With the development of space technology and the performance of remote sensors, high-resolution satellites are continuously launched by countries around the world. Due to high efficiency, large coverage and not being limited by the spatial regulation, satellite imagery becomes one of the important means to acquire geospatial information. This paper explores geometric processing using satellite imagery without ground control points (GCPs). The outcome of spatial triangulation is introduced for geo-positioning as repeated observation. Results from combining block adjustment with non-oriented new images indicate the feasibility of geometric positioning with the repeated observation. GCPs are a must when high accuracy is demanded in conventional block adjustment; the accuracy of direct georeferencing with repeated observation without GCPs is superior to conventional forward intersection and even approximate to conventional block adjustment with GCPs. The conclusion is drawn that taking the existing oriented imagery as repeated observation enhances the effective utilization of previous spatial triangulation achievement, which makes the breakthrough for repeated observation to improve accuracy by increasing the base-height ratio and redundant observation. Georeferencing tests using data from multiple sensors and platforms with the repeated observation will be carried out in the follow-up research. With the development of space technology and the performance of remote sensors, high-resolution satellites are continuously launched by countries around the world. Due to high efficiency, large coverage and not being limited by the spatial regulation, satellite imagery becomes one of the important means to acquire geospatial information. Geometric processing is the basis of image effective utilization. At present, a high accuracy of georeferencing with satellite imagery is achieved by the conventional block adjustment method with ground control points (GCPs), which is on the basis of the sensor model and the system error model ,2,3,4, sThe high accuracy of direct georeferencing for satellite imagery without GCPs can be obtained, either by exterior orientation parameters (EOPs) with high precision, especially pitch, to satisfy the elevation accuracy, which increases the technical difficulty of star sensor design ,10,11,12From these points of view, the Spatial Triangulated Network (STN) is presented , which iThe resulting STN can be applied in two ways. First, the stored ground points with a priori error covariance in the STN can be transferred on the new imagery, and then combined adjustment using the linear mean-square estimator is carried out with the new ground points matched from the new imagery, in which the outputs are the 3D coordinates and the a posteriori error covariance of these stored and new ground points. The new ground points are then added in the STN; meanwhile, the existing ones in the STN are updated with the posterior error covariance and new 3D coordinates. Over time, as more new imagery are introduced, not only the number of ground points increases in the area, but the accuracy of these points improves, as well. These points generate the sequential ground control network called MIN in Dolloff’s paper ,19. SecoThe STN involves several technologies, ranging from the management of the existing spatial triangulation to image retrieval to update of STN to fast processing of the large-scale matrix. This paper derives the positioning model with the oriented imagery, and the experiments prove that the proposed method is superior to the conventional positioning method using SPOT-5 and ZY-3 satellite imagery. Other technologies will be carried out in follow-up research.In this paper, the proposed orientation method for the new imagery using the oriented imagery comprises four parts. First, tie points are acquired by matching new imagery with the oriented imagery. Second, attitude and orbit are modelled based on metadata, and they can be refined with the EOPs of oriented imagery. Third, The EOPs of new imagery and 3D coordinates of the tie points are calculated by combined adjustment. Finally, accuracy is assessed. A flow chart is shown in P is the coordinate vector of ground points; t is the image line acquisition time; S(t) is the vector of satellite positions; λ is the scaling factor; O(t) represents the rotation matrix from the orbit system to the WGS84 system; R(t) is the rotation matrix from the platform system to the orbit system; M is the rotation matrix from the camera system to the platform system; p represents the coordinate vector of image points; c is the vector of interior orientation.Linear array CCD sensors on the satellite for surveying and mapping acquire imagery by push-broom mode, and each line is the result of a perspective projection. The sensor model  is shownroll, pitch, yaw represent the refined orbit and attitude;  is substituted into Formula (1) and linearized using the first order of the Taylor series expansion, shown in Formula (5), which is the observation equation of the conventional block adjustment:The observation equations of the georeferencing method using oriented imagery in this paper are obtained according to Formula (5), shown in Formulas (6) and (7). It represents the observation equation of tie points on the oriented imagery in Formula (6), in which EOPs are known and only coordinates of tie points are unknown. The observation equation of tie points on the new imagery is shown in Formula (7), in which the EOPs and coordinates are the unknowns:inearity , EOPs arinearity , shown iThe simultaneous observation equation of Formulas (6)–(8) with the matrix of weight is shown in Formula (9):The STN contains a series of overlapped oriented imagery eventually covering the region of interest. The image retrieval method is used to acquire the oriented imagery from the STN overlapped with the new imagery. The image extents are extracted from the metadata firstly, which is determined by the four vertexes position described as geographic coordinates in the World Geodetic System 1984 (WGS 84). Secondly, intersections are detected between the oriented and new images on the basis of the vertexes coordinates. Thirdly, the intersecting oriented images are introduced into the combined block adjustment. Tie points, identified on the oriented and new imagery, are necessary for the combined block adjustment. Least squares matching (LSM) techniques are used to automatically obtain the corresponding feature points. The main steps of LSM are: (1) the matching using the pyramid structure with the correlation coefficient is executed firstly, in which the corresponding points are searched within a square window of 5 × 5 pixels, and the size is related to the magnitude of parallax; the correlation size is set to 8 × 8 pixels; (2) least square matching techniques are applied to ensure that the quality of the corresponding matched points is accurate to approximately 0.1–0.2 pixels. The window size is set to 5 × 5 in pixels for least square matching. The coefficient limit is set to 0.8 used to determine whether or not two points are to be considered as possible matches. At last, 133 unique tie points are found throughout the overlapping area of the imagery.In the simultaneous observation equation of the geopositioning method of Equation , the weirvations  to improThe weight x,t are solved from the Formula (10) with the least square estimation, shown in Formula (12):The combined block adjustment includes two steps. First, the initial value of tie points and EOPs are determined, in which the coordinates of tie points are calculated with forward intersection using the interpolated orbit and attitude, and the initial EOPs standing for the coefficients of system error model (Formula (3)) are set to 0. The vectors of unknown corrections n refers to the number of check points; Some GCPs are taken as check points, with which the accuracy is assessed. The calculated coordinates of these points can be achieved with the EOPs after block adjustment. Accuracy assessment is performed by root mean squared error (RMSE) according to the difference of truth and calculated coordinates of the check points, shown in Formula (13):In this study, two groups of datasets are taken as experimental data. The first group contains four SPOT-5 images with different time and spatial resolution taken as experimental data covering an area of France, including two images acquired from the High Resolution Stereoscopic sensor (HRS) with the resolution of 5 m × 10 m and an image obtained from the High Resolution Geometric sensor (HRG) with the resolution of 10 m and an image with the resolution of 2.5 m gained by the super-resolution image processing technique. Twenty six ground truth points (GPS surveyed) are available for GCPs and accuracy assessment, shown in Three experiments are carried out to verify the proposed method in this paper. The first experiment tests new images with conventional adjustment method, and it consists of six cases with SPOT-5 images and four cases with ZY-3 images, where images have different resolutions and base-height ratios. The second one aims at direct georeferencing for stereo pair with the oriented images containing two cases with three subcases for SPOT-5 imagery and three cases for ZY-3 imagery, in which the result is compared with the first test. The third test is positioning for a single image with the oriented images, including two cases with two subcases for SPOT-5 imagery and three cases for ZY-3 imagery. In every subcase, different oriented images are integrated. Images for adjustment are given in Conventional block adjustment is executed for SPOT-5 and ZY-3 imagery. The dataset and positioning accuracy with SPOT-5 are shown in Forward intersection with interpolated and non-refined orbit and attitude is performed for each case without GCP to gain the position of tie points, shown in Block adjustment is carried out with system errors compensated by Formula (3), and different numbers of GCP from 4–7 are applied to the adjustment, shown in Another dataset of ZY-3 images  is also Forward intersection is carried out to achieve the georeferencing accuracy without GCPs, and the result is shown in The second test is direct georeferencing for new stereo image pairs with the oriented images treated as repeated observation, whose accuracy is compared with the conventional method. The test contains two examples conducted with SPOT-5 and ZY-3 satellite images, respectively.The first test example contains two cases with three subcases for SPOT-5 imagery, shown in In Case 1, the new stereo image pair is constituted with Scenes 01 and 02 having the highest base-height ratio among the four images, and different oriented images, Scene 03, Scene 04 and both Scene 03 and Scene 04, are integrated into the adjustment, respectively, which are assigned as Subcases 1, 2 and 3 in Test II in These three subcases perform better than those of conventional forward intersection of Scenes 01 and 02 shown in Case 1 of Test I, in which the horizontal accuracy improvement is 10.44 m, 21.62 m and 22.26 m, respectively, and the vertical accuracy enhancement is about 6 m for all of the subcases, shown in Subcases 2 and 3 perform best among the three subcases, in which the horizontal and vertical accuracy was about 22 m and 9 m, respectively, 11 m better than Subcase 1 for the horizontal accuracy, shown in The horizontal accuracy has also an improvement of above 10 m for these three subcases compared with Cases 4, 5 and 6 in Test I d–f, becaIn Case 2, there are also three subcases. The new image pair is composed of Scenes 01 and 03. Scene 02, Scene 04 and both Scene 02 and Scene 04 with refined orientation parameters is combined for georeferencing with the new pair, assigned as Subcases 1, 2 and 3, respectively, in The accuracy for Subcase 1 is better than Subcase 2, because the