Violence against women is a global public health problem with negative effects on physical, mental, and reproductive health. The World Health Organization (WHO) has identified intimate partner violence (IPV) and sexual violence (SV) as major targets for prevention and amelioration and recently developed clinical and policy guidelines to assist healthcare providers. This project was undertaken to determine the 2013 baseline national policies and clinical guidelines on IPV and SV within the Latin American and Caribbean (LAC) region to identify strengths and gaps requiring action.Each Pan American Health Organization/World Health Organization Regional Office for the Americas (PAHO/WHO) country focal point was contacted to request their current national policy and clinical guidelines (protocol) on IPV/SV. We augmented this by searching the internet and the United Nations Women website. Each country’s policy and clinical guideline (where available) was reviewed and entered into a scoring matrix based on WHO Clinical and Policy Guidelines. A total score for each heading and subheading was developed by adding positive responses to identify LAC regional strengths and gaps.We obtained 15 national policies and 12 national clinical guidelines (protocols) from a total of 18 countries (“response” rate 66.7 %). National policies were comprehensive in terms of physical, emotional, and sexual violence and recommended good intersectoral collaboration. The greatest gap was in the training of health-care providers. National Guidelines for women-centered care for IPV/SV survivors were strong in the vital areas of privacy, confidentiality, danger assessment, safety planning, and supportive reactions to disclosure. The largest gaps noted were again in training healthcare professionals and strengthening monitoring and evaluation of services.Baseline measurement of policy and clinical guidelines for IPV/SV in LAC PAHO/WHO member countries at the time of issuing the 2013 WHO Clinical and Policy Guidelines reveals some important strengths, but also serious gaps that need to be addressed. The most pressing needs are for concerted training initiatives for healthcare providers and strengthening multisectoral monitoring and evaluation of services. A future evaluation of national policies, clinical guidelines, monitoring and evaluation will need to be conducted to measure the progress of the required scaling-up process. Violence against women is a global public health problem and a violation of human rights, which has substantial negative effects on physical, mental, and reproductive health, as well as detrimental social and economic impacts . While tThe prevalence of IPV and SV varies internationally, partly due to different definitions and approaches to measurement. However, a WHO multicountry study  on domestic violence against women in 10 countries, using comparable data, found the highest lifetime prevalence 61 %) of physical IPV in rural Peru . Other s1 % of phIn response to requests from Member States and as part of its efforts to prevent and ameliorate IPV and SV, WHO developed clinical and policy guidelines to assist healthcare providers, who are likely to be the first professional contact for survivors. To develop these clinical and policy guidelines an expert panel was assembled for a Guideline Development Group which included academics, clinicians/ service providers, policy makers, and women’s health and rights advocates from across the globe, including low- and middle-income countries. A literature review was undertaken and scientific evidence for recommendations was synthesized using the Grading of Recommendations Assessment, Development and Evidence (GRADE) methodology . RecommeA useful first step in implementing the new WHO Clinical and Policy Guidelines is to determine the existing (baseline) national policies and clinical guidelines for IPV and SV to identify strengths and gaps. This project, supported by PAHO/WHO, was undertaken to determine the 2013 baseline national policies and clinical guidelines on IPV and SV within the LAC region.Four sources were used to obtain the maximum number of national policies and clinical guidelines in each LAC country member of PAHO in which the primary language was Spanish, English or Portuguese. Each PAHO/WHO country focal point was contacted in July 2013 by the PAHO/WHO Regional Advisor on Family Violence (AG) to inform them about this project, to introduce the trilingual study coordinator (RA), and to ask them to send their current national policy and clinical guidelines (protocol) on IPV/SV. This was followed up by the study coordinator with at least three reminders by email and phone to non-responders. We informed each country at the time of contacting them that we would not publish their individual results, but these would be available to PAHO. PAHO/WHO focal points were our primary source, but we augmented it by an internet search for national policy and clinical guidelines on IPV/SV for each LAC country, contact by one of the investigators with knowledgeable colleagues where available for any LAC country and searching the United Nations (UN) Women website for any documented LAC national policy on IPV/SV.The WHO Clinical and Policy Guidelines were used to develop a scoring matrix for each country. The headings with appropriate subheadings included women-centered care for IPV/SV survivors, additional issues for SV survivors, and training of healthcare providers. The scoring matrix was reviewed and approved by five experts on IPV/SV/CM , including three involved in developing the WHO Guidelines.Each country’s policy and clinical guideline (where available) was reviewed and entered into the scoring matrix by the study coordinator along with the appropriate page number. Two investigators reviewed and approved the scoring matrix entries. The scoring matrix for each country was returned to the appropriate PAHO/WHO focal point who was asked to review and approve it (or provide a correction) in collaboration with their Ministry of Health. Two reminder emails were sent to non-responders. To preserve confidentiality of individual PAHO/WHO countries, a total score for each heading and subheading was developed by adding positive responses from all responding countries to identify LAC regional strengths and gaps requiring action. We defined large gaps as aggregate scores of 3 or less (out of 12), moderate gaps as aggregate scores of 4 to 7 and strengths as aggregate scores of 8 to 12. An overall report was written and submitted to PAHO/WHO.We obtained 15 national policies and 12 national clinical guidelines (protocols) from a total of 18 countries . Countries that responded included Argentina, Belize, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, El Salvador, Guatemala, Guyana, Honduras, Mexico, Nicaragua, Panama, Peru, Uruguay, Venezuela. Seven countries were “non-responders” despite at least three reminders by email or phone and an internet search, and two countries sent information other than national policies or guidelines. Access to policies and guidelines was available to the public via an online version or the country’s Ministry of Health or Women’s Institute in all but 2 responding countries. The definitions of IPV, SV, CM by country varied slightly in wording, but all were consistent with those found in the WHO Guidelines. A few countries used the generic terms “domestic violence” or “family violence”, but the subsequent wording clarified the specific form of violence  