Quality improvement collaboratives are a popular model used to address gaps between evidence-based practice and patient care. Little is known about use of such collaboratives in emergency medical services, particularly for improving prehospital stroke care. To determine the feasibility of using this approach to improve prehospital stroke care, we conducted a pilot study of the Emergency Medical Services Stroke Quality Improvement Collaborative.Seventeen Massachusetts emergency medical service agencies participated in the quality improvement collaborative pilot project. We identified 5 prehospital stroke performance measures to assess the quality of prehospital care, guide collaborative activities, and monitor change in performance over time. During learning sessions, participants were trained in quality improvement and performance measurement, analyzed performance measure results, and shared successes and challenges. Focus groups were conducted to understand participants’ experiences with the collaborative.Participating emergency medical service agencies collected stroke performance measures on 3,009 stroke patients during the pilot study. Adherence to 4 of 5 performance measures increased significantly over time. Participants acknowledged that the collaborative provided them with an efficient and effective framework for stroke quality improvement and peer-learning opportunities.As evidenced in Massachusetts, quality improvement collaboratives can be an effective tool to improve prehospital stroke care. The data collected, improvements made, participation of emergency medical service agencies, and positive experiences within the collaborative support the continued use of this approach. Stroke is among the leading causes of severe long-term disability and death in the United States, ranking fourth as a cause for mortality behind heart disease, cancer, and chronic lower respiratory disease . An estiEmergency medical services (EMS) are the first point of contact for approximately half of all patients with acute stroke symptoms in Massachusetts . PatientGuidelines that focus on the importance of stroke recognition, rapid triage and transport, and hospital prenotification exist for EMS assessment and management of patients with suspected stroke ,9; howevQuality improvement collaboratives (QICs) are a popular method in use in health care to address the gaps between evidence-based practice and clinical patient care. QICs bring together providers from different organizations to work in a structured way to improve the quality of their patient care. Through a series of meetings, participants learn about evidence-based best practices and quality improvement (QI) methods while sharing their own experiences and making changes in their organizations. The Massachusetts EMS Stroke QIC was based on the Institute for Healthcare Improvement’s (IHI) Breakthrough Series approach, which is designed to help organizations make “breakthrough” improvements by creating a forum in which participants can simultaneously learn improvement strategies from each other and from experts . HospitaIn 2008, the Massachusetts Department of Public Health’s (MDPH’s) Heart Disease and Stroke Prevention and Control Program began a stroke QIC pilot, modeled after their Paul Coverdell National Acute Stroke Registry QIC, the Stroke Collaborative Reaching for Excellence (SCORE) . Its purThe EMS Stroke QIC began by developing a set of prehospital stroke performance measures. Participants were recruited and in-person meetings were conducted to educate participants in QI and performance measurement and to share successes and challenges among members. Lastly, performance measure results were collected and analyzed to determine the success of the pilot. The QIC leadership team included representatives from MDPH, statewide leaders in stroke care, and a health services researcher with QI and clinical experience. MDPH determined that institutional review board approval was not required for this project.A set of process-based stroke performance measures was outlined to measure the quality of prehospital care, guide the activities of the QIC, and monitor change in performance over time. Performance measures and intervention strategies were developed based on guidelines supported by the American Heart Association/American Stroke Association ,16 and tA 15-member expert panel, comprising EMS and in-hospital stroke care stakeholders  reviewed relevant literature and guidelines around acute stroke care and developed a list of 10 candidate measures. Each member rated the measures based on 6 dimensions of quality: importance, contribution to better patient outcomes, opportunity for improvement, clarity and completeness, actionability, and overall usefulness. Five measures were selected for use in the pilot project: 1) stroke screening performed, 2) blood glucose tested, 3) time last-known-well documented, 4) time of symptom discovery documented, and 5) stroke prenotification to hospital . Stroke EMS agencies were recruited to participate in the QIC from July through December 2009; data collection began upon recruitment. A purposeful sample was selected to include a variety of organization types, sizes, and geographic locations across the state. Agencies were required to have a well-established electronic patient care record (ePCR) system capable of collecting performance measure data elements as well as an active QI program with dedicated staff resources. Each agency designated a QI team to attend collaborative meetings and participate in improvement activities. Participation was voluntary and agencies were not compensated for their participation in the QIC. At the time of enrollment, agencies completed a baseline survey that inventoried agency characteristics, existing QI infrastructure, and policies around stroke care.An automated QI information system  served as the data repository and automatically managed performance measure calculations. Agencies adapted their existing ePCR systems to electronically transmit all patient records to the central Web-based QI data repository. The repository identified patients with a primary or secondary clinical impression of stroke, suspected stroke, or TIA and automatically compared documented patient care against performance-measure criteria. Patient records identified as not meeting 1 or more performance measure criteria were flagged for manual review by the agency to determine if the record’s narrative description contained the missing data or to verify that the case did not meet performance criteria.Monthly feedback reports based on measure adherence were available to agencies through the automated QI system. Participants had access to their own aggregate and patient level results through a password-protected, secure website. The website displayed the results of each of the 5 measures over time by using easy-to-interpret line and bar charts. These feedback reports offered the opportunity for QI staff within the EMS agency to follow up with EMTs about the care provided.Structured activities were conducted to promote collaborative learning, support, and exchange of ideas and insights across EMS agencies. These included in-person learning sessions, individual calls, site visits, and training modules. At the time of recruitment, a site visit to the EMS agency explained the aims of the program and the expectations of the agency. After the agency started submitting data, a second site visit focused on data quality and validation. If requested, on-site continuing education events were hosted for agency staff and neighboring EMS agencies.Learning sessions were held quarterly during which clinical content and QI experts provided both didactic sessions and hands-on exercises. Educational topics included evidence-based improvement strategies, methods for organizational change, and application of strategies in local settings. In addition, participants provided updates on their improvement activities to the larger group, shared their best practices, and received input from the collaborative on their challenges. Continuing education credits were offered as incentives for attendance.Between learning sessions, each service received individual site calls. These coaching opportunities offered QI strategies specifically tailored to each EMS agency and its improvement focus at that time. The Plan-Do-Study-Act (PDSA) improvement model was introduced and small tests of change were used extensively .P < .05.Agency data were aggregated and analyzed quarterly from baseline (July through December 2009) to June 2012. In this time frame, 3,009 patients with stroke, suspected stroke, or TIA were transported by participating agencies. Agencies joined at different times and with different levels of submission during an initial 6-month period. For this reason, we chose to consider the first 6 months as baseline in order to give a clear indication of where all agencies were at the start. Joinpoint regression analyses  were used to test for significant trends and to determine the average percentage change over time. The overall trends for measure adherence by quarter were computed, and significance was set at To understand participants’ experiences and perceptions of the QIC, 2 focus groups were conducted by an external evaluation firm in May 2011. Focus groups were held either preceding or following a quarterly learning session both for ease of recruitment and to limit burden on participants. The interview guide consisted of 11 questions covering 5 main topics: 1) reasons for participation in the QIC, 2) successes and challenges, 3) experiences and level of satisfaction, 4) use of data and information, and 5) effect on relationships within their community . Two leaSeventeen EMS agencies participated in the pilot phase of the Massachusetts EMS Stroke QIC from July 2009 through June 2012. In a baseline survey, (n=14 respondents), organizations classified themselves as private, municipal, fire department–based, or volunteer EMS services from rural, urban, city, or suburban settings throughout Massachusetts . QI teamPerformance measures were collected and analyzed for 3,009 patients  with a clinical impression of stroke, suspected stroke, or TIA. Four of the 5 stroke quality performance measures  showed significant trends of improvement over time ; all 5 pEleven EMTs representing 11 different agencies and 1 hospital EMS coordinator attended the focus groups. After examination of the data, results were consolidated into 2 emerging themes: incentives for participation in the collaborative and barriers to participation in the collaborative.The overarching theme of the focus groups was that the QIC provided participants with an efficient and effective framework for stroke QI and the opportunity to share and learn from each other. Benefits of continued participation in the QIC included the introduction of new stroke care practices, opportunities for statewide networking, and improved working relationships with hospital staff and medical directors. Barriers to participation were centered on the availability of resources, specifically staff time.Participants described benefits of and barriers to QIC participation:Provided a framework for stroke data collection and analysis using performance measures.Provided data to illustrate improvements in patient care. “Hospitals collect data on everything but no one was asking for