base-height ratio increases from 0.6–1.2 when Scene 02 is involved. The accuracy for Subcase 3 is enhanced greatly, in which horizontal and vertical accuracy reaches 7.77 m and 4.49 m, respectively, owing to the increase of the base-height ratio and the redundant observation. The accuracy can be further improved while more oriented images with higher spatial resolution from different view directions are integrated for positioning.Subcase 1 doubled its horizontal accuracy compared with the conventional forward intersection of three non-oriented images of Scenes 01, 02 and 03 shown in Case 4 of Test I d, becausThe second test example includes three cases with ZY-3 imagery, shown in In Case 1, the new stereo image pair is constituted with backward and forward images of ZY-3 having the highest base-height ratio among the three images. Combined block adjustment is carried out with the new pairs and the oriented nadir image. The horizontal accuracy has an improvement of 15.88 m while the vertical accuracy having an approximate value compared with forward intersection without GCPs of Case 2 in Test I b, shown In Case 2, the oriented backward image is introduced into the adjustment with the new pairs of forward and nadir images. The vertical accuracy reaches 6 m, 8.51 m better than Case 4 of Test I d withoutIn Case 3, the new image pair is composed of the backward and nadir image. The horizontal and vertical accuracy improvement was 3.67 m and 3.51 m compared with the forward intersection of Case 3 in Test I c, which These three cases perform better than the conventional forward intersection of backward, forward and nadir images, shown in The third test is direct georeferencing for the new single image with the oriented images, including two examples with SPOT-5 and ZY-3 images.In Case 1, new Scene 03 is oriented with two oriented images of Scenes 01 and 02 and then introduced into Subcase 1 of Case 2 see . Scene 0The horizontal and vertical accuracy was 9.21 m and 6.92 m in Case 1, approximate to the conventional method with seven GCPs shown in Case 4 of Test I a, becausThe second test example contains three cases with ZY-3 images, in which the block adjustments are carried out with two oriented images and a new image, shown in The accuracy of these three cases is better than the forward intersection in Case 1 of Test I, in which the horizontal accuracy enhancement reaches 14.93 m, 14.37 m and 5.19 m and the vertical accuracy improvement is 4.59 m, 0.30 m and 7.83 m for Case 1, Case 2 and Case 3, respectively, shown in In this paper, according to the repeated observation of satellites, we have presented that the outcome of spatial triangulation of images is introduced into georeferencing without GCPs as repeated observation, which can guarantee the effective utilization of previous achievement. We have deduced the model for direct georeferencing with the repeated observation. As shown by the experimental results, direct georeferencing for stereo images or a single image using oriented images without GCPs has the advantage over the conventional forward intersection in location accuracy, and it can achieve the approximation to the accuracy of conventional block adjustment with GCPs, which extends previous research on accuracy improvement. To date, since little research has been conducted on repeated observation for improvement of accuracy by increasing the base-height ratio and redundant observation, the spatial triangulated network (STN) can be established, managing the outcome of the spatial triangulation of images. Combined adjustment with the STN and new non-oriented images is conducted to achieve EOPs of new non-oriented images and 3D coordinates of tie points without GCPs. STN will then be updated with the new oriented images. The method using STN cannot only provide the solution to georeferencing without GCPs, but also improve the effective utilization of the spatial triangulation outcome. STN based on repeated observation around the world can provide a way to global topographic mapping without GCPs.As the goal of this research was exploratory, there existed a limitation: single data from SPOT-5. However, each mapping satellite revolves in its own unique way, thus leading to different resolution and accuracy of positioning. It is recommended that there is a need for multiple sensor data for georeferencing tests with the repeated observation. The establishment, retrieval and update of STN with multi-sensor data should be further approached. According to the results in this paper, the positioning accuracy with repeated observation can attain the close precision with GCPs owing to the increase of base-height ratio and redundant observation, but not all of the tests can gain such results; therefore, it is necessary to do some follow-up studies on determining the scale of STN, in which the highest base-height ratio and redundant observation can be obtained for the purpose of the optimal accuracy.


Lessons captured from interviews with 12 European regions are represented in a new instrument, the B3-Maturity Model (B3-MM). B3-MM aims to assess maturity along 12 dimensions reflecting the various aspects that need to be managed in order to deliver integrated care. The objective of the study was to test the content validity of B3-MM as part of SCIROCCO , a European Union funded project.A literature review was conducted to compare B3-MM’s 12 dimensions and their measurement scales with existing measures and instruments that focus on assessing the development of integrated care. Subsequently, a three-round survey conducted through a Delphi study with international experts in the field of integrated care was performed to test the relevance of: 1) the dimensions, 2) the maturity indicators and 3) the assessment scale used in B3-MM.The 11 articles included in the literature review confirmed all the dimensions described in the original version of B3-MM. The Delphi study rounds resulted in various phrasing amendments of indicators and assessment scale. Full agreement among the experts on the relevance of the 12 B3-MM dimensions, their indicators, and assessment scale was reached after the third Delphi round.The B3-MM dimensions, maturity indicators and assessment scale showed satisfactory content validity. While the B3-MM is a unique instrument based on existing knowledge and experiences of regions in integrated care, further testing is needed to explore other measurement properties of B3-MM. Health systems around the world are under great pressure to drive forward transformation in order to meet the evolving needs of their populations. The traditional disease orientated approaches currently provided no longer suffice to meet the people’s needs . In manyIntegrated care initiatives are being developed around the world 45. Count478108In particular, the conceptual framework of Valentijn et al. can be used to aid an understanding of the concept of integrated care  and showTo achieve a successful transformation to more integrated care systems, insights are needed into what factors contribute to the progress and success of integrated care interventions. However, there is a lack of substantiation of the working mechanisms in integrated care, partly stemming from poor or non-existent evaluation and measurement of integrated care interventions .Capturing the complexity of measuring integrated care is a challenging task. A first difficulty is that measurement is complicated by the conceptual haziness adhering to integrated care which thus limits the theoretical foundations of existing instruments . A secon1516192021A number of measurement models may be helpful in this activity. One model which has taken the complex dynamic and multiformity nature of integrated care into account and provides insight in the development process of integrated care, by describing four developmental phases, has been designed by Minkman et al. . This moA second model, has been developed by the B3 Action Group on Integrated Care of the European Innovation Partnership on Active and Healthy Aging (EIP on AHA) . Unique Validity is an important feature in selecting or applying an instrument and is defined as ‘the degree to which an instrument truly measures the construct(s) it purports to measure’ . The conThis study has two objectives. As part of the European project SCIROCCO , it is tHow is maturity of integrated care measured by instruments identified in the scientific and non-scientific literature?How relevant are the dimensions, maturity indicators and assessment scale of B3-MM according to international experts in the field of integrated care?Since 2013, the B3 Action Group on Integrated Care of the EIP on AHA has been collecting good practices in integrated care in Europe . The extThere is an increase in literature describing frameworks for scaling health interventions, the majority of which has an explicit focus on scaling up health actions in low- and middle-income country contexts . HoweverRecognizing the need for a structured approach which could stimulate path-breaking changes towards more sustainable health and care systems, partners of the B3 Action Group on Integrated Care of the EIP on AHA developed the B3-MM . The B3-MM is derived from an observational study, based on interviews with decision-makers in 12 European countries, or regions within a country, responsible for health care  over 18 months in 2014–2015. The interviews involved asking three sets of questions, to uncover i) the extent of integration already achieved, ii) the journey taken to get to this point, and iii) a view of future plans and investments. The outcomes of the study served as the baseline for the development of the B3-MM . The matThe art of measuring maturity displayed in the Capability Maturity Model (CMM) was introduced in the mid 80’s by the Software Engineering Institute (SEI) – Carnegie Mellon University . Since t38By regarding the development, implementation and scaling up of health innovations as a multi-stage process , the ratIn this study, we conducted a literature review and a Delphi study to test the content validity of B3-MM as instrument to measure the level of maturity of integrated care. Content validity can be determined using both quantitative or qualitative methods . A qualiA review was conducted to identify articles, papers and/or reports focusing on measures and instruments of the maturity of integrated care. Moreover, we were interested in describing and comparing the dimensions, indicators, measurement scales, and the psychometric property content validity of the selected measures and instruments.The literature search consisted of two parts. For the first part, we built on the work of Bautista et al.  who receTo broaden the search for articles, a narrative review was undertaken. In narrative reviews, the authors have the objective to identify, evaluate and synthesize what is already known about a topic . The preTo be included in the review, we used the two eligible article criteria:availability of full-text English document; ;description of items/constructs/measurement scales of measures and/or instruments on the maturity of integrated care.First, one researcher (LG) screened the titles and abstract of the articles from the main search in the three databases to identify articles for full text read. Two researchers (LG and HV) independently screened the full texts to select articles to be included in the final review.Box 1) of the instruments identified in the narrative review based on the criteria used by Bautista et al. [Data were extracted by looking for descriptions on dimensions, indicators, and measurement scales in the selected articles which matched with the 12 dimensions, maturity indicators and assessment scale of the B3-MM. We marked all matching items and listed them in a table developed in MS EXCEL. Descriptions on dimensions, indicators or measurement scales in the selected articles which