analyses below were conducted using nonparametric statistics. As noted, WCs whose journals frequently cite each will be scored as more similar. If a given article cites a number of references from an array of academic disciplines distantly related it is said to be relatively integrative.Integration scores can be expressed as:citing WCs. While Integration scores are backward looking in that they measure diversity among cited references, Diffusion scores are forward looking in that they measure diversity among papers that refer to a given body of work. Scholarship cited by a broad array of distantly related academic disciplines is said to be relatively diffuse [Diffusion scores can be thought of as Integration in reverse. The formulation is the same, except using the set of papers referencing the given paper to obtain the  diffuse .Given that citations for a given article can accrue ad infinitum into the future, Diffusion scores can change over time. Hence, we want to compare papers of approximately the same age. Carley and Porter  provide We also use the WCs in a somewhat rougher fashion to determine whether a citing paper is out-of-field or in-field. If the citing article’s journal is categorized into any of the WCs for one of our three fields of interest, we considered it to be an in-field citation, even if the journal is also categorized in some other WC.  For exTo be sure, cross-disciplinarity is but one dimension of knowledge creation and diffusion; one could certainly consider others. And measures of cross-disciplinarity could use units other than WCs, such as departmental affiliations or final academic degrees of co-authors . But WCsNature and Science. The mean Integration score of 0.22 for the Cell Biology articles in our study is highly disciplinary, approaching the lowest score derived in the benchmark study, 0.21 for “Mathematics.” The mean of 0.42 for Nature and Science articles in Physical Chemistry is similar to the relatively interdisciplinary score of 0.40 derived in the benchmark study for “Atomic, Molecular, and Chemical Physics,” and the mean of 0.54 for the Cognitive Science articles exceeds the highest Integration score in the benchmark study, the 0.43 derived for the related field of “Neuroscience.”The mean Integration scores for the journals in each field can be seen in Nature and Science within each field are not significantly more interdisciplinary than are those sampled in the disciplinary journals, as indicated by preplanned Mann-Whitney U tests comparing the Integration Scores of the references in our sample. As can be seen more qualitatively in Nature and Science articles are not terribly different from those cited by the disciplinary journals within each field.Critically, the articles in Nature and Science are not generally more interdisciplinary than are those appearing in top disciplinary journals, as measured by their cited references (putative influences on the research conducted), they might yet be shown to be more multidisciplinary in the diversity of the papers citing them (putative impact). Given the great number of eyeballs scanning the pages of Nature and Science and the disciplinary diversity of their owners, the question at hand is whether gaze translates into influence. In order to answer this question, we next examine the articles that cite the sampled articles.Even if papers appearing in U tests reveal no significant mean differences between Cell Biology articles appearing in Cell and those appearing in Nature and Science, nor for the Physical Chemistry articles appearing in the Journal of Physical Chemistry—A versus those appearing in Nature and Science. As was the case when looking at the journals cited by our target articles, the top five journals citing the target Nature and Science articles in these fields are not qualitatively different from those of the disciplinary journals . Significant, but the relatively small differences between means is hardly what one would have expected given the reputations of Nature and Science for multidisciplinary reach.nals see . The stoNature and Science, let us consider raw citation counts. Do articles appearing in Nature and Science garner more citations out-of-field? As can be seen in Nature and Science is about the same as the total citations of articles appearing in Cell. This makes sense, given their similar JIFs. More to the point, the mean number of citations in out-of-field journals is also about the same.Before we dismiss the idea of there being a substantial cross-disciplinary knowledge transfer advantage for articles appearing in Nature and Science  are cited as often as are those appearing in Nature and Science, and they are cited as often out of field. But articles appearing in Nature and Science are cited far more often than are articles in such top disciplinary journals as the Journal of Physical Chemistry–A and Cognitive Science, and so the articles in them are cited more times out of field.The lack of substantial differences in the rate of multidisciplinary diffusion notwithstanding, the raw impact of Nature and Science, with Physical Chemistry and Cognitive Science, represented by relatively low numbers of articles. Indeed, articles in the latter two fields appear so infrequently that one might question how representative of the field they are. Certainly Nature and Science could not be said to be journals of record in those fields. It is an empirical question whether these results might hold for other disciplinary journals within those fields. For example, we chose what we thought would be more focused contrast cases. We might instead have chosen to look at journals that reach across subfields within each discipline, such as the Journal of the American Chemistry Society, Psychological Science, or