prehospital data. The data we are showing makes a difference in the patient ahead of time.”Offered opportunity for learning and sharing best practices. “I like that nothing is proprietary. Presenters will email their presentation to us and allow us to come back and use it in our own department.”Enabled sharing of information, best practices, and challenges among various EMS agencies that would not normally collaborate.Provided networking opportunities between EMS personnel, clinicians, state agency staff, and physicians. “There is a great cross-section of people both geographically and from a variety of services and expertise.”Allowed participants to become familiar with QI tools and use of new strategies to successfully implement change.Competing project priorities and other quality improvement responsibilities.Limited staff time and resources for stroke care. “We have other projects going on, like STEMI [ST Segment Elevation Myocardial Infarction], and our time has to be split. The [EMS] department does not have a lot of resources. However, the technology and automation helps.”Difficulty obtaining buy-in from leadership at the start of the project.Logistical challenges to travel, lack of staff coverage, and funding for the additional cost of overtime, which limited attendance at in-person meetings.QICs are a widely accepted approach in many areas of health care but have not been used previously in the prehospital setting. Furthermore, numerous efforts are ongoing nationally to improve stroke care. Most prehospital QI efforts address stroke identification in the field through a series of educational strategies and the subsequent implementation of stroke screening tools –27. A suOur pilot EMS Stroke QIC was conducted with 17 agencies throughout Massachusetts. In the acute hospital setting, programs such as the Stroke Collaborative Reaching for Excellence (SCORE), the model for this pilot study, have successfully improved the in-hospital care of stroke patients by using a QIC ,15. PartThe 6 components of a successful QI model are 1) clear choice of improvement subject, 2) participants’ objectives and capacity to participate, 3) clear roles and expectations, 4) activities to foster learning, 5) measurable and achievable improvement targets, and 6) the ability of participants to collect and use data and make changes in care . ImplemeFour of the 5 performance measures used to gauge the quality of prehospital care and guide the activities of the QIC participants showed significant and sustained improvement during the project . The fifThis study had several limitations. Performance-measure data were compiled by using data extracted from ePCR systems; therefore, the data quality and accuracy could not be fully assessed. Monitoring and improving data quality was an ongoing effort throughout the project, including using required data fields and reading unstructured narrative text when performance measures were not met. Furthermore, 2 of the performance measures, time last-known-well and time of symptom discovery, were not collected for all patients at the start of the study. Barriers to collecting these elements were identified as 1) data mapping issues within agency ePCR systems, 2) unclear or incomplete documentation, and 3) use of unsearchable narrative text fields to enter the measures. Strategies to address these barriers included 1) bundling stroke care data elements in a single location to make data submission easier and more complete, 2) requiring completion of stroke care data elements before closing the electronic record, and 3) frequent feedback to EMTs on data quality.Factors other than the QI activities described may have influenced our results. Selected EMS agencies were favored, in part, because of their ePCR and information technology resources. Although many types and sizes of agencies were represented, agencies without an ePCR or automated QI system may have different results. Unlike other QICs, such as IHI’s Collaborative model, which lasts 12 to 15 months, the results reported here occurred over 36, months giving participants ample opportunity to implement changes. Four of the 5 measures brought about improvement within the first 12 months, suggesting that shorter QICs may still be effective.Despite these limitations, we believe that using a collaborative approach to QI in the EMS setting is an effective tool to improve prehospital stroke care. The scope of the data collected, the significant improvements made in performance measure adherence, the sustained participation of EMS agencies, and the positive experiences of participants in the collaborative encourage us to continue to use this approach in EMS. Future steps will include the development of the project beyond the pilot stage with the recruitment of a second cohort of EMS agencies and continued work with the pilot cohort to implement QI strategies. The EMS QIC will also begin to work the SCORE in-hospital collaborative to improve care transitions from EMS to ED and ultimately develop a cohesive stroke system of care in Massachusetts.


Sir,Good prescribing practice is an essential part of rational drug use.2 A presc3This prescriber care assessment was carried out through an exit interview in 590 encounters of patients using a pretested, structured questionnaire. We used average consultation time (ACT), average number of drugs per encounter (ANDE), percentage of drugs prescribed by generic name (PDPG), percentage of encounters with an antibiotic prescribed (PAP), percentage of encounters with an injection prescribed (PIP) and percentage of drugs prescribed from essential drugs list or formulary (PEDL) to assess the degree of prescriber care and the situation in our health facilities.Patient diagnosis and prescriber identity were absent in all prescriptions, although the signature was present in(nearly)all. Age was usually mentioned but sex was never mentioned in any of the 590 prescriptions. Duration of treatment and frequency of drug administration are usually mentioned. ACT, ANDE, PDPG, PAP and, PI, of three different hospitals are given in We found that consultation time of a prescriber in government hospitals is very short as compared with the other reports.25 The sh2


Measuring forest degradation and related forest carbon stock changes is more challenging than measuring deforestation since degradation implies changes in the structure of the forest and does not entail a change in land use, making it less easily detectable through remote sensing. Although we anticipate the use of the IPCC guidance under the United Framework Convention on Climate Change (UNFCCC), there is no one single method for monitoring forest degradation for the case of REDD+ policy. In this review paper we highlight that the choice depends upon a number of factors including the type of degradation, available historical data, capacities and resources, and the potentials and limitations of various measurement and monitoring approaches. Current degradation rates can be measured through field data  and/or remote sensing data , with the combination of techniques providing the best options. Developing countries frequently lack consistent historical field data for assessing past forest degradation, and so must rely more on remote sensing approaches mixed with current field assessments of carbon stock changes. Historical degradation estimates will have larger uncertainties as it will be difficult to determine their accuracy. However improving monitoring capacities for systematic forest degradation estimates today will help reduce uncertainties even for historical estimates. Forest disturbances that lead to degradation such as over-harvesting, forest fires, pests and climatic events including drought, wind, snow, ice, and floods have been estimated to affect roughly 100 million of hectares globally per year . This va00-2005) ,4. In pa00-2005) , but oveTo address climate change mitigation actions in the forest sector, five different components have been agreed upon by Parties to the United Framework Convention on Climate Change (UNFCCC) under negotiations for Reduced Emissions from Deforestation and Degradation (REDD+). These include reducing deforestation, reducing degradation, forest enhancement, sustainable management of forests, and forest conservation. The negotiations identify the need to establish national forest monitoring systems that use an appropriate combination of remote sensing and ground-based forest carbon inventory approaches for estimating anthropogenic forest-related greenhouse gas emissions by sources, removals by sinks, and the need to establish reference emission levels using historical data and adjusted for national circumstances .Issues related to assessing and monitoring forest degradation and associated carbon stock changes have been subject to international debate on the political and technical level ,11. ReceHere we provide an overview of methods and approaches for monitoring carbon emissions from forest degradation, with a focus on historical periods. We structure the review around a set of critical issues and assumptions, as follows:• REDD+ has specific monitoring requirements including a focus on the national level, the use of the IPCC guidance, the need to establish a reference emission level, and to assess how REDD+ policies and measures address the drivers and activities causing forest carbon loss,• The IPCC guidance suggests the use of activity data (changes in extent of areas affected) and emission factors (changes in carbon stock within areas) to estimate emissions on the national level, with most effort to be put on the most important emission sources , and with different ways to handle uncertainties (i.e. different Tiers for carbon stock estimation), encouraging continuous improvements over time,• Current and historical assessments of forest degradation need to be consistent, in order through serial correlation to reduce the impact of absolute uncertainty,• Different methods including field measurement and remote sensing are needed to derive activity data and emission factors for different degradation processes. The data availability varies for differing historical periods and regions.Good Practice Guidance for Land Use, Land-Use Change and Forestry (GPG-LULUCF) [Equation 1 provides a conceptual overview of how to estimate gross carbon emission (Cgr_em) from forest land due to deforestation and loss of carbon stock in forest land remaining forest land, at the national level. Following the -LULUCF)  and the -LULUCF) , forest Forest degradation can be defined in many ways -17 but nBesides the definition, in the REDD+ context it is necessary to understand the drivers and activities causing degradation. Such information is needed not only for formulating appropriate REDD+ strategies and policies, but also for the definition of suitable methods for measuring and monitoring. Various types of degradation will have different effects on the forest (carbon) and will result in different types of indicators , which can be used for monitoring degradation using in situ and remote methods. Usually, different degradation processes are present within one country, with interactions among processes and recurrent events that leads to even more carbon emissions. Forest degradation processes may or may not affect large areas, but usually they are not equally distributed over the country's territory. They are often