Masticatory ability is an essential factor for sustaining quality of life and social and systemic well-being, particularly in elderly. This study aimed to reveal the association between subjective masticatory difficulty and skeletal bone mineral density (BMD).Data from the Korean National Health and Nutrition Examination Survey, which was conducted from 2008 to 2011 were analyzed. This study included 13,092 Koreans  over 50 years of age. Masticatory difficulty was evaluated based on a self-reported questionnaire. Areal BMD of the total hip, femoral neck, and lumbar spine as well as lean body mass were determined using dual-energy X-ray absorptiometry. Data about the sociodemographic characteristics, physical activity, number of teeth present, sum of decayed, missing, and filled permanent teeth (DMFT) index and Community Periodontal Index (CPI) were collected. Multivariate logistic regression analysis was conducted to analyze associations between subjective masticatory difficulty and BMD, adjusting for the confounding covariates.Significant differences were observed in the areal BMD of the total hip, femoral neck, and lumbar spine as well as lean body mass accordance with the presence of subjective masticatory difficulty in both males and females. The number of teeth, DMFT, and CPI score did not show significant differences based on the presence of self-reported satisfaction of chewing performance in both males and females. Results from multivariate logistic regression demonstrated that the subjective masticatory difficulty showed significant interactions with skeletal BMD and the associations between masticatory satisfaction and BMD of the total hip and femoral neck were more prominent in females compared to those in males.The skeletal BMD, particularly areal BMD of the femoral neck was significantly associated with subjective masticatory difficulty in elderly, especially in elder females. Masticatory ability is not only a determinant of oral health but also a reflection of the quality of life and social and systemic well-being, particularly in elderly , 2. ChewChewing performance is a complex process which involves intact dentition, integrated oral mucosa, sufficient salivary secretion, healthy temporomandibular joints, and coordination of sensory stimuli, motor nerve activation, and proper response of muscle and other connective tissue structures –18. RehaSpontaneous bone loss is one of the main features of aging and can increase the risk of osteoporotic fracture and mortality , 21. SevEven though, several previous studies have attempted to determine the relationships between skeletal BMD and masticatory function, the relatively small sample sizes of those studies inevitably have limited the validity of the results. The Korea National Health and Nutrition Examination Survey (KNHANES) conducted by the Korean center for Disease Control and Prevention which annually monitors the general health, oral condition, and nutritional status of the South Korean population includes a relatively large number of samples, therefore can provide valid and meaningful results. Hence, the aim of the present study was to investigate the relationships between self-reported masticatory difficulty and skeletal BMD after considering the possible confounders in a nationally representative sample of the Korean population.The present study was based on the data obtained from the 2008 to 2011 KNHANES, a nationally representative survey conducted by the Korean Center for Disease Control and Prevention. This study enrolled 13,092 Korean subjects  over 50 years of age. To enroll a representative sample from the population, a stratified, multistage, and clustered probability approach was used. The survey consisted of a nutritional survey, individual interview, and health examination survey. Data were obtained via household interviews from direct standardized physical examinations. Trained interviewers performed the interviews using structured questionnaires. Written informed consents were provided from all participants. Only data from responders aged over 50-year-old were included.A trained interviewer interviewed the participants using a structured questionnaire. Subjective masticatory discomfort was assessed on a 5 points scale . For the analysis, masticatory difficulties were classified as follows: no problem  and problem .The oral examination was conducted by trained dentists. Periodontal health status was examined using the Community Periodontal Index (CPI) based on the criteria given by the World Health Organization . The CPIAll participants put on uniformed light gown which provided by the survey staff without shoes and trained examiners assessed their weight (kg) and height (cm). The body mass index (BMI) was evaluated by dividing the weight (kg) by the square of the height (m) .Whole body dual-energy X-ray absorptiometry (DEXA) was performed with a QDR Discovery fan beam densitometer , as per the procedures recommended by the manufacturer. The areal BMDs (aBMDs) of the total hip, femoral neck, and lumbar spine were measured with DEXA. The aBMD was calculated as the amount of bone mineral contents divided by the bone scanned area . The DEXThe data about sociodemographic factors and health-related behaviors including smoking, alcohol drinking, menopause and physical activities were assessed by self-administered questionnaires from KNHANES. Monthly household income was adjusted for the number of household members and classified into following four different quartiles. Education level was also classified into four groups based on the Korean education system: elementary school , middle school , high school , and over college education (more than 14 years of education).Cigarette smoking was categorized into following three groups: nonsmoker, smokers who have smoked at least 5 packs in their entire lives, and smokers who currently smoke and have smoked more than 5 packs in their entire lives. Alcohol drinking was classified into following two groups; none or light drinker (0–3 day/month) and moderate to heavy drinker (> 4 days/month).In females, the information about whether menopause had occurred were collected. Physical activity level was measured using the Korean version of the International Physical Activity Questionnaire (IPAQ) short form . The resMetabolic syndrome was diagnosed if participants had at least three fulfilling criteria among the following five criteria as previous reports suggested , 40: (1)P < 0.05.All statistical analysis was conducted using a complex design including stratification, clustering and weighting. Sample weights were constructed for sample participants to represent the Korean population by accounting for the complex survey design, survey nonresponse, and stratification . All values were considered significant when All analysis was conducted separately for male and females owing to the different rate of background bone metabolism and muscle mass between the sexes. Subjective masticatory difficulty was an outcome variable and aBMDs of the total hip, femoral neck, and lumbar spine were the main explanatory variables. Rao-Scott chi-square and independent t test were used to compare the differences in the demographic factors, skeletal BMD, number of teeth, DMFT, CPI, and information about menopause and physical activity for categorical and continuous variables, respectively accordance with the presence of subjective masticatory difficulty. Multivariate logistic regression analysis was used to analyze the interactions between self-reported masticatory difficulty and skeletal aBMD adjusted for the potential confounders. Owing to high collinearity among aBMD of the total hip, femoral neck, and lumbar spine, separate analysis of aBMD of the total hip, femoral neck, and lumbar spine was conducted. Model 1 was unadjusted, while Model 2 was adjusted for age and BMI. Model 3 was adjusted for age, BMI, and general health status and behaviors including smoking, drinking, and presence of metabolic syndrome. Model 4 was adjusted for age, BMI, general health status and behaviors, physical activity, experience of menopause for females, and socioeconomic factors, including smoking, drinking, presence of metabolic syndrome, and levels of household income and education.The differences in sociodemographic factors including age, household income, educational level, and smoking status were statistically significant between participants with subjective masticatory difficulty and those without it in both males and females. On the other hand, presence of metabolic syndrome and alcohol consumption in males and BMI in females did not show significant differences. No significant differences of performing high/moderate intensity physical activity were detected in two groups in both males and females. The number of female participants with menopause was significantly higher in females without subjective masticatory difficulty compared to those with it despite of higher BMD in females without masticatory dissatisfaction Table .Table 1TThe significant differences of aBMD and T score of the total hip, femoral neck, and lumbar spine in accordance with presence of subjective masticatory difficulty was detected in both males and females. The number of teeth, DMFT, and CPI score did not show significant differences in accordance with the existence of subjective masticatory difficulty in both males and females Table .Table 2BResults from multivariate logistic regression demonstrated that the interactions between skeletal BMD and subjective masticatory difficulty were more prominent in females compared to those in males. Significant associations between subjective masticatory difficulty and aBMD of the total hip, femoral neck, and lumbar spine were detected in only Model 1 in males. Otherwise, significant interactions with aBMD of the femoral neck and self-reported masticatory difficulty were observed in Model 1, 2, 3, and 4 in females. aBMD of the total hip also showed significant associations with subjective masticatory difficulty in Model 1, 2, and 3 and aBMD of the lumbar spine showed significant relationships in Model 1 and 2 in females (Table The aim of this study was to reveal the associations between masticatory difficulty and skeletal BMD in elder populations using the KNHANES data in 2008–2011 with large number of samples from an authorized institution after adjusting for confounding covariates. The main finding from the present study was significant association between skeletal BMD and subjective masticatory function in the elder populations, particularly in females. Oral hypofunction in elderly could have impact on maintaining bone and muscle mass through diverse pathways including insufficient nutritional intake and inflammatory mechanisms –43. The Previous studies have shown conflicting results about the sex differences in the interactions between skeletal BMD and masticatory efficiency. One study demonstrated more prominent influences of osteoporosis on lower masticatory efficiency in females compared to those in males , otherwiThe aforementioned results exhibited that there were strong significant relationships between aBMD of the femoral neck and total hip and subjective masticatory difficulties. The aBMD of the lumbar spine would be influenced by several factors including posture and arthritic changes of the spine –51, so aThe results from this study demonstrated a lack of significant differences in the number of remaining teeth, DMFT, and CPI score, accordance with the presence of subjective masticatory difficulty. Several previous studies reported the role of number of remaining and functional teeth and periodontal health on the maintenance of chewing ability, particularly in the elderly –57. ChewThe present study has several limitations. First of all, owing to the retrospective cross-sectional study design, the causal relationships between osteoporosis and masticatory difficulties could not be derived. Secondly, lack of information about other oral health associated factors related to the chewing function, including salivary flow rate, occlusal relationships, masticatory force, and temporomandibular disorders by proper diagnostic criteria inevitably compromise the significance of the results from the study. Thirdly, due to the retrospective study design, precise information about participants, such as underlying diseases and medication history could not be provided.In conclusion, the skeletal BMD, particularly aBMD of the femoral neck was significantly associated with subjective masticatory difficulty in elderly, especially in elder females. The importance of maintaining oral health in elder patients would be emphasized to prevent osteoporosis and this might lead to prevention of frailty in long terms. Understanding this interaction would be warranted for dentist and physicians for better management of frailty and for successful aging.