PLOS Biology. We might also have chosen other prominent multidisciplinary journals, such as PLOS ONE, PNAS, or Journal of the Royal Society Interface. And it is an empirical question what an examination of other disciplines would reveal.It is worth considering several methodological and analytic decisions we made in this study. We contrasted Cell Biology, a life science with relatively high numbers of articles appearing in Nature and Science and those in the disciplinary journals were not great. It is beyond the scope of this paper to address concerns about which measure of interdiscipinarity is best at addressing more subtle questions, such as what are optimal levels of interdisciplinarity in citations or in team composition. Suffice it to say that we were not looking for subtle effects.Another important methodological decision in work of this type is choice of measures. As we noted above, there is no consensus on indicators of interdisciplinarity. We chose to use Integration and Diffusion scores, based on the Rao-Stirling diversity index, because of the appeal of its underlying conceptual basis , its standing in the scientometric community, and the existence of published benchmarks against which we could compare our results. But a case could certainly be made for using other measures. Zhang, Rousseau, and Glanzel , for exaNature and Science through the attention drawn by various publics quite distinct from citation by formal research communities [We further acknowledge that bibliometric analyses themselves provide an imperfect perspective, especially for evaluative purposes, as Lane and others note, , 17, 35.munities –39. And,munities . We alsomunities )?Nature or Science was not matched by a similar diversity at the level of the individual article.Clearly, our paper is meant to be less of a definitive work and more of an exploration of how one might go about addressing such issues of interdisciplinarity and multidisciplinarity. And to that end our findings certainly demonstrate that level of analysis matters. As always in science, one must take care to square the kinds of claims one would like to make with the kinds of evidence produced. In this case, the extreme diversity of the articles appearing in any given issue of should the articles in Nature and Science be? We could not say. Upon reflection, our finding of the lack of substantially increased interdisciplinarity in the articles is actually quite reasonable, given the missions and editorial policies of the journals. Articles are chosen for publication in Nature and Science because, foremost, they are the products of excellent science. The history of science suggests that paradigm-busting work, as it were, is most productive when the science demands it [How interdisciplinary mands it . InterdiNature and Science signify the successful multidisciplinary diffusion of findings? Well, yes, to some degree. The articles appearing in them are not inherently of greater interest to “outsiders” as indicated by measures of the diversity of citing articles, but, in keeping with differences in JIF, they can attract a markedly greater number of out-of-field citations, likely deriving in part from their vetted quality and high profile. But even this claim must be qualified, for it varies by field. Thus, the moral of our story, at least for Physical Chemists and Cognitive Scientists seeking a broader impact: Do excellent work and publish it in Nature or Science.Does publication in


Bangladesh has achieved remarkable progress in healthcare with a steady decline in maternal and under-5 child mortality rates in efforts to achieve Millennium Development Goals 4 and 5. However, the mortality rates are still very high compared with high-income countries. The quality of healthcare needs improve to reduce mortality rates further. It is essential to investigate the current quality of healthcare before implementing any interventions. The study was conducted to explore the perception of healthcare providers about the quality of maternal and neonatal health (MNH) care. The study also investigated patient satisfaction with the MNH care received from district and sub-district hospitals.Both qualitative and quantitative methods were used in the study. Two district and 12 sub-district hospitals in Thakurgaon and Jamalpur in Bangladesh were the study settings. Fourteen group discussions and 56 in-depth interviews were conducted among the healthcare providers. Client exit interviews were conducted with 112 patients and their attendants from maternity, labor, and neonatal wards before being discharged from the hospitals. Eight physicians and four anthropologists collected data between November and December 2011 using pretested guidelines.The hospital staff identified several key factors that affected the quality of patient care: shortage of staff and logistics; lack of laboratory support; under use of patient-management protocols; a lack of training; and insufficient supervision. Doctors were unable to provide optimal care because of the high volume of patients. The exit interviews revealed that 85 % of respondents were satisfied with the hospital services received. Seven out of 14 respondents were satisfied with the cleanliness of the hospital facilities. More than half of the respondents were satisfied with the drugs they received. In half of the facilities, patients did not get an opportunity to ask the healthcare providers questions about their health conditions and treatments.The quality of healthcare is poor in district and sub-district hospitals in Bangladesh because of the lack of healthcare personnel and logistic support. An integrated quality improvement approach is needed to improve MNH care service in district and sub-district hospitals in Bangladesh. The World