Achieving quality improvement in primary care is a challenge worldwide, with substantial gaps between best practice and actual practice. Within the context of Australia, Aboriginal and Torres Strait Primary Health Care (PHC) services have great variation across settings, structures and context. Research has highlighted how these contextual differences can critically influence the success of Quality Improvement (QI) interventions and outcomes. Less understood is the interaction between local context and other factors, which may impact the implementation of QI interventions. This paper aims to explore the strengths and challenges in QI for Aboriginal and Torres Strait Islander PHC services and their priorities for improvement.A multiple case study design was adopted, working with eight Aboriginal and Torres Strait Islander PHC services in Northern Territory, Queensland and Western Australia. Data were collected via a health service survey, semi-structured interviews with health service staff and service users and researcher observations, to explore QI and perceptions of care quality at the service level. Data reported here were analysed using an iterative thematic technique, within-case and across-case.A total of 135 interviews were conducted with health service staff, service users and community members. Participants emphasised the centrality of resilient community, committed workforce and valued Aboriginal and Torres Strait Islander team members in delivering care. A shared purpose around improving the health of community was a significant driver. Key challenges included staff turnover and shortages, a complex and overwhelming acute and chronic care workload, building relationships and trust between health services and the community. Service-suggested priority areas for improvement were categorised into five themes: i) cultural safety ; ii) community engagement ; iii) shared ownership and a team approach around QI; iv) strengthening systems and consistent ways of doing things in the health service; and v) strengthening local workforce .These findings advance understandings of relational, community and cultural factors which are identified priorities for the delivery of quality care in Aboriginal and Torres Strait Islander PHC services across varied contexts.The online version contains supplementary material available at 10.1186/s12913-021-06383-7. Improving health outcomes for Aboriginal and Torres Strait Islander peoples is an important Australian health priority. Access to strong, accessible and appropriate comprehensive PHC is one strategy to achieve this goal, although much of the quality improvement (QI) literature to date refers to more limited primary care. Achieving improvement in the quality of primary care on a broad scale is a challenge worldwide, with evidence that there is a substantial gap between best practice as defined by clinical practice guidelines and actual practice . Ten comPHC services that serve Aboriginal and Torres Strait Islander communities are heterogeneous, with great variety in geographical setting, size, governance and organisational structure. The quality of care provided by such services, and the health outcomes achieved, also varies significantly , 6. In rSustained use of QI in Aboriginal and Torres Strait Islander PHC can improve health care delivery . AlongsiWorking with high-improving services to understand their secrets of success in achieving continuous high improvement in response to QI initiatives/activities, we found no statistically significant association between quality improvement status over time and service size, governance models or remoteness . This suFollowing this work, we are now exploring barriers to quality improvement and strategies to address these in the Leveraging Effective Ambulatory Practices (LEAP) project. This paper explores the key implementation challenges for quality improvement at eight Aboriginal and Torres Strait Islander PHC services and how they interact, along with service-suggested strategies for improvement.The study employed a comparative case study design, collecting qualitative data from eight sites across northern Australia to identify key implementation challenges in reaching quality goals . The oveInvitations to self-nominate for the study were distributed to Aboriginal and Torres Strait Islander PHC services in Queensland (QLD), Northern Territory (NT) and Western Australia (WA) via existing networks. Inclusion criteria were: i) community controlled or Government PHC service; ii) involved in QI audits for three or more years; iii) not meeting own QI goals; and iv) consent from management/board and staff.Eight self-selected PHC services represented a range of jurisdictions, service sizes, remoteness, governance models and approaches to QI. In Australian Aboriginal and Torres Strait Islander PHC services, a number of CQI tools and processes are in use. These include the Northern Territory (NT) Chronic Condition Management Model (CCMM), NT Aboriginal Health Key Performance Indicators (NT AHKPIs), the Queensland Aboriginal and Islander Health Council (QAIHC) Core Indicators reports (from PENCAT tools), ABCD/One21seventy audit tools and the National Indigenous KPIs –29. The Most of the services are situated in remote locations, with two services based in larger regional centres. Five services are Aboriginal Community Controlled Health Services (ACCHS); governed by the local Aboriginal community through an elected Board of Management to deliver holistic and culturally appropriate health care to the community . Three sPHC service survey, noting governance, service delivery and staffing profile;Semi-structured interviews and/or focus groups with health service staff and health service users;Observation of service operations and staff participation in the QI process, captured as reflections from visiting researchers.Case studies in each of the PHC services involved two members of the research team,  visiting the service from late 2018 to early 2019. To enhance validity of findings three data sets were collected with findings triangulated .PHC serData collection tools (PHC service survey and semi-structured interview guides) were co-designed by the LEAP LC at a face-to-face meeting in 2018, prior to data collection.See Supplementary File Health service staff and service users were informed of the research, including dates of the research team visit to the health service and invited to take part in an interview or focus group. This information was shared via the local health service champion/main contact for the research team. It was stressed that taking part in the research was voluntary and individuals could decline to participate without penalty.N = 6) were conducted at the request of staff and service users. Two focus groups were conducted with health service users and four focus groups with health service staff; groups were comprised of either all health service staff or all health service users, with no mixed groups. The number of participants in the focus groups varied: 10 service users attended one focus group; and the remaining groups ranged from two to four participants. The semi-structured interview guide was used to facilitate the focus groups. Duration of the focus groups ranged from 20 to 40 min. All interview and focus group participants provided informed written consent.Service information surveys were completed via structured interviews with the PHC service manager. Semi-structured interviews with local and visiting staff and managers explored how QI is working at their PHC service including enablers and barriers, the workforce and their role in QI, community involvement in QI and ideas for improving quality of care. Aboriginal and Torres Strait Islander community members were asked about their use of the service, their perspectives about care quality, and whether they had opportunities to provide feedback to improve care. A small number of focus groups , Western Australian Aboriginal Health Ethics Committee (884), Queensland Health (HREC/QCH/43490) and James Cook University (H7390).Digital recordings were transcribed verbatim and interview notes and observations from the visiting researchers were imported into NVivo12  software. Data were analysed using an abductive approach which is an inferential process to identify and interpret patterns of meanings and explore novel concepts emerging from the data . Within Following completion of the draft stories, each PHC service was revisited by the researchers to ensure that interpretations reflected the deep contextual knowledge and experience of the interviewees. Changes were made to the stories as a result of discussions, consistent with participatory approaches and PHC services as co-inquirers.Across case analyses comprised of reviewing themes from each study site and identifying common themes related to strengths, challenges and priority areas for quality improvement. Sub-themes were identified directly from each of the service summary reports, and then grouped into overarching themes. These priority areas of improvement were presented to the LEAP LC at a second face-to-face meeting in 2019. Here, participants were invited to take part in a series of Yarning Circles which reflected on priority areas of improvement, their experiences and ideas which were subsequently incorporated into the improvement stories.n = 31). Health service staff interviewed included Aboriginal Health Practitioners/Workers (AHPs/AHWs) (n = 23), other clinical staff (n = 61), and non-clinical staff and managers (n = 20). Approximately two-thirds of interviewees were Aboriginal and/or Torres Strait Islander (n = 84).A total of 135 participants took part in interviews and focus groups across the eight case study PHC services Table . Almost Challenges and strengths of service approaches to QI activities are summarised in Table Suggested priority areas for improvement raised by participants were categorised into five themes: i) cultural safety ; ii) community engagement ; iii) shared ownership and a team approach around quality improvement; iv) strengthen systems and consistent ways of doing things in the health service; and v) strengthening local workforce (and resources). Table This study involving eight PHC services in regional and remote settings adds to our understanding of how common system factors interact and affect responses to QI within PHC across Australia. Self-identified improvement priorities focused on strengthening community engagement and cultural security  in additStrengths of the PHC services identified by staff and community provide evidence of the immutable interconnection between culture, community and the delivery of quality care and builds on what we know about two way learning and community driving health , 23. CriCritically, this study has shown that the involvement of PHC service staff and community members shifted thinking away from a deficit model to solutions focused on service and community strengths, for example strengthening cultural safety and links in community. Furthermore, findings add to the strong body of literature suggesting that the motivation to improve clinical practice can be strengthened through facilitated, decision making involving Aboriginal and Torres Strait Islander staff and community to strengthen understanding of pathways to change, , 37 but The methodology adopted by the research team can help understand ways to work in partnership- with local health workforce, community members and service users in the development of appropriate data collection tools, collection and interpretation of the data. It reinforces the message that improved quality of care in this context will only occur if end users are intimately involved in discussions about what is important . Our resStrengths of this study included an appropriate choice of methodologies to maximise two-way learning through inclusion of both an Aboriginal or Torres Strait Islander and a non-Indigenous researcher for all community visits. An experienced team, case study design, liberal use of data and coder triangulation and the prioritisation of Indigenous voices through the LC at all stages of design and analysis contributed to trustworthiness of the findings. Limitations include the short amount of time researchers could spend in each community that impacted relationship building outside of health services and community input to service summary reports. In addition, only eight Indigenous PHC services were involved, although their distribution over regional and remote settings in three jurisdictions gives some confidence that findings are likely to be transferable to a broader range of settings.To continue to strengthen the quality of primary health care available to Aboriginal and Torres Strait Islander peoples in Australia, it is vital that we broaden our understanding of quality to include the relational, cultural and trust components highlighted as priorities for improvement. Respectful attention in partnership to address these “non-clinical” indicators of quality care, in addition to action on the broader social, environmental and cultural determinants of health are all vital to “Close the Gap”.Additional file 1.