Specialist nurses have a crucial role within the allergy and immunology specialty that reflects their competence in an increasingly complex area of work and ability to use advanced diagnostic testing and therapeutic modalities. A specialist nurse in Qatar follows the local Hamad Medical Cooperation (HMC) guidelines and the competency published by the British Society for Allergy and Clinical Immunology (BSACI).Specialist Allergy NursesLearning domain: Learn and review the written standard operating procedure (SOP) and protocols for all diagnostic and therapeutic allergy procedures, including skin prick testing , intradermal testing, skin patch testing, penicillin testing, food and drug challenges, different desensitization protocols, and biologics and other medication administration. In addition, learn the protocol for immunotherapy administration and maintain an updated knowledge of trends and developments in the field by reading relevant articles, journals, and related material and attending seminars and conferences, as needed.Maintain a safe work environment: Perform all the above procedures and medication administration with a high grade of competency under physician supervision. Apply quality measures to ensure safety. Furthermore, perform stocktaking by regularly checking procedure requirements, availability of items and consumables, date of expiry of items, and medications. Monitor the patients closely during drug and food allergy challenge procedures and record and report patients’ vitals and reactions to treating physicians. Ensure that a patient stays the required observation time after injection(s).General care: Assess patient needs and suggest solutions to patient care problems. Provide education and resources for the patient and family support as needed. React appropriately and on time during patient reaction situations to mitigate early adverse reactions. Maintain patient, employee, and clinic confidentiality.• Develop specialist knowledge and experience in immunology.• Develop nurse-led clinics for administering immunoglobulin replacement therapy safely and effectively based on patients’ preferences .• Coordinate communication between members of the multidisciplinary team to facilitate the appropriate delivery of care.• Provide education and resources for the patient and family support .Specialist Immunology Nurses


Background: Hypereosinophilic syndromes (HES) are a group of relatively rare disorders in which neurological manifestations, including ischemic stroke, are common. The hypothesized pathophysiological mechanisms are hypercoagulability, cardioembolism  and damage to the endothelium. A variable ischemic pattern has been described, including an association of territorial and border zone ischemic stroke. Methods: Three patients who presented to our department with acute stroke were selected aiming to show these three different mechanisms inferred from the stroke pattern on brain Magnetic Resonance Imaging (MRI) and to simultaneously illustrate the three main causes of HES. Results and Discussion: The first patient is a 55-year-old man with an abrupt onset of aphasia due to an acute ischemic stroke involving the left parietal lobule and the angular gyrus; recent lab test had shown hypereosinophilia. An extensive workup excluded primary and secondary causes of hypereosinophilia so a diagnosis of idiopathic hypereosinophilia was done and he was treated with high doses of steroids. The second patient had severe hypereosinophilia and developed multiple small, scattered ischemic lesions, mainly in border zone zones. The history of severe asthma and recurrent sinusitis supported the diagnosis of EGPA (Eosinophilic Granulomatosis with Polyangiitis); considering the severe clinical conditions and the presumptive role of hypereosinophilia in determining her symptoms, steroid treatment was promptly started, with good clinical response. The third patient also presented with multiple metachronous ischemic lesions, both in cortical and border zone distribution and marked eosinophilia; the diagnostic work-up found an ovarian cancer. She was treated with steroids and then underwent surgery and adjuvant chemotherapy. Conclusions: HES should be considered in stroke etiological evaluation, although it is a rare disorder, and border zones pattern without large artery steno-occlusion on neuroimaging may help to raise the suspicion in the neurovascular diagnostic pathway. A thorough research of the sources of hypereosinophilia should be performed to select the appropriate therapy. The one-month interval should not be considered when the symptoms of eosinophil-mediated organ dysfunction require immediate therapy [According to the most recent classification criteria , hypereo–primary or neoplastic HES,–secondary or reactive HES,–idiopathic HES (when the other causes have been excluded) and–other conditions and syndromes accompanied by hypereosinophilia.On the basis of the pathogenic mechanism underlying the increased production of eosinophils, HES can be further classified as:In primary HES the most involved neoplasms are myeloid neoplasms: chronic myeloid leukemia, other myeloproliferative neoplasms (MPN), distinct variants of acute myeloid leukemia, rare forms of myelodysplastic syndromes (MDSs), some MDS/MPN overlap disorders, and a subset of patients with (advanced) systemic mastocytosis (SM) .Reactive or secondary HES is associated with an underlying inflammatory condition  or solid tumors, but also some hematological neoplasms . Other subsets of reactive HES is related to helminth infections, allergic reactions, atopic diseases and drug reactions.The third subtype includes eosinophilic granulomatosis and polyangiitis  or other organ specific conditions (for example chronic eosinophilic pneumonia and others) . HES areNeurologic involvement is not uncommon (65% of cases) in HES and it typically consists in peripheral neuropathy, encephalopathy, and stroke . More inAmong patients admitted to a single center Stroke Unit in the last 5 years, we selected the unique three cases of stroke as presenting manifestation of HES. The patients underwent a complete diagnostic work-up in order to exclude other causes of stroke and to ascertain the cause of HES. All patients underwent a hematological consultation because of HES and the exclusion of hematological malignancies was carried out accordingly to the current guidelines. A detailed neuroimaging study, including Computed Tomography Angiography (CTA) and brain MRI with Magnetic Resonance Angiography (MRA) was performed in our institution as well as the screening for systemic involvement though whole body Computed Tomography (CT) and cardiological tests (including prolonged heart rhythm monitoring and echocardiography) were performed as part of the routine diagnostic pathway of patients with ischemic stroke at our institution.The first patient is a 55-year-old man who was first admitted to the Emergency Department after the acute onset of confusion, altered speech comprehension and production. The episode lasted 45 min and spontaneously resolved. Head CT and neurosonological examination of the neck and cerebral vessels were unremarkable, and the patient was discharged on single antiplatelet therapy  with a diagnosis of transient ischemic attack (TIA). He went back to the hospital two days later after developing writing difficulties, and he was admitted to our Stroke Unit; no further focal neurological deficits were evident on clinical examination. The most relevant aspects of his past medical history were mild hyperlipidaemia and smoking; recent lab tests performed before admission revealed an increase in the absolute and relative eosinophil count above the threshold for HES diagnosis. A second head CT at two days from the symptom onset showed an ischemic lesion involving the left parietal lobule and angular gyrus, confirmed by a Magnetic Resonance Imaging (MRI) scan A–D.An extra- and intracranial CTA was normal as well as a transthoracic echocardiography and an electrocardiogram (ECG)-Holter; no right-left shunt was found on transcranial Doppler ultrasonography (TCD); thrombophilia screening and tests for autoimmunity were unremarkable. On lab examination a moderate hypereosinophilia was confirmed (absolute eosinophil count of 2290/microL). An extensive screening for primary and secondary causes of hypereosinophilia was performed including a total body CT, stool samples for parasites, tryptase and B12 levels determination, hematologic evaluation, lymphocyte typing, bone marrow biopsy and testing for Fip1-like 1 (FIP1L1) and platelet-derived growth factor receptor alpha (PDGFRA) fusion gene, which were all negative. The patient reported an episode of pruritus occurred two months before hospitalization, responsive to steroid treatment. He underwent allergic tests that were positive for Balsam of Peru (BP) and bet v1. Although an atopic condition, which is a known cause of eosinophilia, was identified, it appears unlikely that the persistent hypereosinophilia with eosinophil counts >1500/microL in our patient could be explained by allergy alone . Moreover, BP is one of the most common contact allergens and reactions to BP are typically seen as contact eczema or dermatitis both for topical contact and oral intake with several systemic complications and the reported patient did not have any of these manifestations. Therefore, a diagnosis of idiopathic hypereosinophilia was done.The patient was treated with high-dose intravenous glucocorticoid therapy  and discharged on oral prednisone 25 mg, with a significant reduction in eosinophil count in the peripheral blood and clinical improvement.The second patient is a 64-year-old woman with a previous history of arterial hypertension and paroxysmal atrial fibrillation, on antiplatelet treatment with aspirin and rhythm control with flecainide; she also reported asthma and recurrent sinusitis . She arrived at our attention because of bilateral upper limbs paraesthesia followed, the next day, by psychomotor slowing, right upper limb weakness, instability, and difficulty with walking. Neuroimaging exams (head CT and MRI) revealed multiple bilateral cortical-subcortical ischemic lesions in the cerebral and cerebellar hemispheres, mostly located in border zone areas A–D; no s2 for 6 months, according to the regimen advised by American National Institute of Health). She was then referred to a rehabilitation center and her conditions continued to improve both on the cognitive and on the motor level. After the cyclophosphamide treatment, a maintenance therapy first with azathioprine and then, for side effects (liver enzymes elevation), with methotrexate was started. The patient continues rheumatologic, pneumological and neurologic follow-up.Neurological exam was significant for severe right upper limb paresis and mild left ataxic hemiparesis. The echocardiogram showed akinesia of the apical portion of the left ventricle, without evidence of intracardiac thrombi and a stress cardiomyopathy was suspected. Apixaban was prescribed considering the previous finding of atrial fibrillation. She presented a marked hypereosinophilia in the peripheral blood (5540/microL) and therefore a thorough evaluation of the possible causes was performed: neoplastic markers, parasite tests, serological tests for HIV, Mycoplasma, Borrelia, Syphilis, Vitamin B12, tryptase as well as a blood smear and lymphocyte phenotyping on peripheral blood were all within normal range. The bone marrow biopsy showed increased cellularity and increased eosinophils so cytogenetic and molecular studies including BCR/ABL1, PDGFRA, PDGFRB, FGFR1, PCM1-JAK2 fusion genes were performed and resulted negative. A positive high titer ANA- and AMA-test was detected (1:1280) whereas ANCA test was negative. The