did not match, but which could nevertheless provide an addition to B3-MM, were also identified. Furthermore, we evaluated the overall quality of the measurement property content validity  with relevant experience in the development, implementation and/or monitoring of integrated care interventions. An overview of the type of experts who were invited to the first round of the Delphi survey is presented in Table In the first Delphi round, experts were asked to rank the relevance of the dimensions, indicators and assessment scale of B3-MM to assess maturity of integrate care on a 9-point Likert scale (1 = Extremely irrelevant to 9 = Extremely relevant). The Likert scale corresponds to the conventional format used for comparative assessment and prioritisation of different health options (such as technologies) . The surThe items for which insufficient agreement was found were rephrased by partners of the SCIROCCO consortium and presented to experts in the second Delphi round. A total number of 44 experts were invited to the second round. They were asked to reassess the relevance of the refined maturity indicators of the B3-MM items on the same 9-point Likert scale. Furthermore, they were asked to what extent they considered the addition to the assessment scale relevant by assessing both the actual rank and the optimum rank of integration using the B3-MM. Again, the experts were asked if they had any comments on the rephrased items or feedback on the survey. The second invitation included a report on the outcomes of round one of the Delphi exercise, including (1) a median agreement rating (interquartile range (IQR)) on every statement, (2) the level of agreement among the experts, (3) the level of disagreement among experts, and (4) whether consensus had been achieved. After discussion among the researchers and members of the SCIROCCO consortium, it was decided to exclude certain participants from the exercise due to a perceived conflict of interest: five members from the SCIROCCO advisory board (who had not participated in the first round of the exercise) and two active members of the SCIROCCO consortium (who had participated in the first round) were excluded from further participation. Again, the experts were given one and a half weeks to complete the second Delphi round.The third Delphi round was conducted to explore the level of agreement among experts on the items with insufficient agreement in the second Delphi round. These items were rephrased by partners in the SCIROCCO consortium. Using the same 9-point Likert scale, experts were asked to reassess the relevance of the refined features of the B3-MM. The 13 experts who participated in the second round were re-invited to participate in the third Delphi round. The invitation included a report on the outcomes of the previous round, including (1) a median agreement rating (IQR) on every statement which was included in the second round, (2) the level of agreement among the experts, (3) the level of disagreement among the experts, and (4) whether consensus had been achieved. Experts were given the opportunity to provide feedback on the survey. Due to the project’s deadlines and the small number of statements in the third round, experts were given one week to complete the last round.Before conducting the Delphi survey, we defined the conditions of agreement among experts to be applied during the three Delphi rounds. In order to determine consensus within a Delphi study, many studies use a predefined level of agreement among the experts . However5358The 9-point scale was classified in three options; 1–3 as irrelevant, 4–6 as equivocal and 7–9 as relevant. The experts’ overall consensus on every statement on the items in the B3-MM was analysed using the median of the group’s scores and the “level of agreement” reached. Agreement among the experts on every statement on the items in the maturity model was reached when more than 75% of the experts’ ratings were within the same three-point range  as well as the observed median. Several studies use a cut-off point of more than 75% of participants scoring 7 to 9, and include the condition (without disagreement) that less than 15% of the participants should have a scoring of between 1 to 3 61. In thOut of the 300 articles included in the study of Bautista et al.  a total 556263646566Overall, there is considerable similarity between the content of the original B3-MM model, and the instruments described in the articles selected from the literature review. All 12 dimensions and the related indicators described by the B3-MM corresponded with the content of the 11 retrieved articles Table . Two dimRegarding the assessment of the measurement property content validity of the instruments, we retrieved the data on the assessment of the overall quality rating score from the review of Bautista et al.  for the A total of 31 experts responded to the first survey round (response rate 56%). Three experts did not complete the survey. Furthermore, two experts were excluded due to a conflict of interest. The final analysis included 26 experts (84% completion rate). Reasons for non-participation included one delivery failure, one retirement, and two time constraints. The rest of the respondents did not provide reasons for not participating.The outcomes on every statement of the first Delphi round are shown in Appendix B. Sufficient agreement was found among the experts on all 12 dimensions of B3-MM. Insufficient level of agreement was found for the first few indicators per dimension. Additionally, sufficient agreement was found on the assessment scale of the dimensions, except for the scale of “Innovation Management”.Comments and suggestions with regard to the dimensions, indicators or assessment scale of B3-MM were provided by 17 out of 26 experts (65.4%). Although three experts provided positive comments with regard to the B3-MM, three other experts commented that some dimensions were unclear or that indicators in some of the dimensions were already covered by other dimensions. A total of five experts commented that some indicators/scales were ambiguous or contradictory and did not follow a logical structure. From the experts who provided feedback to the survey, two experts stated that the survey was difficult to understand and four experts did not fully understand the scale assessment in part C.Regarding answers to the question about assessing the actual and optimum rank of integration, 22 out of 26 experts (84.6%) agreed that the actual and the optimum ranks of integration should be taken into account when measuring maturity of integrated care in a region or country.A total of 14 experts responded to the second survey round (response rate 34%). One expert did not complete the survey. The final analysis included 13 experts (92.9% completion rate). One expert was not able to participate due to time constraints. The rest of the potential respondents did not provide reasons for not participating.The outcomes for every statement of the second Delphi round are shown in Appendix C. Sufficient agreement was found among experts on the rephrased indicators, except for the two rephrased indicators, 8.2 and 9.1. Furthermore, 92.3% of the experts scored between 7–9 (median 7) in response to the question on the relevance of assessing both the actual rank and the optimum rank of integration, by applying B3-MM to provide a contextual explanation for the current situation while measuring maturity of integrated care. A total of six experts provided comments on the rephrased indicators. Three experts indicated that the rephrasing of the indicators was performed well. Furthermore, two experts emphasised that some of the rephrased indicators could still be made more explicit to distinguish these indicators clearly from the other indicators in their scale.A total of 10 experts participated in the third Delphi round (response rate 76.9%). The rest of the potential respondents did not provide reasons for not participating. Sufficient agreement was found on both of the two rephrased indicators 8.2 and 9.1 (Appendix D).The main characteristics of the expert group who participated in the first, second and Delphi round are presented in Table This study reports on the content validity of the B3-MM instrument, developed to measure the level of maturity of integrated care. The literature review and Delphi study allowed the assessment of the content validity of B3-MM and enabled the instrument to be enhanced. Following on from the review, the dimensions and indicators of the maturity model correspond to the items of instruments measuring maturity of integrated care in the academic literature. The results of the Delphi study showed that all the dimensions of the B3-MM are considered relevant by experts in the field of integrated care. Initially in the first Delphi round, there was insufficient agreement on the first few maturity indicators on every dimension whereas, after rephrasing the indicators during the second and third Delphi rounds, experts agreed that all the indicators were relevant for the assessment of the maturity of integrated care. As a result, B3-MM is considered to be a comprehensive instrument consisting of a wide range of dimensions applicable to the development of integrated care.The items included in another instrument, called the DMIC, described in two articles, matched all the dimensions of the B3-MM 71. WhileIn line with other studies 47, a varA few limitations need to be considered with regard to this study. The review was based on search terms derived from a systematic literature review which enabled a broad search in several databases. However, a first limitation of the narrative review is the focus on English language studies, which may have led to a language bias. A second limitation is that literature represent a large diversity of concepts (methods and measurements) concerning the measurement of integrated care . Since “The Delphi technique has long been regarded as an appropriate research technique to reach consensus amongst groups of experts and has been widely applied in health and social studies . HoweverThe agreement found among the experts on the items of the B3-MM represents the majority opinion of the experts, yet, it does not mean the ‘right’ answers have been found . The resNotwithstanding the pragmatic nature of the initial development of the B3-MM, this study is considered to be the first step to validate the B3-MM instrument to measure the maturity of integrated care. While today the B3-MM is a unique instrument based on existing knowledge and lessons learned in implementing integrated care, further research on its measurement properties is needed to enhance the quality of the B3-MM as instrument. The determination of the validity of an instrument measuring a construct is important. This further research on its measurement properties should preferably be guided by the COSMIN manual . MoreoveWe acknowledge the contribution of the following researchers participating in SCIROCCO:NHS 24 – Donna Henderson, Andrea PavlickovaUEDIN –Cristina-Adriana Alexandru, Stuart AndersonUVEG – Elisa Vaila Cotanda, Tamara AlhambraEHTEL – Marc Lange, Diane WhitehouseKronikgune – Esteban de Manuel Keenoy, Jon Txarramendieta Suarez, Ane Fullaondo ZabalaOsakidetza – Igor Zabala, Ainhoa MartinAres Puglia – Francesca Avolio, Anna Elisabetta GrapsFNOL – Zdenek Gutter, Michal StybnarNLL – Lisa Lundgren, Ann-Charlotte KassbergVrije Universiteit Brussel – Yannick MarchalThe additional files for this article can be found as follows:10.5334/ijic.3063.s1Appendix ACharacteristics of articles identified.Click here for additional data file.10.5334/ijic.3063.s2Appendix BOutcomes Delphi round 1.Click here for additional data file.10.5334/ijic.3063.s3Appendix COutcomes statements round 2.Click here for additional data file.10.5334/ijic.3063.s4Appendix DOutcomes Delphi round 3.Click here for additional data file.