being discussed.The time frame for the implementation of the 15 policies obtained ranged from 2006 to 2017 and all addressed physical, emotional and sexual violence against women. These were developed by the Ministry of Health (5), in collaboration with one or more other government sources (9), local or regional governments (1), professional associations (2), or other sources (7). Policies addressed sectors in health (15), education (13), justice or police (12), social development (4), media (3), work (3), human rights (1), public security (1), parliament (1) and sports (1). Most policies addressed violence prevention (14), how to respond to disclosure (15), in children and adolescents (14) and women survivors (15). Two countries recommended pre-qualification training and 12 in-service training for health care providers, however the frequency and length of training in all policies was unspecified. The content of training included when and how to respond to violence (3), best ways to respond (8), how to collect forensic evidence (2), specific information about violence against women (VAW) local laws (7), existing services (3), provider attitudes (5), and provider’s own experience of violence (1).Of the 12 national guidelines (protocols) for the health sector that were obtained, 4 guidelines included IPV, SV and CM, 3 covered only SV, and 5 covered one or more of these topics, most commonly CM. Mandatory reporting was required for CM in 10, SV in 9 and IPV in 4 guidelines. If reporting was not mandatory, 10 guidelines recommended respecting the women’s decision about reporting. Ten guidelines differentiated between adult and child survivors of SV. Recommendations in the WHO Clinical Guidelines related to women-centered care for IPV/SV survivors were selectively addressed in many guidelines as shown in Table Additional recommendations for SV survivors such as specific services, risk and management of pregnancy, sexually transmitted infections (STIs), human immunodeficiency virus (HIV), hepatitis B and forensic documentation are shown in Table Training of healthcare providers on IPV/SV and the monitoring and evaluation of policy, guidelines and services are shown in Table The challenges we experienced in obtaining current national policies and clinical guidelines on IPV and SV in LAC are illustrative of some of the difficulties of conducting health and policy research in low- and middle-income countries. We acknowledge the limitation that one third of all countries approached did not respond. The low response rate limited researchers’ ability to carry out subregional comparisons. Nevertheless the information we obtained from the 66.7 % of countries we approached provides a useful baseline snap-shot of the strengths and gaps to inform the implementation of the July 2013 WHO Clinical and Policy Guidelines.Policies:National policies we obtained were fairly comprehensive in terms of covering physical, emotional, and sexual violence and some displayed good intersectoral collaboration by involving a number of government and civil sectors, which are vital for a strong government and community response to IPV/SV. The policies were commendably strong in addressing violence prevention and how to respond to IPV/SV in women and children in a supportive manner. The greatest gap was in the training of health-care providers in virtually all aspects of care for IPV/SV survivors essential for an adequate response.Clinical Guidelines:Women-centered care for IPV/SV survivors was especially strong in the important areas of privacy, confidentiality, danger assessment, safety planning, and supportive reactions to disclosure. Strength was also evident in providing written information and referring to legal, housing and economic empowerment services by a referral pathway. Women with special needs related to mental disorders and/or physical disability and referrals and referral pathways for services were also fairly well addressed. Moderate gaps were evident in selective enquiry for IPV, SV, assessing mental health , providing mental health services, psychological first aid, watchful waiting to see if early distress resolves, providing or mobilizing social support, and structured advocacy and empowerment programs. Moderate gaps were also seen in assessing and providing for children’s safety, providing psychotherapy for children exposed to IPV and meeting the special needs of pregnant women, all of which are essential issues. Documentation with a body diagram or photo of injuries if present which may be essential for legal proceedings was also a moderate gap. Large gaps were evident in advising on coping strategies for stress and assessing for substance abuse and posttraumatic stress disorder. Large gaps were also present on advising women on the potential risks of taking home written materials, directories of existing services, shelters and hotlines, all of which are critical aspects of a healthcare response to IPV/SV. Unfortunately, the WHO guidance does not address IPV/SV in same sex relationships and as our project was to examine baseline adherence to the WHO Clinical and Policy Guidelines, we did not include this important topic in our scoring matrix.There were additional strengths in the care of SV survivors; most guidelines appropriately did not require STI testing before treatment or HIV testing before post-exposure prophylaxis (PEP), advising about recording the time and type of assault, the need for vaginal swabs, the risks of pregnancy, STI’s, Hepatitis B and HIV and emergency contraception within five days of SV. Moderate gaps for survivors of SV were seen in the availability of sexual assault services available 24/7 and the need to collect anal and oral swabs and hair and fibers to assist in legal proceedings. Specific advice about types of emergency contraception, referral for abortion where legal, specific treatment for various STI’s, and offering hepatitis B vaccine were moderate gaps. HIV testing and counselling at first consultation, HIV-PEP appropriateness counselling, shared decision making, starting HIV PEP within 72 h, 2 or 3 drugs for HIV PEP, regular follow-ups, offering adherence counselling, and using drugs that followed national guidelines were also moderate gaps. Large gaps for SV survivors included prioritizing drugs with fewer side effects, although this decision may have been pre-empted by national drug guidelines.The largest gaps noted were in the area of providing training to healthcare professionals who are often the most trusted and consulted by victims of violence. We asked about content, frequency and timing  training, but assessing quality was outside the scope of this effort. Evidence suggests that “one-shot training” is not sufficient and trainings should be repeated/ongoing but this is not what occurs in low- and middle-income countries. The WHO Guidelines state “training should be intensive and content-appropriate to the context and setting. Intensive multidisciplinary training…should be offered to health care professionals where referrals to specialist domestic violence services are possible” (11: pp 35–36). Only half of the guidelines advised in-service training for frontline healthcare providers and provided information to them about IPV/SV and the best ways to respond to disclosure. Large gaps were reported on nearly all training items in the WHO Clinical Guidelines. None of the guidelines included training of prequalification healthcare workers or how direct healthcare providers