whole-body CT scan showed areas of subpleural ground glass in the superior lobe of the left lung, splenic infarcts, and enlargement of para-esophageal and mediastinal lymph nodes. The main findings of the whole body CT scan are the lack of solid neoplasms and the evidence of splenic infarcts. Both lungs and lymph nodes changes have been considered not specific in a bedridden patient with delirium. Heart MRI was then performed which displayed no abnormalities. During the hospitalization, the patient’s conditions worsened, and she developed quadriparesis, altered mental status, frequent episodes of delirium and hallucinations that required pharmacological sedation. Therefore, in the hypothesis of stroke and encephalopathy in the context of a HES , the patient was started on high doses of intravenous corticosteroids (1 g/day for 5 days), followed by oral tapering. The treatment determined a marked clinical improvement and a reduction in the number of eosinophils; following rheumatologic evaluation, during steroid tapering, the patient was started on cyclophosphamide  and a very high D-dimer level . Although her eosinophil count was a little less than 1500, not strictly meeting the criteria for hypereosinophilia, considering the significantly increased value and the co-occurrence of a very high D-dimer, a steroid treatment was started and an extensive diagnostic workup was performed, showing an increased level of CA125 (189.3 U/L); whole-body CT scan revealed a right ovarian mass of 6 cm of diameter, besides splenic and renal infarcts. Thoracic CTA was negative for pulmonary embolism. Intravenous high doses of corticosteroids were started soon after admission (1 g of methylprednisolone for 3 days followed by 500 mg for 2 days) with subsequent oral tapering with some degree of clinical improvement and eosinophil count normalization. She later underwent laparoscopic peritoneal washing and adnexectomy and laparotomic total hysterectomy with partial peritonectomy. The histopathologic diagnosis was clear-cell ovarian carcinoma ; analysis of the BRCA1 and 2 mutation was negative. After surgery 6 cycles of chemotherapy with paclitaxel and carboplatin were administered and at a one-year-follow up there are no clinical or radiological signs of relapse. However, she presented a progressive decline in her cognitive performances with behavioral changes and, more recently, also in her motor abilities.The main clinical features of the three cases are reported in We report three patients with stroke as presenting symptom of hypereosinophilia from three different causes, two of them fulfilling the criteria for HES . The patThe anterior external border zone infarcts are more common than posterior ones because of the high prevalence of ICA disease. Indeed, posterior external border zones infarctions require vertebrobasilar disease with superimposed fetal-type PCA. Among internal border zones infarcts the most common location is on the lenticulostriate–MCA border zone, supplied by the end branches of deep perforating lenticulostriate arteries and medullary penetrators from the pial–MCA. The putative external and internal border zones are superimposed on axial brain MRI images in the The main pathophysiological hypothesis about border zone infarcts is the hemodynamic impairment downstream a severe arterial stenosis or occlusion with basal low perfusion pressure which made these regions more susceptible to ischemia and finally infarction. Another opposite view is that there is an association between border zone infarction and microemboli, supported by autoptic studies . One of Another relevant issue is that external and internal border zone infarcts may have a different pathogenesis, which may be inferred by neuroimaging appearance. As shown in Typically, border zone infarcts have a hemodynamic basis and occur in the context of severe stenosis of extracranial or intracranial arteries, or in systemic conditions that cause brain hypoperfusion such as severe hypotension and cardiac arrest ,13 but iIn conclusion, HES should be considered in the diagnostic work-up of ischemic stroke and the suspicion may be raised and supported by a neuroimaging pattern of lesions symmetrically involving the border zones, in the presence of a marked increase in eosinophils’ count. An extensive diagnostic work-up is hence necessary to establish the type of HES and the correct treatment which should be started promptly.


Preventive health care, delivered through well child care visits, serves as a universal and primary entry point for promoting child wellbeing, yet children with lower socioeconomic status and children of color receive less consistent and lower quality preventive health care. Currently, limited research exists comparing models for delivering preventive care to children and their impact on longstanding racial/ethnic and socioeconomic inequities.Practice-based research networks can help to advance health equity by more rapidly studying and scaling innovative, local models of care to reduce racial/ethnic and socioeconomic inequities in primary care and preventive care utilization. This paper outlines a framework of community engagement that can be utilized by practice-based research networks to advance health equity and details the application of the framework using the GROWBABY Research Network (GROup Wellness Visits for BABies and FamilY Research Network).The GROWBABY Research Network launched in 2020, engaged clinical practices utilizing this unique model of group well childcare - CenteringParenting® - with the following goals: to promote collaboration among researchers, clinicians, patients, and community members; facilitate practice-based research; and increase the use of shared assessment measures and protocols. As a research collaborative, the GROWBABY Research Network connects clinical partners facing similar challenges and creates opportunities to draw upon the assets and strengths of the collective to identify solutions to the barriers to research participation.Primary care, practice-based research networks like the GROWBABY Research Network that intentionally integrate community engagement principles and community-based participatory research methods can advance equitable health care systems and improve child wellbeing. What is already known? Practice-based research networks have had a strong history of collaboration at all stages of study development among practitioners, investigators, network administrators, and office staff independent of study topic and more recently an emerging inclusion of patients as research partners  can support research, innovation, and interventions to reduce racial/ethnic and socioeconomic inequities in primary care and preventive care utilization  launched in 2020 with the following goals: to promote collaboration among researchers, clinicians, patients, and community members; facilitate practice-based research; and increase the use of shared assessment measures and protocols. As a research collaborative, GROWBABY connects clinical partners facing similar challenges and creates opportunities to draw upon the assets and strengths of the collective to identify solutions to the barriers to research participation. GROWBABY operates as a community-based PBRN and is an initiative of the CRADLE  Lab, the research arm of the Vital Village Networks organization at Boston Medical Center which functions as GROWBABY’s backbone organization.Vital Village Networks’ mission is to develop community-based strategies to promote child wellbeing and advance health and educational equity through research, data sharing, and collective action. Developing networks and cross-sector collaborations where community residents co-lead and co-design is a central strategy. Vital Village Networks CRADLE Lab staff use a community-based participatory research approach and an equity-centered collective impact framework, incorporating process elements like a common agenda, continuous communication, and backbone organizational support, for meeting structure and operations to facilitate the development of the GROWBABY Research Network  and 4 Academic Centers). The Steering Committee meets monthly via Zoom to discuss GROWBABY initiatives and collaboratively develops shared agreements, such as Memorandums of Understanding, Data Sharing Agreements, and determines research priorities. The Steering Committee has met 16 times since the inception with additional, ad-hoc small group meetings. See Table Vital Village Networks’ CRADLE Lab, the backbone organization of GROWBABY, engages with dozens of childhood practitioners across the country who are working hard to meet the social and psychological needs of the families they serve, in addition to providing routine medical care. Frequently from under-resourced clinics or FQHCs, practitioners often work overtime to spearhead clinical programs that hold promise of improving breastfeeding rates, child neurodevelopment and language, and physical and mental health. Despite barriers to engagement in academic research and traditional funding streams  clinical sites have responded to immediate, localized needs and developed culturally sensitive interventions unique to their context and clinic. Community-based providers, Promotores, Community Health Workers and other providers are curating unique models of care and generating data and observing results firsthand. For instance, listening to patients’ stories encouraged a practitioner of Reading Children’s Health Center to tailor group care for opioid addiction and similarly, a facilitator of group care at BayClinic UM Baltimore Washington developed a model of group well childcare focused on maternal depression.The GROWBABY Research Network partners with these FQHCs to provide opportunities to participate in research not routinely offered to community-based clinics. FQHCs serve a greater proportion of low-income, uninsured, and publicly insured patients, yet FQHCs are frequently excluded from the research enterprise  to work collaboratively to bring about positive change and their capacity for problem solving  of which funders and researchers sometimes avoid given the complexities with linking data management systems with more dated or homegrown EMRs. However, current evidence collected in academic health services may not generalize to lower resource settings because of exclusion of low-income service settings and BIPOC  individuals from clinical trials (Hacker et al., Further, shared metrics across sites will facilitate a robust evaluation (Surbhi et al., A research network allows us to optimize our data collection pathways (Van Weel, 17 years to translate clinical research into routine practice (Westfall et al., Lastly, PBRNs will likely accelerate the generation of research results. The COVID-19 pandemic has dramatically increased poverty nationally and disproportionately among Black and Latino children, requiring us to think differently and act now. In the traditional academic paradigm, it takes If we want equitable health care systems that can meet the urgent needs of American families, ambitious change will be required. Prioritizing research networks, infrastructure, design and approaches that are participatory and center equity and improve measurement of community strengths and structural racism may unearth new solutions and evidence. True research partnerships with clinical stakeholders from under-resourced contexts and community members most impacted by inequities are not only ethical, but also enable the development of interventions and implementation strategies that are equitable and effective. Primary care-focused, PBRNs like the GROWBABY Research Network built on an explicit framework of community engagement can advance equitable health care systems and support child wellbeing.


