Childhood obesity prevention is a public health priority in industrialized countries. The Reggio Emilia Local Health Authority has implemented a program involving primary and secondary prevention as well as the care of obese children. There are many health-promoting mobile apps, but few are targeted to children and very few are sponsored by public health agencies.The goal of the research was to describe the process and tools adopted to cocreate a mobile app sponsored by the Reggio Emilia Local Health Authority to be installed in parents’ phones aimed at promoting child health and preventing obesity.After stakeholder mapping, a consulting committee including relevant actors, stakeholders, and users was formed. Key persons for childhood obesity prevention were interviewed, focus groups with parents and pediatricians were conducted, and community reporting storytelling was collected. The results of these activities were presented to the consulting committee in order to define the functionalities and contents of the mobile app.Three key trends emerged from community reporting: being active, playing, and being outdoors; time for oneself, family, and friends; and the pressures of life and work and not having time to be active and socialize. In focus groups, interviews, and labs, mothers showed a positive attitude toward using an app to manage their children's weight, while pediatricians expressed concerns that the app could increase their workload. When these findings were explored by the consulting committee, four key themes were extracted: strong relationships with peers, family members, and the community; access to safe outdoor spaces; children’s need for age-appropriate independence; and professional support should be nonjudgmental and stigma-free. It should be a dialogue that promotes family autonomy. The app functions related to these needs include the following: (1) newsletter with anticipatory guidance, recipes, and vaccination and well-child visit reminders; (2) regional map indicating where physical activity can be done; (3) information on how to manage emergencies ; (4) module for reinforcing the counseling intervention conducted by pediatricians for overweight children; and (5) a function to build a balanced daily diet.The pilot study we conducted showed that cocreation in health promotion is feasible, with the consulting committee being the key co-governance and cocreation tool. The involvement of stakeholders in this committee made it possible to expand the number of persons and institutions actively contributing to the project. Obesity, its metabolic consequences , and its risk factors  are responsible for the vast majority of disability-adjusted life years lost worldwide and in industrialized countries in particular ,2. In ItIn 2010, the Reggio Emilia Local Health Authority (LHA) started a program of research and interventions aimed at preventing childhood obesity. The program adopted a multilevel and multisetting strategy for primary prevention in the community (particularly in infant-toddler centers and preschools and in primary and secondary schools); secondary prevention ; and maRecently, several health promotion apps have been developed -11, whicThe efficacy of any health promotion effort depends on its ability to reach and engage the target population. New information technology (IT) tools can help by tailoring the intervention and framing the message according to each family’s needs ,16. HoweCocreation is a process to plan and define public services specifically aimed at reducing the mismatch between beneficiary needs and provided services. Its application in health services and prevention has been recommended ,18, in pThe aim of this paper is to describe the process and tools adopted for cocreating an app to be installed on parents’ mobile phones aimed at promoting childhood health and preventing obesity.This pilot study, using mixed-method research, is one of 9 included in the CoSIE project . This innovative action is aimed at producing guidance on how information and communications technologies can support the process of service cocreation in Europe.The Province of Reggio Emilia, located in northern Italy, has a resident population of about 530,000 inhabitants, of whom about 80,000 (15.4%) are children ages 0 to 14 years . The proThe BMInforma project  is an ongoing multilevel public health program conducted by the LHA involving primary and secondary childhood obesity prevention interventions. It includes all the LHA’s primary prevention routine activities on childhood health promotion, such as development of school cafeteria menus; extracurricular interventions in infant-toddler centers, preschools, and primary and secondary schools in collaboration with municipal educational services; and collaboration with sports associations to promote organized and nonorganized physical activity. Secondary prevention consists of population-based overweight and obesity screening of children aged 5 years. According to the results of a trial conducted locally , familieThis network of services, initially developed in 2011, is still being fine-tuned. Several research projects are nested in this program, such as a cohort study on distal and proximal determinants of childhood obesity and trials to test the efficacy of individual and group interventions for overweight and obese children. Collaboration with other municipal agencies outside the health sector, such as schools, transportation, and city planning, and with nonprofit organizations is becoming more and more important, in line with the indications of the 2014-2019 National Prevention Plan .This background makes the BMInforma project a perfect setting to test innovative and traditional tools for cocreating services with families and for co-governance involving the nonprofit and private sectors and the many province-wide municipal administrations .Here we report the results of the needs assessment phase in which we tried to answer the following questions:Is the network of initiatives and services on childhood obesity prevention and care meeting the needs of parents and children?Are all the components of the network connected and do they share the same objectives?How can we improve the network?Can an app improve the network?What should an app do to be effective?Stakeholder mapping was conducted using an iterative method. Initially, a restricted group of pilot project coordinators, those involved in drafting the application to Horizon 2020, drafted a first list of internal and external stakeholders, decision makers, and beneficiaries of the pilot project. A template was adopted that included the potential influence/contribution of each stakeholder, potential impact of the project on the stakeholder, and possible strategy to involve each stakeholder. Based on this list, a meeting of all internal stakeholders was organized and a new stakeholder analysis was conducted. This step led to the formation of the project steering committee, which included all main internal stakeholders and two experts as external advisors. Finally, the list of stakeholders obtained in the second step was used to create the consulting committee, which included all external and internal stakeholders, decision makers, and parents. During the first meeting of the consulting committee, a third stakeholder analysis was done to identify other public administration sectors and nonprofit associations conducting related projects. The consulting committee decided to remain open to new participants  for the duration of the project and remain active after the end of the project to coordinate local policies on childhood well-being. The project management design, with the main actors and process of evaluation and feedback, is shown in The aim of the semistructured interviews was twofold: the first was to evaluate the BMInforma project and changes that the project led and the second focused on a new phase of the project, begun with the Horizon 2020 grant, to determine what had already been done and what was planned on the agenda.The interviewees, 5 family pediatricians and 3 health care professionals, were identified by the steering committee with the support of the Reggio Emilia LHA. In addition, the 3 project managers of an ongoing trial testing the efficacy of educational group therapy for obese children (Gruppi di Educazione Terapeutica) were interviewed to explore new ways to involve participants (children and their family members) in the pilot research project.The 8 semistructured interviews were carried out by two researchers from the University of Bologna, Italy, between June and July 2018. Each interview lasted about 1 hour; the same question template was used Expectations of pediatricians and health care professionals regarding the effectiveness of the appThe value of cocreationThe semistructured interviews were recorded and transcribed verbatim, and interviewees’ sensitive data were anonymized. Qualitative data analysis was performed using NVivo 12 software . A content analysis was then conducted to identify the context where specific nuclei of meaning had been expressed. Codes of meaning, links between all the participants’ statements, conceptual frameworks, and interpretative hypotheses were created using the NVivo software.Two focus group studies were conducted: one with family pediatricians, the other with parents. The focus group technique, widely used within the social sciences, is an unstructured group interview method that responds to precise rules of preparation, organization, and management. A total of 3 focus group discussions were conducted by the research team from the University of Bologna: one with family pediatricians and two with parents. The mediation of the Reggio Emilia LHA was fundamental in recruiting the participants (both pediatricians and parents). The first focus group discussion was held in May 2018 and involved 14 family pediatricians working in the Province of Reggio Emilia. Thirteen of the pediatricians were female and 1 was male; ages ranged from 30 to 60 years. The focus group discussion lasted about 2 hours  were held in October 2018. There were 5 participants in the first and 5 in the second, and ages ranged from 30 to 50 years. Each focus group discussion lasted about 2 hours and the following topics were discussed: lifestyle , nutrition and physical activities, and the role of IT in their lives.What emerged from the focus groups was analyzed using the same process described for the semistructured interviews, with the addition that word clouds were created through NVivo and used as input during the meetings of the consulting committee.During a national festival on digital innovation that took place in Reggio Emilia on October 20, 2018 (during the needs assessment phase of the pilot study), we organized a cocreation laboratory involving families and professionals called “What do you need on your smartphone for your child’s health?” In a family-friendly environment (with organized entertainment for the children), parents had the opportunity to sit down at any one of 4 tables—on diet, physical activity, communication with family pediatricians, or the relationship with municipal institutions—and talk with experts and decision makers about that topic. The contents of conversations with parents were then summarized by the participant experts. There were also other ways to provide input: four signage totems indicating each of the 4 topics were placed around the space, and parents were invited to leave messages, insights, and comments on Post-it Notes. Also, two tablets were placed in the quietest corners of the room for anyone wanting to leave a video and/or audio message. Last, there were whiteboards available to the children and adults for drawing.To support family participation, Pause and the Reggio Children’s Foundation organized an atelier dedicated to food and tastes in which children could explore vegetables with all 5 senses. All Post-it Notes, notes from the topic table conversations, and videos were then given to the consulting committee without any pre-analysis.Community Reporting for Storytelling, a pan-European movement established in 2007 by People’s Voice Media, uses digital tools to gather, curate, and mobilize lived experience stories. Its methodological approach is based on the Cynefin decision-making framework for complex environments . AdoptinCommunity reporting has three interlinked storytelling models: storytelling, coproduction, and insight. Within this study, the insight approach was used as it provides rich qualitative data to projects by taking the insights from people’s stories to identify a core set of research findings that can be used to inform policy, practice, and service design. Nine participants, including pediatricians, researchers, and members of the pilot project core team, were trained in this approach as part of a 2-day program held May 8-9, 2018, underpinned by peer and experiential learning strategies; the participants explored the following topics:The community reporter movementInsight storytelling techniques:Snapshot stories: short responses to an open questionDialogue interviews: unstructured and unscripted interviews with only one preset question used as a conversation starterResponsible storytelling and cocreated best practice guideSharing stories onlineUsing these skills, participants videorecorded a set of stories from families (parents and children) about what