Caenorhabditis elegans), fly (Drosophila melanogaster), and zebrafish (Danio rerio), to aid in diagnosis. The MOSC has directly contributed to the diagnosis of challenging cases, including multiple patients with complex, multi-organ phenotypes. In addition, the MOSC provides a framework for how basic scientists and clinicians can collaborate to drive diagnoses. Customized experimental plans take into account patient presentations, specific genes and variant(s), and appropriateness of each model organism for analysis. The MOSC also generates bioinformatic and experimental tools and reagents for the wider scientific community. Two elements of the MOSC that have been instrumental in its success are (1) multidisciplinary teams with expertise in variant bioinformatics and in human and model organism genetics, and (2) mechanisms for ongoing communication with clinical teams. Here we provide a position statement regarding the central role of model organisms for continued discovery of disease genes, and we advocate for the continuation and expansion of MOSC-type research entities as a Model Organisms Network (MON) to be funded through grant applications submitted to the NIH, family groups focused on specific rare diseases, other philanthropic organizations, industry partnerships, and other sources of support.Decreased sequencing costs have led to an explosion of genetic and genomic data. These data have revealed thousands of candidate human disease variants. Establishing which variants cause phenotypes and diseases, however, has remained challenging. Significant progress has been made, including advances by the National Institutes of Health (NIH)-funded Undiagnosed Diseases Network (UDN). However, 6000–13,000 additional disease genes remain to be identified. The continued discovery of rare diseases and their genetic underpinnings provides benefits to affected patients, of whom there are more than 400 million worldwide, and also advances understanding the mechanisms of more common diseases. Platforms employing model organisms enable discovery of novel gene-disease relationships, help establish variant pathogenicity, and often lead to the exploration of underlying mechanisms of pathophysiology that suggest new therapies. The Model Organism Screening Center (MOSC) of the UDN is a unique resource dedicated to utilizing informatics and functional studies in model organisms, including worm ( Even though the human genome was sequenced in 2003, the era of functional genomics is just beginning. The deployment of next-generation sequencing revealed a staggering number of variants across individuals, with each human genome containing an average of more than 3 million single nucleotide variants when compared to the reference sequence , 2. Of tImportantly, although a single rare disease might impact only a few individuals, as a whole, rare diseases affect up to 25 million people in the US alone according to the Centers for Disease Control and Prevention (CDC) . BamshadPatients with rare diseases typically have long, expensive, and frustrating diagnostic odysseys, and research with model organisms can significantly shorten their journeys by identifying causative genetic variants and disease mechanisms. The major goal of the NIH-funded MOSC, as an essential component of the UDN, is to provide experimental results to help evaluate a diagnosis, thus concluding the diagnostic odyssey. Such genetic discovery efforts typically lead to the identification of new disease genes. Although uncovering the genetic underpinnings of rare diseases for diagnosis has inherent value , it also provides significant opportunities to study rare disease biology. Such findings can contribute to a better understanding of basic biological systems and pathways, leading to development of treatments and cures and linking rare conditions with more common disease mechanisms , 9.The purpose of the MOSC is to use genetic approaches in non-mammalian model organisms to evaluate the hypothesis that specific genes and variants identified in patients enrolled in the UDN are likely to cause patient clinical phenotypes. The UDN is an NIH Common Fund program arising from the earlier intramural NIH Undiagnosed Diseases Program (UDP), and now consists of a network of academic medical centers dedicated to solving medical mysteries . ThroughDrosophila melanogaster  Core, and a Zebrafish Core. We note that the term “Center” is used for the overall structure of the MOSC, and the term “Core” is used for individual model organism teams due to the administrative structure specified in the NIH funding opportunity announcement. However, activities conducted by the MOSC Cores are significantly more advanced than those typically conducted by traditional research core facilities. The bioinformatics component analyzes specific genes and variants submitted, including the use of public databases of “control” individuals with respect to monogenic disease, such as ExAC and gnomAD [http://marrvel.org/) that is freely available online and now widely used [The initial MOSC structure included a bioinformatics component, a d gnomAD , 15, andd gnomAD , 12, 16.ely used . MARRVELely used , 19.Through extensive model organism studies and the use of MARRVEL, the MOSC provided key contributions and new scientific insights during Phase I of the UDN. During this period, 239 variants in 183 genes from 122 UDN probands were submitted to the MOSC  Core, a Fly (Drosophila) Core, and two Zebrafish Cores. The current MOSC uses a two-step evaluation system: an initial review process to screen variants primarily based on human genetics information, followed by Core level reviews to evaluate their appropriateness for specific model organism studies. As of December 2020, the Phase II MOSC has processed 143 variants in 109 genes for 108 UDN cases and assigned 60 genes for modeling in one of the three model organisms.The success of the Phase I MOSC led to an expansion in Phase II with an allocation of additional UDN resources to functional studies. The current MOSC incorporates a Worm  so that they can be used for further diagnoses, in-depth mechanistic studies, and proof-of-concept translational and preclinical trial experiments.In addition to providing evidence that supports diagnoses, the MOSC also generates tools of significant value for further studies, such as the bioinformatic MARRVEL platform  and valuAlthough the main goal of the UDN is to provide a diagnosis, disease gene discovery also contributes significantly to the lives of patients and their families. Gene discovery helps by: 1) ending the “diagnostic odyssey” of individual patients, reducing unnecessary diagnostic tests, offering prenatal diagnosis options for some families, and improving medical care for individual patients; (2) leading to diagnoses for patients outside of the UDN as diagnostic laboratories incorporate published new disease gene discoveries, including those from the UDN, into their sequencing interpretation and reanalysis processes; (3) facilitating the formation of social media groups, including family advocacy and support organizations that arise from the more precise molecular diagnoses; (4) enabling the future development of precision therapies that target the underlying molecular basis of rare genetic disorders and more common diseases, and (5) driving an interest in and a positive public perception of genomic research for human health, leading to greater public interest and understanding of genomics and rare and undiagnosed disease. While there is clear economic value to the patient and family members that have received a diagnosis based on functional studies performed by the MOSC, it is extremely difficult, if not impossible, to calculate the precise value of these benefits. Achieving a diagnosis prevents the added expenses for patients who would have sought evaluation from additional specialists until they get an answer, and such answers may not be found for many more years in the future if the patient’s condition is novel. In addition, the work by the MOSC has value beyond the individual UDN patient or family because the new disease gene discoveries and phenotypic expansions discovered by the MOSC  ams Fig.  and (2) A multidisciplinary team effort is the first and most important factor for success, because this collaboration brings together many groups spanning different areas of biological science. These benefits include: (1) bridging clinical/medical terms and model organism jargon, (2) coming to a consensus on the current understanding of the genes of interest in the context of medical genetics and model organism genetics, (3) understanding genome sequence analysis and potential pitfalls associated with DNA testing, and (4) having the unique expertise needed to develop and characterize model organism reagents that are robust and reliable to produce data relevant to the patient.Collaboration and frequent bidirectional communication  nomenclature issues in more than 20% of variants submitted to the MOSC. Examples include mismatch between cDNA and genomic coordinates, incorrect representations of short insertions or deletions, and mistakes when manually transcribing information from clinical genetic reports. Even though these submissions have come from top medical genetics centers, the presence of such a high error rate means that the MOSC needs a robust system to perform variant analysis and quality control. A bioinformatics team of integrated physician scientists, clinicians, bioinformaticians, rare and undiagnosed diseases researchers, geneticists, and clinical DNA testing experts facilitate this work. Providing this interdisciplinary resource for clinicians, who usually do not have model organism expertise, is a cost-effective and time-efficient mechanism for assessing the appropriateness of candidate variants for experimental analysis in each of the model systems available, discussed in detail below. The current system involves researchers at Baylor College of Medicine, Washington University in St. Louis, and the University of Oregon who analyze variants for (1) variant nomenclature, (2) minor allele frequencies in public and CMG databases, (3) gene-based metrics and prediction scores from public genomic resources, such as gnomAD, and (4) variant-based in silico prediction scores. The bioinformatics team also examines the clinical scenario as presented by the Clinical Site, studies gene information using OMIM and other databases, and confirms a shared understanding of the clinical question motivating the proposal for model organism studies. This team then communicates these data to the Model Organism Cores for further analysis, and likewise facilitates communication between the Cores and the Clinical Sites. The MARRVEL resource, discussed above, is a crucial tool designed to provide rapid access to the data needed to evaluate a candidate gene and variant for model organism studies, and has saved many hours of research time by conducting searches using this integrative tool versus separate searches across multiple databases. Bioinformatic analyses also leverage the Alliance of Genome Resources (AGR) , which aCaenorhabditis elegans), fly (Drosophila melanogaster), and zebrafish (Danio rerio). Indeed, numerous Nobel prizes in Physiology and Medicine have been awarded to non-mammalian model organism researchers for their insights into human biology [The MOSC utilizes the experimental and genetic tools of three premier genetic model organisms: worm  is a major research organism for studies of animal cell and developmental biology [C. elegans in studies of human disease has defined new Mendelian conditions [C. elegans gene (which is uniformly done for the UDN MOSC cases), the short four-day generation time, the large body of acquired knowledge, and the publicly available biological reagents  facilitate rapid functional studies of candidate disease gene variants. Such investigations can provide information on the pathogenicity of the patient variant, evidence in support of the mode of inheritance including the nature of dominance , insight into disease mechanisms, and possible routes to treatment. biology . Researc biology . The usenditions , uncovernditions , and pronditions ). The hiDrosophila melanogaster (fruit fly) has been used as a model organism to understand fundamental principles of genetics, developmental biology, immunity, and neuroscience for the past century [Drosophila has become an important model system to dissect and understand the molecular mechanisms that underlie human diseases. This is in part because ~ 75% of human genes shown to cause human diseases were found to be conserved in Drosophila when the first genome-wide survey was conducted on ~ 1000 genes registered in OMIM [Drosophila genome allow researchers to engineer flies in many different ways [http://flybase.org/), public stock centers that distribute > 80,000 different strains of flies  and > 1,000,000 DNA clones  supported by the NIH. Genes and variants found in an undiagnosed