The sentence “Also, deletion of SGE1 resulted in loss of pathogenicity in both WT and in aTF1 overexpressing strains .” has been moved from the end of the Results section to the end of the penultimate paragraph of the Results section.This article was republished on December 6, 2016, to correct errors caused by the incorrect resizing of Fig 5 and Fig 7 during the typesetting process, and a correction has also been made in the Results section, under the sub-heading “Induction of effector gene expression mediated by The publisher apologizes for the errors. Please download this article again to view the correct version. The originally published, uncorrected article and the republished, corrected articles are provided here for reference.S1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.


The water column in much of the remainder of the bay was within the mixed layer, and oxygen concentrations in both surface and bottom waters exceeded 5 mg L–1.A comprehensive study of water quality, phytoplankton biomass, and photosynthetic rates in Liaodong Bay, China, during June and July of 2013 revealed two large patches of high biomass and production with dimensions on the order of 10 km. Nutrient concentrations were above growth-rate-saturating concentrations throughout the bay, with the possible exception of phosphate at some stations. The presence of the patches therefore appeared to reflect the distribution of water temperature and variation of light penetration restricted by water turbidity. There was no patch of high phytoplankton biomass or production in a third, linear patch of water with characteristics suitable for rapid phytoplankton growth; the absence of a bloom in that patch likely reflected the fact that the width of the patch was less than the critical size required to overcome losses of phytoplankton to turbulent diffusion. The bottom waters of virtually all of the eastern half of the bay were below the depth of the mixed layer, and the lowest bottom water oxygen concentrations, 3–5 mg L The temporal and spatial variability of plankton populations in the ocean has been a topic of interest to oceanographers for more than a century . It has Among the principal mechanisms that create patches of phytoplankton are water column stratification and spatial variability in the supply of nutrients essential for phytoplankton growth , 17. EstLiaodong Bay, one of the three major bays in the Bohai Sea, is located in the most northern sector of the Bohai Sea near the Liaodong Penisula in northeastern China . The croThe degree of eutrophication in the bay has been mapped based on the status of the benthic macroinvertebrate community  and withIn this study, we tested the hypothesis that the distribution of phytoplankton in the bay was independent of macronutrient concentrations and instead was determined by a combination of temperature, irradiance, and physical processes. More specifically, we hypothesized that patches of high phytoplankton biomass were able to develop in areas where the temperature and irradiance facilitated rapid growth of phytoplankton and where physical mixing was not so vigorous as to preclude patch formation.Given the increasing rate of allochthonous nutrient loading of coastal ecosystems from land runoff, it seems probable that bottom-up controls on the size and frequency of phytoplankton patches in coastal waters will continue to shift from nutrients to light and temperature, with potentially profound implications for fish production –4, the oa.The study area and 66 sampling stations in Liaodong Bay are shown in in situ with a portable dissolved oxygen meter . Salinity (S) and Secchi depths were measured with a digital salinometer  and Secchi disk [™, Mettler-Toledo, LLC, USA) with a resolution of ± 0.002. Dissolved inorganic carbon (DIC) concentrations were calculated from the values of total alkalinity and salinity using the equations in Strickland and Parsons [Temperature (T) was measured chi disk , respectchi disk , and pH  Parsons . Concent Parsons : water s14C tracer method as described by Pei et al. [a, PB M) were calculated based on the estimated photosynthetic rates and concentration of Chl a at 12 incubation stations. The previous study of Pei et al. [a concentrations were positively correlated with temperature at temperatures between 22.5°C and roughly 26–27°C but declined precipitously at higher temperatures. A third-order polynomial function of temperature gave a satisfactory fit to the data (R2 = 0.74). Using the third-order polynomial function of temperature fit to the PB M values at 12 stations, Pei et al. [PB M values and areal photosynthetic rates at all 66 stations.Primary production measurements were carried out at six randomly selected stations in Liaodong Bay on 13 July 2013  and at si et al. . Photosyi et al.  showed ti et al.  estimate4-N), cadmium-copper reduction method for nitrate (NO3-N) plus nitrite (NO2-N), the Griess-Ilosvay reaction for NO2-N, the phospho-molybdate complex method for phosphate (PO4-P), and the silico-molybdate complex method for silicate (SiO3-Si). Dissolved inorganic nitrogen (DIN) was calculated as the sum of NO3-N, NO2-N, and NH4-N. To avoid polymerization of silicon, samples were thawed for at least three hours prior to analysis [a was extracted from GF/F filter samples overnight in methanol and then measured with a spectrophotometer (Model TU-1901) using the equations of Jeffrey and Humphrey [Chemical analyses were carried out using the methodologies of Shen et al.  and Pei analysis . All nutHumphrey .a concentrations, and environmental parameters on two different days at the seven randomly selected stations were compared with paired t-tests. The differences were not significant at p = 0.05. We concluded that temporal variability during the timeframe of this study was small and therefore combined the results from all three cruises in our analysis of the data.The mean and median depths of the bay at the 66 stations we sampled were 4.8 and 5.1 m, respectively, and the range of depths was 0.5–9.4 m. The surface and bottom salinities averaged 22 and 25, respectively. The corresponding mean temperatures were 24.9 and 23.8°C, respectively. Measurements of nutrient, Chl a  and was not explained by differences of oxygen solubility; the mean percentages of DO saturation in the offshore stations west and east of 121.6°E were 117% and 99%, respectively, the difference being significant at p<10−6. Mean Secchi depths at the offshore stations west and east of 121.6°E were 0.95 and 0.74 m, respectively, the difference being significant at p = 0.02. Thus the light regime in the water column was more favorable for phytoplankton growth west of 121.6°E. Not surprisingly, the mean areal photosynthetic rates in the western group of offshore stations, 1183 mg C m–2 d–1, was higher than the mean of the eastern group, 822 mg C m–2 d–1, but the difference was not statistically significant .Examination of the relationship between dissolved oxygen (DO) concentrations and salinity  revealeddong Bay . The stat-test revealed a significant (p<10−6) positive difference between the temperatures of surface and bottom waters. The greatest thermal stratification occurred in the southeastern part of the bay, where the difference in the temperature of surface and bottom waters consistently exceeded 1.3°C.A paired t-test, p<10−4). The differences were greatest in the southeastern part of the bay, where bottom salinities exceeded surface salinities by more than 1. At all but six stations in the remainder of the bay, bottom salinities exceeded surface salinities by less than 1, and surface salinities exceeded bottom salinities at 20 stations in the bay.Salinities were likewise significantly different between surface and bottom samples . SPM concentrations were 73.6 and 108 mg L–1 in the surface and bottom waters, respectively, and they were higher in bottom water than surface water  at 67% of the stations in the bay, particularly off the mouth of the Liaohe River.Surface concentrations of nitrate and Chl Despite the shallowness of Liaodong Bay and the fact that the tidal amplitude ranges between 0.8 and 2.7 m, the bottom waters of substantial parts of the bay were below the depth of the mixed layer as it is traditionally defined in terms of differences in potential density . In partBecause light and temperature appear to be the principal factors constraining photosynthetic rates in the bay, the patterns of primary production were relatively easy to explain on the basis of the distribution of temperature and Secchi depths. Temperatures were within the optimal range of 23–27°C at all stations in the central part of the bay and adjacent to the southeastern shoreline. Temperatures were supraoptimal (>27°C) in the estuary of the Liaohe River, near the mouths of the Xiaoling and Daling rivers, and at four stations intermediate between the mouths of the Daliao and Daqing rivers. Temperatures were suboptimal (<23°C) at most of the offshore stations in the northwestern part of the bay.a  Ralfs, and Coscinodiscus oculus-iridis Ehrenberg are the dominant species in summer in Liaodong Bay [2 and caused severe economic losses [Previous studies have suggested that diatoms such as dong Bay , 53. Howdong Bay  and in tdong Bay , 55. Cordong Bay . An espec losses . Much diSome studies , 26 haveObservations of phytoplankton patches and examination of their mechanisms of formation might provide clues as to why HABs have become more frequent. However, phytoplankton patchiness and thin layers have been studied less in the coastal areas of China compared, for example, with the Layered Organization in the Coastal Ocean project carried out in Monterey Bay, California, a study that has involved intensive multi-investigator efforts , 60. A sIn Liaodong Bay, phytoplankton patchiness may also be affected by diel phenomena, as suggested by the observations of Benoit-Bird et al. , the shia. Three regions of high assimilation numbers were observed with locations consistent with the areas of high biomass and production. Phytoplankton growth rates seem not to be limited by nutrient concentrations, with the exception of a few stations in the northwest and southeast sectors of the bay. Instead, phytoplankton growth rates are controlled by the distribution of water temperature and variation of light penetration restricted by water turbidity. Combining information on temperature and Secchi depths revealed five patches where surface temperatures were in the range 23–27°C and Secchi depths were greater than 1 m. These patches of optimal conditions for phytoplankton growth corresponded closely to the patches of high areal photosynthetic rates, with the exception of a linear region along the shoreline adjacent to the mouth of the Daqing River. Based on the relationship between DO concentrations and salinity as well as the spatial distribution of oxygen in the surface water, the sampling stations of Liaodong Bay could be divided into three groups. The stations in the third group, located offshore and west of 121.6°E longitude, were the most favorable for phytoplankton growth as a result of their greater Secchi depths and hence better light regime. Bottom waters of nearly all of the eastern bay were below the depth of the mixed layer and were characterized by the lowest oxygen concentrations, 3–5 mg L–1. In contrast, the water column in much of the remainder of the bay was within the mixed layer, and oxygen concentrations were higher than 5 mg L–1 in both surface and bottom waters. Apparently, patches of phytoplankton in Liaodong Bay were determined to a large extent by temperature and light and not by nutrients in this study. As humans discharge more and more nutrients into coastal waters as a result of fertilizer usage and wastewater disposal, the importance of nutrients in the formation of patches and HABs will lessen. In contrast, the importance of light and temperature will increase under the growing influences from both human activities and climate change. Overall, our results complement earlier work by identifying factors that control the development and size of patches other than nutrients, and prove our hypotheses are correct, but with some caveats: the change from nutrient limitation to light and temperature limitation, combined with other factors of Si/N ratio shift, diel effects and the effect of toxic pollutants, may have favored dinoflagellates and HABs. Thus, our results provide a reference for coastal studies related to phytoplankton shift from diatoms to dinoflagellates, and the increasing problems of eutrophication, HABs and hypoxia.In this study, several patches of high biomass and production with horizontal dimensions of roughly 10 km were apparent from examination of areal photosynthetic rates and concentrations of Chl S1 Dataset(XLS)Click here for additional data file.