Accessible planning tools tailored for low-and middle-income countries can assist decision makers in comparing implementation of different cervical cancer screening approaches and treatment delivery scenarios in settings with high cervical cancer burden.The Cervical Precancer Planning Tool (CPPT) was developed by PATH for users to explore and compare the accuracy of screening approaches, what treatment equipment to procure, and how best to deploy treatment equipment in a given country. The CPPT compares four screening approaches: 1) visual inspection with acetic acid (VIA), 2) HPV testing, 3) HPV testing followed by a VIA triage, and 4) HPV testing followed by an enhanced triage test. Accuracy of screening outcomes  is based on published sensitivity and specificity of tests to detect cervical precancerous lesions. The CPPT compares five scenarios for deploying ablative treatment equipment: 1) cervical precancer equipment at every location a woman is screened (single visit approach), 2) equipment only at a hospital level, 3) a single unit of equipment in each district, 4) allowing two districts to share a single unit of equipment, and 5) equipment placed at select district hospitals paired with mobile outreach. Users can customize the CPPT by adjusting pre-populated baseline values and assumptions, including population estimates, screening age range, screening frequency, HPV and HIV prevalence, supply costs, and health facility details.The CPPT generates data tables and graphs that compare the results of implementing each of the four screening and five treatment scenarios disaggregated by HIV status. Outputs include the number and outcomes of women screened, cost of each screening approach, provider time and cost saved by implementing self-sampling for HPV testing, number of women treated, treatment equipment needed by type, and the financial and economic costs for each equipment deployment scenario.The CPPT provides practical information and data to compare tradeoffs of patient access and screening accuracy as well as efficient utilization of equipment, skilled personnel, and financial resources. Country decision makers can use outputs from the CPPT to guide the scale-up of cervical cancer screening and treatment while optimizing limited resources. Cervical cancer is the fourth most common cancer affecting women worldwide and the second most common cause of cancer mortality in women under 50 years of age, resulting in an estimated 342,000 deaths worldwide in 2020 . Nearly Although 116 countries have implemented HPV vaccination for adolescents to some extent since it first became available in 2006 , supply,With the option to forgo a pelvic exam in favor of self-sampling, the advent of highly sensitive molecular-based DNA testing for HPV holds great promise to increase the effectiveness and reach of cervical cancer screening programs worldwide. The inclusion of a second sequential screening test, commonly referred to as a ‘triage test’, is one option to increase the specificity of a screening approach and identify women at highest risk of developing cervical cancer who require follow-up. WHO guidelines for screening and treatment of cervical precancerous lesions were updated in 2021 . The recLMICs face multiple complex decisions and considerations in transitioning from absent or opportunistic screening to adopting the guidelines and ambitious coverage targets from WHO. The predominant approach for cervical cancer screening in LMICs remains naked eye visual inspection with acetic acid (VIA)  because There is a need for accessible decision-making tools that LMICs can use to guide strategy decisions, clinical guidelines, policy, and operational plans to increase both the coverage of cervical cancer screening as well as program effectiveness in terms of identifying and delivering treatment to women with cervical precancer . In thisPATH’s website, along with a training video and fact sheet [The Cervical Precancer Planning Tool (CPPT) was developed by PATH for users to explore and assess what screening approaches are most appropriate, what treatment equipment to procure, and how best to deploy equipment in a given country. Key outputs are provided in terms of the number of women screened and treated in each scenario and the related costs. Target users of the CPPT include ministry of health (MOH) and other government officials, implementing partners from non-governmental organizations, and funders focused on improving quality and coverage of screening and treatment in LMICs. The CPPT was developed with input from MOHs and advisors from 21 countries across sub-Saharan Africa, Latin America, and Asia. The CPPT was developed using Microsoft Excel  to ensure maximum accessibility for target users. The CPPT is accessible in both English and Spanish languages for public download from ct sheet .The CPPT includes distinct screening and treatment modules that are linked. The country-level, annual, scenario-based tool contains adjustable baseline data for 14 countries in sub-Saharan Africa, Latin America, and Asia that were gathered from literature reviews, global databases , and primary data collection led by PATH to help define scenarios and vet inputs. The countries that have baseline data inputs in the model are El Salvador, Ethiopia, Ghana, Guatemala, Honduras, Kenya, Malawi, Myanmar, Nicaragua, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. In addition, any country can use the CPPT by inputting their own data. After the user reviews (or enters) the required baseline data in the screening module, the CPPT automatically calculates results for four different screening approaches. After further selections are made and data are input into the treatment module, the CPPT automatically calculates results for five different treatment approaches. The CPPT defines ‘cervical precancer’ as cervical intraepithelial neoplasia (CIN) grade 2 + . Examples of baseline data are summarized in Table The CPPT estimates the number of women screened and treated in each of the scenarios presented, which can be used as one element to calculate tradeoffs between scenarios. The CPPT utilizes population, demographic, and guideline information to calculate the total number of women that need screening in a country and distributes the total number of women screened equally across the number of years that a user inputs for the recommended screening frequency . The screening results are disaggregated by HIV status, since the prevalence of cervical precancer CIN2 +) and the recommended screening frequencies are different for those women with and without HIV . Figure  + and thThe CPPT treatment module focuses exclusively on women who are eligible for ablative cervical precancer treatment  that can be offered at a primary care level. Of the women who screen positive, 87.7% are estimated as being eligible for ablative treatment , and womThe outputs in the treatment module for each scenario include the total number of women to be treated with ablative procedures, along with the number of units of treatment equipment needed by type and the corresponding equipment utilization rates. The CPPT calculates the number of women indicated for ablative treatment by multiplying the total number of women indicated for treatment  by the expected treatment completion rate. The CPPT varies treatment completion rates between 50–90% based on the estimated distance a woman would need to travel after screening to obtain the necessary treatment Table . EquipmeIn addition to estimating the number of women screened and treated in each scenario, the CPPT includes cost as an output for each scenario. In the screening module, the CPPT calculates annual financial costs, including capital equipment and test supplies, for each of the four screening approaches based on the number of units of capital equipment and test supplies needed to screen the women, the price of each test supply, and the expected lifespan of capital equipment. The upfront cost of capital equipment is distributed equally across the lifespan of the equipment. In addition, the CPPT calculates annual economic costs, including health care worker and lab technician costs, based on the provider and lab technician time spent for each patient, their respective annual salaries, and total number of women screened in a country per year. Provider time for screening includes the time it takes to register the woman, prepare for and perform a pelvic examination, collect the sample, and counsel the woman. The lab technician time includes the time it takes to prepare, run, and analyze each specimen. Lastly, the CPPT calculates cost savings and provider time saved related to self-collection for HPV screening approaches, which eliminates the need for a provider to conduct a pelvic exam and collect the sample. Costs to the patient and provider training are excluded from the tool. Baseline costing data in the model, much of which is adjustable by the user, comes from the UNICEF supply catalogue (supplies) , the WHOLike the screening module, the treatment module contains health system financial costs and economic costs but excludes patient costs. Capital equipment costs are distributed equally over the five-year lifespan of the equipment, meaning that one-fifth of the equipment costs is captured for the total cost per year. Gas costs are also included as a financial cost if gas cryotherapy is used to treat women. Provider time costs include the time to register the woman, prepare the room, conduct the treatment, and counsel the woman.Here, we present select outputs from the CPPT, using Uganda as an example. These outputs can be replicated by downloading the CPPT and selecting ‘Uganda’ on the Screening Inputs tab, using all provided baseline values, and then selecting ‘HPV + VIA triage’ as the screening method on the Treatment Inputs tab.Figure Selecting cervical cancer screening and treatment approaches for a given country inherently requires countries to carefully weigh the benefits and consequences of each option and evaluate these tradeoffs within the context of their specific country context, such as cervical cancer burden, geography, budget, and health system capacity. Table The CPPT estimates 13,559 women will screen positive per year in Uganda when a ‘HPV + VIA’ screening approach is implemented, of which 11,891 women per year will be indicated for ablative treatment. Table Table Approaches to secondary prevention of cervical cancer are actively evolving, bolstered by the WHO call for elimination, expanding options for HPV assays, emerging alternative technologies for screening, and a resurgence in the use of and normative guidance for thermal ablation. The CPPT is an accessible and user-friendly tool that can aid LMICs in their planning, decision making, and budgeting to expand screening coverage and increase effectiveness to deliver treatment to women with cervical precancer. The four screening approaches and five treatment scenarios were selected based on a combination of current guidelines, common screening and treatment practices in LMICs, and knowledge of emerging technologies for cervical cancer detection and treatment available at the time the CPPT was developed.Because VIA does not require specialized equipment or laboratory infrastructure, this approach has the lowest capital cost and is the most straightforward to scale-up in low resource settings. However, the highly subjective nature of the approach results in inconsistent performance across providers and settings, thereby limiting the population-level effectiveness of VIA-based screening programs even when high coverage is achieved in a given country. A cluster-randomized controlled trial of 52 primary health care centers in India comparing both HPV and VIA approaches to no screening intervention found that a single round of HPV-based screening resulted in a 53% reduction in the incidence of advanced