patient that are confirmed to be deleterious can be further studied in flies to identify disease mechanisms or test FDA-approved drugs that may be beneficial for the patient through high-throughput screens. This approach has already been effective in identifying several personalized treatments that can be returned to the bedside in a short timeframe [ century , 45. In  in OMIM . Of the  in OMIM , 47, the in OMIM . This isent ways –50. By ient ways . Detaileent ways . All of imeframe , 32, 51.Danio rerio) has emerged as a premier organism to study human biology [http://zfin.org) and public stock centers that distribute mutant and transgenic zebrafish strains and molecular reagents , both of which are supported by the NIH. Because organs, cell types, and gene functions are well conserved across vertebrates, analysis of zebrafish mutants provides insights into gene functions in other vertebrates, including humans [The zebrafish , which would include: (1) a central MOSC-like structure that is focused on providing functional information for timely diagnosis, and (2) deep mechanistic studies that extend to a larger network of researchers.For (1), a MOSC-like structure, we envision continuation of a multidisciplinary central MON team, including the communication elements detailed above. We note that such an effort may extend beyond the needs or priorities of any single NIH institute or center, in keeping with the observation that most undiagnosed patients are medically complex and have multiple organ systems affected, and that undiagnosed diseases afflict both children and adults. This funding model would sustain and expand a team and system with similar concepts, structures, and components as the current MOSC, but would also integrate additional specialists in the model organism research field who have the expertise to pursue mechanistic and translational studies related to newly discovered disease genes or specific clinical phenotypes. In addition, we envision the central MON could garner additional support from philanthropy and rare disease family groups to fund mechanistic studies that not only extend and deepen discoveries from currently NIH-funded gene discovery programs like the UDN and Centers for Mendelian Genomics (CMG), but also include the many other historically identified disease genes where the underlying disease mechanism is not currently known. These mechanistic studies could focus on genes under study in the MON and on solving undiagnosed diseases.For (2), mechanistic studies, we envision that studies by the MON would extend to examining pathways and therapeutics and constitute “deep dives” into individual genes and variants. Such studies have traditionally been funded through disparate investigator-initiated ‘R’ grant mechanisms. Although these mechanistic studies have thus far not been a formal part of the MOSC, they have been undertaken for some diseases in parallel to the ongoing diagnosis efforts using alternative funding sources, including administrative supplements, non-NIH grants, and institutional as well as philanthropic support , 30, 34.We envision that genetic variants will continue to be submitted by clinicians in various research initiatives to the future MON and will flow through the following pipeline: (1) sequencing and bioinformatics, (2) pathogenicity studies in one of the Model Organism Cores, that includes three organism cores outlined and justified above (diagnosis), and 3) mechanistic studies in select cases . In addition, some questions related to specific cell types affected in the patient might benefit from the use of patient biopsy or derived cells. The MON should have ways to incorporate or establish collaborations that provide mouse models, cellular transfection models, patient derived cells , and human pluripotent stem cell-derived models of relevant cell or organ types whenever necessary.Mus musculus) because large-scale functional studies using mice were cost-prohibitive at the time that the NIH conceived the MOSC idea (~ 2015). Considering the value of investigations using mice in the context of rare diseases [https://commonfund.nih.gov/komp2) and International Mouse Phenotyping consortium  to leverage the phenotypic data of null mutant animals in the informatic pipeline for variant prioritization. Due to rapid advancements in CRISPR-based gene knock-in and knock-out technologies in mouse and other species [The current MOSC does not take direct advantage of the mouse , which can be differentiated into disease-relevant cell types and organoids to attempt to recapitulate the patient’s condition , 77. SomAs we describe above, much progress has been made in the development of model organism research as a tool for rare disease gene discovery. However, several challenges remain before these processes can become scalable and as easy to execute as some existing fee-for-service tests, such as exome or genome sequencing. First, disease modeling requires significant understanding of model organism biology and genetics to tailor the experimental design and analysis to the specific gene, the specific variant(s), and patient-specific clinical information in the context of the particular focal research organism. For example, to uncover a variant-specific disease mechanism, even when the null phenotype in the model organism is known, research organism experimental design often must be modified based on patient genetics, human population information, the possibility of incomplete penetrance/expressivity, and the possibility of a gain-of-function or dominant negative effect. Second, due to these complexities, the bulk of this research requires PhD-level personnel with sufficient expertise and experience to navigate the existing information, determine feasibilities of the model organism, design an experimental strategy to support pathogenicity, perform the experiments, and then bring the discovery to publication. It can be challenging to identify qualified research scientists to carry out this work in a sustainable fashion.We envision NIH support for deep dives into mechanisms that would extend beyond the MON program and which would be supported by multiple NIH institutes, perhaps through competitive ‘R’ grants. Importantly, such support would also enable external model organism experts to join the MON. We are advocating for support for two distinct and important activities that will be carried out by the future MON: (1) providing rapid diagnosis and (2) uncovering disease mechanisms. To expand further, Activity (1), the diagnosis of undiagnosed diseases patients, involves using model organism experiments to provide data that solve a medical mystery for a patient in a timely manner; and Activity (2) the mechanistic understanding of previously undiagnosed diseases, includes understanding the underlying biology of disease, using rare diseases to understand common diseases, and preclinical identification and testing of therapeutics, which is a more in-depth effort.https://undiagnosed.hms.harvard.edu/research/funding-opportunities/). The scientific justification for this dual set of goals (diagnosis and mechanism) is that the work on diagnosis must progress in a timely manner to provide answers for patients and their families. However, at the same time, more in depth biological studies, albeit slower, must also be supported to translate these discoveries to therapeutics and to common disease biology. Furthermore, even when initial studies do not support the conclusion that nominated variants cause the particular patients’ diseases, such negative results are valuable for the diagnostic mission because they prompt the clinical group to consider other candidate genes and variants. In addition, this work defines the functions of the investigated genes and variants, which might fit a different undiagnosed disease, especially for previously unstudied genes.The key feature of the components and activities of the current MOSC that distinguish it from other efforts is that they target a particular undiagnosed patient to provide timely information for diagnosis. In addition to the defining contribution of the MOSC towards diagnosis , the future MON should also make significant contributions towards understanding the mechanistic basis for how a variant contributes to disease pathophysiology. Although mechanistic studies are not warranted in all cases, we strongly believe that they are a powerful extension of MOSC diagnostic work on new and unstudied disease genes. Moreover, MOSC researchers generate animal models, acquire relevant expertise, and are thus well-positioned to carry out such mechanistic studies. In addition, because mechanistic studies require time, expertise, and resources, investigators outside of the central MON team should have the opportunity to drive these mechanistic studies. Given the large number of known disease genes with unknown mechanisms and expertise existing in laboratories outside of the MON, we envision that these future collaborations with experts in particular genes and pathways would become part of a larger NIH effort to uncover genetic disease mechanisms, in which the future MON might be only one of the contributors. These investigator-driven mechanistic studies could be proposed using any model organism or cellular or biochemical system, and combinations thereof. We envision that these studies could be supported by specifically targeted R01, R03, or R21 mechanisms. The Coordinating Center of the UDN has been exploring the benefit of providing funding  to recruit external researchers with expertise in specific genes and pathways, and these efforts have indeed facilitated the mechanistic understanding of disease mechanisms , the Rare and Atypical Diabetes Network , the Accelerating Medicines Partnership Type 2 Diabetes Consortium , and the Rare Disease Clinical Research Network . We believe these groups would benefit from ongoing and open communication with the future MON and the UDN to ensure that patients are reviewed by the most appropriate group and to avoid duplication of efforts.The UDN MOSC is a centralized system of several laboratories with broad expertise, knowledge, and techniques working collaboratively to solve many cases together. An alternative model is for many individual laboratories with gene-specific expertise to work on particular cases in which their genes of interest are the prime candidate of the undiagnosed condition. The Rare Diseases: Models & Mechanisms Network (RDMM) in Canada is a national network of model organism researchers and clinicians that has been using this “distributive model” of functional studies for the past four years . The UDNhttps://j-rdmm.org/indexEn.html), Australia (AFGN) , and Europe (Solve-RD) (http://solve-rd.eu/rdmm-europe/) have developed RDMM-like networks over the past two years.In the RDMM approach, clinicians from around the country submit genes and variants of interest together with the clinical description of the patient. A group of clinicians that form the Clinical Advisory Committee (CAC) reviews these submissions and assesses the quality of candidate variants. The CAC passes information about appropriate gene variants to a group of biologists and bioinformaticians that form the Scientific Advisory Committee (SAC). Next, the SAC searches an internal database that contains information about model organism researchers in Canada and their expertise, to match the clinician and model organism researchers and encourage collaboration. The clinician and model organism researcher can then make specific research plans and co-submit a short research proposal back to the SAC. The SAC reviews these applications and decides whether or not to fund the project. Successful applicants receive a CAD$25,000 grant for one year to pursue the project. Interest in the project is extremely high: as of early 2020, 88% (543) of model organism laboratories across Canada had enrolled in the database, and RDMM had funded 105 projects related to 87 genes. The network published 20 peer reviewed research articles including new disease gene discoveries, phenotypic expansions of known disease genes, or mechanistic studies of known rare diseases. Due to its success in Canada, funding agencies in Japan (IRUD/J-RDMM)  work together to sustain and expand a competitive program for an ongoing UDN MOSC in the form of a MON, because most undiagnosed patients have multiple organ systems affected. It is possible that grant funding to establish the MON or MON-like structure could also be prioritized either through mechanisms such as an entirely new Common Fund initiative that is more focused on in vivo functional studies and mechanistic research, or through specific efforts by different NIH institutes. We argue that the work to sustain the MOSC and its transformation into a larger MON is highly justified and that efforts to sustain a steady pace of high impact gene discovery will pay off for rare and undiagnosed diseases, as well as impacting our understanding of common diseases.