keeps them well.The community reporters trained in stage 1 gathered more insight stories and uploaded them to the Institute of Community Reporters website  from JunA conversation of change activity was run October 30, 2018, using findings and extracts from the stories gathered during stages 1 and 2 as part of a consulting committee workshop. Adopting facilitation techniques that drew on aspects of open space technologies, Brené Brown’s vulnerability research and story dialogue techniques , storiesThe consulting committee members received all materials collected in the interviews, focus group sessions, community reporting, and cocreation lab during a plenary session workshop. The materials were organized into the main topics by the social science researchers of University of Bologna and by curators of People’s Voice Media.The first section of the workshop was a conversation of change activity and involved the findings from the community reporter stories and key exemplary extracts used to prompt thinking about family well-being. Learning from the stimuli was grouped into three categories:Key messages of the storiesKey learning from the stories for health care servicesExperiences of the consulting committee members and how the stories relateFrom this, a set of unstructured ideas for the mobile app was produced. This learning was taken forward into the second section of the workshop and combined with other inputs, including focus group sessions, interviews, and the public cocreation lab. Using these, the consulting committee worked in subgroups to summarize and develop the materials in three phases: identifying all possible topics related to family well-being, grouping topics into macro areas that should be covered by the app, and transforming needs into contents or functions the app should include.After the group completed a list of objects/functions the app should have, back-office work was done to produce a list of the app’s requirements to help the technicians of the regional health authority’s IT service produce technical specifications. The subgroups were organized in order to better deal with topics that had similar technical issues. Interventions and services that can be provided to families should be evidence-based and recommended by regional and international guidelines. The choice of interventions to be delivered among those that are evidence-based should be made through a needs assessment phase and an evaluation of sustainability and acceptability in the local context. In this phase, the codesign tools are focus groups, interviews with key actors, and community reporting, all of which are discussed and analyzed by a consulting committee made up of the actors, stakeholders, and users. Synthesis of the input from the needs assessment phase is then conducted by the consulting committee. As soon as different prototypes of the app are delivered, according to the established cocreation approach, interviews with convenience samples of potential target families will be conducted to give feedback and continue the cocreation process. Finally, the app public release will automatically collect feedback from users’ interactions and comments, leading to new iterations of the app .The final list of stakeholders included 17 organizations or groups within organizations . Most weThe process of stakeholder mapping was explicitly designed to increase the engagement of stakeholders who were not initially involved in the project. In fact, starting as the object of the mapping, they became active subjects who defined the map itself throughout the different steps . The proInterviews provided insight for the evolution of the BMInforma project and the cocreation of the app. All health professionals confirmed the project gave them new skills and more awareness of the problem and sharpened existing skills such as providing appropriate treatments. Observing what emerged from the cocreation of the app, interviewees demonstrated their interest in profiling the app user in order to allow each family to directly assess part of the information in their electronic health file. The personal page might include information such as the school menu and vaccination appointments.The topics that emerged from the parent and pediatrician focus groups had more to do with the use of IT, and particularly of apps, during their daily activities. Mothers showed great readiness to use an app to manage their child’s weight. In particular, the mothers viewed the possibility of creating new recipes (thus stimulating creativity in the kitchen), checking the family’s diet, and learning about opportunities to improve their habits in a positive manner. The pediatricians raised concerns that the app could increase their workload rather than be an instrument to facilitate work and warned that the app cannot substitute the pediatrician in dealing with the patient’s need.During the cocreation lab, about 100 Post-it Notes, conversation notes, and 10 drawings were collected. The notes were grouped according to the four topic areas of the lab  to be further analyzed by the consulting committee subgroups. No video or audio messages were collected.Analysis of the 17 community reporter stories gathered brought to light the following key trends:Being active in a variety of ways, often involving play and being outdoors, was seen as important in the families’ livesTime to oneself, with family, and with friends was important to supporting the families’ overall well-beingThe pressures of life and work and not having time be be active and socialize were detrimental to families’ overall well-beingTwo key anomalies were seen. One story identified how volunteering can support well-being, and another about a young girl’s use of a step-counting bracelet revealed how there can be unintended negative consequences of health  interventions.When findings were explored during the conversation of change activity, learning across four key themes was extracted by the consulting committee:Strong relationships with peers, family members, and the community support well-beingAccess to safe (outdoor) spaces that can be used for unstructured activities  is important to familiesChildren need to have age-appropriate independence to realize and actualize their sense of self and enable them to support their own well-beingProfessional support based on discussion and exchange should be nonjudgmental and stigma-free and promote family independence and their autonomy in making decisions about their livesThe consulting committee’s work produced four lists of objects and functions that should be included in the app, divided into main topics: diet and healthy menus, physical activity, relationships with public institutions, and communications with family pediatrician. Several topics were included in more than one list, highlighting the overlap between themes. Small working groups of the consulting committee, integrated with external experts, conducted analyses of the overlapping areas, made observations of technical issues to be addressed, and produced a final list of technical specifications and requirements of the app .The cocreation process described here succeeded in producing a list of the content of the childhood obesity prevention app; the content items proposed by the different cocreation process participants and from the users’ (parents) and beneficiaries’ (children) suggestions were largely consistent. Mixing several cocreation tools, some of which were more conventional  while others were more innovative , made it possible to balance input from citizens and institutions. Finally, the process succeeded in transforming the consulting committee into an active community that brought together different sectors, favoring synergy and operating in a “health in all policies” perspective .This study is merely descriptive; we cannot rule out that similar or even better results and a similar level of decision sharing could be reached with another process. Furthermore, we have reported the process used to determine app content; we do not yet have any information about how the app will actually be used and whether it will be effective in promoting healthy behaviors in children.A critical point was parent involvement in the consulting committee. The core group proposed not to include specific parent associations because of their focus on some aspects of parenting; we initially included only a representative of the school parent councils, a choice supported by the other stakeholders on the committee. The limited representation of final users on the consulting committee resulted in an orientation more toward co-governance than cocreation. In the literature, in fact, co-governance does not involve any of the beneficiaries; co-governance refers to the joint participation only of public agencies, the private sector, and nonprofit organizations in decision making and the planning of public services -42. The The fact that many members of the consulting committee were simultaneously stakeholders and potential users made our cocreation process different from all the previous experiences of cocreation in health interventions , where end users provided input on the needs and tested the prototypes but were not involved in the identification of the aims or in the conduction of the project -47. In oWe obtained a detailed list of content and requirements suitable for technical development of the app. Adopting strategies proposed in a previous review on weight management apps, the CoSIE app as outlined by the cocreation process fulfills most of the quality requirements  38]..38].Surprisingly, content and topics families proposed were consistent with those identified by the institutions, with a few exceptions. For example, during the public lab, a couple of parents asked for an online pediatrician to provide quick answers to questions posted through the app; the health care professionals, however, considered this unfeasible. In the scientific literature, we found only one study in which parents could directly contact a dietician or psychologist through the app ,49. AlthWhat to do in case of an emergency was another topic both parents and health practitioners requested. This topic is not strictly related to obesity prevention and, to our knowledge, not present in other similar apps, but it was recognized as a way to make the app useful and appreciated by parents.A proposal for gamification of the app emerged particularly from the institutions, who saw it as a way to engage families. Both users and institutions agreed that the app should not be used directly by the child but by the parent only . This is the main barrier to gamification but also guarantees that any game is played with a parent or at least under the parent’s supervision. The solution was to develop games only for designing a healthy menu and planning the right physical activity over the course of a week.In general, health services have several specific characteristics that make cocreation particularly challenging. Analyses have both highlighted the theoretical benefits of involvement strategies to health care  and identified numerous tensions and contradictions that play out in practice ,23,51-54The main difference between public health services and other public services is that the former demand scientific evidence of the efficacy of any intervention before it can be provided. In the case of primary prevention, we often see interventions with scientifically proven efficacy, but they have rarely been compared in head-to-head experiments measuring the relative efficacy of different interventions with the same aim. Furthermore, in most cases different preventive interventions are not mutually exclusive, and using interventions together can be a successful strategy . TherefoPrevention and health promotion interventions raise another issue: these interventions, particularly those aimed at changing risky behaviors and promoting healthy lifestyles, are not perceived as needs by the target population ,59. The When the service provided is a prevention intervention targeting childhood obesity, the definition of users and beneficiaries is also challenging; while the beneficiaries are the children themselves, we are interested in changing the entire family’s behaviors . Finally, in our pilot project, the users of the app will be only the parents; a positive effect on the beneficiaries (children) can only be achieved by changing the behaviors of the larger target (the family) ,62.The next step of the process will be the development of the app prototype during which conversations with the consulting committee subgroups will be still in place. The first app prototype will be tested by users (families and pediatricians). Initially, user feedback will be collected through focus groups. The app itself will collect qualitative and quantitative feedback; the use of different services in the app will be logged and it will be possible to comment on the various app functions by means of a short text or simply clicking on a like or do not like icon.Cocreation in health promotion and prevention has some unique features that must be taken into consideration. The pilot study we conducted showed that cocreation is feasible. The key co-governance and cocreation tool was the consulting committee. Including stakeholders on this committee made it possible to expand the number of persons and institutions actively contributing to the project.