Health Organization (WHO) estimates that nearly 289,000 women died of complications during pregnancy or childbirth in 2013, and among them, 99 % of all maternal deaths occurred in the developing countries of Sub-Saharan Africa and South Asia –6. HowevMaternal and neonatal deaths are usually associated with a poor health environment and a serious lack of healthcare resources, including medicines, healthcare professionals, and healthcare infrastructure , 8. PoorIn the developing world, including African countries, healthcare systems suffer from various inadequacies related to staff training, prenatal screening, knowledge and use of evidence-based protocols, prompt cesarean delivery, multidisciplinary care, and lack of quality improvement (QI) support . A weak High maternal and neonatal deaths and stillbirth rates along with the inadequacies and dissatisfaction of healthcare providers and recipients indicate that the quality of healthcare is poor in Bangladesh . An evalHowever, very few studies have been carried out to assess the quality of healthcare services in Bangladesh, including the MNH care provided by the public hospitals. This study was conducted to explore the perception of healthcare providers regarding the quality of their MNH care, as well as to investigate patients’ satisfaction with their MNH care from the district and sub-district hospitals in Bangladesh.Mixed-method approaches  were adopted to collect data between November and December 2011. Specifically, group discussions (GDs) with healthcare administrators and professionals and in-depth interviews (IDIs) with paramedics and ancillary staff to explore healthcare providers’ perception on the quality of care. Client exit interviews were conducted with patients and their attendants to assess their satisfaction with the healthcare received at the facility.Fourteen public hospitals in Thakurgaon and Jamalpur districts were purposively selected as the study settings based on assessment of progress towards achievement of MDGs 4 and 5. Thakurgaon was selected for high performance and Jamalpur for low performance .The study settings were district-level hospitals, comprising two district hospitals and two maternal and child welfare centers (MCWCs), and ten sub-district-level hospitals called upazila health complexes (UHCs). UHCs are primary healthcare centers and the first point of referral. Each of these health complexes serves a population of between 200,000 and 400,000 and has a bed capacity of between 31 and 50.Participants for GDs and IDIs were selected purposively. The healthcare administrators and professionals at MNH services, including consultants, medical officers, nurses, and family welfare professionals, and visitors to three types of healthcare facilities were selected for GDs. The IDIs were conducted with paramedics and ancillary staff, including laboratory technicians, pharmacists, and maternal and neonatal ward supervisors and staff Table . They weThe GDs and IDIs with healthcare professionals explored the following aspects of MNH service provision: perceptions and experiences of MNH service provision, barriers to providing quality MNH services to the patients, and suggestions regarding how to improve the quality of MNH services.In conducting GDs and IDIs, semi-structured open-ended questions with probes were used and pretested in one of the public hospitals not included in the study. The qualitative data was collected by a team comprised of two physicians and one anthropologist. Four teams were involved in the data-collection process and they received three days of training from the investigators before they conducted GDs and IDIs. The teams visited each hospital to collect relevant data. GDs and IDIs took 120–150 and 30–40 min to complete, respectively. The interviews were audio taped and handwritten notes were made. In each type of session, a facilitator requested one of the participants to express his/her perception about the MNH services provided to the patients from their healthcare facility. This was an ice-breaking exercise as well as a thought-provoking mechanism for the participants. The facilitator then gradually introduced a series of prompts to encourage discussion about their perception on the quality and availability of healthcare infrastructure, cleanliness, services, training, and adequate personnel and logistics, laboratory support, use of patient-management protocols, and the necessity of training and supervision.The collected qualitative data was analyzed following a thematic approach. First, the audiotape record and handwritten notes were transcribed and then the transcripts were checked and validated. A thematic framework was developed with the coding of transcription undertaken by using this framework. Finally, the data was charted and interpreted.A convenient sampling method was implemented in the exit interviews to help recruit the respondents (mothers of newborns or their attendants) who had received services from maternal, labor, and neonatal wards at least 3 days following discharge Table . AttendaThe data was collected by two physicians. Four teams were involved in the data-collection process. The teams visited each hospital and interviewed the patients discharged during that day or their attendants. A total of 112 exit interviews were conducted, with eight from each hospital.For data collection, a structured questionnaire was developed through workshops attended by obstetricians, pediatricians, and relevant program personnel from the Bangladesh Ministry of Health and Family Welfare. The structured questionnaire was first developed in English and later translated into Bangla for the use of the respondents. To check its internal validity, the Bangla version was back-translated into English. The prepared