The Computer Systems Laboratory (CSL), National Institute of Standards and Technology (NIST), hosted the twenty-first North American ISDN Users’ Forum (NIUF) at its Gaithersburg, Maryland, site on June 21–24, 1994. About 175 users, implementors, and service providers of ISDN technology attended the meeting. CSL collaborated with industry in 1988 to establish the NIUF to ensure that emerging ISDN applications meet the needs of users. A Cooperative Research and Development Agreement (CRADA) with industry was established in 1991 to govern the management of the forum; as of June 1994, the CRADA had 32 signatories from industry and academia. CSL serves as chair of the forum and hosts the NIUF Secretariat. NIUF membership is open to all interested users, product providers, and service providers; meetings are held three times a year at various locations throughout North America.International standards for ISDN support global communications for the exchange of voice, data, and image information among users, independent of any manufacturer, service provider, or implementation technology. ISDN standards are developed by the International Telecommunication Union - Telecommunication Standardization Sector (ITU-T) and in North America in particular, by the Exchange Carriers Standards Association (ECSA) accredited standards committee, T1, under the umbrella of the American National Standards Institute (ANSI).ISDN standards provide a broad variety of options and parameters to meet many potential needs and applications. To ensure interoperability and terminal portability within the ISDN network and its attendant equipment, a uniform subset of options and parameters must be selected for implementation. Each application usually requires only a subset of total functionality available in the standards; for ISDN products and services to work together in a multivendor environment, common sets of options must be selected.To cope with this proliferation of choices and to provide interoperable products and services which meet the needs of users, the standards specification process has been augmented to develop application profiles, implementation agreements, and conformance criteria. The NIUF addresses all of these areas.To promote an ISDN forum committed to providing users the opportunity to influence developing ISDN technology to reflect their needs;To identify ISDN applications, develop implementation requirements, and facilitate their timely, harmonized, and interoperable introduction; andTo solicit user, product provider, and service provider participation in the process.The NIUF seeks to achieve three principal goals:The actual work of the NIUF is accomplished in two workshops: the ISDN User’s Workshop (IUW) and the ISDN Implementor’s Workshop (IIW). The IUW produces application requirements which describe potential applications of ISDN and the features which may be needed. The IIW develops application profiles, implementation agreements, and conformance criteria which provide the detailed technical decisions necessary to implement an application requirement in an interoperable manner. The NIUF Executive Steering Committee coordinates the activities of the two workshops.42 applications for development of application profiles are in process;application profiles have been completed for 17 applications;15 implementation agreements have been completed; and12 conformance tests have been completed.Since its inception in 1988, the NIUF has achieved the following:CSL established the NIST Special Publication 823 series, Integrated Services Digital Network Technology Publications, to publish the approved implementation agreements, conformance tests, and other NIUF documents. To date five documents have been published. Copies of these documents are available for sale by the Government Printing Office, (202) 512-1800 or the National Technical Information Service, (703) 487-4650.A special one-day National Information Infrastructure (NII) Seminar focused on “Clarifying the Vision of the Information Highway.” Dr. Arati Prabhakar, NIST Director, presented the keynote address on the NII Task Force. Other presentations covered High-Performance Computing and Communications; information technology applications such as education, libraries, healthcare, and the environment; and NII application projects at NIST including the NIST NII Agent and the Advanced Technology Program (ATP) Focused Program on Information Infrastructure for Healthcare.Tutorials presented at the June meeting included an overview of the NIUF for new users and implementors; a session on point-to-point protocol over ISDN; and a general survey of the ISDN wiring and powering work program.Highlights from the Executive Steering Committee standing groups included an update on the new NII Working Group (NIIWG) and its agenda for meeting the needs and challenges for NII applications. The group’s charter states that the NIIWG will focus on “the requirements of efficient access to the information infrastructure, the use of standards, interoperability and the development of suitable ISDN technologies to support the NII.” The NIIWG Applications Committee and the NIIWG Architecture Committee created charters and established future projects. The NIIWG Applications Committee will re-categorize existing NIUF ISDN application profiles into appropriate NII application categories, such as healthcare. The NIIWG Architecture Committee plans to develop an ISDN portion of the NII model. The Versions — Capability and Analysis Planning meeting consisted of a presentation by a representative from Bell Atlantic on the content and schedule for National ISDN-3 specifications.IUW working group highlights included the following: the IUW General Users’ Meeting revamped and prioritized NIUF applications, which will now be categorized as complete, inactive, or open/ongoing. The IUW and the IIW will jointly draft a letter to regional user groups to ask for assistance in championing applications within the NIUF. The Government Services Group has established a “Government” newsletter to promote local, state, federal, and international government ISDN success stories. The Private Industries Group addressed the “road blocks” that face industry organizations in the deployment of ISDN. At the Mass Market Industries Group, speakers from MFS Datanet, AT&T Global Business Communications Systems, and IBM shared their experiences with various ISDN applications. The Enterprise Network Data Interconnectivity Family demonstrated remote local-area-network (LAN) access for ISDN devices using a single B channel between seven vendors for bridging and routing, a milestone event. The Ad Hoc Group on the Simplification of ISDN Ordering, Provisioning, and Installation approved as working group stable two packages, P and Q, which were an outgrowth of ISDN Solutions ’94.The IIW enjoyed a successful week. To maximize the effectiveness of its resources and expertise, the IIW reorganized into the following functional groups: Application Profile Team, Technical Working Group, Application Analysis, ISDN Conformance Testing, and ISDN CPE (Customer Premises Equipment) and Software Working Group.IIW working groups reported the following activities: the Call Management Profile Team discussed open applications and determined that there are no profiles to be written at this time. At its first meeting, the Multimedia Applications and Networking Profile Team and Family announced it will focus on the development of application profiles and implementation agreements surrounding the definition, service description, network and interoperability requirements for providing end-to-end ISDN-based multimedia services. The Security and Network Management Technical Working Group and Profile Team established the foundation for contributions to NII security. The ICOT ACT 23 Working Group reviewed Basic Rate (BRI) and Primary Rate (PRI) protocol implementation conformance statements (PICS) and finalized these documents.The ISDN CPE and Software Working Group is collecting information on ISDN-based products for inclusion in its third edition of the “Catalog of National ISDN Solutions for Selected NIUF Applications,” to be published in February 1995. Previous editions of the catalog have been distributed to thousands of end users, systems integrators, service providers, and product manufacturers and distributors.The PBX Issues Subcommittee defined and categorized issues as they relate to PRI users and implementors, with a view toward providing technical and business solutions for these requests. These issues will be used for input to the ongoing national ISDN process. The ISDN Powering and Wiring Group received Plenary approval for certain sections of their current ISDN Powering and Wiring Guidelines . Future work might include a pamphlet for ISDN Wiring and a possible new document on ISDN Wiring and Powering for High-Rise and Apartment Buildings. The CPE Compatibilities and Capabilities Profile Team heard a presentation on processing for CPE-to-CPE application interoperability between heterogeneous systems.The closing Plenary approved three new documents and announced two documents as working group stable. Also approved were sue working group charters: National Information Infrastructure Working Group (NIIWG); NIIWG–Applications Committee; NIIWG–Architecture Committee; ISDN Security Family; Multimedia Applications and Networking Profile Team and Family; and Private Industries.For more information about the NIUF and its publications or to obtain conference proceedings, contact the NIUF Secretariat: Sara Caswell, Computer Systems Laboratory, National Institute of Standards and Technology, Building 223, Room B364, Gaithersburg, MD 20899-0001; telephone (301) 975-2937 or fax (301) 926-9675.