Surgical strategy to increase the number of liver transplants in the pediatric population is the ex-situ liver transection (reduction or split). However, it is associated with complications such as hemorrhage and leaks. The human fibrinogen and thrombin sponge is useful for improving hemostasis in liver surgery.  Compare pediatric liver transplants with ex-situ liver transection (reduction or split) with or without the human fibrinogen and thrombin sponge.  Was performed a prospective analysis of 21 patients submitted to liver transplantation with ex-situ liver transection with the application of the human fibrinogen and thrombin sponge in the wound area (group A) and retrospective analysis of 59 patients without the sponge (group B).  The characteristics of recipients and donors were similar. There were fewer reoperations due to bleeding in the wound area in group A (14.2%) compared to group B . There was no difference in relation to the biliary leak .  There was a lower number of reoperations due to bleeding of the wound area of the hepatic graft when the human fibrinogen and thrombin sponge were used.  When talking about liver transplantation with ex-situ liver transection, these are two possible procedures: hepatic reduction or splitHepatic reduction, described by Bismuth et al. in 1984The split technique was described by Pichlmayr in 1988,,,,,,,Currently, the ex-situ liver transection technique achieves good results in the literature, with survival rates similar to the results of transplants with whole graft,,,,The human fibrinogen and thrombin sponge (Tachosil(r))The objective of this study was to compare pediatric liver transplantation with the ex-situ liver transection with or without the use of the human fibrinogen and thrombin sponge.The project was approved by the Research Ethics Committee of the Federal University of São Paulo/Hospital São Paulo, with number 38311/2012.A prospective study of pediatric patients submitted to liver transplantation with the ex-situ liver transection technique and with the use of the human fibrinogen and thrombin sponge was carried out at Hospital São Paulo, Escola Paulista de Medicina - UNIFESP, São Paulo, SP, Brazil, from January 2012 to May 2016. The control group was formed by a historical cohort, with prospective data collection, starting in January 2004, of all patients submitted to liver transplantation with ex-situ liver transection technique without the use of the human fibrinogen and thrombin sponge in this same service.The study included 80 patients and divided into two groups: the first, classified as group A, was composed of 21 patients submitted to the transplantation with the use of the human fibrinogen and thrombin sponge; and in the control group (group B) were included 59 patients submitted to the transplantation without the use of fibrinogen sponge and human thrombin.Inclusion criteria were children of up to 18 years of age, of both genders, submitted to liver transplantation with ex-situ liver transection technique independent of indications of liver transplantation. Patients older than 18 years and cases in which the parents or guardians refused to sign the free and informed consent form were excluded.Potential donors were selected for hepatic transplantation with the ex-situ liver transection technique when, if possible, they fit within the criteria of this institution: under 50 years of age, hemodynamic stability, less than four days in the intensive care, ALAT (U/l) and ASAT (U/l) levels less than twice normal, GGT below 50 IU/l, sodium levels below 160 mmol/l and less than 30% fat infiltration In the macroscopic analysis. Due to the severity of the recipients and the urgency of a liver graft for transplantation, not all donors met these criteria.Aiming for the most appropriate matching between donor and recipient, the size, weight and BMI data of both were taken into account in the decision to perform the liver transection. The logistics between liver graft extraction, liver transection (reduction or split) on an auxiliary table, and graft implantation were designed to achieve maximum cold ischemia time of 12 h.After liver graft revascularization, primary hemostasis and raffia of the bile ducts of the wound area were performed. According to the manufacturer's instructions, the previously moistened sponge and was applied the yellow side, on which the active principles of the product were found, to the wound surface of the liver graft. Sponge compression was carried out with the aid of a wet compress for about 2 min in order to obtain a correct sponge fixation and local hemostasis.When necessary, because of the extent of the wound area being larger than the surface of the sponge, more than one was used and the application process was repeated .The outcomes evaluated in this study were: use of blood products, bleeding of the wound area, biliary leak and collection of the wound area, and survival of the patient and liver graft in 30 days.The analyzed data are represented in mean, median, standard deviation and percentage. Student's t-test, chi-square, Fisher exact, Mann-Whitney and Kaplan Meier survival curve were applied when indicated. The statistical analysis program SPSS version 2.0 was used, with p <0.05 being considered significant.The two groups were similar in terms of demographic characteristics, including age, gender, diagnosis of liver disease, weight, height, blood typing and PELD range.In relation to the donors, except for the level of bilirubin (mg/dl), which was higher in group A (0.71±0.55) than in group B (0.47±0.37), but both above the normality, there was no difference in the other characteristics and both group were similar to age (years), gender, body mass index (BMI), use of inhaled drugs, alcohol consumption (mg/dl), creatinine (mg/dl), urea (mg/dl), ALAT (U/l), ASAT (U/l), bilirubin (mg/dl), alkaline phosphatase (U/l) and GGT (U/ l).Group A consisted of 18 (85.7%) patients submitted to the split technique and three (14.3%) to the reduction technique; in group B, 36 (61%) patients were submitted to the split technique and 23 (39%) to the reduction technique (p=0.056).The parameters analyzed in the surgical procedure  showed tWhen the reoperations by bleeding of the wound area were analyzed, there was a lower frequency in group A (14.2%) than in B (41.7%), with a statistically significant difference (p=0.029).Regarding the biliary leak and collection of the wound area, as well as the type of treatment indicated for the collection, such as reoperation, puncture and drainage of the collections, there was no statistical difference when comparing the two groups.Regarding the early survival in 30 days, comparing the two groups, group A presented survival of 80.9% in 30 days and the B 87.7%, with no statistically significant difference (p=0.328). Early 30-day survival of liver grafts was also similar, comparing the two groups .The two groups studied did not present statistical differences regarding the demographic characteristics of the donors and recipients, forming two groups similar and comparable for possible outcomes. The techniques of ex-situ liver transection were similar in reduction and split.,,,,,,An alternative to the ex-situ split technique would be the use of split in-situ, in which the liver graft is divided with the donor still the heart beating. This technique has already been described in the literatureThese conditions are difficult to find in Brazil due to their extension and non-standardization of health services, so this technique has been little used in the country. The Pittisburgh transplant group published a comparison between in-situ and ex-situ split techniques in 2000, showing no difference in patient survival and hepatic graft survivalHemotransfusion frequency was observed in 100% of patients in both groups during liver transplantation, red blood cell transfusion volume was statistically similar, and the median use of blood products (ml/kg) was 35.1 in group A and 36.5 in group B, with no statistically significant difference (p=0.83).In a study published in 2010, Toti el al. compared the use of human fibrinogen and thrombin sponge with fibrin glue in the wound area of patients submitted to liver transplantation with the ex-situ split technique. The authors described no difference in the need for the use of blood transfusion between the two groups, but did not demonstrate data of transfusion at work and only cited this information during the textWhen the reoperations by bleeding of wound area were analyzed we observed that in group A - where the human fibrinogen and thrombin sponge were applied - the reoperation rate was lower (14.2%) than in the Group B , demonstrating that this instrument may help in the hemostasis of the wound area of patients submitted to pediatric liver transplantation with the ex-situ liver transection technique (reduction or split).,,,,,,In the literature, articles involving the use of this sponge for hemostasis of the wound area in hepatectomy and in liver transplants with the ex-situ liver transection technique and/or living donor, corroborate this findingIn 2008 a traditional pediatric transplant group in Belgium published a report of the use of human fibrinogen and thrombin sponge in four children undergoing liver transplantation using the liver transection technique . However, it was a series of cases without a control group and the author's opinion is that the human fibrinogen and thrombin sponge used on the wound area of the graft leads to a good and effective hemostasis, which occurs by describing the use of only one concentrate of red blood cells per patient during the transplantation, as no patient presented bleeding in the postoperative periodIn 2011 Mirza et al. published a prospective and multicenter study analyzing the use of the human fibrinogen and thrombin sponge in a population composed of individuals submitted to liver transplantation with the ex-situ liver transection technique and others to hepatectomy. Sixteen patients were included, 13 of whom underwent liver transplantation. The authors demonstrated good hemostasis of the wound area with the use of the human fibrinogen and thrombin sponge within 3 min in 81% of the patients studiedIn this study, there was no statistically significant difference in the biliary leak rate of the wound area, as well as in