questionnaires were pretested in a public hospital not included in the study. The pretested structured questionnaire included questions related to the patient waiting time to receive care, level of satisfaction with the cleanliness of the hospital, drug supplies, adequate time given by healthcare professionals and the opportunity to ask questions, and the MNH services provided to the patients. The data was entered into Epi-Info  and analyzed by both Epi-Info and SPSS . The mean age and percent distribution of the satisfaction level of the clients were calculated. The Chi-squared test for p value was calculated to obtain the significance of the differences in the various areas of satisfaction levels of the clients in different hospitals.The study was approved by the Ethical Review Committee of the Centre for Injury Prevention and Research, Bangladesh. Informed consent was obtained from each of the participants involved in the IDIs and GDs. In conducting the exit interviews, written consent was obtained from the patients or their attendants. All three types of written consents were obtained after explaining to the participants about the purpose of the study and the importance of their views as service providers and clients.For privacy and confidentiality of information, the study participants were reassured that all information received would remain anonymous and the collected data would be used for this research only. They were also informed that their participation would be voluntary and they could withdraw from the interview at any point.Hard copies of the collected data were kept in a secured place. The interviewers and investigators had access to the audiotape data. The electronic databases were secured by setting a password and had access only to the investigators and the data manager involved in the study.The results of this study have been described in two parts. The first part is qualitative, which covers the perception of healthcare providers and support staff on quality care. The second part covers the results of the quantitative method, where patients’ satisfaction on quality of care was assessed through exit interviews.GDs with the managers and senior-level professionals at healthcare service providers and IDIs with the lab technicians/pharmacists, ward masters/nursing supervisors, ancillary staff at the maternal or neonatal ward, and the cleaners of all 14 hospitals were organized in the Thakurgaon and Jamalpur district hospitals. All respondents in both types of interviews stated that the MNH services had rapidly expanded because of a MNHI program. At the facility level, the MNHI program provides technical support to implement facility-based emergency obstetric care and neonatal healthcare services with a special focus on quality care through the development of human resources, strengthening the referral system, timely supply/procurement of logistics and drugs, regulating MIS and linking it with the community, and organizing coordination and review meetings/workshops. It also mobilizes ample resources to encourage innovation and strengthen healthcare systems for better performance. However, the quality of care was still a great concern. The main issues affecting the quality of healthcare services revealed by the healthcare providers were: i) shortage of personnel, workload, and overcrowding, ii) inadequate logistics and laboratory support, iii) under use of patient-management protocols, iv) lack of training, and v) insufficient supervision.The GD and IDI data showed that most of the participants from all 14 facilities in both districts perceived that a shortage of personnel at different levels was the main barrier to ensure the quality of care in their facilities. The majority of the respondents mentioned that they were not very happy with the present situation of the quality of care in these hospitals. In terms of the volume of work, the respondents exceeded their existing capacities to deliver healthcare to their patients.In a GD, one of the doctors from Jamalpur District Hospital said, “This is a 100-bed hospital, but we have around 250 patients. This is very difficult for us. On average, each doctor serves 40 patients a day.”Regarding the shortage of hospital beds and infection control, during a GD one of the doctors from the neonatal ward of the Jamalpur District Hospital stated, “This is a 100-bed hospital, but there are always about 300 patients staying here. Two thirds of patients share a bed and naturally, it is very easy to transmit infections from one patient to another. Therefore, we are using antibiotics for almost all patients to prevent hospital-acquired infections.”In another GD, the medicine specialist at Thakurgaon District Hospital described his experience as: “I need to work 96–100 h a week. It is really difficult for a person to work in this way for a long time and to maintain the expected quality of work.”During a GD, a medical officer at Jamalpur MCWC said, “After delivery, when the mother and the baby are both in a bad condition, we are in great trouble. To whom should I attend, the mother or the baby?”Similarly to respondents from the district hospitals and MCWCs, most of the respondents from the UHCs also reported the shortage of human resources in their facilities, which caused an overloading of their responsibilities.In the IDIs, about half of the ward masters and nursing supervisors, and all of the ancillary staff of all surveyed healthcare facilities reported that because of the shortage of personnel they were overburdened with a heavy workload, which was similar to the findings of the GDs. As a result, they could not provide quality healthcare to their patients. All the cleaners interviewed suggested to take measures to restrict visitors because the