Utilization of four types of health services: primary, nursing, mental and emergency care; are assessed using multivariate and multi-level negative binomial regressions with fixed/random effects and dynamic models conditional on prior HCU and lagged health events.This study investigates the prisoner and prison-level factors associated with healthcare utilization (HCU) and the dynamic effects of previous HCU and health events. We analyze administrative data collected on annual adult prisoner-stay HCU (In a prison setting with health screening on detention, removal of financial barriers to care and a nurse-led gatekeeping system, we find that health status, socio-demographic characteristics, penal history, and the prison environment are associated with HCU overtime. After controlling for chronic and past acute illnesses, female prisoners have higher HCU, younger adults more emergencies, and prisoners from Africa, Eastern Europe, and the Americas lower HCU. New prisoners, pretrial detainees or repeat offenders utilize more all types of care. Overcrowding increases primary care but reduces utilization of mental and emergency services. Higher expenditure on medical staff resources is associated with more primary care visits and less emergency visits. The dynamics of HCU across types of care shows persistence over time related to emergency use, previous somatic acute illnesses, and acting out events. There is also evidence of substitution between psychiatric and primary care.The prison healthcare system provides an opportunity to diagnose and treat unmet health needs for a marginalized population. Access to psychiatric and chronic disease management during incarceration and prevention of emergency or acute events can reduce future demand for care. Prioritization of high-risk patients and continuity of care inside and outside of prisons may reduce public health pressures in the criminal system. The prison environment and prisoners’ penal circumstances impacts healthcare utilization, suggesting better coordination between the criminal justice and prison health systems is required.The online version contains supplementary material available at 10.1186/s40352-021-00136-8. Prisons face a significant challenge to meet the healthcare needs of prisoners who have a high prevalence of infectious, chronic physical and mental illnesses, substance abuse problems as well as multi-morbidities  and its determinants in prison relies on cross-sectional designs and shows greater use than in the general population  consultations, mental and emergency HCU. Unlike in the community setting, financial barriers to access such as the cost of health care are removed, timely access to primary care and specialist psychiatric care is assured, and a comprehensive health screening upon incarceration identifies the presence of chronic illness and potential unmet health needs. Hence, we are able to investigate the specific role of the multiple need factors, demographic, ethnic and socio-economic backgrounds for this vulnerable population, independently of otherwise important factors affecting HCU in the community. The prison healthcare system is organized as a nurse-led gatekeeping system with continuity of care between primary and mental health care professionals. By analyzing longitudinal data over a period of 5 years (2013–2017) across four prisons, we investigate the dynamics of care utilization across these four types of services in relation to time spent in the prison and previous health events.Governed by federal laws, the Swiss prison system is organized and managed at the cantonal (state) level, implying that the prison systems differ substantially across cantons. However, the principle of equivalence of care established by international norms Elger, , and govThe prison system in canton of Vaud is managed by the public administration. There are four prisons for adults, and a fifth prison that houses minors and young adults (not included in this study). Bois-Mermet and Croisée prisons house mainly pretrial (remand) prisoners, and Tuilière houses some male remand prisoners and all female prisoners in separate sections. The Plaine de l’Orbe prison houses prisoners with long sentences.Healthcare service provision in prison is independent of the judiciary and penitentiary authorities since 1995 UNODC,  and is mOn-site healthcare services in prisons are reimbursed by health insurance, which is mandatory for Swiss residents. For individuals with health insurance before incarceration, the insurance is financed using private funds whenever possible. For prisoners without the means to pay , the prison administration either bears the medical costs directly, or obtains subsidies from the canton’s social insurance fund to purchase health insurance. In the context of this analysis, there are virtually no financial barriers of access to care for patients in prison.Figure The study uses anonymized longitudinal administrative data between 2013 and 2017 of all adult inmates already incarcerated on January 1, 2013 and those who entered or re-entered at any time between 2013 and 2017 in the four closed prisons of Canton of Vaud. The bespoke database collected by the SMPP routinely extracts selected data from the prisoner and patient record for monitoring trends in prisoner characteristics, health status and healthcare utilization in the prisons. Data contain detailed information on HCU, demographics, social situation, health status, penal circumstances and duration of prisoner stays. The unit of observation is every prison stay during the same calendar year, which we define as the year-stay. An individual may have one or several year-stays during the same calendar year or year-stays that cover several calendar years. For example, a prison sentence executed from 1st July 2014 to 31st July 2015 generates 2 year-stays (1st July to 31st December 2014 and 1st January to 31st July 2015). After cleaning the data and keeping stays for inmates with a medical examination upon entry , the panel includes 10,136 year-stays, effectuated by 4928 prisoners, over the 5 years. For the dynamic analysis the sample is restricted to prisoners with repeated observations, that is with at least 2 year-stays over the 5 years (sample size = 5208).Anderson’s framework and its extensions  or/and mental  chronic conditions as well as substance abuse problems grouped into categories according to the International Classification of Diseases, version 10 (ICD-10). A detailed description is available in previous research ; the detention regime . Individuals whose crime is related to severe mental disorders and high risks of recidivism are mandated psychiatric treatment under the Swiss Criminal Code  the prison occupancy rate, defined as operating capacity  divided by a prison’s designated capacity; ii) the yearly in-flow of new prisoners to each facility to account for the turnover of inmates during the year; iii) yearly costs in millions CHF (1 CHF ≈ 1 USD in 2020) of the full-time equivalent workforce in each facility, which measures the available resources allocated for onsite healthcare in each prison.N = 10,136) and include the four groups of explanatory variables described above, year and prison fixed effects. The latter accounts for differences in unmeasured facility level factors that affect HCU constantly over time. Negative binomial or Poisson regression models are used to model HCU. The distributions account for the count nature of the data (non-negative integers) as well as the skewness and heavy tailed distribution of the outcome variables. The negative binomial model does not impose equidispersion , which is measured by the significance of the over-dispersion parameter  are estimated using all observed prisoner year-stays . These models are estimated on the full sample using a mixed effects generalized linear model (GLM) regressions with prison and prisoner level random effects and exploit variations between and within prisons over time. Hence, our three prison-level variables associate differences in the environmental circumstances across the 4 different prisons, and over the 5 years with HCU, conditional on unmeasured differences between prisons estimated by the random effect. Negative binomial distributions fit the best for GP, mental and emergency HCU, while the Poisson distribution is chosen for the nursing HCU.N = 5208). The estimation sample, therefore, only includes prisoners with at least two prisoner-year stays because the models include all M1 variables plus one period lagged variables of both HCU defined as the number of consultations in the previous year-stay for the 4 types of healthcare services, and the number of acute events experienced by inmates during their previous year-stay. Acute events are for somatic diseases , for crisis events , and for psychiatrically diagnosed acting out events . The dynamic models also control for baseline HCU and for length of lagged stay. Acute health events provide important additional information on the health status and risk profile of prisoners, and dynamic specification ensures we avoid the fact that contemporaneous HCU and acute events are simultaneously determined. The statistical analyses were performed using Stata 15.1.The third group of models (M3) uses past prisoner year-stay information to account for the dynamics of HCU , 27% of African origin (i.e. countries not on the Mediterranean rim), and 17% have Swiss origin. Prisoners having health insurance coverage prior to incarceration account for 24% of stays, and married individuals for 20%. In 23% of the stays, drugs abuse is reported with 19% diagnosed with personality disorder. Prisoners are diagnosed with infectious diseases and skin conditions in 8% and 11% of stays respectively. 22% of stays are executed in pretrial detention. Half of the stays are for drug related offenses and on average, total time spent in prison is about 19 months, and the mean length of year-stay is 148 days. The occupancy rate during prison year-stays ranged from 87% to 170% , reflecting the lower incidence and greater randomness of emergency events.Table Female inmates display significantly higher rates of nursing, mental and emergency HCU. The frequency of GP visits increases with age, but emergency admissions decline relative to the youngest age-group (18–25). Mental HCU is higher for younger women. Compared to Western European origin, being of Swiss origin is associated with a larger volume of nurse and mental care consultations. Detainees of African, eastern European and American origins have significantly lower nursing, mental and emergency HCU, while inmates from North Africa have higher utilization of GP and mental care. Health insurance prior to incarceration is significantly associated with lower rate of nursing care but more mental care.Chronic somatic conditions are associated with higher volumes of GP and nurse’ consultations. Circulatory diseases double the risk of emergency consultations while infectious, endocrine and digestive diseases significantly increase the risk by around 30%. Only infectious and endocrine diseases are associated with an increase in the rate of mental healthcare.A number of psychiatric conditions and substance abuse disorders are significantly and positively associated with primary care and emergency care. Drug addiction in particularly is associated with higher volumes of primary and emergency healthcare. Personality disorders double emergency admission risk, while schizophrenia, mood, and neurotic disorders increase it by 50%. An increase in the number of comorbidities is associated with significantly higher rates of GP and nurse HCU.Prisoners in pretrial detention are associated with significantly higher volumes of GP, nursing and mental HCU but significantly higher emergency HCU. Total time spent in prison is significantly and negatively associated with HCU after adjusting for the current length of year-stay as an exposure variable. Each additional stay in prison is associated with an increase in the rate of utilization for GP, nursing and emergency healthcare of between 4% to 25%. Prisoners convicted of sexual offences have higher rates of mental healthcare while drug related offenders consume nursing, mental and emergency HCU less frequently relative to inmates convicted for reasons other than violence, sexual crime, or drugs.Results from M1 models (that include prison fixed effects) associate higher occupancy rates with significantly reduced mental care utilization while an increase in new prison entrants is associated with higher nurse and emergency consultations. An increase in expenditure on staff resources significantly increase rates of consultations for mental healthcare.Multilevel regression models (M2) with prison random effects indicate that higher occupancy levels are associated with significantly more GP and nurse visits, but significantly lower emergency and mental care. Nurse and mental health visits are positively associated with an increase in the number of new prisoners, while higher expenditure on staff was associated with decreases in the rates of mental care and emergency care utilization.Previous acute somatic illnesses are significantly associated with greater numbers of GP and nurse consultations in the following stay. Acting out events significantly increase future nursing, mental and emergency HCU. The use of one healthcare service in the previous stay shows significant persistence in utilization of GP, mental, and emergency healthcare. There are cross sector spillovers with past GP HCU significantly associated