should collect forensic evidence, so necessary for legal prosecution of perpetrators. Only one guideline suggested the length and frequency of training and there was poor psychological support for vicarious trauma among healthcare providers caring for IPV/SV patients. Clearly training is a crucial step in implementing the WHO Clinical and Policy Guidelines [However, development of policies and guidelines is only the first step; monitoring and evaluating services for IPV/SV survivors are essential for implementation. Large gaps were reported in promotion of mechanisms and meetings for intersectoral collaboration and evaluation of services. To the best of our knowledge, there are no regional efforts to assess the implementation of health sector policies/protocols, though there may be some ongoing country-specific initiatives. The gap between policy, funding and implementation is key. PAHO is currently preparing a Regional Strategy and Plan of Action on strengthening health systems to address VAW to be reviewed and (hopefully) approved by Ministers of Health from 35 countries in the Americas. This document highlights the gap between policy and implementation and tries to push for advancements in terms of the creation of dedicated budget lines for VAW work within health budgets, for instance. Optimal evaluation should include intersectoral collaboration as well as input from women survivors of IPV/SV. Intersectoral collaboration is essential to improve policies and services, but also to change the public perception against IPV/SV especially in patriarchal societies where VAW may be tolerated or ignored.Baseline measurement of policy and clinical guidelines for IPV/SV in LAC PAHO/WHO member countries at the time of issuing the 2013 WHO Clinical and Policy Guidelines reveals some important strengths, but also serious gaps that need to be addressed. While there are specific topic gaps within women-centered care for IPV/SV survivors and additional issues for SV survivors, the most pressing needs are for concerted training initiatives for healthcare providers and strengthening multisectoral collaboration, monitoring and evaluation of services. A future evaluation of national policies, clinical guidelines, monitoring and evaluation will need to be conducted to measure the progress of the required scaling-up process.


We asked our Section Editors to discuss the breakthroughs in their fields of expertise, and what these might mean for the future. As in previous years, exome and whole-genome sequencing are leading the way in our understanding of disease mechanisms, their diagnosis and treatment, while information about the protein products of the genome has also grown, driven by novel technological advances. Precision medicine is now taking off as an important topic in the public health sphere and in education, and no discussion of 2015 would be complete without a mention of the huge advances in gene editing technologies, the implications of which have dominated ethics and policy debate.Functional annotation of the human genome through gene discovery took a notable “leap” in 2015 with insight into gene function provided using Mendelian genomics approaches, primarily exome sequencing, to study the specific rare variants underlying disease trait manifestation.Genome Medicine dedicated an entire issue (July 2015) to this topic with notable papers describing advances in emergency medical genomes [The numbers of gene discovery publications are too numerous to single out any one; however, the UK Wellcome Trust Deciphering Developmental Disorders (WTDDD) , 2 and U genomes  and revi July 201 to this This effort to functionally annotate the human genome has been greatly facilitated by a web-based platform for rare disease gene discovery—the Matchmaker Exchange —that hasJames R. Lupski,Section Editor,Genomics and epigenomics of diseaseAs we look forward in 2016 the clinical data available that may enhance biological research efforts will likely continue to explode. More and more we may find that model organism studies look toward human genetics and medical genetics data to provide important insights into biology and in so doing reveal fundamental understanding of disease processes. Moreover, such new understanding may foment novel approaches to disease management and potentially enable therapeutic intervention for rare variant associated disease.There is increasing awareness of pharmacogenomics (PGx) as a key component in personalized medicine. A recent evaluation of all 517 medications labeled by the European Medicines Agency (EMA) between 1995 and August 2014 demonstrated that 15 % of these drugs include PGx information which covers pharmacokinetic  and pharmacodynamic targets [S-methyltransferase gene TPMT to avoid hematotoxicity associated with thiopurine drugs, such as azathioprine [DPYD variants contribute to fluoropyrimidine-induced severe toxicity [DPYD testing is still not officially recommended [Major efforts have been initiated to implement genetic testing of actionable pharmacogenes into clinical practice. The Clinical Pharmacogenetics Implementation Consortium (CPIC), a group of international experts, is working on evidence-based guidelines which are standardized and provide PGx data to individualize the prescribing of drugs . Howeverhioprine . Convinctoxicity . Althougommended .Matthias Schwab,Section Editor,Pharmacogenomics and personalized medicineThe vision of personalized medicine and PGx is rather complex and strategies are needed for better clinical implementation. The use of electronic clinical decision support (eCDS) like the US-initiative eMERGE  will promote the progress of clinical implementation of PGx. However comprehensive and systematic phenotypic characterization of the patient, including diseases and drug therapy, by high-throughput technologies is mandatory. Computer-based, direct interview methods are available to assess the patients’ phenotypes independent of physician input in a standardized manner . Multi-oIn 2015, the USA launched the precision medicine initiative that includes two components: one focusing on cancer genomics and treatment, and one focusing on generating data on long-term health and disease in a national cohort research study of one million or more people .The field of pathogen genomics continues to expand. Molecular technologies are being integrated into the diagnosis, treatment, and control of infections. For example, rapid metagenomic identification of viral pathogens in clinical samples can be accomplished by real-time nanopore sequencing analysis . The CenHealthcare, focusing on implementation of public health genomics, presented data and information on a range of ongoing public health activities, including reducing the burden of hereditary breast and ovarian cancer, screening children for familial hypercholesterolemia, and engaging medically underserved populations in family history education [We also saw increasing applications of human genetics into public health programs. While genetics has been part of public health since newborn screening began in the 1960s, genetics is becoming a priority area for prevention and treatment of common chronic diseases such as cancer and heart disease. A special 2015 issue of the journal Because of the rapid evolution of genomic medicine, a crucial function in public health genomics is to identify evidence-based genomic applications that can improve health, inform and engage various stakeholders, and integrate genomics into