Unintentional injuries have emerged as a significant public health issue in low- and middle-income countries (LMIC), especially in Vietnam, where there is a poor quality of care for trauma. A scarcity of formal and informal training opportunities contributes to a lack of structure for treating trauma in Vietnam. A collaborative trauma education project by the JW LEE Center for Global Medicine in South Korea and the Military Hospital 175 in Vietnam was implemented to enhance trauma care capacity among medical staff across Ho Chi Minh City in 2018. We aimed to evaluate a part of the trauma education project, a one-day workshop that targeted improving diagnostic and surgical skills among the medical staff (physicians and nurses).n = 27) voluntarily completed the post-workshop questionnaire. Quality of contents, satisfaction with teaching skills, and perceived benefit were used as outcomes of the workshop, measured by 5-point Likert scales (score: 1–5). Descriptive statistics were performed, and open-ended questions were analyzed by recurring themes.A one-day workshop was offered to medical staff across Ho Chi Minh City, Vietnam in 2018. The workshop was implemented to enhance the trauma care knowledge of providers and to provide practical and applicable diagnostic and surgical skills. To evaluate the workshop outcomes, we utilized a mixed-methods survey data. All participants  = 0.62). The mean score of the satisfaction regarding the teaching skills was 4.19 (SD = 0.61). The mean score of the perceived benefit from the workshop was 4.17 (SD = 0.63). The open-ended questions revealed that the program improved their knowledge in complex orthopedic surgeries neglected prior to training.Positive learning experiences highlighted the need for the continuation of the international collaboration of skill development and capacity building for trauma care in Vietnam and other LMIC. Unintentional injuries, including traffic accidents, have emerged as a leading cause of death and disability representing a significant public health issue in low- and middle-income countries (LMIC), especially in Vietnam . Over 90Despite the high burden of traffic accidents, the quality of care for trauma has been a continuing challenge in Ho Chi Minh City and Vietnam overall . In Ho CThe collaboration between the Military Hospital 175 and Seoul Medical University College of Medicine officially began with a memorandum of understanding (MoU) in 2013. Responding to the plan to establish a new Trauma and Orthopedics Center within Military Hospital 175 in 2015, the JW LEE Center for Global Medicine, Seoul National University College of Medicine in the Republic of Korea implemented a project for strengthening trauma care capacity with the Military Hospital 175. Training is one of the widely delivered intervention methods to increase trauma care capacity in LMICs [The objective of the workshop was to train participants in trauma-care knowledge and skills and to apply their newly gained skillsets. In this paper, we seek to describe the structure of the overall project for strengthening trauma care capacity, to review the workshop contents, and to discuss participants’ initial responses to the workshop in order to improve future workshops and training.We used a quantitative-dominant mixed-methods research design to evaluate the trauma evaluation project.The Military Hospital 175, a tertiary hospital that operates under the Vietnamese National Ministry of Defense in Ho Chi Minh City, is a central military hospital in the Southern region of Vietnam that carries out medical services for senior officers in the army, but it is also open to the public. It is a teaching hospital that educates and trains clinicians including surgeons, orthopedists, internists, and residents.n = 11). A total of 27 provider participants (physicians and nurses) voluntarily completed the questionnaire and 25 participants completed all of the questions. We obtained a 100% response rate.There were a total of 111 healthcare professionals  employed in the target hospital departments  at the time of study recruitment, and 63 (physicians and nurses) were available and registered to participate in the study. Recruiting internal medical staff was prioritized and the primary method of recruitment was by invitation via e-mail and phone calls. Additionally, since the Military Hospital 175 is a public teaching hospital, the communication department disseminated newsletters and dispatch (for military institutions) to the hospitals in the Ho Chi Minh City area for recruitment as well. Of 74 total registrants, 27 (36%) attended the workshop and were asked to complete the post-workshop questionnaire. About 40% of the attendants came from another institution , the intervention sought to educate trauma professionals in Vietnam by conducting an education program emphasizing the local needs.Strategies used in the project were based on Kern’s framework for curriculum development, which describes a logical and systematic approach to developing, implementing, and evaluating medical education programs . DrawingFirst, a general needs assessment was conducted based on the published literature and reports on the need for trauma care, and country-specific needs were identified.A specific needs assessment was conducted with stakeholders  at the Military Hospital 175. A stakeholder analysis was conducted at the 20th scientific conference hosted by the Military Hospital 175 in 2015. One of the trauma specialists attended the conference and met with several stakeholders to discuss the local problems and needs. Based on the stakeholder meetings, a need for essential resources was recognized along with a need for facility, equipment, and personnel. Skill-based training was prioritized for this partnership between the two institutions because the construction was a responsibility of the Vietnamese government. The discussions elucidated the need for and willingness to participate in the proposed training programs.We used both needs assessments to develop the goals and objectives of the curriculum: 1. to share experiences and skills in the field and 2. to teach the concept of trauma patient care system in order to strengthen the capacity of trauma care at the Military Hospital 175.The Strengthening Trauma Care Capacity Project is a multimodal educational program. The first part of the project is the Trauma Care Capacity Strengthening Training Fellowship Program in Korea (2016–2018), which is a 3-month invitational training program. The scope of the training includes lectures, mentorships, hands-on learning, visual learning, and field trips to various trauma centers in Korea. The Military Hospital 175’s leadership selected trainees based on ability, English competency, and needs and provided training expenses for all three months except airfare. The coordinators interviewed trainees prior to their fellowship to understand the training needs, and the examples of their requested areas included Microsurgery, Traumatic Emergency, Knee Arthroscopy, Sports Medicine, and Hand Surgery. The second part of the project is the one-day Trauma Care Strengthening Workshop (2018). The Vietnamese physicians led the curriculum development because the trauma system between Vietnam and Korea is different. The Military Hospital 175’s leadership and surgeons discussed what program they envisioned and the detailed lecture topics via e-mails. Professors from Korea who instructed the trainees during the Trauma Care Capacity Strengthening Training Fellowship Program were first consulted to develop and teach the workshop. The content of the lecture was consulted with Vietnamese professors in charge.We built a collaborative partnership between Vietnamese and Korean health care professionals, administrators, and coordinators to implement the program. Table We developed an evaluation plan for the program including the workshop. The evaluation questionnaire was distributed at the end of the workshops to assess the quality of the didactics. The participants were asked to fill out the form and they submitted it immediately after the workshop.The program coordinators conducted pilot tests of the questionnaire and made appropriate modifications to ensure readability and understanding. The surveys were translated from English to Vietnamese. Institutional Review Boards at the Seoul National University Hospital approved the research including the protocol and instruments (#1910–064-1070).A 14 item questionnaire using a 5-point Likert scale  was used to measure participant satisfaction with the workshop and its contents. The quality of contents, satisfaction with teaching skills and tools, and perceived benefits were used as outcomes of the workshop. The participants rated the overall quality of education, whether the teaching methods used helped them to learn effectively, whether course handouts and texts reinforced their learning, whether the course objectives were met, and whether the course satisfied their own needs and expectations. Open-ended questions were asked to explore detailed information, such as their satisfaction and experiences after the training, and to obtain recommendations for future workshops. The questionnaire also asked for participants’ demographic information: name, gender, age, title, specialty, years of experience, and employment at the Military Hospital 175.n = 27), and 25 participants fully completed the survey. Two participants did not complete the evaluation part of the survey; therefore, they were excluded from the evaluation part of the analysis. Mean item descriptive statistics were calculated and all quantitative data were analyzed using STATA software version 13. For qualitative data, first, two researchers read all of the answers and independently generated lists of initial themes. The team met to discuss the themes into a set of codes. We coded open-ended answers to extrapolate recurring statements and themes. One researcher coded the transcripts using excel. Coded transcripts were qualitatively analyzed, and two senior researchers reviewed the codes. All authors agreed with the final themes.All of the participants completed the survey  and their availability as the workshop was held on a weekday. All participants responded to the demographic questions, and 93% of the participants fully answered both demographic and evaluation questions, which was higher than expected. The majority of the participants were from the Military Hospital 175, reflecting our target population. However, we observed that study participation