with higher nursing and mental care consultations. Past nursing and emergency HCU significantly increase GP visits the following year. Conversely, past mental HCU is associated with significant reductions in primary care consultations.This study exploits a comprehensive longitudinal database for monitoring healthcare delivery in the canton of Vaud, Switzerland. It investigates prisoner and prison-level determinants of the demand for routine primary, specialist mental health and emergency care services over time. This prison setting with comprehensive health screening, removal of financial barriers to care and a standardized nurse-led gatekeeping system provides novel insights into the relative importance of health status, socio-demographic characteristics, penal history and the prison environment for a marginalized, high risk population difficult to research. The longitudinal analysis assesses the persistence of prior acute somatic and psychiatric related events on future utilization across the different care specialties.The findings that female prisoners show higher nursing, mental care and emergency care are consistent with the epidemiological evidence and previous studies underlining the greater need of mental and social support for female prisoners . There is also persistence of past emergency HCU, which increases emergency use by 5% in the following period as well as primary care utilization, indicating the need for routine follow-up.Total time spent in prison reduces all types of HCU with each additional year in prison associated with a 6.4% to 13.4% decrease in HCU depending on the specialty. Conversely, each new detention in prison increases HCU, in particular emergency visits, while remaining in pretrial detention is associated with notably higher mental health use. Many prisoners present with multiple health conditions that have been neglected, and prison provides the first access to healthcare for a long time. Hence, the observed reduction in HCU over time may reflect improved health status and lower care needs after initial treatments. Prisoners, especially those with long stays, will have repeated contacts with the same health care professionals, which can improve the (agency) relationship between physicians and patients and treatment compliance  and inmate turnover increased in most of facilities. Greater prisoner density would favor propagation of infectious and parasitic diseases  of prisoners’ generalist (GP), nursing, mental and emergency healthcare utilization. Appendix A2. Results of the dynamic regression models (M3) of prisoners’ generalist (GP), nursing, mental and emergency healthcare utilization.


The rapid and uncertain trajectory of community spread in nursing homes statewide spurred action by the University of North Texas Health Science Center to create a nursing home (NH) COVID learning community. As an existing ECHO hub, we assembled an interdisciplinary team leveraging local NH partnerships, a regional Quality Improvement Organization (QIO), and a regional emergency response task force to rapidly scale up delivery. Specialist teams include a geriatrician and NH medical director, administrator, nursing administration, infection control expert, and a QIO specialist. With the IHI curriculum as a road map for essential training elements, we adapt each week’s agenda based on the interests and concerns of the participating nursing facilities and the incidence rate in our community. At this time, we have two more sessions before completion of phase 1. The three cohorts are engaging 151 participants from 68 nursing facilities with a total attendance of 747.


Lama glama has been present in Central Italy since 2016 after escaping from a zoological garden. In 2020, only three individuals were confirmed to be still present within a 40-hectare area, following a field survey. We carried out questionnaires with the resident human population to determine the local perception and the acceptance of two possible management actions, i.e., direct killing and surgical sterilization. Llamas are quite docile domestic animals, thus local perception was, in general, very positive and also linked to the exotic origin of the species, making llamas a welcome observation and a pleasant surprise. The observed decline of this population may be due to predation by wolves and poaching, together with the lack of suitability of natural environment, which may have prevented llamas establishing an invasive population. In this context, however, individual removal action should be conducted before the population shows a demographic rebound.Domestic mammals may become invasive alien species when introduced within natural environments and when they establish reproductive populations. One of the most common pathways of species introduction is represented by intentional or accidental escapes from confined environments, including zoos, farms and enclosures. A feral population of llama Lama glama has been present in Central Italy after escaping from a zoological garden and starting to reproduce. We updated demographic status and distribution of this population and investigated societal perception towards the llama presence and management in the area through a standard questionnaire. Field data were collected through direct (transects traveled by car and on foot) and indirect  research. The feral population appears to be declining. In July 2020, the population was represented by three individuals , identified also through photoidentification, most likely located within a 40-hectare area. The majority of citizens are aware of the presence of feral llamas and show a positive attitude toward them and a negative one toward management actions. The case of feral llamas in Italy is an evident example of unsafe management of a species which should have kept in a zoo and which, once set free, was able to catalyze the attention of the general public. The decline of this population limits the need of drastic management actions that, given the appreciation expressed by people and press toward these animals, would have been at risk of conflict with the public opinion. Removal action should be rapidly taken, i.e., before any demographic rebound and before the population becomes a stable feature of the local landscape.Since 2016, a feral population of llama  Camelus dromedarius was introduced to Australia in 1840 and it is quickly expanding, threatening the native vegetation [Biological invasions are one of the main causes of the current global biodiversity crisis ,2,3. Aligetation ,32,33. Agetation ,36,37,38getation ,40,41,42Lama glama, is the domestic form of the guanaco Lama guanicoe [The llama, guanicoe , which wguanicoe ,45. The guanicoe . In Centguanicoe . Llamas guanicoe . Potentiguanicoe . In this work we aimed at (i) updating the demographic and distribution status of this population of free-ranging llamas five years after the zoo closure  and (ii)Quercus cerris, Quercus pubescens, Castanea sativa: 38%) alternated with vineyards (27%), surrounded by scrublands (11%) and fallows (mostly with Bromus erectus: 14%), with rare human settlements (8%) and coniferous woodlands (2%). Wild ungulate assembly includes roe deer Capreolus capreolus, wild boar Sus scrofa and introduced red deer Cervus elaphus and fallow deer Dama dama; the only large carnivore in this study area is the grey wolf Canis lupus. The former zoological garden of Cavriglia hosts currently a camping area (“Camping Orlando”) and several abandoned buildings and precincts [Quercus cerris, Quercus robur, Carpinus betulus, Salix spp. and Populus spp.: 45%), wetlands/riverine vegetation (22%), scrublands (8%) and farmlands (23%), with scattered human settlements (2%). The wild ungulate guild of this area includes the wild boar, the roe deer and the fallow deer; furthermore, feral domestic pigs Sus scrofa domestica are also reported. Our study area (about 9000 hectares) included a hilly area in Central Italy , with two Special Areas of Conservation (SAC) included in a network of nature protection areas within the European Union called Natura2000 (following the Habitats Directive 92/43/EEC and the Bird Directive 79/409/EEC). SACs covered over the 75% of the surveyed area : IT5190002 “Monti del Chianti” and IT5180012 “Valle dell’Inferno e Bandella”). The SAC “Monti del Chianti” (about 7500 hectares) is included in the Chianti hills area, mostly covered with deciduous woodlands  in a bar graph.We assessed social perception in a sample of residents of the municipalities of Greve in Chianti, Radda in Chianti, Gaiole in Chianti, Cavriglia, Montevarchi and Bucine (N = 84) by administering a structured questionnaire , to asseSocial perception was also assessed through a media content analysis, which helped understand the communication environment and public attitudes toward this topic . In SeptIn our survey (July 2020), we were able to detect only three llama individuals, one male and two females. After the total closure of the Cavriglia Zoological Park, at least 27 occurrences of free-ranging llamas were collected and/or reported on online platforms, social networks and websites of video/photo sharing between 2017 and 2020 . No evidn = 13 photos with a total of 17 llamas), five or six in 2018 , four or five in 2019  considered llamas as a potential touristic attraction, therefore resulting in a general positive attitude. Half of the surveyed citizens (53%) were against the removal of llamas to protect native biodiversity, although most of them (81%) also confirmed that this practice would only produce a limited, temporary regret in the resident human population, with no effect on tourism and local economy . The media content analysis was carried out on 18 newspaper/popular magazine articles , eight oIn our work, we updated the demographic and distribution trends of the only currently known population of feral llamas in Europe, four years after humans stopped food provision in the zoo borders and three years after the previous assessment . We alsosensu [sensu [Despite the amount of photographic evidence, it was not possible to accurately reconstruct kinship relationships among individuals observed since 2016, also because of the presence of monochromatic white individuals. Furthermore, five white llamas were observed in “Valle dell’Inferno and Bandella” Natural Reserve in 2019, although field work in September 2019 and September 2020 did not confirm their occurrence. Therefore, only three individuals were confirmed in summer 2020, located in a very small area (40 hectares) around Monteluco in the municipality of Gaiole in Chianti (Siena). These individuals included two females (one brown and one brown with white head) and one male (brown with a white head and front legs). One of the hind legs of the male appeared to be injured after a collision with a car in 2019. We feel confident that it is very unlikely that further individuals would not have been detected in our survey, because (i) llamas, particularly adult ones, are confident and well-adapted to human presence and food provision . Howeveu [sensu .n = 4) were negative with respect to the presence of llamas in the study area, specifying how the introduction of an ungulate species may represent an additional potential source of crop damage, together with wild boar and deer. Citizen who felt that llamas could represent a tourist attraction discussed that this would happen only if llama–man encounters occurred. In other words, the choice of visiting the Chianti area would not be influenced by the presence of the llamas. Unfortunately, it was not possible to carry out a survey investigating tourist perception due to the very limited tourist pressure in summer 2020 related to the emergency status due to the SARS-CoV-2 pandemic outbreak [Sciurus carolinensis introduced to Italy [Capra ibex reintroduced to the Marmolada massif, where they became extinct [The general positive social perception toward the presence of feral llamas in the study area fulfilled our prediction. This positive perception may have been promoted by the high visibility of these animals , as alsooutbreak . Opinionoutbreak . A populto Italy , ibex Ca extinct ).Considering our data on abundance and distribution of this population and on the species traits , removal from the environment appears to be still technically feasible and with a relatively small operational effort. Understanding factors which determine the success of invasive species requires information on both successful and failed introductions. Not publishing the data on failed introductions would cause publication bias, hampering appropriate scientific syntheses. Domestic mammals can become invasive alien species when introduced by humans within natural environments. One of the most common pathways of species introduction is represented by intentional or accidental escape from confined environments, including zoos, farms and enclosures. The case of free-ranging llamas in Central Italy was reported as an example of unsafe management of animal species in a confined environment . ConversAfter our survey, an agreement between the Tuscany Region, the Municipality of Gaiole in Chianti, the Province of Siena, the Italian Forestry State Body and several associations of hunters and animal rights groups organised the captures of the last free-ranging llamas, to ensure their safety and that of motorists. All the individuals recorded in our work and a newborn  were captured with the help of veterinarians and moved to an enclosure at the Wildlife Rescue Center of Semproniano (province of Grosseto).