ongoing public health programs . To helpMuin J. Khoury,Section Editor,Genomic epidemiology and public health genomicsWhile the precision medicine initiative will take years to mature and lead to tangible discoveries and products, 2016 promises to be an exciting year for the intersection of precision medicine and population health. Some key areas to watch include: (1) developing more robust approaches to obtain empirical data on the impact of genomics and precision medicine on population health; (2) developing metrics for best practices on genomics and population health including indicators for successful implementation and outcomes; and (3) exploring key concepts for the development of “precision public health”  beyond gI have chosen four articles published in 2015 that I feel either demonstrate the versatility of proteomic, metabolomic, or lipidomic approaches to medicine, or will have significant impacts as new approaches in the near future.While liquid chromatography mass spectrometry (LC-MS) dominates as a tool for both metabolomics and proteomics, users have to decide whether they will perform nontargeted, discovery approaches, which are at best semiquantitative in nature, or targeted approaches relying on triple quadrupole MS, which, while quantitative, only target a limited number of metabolites or peptides. Developments in 2015 have questioned these separate workflows. Guo and colleagues  describeSimilar approaches can be used to reconstruct lipidomes, using the fact that all lipid species consist of a series of building blocks such as individual fatty acids and head groups. Ni and coworkers  describeOne problem with new bioinformatic tools that limits their uptake is that they may be written in a variety of languages. Giacomoni and coworkers  borrow aJulian L. Griffin,Section Editor,Proteomics & metabolomics in medicineMetabolomics, proteomics, and lipidomics are also delivering in terms of translational medicine. For example, Eiden and colleagues  used LC-2015 has witnessed an acceleration of the convergence of big data and genomic medicine that supports the implementation of personalized medicine using systems biology approaches. These are now being developed globally through advanced education programs targeted at research and healthcare professionals as well as the public.These trends were discussed at the Big Data and Healthy Living Technologies Roundtable organized by BioHealth Computing and the European Scientific Institute, the training branch of CERN, in Archamps, France , and durIn relation to the first issue, Siwo et al. highlighted  how clouCharles Auffray,Section Editor,Systems medicine and informaticsThrough the consolidation of these trends, 2016 should therefore see more advances toward the actual implementation of participatory, preventive, predictive, personalized (P4) systems medicine to understand wellness and tackle unmet medical needs worldwide.While many genomic policy issues continue to attract significant attention from both the academic community and the general public, the social and ethical challenges associated with the new gene-editing technology dominated in 2015.The prospect of being able to efficiently edit the human genome—through the application of a technology known as CRISPR-Cas9—has stirred debate about if and when the modification of the human germ line can ever be ethically justified. Some in the ethics community have called for a complete ban, fearing, inter alia, the unknown future consequences of altering the human genome. Those who support the cautious clinical application of gene editing note the potential to cure rare monogenic diseases . The debAnother policy challenge that received attention in 2015 was the regulation of direct-to-consumer (DTC) genetic testing. In 2013, the California company 23andMe was prohibited by the US Food and Drug Administration from providing health-oriented testing to its consumers. But in 2015, the company was granted permission to start providing a limited array of services  , thus onTimothy Caulfield,Section Editor,Ethical, legal and social issues2016 will undoubtedly see the emergence of new ethical challenges, such as the regulation of the noninvasive prenatal testing market and the growing (and largely evidence-free) DTC genetic testing industry for lifestyle, fitness, and nutrition. But as the science continues to move forward quickly, gene editing seems likely to remain a dominant policy issue in 2016.


As in the past, satellite meetings and special interest group meetings (SIGs) will be held on Friday, July 8th, and Saturday, July 9th, prior to the main conference at the main meeting venue, the Swan and Dolphin Hotel. Several applied knowledge exchange sessions (AKEs) have also been scheduled for Saturday and are smaller in size in order to provide a more intimate meeting environment. Check out this year’s 3DSig: Structural Bioinformatics and Computational Biophysics will be holding its 12th meeting and has become one of the largest meetings that brings together world-class scientists studying structural computational biology. Keynote speakers include David E. Shaw of Columbia University; Ruben Abagyan of the University of California, San Diego and Molsoft LLC; Heather Carlson of the University of Michigan; Bruce Donald of Duke University; Koby Levy of the Weizmann Institute; Rafael Najmanovich of the Université de Sherbrooke; and Shoshana Wodak of the Free University of Brussels.This year, two popular satellite meetings are convening once again for two days on Friday, July 8th, and Saturday, July 9th. three data analysis challenges for its annual contest. Scientists present their analyses of these data set challenges and prizes are awarded for best analyses and presentations.The 15th annual International Conference on the Critical Assessment of Massive Data Analysis (CAMDA) is the other major satellite meeting being held on July 8th and 9th. CAMDA focuses on the analysis and integration of massive data sets, and the scientific committee of CAMDA has posted COSIs). These SIGs span all topic areas in the field of computational biology, including bio-ontologies, high-throughput sequencing, open source bioinformatics software, data visualization, and RNA biology. There really is a SIG for everyone, and these smaller meetings provide an atmosphere conducive to scientific discussion and exchange. Two new SIGs are debuting this year: “SysMod: Computational Modeling of Biological Systems” and “TransMed 2016: Translational Medicine Informatics & Applications.” SysMod aims to close the gap between bioinformatics and systems biology modeling and will include talks on modeling metabolism and modeling biochemistry. TransMed will cover topics related to the burgeoning field of translational medicine informatics, including clinical and molecular data storage and integration infrastructure, curation and harmonization of clinical, ‘omics, and imaging data, and computational approaches for target selection and drug discovery, as well as other related topics.ISMB is fortunate to host numerous one- and two-day SIGs prior to the main meeting. Many of the SIGs are organized by ISCB’s Communities of Special Interest —Opportunities and Challenges for Integrating Bioinformatics into the Clinical RealmAKES05: Cytoscape 3 User Tutorial: Introduction to network visualization and analysis using CytoscapeMake sure you consider all of these pre-meeting sessions during your conference planning and make the most of your time at ISMB 2016.