wards often become messy and dirty because of overcrowding by visitors.Almost all of the healthcare providers at the 14 facilities stated that they lacked logistic support in the drug-dispensary, laboratory, and imaging services, and the blood bank. They also emphasized that their facilities did not have adequate infrastructure.In a GD, a doctor from an UHC in Thakurgaon district said, “Our X-ray machine is not working. We have an incubator, but we do not have its operator. So it is useless…. There are only two doctors available in the hospital”.The doctors and nurses at all the UHCs noted during their GDs that because of the lack of a blood bank, they could not manage their patients with ante- or postpartum hemorrhages and the quality of care could not be ensured. On the contrary, healthcare providers at the two MCWCs said that logistic support was available and they could maintain some standard of quality care. However, they expressed that there were opportunities to improve the quality of care further.During IDIs, most of the ward masters and nursing supervisors said that because of an inadequate and irregular supply of logistics and medicines and the lack of a blood bank, it was difficult to manage regular healthcare activities. All laboratory technicians interviewed stated that they performed routine laboratory tests only. Although they had the expertise to perform other important laboratory tests, they could not perform these tests because of the unavailability of the required instruments and reagents.Regarding the use of patient-management protocols, the majority of the respondents of GDs conducted in the district hospitals reported that they had protocols on eclampsia and diarrhea. However, it was not always possible for them to follow those protocols because of the shortage of personnel. One of the nurses from the Jamalpur District Hospital said, “We can’t always provide care according to the protocol due to shortage of personnel.”However, most of the participants from the two MCWCs in the GDs expressed that they could follow the patient-management protocols to manage postpartum hemorrhage and eclampsia patients. Participants from most of the UHCs mentioned that they only used protocols to treat diarrhea and tuberculosis cases, and to provide postnatal and neonatal care. They opined that quality of care could be much better if they could use protocols for other health events.Healthcare providers expressed their concern about not receiving any in-service training and refresher courses in obstetric and neonatal care, in particular in general and emergency management. They noted that several important and new management issues in obstetrics are emerging, in which they need to be well versed. This critically affects the quality of care rendered to the women and often results in loss of life. The providers’ dissatisfaction with a lack of training and refresher courses was expressed in a GD by one of the obstetricians at Thakurgaon District Hospital: “Since I qualified, I remember that I only attended an obstetrics life-saving skills training and a post abortion care course. But I cannot remember what we were taught; I need a refresher course”.In response to the question regarding training, the majority of the IDI respondents, including nursing supervisors and laboratory technicians, mentioned that training could be a good initiative for an improved quality of care. The cleaners, who did not receive any sort of professional training, said that it would be an advantage for them to learn how to work better if they could have some training in future. According to their perceptions, in-service training needs to be organized regularly to enhance the quality of healthcare.Both doctors and nurses reported that there was no supervision of their clinical work by their higher authorities. They said that merely having management guidelines was not enough to maintain the quality of care, as they often did not have time to follow the guidelines during emergencies.The following quote from a GD by a medical officer at Jamalpur District Hospital depicts the situation regarding supervision: “I feel there is no supervision at this hospital because when we are working in the labor ward, we work alone and we manage the wards by ourselves”.In IDIs, when the participants were asked about monitoring and supervision, the majority of the respondents stated that the monitoring and supervision processes at their hospitals were weak. When they were asked if they would accept a system of accountability, all reported affirmatively. They expressed that a system of accountability would boost their morale to work more sincerely and with more responsibilities. They also considered that the system could stop unauthorized absences from the workplace.Healthcare providers from all the hospitals were willing to participate in a quality-assurance process if it really helps them to improve their working environment. The healthcare providers suggested that these QI issues should be discussed at a national level and solutions should come from there. In both GDs and IDIs, the respondents reported that training should be organized for all types of healthcare providers to help them maintain a standard of quality healthcare services. In addition, many participants proposed that extra incentives should be offered to the healthcare providers to motivate them to improve their quality of care. They also suggested that there should be a body, including service providers, nongovernmental organization partners, and political parties, responsible for the monitoring and supervision of all types of facility activities to ensure the quality of care.In this study we assessed the clients’  level of satisfaction regarding the quality of care they received. The