focused on specific areas, and this should be considered in national measurement and monitoring efforts ,19.The main drivers for direct forest degradation include:Extraction of forest products for subsistence and local markets: privately or communally managed forests are often subject to extraction of forest products for immediate use or sale by local households, such as collection of fuelwood for cooking, collection of fruits, roots and other edible or medicinal tree parts, collection of fodder for livestock, and harvesting of timber and thatch for construction. In addition, most developing countries have seen rapid urbanization in recent decades, which has created a market for forest-based products  that, in some cases, has resulted in forest degradation.a. Industrial/commercial extraction of forest products: Large scale selective logging and other harvesting practices often occur in unregulated forest areas, exacerbated by poor logging practices such as multiple entries into forests [b.  forests .Uncontrolled anthropogenic wildfire: This is a major source of degradation in many types of forests, and may be deliberate or accidental.c. UNFCCC Decision 4/CP.15  requests1) Areas of forest that remain forest and are affected by degradation , ideally stratified into different disturbances or degradation types. How much forest area, and where, is undergoing degradation? Such statistics, calculated through forest inventories or through remote sensing, are also referred to as Activity Data (AD). The GPG-LULUCF identifies three approaches to represent land areas, in increasing order of complexity . For the-1yr-1) are also referred to as Emission Factors (EF). These changes should be calculated for each of the five forest carbon pools: aboveground biomass, belowground biomass, deadwood, litter, and soil organic matter [2) Changes in forest carbon stocks due to the degradation processes per unit area. How much carbon is lost from the forests and released to the atmosphere due to the degradation process? Such amounts, commonly measured through forest field sampling and repeated forest inventories ,➣ Data from targeted field surveys (including interviews) and from research and permanent sample plots, often implemented as local studies,➣ Commercial forestry data (i.e. logging concessions and harvest estimates),➣ Proxy data from domestic markets  such as timber production rates estimated from sawmill, sales, and export statistics .If available, the collection of national forest data through periodic forest inventories since the 1980s allows the estimation of emissions associated with historical and current forest degradation processes . When deThe estimation of forest carbon stock change with relatively low uncertainty (i.e. at Tier 3 level) assumes that consistent measurements are made at different points in time, i.e. before the degradation and at several points in time afterwards, to establish reliable emission factors. In most developing countries, however, the necessary long-term forest datasets are almost non-existent, or are focused on specific field assessments for commercial timber which cover only limited parts of the country. In these cases, the time variable has to be substituted by space . This latter approach would consider the carbon stocks of intact and unmanaged forests as the reference value and by comparison would estimate the emissions of the degraded forests per unit of area.Permanent sample plots are typically used to monitor changes in studies on forest resources and temporal dynamics. When historical records exist, it is worthwhile repeating measurements using the same sampling scheme. Forest inventory data are routinely collected by forestry organizations in many countries and are usually not focused on assessing the impact of forest degradation on carbon stocks. However, earlier inventories, for example those that focus on merchantable volumes of commercially interesting species, can be correlated with similar inventories in the present era, supplemented by information on forest properties that allows for the assessment of biomass, enabling an estimate of historical biomass content of the forest .Measurement and monitoring of the area affected by forest degradation through remote sensing offers a series of advantages: i) it represents a consistent, coherent, transparent and fairly accurate way of reporting on area, and it allows for near-real time reporting on land use changes, ii) it offers spatially detailed national data even on remote and logistically complicated regions, and iii) it is the only approach that offers, potentially at least, objective information on historical trends in areas where data do not exist today. However, it also has several disadvantages: i) it can be hampered by clouds in some regions , ii) it is limited by the technical capacity to sense and record the change in canopy cover  and iii) image interpretations may be difficult equivocal and/or labor intensive, especially if national estimates are to be derived. Not all degradation processes can be monitored with high certainty using remote sensing data Table . The morMapping forest degradation with remote sensing data is more challenging than mapping deforestation  because With these issues in mind, there are three main approaches to evaluating forest degradation with remote sensing:➣ Direct detection of degradation processes (observing forest canopy damage) and area changes, in which the features of interest to be enhanced and extracted from the satellite imagery consist of forest canopy gaps, small clearings and the structural forest changes resulting from disturbance ,33,34. T➣ Indirect approaches (observing human infrastructure) are useful when degradation intensity is low (little canopy damage) or when the direct approach cannot be applied due to infrequent coverage and little spectral evidence remains from the canopy gaps. The remote sensing analysis focuses on the spatial distribution and evolution of human infrastructure , which is used as a proxy for newly degraded areas ,36. This➣ Monitoring carbon emissions from biomass burning. This approach includes three primary categories: detection of active fires, mapping of post-fire burned areas (fire scars) and fire characterization . For the purposes of emission estimation, the latter two categories, described in GOFC-GOLD (2010), are more relevant. The 'bottom up' method  uses theMany developing countries will not have the data and capacities to provide suitable carbon emissions estimates on all types of forest degradation for historical periods . Table 2Historical monitoring of industrial/commercial extraction of forest products can benefit from the use of archived satellite data, which could be analyzed with the support of other data sources such as forestry concession data. Specific emission factors can be estimated from present-day data on carbon stock losses due to similar degradation processes (i.e. as occurring at present) and by studying their chronosequences, applied consistently for historically periods with suitable activity data. In this case the estimation of historical reference emissions is driven by the activity data. A similar approach could be applied for the case of fires.Table The authors declare that they have no competing interests.MH and RMRC led the review and the drafted the majority of the manuscript. DM, YH, PVL, GPA, CS, MS, VA and KMD conceived the study, added to the review and contributed to the manuscript. All authors read and approved the manuscript.


Cognitive dysfunction in Parkinson's disease contributes to disability, caregiver strain, and diminished quality of life. Cognitive rehabilitation, a behavioral approach to improve cognitive skills, has potential as a treatment option to improve and maintain cognitive skills and increase quality of life for those with Parkinson's disease-related cognitive dysfunction. Four cognitive rehabilitation programs in individuals with PD are identified from the literature. Characteristics of the programs and outcomes are reviewed and critiqued. Current studies on cognitive rehabilitation in PD demonstrate feasibility and acceptability of a cognitive rehabilitation program for patients with PD, but are limited by their small sample size and data regarding generalization of effects over the long term. Because PD involves progressive heterogeneous physical, neurological, and affective difficulties, future cognitive rehabilitation programs should aim for flexibility and individualization, according to each patient's strengths and deficits. Cognitive dysfunction is a nonmotor feature of Parkinson's disease (PD) that contributes significantly to disability, caregiver strain, and diminished quality of life over the course of the disease , 2. WhilWith advances in medical and surgical interventions for motor symptoms, individuals with PD are living longer and facing greater disability related to cognitive impairments. Accordingly, there is a corresponding need to address cognitive changes therapeutically. Yet, to date, there are no definitive treatments for cognitive dysfunction in PD . MedicatCognitive rehabilitation, a behavioral treatment approach for individuals with cognitive dysfunction, is designed to reduce functional impairment and increase engagement in daily adaptive activities. Although there is variation across programs, the essential elements of cognitive rehabilitation consist of basic skills training related to performance of vocational, social, and adaptive daily living skills. Subsets of cognitive training programs target improvements in specific cognitive domains, including visuospatial awareness, attention, working memory, or executive functioning, which are the essential cognitive skills to complete daily living tasks. Cognitive rehabilitation strategies consist of restorative or compensatory techniques. Restorative techniques focus on strategies to improve cognitive functioning to closer to the patient's level before there was an obvious decline. Specific restorative skills include techniques to improve recall of information over increasing periods of time  or using less intense cues (vanishing cues), computerized drills and repeated prompting to improve memory and attention and recall of remote memories (reminiscence therapy). Compensatory techniques provide strategies that organize information to improve recall and learning and provide instruction in self-management strategies. Compensatory techniques also include using multiple senses to improve learning and retrieval, procedural training to learn increasingly more complex behaviors, and external cues such as memory notebooks or calendars to improve recall. Programs may also teach, in-person or with the aid of computerized devices and software, strategies to improve self-management, such as problem solving, time management, and compensation for impaired memory . ExaminiThe short- and long-term cognitive impairments following traumatic brain injury (TBI) are optimal targets for cognitive remediation, and positive outcomes following cognitive rehabilitation have been consistently demonstrated . Standar Cognitive rehabilitation programs for neurological disorders, including studies in Alzheimer's disease (AD), vary considerably in content , administration , timing (1 session versus 15 sessions) and setting (inpatient versus outpatient) , 15. In Lack of agreement regarding the definitions