Dissemination of genetic testing for disease susceptibility, one application of “personalized medicine”, holds the potential to empower patients and providers through informed risk reduction and prevention recommendations. Genetic testing has become a standard practice in cancer prevention for high-risk populations. Heightened consumer awareness of “cancer genes” and genes for other diseases , as well as the burgeoning availability of increasingly complex genomic tests , has escalated interest in and demand for genetic risk assessment and the specialists who provide it. Increasing demand is expected to surpass access to genetic specialists. Thus, there is urgent need to develop effective and efficient models of delivery of genetic information that comparably balance the risks and benefits to the current standard of in-person communication.The aim of this pilot study was to develop and evaluate a theoretically grounded and rigorously developed protocol for telephone communication of BRCA1/2 (breast cancer) test results that might be generalizable to genetic testing for other hereditary cancer and noncancer syndromes.Stakeholder data, health communication literature, and our theoretical model grounded in Self-Regulation Theory of Health Behavior were used to develop a telephone communication protocol for the communication of BRCA1/2 genetic test results. Framework analysis of selected audiotapes of disclosure sessions and stakeholders’ feedback were utilized to evaluate the efficacy and inform refinements to this protocol.Stakeholder feedback (n=86) and audiotapes  of telephone disclosures revealed perceived disadvantages and challenges including environmental factors , patient-related factors , testing-related factors , and communication factors . Resulting modifications to the communication protocol for BRCA1/2 test results included clarified patient instructions, scheduled appointments, refined visual aids, expanded disclosure checklist items, and enhanced provider training.Analyses of stakeholders’ experiences and audiotapes of telephone disclosure of BRCA1/2 test results informed revisions to communication strategies and a protocol to enhance patient outcomes when utilizing telephone to disclose genetic test results. Dissemination of genetic testing for disease susceptibility, one application of “personalized medicine”, holds the potential to empower patients and providers with informed risk reduction and prevention recommendations ,2. GenetGiven the complexity and limitations of genetic testing for disease susceptibility, pre- and post-test counseling are recommended across a variety of fields  to optimize patients’ informed consent, understanding of, and adaptive behavioral and psychosocial responses to genetic test results ,12,18,19We utilized our preliminary data from patients and providers , our teaThis study and related work ,34,44,45The literature and our preliminary data support the hypothesis that both short-term cognitive (knowledge and perception) and psychological  outcomes and longitudinal adjustment and performance of surveillance behaviors, in response to receipt of genetic test results, will be moderated by biological  experienced by patients in response to stressful procedures or life events [State anxiety was measured with the 20-item State Inventory of the State-Trait Anxiety Inventory (STAI), which is a sensitive indicator of transient or situational changes in anxiety , GC experiences (3 items), and GC perceptions of patient experiences (3 items) with, and suggestions for improving their telephone disclosure session .Changes in pre-test and 3-5 days post telephone disclosure scores were calculated for each participant and each construct, which are reported separately . Pre-defFramework analysis was utilized to analyze open-ended responses regarding patient and GC reported advantages, disadvantages, and recommended modifications  ,57,78-80A total of 167 eligible subjects were approached for participation. Of the 167 eligible subjects, 100 (59.9%) agreed to participate, provided informed consent, and completed the baseline assessment, and 95 proceeded with BRCA1/2 testing . A totalAll participants were women, 10% (9/86) were non-white, 59% (51/86) had a personal history of cancer, and 50% (43/86) had a college degree or graduate education. The majority of participants  received an uninformative negative result . Nine women received a positive result , 4 received a true negative result , and 2 received a variant of uncertain significance. Provider checklists revealed high fidelity to communication topics .Patients and providers identified several advantages for patients to telephone disclosure of genetic test results, including patient conveniences, setting, and timing. Patient and provider reported advantages for patients did not differ. Providers also identified advantages of telephone disclosure for genetic counselors, including setting, scheduling, and efficiency . Most paModifications to the original communication protocol were informed by the audiotape review  as described above, open-ended survey responses from patients (n=86) and providers (n=4) on 86 disclosure sessions, our theoretical model, and the literature, and developed by a clinical health psychologist. Primary modifications are summarized in The goal of this pilot study was to evaluate stakeholder (patient and provider) experiences with our telephone disclosure protocol, grounded in our theoretical model, to inform refinements to our initial protocol for the delivery of genetic test results and to obtain preliminary outcome data for future research. To our knowledge, this is the first study to describe the development and refinement of a telephone communication protocol for the disclosure of genetic test results informed by provider and patient feedback, as well as systematic review of communication sessions grounded in a theoretical model of health behavior ,43. ThisThe results of our study indicate that patients and providers identify both advantages and disadvantages of telephone disclosure of genetic test results . AdvantaTo address these challenges, provider training, including additional verbal probes and procedures to assess patients’ psychological response and understanding, as well as situations unique to non-in person communication, must be incorporated into counseling to ensure effective communication of health information via telephone. Professional or educational training for alternative counseling models that incorporate these probes and procedures could prove invaluable for future counseling for both novice and experienced genetic counselors. Evolving genetic technologies have the potential to expand the reach of genetic testing. Realizing the associated health gains will require a workforce of genetic counselors with training in telephone and other nontraditional models of communication of genetic information. Research has shown that effective communication between providers and patients can be achieved through these technologies and might result in improved outcomes . Future In this paper, we present a model for adapting the standard genetic counseling model for innovations in the delivery of genetic medicine. Our model includes stakeholder (patient and provider) input, as well as systematic review of audiotapes of pilot sessions of telephone disclosure of genetic testing results and is theoretically informed. We expect this model will be broadly applicable to adaptions of counseling for other innovations in the delivery of genetic/genomic test results. For example, we are currently employing adaptations of this model to study the potential to increase access by utilizing telemedicine to deliver genetic counseling services to community practices where genetic counselors are not available , to infoWe acknowledge several limitations to this study. Despite the recruitment of a clinical population, we had relatively low representations of some subgroups . Thus, our findings may not be generalizable to a more diverse population. Our on-going multi-center randomized study aims to increase representation of these subgroups. It will also inform how cognitive and affective responses might differ between patients receiving in-person and telephone communication of genetic test results.Providers delivering and patients receiving genetic test results by telephone identified advantages to telephone disclosure  and disadvantages . Review of stakeholder reported experiences and audiotapes of telephone disclosures lead to a number of communication strategy and protocol revisions to enhance patients’ cognitive, affective, and behavioral responses to genetic test results in the context of telephone disclosure of genetic test results.