cervical cancer and 48% reduction in death after 8 years, whereas no statistically significant benefit was detected in the VIA group , 20. A rCountries must evaluate and select one or more screening approaches that reflect both their population needs and health system capacity. When implemented as HPV tests using self-sampling, the WHO target of twice-per-lifetime screening requires minimal provider time and could be implemented with innovative outreach approaches outside of fixed health facilities. Based on average HPV prevalence among HIV uninfected women targeted for screening, approximately 12% of women  will reqIn recognition of the differences in HPV prevalence, cervical cancer risk, and recommended screening intervals among WLWH, the CPPT disaggregates results in the screening approaches by HIV status. With high sensitivity but low specificity for CIN2 + , the implementation of HPV testing alone among WLWH, for whom HPV prevalence can be 50% or higher , 29, canThe fourth screening approach (‘HPV + enhanced triage’) was included to leave a placeholder for novel approaches that are still under development or evaluation, especially triage tests that can further identify HPV positive women with the highest risk of developing cervical precancer and/or cancer.Extended HPV genotyping, viral and host methylation of specific genes, dual staining for p16/Ki67, and detection of viral oncoproteins E6/E7 are examples of promising approaches to further identify HPV positive women at highest risk of cervical cancer , 32. An The overall effectiveness of a country’s efforts on secondary prevention of cervical cancer depends both on accurate identification of women at risk of cervical cancer and then successful linkage to and completion of treatment. The 2019 WHO Guidelines for the Use of Thermal Ablation for Cervical Pre-Cancer Lesions recommend thermal ablation as a treatment alternative to cryotherapy for both HIV infected and HIV uninfected women . In addiSeveral resources are available to countries as they embark on revising clinical guidelines, adapting health systems, and planning budgets to improve cervical cancer screening and treatment, including the Cervical Precancer Planning Tool (CPPT) presented here, Improving Data for Decision Making in Global Cervical Cancer Programmes (IDCCP) Toolkit and the Cervical Cancer Prevention and Control Costing (C4P) Tool, and cost-effectiveness analyses. Table The IDCCP Toolkit was developed by WHO and a consortium of partners with the goal of developing global standards, tools, and guidance for improving the availability and use of high-quality data for decision-making in cervical cancer programs in LMICs. Published in 2018, the IDCCP includes five sections, four of which provide guidance and tools that countries can adapt independently to gather information on data systems and implement new data collection for monitoring and evaluation of cervical cancer prevention programs: 1) Rapid situational assessment of data and data systems, 2) Population-based survey modules, 3) Patient and program monitoring, and 4) Facility-based surveys. The fifth section, “Prevention and control costing: analysis and planning module for screening and treatment”, introduces the country decision makers to the WHO Cervical Cancer Prevention and Control Costing (C4P) Tool . The C4PIncreasingly, comparative modeling and health economic analyses are conducted to guide decision making, priority setting, and resource allocation for health care systems. Cost-effectiveness analyses (CEA) estimate both the costs and health gains of a given intervention, relative to an alternative intervention, by estimating how much it costs to gain a unit of a health outcome . Therefore, CEA can be a key resource for LMICs where financial resources are limited and the benefits of health interventions and approaches for prevention and treatment need to be maximized, such as adopting new approaches for improving screening and treatment for cervical cancer. Given the level of expertise required, cost-effectiveness analyses are most often conducted by specialized academic teams funded through research grants. These analyses take considerable time and dedicated funding, especially when country-specific data collection is needed to parameterize the model and include sensitivity analyses to evaluate assumptions. There is considerable variability in the rigor of cost-effectiveness studies, although the recently published HPV-FRAME  issued aAchieving 70% coverage of cervical cancer screening and 90% treatment for screen positive women are ambitious goals set by the WHO, but progress can be achieved when guided by evidence-based decisions and concrete action steps. Advances in normative guidelines and planning tools, such as the CPPT, can aid decision makers and program planners as they develop new cervical cancer control strategies that harness the most effective screening and treatment technologies and implementation approaches for their country’s needs.


School bullying and cyberbullying victimization and perpetration are prevalent in adolescents with autism spectrum disorder (AASD). However, the levels of adolescent–caregiver agreement regarding the bullying involvement of AASD and the factors associated with these levels remain to be evaluated. In the present study, we evaluated the levels of adolescent–caregiver agreement on the school bullying and cyberbullying involvement experiences of AASD and the factors associated with the levels of agreement. This study included 219 dyads of AASD and their caregivers. The school bullying and cyberbullying involvement experiences of the participating AASD were assessed using the School Bullying Experience Questionnaire and the Cyberbullying Experiences Questionnaire, respectively. Attention-deficit/hyperactivity disorder, oppositional defiant disorder (ODD), depressive and anxiety symptoms, and autistic social impairment were also assessed. AASD and their caregivers had poor to fair levels of agreement regarding the school bullying and cyberbullying victimization and perpetration experiences of AASD. Severe inattention, hyperactivity–impulsivity, ODD, depressive and anxiety symptoms, and autistic social impairment were associated with high levels of adolescent–caregiver agreement. When assessing the bullying involvement experiences of AASD, mental health professionals should obtain information from multiple sources. In addition, the factors influencing the levels of agreement should be considered. School bullying victimization and perpetration are prevalent in adolescents with autism spectrum disorder (AASD). A meta-analysis of the results of 34 studies on students with autism spectrum disorder (ASD) found that the pooled prevalence estimates for victimization, perpetration, and perpetration–victimization were 67%, 29%, and 14%, respectively; the risk of victimization in students with ASD was significantly higher than that in typically developing students and students with other disabilities [Cross-sectional studies have revealed that bullying victimization is strongly associated with internalizing  and externalizing  mental health problems ,5,6; furSevere autism symptoms increase the risk of bullying involvement in individuals with ASD . ImpaireMental health professionals may require information provided by caregivers of AASD to assess the bullying experiences of AASD in clinical and counselling settings. However, the level of agreement between the information provided by AASD and that provided by their caregivers regarding their bullying victimization and perpetration experiences warrants further research. In one study, adolescents with typical development and their mothers exhibited fair to moderate levels of agreement regarding their school bullying involvement experiences; by contrast, no strong agreement regarding bullying involvement and its social effects was noted between AASD and their mothers . To the Few studies have explored the factors influencing the levels of adolescent–caregiver agreement regarding the school bullying and cyberbullying involvement experiences of AASD. Older aged adolescents and girls as well as more severe ASD symptoms, social skill deficits, attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), depression, and anxiety are strongly associated with a higher likelihood of school bullying involvement in AASD ,7,15,16 The present study evaluated the levels of adolescent–caregiver agreement regarding the school bullying and cyberbullying involvement experiences of AASD and the factors associated with these levels. We hypothesized that AASD and their caregivers would have low levels of agreement. We further hypothesized that factors such as adolescent demographics, ADHD, ODD, depressive and anxiety symptoms, and autistic social impairment would be associated with the level of adolescent–caregiver agreement regarding the bullying involvement of AASD.Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision [AASD and their caregivers were enrolled from the outpatient clinics of three hospitals providing clinical services for children and adolescents with mental health problems in Taiwan between November 2010 and October 2012. The inclusion criteria for AASD included an age of 11–18 years and a diagnosis of ASD by a board-certified child psychiatrist based on the criteria outlined in the Revision . AASD winever) to 3 . Higher total scores on the first and final eight items of the questionnaire indicate more severe school bullying victimization and perpetration, respectively. The cyberbullying victimization and perpetration experiences of the participating AASD within the preceding month were assessed using the 6-item Cyberbullying Experiences Questionnaire (CEQ) [never) to 3 . Higher total scores on the first and final three items of the questionnaire indicate more severe cyberbullying victimization and perpetration, respectively. The validity and reliability of the SBEQ and CEQ in Taiwan are satisfactory [The school bullying victimization and perpetration experiences of the participating AASD within the preceding month were assessed using the Chinese version of the 16-item School Bullying Experience Questionnaire (SBEQ) ,26. The re (CEQ) . The CEQsfactory . In thisnever) to 4 . Higher total scores indicate higher levels of autistic social impairment in the dimensions of social communication, manneristic behaviors, social awareness, and social emotion. The validity and reliability of the SRS, including its Taiwanese version, are satisfactory [The participating caregivers rated the severity of autistic social impairment in the care recipients using the Taiwanese version of the 60-item Social Responsiveness Scale (SRS) ,29. Eachsfactory ,29.not at all) to 3 (very much). Higher total scores for the subscales indicate higher severity levels of caregiver-reported inattention, hyperactivity–impulsivity, and ODD. The validity and reliability of the SNAP-IV, including its Taiwanese version, are satisfactory [The participating caregivers rated the inattention, hyperactivity–impulsivity, and ODD symptoms observed in the care recipients within the preceding month. These symptoms were assessed using the Chinese version of the 26-item Swanson, Nolan, and Pelham Scale version IV (SNAP-IV) ,31, whersfactory ,31.The participating AASD self-reported the depressive symptoms that they had experienced within the preceding month using the Taiwanese version of the 27-item Children’s Depression Inventory (CDI) ,33, whernever true about me) to 3 (often true about me). Higher total scores indicate higher severity of anxiety symptoms. The validity and reliability of the MASC, including its Taiwan version, are satisfactory [The participating AASD self-reported the anxiety symptoms that they had experienced within the preceding month using the Taiwanese version of the 39-item Multidimensional Anxiety Scale for Children (MASC) ,35, whersfactory ,35.Data regarding sex were expressed in number and percentage values, and data regarding age, school bullying and cyberbullying involvement, ADHD, ODD, depressive and anxiety symptoms, and autistic social impairment were expressed in mean and standard deviation values. Using intraclass correlation (ICC) we evaluated the levels of agreement between AASD- and caregiver-reported information regarding the school bullying and cyberbullying victimization and perpetration experiences of AASD. According to Cicchetti , ICC valz test statistics and their corresponding p values. Because multiple comparisons were conducted, a p value of < 0.00625 (0.05/8) was regarded as significant.We further examined the factors associated with the levels of adolescent–caregiver agreement in multiple groups of AASD. We categorized the participating AASD according to their demographics, ADHD, ODD, depressive and anxiety symptoms, and autistic social impairment. For continuous variables, the median score was used to divide the AASD into low- and high-scoring groups. Then, the differences between the groups  in terms of the ICC were investigated. Fisher’s transformation was used to convert the sampling distributions of the ICCs and their differences into a normal distribution . Next, wThis study analyzed 219 dyads of AASD and their caregivers. In the present study, the AASD and their caregivers exhibited poor to fair levels of agreement regarding the school bullying and cyberbullying victimization and perpetration experiences of the AASD. Severe inattention, hyperactivity–impulsivity, ODD, depressive and anxiety symptoms, and autistic social impairment were all associated with high levels of adolescent–caregiver agreement regarding multiple types of bullying involvement.Poor to fair levels of adolescent–caregiver agreement regarding the bullying involvement experiences of AASD indicated that the AASD and their caregivers differentially observed and interpreted interactions between AASD and peers in schools and the cyberspace. This result might be explained based on the characteristics of AASD and their caregivers. On the part of AASD, core ASD deficits, such as impaired intention attribution and ToM performance, may limit the ability of AASD to comprehend others’ behavioral intentions and thus, may increase the likelihood of misinterpretation. In one study, van Roekel et al.  indicateOn the part of caregivers, caregivers are not usually at the scene of school bullying or cyberbullying; thus, they are often not aware of bullying incidents at the time; this element is particularly true for the caregivers who rarely communicate with the teachers of their care recipients. Studies have found that there were discrepancies for externalizing and internalizing symptoms  and ASD Positive associations were observed in the present study between severe inattention, hyperactivity–impulsivity, ODD, depressive and anxiety symptoms, and autistic social impairment and high levels of adolescent–caregiver agreement regarding multiple types of bullying involvement. These findings may be explained by the fact that caregivers of AASD with ADHD, ODD, emotional problems, or autistic social impairment may put greater effort into monitoring the daily activities, behaviors, and peer interactions of these adolescents than the caregivers of AASD without behavioral, emotional, or social interaction problems. A meta-analysis of 75 studies revealed that individuals with ASD showed multiple dimensions of social cognitive dysfunctions, such as ToM performance and emotion perception and processing . Social Bullying involvement can result in AASDs mental health problems. Reliable information sources help develop intervention programs for bullying involvement in AASD. Based on the results of this study, we proposed several suggestions for enhancing caregivers’ and AASDs reports on bullying involvement. First, to comprehensively assess the bullying involvement of AASD, mental health and educational professionals should consider information provided by both AASD and their caregivers. Second, because caregivers play a vital role in reducing the likelihood of bullying involvement for AASD, mental health and educational professionals should encourage caregivers to increase knowledge about school bullying and cyberbullying involvement. Third, caregivers should develop communication patterns with AASD and spend time on discussing about their school lives and peer interaction to early detect the likelihood of bullying involvement in their care recipients, even in those without severe behavioral, emotional, or social interaction problems. Fourth, because problem solving between caregivers and teachers is critical to maximizing AASD outcomes , enhanciThis study had some limitations. First, we did not collect the relevant data from the teachers and peers of the participating AASD; thus, whether the AASD and caregivers had misreported bullying involvement could not be investigated. Second, we excluded AASD with comorbid intellectual disabilities or major psychiatric disorders even though intellectual disabilities increase the risk of bullying victimization . Thus, tWe observed poor to fair levels of adolescent–caregiver agreement regarding the school bullying and cyberbullying involvement experiences of AASD. Mental health professionals should obtain information from multiple sources when assessing the bullying involvement experiences of AASD. ADHD, ODD, depressive and anxiety symptoms, and autistic social impairment were found to be associated with the levels of adolescent–caregiver agreement regarding bullying involvement. Mental health professionals should consider these factors when assessing the bullying involvement of AASD and developing the relevant interventions to help AASD and their caregivers manage bullying involvement.


Makerere University College of Health Sciences has been collaborating with the Uganda Heart Institute to build capacity for research, training and clinical care in cardiovascular medicine for the last 34 years to appropriately respond to rising societal needs for advanced cardiovascular care which was lacking before this period.To describe the major milestones in the MakCHS-UHI cardiovascular training collaboration and chart way for future collaborations.This short communication highlights some of the salient features and important milestones in the collaboration journey of the two institutions.Clinical centres of excellence in specialised fields of health care, such as the Uganda Heart Institute for Cardiology, provide a conducive academic environment for MakCHS clinical scientists to provide high quality evidence-based care to meet societal needs. The Uganda Heart Institute (UHI) was established jointly by Makerere University, the Uganda Heart Foundation, Mulago Hospital and Ministry of health over 30 years ago to provide cardiovascular care, training and research. Right from its inception, the UHI has been collaborating with Makerere University through training by providing a teaching site for Makerere University undergraduate and postgraduate students. Most UHI faculty trained at Makerere University medical school, now called Makerere University College of Health Sciences (MakCHS), and are trainers for programs at MakCHS as clinicians, supervisors of graduate research and investigators on collaborative research projects. Makerere University faculty with super-specialised training in cardiovascular sciences participate in training of fellows at the UHI.The UHI has a 10-year-old cardiovascular sciences training program where doctors completing their masters level training in internal medicine, paediatrics, surgery, anaesthesia and critical care are invited to join a three-year fellowship in adult cardiology, paediatric cardiology, adult cardiac surgery, paediatric cardiac surgery or cardiac anaesthesia and critical care. Two fellows per program are competitively selected annually resulting in eight fellows/year and 24 at any one time.The UHI has seven main clinical departments of adult cardiology, paediatric cardiology, adult cardiac surgery, paediatric cardiac surgery, cardiac anaesthesia and critical care and cardiac nursing. These departments are supported by an accredited clinical laboratory, pharmacy, radiology and a nutrition and cardiac prevention unit. As Uganda's only tertiary center for cardiovascular disease, UHI sees >20,000 outpatients and admits >5000 inpatients each year and performs >15,000 echocardiograms and >20,000 electrocardiograms annually. UHI also has one of the only functional public cardiac catheterization laboratories in Uganda, performing over 1000 diagnostic and therapeutic procedures a year, as well as a busy open-heart surgical program, performing over 500 cases each year. UHI also offers short term courses in cardiac diagnostics to doctors and physicians around the country. All courses at UHI are accredited by the Uganda Medical and Dental Practitioners Council (UMDPC). Through its different programs, the UHI has over 30 faculty involved in the daily management of patients with cardiovascular diseases as well as teaching and supervision of research. Impact of academic research at MakCHS and UHIPhysicians from Makerere University College of Health Sciences (MakCHS) and UHI have been collaborating for over a decade to conduct world-class research on cardiovascular diseases. From inception, this research partnership has included an intentional mentoring component, with early career investigators included on nearly 100% of publicationsMakerere University has hosted several research training grants over the last 15 years which has resulted in further development of UHI faculty. The most recent grant has been the Training Health Researchers into Vocational Excellence (THRiVE) consortium which was established in 2009 as a regional network of research excellence partnering with some of the best universities and research institutes in East Africa together with Cambridge University and London School of Hygiene and Tropical Medicine both in UK. THRiVE resulted in over 450 publications and 57 masters research fellows, 31 PhDs, 19 postdocs (including UHI faculty).NURTURE was the other prominent grant that supported development of UHI faculty. NURTURE aimed to develop a sustainable culture for supporting research training and mentoring for career development of upcoming faculty fostering continuous professional development and retention of independent researchers. In total, 70 junior and mid-level faculty at MakCHS and affiliated institutions were supported to carry out research in various non-communicable diseases (NCD) including Cardiovascular-diseases (CVD). Many junior and senior level UHI faculty were supported through this grant.4Through these collaborative capacity building grants, the UHI and indeed Uganda has become a world leader in rheumatic heart disease (RHD) research, providing much needed data and evidence on RHD epidemiology, pathogenesis and new treatment approaches. This knowledge has resulted in improved diagnostic capacity of the health care workers and better outcomes of patients with RHD over time.Other training partnerships between MakCHS and UHI have included the NIH funded Medical Education Partnership Initiative (MEPI) CVD linked award. Senior faculty at the UHI and several mid-level faculty were beneficiaries of this training collaboration for their doctoral and masters level studiesClinical centres of excellence in specialised fields of health care, such as the Uganda Heart Institute for Cardiovascular medicine, provide a conducive academic environment for MakCHS clinical scientists to provide high quality evidence-based care to meet societal needs.The MakCHS-UHI collaboration will continue to build capacity in cardiovascular medicine while providing a platform that can be benchmarked by other yet to be developed specialty areas.