was uneven across specialty and across the profession. This may be due to the scheduling conflicts due to the long length of the workshop. For future workshops, we can identify ways to improve attendance diversity by ensuring stakeholder buy-in from all appropriate specialties. Another limitation is the fact that the workshop was a one-time event, making the study cross-sectional instead of longitudinal. In terms of evaluation design considerations, although randomization may be a possibility, this would likely be more expensive and less manageable. More work is needed to track longitudinal outcomes for methodologically rigorous intervention and evaluation. Although the sample size is small, this type of study can be replicated in other cities, and lessons learned can be applied to other settings in LMIC that are implementing trauma care education programs. The post-workshop questionnaire did not objectively test the post knowledge of the participants, a major limitation. This study, therefore, only examines self-reported participant reaction to the workshop, the minimal level of training effectiveness. Future workshops will include pre-tests and post-tests to measure changes in the participants’ knowledge and observations. Although using a 5-point Likert scale is widely accepted, the reliability and validity of the questionnaire need to be further tested for future evaluations.In order to address the high morbidity and mortality from traffic accidents in Ho Chi Minh City, a trauma care workshop was developed by Military Hospital 175 in collaboration with the JW LEE Center for Global Medicine and Seoul National University. Participants found the major strengths of the workshop as teaching relevant and practical knowledge. The new Trauma and Orthopedics Center of Military Hospital 175 was completed in late 2019, and positive learning experiences highlighted the need for the continuation of the international collaboration of capacity building for trauma care in Ho Chi Minh City. Trauma care improvement heavily relies on the regional, organizational, and provider and patient-level factors. Future collaborations should not only focus on developing the skills of providers but also on engaging and educating patients and other relevant stakeholders with the goal of reducing traffic accident mortality.


With the global population aging and life expectancy increasing, dementia has turned a priority in the health care system. In Chile, dementia is one of the most important causes of disability in the elderly and the most rapidly growing cause of death in the last 20 years. Cognitive complaint is considered a predictor for cognitive and functional decline, incident mild cognitive impairment, and incident dementia. The GERO cohort is the Chilean core clinical project of the Geroscience Center for Brain Health and Metabolism (GERO). The objective of the GERO cohort is to analyze the rate of functional decline and progression to clinical dementia and their associated risk factors in a community-dwelling elderly with subjective cognitive complaint, through a population-based study. We also aim to undertake clinical research on brain ageing and dementia disorders, to create data and biobanks with the appropriate infrastructure to conduct other studies and facilitate to the national and international scientific community access to the data and samples for research.The GERO cohort aims the recruitment of 300 elderly subjects (> 70 years) from Santiago (Chile), following them up for at least 3 years. Eligible people are adults not diagnosed with dementia with subjective cognitive complaint, which are reported either by the participant, a proxy or both. Participants are identified through a household census. The protocol for evaluation is based on a multidimensional approach including socio-demographic, biomedical, psychosocial, neuropsychological, neuropsychiatric and motor assessments. Neuroimaging, blood and stool samples are also obtained. This multidimensional evaluation is carried out in a baseline and 2 follow-ups assessments, at 18 and 36 months. In addition, in months 6, 12, 24, and 30, a telephone interview is performed in order to keep contact with the participants and to assess general well-being.Our work will allow us to determine multidimensional risks factors associated with functional decline and conversion to dementia in elderly with subjective cognitive complain. The aim of our GERO group is to establish the capacity to foster cutting edge and multidisciplinary research on aging in Chile including basic and clinical research.NCT04265482 in ClinicalTrials.gov. Registration Date: February 11, 2020. Retrospectively Registered.The online version contains supplementary material available at 10.1186/s12877-020-01866-4. Population ageing, driven by rising life expectancies and declining fertility rates, is one of the most important transformations the world is undergoing today. World population over 60 years old is now 12% and is expected to reach 21.5% by the year 2050. Within the same period, the increase in the population over 80 years old will be even more pronounced, going from 1.7 to 4.5% of the population : by 2025This population ageing is associated with a strong increase in the number of people living with dementia, which is estimated to reach 140 million by 2050. Dementia is the most significant global challenge for health and social care in the twenty-first century . In ChilMost of the dementia syndromes are preceded by a prodromal phase characterized by the presence of a broad range of very subtle manifestations of cognitive decline. Common presentations are, amongst others, concerns about cognitive decline, also known as subjective cognitive complaint (SCC), of people who may or may not have deficits in objective testing , reporteOn the other hand, studies focused on the risk factors associated with functional decline (FD), i.e. the ability to perform daily routines, are less known. The determination of FD has been commonly used as a critical line dividing between predementia and dementia stages. However, the notion that FD starts only at the stage of dementia has been challenged with several studies showing that minor impairment in complex activities of daily life (ADL) precedes dementia in many years , 19, andFinally, predicting the risk of FD and the risk of dementia is associated with a complex interplay of non-modifiable and modifiable risk factors such as overall health and lifestyle factors . The intTo the best of our knowledge, no previous study has reported multidimensional risk factors  associated with the prognosis of elderly with SCC on the evolution of FD. Also, there is a scarcity of cohort study on cognitive decline in Latin-American and no studies have been carried out in Chilean on risks associated with progression to dementia. The present paper reports the aims and design of a cohort study, being conducted in Chile by the Geroscience Center for Brain Health and Metabolism (GERO).The general objective of this study is to analyze the rate of functional decline and progression to clinical dementia and their associated risk factors  in a community-dwelling elderly with SCC, through a population-based study. The specific objectives are to determine: i) longitudinal evolution of biomarkers measured from blood, stool and structural and functional magnetic resonance neuroimaging (MRI), ii) evolution of health-related outcomes, including quality of life, comorbidity and risk factors, and iii) mortality rates. We also aim to build the capacity to undertake clinical research on brain ageing and dementia disorders and to create data and biobanks with the appropriate infrastructure to conduct other studies and facilitate to the national and international scientific community access to the data and samples for research.The GERO cohort is the core clinical project of the GERO program grant, which is supported by the Fund for Research Centers in Priority Areas Program (FONDAP) of the Chilean national research and development agency . GERO is initially funded for 5 years, and its main aim is to establish a center for studying brain aging in Chile, including basic and clinical research.The cohort recruits the potential participants from the general population, using a door-to-door strategy. The sample framework corresponds to the territories assigned to three primary healthcare centers selected by convenience according to their socioeconomic heterogeneity, which belong to three different districts in Santiago (Chile): Macul, Peñalolen and La Reina. The sample considers a two-stage selection process. The first stage includes a sample of quadrants within each territory, where the contact to all houses is attempted. The second stage proceeded when in a home is found more than one potential eligible participant, choosing one randomly. Territories encompassed a population between 14,937 and 39,458 people , of whicSubjects are eligible for the study if they fulfil the following criteria: i) 70 years old or older; ii) presence of a knowledgeable informant and/or presence of a contact that allows the follow up of the participant, and iii) being affiliated to the public health insurance.Eligible participants are invited to the study and receive a first evaluation to confirm the following criteria:Subjective cognitive complaint either self-reported or reported by a knowledgeable informant.Clinical Dementia Scale— frontotemporal lobar degeneration (CDR-FTLD) equal or inferior to 0.5 .Signed informed consent.Inclusion criteria: Eligibility criteria plus:Report of medical diagnosis of dementia.Mini-mental State Examination (MMSE) < 21 and Pfeffer questionnaire > 2 , 29.Institutionalization .Illiteracy, meaning that is not able to write or read.Visual and auditory acuity not adequate for neuropsychological testing.Important limitation of mobility incompatible with the availability to be independent in daily life activities and/or attending a clinical center for further evaluation.Report of medical diagnosis of Parkinson’s disease.Report of medical diagnosis of one or more of the following conditions causing severe impairment in functionality: any psychiatric or neurological disorders, brain tumor, subdural hematoma, progressive supranuclear palsy, or history of head trauma.Report of medical diagnosis of stroke occurred in the last 3 months.Presence of a fatal disease .Exclusion criteria:The recruitment process considers two steps. First, a lay team contacts each home to determine the presence of eligible individuals. In