distribution of the clients or their attendants is provided in Table Clients’ perception of satisfaction were judged in six areas: 1) waiting time to receive care from healthcare providers after entering the hospital; 2) cleanliness of the hospital; 3) adequate time given by the healthcare providers; 4) the opportunity to ask the healthcare providers questions about their care; 5) satisfaction with the drugs received from the hospitals; and 6) satisfaction with the MNH services received from the hospital.From the exit interviews, it was revealed that the average mean waiting time before being seen by a healthcare provider was 10.95, 9.67, and 4.79 min at district hospitals, MCWCs, and UHCs, respectively.p = 0.001). Regarding drug dispensing, 75.0 % and 56.2 % of the clients of the district hospitals and UHCs were satisfied; however, only 25.0 % of the respondents from the MCWCs were satisfied with the drugs they received (p = 0.015). More than three-fourths of the respondents of all three types of hospitals mentioned that physicians had given enough time to them. There was no statistical significant difference (p = 0.405) in the proportions of the respondents’ response on time given by the physicians among the three types of healthcare facilities. However, when the same clients were asked whether they had enough opportunities to ask questions to the physicians regarding their health issues, only 31.0 % of the respondents from the district hospitals replied positively and a small proportion of the clients of the MCWCs and UHCs  had opportunities to ask questions. These differences were statistically significant (p = 0.045). More than 87.0 % of the clients of all three categories of hospitals were satisfied with the MNH services they received during their stay at hospital; however, no statistical difference was observed (p = 0.834)  than at district hospitals and MCWCs . The difference was statistically significant . However, the quality of care remained debatable . This stIn this study, it was revealed that because of an inadequacy of beds and patient overcrowding, sometimes two or three patients share one bed and they have a higher chance to develop hospital-acquired infections and compromise quality care. Likewise, emergency departments are also overloaded with patients. The findings from a number of studies show that overcrowding in the inpatient and emergency departments contributes to poor quality of care –23.In the current study, doctors and nurses acknowledged that the insufficient supply of laboratory support and an absence of blood-transfusion systems have an effect upon the quality of the diagnosis and treatment of the patients. A similar situation was revealed in two studies conducted in Bangladesh and Malawi , 24.Furthermore, our study showed that doctors, nurses, and other healthcare professionals did not always use medical protocols to provide standardized care in these medical settings. However, written protocols are a prerequisite for standardized patient care .Most of the doctors and nurses mentioned that they did not receive any formal training or refresher training after their graduation from medical colleges or nursing institutes, which promotes their lack of efficiency to provide quality of care. From an educational impact of a hospital-based neonatal resuscitation program in Ghana, it was revealed that practical evaluation of knowledge and skills improved from 58 % to 81 % after postgraduate training, and this improvement continued for 9–12 months after training . In our Although healthcare providers at all three categories of hospitals opined that they were unable to provide quality of care, most patients at the same hospitals were highly satisfied with the services they received. These two findings were self-contradictory.Studies conducted in Bangladesh showed that the major contributing factors of being satisfied were short waiting times and a long consultation time with healthcare providers , 28. In The mixed methodology matrix was the strength of this study, as throughout we tried to find perceptions from multiple perspectives to enhance and enrich the meaning of quality of care of the healthcare facilities. Here, qualitative and quantitative data were merged to develop a more complete understanding about the perception of both types of respondents, as well as compare and validate the surveyed data.Some limitations exist in this study. First, the sampling of facilities was not randomized, but they included all the district and upazila hospitals in the two districts. However, there are 593 public health facilities in 64 districts of Bangladesh . BecauseThe quality of MNH care is poor in district and sub-district hospitals in Bangladesh because of a lack of healthcare personnel and logistic support, including equipment, essential drugs, and laboratory needs. This information could be used to strengthen the national-level policy for improving the quality of MNH care at the facilities. In each type of public hospital in Bangladesh, there area fixed number of healthcare personnel and a fixed amount of logistic support, as specified by the GoB. However, the population of each district or sub-district is not the same. Therefore, a change in the policy is required to ensure the distribution of healthcare personnel and logistic support should be proportionate to population of the district or sub-district. In our study, it was also revealed that healthcare providers were dissatisfied with their quality of care; however, the majority of their patients were satisfied with their level of care. This is mainly because the patients were unaware of their health rights. An awareness-raising activity should be launched to educate patients that it is their right to obtain quality care.