the collection area near the wound area between the group that used the sponge , and the group that did not used the sponge .,,,,Biliary leak in hepatic transplantation is an important cause of morbidity. Literature rates vary from 5-10% of liver transplants with whole liver and are directly related to complications of the hepatic arteryIn the literature, the use of human fibrinogen and thrombin sponge and its relation with biliary leak and collection of the wound area is still controversial.Toti et al., in a retrospective study in 2010 demonstrated a reduction in the biliary leak rate in adult patients submitted to liver transplantation with split and sponge use in the wound area compared to fibrin glue use in the wound area, reducing the rate of leak of 43.75% without the use of the sponge, to 6.25% with its useOn the other hand, Mirza et al. demonstrate a rate of 12.5% of reoperation due to bile leak of the wound area in pediatric patients submitted to liver transplantation even with the use of the human fibrinogen and thrombin sponge in the wound areaIt was studied the early survival in 30 days, because after this period the human fibrinogen and thrombin sponge has been absorbed and is no longer present in the patients' bodies. Both groups presented 30-day mortality and graft loss in 30 days similar, with no statistically significant difference. Patient survival at 30 days in group A was 80.9% and in B, 87.7% (p=0.32). The graft survival in group A was 76.1% and in B, 78.4% (p=0.668). Regarding patient and graft survival in 30-day period, the values are similar to those presented by the other authors in the literature. The one-year survival of pediatric patients undergoing liver transplantation with the ex-situ liver and graft transection technique is described in the literature in about 73% and 63%Comparing pediatric liver transplantation with the ex-situ liver transection technique (reduction or split) with or without the use of the human fibrinogen and thrombin sponge, was observed a smaller number of reoperations due to bleeding of wound area of the liver graft when the human fibrinogen and thrombin sponge were used.


Earthquakes, which can cause widespread territorial and socio-economic destruction, are life-threatening, unexpected, unpredictable, and uncontrollable events caused by the shaking of the surface of the earth. The psychological consequences, such as PTSD, anxiety, depression, and suicidal ideation, are well-known to clinicians and researchers. This study was conducted with the aim of evaluating the use of the Eye Movement Desensitization and Reprocessing (EMDR) Integrative Group Treatment Protocol on a sample of adolescents, after the earthquake in Central Italy on 24 August 2016. The objective of the EMDR intervention was to reduce PTSD symptoms. Before and after EMDR, specific assessment to find changes in PTSD symptoms was made using the Impact of Event Scale-Revised and through the analyses of the Subjective Units of Disturbance. The EMDR treatment was given in three sessions , each lasting 90 min, and the results at follow-up phase (T4) were also monitored. The results are very encouraging, showing significantly reduced PTSD symptoms in the majority of the subjects. The clinical implications and limitations will be discussed. Earthquakes have always characterized human history as they are among the most common and devastating natural disasters. Today, despite scientific progress in increasing the predictability of seismic phenomena, earthquakes continue to cause devastating damage, and major destruction all over the world.The consequences of earthquakes are not limited to the dangerousness of physical damage, indeed their traumatic repercussions have always been a subject of study in psychology. Post-traumatic stress disorder (PTSD) is the most-studied psychopathology resulting from earthquakes and natural disasters, due to the very high correlation ratios between earthquakes and this psychopathology, as documented in various studies e.g., . In receAssociazione EMDR Italia between September and October 2016 when the receivers were students of the Istituto di Istruzione Superiore di Amandola (Fermo Province) who had survived the earthquake, and the aim was to treat PTSD through administration of the EMDR-IGTP (Integrative Group Treatment Protocol).The project came into being following the intervention by the Due to its particular geodynamic position where the African and Eurasian plates converge, Italy has frequently been subjected to very strong seismic events sadly noted for the great damage they cause, above all in the zones of the center and south affected by the tectonics of the Apennines. One of the most recent seismic event in Italy, defined “Amatrice-Norcia-Visso seismic sequence” by the National Institute of Geophysics and Vulcanology, made itself felt from the end of summer 2016 to January 2017 with various tremors of magnitudes between 5.5 and 6.5 on the Richter scale.On 24 August 2016, an earthquake with a magnitude of 6.0, with the epicenter along the Valle del Tronto between the communes of Accumoli (Rieti Province) and Arquata del Tronto (Ascoli Piceno Province) struck the regions of Abruzzo, Lazio, Marche, and Umbria in Central Italy .The Civil Protection Department reported 299 dead, numerous injured, and serious damage throughout the area .Two months later, on 26 October 2016, two more tremors, with the epicenter on the Umbria-Marche boundary and magnitudes of 5.4 and 5.9, were recorded in the Macerata province communes of Castelsantangelo sul Nera and Ussita, respectively, and followed by a series of tremors with magnitudes of between 3.0 and 4.5. On 30 October 2016, a devastating 6.5-magnitude tremor, with the epicenter between the towns of Norcia, Preci, and Castelsantangelo sul Nera in the Province of Perugia, caused numerous collapses and serious damage but no victims.On 18 January 2017, four tremors with magnitudes of 5.1, 5.5, 5.4, and 5.0 hit the previously stricken areas, with the epicenters in the Aquila Province communes of Montereale, Capitignano, and Pizzoli, and the Rieti Province commune of Cagnano Amiterno, respectively. The emergency situation was further worsened by the bad weather: an intense cold snap and heavy snowfalls with snowdrifts over a meter and a half high hampered rescue operations to the stricken populations .Associazione EMDR Italia carried out a post-emergency intervention in the commune of Amandola (Fermo Province) to provide the population with specialist psychological support through a team specialized in psychotraumatology in emergency situations. The intervention started officially on 13 September with an informative meeting in the Council Room of the Amandola commune, and the various sessions were held mainly in the communal library, although specialist interventions were also held in private homes. Thanks to the collaboration of the Amandola commune, group interventions according to the EMDR-IGTP protocol were carried out in local primary and secondary schools  to practice EMDR in emergency contexts. The intervention continued via further humanitarian missions even after the new tremors in January, at the same time as the emergencies caused by the weather , as a result of the high need for mental health services occurring as a result of the destruction of Mexico’s Pacific coastline in 1997 by Hurricane Pauline. The team of doctors had initially designed a traditional, individually applied EMDR intervention aimed only at a limited number of children, adolescents, and adults who had lost family members or become homeless. However, on the first day in the field, those in need of treatment numbered more than 200. The AMAMECRISIS team were faced with the challenge of developing a suitable methodology to give so many needing support simultaneously an efficacious and specific treatment for trauma, such as the EMDR, initially developed to be applied to one person at a time .The EMDR-IGTP protocol combines the EMDR therapy of eight standard phases , 2001 wiThe advantages of the application of this protocol, apart from its simultaneous applicability to several subjects, are connected with the non-specificity of the setting, which must no longer necessarily be “private” and thus difficult to find in emergency situations. In addition, the IGTP protocol does not ask the subjects in the group to verbalize information regarding the trauma, the therapy can be applied over several consecutive days, there are no particular tasks to carry out between sessions, and treating several subjects makes it possible to rapidly involve many sections of the affected community. A further advantage offered by application of the IGTP protocol is that the clinical specialists can be assisted by paraprofessionals, teachers, and family members, and this makes wider application of the treatment protocol possible in particular emergency situations where the availability of professionals is limited .The protocol modified by The efficacy of the EMDR-IGPT approach has been documented in the literature by pilot studies in the field  and variIn the specific field of earthquakes, there are as yet few studies and these present some methodological limitations, despite pointing out that EMDR seems a suitable methodology also for dealing with natural calamities . A studyGiven the mode of operation of the health care providers and the humanitarian aim of the intervention, it was not possible to implement a randomized, delayed treatment condition. Here it is necessary to focus attention on certain ethical concerns  in the context of humanitarian emergencies, based on the indications of the R2HC program  of Bovisio Masciago  and Article 10 of the “National Board of Italian Psychologists Code of Ethics for the Psychologist.” Moreover, regarding the ethical issues, the study was implemented following the request for intervention by the City of Amandola and upon the approval of the ethic panel of the EMDR Italian Association .This study was conducted in accordance with the Declaration of Helsinki (2001), under the approval of the research guidelines of the Prior to data collection, all subjects  received complete information concerning the rationale and effectiveness of EMDR and the study procedures, and gave written informed consent for their participation in the study.Istituto di Istruzione Superiore di Amandola (Fermo Province) agreed to take part in the study. Of the 119, 116 gave valid answers when filling out the socio-demographic form regarding age and sex. The initial sample was thus composed of 65 males  and 51 females  for a total of 116 subjects aged 13–20 .In choosing the sample, it was decided to exclude all participants who, in the view of the care providers, had in the assessment phase shown symptoms of psychosis or dissociative disorders, or presented a clear risk of harming themselves or others, but no participant fulfilled any of these conditions. All 119 students of the In a clinical and preventive perspective, support with the EMDR-IGTP protocol was made available to all participants, but here analysis will be of the data of the 45 out of 104 subjects (56.7% of the whole sample) who at T1 scored more than 24 points (possible diagnosis of PTSD). Of these, 17 (16.3%) scored from 24 to 32 points , 7 (6.7%) scored from 33 to 36 points (full PTSD), and 21 (20.2%) scored more than 37 points (severe PTSD).Table 1).At T1, valid answers were given to all the items on the socio-demographic form except for the one concerning previous trauma, where a single answer was missing. All the subjects said that they were at home during the earthquake, except for one who was away from home; 42 (93.3%) said they lived at home, 3 (6.7%) away from home. None had been physically injured, only one reported injured family members, and 8 out of 45 (17.8%) reported damage to property due to the earthquake. 