positive cases, the person receives a second visit by a trained psychologist who proceeds to check for eligibility. In case of acceptance, the inclusion and exclusion criteria protocol are applied. If the subject fulfils the criteria, the psychologist schedules a medical interview. Following this evaluation, a neurologist decides if the subject fulfil the inclusion criteria of the cohort see Fig. .Fig. 1FThe fieldwork is preceded by an outreach campaign  raising awareness about the visit of interviewers and the relevance of participating in the study. Rates of contact and response are monitored permanently, and the procedures around the contact and first interview are checked in the field and also by telephone to a subsample of the participants. Contact to homes is attempted up to three times on different days and hours before considering it frustrated. The fieldwork started in November 2017 and is expected to finish at the middle of 2020. Up to date, the recruitment has not been completed.The lay team and psychologists involved in the first contact and recruitment received specific training on their labor in the field. The lay team completed a whole training week, which included theoretical and practical elements. Psychologists received a 12 weeks length training, which covers several sessions of neuropsychological assessment.The sample size needs to satisfy two criteria, one concerned with the statistical power required to explore multiple associations with outcomes, and other related to the feasibility to perform a wide range of assessments to each participant assuming costs and logistics. Both criteria meant a trade-off between the tolerance to uncertainty around the parameters to be estimated and the number of assessments that would be investigated throughout the study. The final sample chosen was 300 participants. This number allows maintaining the integrity of the original protocol and permits to test associations equivalent to an Odds Ratio (OR) around 1.5  in cases of exposition and probability of the outcome close to 50%, using a significance of 5%. It is expected to follow each participant 3 years, accumulating roughly 900 person-years of follow up.Socio-demographic, health-related outcomes , clinical stages and symptoms, psychosocial, neuropsychological, neuropsychiatric, motor, neuroimaging, blood biomarkers, stool, and genetic samples will be performed as baseline evaluation and every 18 months, with the exception of the genetic study that will be performed only at baseline and neuroimaging at baseline and 36 months. Patients’ health status, functionality, and involvement in the GERO cohort will be monitored every 6 months by a telephonic questionnaire in order to assess general well-being and keep contact with the participants.To avoid a significant attrition of the sample the following strategies have been considered: to recruit only people who have at least one person that can facilitate the contact with him or her, it means a person who can be contacted for asking about the location of the participant; telephone contact every 6 months; and domicile visit in case of absence of contact or attending to assessment appointments. Additionally, all transport costs of participants are being covered by the GERO cohort administration, as well as any food that is required during the days of assessment. Initially, the end of the follow up of the cohort is programmed for October 2022.The protocol considers an intensive and deep multidimensional study of factors related to the prognosis of FD and dementia development. The range of assessments includes: socio-demographic, health-related outcomes , clinical stages and symptoms, psychosocial, neuropsychological, neuropsychiatric, motor, neuroimaging, blood biomarkers, genetic and stool samples to perform gut microbiome studies  will be performed. The procedure will be repeated at each measurement time, every 18 months. Random effect models will be used for describing trajectories of participant subgroups and the whole cohort according to main variables, using Markov-Chain Montecarlo procedures , 87.The association between variables and outcomes will be explored broadly using different machine learning methods, such as elastic net procedure, random forest procedure, based-tree methods, and support vector machines . These pMissing data and loss of follow up of participants are common in observational studies, mainly in cohorts. Firstly, cases with missing data in any outcome will be explored and compared with cases without missing data describing any pattern. Secondly, two strategies will be followed to estimate results: i) to analyze only cases with complete information (i.e. assuming that missing data is completely at random); and ii) imputing data according to multivariate imputation by chained equation techniques , 91. TheThe GERO cohort has been carefully designed to avoid undermining the usual care of participants in their common health services facilities. Even more, a linkage between the health assessments provided by the cohort and the usual health care has been promoted.In cases when the cohort’s assessment detects a new health condition  the participants are derived to the primary healthcare center of their territory. In the case of detection of a significant neurological disorder  the participants are directly derived to specialized care according to their Health District, communicating the decision to the primary health care.Primary care health centers, specialized care polyclinics and the direction of the Health District involved have been informed about the study and jointly the protocol of derivation and communication were established.The access to data and biospecimens is regulated by the GERO directorate in accordance with the local Institutional Review Board authorization. A bilateral agreement must be signed before sharing of data. Access to the server will not be granted.The project was approved September 2016 by the Ethic Committee of the Servicio de Salud Metropolitano Oriente, Santiago (Chile). A written informed consent to participate in the study is obtained for all participants of the GERO cohort.Our group, in collaboration with the Ministry of Health, the Hospital del Salvador and other faculties of the University of Chile, created in 2018 the CMYN, a clinical facility that houses one of the three Memory Units of the Chilean’s Dementia Plan, and it is conformed by a multidisciplinary team . Nowadays, GERO and CMYN train professionals in primary care centers and neurology, psychiatric and geriatric residents in brain ageing and dementia. Additionally, we perform outreach activities on geroscience, brain ageing, and dementia to the broad community, mainly in the three districts of the GERO cohort and in Hospital Salvador, and to the scientific and health community. We designed a brochure to inform about the GERO cohort and performed broader dissemination through media . Finally, our group lead a policy paper on dementia to inform public policy .The current paper presents the study protocol of a Chilean cohort in brain aging and dementia: the GERO cohort study. This project mainly focuses in identifying risk factors associated with functional decline and progression to clinical dementia in the elderly with SCC by determine factors related to biomedical, clinical and psychosocial variables.To date, important contributions have been realized in the Latin-America region allowing to know the prevalence and incidence of dementia , 10, 93,From a public health perspective, identification of SCC and MCI subjects with higher risk of pathologic trajectories would be valuable as a diagnostic tool to focus prevention in subjects at higher risk of FD and dementia. Additionally, between SCC and MCI, SCC could be a better valuable target for public policy interventions, since it is built on the subjective self or informant-reported perceptions, which are closer to the awareness that could target health care consultation. Moreover, the diagnosis of MCI required the demonstration of an objective decline in cognitive performance limiting the diagnosis of MCI in primary care centers. Also, the concept of MCI has been criticized due to overlap of MCI and AD dementia suggesting ambiguity in the MCI concept and the criteria of MCI are continuing evolving .The collective approach will allow us to i) improve diagnosis for neurodegenerative disease, ii) evaluate age-related risk factors and genetic variations linked to neurodegeneration, iii) understand how molecular mechanisms involved in aging lead to neurodegeneration and iv) explore novel biomarkers to evaluate the onset and progression of neurodegeneration. GERO’s aim is to establish a center for studying brain aging in Chile, including basic, translational and clinical research.The availability of a GERO biobank will allow fostering translational studies by collecting peripheral samples for research use to improve our understanding of health and disease in the Chilean population. Additionally, biological analysis and associated clinical data are necessary to contribute in early diagnosis, prognostic and treatment for the aging population . The devFurthermore, GERO platform will provide strategies, methods and tools to conduct longitudinal studies on a community base in populations with diverse epidemiological settings.The main strengths of the GERO cohort is recruitment of participants at their home, allowing recruiting either people attending clinical center and people not attending. People not attending clinical center probably represent a higher risk group under-represented in previous studies . MoreoveOne of the main limitations of our study is a relatively small sample size. Due to our research strategy to prioritize a multidimensional and extensive evaluation, time and budget constraint, we limited the cohort size. Nevertheless, we selected a continuous outcome and will study the rate of change rather than a categorical outcome that allow to overcome possible limitations due to the sample size , 116. AlOur work will allow us to determine multidimensional risks factors associated with the prognosis of elderly with cognitive complaint on functional decline in Chilean population. The GERO cohort will help to design public health policies tailored to prevent aging disease, and contribute to a better understanding of cognitive impairment and dementia in Latin America and the world. GERO’s aim is to establish a center for studying Brain Ageing in Chile including basic and clinical research.Additional file 1.