of PD-cognitive dysfunction and procedures  that best identify cognitive changes and impairments is a major challenge to treatment. This is particularly evident in PD-Mild Cognitive Impairment (PD-MCI), which has been defined inconsistently across studies. In general, MCI refers to an intermediate severity of acquired cognitive dysfunction between the cognitive status of “within normal limits” and “demented.” Whereas the MCI classification was developed and validated for conversion to Alzheimer's disease (AD) , similarPrevalence of PD-MCI and more subtle cognitive dysfunction in PD ranges from 21% to 55%, depending on the duration of the disease and which PD-MCI criteria and neuropsychological measures were used , 17, 18.In patients with PD-MCI, executive dysfunction/attention and memory impairment are the most prevalent deficits reported , 17. By  Cognitive deficits are noticed in daily life when they result in impaired performance in job-related duties, activities of daily living, and other activities that contribute to an individual's level of independence and well-being. For example, safety, financial planning and paying bills, driving, and occupational performance can be of concern in patients who demonstrate impairments in executive functions –23. AccoThis integrative paper provides an overview of the types of cognitive impairments that are targeted in rehabilitation for cognitive dysfunction in PD and compares the content and delivery methods of cognitive rehabilitation interventions applied to patients with PD. Strengths and limitations of the current literature and future directions for cognitive rehabilitation in PD are discussed.To identify relevant studies for the integrative review, keyword searches of abstract and titles were conducted in the PubMed and PsycINFO databases for studies published prior to July 2011. We used search terms (1) “Parkinson's disease” and “cognitive training”, (2) “Parkinson's disease” and “cognitive rehabilitation”, (3) “Parkinson's disease” and “cognitive remediation,” (4) “Parkinson's disease” and “training” and “executive.” Articles were included if they were original research in English, included individuals with Parkinson's disease, and described any type of intervention for cognitive functioning with pre- and postassessments.n = 5), not being in English (n = 2), not reporting cognitive rehabilitation interventions , not including pre- and postsassessments (n = 2), and subject population not individuals with Parkinson's disease (n = 2). The PubMed search yielded a total of 18 unique articles and 3 additional studies were found in the PsycINFO database. Of the 21 abstracts reviewed, 17 were excluded. Reasons for exclusion were not reporting original research  of cognitive rehabilitation programs targeting executive functioning, attention, and visuospatial abilities see . In Sinforiani and colleagues' open trial , 20 patin = 14) open trial to test the feasibility of an attention process training intervention for patients with a minimental state exam (MMSE) score >23 and idiopathic PD. The intervention consisted of in-person training with practice exercises and worksheets on attention tasks. Daily at-home practice exercises were also encouraged for all participants. Fourteen participants completed the program, and the self-report ratings on feasibility yielded positive results. The average rankings were between “some” to “much” perception of progress in improving their attention and enjoyment. The author reported that the participants improved on the measures of executive skills consisting of Digit Span backward, Stroop Color Word Test, Trail Making B, and Controlled Oral Word Association Test. This open trial successfully demonstrated the feasibility of administering an in-person cognitive training program and patients' acceptance of training. However, because of the small sample, study design and minimal outcomes measures, in addition to the lack of control group and long-term followup, conclusions as to the effectiveness of the intervention and translation into short-term or long-term functional outcomes are limited.Mohlman et al.  completeThe two RCTs investigating cognitive rehabilitation in PD included relatively small sample sizes; however, these studies improved upon the literature by comparing the benefits of cognitive training programs to usual care received by individuals with PD. Sammer and colleagues  conducteAnother small RCT compared a 4-week outpatient computer-based cognitive training program to a speech therapy program matched on participation time . All 33 Cognitive rehabilitation programs are increasingly recognized as beneficial alternatives to or adjunctive therapy for medications for improving specific types of cognitive dysfunction in patients with neurological disorders or maintaining patients at their current level; however, there is limited evidence for the effectiveness of cognitive rehabilitation in PD. The cognitive training programs for TBI and AD, which utilize the most well-developed programs have shown improvements in memory, attention, executive functioning, and problem solving , have deAlthough the current studies in PD are limited in sample size, it appears that cognitive training programs are both feasible and well accepted by PD patients. The cognitive targets of the reviewed pilot studies focus on attention and executive impairments in nondemented patients using both computers and in-person interventions. As the literature on cognitive rehabilitation programs grows, it would be beneficial for studies to use similar assessments to enhance comparisons between studies and to include both measures of neuropsychological and everyday functioning to evaluate the generalizability of the program into the patient's daily functioning. Based on the current literature, the effectiveness of cognitive training to demonstrate targeted short-term improvement on objective assessments following rehabilitation is promising –28; howeFuture cognitive rehabilitation outcomes studies in PD will need to address the limitations uncovered in programs developed for other neurologically impaired populations and the obstacles inherent in working with PD patients. Cognitive rehabilitation is often time-consuming for patients, caregivers, and therapists and can be costly to implement. In addition to these logistical obstacles is the lack of ecologically valid outcome measures to demonstrate improvement in patients' daily functioning or generalization of their newly acquired abilities to other areas of daily living. Well-controlled and described randomized studies using appropriate control groups with longer-term follow-up evaluations including ecologically valid outcome measures would be an initial step to demonstrate actual efficacy of cognition rehabilitation in PD. Additionally, PD itself poses several inherent obstacles for success in terms of cognitive rehabilitation. Researchers will also need to address these issues when developing future cognitive rehabilitation programs for patients with PD, including the heterogeneity of cognitive impairment, variability of functioning for patients with on/off fluctuations, cooccurring depression and anxiety, apathy, the mobility issues that restrict access to biweekly individualized programs, and the optimal disease stage in which improvements in cognitive functioning would be most beneficial. Personalized approaches to tailor treatment to individual strengths and deficits are recommended. If skills learned in cognitive rehabilitation carry over into everyday functioning and improve problem-solving and adaptive abilities, the programs could create positive and long-lasting benefits for patients by improving quality of life and potentially decreasing caregiver burden.


Health policy makers have stated that diabetes prevention is a priority; however, the type, intensity, and target of interventions or policy changes that will achieve the greatest impact remains uncertain. In response to this uncertainty, the Diabetes Population Risk Tool (DPoRT) was developed and validated to estimate future diabetes risk based on routinely collected population data. To facilitate use of DPoRT, we partnered with regional and provincial health-related decision makers in Ontario and Manitoba, Canada. Primary objectives include: i) evaluate the effectiveness of partnerships between the research team and DPoRT users; ii) explore strategies that facilitate uptake and overcome barriers to DPoRT use; and iii) implement and evaluate the knowledge translation approach.e.g., observer notes) and active  methods.This protocol reflects an integrated knowledge translation (IKT) approach and corresponds to the action phase of the Knowledge-to-Action (KtoA) framework. Our IKT approach includes: employing a knowledge brokering team to facilitate relationships with DPoRT users (objective 1); tailored training for DPoRT users; assessment of barriers and facilitators to DPoRT use; and customized dissemination strategies to present DPoRT outputs to decision maker audiences (objective 2). Finally, a utilization-focused evaluation will assess the effectiveness and impact of the proposed KtoA process for DPoRT application (objective 3). This research design utilizes a multiple case study approach. Units of analyses consist of two public health units, one provincial health organization, and one provincial knowledge dissemination team whereby we will connect with multiple regional health authorities. Evaluation will be based on analysis of both quantitative and qualitative data collected from passive (DPoRT offers an innovative way to make routinely collected population health data practical and meaningful for diabetes prevention planning and decision making. Importantly, we will evaluate the utility of the KtoA cycle for a novel purpose – the application of a tool. Additionally, we will evaluate this approach in multiple diverse settings, thus considering contextual factors. This research will offer insights into how knowledge translation strategies can support the use of population-based risk assessment tools to promote informed decision making in health-related settings. Diabetes is rising at an alarming rate in Canada. In particular, Type 2 Diabetes Mellitus (T2DM) accounts for over 90% of diabetes and is a leading cause of death and disability . CurrentWithout urgent preventative action, diabetes will continue to deteriorate the health status of the Canadian population and overwhelmingly burden the healthcare system. Several governments and health policy makers at all levels have authoritatively stated that diabetes prevention is a priority through policy announcements and strategic system investments worldwide ; howeveri.e., accessible to public health units and organizations). Other salient features that ensure a tool can be adapted include: practicality, applicability to important target populations, validity and robustness [Decision makers have access to self-reported prevalence data on diabetes, but rarely have access to diabetes incidence and true prevalence of physician diagnosed diabetes. They lack tools that facilitate the use of this data to inform population planning or prevention strategies. Specifically, they lack tools that can apply readily available data to determine optimal diabetes prevention strategies based on the unique socio-demographic and risk factor composition of populations