To analyze the correlation of ICU nurses' cognitive level with their attitude and behavior toward the prevention of ventilator-associated pneumonia (VAP).  A total of 90 ICU nurses working in the adult internal medicine ICU, adult surgery ICU, subacute respiratory care ward, etc. from January 2018 to June 2019 were chosen as the subjects to carry out questionnaire survey with the cognition scale, and the correlation analysis on their cognitive level, attitude, and behavior toward the prevention of VAP was conducted. R2 = 0.668, 0.734).  The linear fitting analysis finding showed that the cognitive level presented a positive correlation with the attitude score and behavior score ( Improving ICU nurses' cognitive level, attitude, and behavior toward preventing VAP is conducive to the upgrade of their quality of nursing services. In addition, the ICU nurses' cognitive level is positively correlated with their attitude and behavior. Ventilator-associated pneumonia (VAP), as the most common type of nosocomial infection, occurs mainly in mechanically ventilated patients who underwent incision of the trachea or tracheal intubation . VAP refSome studies have pointed out that applying the concept of combined care, such as elevating the head of the bed by 30–45°, performing oral cleaning, daily assessment of whether sedative use can be interrupted, and evaluation of the indicators of detachment from the ventilator, can effectively prevent VAP . CaregivA total of 90 nurses working in the adult internal medicine ICU, adult surgery ICU, subacute respiratory care ward, etc. from January 2018 to June 2019 were chosen as the subjects. The study met the World Medical Association Declaration of Helsinki .  FigureInclusion criteria were as follows: ① nurses who directly provided services for ICU patients; ② nurses who engaged in continuous ICU nursing work for over 1 year; ③ nurses on the regular payroll or contract nurses who engaged in the ICU work in a Grade III Level A hospital; ④ nursing personnel who served in the ICU, had a length of providing care service for over 3 months, and took care of patients using ventilator for not less than 48 hours, those who were willing to join the study and sign the informed consent, and those who were able to fill in the questionnaire by themselves; and ⑤ nurses who were at their post during the research.Exclusion criteria were as follows: ① nurses who were not at their post due to taking a vacation, going on a field trip, engaging in advanced studies, or other reasons; ② persons in charge of nursing administration, including deputy head nurse, head nurse, supervisor, and director, who provided interdisciplinary support to ICU work for less than 3 months; ③ those who experienced stressful events such as serious disease, divorce, and losing their spouse; ④ those who had obvious psychological illness; and ⑤ those who were participating in other trails.The general data of 90 subjects were collected, including gender, age, nationality, education background, job title, years of clinical work, years of ICU work, monthly income, religious faith, living condition, whether they had received medical ethics education and training, whether they had experience in providing VAP care, whether they had qualification certificate of specialist nurse, and the level of qualification certificate of specialist nurse.α coefficient of the questionnaires was 0.8524. The anonymous questionnaires were distributed by the researcher, the unified instruction was applied to inform the subjects of the method of filling in the questionnaires in detail, the study subjects were asked to complete it independently, and then the questionnaires were retracted on the spot. A total of 90 questionnaires were distributed, and 90 valid questionnaires were retracted, resulting in a 100% response rate.This study used a self-designed structured questionnaire, which referred to the optimal nursing evidence for preventing VAP recommended by American Association of Critical-Care Nurses (AACN)  and the The cognition investigation for VAP prevention care included the following items: (1) aspiration of sputum should be performed to mechanically ventilated patients in a timely manner; (2) the cuff pressure of the tracheal cannula should be maintained at 20–30 cmH2O; (3) condensate water from ventilator tubing should be poured into medical waste bags or handled by centralized processing; (4) enteral nutrition should be discontinued when the gastric residual volume reaches 150–190 ml; (5) compared with cotton balls, a soft-bristle toothbrush can better remove dental plaque; (6) persistent subglottic secretion drainage prevents early VAP occurrence; (7) the cuff pressure of the tracheal cannula should be detected with the cuff pressure gauge; (8) the mechanically ventilated patients should be detected for gastric residual volume once every 5 hours; (9) the ventilator tubing should be changed only if tubing fails or is contaminated; (10) chlorhexidine products should be used for oral care when patients have poor oral hygiene or dental plaque.The questionnaire for attitude toward VAP prevention included the following items: (1) implementing nursing measures for patients is necessary to preventing VAP; (2) good nursing measures work better in guiding the prevention of VAP; (3) ICU nurses should learn relevant theoretical knowledge of VAP nursing; (4) ICU nurses should learn the relevant operation skills of VAP nursing; (5) rich nursing knowledge greatly benefits the nursing operations of preventing VAP; (6) departments should develop guidelines for nursing operations to prevent VAP; (7) departments should develop measures to effectively supervise the implementation of VAP prevention nursing; (8) the nursing operations for preventing VAP should be completed by ICU nurses; (9) the nursing operations for preventing VAP should be completed by the trained nurses; (10) nurses should actively participate in relevant training of nursing to prevent VAP; (11) nurses should actively learn the latest information of VAP prevention nursing; (12) with or without supervision, ICU nurses should be able to implement VAP prevention nursing; and (13) ICU nurses should carefully implement nursing to prevent VAP regardless of the workload.After gathering all subjects, the researcher distributed and collected the questionnaires on the spot, and the ICU nurses' scores on cognition, attitude, and behavior toward preventing VAP were recorded.The correlation of ICU nurses' cognitive level of preventing VAP with their attitude was analyzed.The correlation of ICU nurses' cognitive level of preventing VAP with their behavior was analyzed.X2 test and expressed by (n(%)), the measurement data were examined by the t-test and expressed by , the enumeration data were examined by the Scores on ICU nurses' cognitive level, attitude, and behavior toward preventing VAP are given in R2 = 0.668, 0.734)  see .R2 = 0.668, 0.734), which fully demonstrated that with higher cognitive level of preventing VAP, the ICU nurses had better nursing attitude and their nursing behaviors and their measures could be more standardized and professional. The deficiencies of the study are as follows: first, the selected subjects were all nurses from the departments of our hospital, so the subject source lacked diversity; second, there was a lack of long-term follow-up observation of the subjects; third, the ratio of male to female nurses had a large difference; and finally, scales were still the method for clinical evaluation, so there must be certain subjective and intentions when patients were answering the questions, which might affect the final results of the clinical trial to some extent. Therefore, it is necessary to improve the research design, prolong the follow-up time, expand the sample size, and select more male nurses in the future studies for deeper exploration, so as to deeply and carefully explore the correlation of ICU nurses' cognitive level with their attitude and behavior toward the prevention of VAP in multiple angles and aspects.ICU is an important department in hospitals, and maintaining the life of patients using ventilator is one of the common treatment modalities used in ICU. VAP is the most frequent complication in ICU, which is associated with the destruction of respiratory mucosa by invasive procedures, poor patient immunity, the medical workers' cognitive level, attitude, and behavior, and ward environment . RelevanIn conclusion, the ICU nurses' cognitive level of preventing VAP needs to be improved and their nursing attitude and behavior are in a good state. Improving the cognitive level of ICU nurses is beneficial to the improvement of their attitude and behavior because the three elements are in positive correlation.