Objective: Distributed models of the arterial tree allow studying the effect of physiological and pathophysiological changes in the vasculature on hemodynamics. For the adult, several models exist; however, a model encompassing the full age range from newborn to adult was until now lacking. Our goal is to describe a complete distributed hemodynamic model for normal development from newborn to adult.Methods: The arterial system was modeled by 121 segments characterized by length, radius, wall thickness, wall stiffness, and wall viscosity. The final segments ended in three-element Windkessels. All parameters were adapted based on body height and weight as a function of age as described in the literature.Results: Pressures and flows are calculated as a function of age at sites along the arterial tree. Central to peripheral transfer functions are given. Our results indicate that peripheral pressure in younger children resembles central pressure. Furthermore, total arterial compliance, inertance and impedance are calculated. Findings indicate that the arterial tree can be simulated by using a three-element Windkessel system. Pulse wave velocity in the aorta was found to increase during development.Conclusions: The arterial system, modeled from newborn to adult bears clinical significance, both for the interpretation of peripheral measured pressure in younger and older children, and for using a Windkessel model to determine flow from pressure measurements. Arterial models help in understanding of hemodynamics and allow simulated experimental interventions that may not be easily performed in the human . To dateOur general aim was to develop a full-scale distributed model of the systemic arterial tree, consisting of realistic segments derived from physiological measurements, throughout development from newborn to adult. To describe all model parameters as a function of age, growth charts were used. We investigated pressure-flow relations in the model, with as a first aim to determine the central to peripheral pressure transfer functions . The second aim was to derive and determine the applicability of Windkessel models, based on characteristic impedance and the lumped parameters, as found by network analysis, describing total arterial resistance, compliance, and inertance. The first aim provides understanding of the relation between peripheral measured pressure and central pressure. The second aim gives insight in the applicability of 3- or 4-element Windkessels for realistic modeling of the input impedance of systemic arterial tree . CombineThe model of the arterial tree was developed using the description of Westerhof  with theTo model the development of the arterial system, the following age dependent descriptions were assembled: height; proportional length and radius of body divisions ; weight; and based on the previous, proportional volume of body divisions. These descriptions allow determining the dimensions of the arterial segments for any age. Once these dimensions are known, the pressure and flow transfer function of each segment can be calculated. Bringing all pressure and flow transfer functions together, the entire arterial system can be modeled. A flow wave with the correct stroke volume and heart rate for each age is used as input. Then pressure and flow can be calculated in each segment.Thus, the current model is based on two main constituents: first, the original model by Westerhof et al.   = 1.06. Thus, a 20 % higher perfusion is accompanied by a 6 % increase in radius.To correctly model growth of the arterial system, i.e., segment length, radius and wall thickness, the following was considered. In the newborn, average tissue metabolism and tissue perfusion  are highTo account for an increased mean arterial pressure with increased age , vasculaTransfer of pressure and flow over each segment is governed by transverse and longitudinal impedances. Transverse impedance is given by Jager et al. , longituStarting from the distal impedances of the segment considered, pressure and flow transfer can be used to yield the impedance at the proximal site. Using standard circuit analysis for each frequency, multiple segments can be combined and finally resulting in the impedance of the entire arterial tree. Details on this approach can be found in the literature , 32, 33.The following adaptations were made to the original description of the arterial segments and wall properties . Radii oThe parameters of the arterial vasculature for ages of 0, 1, 2, 5, 10, 15, and 20 years can be found in the Cardiac output and heart rate were taken from Wiesener , where cFor the aortic segments, the Moens-Korteweg pulse wave velocities were calculated . CarotidWindkessel compliances are assumed to increase proportional to the volume of the body division they are in . ConversIn Brachial systolic and diastolic blood pressures are presented in The transfer functions between aorta and the above-mentioned arteries are shown in The percentage of resistance that resides in the vessels relative to the total resistance (thus including Windkessel resistance) was 11% at 0 years and decreased to 7% for 20 years, indicating a small pressure drop over the conduit arteries. When the shear rate was not kept constant by an increasing vascular radius to accommodate for the higher tissue perfusion at younger age, the resistance in the vessels relative to the total resistance was 26% at 0 years, causing a considerable pressure-drop.Moens-Korteweg pulse wave velocities  in the aInput impedances as determined from Fourier analysis of pressure and flow are given in the A model of the arterial system was developed that describes hemodynamics during development from 0 to 20 years, from newborn to adult. The system is based on anatomy, stature, proportional growth of different divisions of the body, and weight, all as described in the literature , 17, 18.Our main findings are that the pressures for the age range of 0–5 years are quite similar throughout the arterial system. After the age of 10 years, the pressure transfer functions appear to have taken their final forms, remaining quite similar during further development to adulthood. This suggests that transfer functions developed for the adult may work acceptably for children of 10 years and older, but not for younger children. In the latter group, less amplification is present, and an adult transfer function would overcorrect systolic pressures, resulting in estimations that are too low. This observation fits with recent findings of systolic pressure underestimation is younger children , 44. IndGevers et al.  used higThe transfer functions derived by Cai et al.  give theMilne et al.  measuredIn older age, it is quite well-established that pulse pressure amplification is reduced , 50, andWhen comparing brachial pressures of the model to measured pressures in a population study by Flynn et al. , systoliOur model is highly versatile and allows making changes to describe diverse anatomical aberrations . It could also be used to investigate the effects of childhood obesity on the pressure wave shape , 56. AlsBoth the 3- as well as the 4-element Windkessel seem to provide an acceptable lumped parameter model description of the arterial input impedance. The parameters can be estimated based on gender (which we did not investigate), age, height and weight. We suggest that the findings of the current study can serve as a basis for further development of a Windkessel model, which could be used to estimate cardiac output from pressure measurements . To our 0.38 in children and adolescents , thus the pressure drop in the vessels was small for the given cardiac outputs. Without this implementation of constant wall shear stress, the pressure drop would have become substantial.Pulse wave velocity showed a gradual increase over the years. At younger age, vascular diameters were smaller, however, wall thickness was relatively even more reduced, since the mean arterial pressures were lower . This results in a lower wall thickness/radius ratio and thus, according to Moens-Korteweg , a lowerCarotid to femoral velocities were higher than the aortic Moens-Korteweg velocities . In the Another explanation is that arterial stiffness in the model is too high. To obtain pulse wave velocities at the same absolute value as Reusz et al.  found atOur work is a first step in the development of a distributed model that accurately describes pressure and flow relations in healthy children. The length, radius and wall thickness of the arterial segments were estimated based on growth curves and not measured in groups of individuals in certain age ranges. Detailed measurements of the vasculature as a function of age would possibly allow further improvement of the model description. Potential sex differences that may include differences in cardiac output and tissue perfusion were not considered.In the current model, the arterial stiffness of the arterial segments is based on the original description of Westerhof et al.  distinguRadii of the arterial segments were assumed to grow proportional to the increase of length of the body division. When keeping the shear rate constant during development, by correcting radii to accommodate for the higher tissue perfusion at younger age, the resistance of the conduit vessels was acceptably low relative to the tissue resistance for all ages. Without shear stress correction however the conduit vessel resistance would cause considerably lower pressures at tissue level at younger ages. Our first assumption that radii would increase with length may be incorrect, but, together with the shear stress correction, seems to give acceptable results.The model describes the systemic arterial tree with a closed ductus arteriosus . Interesting future work could aim to describe the transition from the neonatal circulation toward the closing of these shunts and the impact on cardiac output .In our approach, the flow wave shape was the same for all simulations. A different flow wave shape may give other pressure wave shapes and for instance give rise to higher systolic pressure amplification. However, since the transfer functions are only determined by arterial parameters, these are independent of the flow wave shape that was used.Finally, reflexes of the autonomic nervous system and autoregulation of organs were not incorporated in the model.To our knowledge, we presented the currently most complete distributed model of the arterial system for the age range from newborn to adult. Important results encompass the finding of peripheral pressures in younger children to resemble their central pressure, and that input impedance may be described by a simple Windkessel model.The results carry clinical significance for the interpretation of peripheral measured pressures in younger and older children. Further application of our model may e.g., aid in estimating cardiac output in children in intensive care, or to investigate effects resulting from vascular aberrations.All datasets generated for this study are included in the article/Main findings of this study were presented at the Artery 2011 meeting.BW and JW conceived the study, developed the model, and wrote the manuscript. MG wrote the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