of interest , includibustness .Considering the potential benefits of a population-based risk prediction tool and responding to the rising incidence and consequences of diabetes within Canada, the Diabetes Population Risk Tool (DPoRT) was developed and validated to estimate future diabetes risk based on routinely collected population data .e.g., epidemiologists, public health decision makers). To accomplish broad applicability, the tool works on risk factor data available to users at community, regional and provincial levels . A recent systematic review of all diabetes risk tools found that of over 90 existing tools, DPoRT was the only one built specifically to inform population intervention strategies [e.g., ethnic groups) [DPoRT, developed by Rosella and colleagues , is a norategies . DPoRT w groups) . SpecifiResearch has shown that passive knowledge translation (KT) strategies are likely insufficient to maximize uptake and utilization of knowledge products and innovations in various sectors -16, inclWe are not aware of any published studies of KT approaches specifically designed to support the application of tools designed to generate future population-level risk profiles to facilitate decision making. Work in related domains, including clinical decision-rules ,25 and ge.g., DPoRT) by knowledge users in health-related settings  has yet to be undertaken. Thus, this protocol addresses the process of moving DPoRT into action through the collaborative efforts of researchers and DPoRT users. Our conceptualization of the KtoA framework, adapted for this project, is presented in Figure The KtoA framework describes the KT process as encompassing two key components, knowledge creation (represented by a funnel that distills and tailors information into useable knowledge products or tools) and action (facilitated through a dynamic context-driven process) . The KtoThe overarching goal of this project is for researchers and decision makers in varied health-related settings to work collaboratively to build capacity and facilitate the use of DPoRT as a strategic aid for population-based risk assessment, intervention and planning decisions. In an effort to empower health organizations to use DPoRT for their own decision making and surveillance activities, we have developed an IKT strategy in partnership with regional and provincial decision makers in Ontario and Manitoba, Canada. To achieve this goal, the specific objectives of this project are to:1. Create and support partnerships with DPoRT users in health-related settings, through use of a knowledge brokering (KB) team. This is a foundational objective that will underpin all aspects of the project. In particular, the KB team will: facilitate and support ongoing relationships with DPoRT users; provide tailored training to help health setting staff learn to use DPoRT; and adapt DPoRT application to the local sites’ needs2. Complete the action cycle of the KtoA framework  in multi3. Evaluate the effectiveness and impact of the KtoA process using a case study approach to provide description, understanding and assessment of the KT strategies used to put DPoRT into action. Our specific evaluation objectives are: to evaluate the effectiveness of the partnerships; to evaluate the effectiveness of the KtoA approach; and to identify strategies that facilitate uptake and overcome barriers to DPoRT use, including core elements needed for sustained use.Health organizations in this study and the populations they serve vary considerably, and there is increasing recognition that differences in context make it difficult or impossible to replicate interventions exactly the same way across different conditions . It has e.g., public health [To facilitate our intended IKT approach, we will use a KB team. In the literature, knowledge brokers have been described as trusted, knowledgeable, skilled and solution-oriented individuals or groups who act as ‘go-betweens’ to bring key stakeholders together in formal and informal venues for the purpose of acquiring, sharing and applying knowledge to improve decision making and/or the management/delivery of services -39. Knowc health , mental c health , communic health , and clic health ,44). As c health , we beliWe have designed a utilization-focused evaluation ,46 leverThe Research Ethics Board at Public Health Ontario (PHO) has approved this study protocol.e.g., managers, directors, Medical Officers of Health, Chief Executive Officer or equivalent) working in health-related organizations were identified as the ideal users of the tool. It was expected that they would benefit most from identifying risks based on their unique community structures that could be used to directly inform jurisdictional programming decisions. As elaborated below, the participating organizations represent diverse contexts and will permit exploration of how the action cycle of the KtoA framework plays out under different conditions as well as allow us to test the robustness of our IKT approach.When DPoRT was developed, epidemiologists and decision makers  is a local public health department serving over 1.3 million residents in three primarily urban municipalities. PPH is part of the Health Services Department within the regional government whereby Peel Regional Council serves as its Board of Health. PPH’s 700-member staff provide services specified in the Ontario Public Health Standards and the Health Protection and Promotion Act . Peel is2 and includes 2 upper tier governments, 2 cities and 24 smaller municipalities. In 2006, the total population for Simcoe and Muskoka was 479,767; projections suggest this number will be 40% higher and will include many seniors by 2025. The SMDHU Board of Health is an autonomous governing structure made up of appointees from the County of Simcoe, District of Muskoka, City of Barrie, City of Orillia and Provincial designates. The health unit has 400 staff members. Within SMDHU there will be two main beneficiaries of DPoRT: the Planning and Evaluation team within Corporate Services and the Chronic Disease Prevention Healthy Lifestyle (CDP-HL) team within Healthy Living Services. The Medical Officer of Health, one epidemiologist, and one manager from the CDP-HL team will be the primary participants.Simcoe Muskoka District Health Unit (SMDHU) is a local public health unit situated at the north end of the Greater Golden Horseshoe and in the heart of Ontario’s ‘Cottage County’. The health unit’s jurisdiction covers over 8,000 kmDPoRT was validated in Manitoba because of the different population structure from Ontario, thus demonstrating the robustness of the tool . More ime.g., phone, email, in-person meeting), role of the individual(s) spoken with, type of activity being conducted , length of time spent on interaction/activity, purpose of the interaction, actions taken to address issues/concerns, and outcomes/decisions that followed. The KB team will also keep a reflexive journal of critical reflections on partner interactions and setting processes. The purpose of recording observational notes is to understand the effectiveness and intensity of the knowledge brokering strategy as well as provide feedback on how the KB team can improve, given that we are utilizing an IKT approach.Throughout the KtoA cycle, the KB team will keep a record of the nature and sequence of events occurring at each site. At an initial site meeting and throughout the KtoA cycle, the KB team will inform participating staff about the collection of observational notes, the type of data that will be logged, the reason for recording such notes, and will explain that individuals can opt out if they prefer to not have their interactions with the KB team logged. Potential events that may be recorded include: requests by DPoRT users for technical support or resources related to DPoRT, discussions with the KB team to troubleshoot barriers to DPoRT use, discussions to support the development of knowledge products, etc. The log will record the type of interaction that the KB team engages in   to indivIn order to assess the effectiveness of the partnership between the KB team and each site, participants will be invited to complete the Partnership Self-Assessment Tool (PSAT) developed by the Center for the Advancement of Collaborative Strategies in Health  based one.g., surveillance, program planning, etc.), a member of the KB team will conduct semi-structured interviews at each site with those who have used DPoRT (either directly or indirectly via outputs). The purpose of these interviews is to understand the effectiveness and impact of the KtoA process on DPoRT uptake, the effectiveness of the partnerships, and to assess actions, such as training and support, taken by the KB team. The questions in the interview guide will follow the OMRU guidelines [Approximately two to three months after DPoRT users have begun using the tool for their site-specific purposes  should mitigate the potential for recall bias [Additionally, given that implementation process-related data will be collected several months following the establishment of partnerships and training workshops, recall bias may limit the accuracy of DPoRT users’ descriptions of the implementation process. However, the use of multiple sites, and data sources  and health planning (forecasting future disease burden and estimates of the effects of diabetes prevention). This project features a unique modification of the conventional KB strategy (a KB team approach), which will be examined as part of the evaluation. Our novel application of the KtoA framework (the application of a tool versus previously generated knowledge), and our evaluation of this strategy will be useful to others designing or evaluating KT strategies, particularly on the application of decision support tools, which are gaining popularity. The ultimate goal of DPoRT utilization would be to impact health outcomes, specifically diabetes incidence, as well as the consequences of diabetes, including cardiovascular disease, stroke, kidney disease, etc. Both diabetes and its consequent comorbidities may be reduced by the provision of more effective and efficient programs informed by DPoRT outputs. Importantly, this research will offer insights and lessons learned about the contemporary phenomenon of KT strategies to support uptake and application of population-based risk assessment tools for informing decision making regarding prevention strategies that can be used by other health-related settings interested in pursuing similar efforts.AAR: After action review; CCHS: Canadian community health survey; CDP-HL: Chronic disease prevention – healthy living; CDPI: Chronic disease prevention initiative; DPoRT: Diabetes population risk tool; KB team: Knowledge brokering team; KtoA: Knowledge to action; KT: Knowledge translation; IKT: Integrated knowledge translation; MCPH: Manitoba centre for health policy; NTK: Need to know (team); OMRU: Ottawa model of research use; PHO: Public health Ontario; PSAT: Partnership self-assessment tool; RHA: Regional health authority.The authors declare that they have no competing interests.This manuscript was prepared based on a Canadian Institutes of Health Research funded grant developed by LR, LP, DM, CG, PC, RF and PM. The grant was adapted into a draft manuscript by LR, CB, and KK. All authors contributed to the refinement of the protocol and have approved the final version of this manuscript.