In line with the Sustainable Development Goals (SDGs), the reduction of the under-5 mortality rate to ≤25 deaths per 1000 live births by 2030 is the primary target of Myanmar’s national strategic plan for newborn and child health  was late). Even during the COVID-19 pandemic in 2020, vaccination coverage for tuberculosis, diphtheria, tetanus, pertussis, hepatitis B, measles, rubella, and polio was greater than 80%; the target coverage rate of 88% for 3 doses of the pentavalent vaccine  and oral polio vaccine (OPV) was reached successfully  by crises related to the military coup ,7. Poor Overall declines in vaccine coverage in Myanmar not only impart health risks to children who cannot access immunizations. but also threaten the health of their communities. A key component of preventing disease outbreaks is the achievement of herd immunity . DespiteThe administrative responsibility of EPI is shared by multiple stakeholders, including the Ministry of Health, UNICEF, WHO, Gavi, the Vaccine Alliance and the implementing partners . Han et Urgent and sustainable action is required to prevent children from dying from VPDs before outbreaks are too advanced to control and spill over into surrounding nations. First, we reiterate our call to the Myanmar military to 1) immediately stop all forms of violence against civilians, including against health care workers and health infrastructure, 2) allow health services to resume throughout the country, including in IDP camps, 3) ensure safe and unimpeded access for international and local aid organizations to provide health and humanitarian assistance to IDPs, and 4) cooperate with multiple stakeholders to provide equitable access to health services (including childhood immunization) for all people in Myanmar, especially those in IDP camps who can only be reached by ethnic and community-based organizations or non-governmental and UN entities. We firmly call on UN organizations and the global community to ensure the full implementation of UN Security Council Resolution 2286, which strongly condemns attacks on health care personnel in conflict situations , and to


Introduction: Vietnamese nail salon technicians are continuously exposed to neurotoxins linked to cognitive impairments and Alzheimer’s disease. This study examined the association of occupational exposure with cognitive function and depressive symptoms among Vietnamese nail salon technicians. Methods: The sample included 155 current or former Vietnamese female nail technicians and 145 control group participants. Measures included the Montreal Cognitive Assessment (MoCA) and the Center for Epidemiologic Studies Depression Scale (CES-D). Results: Average cognitive functioning was significantly higher for the control compared to the nail technician group . No differences were observed for depression. Multivariate findings revealed that exposure was negatively associated with cognitive functioning . Discussion: Nail salon work and the extent of occupational exposure were associated with lower cognitive functioning among Vietnamese nail technicians. Longitudinal research can further examine the risk for cognitive decline and dementia for this vulnerable population. Occupational exposure to commonly used chemical substances in nail products, including organic solvents , plasticizers, resins, and acids, can pose significant risks for cognitive impairment . Many ofDespite growing evidence of the direct association between toxic chemical exposure and adverse health effects , the relThe majority of research on neurotoxin exposure has been oriented towards industrial workplaces that routinely use hazardous chemicals and solvents: workplaces such as dental offices , electroDespite the potential health and cognitive risks of nail salon work, relatively little is known regarding the occupational risks among Vietnamese women nail technicians who comprise a significant majority of the nail-care industry workforce. Past research has found that the incidence of dementia differs by race and ethnicity  and thatThe current study adds to existing research by examining the association of nail salon occupational exposure with cognitive impairment and depressive symptoms in a vulnerable immigrant and refugee population. More specifically, we examined the association of neurotoxin exposure with cognitive impairment and depressive symptoms among two groups of Vietnamese women in Northern California: the nail technician group (NT group) and a demographically similar control group. We hypothesized that Vietnamese nail technicians would experience lower cognitive functioning and higher levels of depressive symptoms compared to a control group. This study addresses a critical gap in knowledge for a vulnerable population and provides further evidence for the link between neurotoxin exposure in nail salons and the potential risk of cognitive decline and Alzheimer’s disease.n = 155) and a control group (n = 145) who will be an approximate match with the NT group on demographic and acculturation variables.The sample consisted of Vietnamese female participants aged 40 or above: a nail technician (NT) group  and (blinded for review) in Northern California. Adopting practices from community-based research frameworks, we identified and received support from community liaisons through partnering organizations who are, or have been, nail technicians themselves or have family members working in the industry. Recruitment efforts included public announcements on popular Vietnamese-specific ethnic radio stations to help increase the study sample. In addition, the research team approached community-based organizations and coordinators for suggestions of possible participants, gathering a list of potential participants and their contact information. The research team contacted potential participants via phone stating the research’s purpose and obtained participants’ permission for further communication. The research team agreed to meet with participants at an appropriate location that was convenient and comfortable for participants to formally provide informed consent and share information relevant to the study. Recruitment at nail salons involved the research team first approaching the nail salon owners and explaining the objectives of this study to improve workers’ health. With their permission, the staff then approached workers for recruitment and data collection into the study. The final sample included 300 participants, with 155 who were current or former nail salon workers and 145 who did not work in nail salons. IRB approval was sought and obtained through the PI’s institution, and the review board approved the study after a careful review of the ethical considerations of the research.Occupational exposure: Self-reported workplace size , adequacy of ventilation , years of employment, and the number of hours of work per week. LoSasso et al. and Tabachinick et al. used similar proxies to estimate exposure to neurotoxicants and found a direct association between these variables and performance on neurobehavioral tests [Demographics: Age, education, marriage status, and occupational status. Acculturation: English proficiency.al tests ,17,27. DCognitive functioning: The Montreal Cognitive Assessment (MoCA) is a commonly used 12-item cognitive screening instrument tool (scores range between 0 and 30 with higher scores indicating better cognitive functioning) that assesses short-term memory, visuospatial construction, executive functions, attention, concentration, language, and temporal and spatial orientation [entation . The insentation . Depressentation . The scaentation .2 test (or Fisher exact test) was used for categorical variables. Toxin exposure among nail salon workers was described by reporting the means (standard deviations) and counts (proportions). Multiple linear regression analysis was used to further evaluate the association between the outcomes and factors, where the primary interest was the association between the outcomes and exposure indices. The exposure index is defined as the product of years working in the current nail salon  and nail-related working hours per week. For non-nail workers, the exposure index is zero. Covariates included age, education, the status of living alone or not, and the ability to speak English. Diagnostic plots were examined, and no nonlinear patterns were noticed. Sensitivity analysis was also performed using the Huber–White robust standard error estimator in linear regression for potential heterogeneous variances. Based on the fitted regression, marginal predictive MoCAs  were predicted at different values of the exposure index, averaging across other factors. Additional sensitivity analyses using linear regressions were performed in the subgroups of nail salon workers and current full-time nail salon workers, respectively.The primary outcome is the MoCA test score, and the secondary outcome is the CES-D depression scale. The primary interest lies in the association between the MoCA score and neurotoxin exposure. Characteristics of participants (demographic characteristics and outcomes) were summarized and compared between non-nail salon workers and nail salon workers. The Wilcoxon test was used to compare continuous and ordinal variables, and the χp < 0.05 was used to determine statistical significance.There were 31 participants (10%) with missing values , and these participants were excluded in the regression analysis. Sensitivity analysis was performed for linear regression based on multiple imputations for missing values using MICE (multiple imputations chained equations) under a missing-at-random assumption . Data wep = 0.017). Similarly, the education-adjusted MoCA score was significantly higher for non-nail salon workers (control group) and nail salon workers (p = 0.021). However, there is no significant difference between the two groups on the average CES-D  (p = 0.22). Of the 300 participants, there were 155 nail salon workers and 145 participants who had not worked as nail salon workers. Of the 155 nail salon workers who participated in the study, p = 0.017). That is, with an increase of 100 in the exposure index , the MoCA score is expected to decrease by 0.29. Higher education was also significantly associated with a higher MoCA score. Living alone, the ability to speak English and age were not significantly associated with MoCA scores after an adjustment by other demographic and acculturation factors. To our knowledge, this study is the first to examine nail salon exposure as a risk factor for poor cognitive functioning and depression among Vietnamese. Findings from this study indicated that working as a nail salon technician was associated with lower cognitive functioning among middle-aged Vietnamese women, as measured by the MoCA. In addition, the extent of exposure to environmental hazards, as measured by the number of years of work in a nail salon and the hours worked per week, was associated with lower cognitive functioning, even when controlling for demographic and acculturation factors. While our study did not directly measure neurotoxin exposure, our findings are consistent with past research indicating the risk of cognitive impairment from long-term exposure to neurotoxins in occupations, such as dental technicians and carpet layers ,2,3,9,13The lack of association between depressive symptoms and nail salon workplace exposure is discrepant with a number of prior studies ,11,12. AAlthough this study has many important strengths, there are several limitations. The study used purposive, snowball sampling specifically in Northern California, and the generalizability of the study results to the larger population of Vietnamese women nail technicians in the US may need further consideration. Another limitation is that the analyses did not account for the potential clustering effects  due to unavailable information about cluster identification within neighborhoods. In addition, our study design is cross-sectional in nature, which limits conclusive determinations in the directionality of occupational exposure and cognitive functioning. More in-depth analysis regarding the association of nail salon work and loss in specific dimensions of cognition functioning, such as memory, attention, and executive functioning, can provide further insights. However, our findings are consistent with past research which has suggested that the frequency and degree of exposure to neurotoxins, such as phthalates and other semivolatile organic compounds, may contribute to greater risk . AlthougDespite these limitations, our study provided important and novel insights into the relationship between occupational exposure, nail salon work, and cognitive functioning among a vulnerable immigrant refugee population. Future longitudinal research can examine exposure to specific neurotoxins in the workplace and the risk of cognitive decline, which would confirm and extend our findings. This study highlights the need for future consideration of community-based, targeted strategies to prevent occupational exposure to toxins for Vietnamese women employed in the nail-care workplace environment. Geriatricians and other providers who work with this population can conduct more comprehensive screening for cognitive changes that may be related to workplace environmental hazards. Public policy can advocate for better protective equipment and ventilation in these types of workplace settings. Public service announcements that are targeted to Vietnamese communities can increase awareness of the long-term effects of neurotoxins associated with nail salon work.This study provided findings on the relationship between nail salon work, cognitive functioning, and symptoms of depression among a sample of community-dwelling Vietnamese women living in Northern California. Our findings are consistent with past research indicating the risk of cognitive impairment in occupations from long-term exposure to neurotoxins and provide insight into the risks from exposure for Vietnamese women who are over-represented in the nail salon industry. Nail salon work has provided a source of income for many Vietnamese who identify as refugees, as a way to support one’s family that provided flexibility and had relatively low start-up costs, even for those with little to no formal education. As involuntary migrants who escaped persecution, nail salon work is a means of survival that requires no prior training and can be performed with little English ability. Our findings indicated that Vietnamese women who worked in the nail salon industry may experience risks in their cognitive functioning, although these results should be taken with caution because we did not control for factors that were not included in this study, such as levels of neurotoxins and possible exposure in other settings. Further research is needed to investigate the relationship between acculturation and exposure to neurotoxins through data collection on biomarkers, cognitive functioning, and mental health for this understudied and underserved population.