Poorly managed hospital discharges and care transitions between health care facilities can cause poor outcomes for both patients and their caregivers. Unfortunately, the usual approach to health care delivery does not support continuity and coordination across the settings of hospital, doctors’ offices, home or nursing homes. Though complex efforts with multiple components can improve patient outcomes and reduce 30-day readmissions, research has not identified which components are necessary. Also we do not know how delivery of core components may need to be adjusted based on patient, caregiver, setting or characteristics of the community, or how system redesign can be accelerated.Project ACHIEVE focuses on diverse Medicare populations such as individuals with multiple chronic diseases, patients with low health literacy/numeracy and limited English proficiency, racial and ethnic minority groups, low-income groups, residents of rural areas, and individuals with disabilities. During the first phase, we will use focus groups to identify the transitional care outcomes and components that matter most to patients and caregivers to inform development and validation of assessment instruments. During the second phase, we will evaluate the comparative effectiveness of multi-component care transitions programs occurring across the U.S. Using a mixed-methods approach for this evaluation, we will study historical (retrospective) and current and future (prospective) groups of patients, caregivers and providers using site visits, surveys, and clinical and claims data. In this natural experiment observational study, we use a fractional factorial study design to specify comparators and estimate the individual and combined effects of key transitional care components.Our study will determine which evidence-based transitional care components and/or clusters most effectively produce patient and caregiver desired outcomes overall and among diverse patient and caregiver populations in different healthcare settings. Using the results, we will develop concrete, actionable recommendations regarding how best to implement these strategies. Finally, this work will provide tools for hospitals, community-based organizations, patients, caregivers, clinicians and other stakeholders to help them make informed decisions about which strategies are most effective and how best to implement them in their communities.NCT02354482 on clinicaltrials.gov on 1/29/2015Registered as  Though improving transitional care (TC) is a patient safety and quality improvement priority with numerous national initiatives implementing various combinations of interventions to improve the quality of care transitions –6, patieThe hospital discharge is a complex, multi-step process requiring integrated communications among the inpatient care team, the patient and caregiver, the outpatient care team, and community services . ResearcLack of assessment of patient and contextual issues represents an important gap in evidence regarding TC programs. While researchers have worked to develop interventions that can improve care transitions, few have looked to the promise of enhanced transitional care with an emphasis on what is most meaningful and important to patients and family caregivers .Moreover, efforts at coordination across the continuum of care face difficult barriers, especially given the unique aspects of each patient , and given that specific factors contributing to ineffective care transitions often differ among health and community-based organizations and contexts. To apply findings from the current widespread experimentation to improve transitional care requires a comprehensive evaluation using comparative effectiveness research techniques. In response to the Patient Centered Outcome Research Institute (PCORI) Transitional Care funding announcement, we proposed and received the award for Project ACHIEVE . This project aims to learn from patients and caregivers which transitional services and outcomes matter most to them, rigorously evaluate current efforts at improving care transitions, and develop recommendations on best practices for patient-centered care transition interventions and guidance for scalability and large-scale dissemination.Following NIH recommendations on mixed-methods research , ProjectProject ACHIEVE was approved by the Institutional Review Board (IRB) at the University of Kentucky (IRB Number 14–0789-F3R). Each partner site also obtained approval from its own institution’s IRB for its study activities such as focus groups or survey administration. Informed consent will be obtained from all focus group participants. Patients enrolled in the survey will provide HIPAA authorization for release of their personal health information to enable collaborators on the ACHIEVE team to contact them for recorded verbal consent and survey conduct.Project ACHIEVE will focus on Medicare fee-for-services beneficiaries and study diverse high risk patient populations, including those with: 1) multiple chronic conditions; 2) mental health issues; 3) rural area domicile; 4) limited English proficiency or low health literacy; 5) low socioeconomic status; 6) Medicare and Medicaid dual eligible; and 7) disabled and younger than 65. Project ACHIEVE will primarily focus on patient transitions from hospital to home, but will also evaluate transitions to and from skilled nursing facilities and home with a focus on Medicare beneficiaries. This expanded evaluation is necessary given the proportion (20 %) of older adults who move from hospital to SNFs and then to long term care or home , 19.The research team reviewed several previously developed conceptual frameworks on diffusion and dissemination of evidence-based practices including the promoting action on research implementation in health services (PRAiHS) framework , interacBelow we delineate the specific methodology and study design for each of Project ACHIVE’s specific aims.Project ACHIEVE’s Model for Coordinated Care Fig.  identifiMuch of the current available data influencing the readmission discourse has come from large administrative data sets. Additional highly relevant information can be gained by exploring patient and caregiver perspectives on care transitions through focus groups, garnering unique insights leading to more patient- and caregiver-centered interventions. Our proposed patient and caregiver focus groups will occur at multiple sites to ensure diversity including: Boston, Philadelphia, Colorado, Southern California, Kentucky, Louisiana and elsewhere as needed. To understand patients’ and caregivers’ experiences of care transitions and determine how well specific TCCs meet individual healthcare needs, we will use mixed methods with a community-based participatory research (CBPR) approach –26. ThisWe will analyze qualitative data using the constant comparative method to determine patients’ perspectives on the care transition experience, and we will analyze quantitative data using frequency analysis to determine factors associated with both poor and optimal outcomes from the patients’ and caregivers’ perspective. NVIVO 10 software  will be used for qualitative data management and analysis. We will employ the constant comparative method of qualitative data analysis . A team The comparisons to be supported within the retrospective and prospective analyses are designed to identify the individual