It is recommended that developers of Point Of Care Tests (POCTs) assess the care pathway of the patient population of interest in order to understand if the POCT fits within the pathway and has the potential to improve it. If the variation of the pathway across potential hospitals is large, then it is likely that the evaluation of effectiveness is harder and the route towards large-scale takes adoption longer. Evaluating care pathways can be a time-consuming activity when conducted through clinical audits or interviews with healthcare professionals. We have developed a more rapid methodology which extrapolates the care pathway from local hospital guidelines and assesses their variation. Sepsis kills 46,000 people per year in the UK with societal costs of up to £10 billion. Therefore, there is a clinical need for an optimized pathway. By applying our method in this field, we were able to assess the variation in current hospital guidelines for sepsis and infer the potential impact this may have on the evidence development on innovations in this applications. We obtained 15 local sepsis guidelines. Two independent reviewers extracted: use of the national early warning score (NEWS), signs and risk factors informing the decision to prescribe antibiotics, and the number of decisional steps up to this point. Considerable variation was observed in all the variables, which is likely to have an impact on future clinical and economic evaluations and adoption of POCT for the identification of patients with sepsis. It is recommended that developers of Point Of Care Test (POCT) understand the care pathway of the patient population of interest. The care pathway is the journey of a patient with a specific condition in the healthcare system , and itsMethods to analyze the pathways include review of national guidelines, interviews with stakeholders  and audits. These can be time-consuming, especially if the aim is to sample many hospitals. We decided to analyze hospital guidelines as a proxy for the real care pathways. Understanding how hospital guidelines are used in practice represents a powerful tool, especially in complex diseases where the definition of the disease is non-trivial. Indeed, guidelines could serve as an operational definition of the disease: when in the pathway initiation of treatment is recommended, then a patient can be considered “diseased”.When guidelines are not standardized across the country, variations can affect prevalence and, indirectly, clinical and economic evaluation of the POCT . Also, adoption of new POCT is harder in a fragmented clinical scenario.We developed a methodology to evaluate variation in local hospital guidelines and we focused on guidelines for identification of patients with suspected sepsis. This work is relevant to the evaluation of POCTs intended to fit into the sepsis care pathway, for example those based upon procalcitonin (PCT) testing.Sepsis is a syndrome with a complex definition : it is aSepsis: recognition, diagnosis, and early management was published by the National Institute for Health and Care Excellence (NICE) in 2016 [Clinical guideline NG51  in 2016 . This pr in 2016  and upda in 2016 . Red Fla in 2016 , built uNICE acknowledges that the application of its clinical recommendations is not mandatory, given that local and individual circumstances must also be taken into consideration. Both NICE and the Royal College of Emergency Medicine (RCEM), author of three national audits of severe sepsis and septic shock since 2011/12, recommend that all emergency departments have a sepsis lead and their own individualized sepsis protocol. The RCEM reports that this is the case in 95% and 96% of departments respectively . Thus, tIn this paper, we analyze local guidelines for the identification and risk stratification of adult patients with suspected sepsis in non-specialist acute hospitals (NHS Trusts) in England. Our aim is to investigate variation in care pathways and discuss its implications. To our knowledge, this is the first formal evaluation of its kind in relation to local sepsis guidelines.We obtained local sepsis guidelines from non-specialist acute NHS Trusts in England, and extracted information about the pathway for identification of suspected sepsis. Our scope was to include guidelines applicable to a general adult population, not those relating only to specific groups such as pregnant patients or those with suspected neutropenic sepsis.We aimed to include a representative sample of 10% of Trusts in England, which we considered to be achievable based on the resources available, and a good balance between resource and the value of the exercise. In choosing those to request, we sought to include variation in factors that may influence organizational operation, such as geographical location, size, and governance arrangements. Thus, our sampling strategy was designed to capture variation in practice while minimizing the required sample size. The choice of Trusts was arbitrary other than varying these factors, and the inclusion of our own Trust. Guidelines were requested by freedom of information (FOI) requests in August 2018. The Freedom of Information Act 2000 gives anyone the right to request information from public bodies in the UK, who should respond within 20 working days . Trusts’Responses were deemed valid for analysis if they included a guideline for the identification of sepsis in adults. Two independent reviewers (authors AB and EK) read each response and listed all physiological signs, clinical signs, and risk factors included for identification of suspected sepsis. These items were consolidated into groupings by our local sepsis lead (author BM) as shown in To validate the reproducibility of the reference results, two independent reviewers who were not involved in the process described above (authors AW and AJ) were provided with the instructions, item groups, and guidelines to perform data extraction. To evaluate the feasibility of this approach as a standard methodology, the reviewers recorded the length of time taken for analysis of each guideline. The data extraction error rates were calculated by dividing the number of errors by the number of potential errors .All 15 Trusts responded to the FOI request throughout September and October 2018, with response times ranging from 3 to 39 working days. Three responses were excluded prior to data extraction: one Trust 14 in  did not The remaining guideline publication dates ranged from 2012 to 2017, with the majority (9/12) having been published within the two years prior to the analysis. The guidelines ranged in length from a single page to 16 pages, and had different formats, with information presented variably as prose, lists, tables, and flow diagrams.One further guideline 11 in  was exclThe aggregate NEWS score was incorporated into 7 Trusts’ guidelines, and the use of individual NEWS scores into 5. The use of NEWS in one guideline was indeterminate due to the statement “Does your patient have an EWS (Early Warning Score) ≥ 3...”. This is because an individual NEWS score cannot exceed 3, but a threshold of 3 is not normally applied to aggregate score. The relationship between EWS and NEWS was also unclear. Three Trusts  up to the recommendation to prescribe antibiotics. The data extraction error rates, when comparing results from guideline-naïve reviewers to the reference results, were 10% and 13% for raters 1 and 2, respectively. There were 133 errors in total : 35  instances of items in the guidelines being missed, 3  of items being included that were not in the guideline, 88  cases of step numbers being misinterpreted, 6  cases of items being allocated to the wrong group  the outcome of interest with reasonable certainty . Using aDiagnostic test accuracy refers to the ability of a test to discriminate between those who have and those who do not have the target condition. Certain measures of diagnostic accuracy are intrinsically linked to disease prevalence, including the positive and negative predictive values (PPV and NPV). These are the probabilities that a patient who tests positive has the disease, or one who tests negative does not have the disease, respectively. More recently it has also been shown that sensitivity (the proportion of patients with the target condition who have a positive test result) and specificity (the proportion of those without the target condition who have a negative test result) are likely to depend on prevalence if these measures are evaluated in different clinical settings, e.g., emergency departments versus intensive care units . WithoutTo assess cost-effectiveness and affordability economic evaluations are used ,32. EconFinally, from a practical perspective, if only one  care pathway(s) needed to be modified on a national scale, as opposed to a large number of local pathways, a new POCT could be implemented more quickly and at less expense.As mentioned in the previous section, economic evaluations are based on a model structure that maps processes and outcomes. This structure is built on the care pathway because it is an overall representation of the clinical decisions of patients, nurses and doctors ,32. If tThe care pathway also informs the protocol of clinical studies: the point in the pathway where the test might fit defines the patient population of interest and the series of decisions in the pathway defines the study processes. A protocol based on one pathway when there is large variability across the country is unlikely to be generalizable or transferable to other settings.Outcomes  are essential in economic evaluations but are also the endpoints of clinical studies. Outcomes are also affected by variation in the pathways. In our sepsis case study, for example, varying pathways could mean a difference in the group of patients treated with antibiotics for suspected sepsis within each organization. With each step in a pathway, patients not fulfilling the criteria are diverted, and so Trusts with longer pathways, by, for example including more signs and symptoms, are likely to treat fewer patients. In addition, the number of steps and items to consider when deciding whether to prescribe antibiotics may influence the timeliness of any intervention. Thus, variations in guidelines may affect patient outcomes ,34. ThisTo our knowledge, this analysis is the first of its kind, irrespective of medical specialty. Our approach uses readily available resources and avoids biases inherent in practitioner surveys , and thoOur data extraction methodology, involving two independent reviewers, aligns with that of systematic literature reviews . Our valA study by Drennan et al , in whicWe devised a strategy to minimize bias in sampling Trusts, while considering factors that may affect the way in which Trusts operate, including a similar number of sites to that represented in several recently published, high-profile trials ,43,44. WResponses from four of the five Trusts with the fewest beds were excluded; one because of discrepancies within the guideline and the others because a guideline matching the request was not received. Therefore only 12 of 15 Trusts (80%) had a local sepsis guideline, compared to 96% recently reported by the RCEM [We have proposed a novel methodology for analyzing variation in local clinical guidelines, and using this we found large variation in the identification of patients with suspected sepsis across UK hospitals.We advise POCT developers to analyze and visualize the care pathway of patient groups that are likely to benefit from their technology at the early stages of development . This would allow them to understand if their technology has the potential for integration into the current pathway and to be useful to patients, clinicians, and/or laboratory technicians. As we have shown in this discussion, a possible barrier to adoption of a new technology is the variability of the care pathways. It is useful to identify this issue in the early stages of POCT evaluations so that it can be taken into account when planning and conducting economic and clinical studies, and the route to widespread adoption.