13 (28.9%) reported previous therapeutic treatment; 11 (25%), previous exposure to traumatic events (In the first treatment session (T1), a socio-demographic form was administered to collect data on sex, year at school, current living status, location during the earthquake, injuries received during the earthquake, injured family members, damage to property, previous therapeutic treatment, and previous exposure to potential traumatic events.In the first and last treatment sessions (T1 and T3) and in the follow-up (T4), the adult version of the self-report IES-R  questionnaire was administered, in order to assess PTSD .The IES-R, the updated version of the IES questionnaire , assesseFor the data analysis, questionnaires with at most two omitted answers were considered valid. When one or two answers were missing, a substitute value (the average of the column) was inserted. At T1, 104 questionnaires were considered valid, of which 9 had one missing item and only 1 had two missing items.The relative scores on the Subjective Units of Disturbance (SUD) scale at T1 and T3 were also taken into consideration. At each EMDR-IGTP session, the subjects were asked to make a drawing connected to the earthquake, to assign a score from 0 to 10 to represent the negative emotions associated with the drawing (SUD score) and to carry out bilateral stimulation four times. EMDR-IGTP treatment aims to reduce the SUD score associated with negative emotions regarding the event from the first drawing in a session to the last, and from the first session to the last. In the EMDR protocol, the reduction of the SUD score acts as an indicator for what is represented in the mind of the subject and for the negative emotions which the drawing arouses in the subject.The results of the IES-R questionnaire of the 45 subjects with scores over 24 at T1 were monitored up to the third EMDR-IGTP administration (T3), where 36 questionnaires were considered valid, and at the follow-up (T4), where 35 were considered valid.Analysis of the PTSD level of subjects at T1 showed 17 with partial PTSD (37.8%), 7 with full PTSD (15.6%), and 21 with severe PTSD (46.7%). The IES-R questionnaire scores went from a minimum of 24 to a maximum of 65 (average: 38.27 and std dev: 11.42).During assessment of the follow-up at T4, the IES-R questionnaire showed 13 subjects without PTSD (37.1%), 8 with partial PTSD (22.9%), 3 with full PTSD (8.6%), and 11 with severe PTSD (31.4%), as well as 10 missing cases.Table 2 and Figure 1.The results of the total scores and of the IES-R subscales are shown in post hoc Bonferroni-corrected analysis were performed to determine the significance and direction of the differences of the IES-R scores relating to the first and third administrations (T1 and T3) and the measures performed at follow-up (T4).To compare the results of the IES-R and subscales at T1, T3, and T4, an ANOVA for repeated measures and a F(2.58) = 17.195, p < 0.001, η2 = 0.37 showed statistically significant differences between T1 and T3, and between T1 and T4, but not between T3 and T4.The analysis of the total scores on the IES-R scale with F(2.58) = 10.802, p < 0.001, η2 = 0.27; a significant difference between T1 and T3 and between T1 and T4, but not between T3 and T4 for the avoidance subscale with F(2.58) = 12.961, p < 0.001, η2 = 0.31; and the same for the intrusion subscale with F(2.58) = 14.648, p < 0.001, η2 = 0.34 (Table 3).Analysis of the subscales showed a significant statistical difference only between T1 and T3 for the hyperarousal subscale with t-test for paired samples were performed to verify the reduction of the SUD score at the ends of the first  and third sessions , as well as of the first and the last scores on the SUD scale from the first session to the last (SUD A and SUD D at T1 and T3).To analyze the scores on the SUD scale, an ANOVA for repeated measures and a Table 4).The results of the analysis showed a significant reduction of the SUD score during the first administration between the first score (SUD A) and the third and fourth scores (SUD C and SUD D) (p < 0.05) .As well as the average decrease recorded in each phase of the administration, it is interesting to note, as evidence of the progressive working-through of the trauma, that also the initial levels of SUD (A) progressively diminish over time, in the same way that there is a significant reduction of the SUD linked to the final reading (D) between T1 and T3  made it possible to hypothesize the efficacy of the EMDR-IGPT treatment in reducing in the subjects, in every phase of the intervention, both the PSTD symptoms and the negative emotiveness connected with the representations of the traumatic event.The results of this research obtained positive confirmation with regard to the EMDR-IGTP protocol for the treatment of PTSD in a sample of adolescent survivors of an earthquake, for both the results of the IES-R scale and those of the analysis of the SUD scales.The analysis of the IES-R scale and relative subscales makes it possible to hypothesize the efficacy of the treatment in reducing the number of subjects with probable PTSD, as seen in the comparisons between the first and final sessions of the treatment, between the first session and administration of the IES-R questionnaire in the follow-up more than 3 months later, in the total scores and in the scores on the avoidance and intrusion subscales. The analysis thus seems to confirm the efficacy of the treatment and the lasting nature of the results of application of the EMDR-IGPT protocol, as already documented in various studies and despite possible retraumatization caused by successive tremors. With regard to the hyperarousal subscale, the only significant result was the reduction between the first and last administration, and not the reduction concerning the results which emerged in the follow-up. This latter fact can be explained by the clinical significance of the hyperarousal scale, which highlights a state of alarm and continued perception of a state of possible danger. Yet considering the living conditions of the population studied (temporary housing in the stricken areas) and their exposure to a second earthquake, this does not come as a surprise. Indeed, it acknowledges the importance of a structured intervention with the dual aim of managing PTSD symptoms and preventing the worsening of the post-traumatic condition in vulnerable subjects. The fluctuating scores of the results of the IES-R questionnaire were found, although much less markedly, in other studies on the efficacy of the EMDR treatment, in particular in the reference study by The results of analysis of the SUD scores can be used as general indicators of the therapeutic process and of the working-through of the traumatic event, in that they provide a relative indication of the negative emotional load associated with the subjects’ representations of the event . These rIt is necessary to underline certain limits of this research determined by the humanitarian nature of the intervention, such as the relatively limited sample number, the absence of randomization procedures and the impossibility of setting up a control group, a forced choice due to the priority of guaranteeing to all receivers of the intervention treatment aimed at preventing medium- and long-term psychological disturbances arising and treatment of the acute and chronic symptoms due to post-traumatic stress.This study allows us to hypothesize the efficacy of the EMDR-IGPT intervention in a group of adolescent earthquake survivors. Today, EMDR continues to be the subject of scientific research in the field of PTSD therapy and its efficacy continues to be confirmed by many studies. However, especially in the field of emergencies, which are characterized by a series of challenges due to the event’s implicit characteristics, such as non-predictability and the ethical implications which oblige sudden intervention, there is an important difficulty in monitoring the results of the intervention.Further studies and scientific evidence are auspicable and, as underlined by Shapiro herself, the need continues for studies concerning this issue, especially to reach a more profound understanding of the underlying mechanisms and neurobiological correlates of the treatment .GM, MZ, and CC planned the research design and wrote the article; CM and SP contributed to the manuscript; DT and VL contributed to the statistical analyses under CC’s supervision.GM and MZ are offering education in EMDR field to licensed psychotherapist. GM is a coordinator of the “Emergency Section” in the EMDR Italian Association. The other 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. The handling Editor declared a shared affiliation, though no other collaboration, with several of the authors, GM, SP, and DT.