Scientific Reports 10.1038/s41598-020-68117-9, published online 07 July 2020Correction to: The original version of this Article contained an error in the Acknowledgments section.“This paper is supported by the SILICOFCM project that has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 777204. This research was also funded by Ministry of Education and Science of Serbia, grants OI 174028, III 41007, III 45019 and PROMIS, Science Fund of the Republic of Serbia. The authors acknowledge support from the City of Kragujevac, Serbia.”now reads:“This paper is supported by the SILICOFCM project that has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 777204. This research was also funded by Ministry of Education and Science of Serbia, grants OI 174028, III 41007, III 45019. The authors acknowledge support from the City of Kragujevac, Serbia.”The original Article has been corrected.


Preeclampsia (PE) is a common obstetric disorder typically affecting 2–8% of all pregnancies and can lead to several adverse obstetric outcomes for both mother and fetus with the greatest burden of severe outcomes in low middle-income countries (LMICs), therefore, screening for PE is vital. Globally, screening is based on maternal characteristics and medical history which are nonspecific for the disorder. In 2004, the World Health Organization acknowledged that no clinically useful test was able to predict the onset of PE, which prompted a universal search for alternative means of screening. Over the past decade or so, emphasis has been placed on the use of maternal characteristics in conjunction with biomarkers of disease combined into predictive algorithms, however these are yet to transition into the clinic and are cost prohibitive in LMICs. As a result, the screening paradigm for PE remains unchanged. It is evident that novel approaches are needed. Vibrational spectroscopy, specifically Raman spectroscopy and Fourier-transform infrared spectroscopy (FTIR), could provide better alternatives suited for implementation in low resource settings as no specialized reagents are required for conventional approaches and there is a drive to portable platforms usable in both urban and rual community settings. These techniques are based on light scattering and absorption, respectively, allowing detailed molecular analysis of samples to produce a unique molecular fingerprint of diseased states. The specificity of vibrational spectroscopy might well make it suited for application in other obstetric disorders such as gestational diabetes mellitus and obstetric cholestasis. In this review, we summarize current approaches sought as alternatives to current screening methodologies and introduce how vibrational spectroscopy could offer superior screening and diagnostic paradigms in obstetric care. Additionally, we propose a real benefit of such tools in LMICs where limited resources battle the higher prevalence of obstetric disorders. Antenatal screening programmes are used around the world to identify pregnant women at risk of common obstetric disorders. These programmes result in improved maternal and fetal outcomes and identify those at need of additional antenatal care. Common screening procedures involve maternal biochemical tests for infections, screening for fetal syndromes such as Down's syndrome, and fetal morphological examinations for structural anomalies which are sensitive and specific. In contrast, several screening paradigms used for pregnancy complications such as preeclampsia (PE) and gestational diabetes mellitus (GDM) commonly rely upon risk factor based screening at booking appointments, familial medical history and the development of symptoms prior to diagnosis. The current screening procedure for PE is limited to assessing maternal characteristics to determine the risk of later PE development, while blood pressure and proteinuria estimations are used to confer a diagnosis of PE. These measures are non-specific and a focus on developing superior screening and diagnostic tests for PE has emerged. These new tests are based on combining maternal characteristics and biophysical measures into diagnostic and screening algorithms. Although progress has been made, clinical translation of these tests remains limited due to the variable performance in different patient populations and the unknown cost-effectiveness of introducing these approaches , both ofUniversal demand for improved screening and diagnostic tests for many types of non-obstetric diseases and disorders has recently geared toward the use of vibrational spectroscopy. Combining vibrational spectroscopy with algorithms offers the possibility of simple and automated disease classification tools suitable in a clinical setting. In vibrational spectroscopy, chemical bonds within molecules differentially interact with incident light, yielding valuable information about the nature and composition of the sample of interest generating a unique spectral fingerprint suitable for diagnostic use and that can be applied to the types of samples routinely collected for diagnostics especially plasma, serum and urine. Additionally, vibrational spectroscopy can support the identification of novel disease biomarkers to assist in future test design.This review will summarize how vibrational spectroscopy might provide a novel screening and diagnostic tool for obstetric diseases with a focus on PE. Therefore, the screening and diagnostic paradigms of PE will be outlined along with consideration of their limitations and recent progress in developing superior tests.Hypertensive disorders, including preeclampsia, chronic hypertension and gestational hypertension, are the second most common cause of maternal mortality worldwide accounting for 14% of all maternal deaths annually . PE typiEarly recognition of PE is one of the major challenges in obstetric care worldwide. Globally, screening paradigms involve assessing women for risk factors for the development of PE and subsequent monitoring of disease development. Current PE screening guidelines for the UK issued by the National Institute for Health and Care Excellence (NICE) involve determining a women's risk at the booking appointment during the first trimester. These include: >40 years of age, nulliparity, a 10-year pregnancy interval, a previous diagnosis of preeclampsia or family history of the disease, BMI > 30, pre-existing vascular or renal disease and multiple pregnancies . Women dAssessing individual maternal characteristics and medical history to screen for PE is simple and of minimal cost, although its predictive value has been subject to much debate. A previous history of preeclampsia confers the highest predictive risk factor with a relative risk value of over 7 . HoweverPE prognosis relies on early recognition, timely diagnosis and increased monitoring to reduce the risk of maternal and fetal morbidity and mortality. Therefore, early screening and subsequent accurate diagnosis of these conditions are of utmost importance to identify those at risk of disease development and such paradigms have been investigated thoroughly and subjected to much debate. It is evident that alternative screening and diagnostic tests for PE which are sensitive, specific and simple to administer are needed, and much attention has focused on such necessity over the past decade. Advances in treatment and interventions also highlight the need for better screening and diagnostic strategies and tools. For example, the ASPRE study suggested that early prophylactic use of aspirin during gestation (150 mg/day) significantly reduced the incidence of preterm PE by 62% . Meta-an+6 weeks has poor detection rates for PE at 25 and 37.5%, respectively, for a false positive rate of 10%  was significantly higher than in those women who did not develop PE . Subseque of 10% , 24.Improper trophoblast invasion is one of the main etiological components of PE and results in defective uteroplacental circulation measurable as increased pulsatility index and resistance in uterine arteries . Uterine+6 weeks to aid the diagnosis of PE and a recent multicentre study suggests such testing reduces both the time taken for clinicians to diagnose PE and the incidence of adverse obstetric outcomes  vibrational modes with distinct FTIR and Raman activity as illustrated in Fourier-transform infrared (FTIR) and Raman spectroscopy are common and complementary vibrational spectroscopic techniques which provide information on the vibration modes present within a material. However, fundamentally and experimentally they differ significantly and they have distinct gross selection rules. FTIR spectroscopy involves the absorption of infrared light resulting in excitation of a molecule from its ground vibrational state to an excited vibrational state, altering its bond properties and causing a change in dipole moment—the charge distribution of molecular bonds. In contrast, Raman spectroscopy relies upon the relatively weak phenomenon called inelastic scattering where scattered photons are of different energy to the incident photons. Such scattering occurs as a result of induced molecular dipoles in polarisable bonds where their electron cloud can be disrupted as a result of vibrational transitions within molecules. Each molecule contains a set number of vibrational modes, and a non-linear molecule contains 3N-6  decrease throughout gestation, while unidentified blood components  increase  were able to identify both PE subject groups compared to their respective matched normotensive control group with over 80% accuracy. Nuclear magnetic resonance (NMR) spectroscopy later revealed serum levels of arginine and citrate were decreased significantly in early-onset compared to late-onset PE while levels of glutamate, choline, alanine and lactate were significantly increased in the early-onset subject group (n = 9) at an unknown stage of gestation revealed spectral differences between healthy and preeclamptic women. Spectral differences were attributed to decreasing intensity of amino acid associated bands and increasing band intensities of lipid-associated molecules in PE. Using principle component analysis (PCA) and linear discriminant analysis (LDA), sensitivity and specificity of 78 and 90% respectively was obtained for the diagnosis of PE  or community-based testing regimes. The considerable interest in developing handheld devices for diagnostic application will further support this. Handheld Raman and FTIR devices have long been used in the pharmaceutical industry and have recently begun to transition into the field of diagnostics. Interoperative Raman probes have been used in real time to aid surgical resection of brain cancer with high sensitivity (93%) and specificity (91%), improving clinical decision making . Raman p methods . The dev methods . As thisOR, CJ, and CT contributed to the conception and design of the review. OR wrote first draft of the manuscript. CJ, HG, AN, PD, and CT wrote sections of the manuscript. SJ, MM, TT, JB, AN, and MN provided clinical oversight. OR, CJ, EP, and PD provided oversight into the vibrational spectroscopy techniques. All authors contributed to the article and approved the submitted version.CT has funding from Bristol Myers Squibb. The remaining 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.