China’s healthcare system is experiencing significant growth from expanded government-backed insurance, greater public-sector spending on hospitals, and the introduction of private insurance and for-profit clinics. An incremental reform process has sought to develop market incentives for medical innovation and liberalize physician compensation and hospital finance while continuing to keep basic care affordable to a large population that pays for many components of care out-of-pocket. Additional changes presently under consideration by policymakers are likely to further restructure insurance and the delivery of care and will alter competitive dynamics in major healthcare industries, notably pharmaceuticals, medical devices, and diagnostic testing. This article describes the institutional history of China’s healthcare system and identifies dilemmas emerging as the country negotiates divisions between public and private in healthcare. Building on this analysis, the article considers opportunities for public-private partnerships and greater systems integration to reconcile otherwise incommensurable approaches to rewarding innovation and improving access. The article concludes with observations on the public function of health insurance and its significance to further development of China’s healthcare system. Healthcare is arguably the most complex of the institutional systems with which people interact on a regular basis. In every country, healthcare systems combine to differing degrees public state administration and private market economies for insurance and the provision of care. Debates about the superiority of predominantly public or private systems have a strong ideological component, and international comparisons are made difficult by the reality of subtly different mixes of public and private in each country and the shifts induced over time by frequent reforms Saltman . Health A decade of reforms to China’s healthcare system has significantly broadened government-backed insurance coverage and the availability of basic care. Industry analysts predict healthcare spending in China to grow further to $1 trillion by 2020, which would triple 2010 levels and then comprise an estimated 7 percent of GDP  companies. The article also draws upon published data and official reports from the former Ministry of Health and other government ministries, interviews and speeches by government officials, commercial databases accessed through university subscription, and existing scholarship in health economics and policy.This article adopts a historical perspective on institutional change while also drawing on concepts from health economics and political science concerning public, private, and hybrid institutions. A longstanding body of research has examined markets as optimal for the production and exchange of private goods, while government is needed to generate public goods and regulate areas subject to market failure  earn revenue from markups on diagnostics and drug sales, leading direct financial incentives for doctors to over-prescribe brand-name drugs and diagnostic tests  encompasses a range of practices including herbal medicine, acupuncture, therapeutic massage, movement and exercise, and dietary therapy Sivin . TCM hasmateria medica. Hospital pharmacies stock TCM treatments alongside small molecule drugs. In addition, specialized TCM clinics can be found across the country at which people can build long-term relationships with their doctor, in contrast to crowded hospitals where patients typically must see the next available physician . NCMS operates on a local basis, and deductibles and copayments typically increase for treatment away from home  program, which covers employees in private and state-owned enterprises, government, social organizations, and non-profits. Employees of state-owned enterprises and their dependents were previously covered under a government employee insurance scheme. In 2007, the government ran pilot programs in 79 cities to test coverage of non-working urban residents, including family members of people covered by UEBMI. This new Urban Residents Basic Medical Insurance (URBMI) was expanded nationally the following year  in new health sector spending, spread among the urban and rural insurance schemes  in new healthcare spending alongside a proposal to expand insurance plans by offering catastrophic disease coverage nationwide by 2020. Specifics remain to be developed, but the government has proposed covering treatment costs above an upper limit of 50,000 RMB , either completely or on a sliding scale. However, as the H&FPC plans additional reforms, institutionalized behaviors among the key players in the healthcare system are challenging the balance it seeks to strike between public and private in insurance and the delivery of care.With few exceptions, hospitals in China are built, owned, and operated by public authorities. They receive national and provincial or city government funding based on metrics such as the number of beds filled on a monthly or annual basis and staff size relative to the number of patients treated and discharged. At the same time, the government limits hospital revenue through the “Yellow Book”, a price list for thousands of medical procedures and services, many set at or even below their direct cost , hospitals capture the difference between wholesale and retail prices. Furthermore, studies of health spending in China suggest that hospitals regularly receive kickbacks from drug companies and medical suppliers  China’s hospitals handled 2.3 billion outpatient visits and 108 million inpatients in 2011  containing cash. A regulation proposed by the Ministry of Health in August 2012 would require doctors and patients to sign an agreement in which the doctor vows not to ask for money and the patient vows not to try to hand over an envelope , five (bachelors), six (bachelors), seven (masters), or eight (full M.D.) years of education. Specialists have another two years of training  in 2012  in southern China spread to infect individuals in 37 countries. SARS eventually infected only 8,500 people worldwide with just 916 recorded fatalities   involve a negotiated division of resources, responsibilities, and rewards between governments and private sector firms Nishtar . In theoAnalysts have warned in recent years that declining success in pharmaceutical research and cost-cutting measures in developed countries are reducing incentives for firms to invest in drug discovery , offer a second area of biomedical knowledge development in which PPPs can respond to domestic health needs and generate international revenue. In late 2012, the Ministry of Health began to solicit expert input on the basic structure of a system that will include: “summarized medical records, outpatient services, hospitalizations, physical check-ups, referrals, [and] medico-legal statements and reports”  Press conference of medical and health system leadership team. http://www.china.com.cn/zhibo/zhuanti/2013lianghui/content_28211342.htm. Accessed 29 March 2013.bAn exchange rate of 6.25 RMB per 1 USD is used throughout the article, based on the average for calendar year 2012.cThis estimate is based on cases compiled at: China Daily Forum (ly Forum .dAuthor’s analysis of data from P.R. China, Statistical Yearbook; OECD iLibrary; ClinicalTrials.gov; and IMS health.Arthur Daemmrich is an associate professor at the University of Kansas Medical Center in the Department of History and Philosophy of Medicine with faculty affiliations in the Department of Health Policy and Management and the Department of Preventive Medicine and Public Health. Contact: adaemmrich@kumc.edu


Many older adults manage multiple chronic conditions (i.e. multimorbidity); and many of these chronic conditions share common risk factors such as low socioeconomic status (SES) in adulthood and low SES across the lifecourse. To better capture socioeconomic condition in childhood, recent research in lifecourse epidemiology has broadened the notion of SES to include the experience of specific hardships. In this study we investigate the association among childhood financial hardship, lifetime earnings, and multimorbidity.Cross-sectional analysis of 7,305 participants age 50 and older from the 2004 Health and Retirement Study (HRS) who also gave permission for their HRS records to be linked to their Social Security Records in the United States. Zero-inflated Poisson regression models were used to simultaneously model the likelihood of the absence of morbidity and the expected number of chronic conditions.Childhood financial hardship and lifetime earnings were not associated with the absence of morbidity. However, childhood financial hardship was associated with an 8% higher number of chronic conditions; and, an increase in lifetime earnings, operationalized as average annual earnings during young and middle adulthood, was associated with a 5% lower number of chronic conditions reported. We also found a significant interaction between childhood financial hardship and lifetime earnings on multimorbidity.This study shows that childhood financial hardship and lifetime earnings are associated with multimorbidity, but not associated with the absence of morbidity. Lifetime earnings modified the association between childhood financial hardship and multimorbidity suggesting that this association is differentially influential depending on earnings across young and middle adulthood. Further research is needed to elucidate lifecourse socioeconomic pathways associated with the absence of morbidity and the presence of multimorbidity among older adults. Chronic conditions generally cluster and individuals with one chronic condition are likely to have other conditions as well. As such, many older adults now manage two or more chronic conditions at the same time (i.e. multimorbidity),2; and eA substantial literature exists documenting the positive association between childhood SES and adult health; specifiFinancial hardships in childhood can greatly influence subsequent access to financial/economic resources,,20 whichThe aims for the present study were threefold. The first aim was to determine the association between childhood financial hardship and multimorbidity adjusting for demographic and socioeconomic characteristics. The second aim was to determine the association between lifetime earnings and multimorbidity; and the third aim was to determine if lifetime earnings act as an effect modifier in the association between childhood financial hardship and adult multimorbidity.The Health and Retirement Study (HRS) is a national longitudinal study of the economic, health, marital, family status, and public/private support systems of older Americans funded by the National Institute on Aging and the Social Security Administration and conducted by the Institute for Social Research Survey Research Center at the University of Michigan . The HRSMultimorbidity was operationalized as the count of six chronic conditions reported in the 2004 HRS. The chronic conditions of interest were cancer, heart disease, lung disease, stroke, diabetes, and hypertension. Chronic