and combined effects of key TC components that are most highly valued by patients and that are included in formal TC models already in use today through national programs. A traditional clinical trials approach to this research design would seek to estimate TC component effects and interactions using a full factorial experiment; however, the large number of possible combinations of TC components that a patient may receive based on the clinical and community setting in which they receive care renders such an approach infeasible under the time and resource constraints of this study. As an alternative, we use a fractional factorial (FF) study design to specify comparators and estimate the individual and combined effects of key TC components. Fractional factorial designs have traditionally been used in designed experiments where the treatment groups are pre-specified. In our observational study, we will not necessarily have all the groups for a FF, but this design will allow us to know which higher order interactions are confounded with lower order effects, which will result in better interpretation of our results.This analysis exploits variation in the incidence and timing of TCC cluster adoption in order to examine which types of patients and hospitals achieve the greatest improvements under which TCCs and clusters.1) Medicare claims data; 2) Kaiser Permanente Southern California (KPSC) will provide clinical data from its EHR regarding process and outcome measures and claims data across KPSC medical centers involved in their TC efforts; 3) Health Research & Educational Trust (HRET), Essential Hospitals Institute (EHI), and Joint Commission Resources (JCR) are three HENs engaging about 1800 hospitals to reduce rehospitalizations, and they will provide data on what TCCs hospitals implemented, their readmission rates over time and hospital demographics.Our data sources allow for identification and examination of process measures to evaluate the success of implementation of TCCs and adaptation of established models, as well as measurement of pre-implementation/post-implementation changes in care delivery patterns and outcomes. We will conduct pooled analyses of all patients as well as focused analyses of ACHIEVE targeted patient populations. A retrospective longitudinal cohort design will be employed. Hospitals that implemented different clusters converted from pre status to post status at different times during the study period, enhancing the study’s ability to distinguish program effects from general temporal trends in patient care. Hospital level  and patient level  analytic strategies will be used to address the possibility of non-equivalence among hospitals and their patients. Fixed-effects, difference-in-difference estimation will be used to compare pre-post changes in outcomes between TCC cluster implementing and non-implementing hospitals while controlling for baseline differences in patient and hospital characteristics. Hierarchical general linear latent and mixed models (GLLAMM) will account for the clustering of patients within hospitals and the temporal correlation among observations. Marginal structural model specifications and instrumental variables analysis will be used to provide further protection against selection bias and confounding on unobserved patient heterogeneity, following PCORI’s methodological standards for patient-centered outcomes research . These aUsing information from the focus groups and retrospective analysis, we will undertake a prospective cohort analysis of patients and caregivers exposed to pre-defined clusters of TCCs.Based on results from focus groups, an updated review of available literature, input from Scientific and Stakeholder Advisory teams, and ACHIEVE’s preliminary findings, we will identify key domains/subdomains, items and measures to include in the development of patient, caregiver and provider surveys. In addition to demographic information, we anticipate that the surveys will include some of the following domains and measures: a) Patient—experience, involvement in care, engagement, receipt and understanding of care plan and medications, access to transportation and care, assessment of the various TCCs, extent to which patient needs were met, follow-up primary care provider visit, follow-up lab and tests, community services connection and usage, adverse drug events, 30-day emergency department visits and rehospitalizations; b) Caregiver—experience, involvement in care, anxiety, burden, understanding of patient’s care plan and medications, caregiver assessment of extent to which patient’s needs and their own needs were met, access to support; c) Provider—facilitators and barriers to implementing TCCs, provider assessment of various TCCs , adaptation of TCCs, organizational contexts , community collaboration.Identification of appropriate and diverse hospitals and community-based organizations will be essential. Recognizing that hospital and community contexts do not remain static, we propose to develop a purposively selected hospital list for recruitment. We will select hospitals to ensure representation of: 1) urban and rural areas; 2) safety-net; 3) critical access; 4) integrated delivery system; 5) involvement in care delivery demonstrations . Participating hospitals will assist the ACHIEVE research team to identify and recruit eligible patients, caregivers, and providers to complete surveys and provide necessary clinical data through a secured mechanism.Using a fractional factorial design, hospitals will serve as the primary sampling unit, with selection determining patients/caregivers available for further study. Hospitals will be selected so that a sufficient number/combination of TCC clusters can be compared  for a subpopulation. Specifically, patients will be sampled from their respective hospital (stratified random samples by subpopulation) and outcomes compared based on TCC clusters received. Replication within a TCC cluster will allow for comparison of TCCs while accounting for the hospital-effect. Use of the fractional factorial relies heavily on having enough hospitals and TCCs for sufficient combinations to yield a connected design (estimable differences). Therefore, in the selection of hospitals, availability of subpopulations and presence of particular TCCs will be carefully considered.To provide flexibility for the dynamic study design where outcomes and TCC clusters are identified in year 1, several conditions were considered, e.g. continuous outcomes are expected but binary outcomes are also possible. The base sample size was estimated using contrasts within a one-way ANOVA then augmented to account for subpopulation analyses and nesting of patients within hospitals. While comparisons will be made overall, of greater interest is the comparison of TCC clusters specific to particular subpopulations, and the overall sample size will need to be sufficiently large to allow for comparisons within these smaller contexts. Additionally, the recruitment of patients nested within hospitals may impact the independence of observations and sample size estimates should also be augmented by the design effect. To allow for sufficient heterogeneity in the sample, we assumed that we would need approximately 6 such TCC clusters. To account for the nesting of patients within hospitals while comparing multiple TCC clusters for particular subpopulations, 300 