How the similarities between these two conditions can help us cope with the emergency effort represented by the management of cancer patients in the COVID-19 era, today and in the future? In a manner similar to the Cancer Moonshot initiative in the United States, we can hypothesize a multinational moonshot project towards the management of cancer patients during COVID-19 pandemic. In particular, we believe that the main road to elaborate meaningful scientific evidence is represented by the collection of all the data on COVID-19 and cancer comorbidity that are and will become available in cancer centers, coupled with the design of large clinical studies. To address this goal, it is essential to identify the entity that can produce this scientific evidences and the potentially most successful research strategy to undertake. The largest Italian organization for cancer research, Alliance Against Cancer , is called to play a scientific leadership in addressing these challenges, which requires the coordination of oncology teams at regional, national, and international levels. To fulfill this commitment, ACC will create a liaison with health government agencies in order to develop “dynamic” indications able to fight such an unpredictable pandemic.If we focus our attention on seven main features of COVID-19 infection ( As of May 4th, 2020, there were 99,981 COVID-19 positive cases , and 29,079 deceased in Italy [Italian Association of Cancer Registries) for 2019, there are about 1000 new cancers diagnosed and 400 cancer deaths every day with an expected prevalence of cancer patients by 2020 corresponding to about 6% of the general population [In Italy, according to the estimates by AIRTUM , clinical pictures with the involvement of different organs and systems, age of the subjects, and higher incidence in males as compared to females.Clinical Worse morbidity and mortality in the most fragile subjects, notably elderly and/or carriers of other chronic illnesses .Absence, to date, of effective medical remedies, such as anti-viral treatments or vaccines capable of protecting the general population from an infection which, as in the pandemics of the past, is not only affecting healthcare but causing the worst economic and social crisis after the Second World War. Importantly, several studies are evaluating the role of sound therapeutic approaches, including tocilizumab , convalescent plasma therapy, and the antiviral remdesivir, which has recently received emergency approval by the US Food and Drug Administration.increasing number of treatments proposed by unconfirmed sources and not supported by substantial evidence are being offered in COVID-19 patients outside the framework of clinical trials.However, regrettably, an Psychological suffering related to the fear of infection and the loneliness caused by the necessary social distancing measures put in place at hospitals and homes.Social and economic deprivation could be associated with COVID-19 onset and prognosis; in particular, the infection seems to hit the poor more often and harder than more affluent individuals.globalization.The extremely rapid spread of the virus, as a result not only of its very active transmission modes but also due to One of the few certainties is the awareness that this has been and continues to be a war on two fronts (treatment of both neoplastic diseases and COVID-19 infection), with probably some critical common issues capable of adding up not in a linear but in an exponential way. In particular, there are at least six main features of COVID-19 infection that deserve consideration as detailed below.heterogeneity, fragility, lack of effective treatments and vaccines, “miraculous cures”, psychological suffering, deprivation, and globalization), we may establish parallelism with the challenges faced in the steep road to the understanding and treatment of neoplastic diseases. Keeping this hypothetical parallelism in mind, one could reason how the lesson from COVID-19 epidemic can be applied to cancer and vice versa, and how the similarities between the two conditions can help us cope with the emergency effort represented by the management of cancer patients in the COVID-19 era, today and in the future? In a manner similar to the Cancer Moonshot initiative in the United States [multinational moonshot project towards the management of cancer patients during COVID-19 pandemic? In line with the Moonshot model, we believe that the main goal should be the elaboration of scientific evidence capable of supporting, on the one hand, patients and healthcare professionals by giving them certainties in their daily choices, and, on the other hand, governments and policy-makers in health policy settings.If we focus our attention on these seven issues , which was established in 2002 by the Italian Ministry of Health as the network of high standard institutes for patient care and research (IRCCS) in cancer [To address this goal, it is essential to identify the entity n cancer . Its prin cancer .In particular, we believe that the main road to elaborate meaningful scientific evidence is represented by the collection of all the data on COVID-19 and cancer that are and will become available in cancer centers, coupled with the design of large clinical studies. In order to evaluate clinical outcomes, cancer patients admitted to various centers in pre-COVID-19 years may be used as historical controls. What data should be collected in this general research strategy?pharmacological data with the aim to learn about potential unfavorable interactions between cancer drugs and drugs used in the treatment of the COVID-19 infection. In particular, can oncological treatments in cancer patients with asymptomatic infection be considered without consequences? Can immunotherapy with checkpoint inhibitors influence the course of infection with particular regard to PD-1-related pneumonia? Can the reactivation of COVID-19 infection occur during chemotherapy? Unfortunately, pharma industries provided little or no initiatives in this context. Likewise, the EU has not been proactive for cancer patients during the pandemics and did not provide support to collaborative research, development and sharing diagnostics, clinical trials cooperation, nor to transborder assistance.The first operational proposal could be the collection of clinical signs and symptoms from the organs and tissues known as target of SARS-CoV-2 infection. This type of data are required to disentangle those due to the infection from those due to malignancy and improve the personalized treatment. A typical example is lung lesions visualized by diagnostic imaging. Here, the collection of data obtained with instrumental investigations can help define the radiological criteria able to differentiate SARS-CoV-2 infections from primary or metastatic lung tumors . The second key point would be the possibility to run clinical trials in patients who did not undergo guideline-recommended therapies during the pandemics, such as those who did not get or delayed the adjuvant treatment. Here, the involvement of general practitioners would be essential to collect data and recruit patients. The third aspect is represented by the need to analyze Serologic tests in cancer patients could play a crucial role since they would allow to verify the prevalence and the intensity of the immune response against SARS-CoV-2 together with the clinical impact of different treatments in different tumor types.The systematic collection of well-annotated biological samples from COVID-19 infected cancer patients is an essential part of our proposal. It represents the best way to study the biological aspects and any long-term consequences of the infection, including a possible impact on tumor prognosis . ExampleAgenzia Italiana del Farmaco, AIFA) is already doing. Moreover, oncology research centers have laboratories equipped with technological equipment and instruments that can significantly contribute towards the molecular study and the control of the infection.IRCCS are called to play a scientific leadership in addressing these challenges that involve the coordination of oncology teams at regional, national, and international levels, to create a liaison with health government agencies and the development of “dynamic” indications fit with an unpredictable pandemic. Their mandate includes the implementation of randomized clinical trials independently of the pharmaceutical industries with the aim to avoid interferences related to various conflicts of interest involving investigators and institutions, similarly to what Italian Medicines Agency (In conclusion, we can win this war only if we acknowledge the need for a strategy that includes what we learn from the research on both cancer and COVID-19. On these grounds, we endorse an approach similar to what we have called “liquid dynamic medicine”, i.e., the matching of dynamic changes in the tumor and dynamic changes in the therapy . Indeed,