conditions were assessed in the HRS by a series of questions where respondents were asked if a doctor had ever told them if they had one of these diseases.childhood financial hardship with the dichotomous (yes/no) question from the HRS: 1) While you were growing up, before age 16, did financial difficulties ever cause you or your family to move to a different place?We operationalized lifetime earnings. Average annual lifetime earnings were calculated as the mean annual earnings of the respondent from age 20 to age 50. We selected up to age 50 because this is the age of eligibility for the HRS, thus all respondents would potentially have earnings up to age 50. Years with zero earnings were excluded from the calculation of average annual lifetime earnings to avoid misclassifying respondents who may temporarily leave the labor market (e.g. respondents with child-rearing responsibilities) [We used average annual lifetime earnings during young and middle adulthood to operationalize ilities) . Earningilities) . For easEducational attainment was used as an indicator of adult SES . It was Demographic characteristics such as gender, race (white/non-white), ethnicity (Hispanic/non-Hispanic), and age were assessed by self-report in the HRS. Tertiles were created for the age variable: 50-59, 60-69, and 70 and older for univariate and bivariate analysis.In order to test the association among childhood financial hardship, average annual lifetime earnings, and multimorbidity, bivariate and multivariable tests were performed. Bivariate analyses using Wilcoxon-Mann-Whitney tests were conducted to determine differences in multimorbidity between demographic categories and Kruskall-Wallis tests were conducted to determine differences in multimorbidity across SES categories. Additionally, unadjusted rate ratios were estimated with robust standard errors to quantify differences across demographic and SES categories in multimorbidity.Y = 0), zero-inflated Poisson (ZIP) regression was used [yi|xi) = pi + (1 - pi) exp(-μi) when i y= 0 and; 2) iy≥1 [To take into consideration the count nature of the outcome variable and the substantial number of respondents reporting no chronic conditions . Next, we adjusted for demographic (Model 2) and socioeconomic characteristics (Model 3). We then developed unadjusted models to evaluate the association between lifetime earnings and multimorbidity in 2004 (Model 4). Next, we adjusted this model for demographic (Model 5) and socioeconomic characteristics (Model 6). We then entered average annual lifetime earnings into Model 3 to evaluate the influence of lifetime earnings on the childhood financial hardship adjusted model (Model 7). To determine if the association between childhood financial hardship and multimorbidity was modified by lifetime earnings, we entered an interaction term  into the model (Model 8) [SAS 9.2Model 8) .Table Bivariate analysis suggests differences in multimorbidity across all demographic and socioeconomic categories except Hispanic ethnicity  = .55; CI: .28, .91; see Table Including childhood financial hardship and lifetime earnings into the ZIP model  decreases by 5%. Additionally, when we included both childhood financial hardship and lifetime earnings in our models, the association between lifetime earnings and multimorbidity remained unchanged and the association between childhood financial hardship and multimorbidity was only slightly reduced. However, our tests of interactions revealed that lifetime earnings significantly modifies the relationship between childhood financial hardship and multimorbidity. This suggests that the influence of financial hardship in childhood on subsequent multimorbidity may be altered by earnings occurring in young and middle adulthood. More specifically, our findings showed that for older adults experiencing childhood financial hardship an increase by $10,000 in average annual earnings reduces the expected number of chronic conditions by 5%. Lastly, although we were primarily interested in determining the association among childhood financial hardship, lifetime earnings, and multimorbidity over and above the influence of other socioeconomic indicators such as educational attainment, it should be noted that increasing education was not consistently associated with an increase in the count of the six chronic conditions in this study. In particular, educational attainment was not associated with the absence of morbidity; and when compared to the less than high school group, only the high school/GED category showed a protective association with multimorbidity.We evaluated our hypotheses using ZIP regression; and, the benefit of a ZIP modeling approach is the simultaneous estimation of factors associated with multimorbidity and the absence of morbidity. In fully adjusted models, childhood financial hardship was not associated with the absence of morbidity and lifetime earnings was only associated with the absence of morbidity in unadjusted models. Consistent with the literature, the logistic portion of our ZIP models showed that age was strongly negatively associated with the absence of morbidity . Lastly,The lack of an association between the several indicators of socioeconomic circumstances in this study  and demographic characteristics (i.e. race and gender) and the absence of morbidity was unexpected. Research has shown a negative association between socioeconomic status and morbidity,39 and mFinancial and economic circumstances occurring in childhood and throughout the lifecourse have been shown to affect adult health outcomes . ResearcAdditionally, it has been suggested that many chronic diseases share common risk factors . In partThere are limitations to the present study. First, respondents in the HRS were asked to recall childhood financial hardship experiences; as a result, the measures of childhood financial hardship may be subject to recall bias. Second, our sample only included those individuals who provided permission for their social security records to be linked to their HRS records potentially introducing sample selection bias. However, it has been shown that the HRS respondents who grant permission for their social security were not very much different from those who did not . In addiMultimorbidity has considerable implications for health-related research, health care, and many government systems . Due to the single disease focus in research and health care,67, we kThe authors declare that they have no competing interests.RDT-S, YL, GS, and SVS conceived of the study; RDT-S and YL developed the analysis plan and performed the statistical analysis; RDT-S, YL, GS, and SVS interpreted the results; RDT-S wrote the first draft of the manuscript. RDT-S, YL, GS, and SVS edited the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/313/prepub


In 2010, in Veneto Region, Italy, surveillance of summer fevers was conducted to promptly identify autochthonous cases of West Nile fever and increase detection of imported dengue and chikungunya in travelers. Surveillance highlighted the need to modify case definitions, train physicians, and when a case is identified, implement vector control measures In 2010, a special surveillance for West Nile virus (WNV), dengue virus (DENV), and chikungunya virus (CHIKV) was initiated in the Veneto Region of northeastern Italy. The surveillance had 2 main objectives. First, we aimed to increase the detection rate of imported chikungunya and dengue in travelers from areas to which these diseases are endemic, including in new immigrants and settled immigrants visiting relatives and friends, and to promptly identify potential autochthonous cases. Second, we aimed to detect autochthonous cases of West Nile fever (WNF) and West Nile neuroinvasive disease (WNND), which were already included in regular surveillance, to acquire a more reliable picture of disease transmission in the region.In accordance with the study protocol, possible cases detected by general physicians and emergency department physicians had to be referred within 24 hours to the closest Unit of Infectious or Tropical Diseases. Serum samples from persons with possible cases were sent to the regional reference laboratory  for confirmation. If neuroinvasive disease was present, the specific protocol for WNND was followed , and absence of other obvious causes of fever. After malaria was ruled out, cases were further classified as probable if rapid tests yielded positive results for dengue and chikungunya viruses. Rapid tests included detection of anti-CHIKV IgM by using the OnSite Chikungunya IgM Combo Rapid Test  and of DENV nonstructural protein (NS) 1 antigen by using the Dengue NS1 Ag STRIP  on serum samples. Samples from persons with possible cases were sent to the regional reference laboratory for second-line laboratory testing and confirmation. Second-line laboratory testing consisted of detection of DENV and CHIKV nucleic acids in plasma specimens by using real-time PCR and endpoint PCR, respectively, and detection of serum IgM and IgG by using an anti-CHIKV indirect immunofluorescence assay , DENV IgG DxSelect , and DENV IgM Capture DxSelect (Focus Diagnostics). Samples with DENV -positive results by ELISA were further tested by plaque-reduction neutralization test to confirm specificity of antibody response. Confirmed cases were defined as the presence of viral nucleic acid in blood specimens or by seroconversion or detection of increasing serum levels of specific IgM and IgG. Possible autochthonous cases of WNF were defined as fever >38°C for <7 days, age >15 years, no recent travel history, rash, and absence of other obvious causes of fever  of 38 possible cases of autochthonous WNF were confirmed. All were positive for WNV IgM and/or IgG and confirmed by plaque-reduction neutralization test, but none were WNV RNA positive. Clinical descriptions of WNF and WNND cases are reported elsewhere ; the published report concluded that “the possibility of introducing CHIKV into Italy cannot be ruled out on the basis of current evidence.” The index case had occurred ≈2 months before the first case was diagnosed  in 2007, which was detected, by coincidence a few days after the imported cases in Italy had been reported , clinical cases were observed in animals and humans.The success of this pilot phase prompted regional authorities to propose a 3-year plan, which the Ministry of Health has approved and funded, as part of the integrated surveillance of arboviral diseases, along with animal and entomologic surveillance. Relying only on the latter 2 would not be sensible. However, mosquito surveillance was able to predict cases in animals and humans . ExpecteConcerning the new plan for human surveillance of summer fevers, the case definition, particularly for WNF, has been modified by removing the compulsory presence of rash, to enhance sensitivity. Training and sensitization of general practitioners and emergency department physicians play a fundamental role. On the basis of a predefined threshold of vector intensity in an area where a new case has been identified, immediate vector control measures will be started when necessary.