This study proposes a new practical approach for tracking institutional changes in research teamwork and productivity using commonly available institutional electronic databases such as eCV and grant management systems. We tested several definitions of interdisciplinary collaborations based on number of collaborations and their fields of discipline. We demonstrated that the extent of interdisciplinary collaboration varies significantly by academic unit, faculty appointment and seniority. Interdisciplinary grants constitute 24% of all grants but the trend has significantly increased over the last five years. Departments with more interdisciplinary grants receive more research funding. More research is needed to improve efficiency of interdisciplinary collaborations. Over the past two decades, interest and investments in large-scale interdisciplinary team projects have grown dramatically, evident by the steep growth in interdisciplinary publications, journals, requests for proposals by public agencies and foundations, and research collaborations ,2. The iWe define teamwork as the set of behaviors by two or more interdependent individuals as a function of coordinating requirements imposed by independent tasks in achieving common goals . Better,While several validated measures of team performance are based on direct observation of team activities, these measures are not practical (take a long time to collect data and require large staff and budget) for the assessment of large numbers of teams , especially research teams in post-COVID times that function asynchronously across several settings . EvaluatThis study proposes a pragmatic approach for tracking institutional changes in research teamwork and productivity in real time using common institutional electronic databases such as eCV and grant management systems. Broad national dissemination of this approach across other CTSA hubs could provide a standard metric for comparing teamwork productivity across different programs and academic units, facilitate our ability to assess effectiveness of various team-training activities, and improve quality and value in interdisciplinary research. Implementation of best practices in interdisciplinary team science and strong collaborations with communities, special populations, patients, and stakeholders will enable high-impact, innovative research to improve the health of our communities and nation.Data on faculty publications were obtained from the institutional eCV online Faculty Profile system from 2018 to 2021. Faculty profiles were created to allow faculty and clinical providers to specify their Curriculum Vitae (CV) information in one electronic location so that the information could be collected for many purposes including NIH Biosketches and institutional annual reports. Data on faculty grants were obtained from the institutional grant management system CLICK from 2015 to 2020. The CLICK Portal software integrates all aspects of grants management into a single system, including Institutional Review Board approvals, animal studies, grant management, financial conflict of interest, research agreements, and safety. The database included information on the proposal number, grant PI, co-Is, credited departments and percent effort, submission status , proposal state (funded or not), project sponsors, submission date and title, as well as the award amount.Using the institutional eCV database (n = 1300) available at three health sciences schools, we selected a purposeful (diverse) sample of clinical, basic science, and translational science departments that included departments of Biochemistry and Medicine (School of Medicine), Pharmaceutical Sciences (School of Pharmacy), and Oral Biology and Community and Pediatric Dentistry (School of Dentistry) (n = 340). In the department of Medicine, faculty were further divided into divisions. We excluded individuals who did not have a faculty appointment (postdocs or instructors) and who had less than 5 publications in the last 3 years to allow for an accurate assessment of faculty teamwork. These cutoffs were set to optimize faculty inclusion/exclusion criteria, institutional generalizability, and statistical stability. The research team agreed that a researcher’s pattern of collaboration could be defined with reasonable validity based on their random set of 5 publications. While more data (more publications over longer period of time) are more desirable for statistical power, excluding faculty with fewer publications over shorter period of time would bias the sample against junior and newly hired faculty. A similar approach is used for clinical quality assessment .By the type of appointment, the faculty were categorized as tenure track vs nontenure track/clinical. After excluding nonfaculty appointments, faculty with less than five publications on Web of Science, and individuals with missing information on appointment status, the final analytic sample included n = 187 faculty.To quantify each faculty propensity for interdisciplinary research, we collected data from the five most recent peer-reviewed publications per faculty member identified from the Web of Science Core Collection. We recorded the publication’s number of authors, number of unique organizations they represent, and the number of unique fields of expertise  based on each author’s affiliation. We also recorded the total number of publications per faculty from 2018 to 2021. Publications were excluded if organizations and/or fields were not listed in the database, if the publication only had one author, and if a paper had a large number of authors (>20). Publication characteristics were compared by faculty seniority and appointment type using nonparametric Wilcoxon Rank Sum Test (p < 0.05).Our grant analysis was based on the proposal data from the years 2015–2020  from all decanal units at the institution. Interdisciplinary proposals were defined as proposals with multiple investigators from multiple departments. Comparisons were made between interdisciplinary versus single-discipline proposals in regard to the number of investigators, number of departments, type of sponsor, and amount awarded. The percentage of interdisciplinary proposals was summarized at the investigator and department level, and trends over time were explored.The sample of faculty (n = 205) was closely split among assistant (n = 79 or 39%), associate 61 or 30%) and full professors (65 or 32%), with two-thirds (68%) of the faculty being on tenure track. For this cohort, we identified 1,025 manuscripts published within the last 3 years . The higher the seniority of the faculty, the more interdisciplinary their publications tended to be   were from a single discipline, with 87% of them involving only one investigator and 13% involving multiple investigators from the same department. There were 2,460 interdisciplinary proposals  with 2 or more investigators from different departments. The average number of investigators per proposal was 3.0 for interdisciplinary (SD 1.4) compared to 1.2 for monodisciplinary (SD 0.5).Fig. Among all academic departments and decanal units that submitted at least one proposal in 2015–2020, 6% (n = 6) submitted only single discipline awards, 82% (n = 78) submitted both single and interdisciplinary awards, while the remaining 12% of the decanal units submitted only interdisciplinary proposals. Decanal units that submitted both single discipline and interdisciplinary proposals received the highest total funding  and had the highest amount awarded per grant  compared to the departments that submitted no interdisciplinary proposals  Younger investigators are more likely to be risk takers and try new approaches outside of the traditional norms including interdisciplinary collaborations and (2) senior faculty are free from the constraints of tenure expectations and have a wider circle of colleagues from various disciplines formed through various administrative and professional activities, hence, their interdisciplinary collaborations should increase with time –25. ThisDespite the widespread agreement on the importance and promises of interdisciplinary research teams (IDRT), barriers for effective IDRT implementation remain significant. Prior studies across a wide range of academic disciplines have identified several common barriers to IDRT including (1) university organization that favors mono-disciplinary departmental structure;  (2) tenuDeveloping efficient and sustainable mechanisms for tracking interdisciplinary teamwork in academia is extremely important to be able to evaluate and disseminate numerous programs that aim to promote interdisciplinary collaborations in research ,32. WhilOur study is unique in several important ways. To our best knowledge, this is the first study demonstrating an empirical approach to tracking the impact of programmatic and educational activities focused on promoting academic interdisciplinary collaboration and teamwork using existing institutional databases. Our findings also demonstrated one of many benefits of interdisciplinary collaboration in research – ability to attract greater amounts of extramural funding from the most prestigious sources reflected in national rankings of programs and academic institutions (the NIH and NSF awards). Finally, our findings that senior tenure track faculty have greater interdisciplinary collaborative networks point to a potentially important relationship between research interdisciplinarity and academic tenure and promotion. This finding is consistent with prior observations of Way et al. 2017 that academic productivity over one’s career is not always linear and could be affected by a variety of personal, discipline-specific, and organizational factors .Despite the strengths and innovation of the approach presented here, the quantitative findings should be interpreted with caution and only as an example of potential applications for this approach. First, the study is based on a sample of departments, publications, and grants from a single institution which may limit the study generalizability across units and organizations. Because our analysis of publications only covered a relatively short time period, we cannot demonstrate causality between the extent of faculty interdisciplinary collaborations and their ability to receive tenure/promotion. Because of the relatively small number of grants and manuscripts submitted by individual investigators and some departments annually, our statistical analysis was limited and could not include subgroup analysis  .In summary, this study provides empirical evidence of the benefits of interdisciplinary collaboration in research and identifies an important role that senior faculty may be playing in creating the culture of interdisciplinary teamwork. Our findings suggest several possible mechanisms how interdisciplinary collaborations could facilitate diversity, equity, and inclusion in clinical and translational research including the role of funding sources and cultural norms within decanal units. More research is needed to help minimize barriers for interdisciplinary collaborations for junior investigators and in academic fields that traditionally do not receive federal research funding and engage in mainly single discipline scholarly pursuits.