This study analyzes the appropriateness of an improved version of one of the most frequently used instruments for the screening of high-risk alcohol consumption. This adaptation was created in accordance with certain limitations recognized by other researchers and in an attempt to adjust the content and scales of some items to a more consensual definition of binge drinking. After revising items 2 and 3, the areas under the ROC curves of the AUDIT and of different abbreviated versions were calculated. A total of 906 minors  between the ages of 15 and 17 were evaluated. Stratified sampling was conducted on a population of high school students in the city of Valencia (Spain). One school was randomly chosen from each of the city’s 16 school districts. Information was collected on sociodemographic aspects, consumption patterns and the AUDIT containing the improved items. The percentage of underage BD reached 36%, regardless of gender or age. BD groups have been differentiated by different intensity levels, both in males and females. Upon comparing the effectiveness of the distinct versions of the AUDIT, it is recommended that researchers and clinics use the combination of the revised items 2 and 3 to ensure a more precise identification of underage BD. A cut-off point of 5 for this test would permit identification of 94% of the underage BD and would notably reduce false positives. One of the most frequently used screening instruments for the identification of high-risk alcohol consumption in youth is the AUDIT and its abbreviated versions  which waOf the three dimensions included in the AUDIT , the first of these dimensions is the most frequently used to determine consumption in youth . The thrThese results support the conclusions obtained in the revision conducted by weekly” or “daily or almost daily” on the AUDIT-C, even though said drinking took place only three times a week. For Question 2, the numerical amount for any respondent who reports consuming 10 or more drinks on a typical day, whether it is 12, 15, or 30 drinks, will be coded as 10.Despite the fact that they are very frequently used instruments, limitations have been suggested with regards to their efficiency in identifying BD. On the one hand, reference has been made to the measurement scales used for the different items. On the other hand, in an attempt to better identify underage BD, an effort has been made to more precisely specify the cut-off points of the scales. In this regard, no consensus has been reached either, and there is still a very wide range for the AUDIT, varying between 2 and 10 points . For minFurthermore, some researchers have tried out new combinations of items in order to better predict the pattern of underage consumption. Again, in this case, consensus has yet to be reached. All of this disagreement has led to an interest in making improvements in the wording of the consumption items (AUDIT-C) given that these are the most explanatory of the youth consumption pattern. Included in the suggested changes is the modification of item 3, reducing the number of drinks  engaged in BD, 52.9% (n = 173) were female and 47.1% (n = 154) were male. Differences were not found based on gender , or age .Nine hundred and six participants, 468 women and 438 men, took part in the study. Their ages ranged from 15 to 17, with mean age Stratified sampling was carried out on a population of mandatory secondary school (grades 7–10), upper secondary (grades 11–12), and vocational training students in the city of Valencia (Spain). One school was randomly chosen from each of the 16 school districts in the city. Questionnaires were administered in classrooms during the school day. In all cases, participation was voluntary and anonymous.A self-report diary was used, in which, for each day of the week, participants were to indicate the type and number of drinks consumed and the approximate time when the drinking took place. Each use was converted to grams of alcohol, based on the Spanish SDU  . This vaBased on the SDUs consumed and the number of hours in which this consumption took place, participants were classified as BD or non-BD. In all cases, there was compliance with the consumption proportion of seven or more SDUs in a 2 h interval for males and the consumption of six or more SDUs during the same time interval for females .Participants also filled out the 10 AUDIT items ? The response scale was adapted based on the results obtained in prior studies conducted with minors and university students ((0) Never; (1) Sporadically -less than once a month-; (2) between 1 and 4 times; (3) between 5 and 8 times; (4) between 9 and 12 times; (5) 13 or more times.Next, the consensual definition of BD was used to improve item 3. It was worded as follows: students . FollowiHow many SDUs do you tend to have on a day when you drink alcohol? And maintaining its original response scale (0) 1 or 2; (1) 3 or 4; (2) 5 or 6; (3) 7 to 9; and (4) 10 or more.The wording of item 2 was also improved, changing number of drinks for number of Spanish SDUs consumed in 1 day. Finally, it is worded as follows: Then, based on self-reports, these two new variables were generated. Later the value of the AUDIT-CR was calculated (A1+A2revised+A3revised), and the usefulness of the A3revised item was assessed. Finally, considering the recommendations from some prior studies, the A2revised+A3revised variable was also calculated.number of grams consumed in a BD session and number of hours of consumption for females and for males. In all cases, the extraction procedure consisted of two phases, which led to a natural classification of the subjects into different groups.Four cluster analyses were also conducted with the BD and non-BD youth, based on the values of a posteriori tests, using the eight groups obtained in the clusters as independent variables (IVs) to determine whether there were differences in the grams consumed and the number of hours.An analysis of variance (ANOVA) was performed, with its corresponding Receiver Operating Characteristic) curve was calculated using the method proposed by The area under the ROC . In the case of the BD males, two groups were produced (BD1M/BD2M). Of the non-BD, two female (NONBD1F/NONBD2F) and two male (NONBD1M/NONBD2M) groups were produced.The cluster analysis among BD females produced two differentiated groups (BD1F/BD2F)  = 326.905; p < 0.0001] and in the number of consumption hours .The ANOVA performed among the eight groups (four BD and four non-BD) indicated that there were significant differences in the number of grams consumed [Table 3), it was found that the subgroups consuming the larger number of grams (BD1F and BD2M) took twice the amount of time in drinking this quantity. Furthermore, both are similar in terms of quantity consumed, as well as in time spent drinking.Upon comparison of the four BD groups . This area ranges from 0.741 in the case of the AUDIT to 0.801 in the case of the AUDIT-C.When considering all of the interviewees, differentiated according to the eight resulting groups of the BD/non-BD clusters, the three classic versions of the AUDIT yielded lower values in the area under the ROC curve as compared to the results obtained for the modified versions of this instrument .But the most parsimonious combination that also permits a slight increase in the explained area is the one that includes the sum of the A2R and A3R  and 75% of the non-BD (specificity). When the cut-off score was established at 4, the sensitivity increased slightly, but the specificity was much worse.This study analyzes the appropriateness of an improved version of the AUDIT. The adaptation has been carried out based on the limitations recognized by other researchers  and by aWithin the group of heavy drinkers, the underage population warrants special attention due to the potential repercussions on its bio-psycho-social development and maturity . In SpaiFurthermore, the presence of females of this age is also evident, confirming the trend that has been warned of in prior national epidemiological surveys  that fouOur findings provide further insight into the understanding of the existence of different subgroups within the BD collective, both males and females, based on the seriousness of their behavior -a greater quantity of alcohol consumed, for more hours and at a greater frequency-. In addition, it should not be forgotten that among the BD groups that consume the most, both males and females drink similar amounts of alcohol and they do so in the same number of hours. This leads to a clearly greater risk for females, given that they are more vulnerable to the consequences of alcohol consumption. Furthermore, this result quantifies results of previous research  claimingThe healthcare and social implications that are generated in the BD minors would be reduced if it were possible to detect and intervene in this behavior as early as possible. This suggests the need for sufficiently powerful screening measures to identify this consumption pattern with the least possible error. This would offer improvements not only in the clinical and prevention areas but also in the area of research  given thAs found in the literature that was consulted , of all Upon comparing the three versions of the revised AUDIT -AUDITCR/A3r/A2r+A3r- the last combination stands out (A2r+A3r) given that it identifies the greatest number of BDs and reduces the number of false positives. It may be stated that the recommendations of The reliability obtained through this new combination of items is very similar to that of the complete original scale -0.74, qualified as an acceptable reliability coefficient-. This result is not surprising, given that the items have been reformulated in order to note different aspects of BD. Item 2 reveals a more than intense consumption, as it is conducted over one entire day, whereas item 3 notes the frequency with which BD is engaged in. The combination of both not only informs of having reached a limit in BD in the form of overconsumption, but also if the youth drinks in a manner that extends over a longer period of time.Despite the fact that the AUDIT and its abbreviated versions appear to be appropriate tools to screen adolescents who are engaging in this behavior, the identification of heavy drinkers is improved by using a more parsimonious combination of two items. Even in those cases in which researchers recur to item 3 in order to classify BD/non-BD  it wouldIn fact, it is recommended that researchers and clinics use the combination of the two items (A2r+A3r) proposed in this work for a more precise identification of BD minors. Specifically, starting from a cut-off point of 5, it may be possible to identify 94% of the underage BD. The sensitivity and specificity values attained are three points higher than those achieved using the three-item combination proposed by Our study may be limited in that it relies on self-reporting. This method of data collection has been questioned in adult samples, given that it may present an underestimation of consumption . HoweverAccording to the recommendations made by It was not necessary for the study because there was no ethics relevant problems. People just filled out questionnaires/tests, afterward they got feedback on their scores. No manipulation or violation was done. The study was undertaken in compliance with Spanish legislation (approved by the Department of Education) and the code of ethics for research involving human subjects outlined by the University of Valencia Human Research Ethics Committee. The adolescents and their legal representatives signed an informed consent form.M-TC-T and J-AG-C conceived of the study and collected the data. M-TC-T and M-DS-B analyzed the data. M-TC-T, PM-S, and J-AG-C wrote the paper. M-TC-T, J-AG-C, PM-S, and M-DS-B approved the final version to be published.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.