Phoenix canariensis) forms dense patches among native riparian shrubs like arroyo willow . The structural differences between the palm and native shrubs are visually obvious, but little is known about palm’s effects on the ecosystem. We tested for the effects of the palm on a riparian invertebrate community in June 2011 by comparing the faunal and environmental variables associated with palm and willow canopies, trunks and ground beneath each species. The palm invertebrate community had lower abundance and diversity, fewer taxa feeding on the host , and more taxa likely using only the plant’s physical structure . There were no observed effects on the ground-dwelling fauna. Faunal differences were due to the physical and trophic changes associated with palm presence, namely increased canopy density, unpalatable leaves, trunk rugosity, and litter accumulations. Palm presence and resulting community shifts may have further ecosystem-level effects through alteration of physical properties, food, and structural resources. These results were consistent with a recent study of invasive palm effects on desert spring arthropods, illustrating that effects may be relatively generalizable. Since spread of the palm is largely localized, but effects are dramatic where it does occur, we recommend combining our results with several further investigations in order to prioritize management decisions.Despite the iconic association of palms with semi-arid regions, most are introduced and can invade natural areas. Along the San Diego River , the introduced Canary Island date palm ( Washingtonia spp.) and the date palms (Phoenix spp.), are commonly used in landscaping W. filifera and P. dactylifera L.) outcompete native vegetation for sunlight, space, and water; and thick layers of wide, fibrous palm frond litter prevent new plants from growing Images of many semi-arid and/or semi-tropical regions would not be complete without picturesque palms, but in areas such as California these palms are mostly non-native. Tropical icons, such as the fan palms (P. canariensis) is a particularly popular landscaping species in warm climates throughout the world Arundo donax), but localized spread and dense patch formation are common along Southern California rivers due to the high propagule pressure of horticultural sources, the high fecundity of established adults The Canary Island date palm  On the San Diego River floodplain, the Canary Island date palm  is found at mid-riparian elevations and often in association with arroyo willow . Permission to perform studies in this area was granted by the City of San Diego, owners and managers of the land, and the San Diego River Park Foundation, managers of the park. No other special permits were required, and no protected species were involved. Fifteen pairs of Canary Island palm and nearby (10–20 m apart) arroyo willow shrubs were selected. Pairs were at least 50 m apart. The canopy, stems and ground beneath the dripline of each woody plant were sampled for invertebrate community and environmental variables.Each plant canopy and trunk was sampled mid-day (10 am – 2 pm) over two consecutive sunny, warm (24–26 deg C) days using a leaf blower that had been modified to vacuum Ground-dwelling fauna were sampled using pitfall traps, each consisting of a 15 cm-diameter ×15 cm-deep bucket with a lid suspended 2 cm above the opening to reduce escape of flying invertebrates and predation by larger animals, and green leaves placed in the bottom as a refuge to reduce risks of desiccation and within-trap predation. One pitfall trap per plant was set in the ground beneath the dripline and left in the field for 6 days. When possible, invertebrates were identified, enumerated and released in the field. The remaining samples were transferred to zipped plastic bags and kept cool until frozen in the lab. Invertebrates were sorted from plant material and debris, enumerated and identified to the lowest taxonomic group possible and/or separated by the morpho-species concept using a stereomicroscope.The differences in structure and resulting physical and biological properties between each woody species was quantified by measuring the physical properties of each plant, the biomass of plant litter, and the percent ground cover and light attenuation under each canopy.Plant physical properties taken per plant consisted of height, measured using a clinometer, canopy area (longest diameter × perpendicular diameter) measured with measuring tape, and trunk diameter at ground level, measured with a diameter tape. Five subsamples of leaf toughness, measured with a penetrometer, and trunk rugosity were taken per plant and averaged. Trunk rugosity was estimated using a 100 cm long string, run vertically and in contact with the surface of each trunk at about chest height. The distance between each end of the string was then measured and subtracted from the 100 cm total length to give an estimate of amount of rugosity . Rugosity index is presented as a percent .2 quadrat subsamples, weighing the biomass in the field with a handheld scale, and averaging the three subsamples. Percent ground cover under the dripline of each plant was estimated by averaging visual estimates of cover within three 0.25 m2 quadrats . Photosynthetic-light attenuation of each plant canopy was measured using an Apogee Quantum handheld light meter during mid-day (10 am –2 pm) over two consecutive sunny days. Three measures were taken at each plant, standardized to full sunlight (under-canopy light [µmol photons m−2 s−1]/full sunlight [µmol photons m−2 s−1]), and averaged.The biomass of plant litter for each plant was estimated by clipping (if needed) and collecting all litter within three 0.25 mAll data were log (x+1) transformed or arcsin square root transformed (proportion data) before analyses Multivariate analyses were carried out on invertebrate assemblages of the palm and willow plants using Primer Software Significance testing for differences in faunal composition between palm and willow plants and between pair number, or site , were done using an analysis of similarity (ANOSIM) procedure. This is a randomized permutation test based on rank similarities of samples 2≥0.04. Tests of the environmental variables that best explain community differences were conducted using the Bray-Curtis similarity indices with the BEST Analysis in Primer Software using the BVSTEP method  with fixed starting variables and a Euclidean distance resemblance measure. BVSTEP sequentially adds environmental variables, keeping those that best explain faunal community patterns and eliminating those that explain least. Several iterations of the test are run with a random selection of variables to ensure that the best match is found Relationships between the environmental variables and species diversity and total abundance were tested with forward, stepwise multiple regressions using JMP® 9 Statistical Software. Variables included in the model met the criteria of p≤0.05 and rThe palm had on average a 24% larger canopy area and 3 times wider trunk than the willow . The greThe palm had only about 60% of the invertebrate abundance and 60–70% of the species per sample than the willow . DiversiThe palm canopies and/or trunks had higher proportions of arachnids, lepidopterans, neuropterans and psocopterans than willow, while willow canopies and trunks had higher proportions of coleopterans and hymenopterans . None ofLinepithema humile, Hymenoptera), leaf hoppers , a jumping plant louse (Hemiptera: Psyllidae), a minute brown scavenger beetle , an inch worm caterpillar (Leptidoptera: Geometridae), and an array of midges (Diptera); while palm canopies hosted a bark louse , a hemerobiid lace wing (Neuroptera), and a crab spider (Aranae: Thomsidae) , although there was still no difference in the ground-dwelling invertebrate communities beneath the palm and willow . The palm and willow faunal communities differed for inhabitants of the canopies  and inhabitants of trunks  . About 6omsidae) .Epinotia emarginana), a bark louse (Psocoptera), a leaf hopper  that feeds on cottonwoods and willows, and a cobweb spider (Aranae: Theridiidae) , one leaf hopper , a jumping plant louse (Hemipteran: Psyllidae), a caddisfly (Trichoptera), and two types of pompilid wasps; and palm trunks hosting higher abundances of the oak leaf-roller moth (idiidae) .The larger area and/or denser canopies associated with palm were associated with lower total abundances of canopy fauna  and diveBaccharis salicifolia), sandbar willow , and black willow  The presence of the Canary Island date palm was associated with lower riparian invertebrate abundance and diversity, especially for canopy and trunk dwelling communities, and shifted the composition of these communities from a mix of beetles, midges, leaf hoppers, parasitoid wasps, and spiders to communities dominated by bark lice, the adult oak-roller moth and spiders. The palm, however, seemed to discourage inhabitation by the introduced Argentine ant despite the ant’s affinity for nesting in plant litter Neither the piles of accumulated, fibrous leaf litter nor any of the other characteristics of the palm seemed to affect the ground dwelling invertebrate community during this study. It may be that the ground beetles, spiders and Argentine ant, which all prefer cover and were found throughout the study area, obtained suitable cover and/or food from both the accumulated palm litter and the living grass and fine willow leaf layers beneath the willow during this time period The presence of the palm alters the ecosystem directly and indirectly through both trophic and structural means Vireo bellii pusillus), an obligate riparian species in this region, exclusively feeds on insects such as hemipterans, beetles and, in particular, caterpillars These effects may extend to vertebrates within the ecosystem through direct interactions e.g.,  or indirDespite the different nature of our California study systems– desert springs and a coastal riparian system– the findings in this study were similar to those of As seen in California, moist ecosystems within arid and semi-arid climates may be susceptible to palm invasion and similar effects on the physical environment and invertebrate community Further testing of the effects of palm presence on the invertebrate community during other times of the year, and the effects of both palm presence and its associated invertebrates on common and threatened riparian vertebrates, and on other ecosystem processes , are needed to assess the threat level of these relatively understudied invaders. Understanding the effects of the palm at this point, while it mostly exists in localized patches, is important for making management decisions. A species does not have to be abundant to have a relatively large impact on its ecosystem (e.g., ecosystem engineers, Study of the rates and patterns of spread of the palm are also needed. Anecdotal data from Southern California reveals mostly localized spread of the palm around parent plants