patients will be recruited in 40 hospitals for a total sample size of 12,000 patients.For survey administration and data collection we will use computer-assisted telephone interviewing (CATI) to administer patient and caregiver surveys. After receiving a list of patients from participating hospitals, the research team will call patients and caregivers between 7 and 45 days post discharge to assess delivery of transitional care services and to ensure patient and caregiver recall about post-discharge care and events. To obtain high response rates, we will incorporate steps from the Dillman tailored design method  for admiMedicare Fee-for-Services claims data will be collected through re-use agreement with CMS or ResDAC. Participating hospitals will submit clinical data on a monthly basis through a secured web-based platform. And KPSC will provide data for its 10 medical centers through its system integrated electronic health record.Survey data will be compiled and cleaned, and descriptive statistics will be generated from the survey results. Psychometric analyses will also be conducted to examine items for variability of response, calculate reliability statistics and item inter-correlations, and examine the factor structure of the measures. Composite scores will be created and the survey data will then be used to examine the study’s aims and hypotheses regarding TC delivery and outcomes.Continuous variables will be summarized with descriptive statistics ; categorical variables will be described with counts and percentages. Numerical and graphical summaries will be provided overall, by subpopulation context, and by TCC and cluster. Simple comparisons of groups will be made using ANOVA for continuous variables and chi-square tests for categorical outcomes. Given the hierarchical nature of the selection of patient/caregivers through hospitals, primary analyses will utilize hierarchical models to investigate the relationship of outcomes to both patient/caregiver and hospital characteristics; GEEs  and GLMMs  will be the primary models used.The provider interview guide is based on determination of key contextual factors influencing TCC intervention selection and adaptation. Examples of likely contextual factors include: performance of a root cause analysis before selecting interventions; rural vs. urban location; poverty concentration in the served area; presence of and trust in partners across the care continuum; availability of electronic information exchange infrastructure; use of common improvement tracking measures and/or common risk identifiers; establishment of cross-continuum case review committees; etc. We will perform group interviews with 20 groups of 3 to 5 people from existing community programs, selecting communities that vary by geographic location, size, urbanicity/rurality and poverty concentration. These could be 3 to 5 people from a single provider  or from a group of providers (representatives from cross-continuum teams in the case of multi-provider or cross-setting interventions), to test the validity of identified contextual features.The survey will be conducted through web mode and mailings to collect information on barriers and facilitators in different organizations and evaluate the quality of transfer processes and transitional care where applicable. Both hospital-based  and post-acute or community providers will be targeted. We will use Medicare claims data to identify the providers who next see patients discharged from any given hospital, generate diagrams of referral patterns using UCINET software, and count referrals per provider.The purpose of hospital site visits will be to validate hospital self-reporting, assess the implementation of TCCs, seek feedback on study protocol and process, evaluate hospital contextual factors impact such as leadership commitment, teamwork structure, physician engagement, staffing, etc., and identify barriers and facilitators. Site selection strategy is to include a representative mix of candidates based on geographic regions, population setting, ownership characteristics of organization, community or health system size, population served, and transitional care models/programs implemented. During the visit, our research team will meet with different teams to conduct semi-structured interviews. The teams include leadership and management, transitional care implementation team, internal stakeholders and partners, and post-acute and community partners.Based on study findings , we plan to develop a toolkit to guide hospitals, post-acute providers and community organizations on implementing TCC clusters effectively, aligned with the characteristics of patient populations they serve and local health and community contexts. The ACHIEVE team will also develop multiple whitepapers to provide resources to patients and caregivers and engage them in the TC process.The members of ACHIEVE team have access to multiple venues for knowledge and experience dissemination. In the last year of the study, we will finalize a large-scale dissemination and implementation plan. The ACHIEVE team will share the study findings  through webinars, seminars, workshops, and presentations at national conferences when final results are available. We will also prepare manuscripts for peer-reviewed publications to include a description of the project’s methodology; the findings from focus groups, surveys, effectiveness of TC clusters on outcomes; barriers and facilitators of TCC implementation; and description of the best clusters of TCCs for different patient subpopulations.Traditionally, efforts to reduce readmissions have focused on hospitals, but experts now recognize that multiple factors along the care continuum influence readmissions and must be addressed in a comprehensive manner . CapitalImplementation research focuses on understanding how programs are implemented, translated, replicated, and disseminated in “real-world” settings and can consider any aspect of implementation, including the factors affecting implementation, the processes and the results of implementation, how to introduce potential solutions into a health system or how to promote their large-scale use and sustainability. It expands the focus of traditional research from discovering what works to also discovering how the implementation works in specific contexts, and emphasizes establishing external validity so that knowledge about how to effectively implement programs can be applied to a wide range of settings . UndertaThe Project ACHIEVE research team possesses vast experience implementing care transition interventions , 6, 32,


Traditional knowledge and nutritional value of indigenous foods of the Oraon tribal community in Jharkhand, India was explored. Focus group discussions were conducted with adult members to identify commonly consumed indigenous foods. Taxonomic classification and quantitative estimation of nutritive value were conducted in laboratories or utilized data from Indian food composition database. More than 130 varieties of indigenous foods were identified, many of which were rich sources of micronutrients like calcium, iron, vitamin A, and folic acid. Some were reported having medicinal properties. Utilization and ease of assimilation of indigenous foods into routine diets can be leveraged to address malnutrition in tribal communities. The global community is increasingly looking towards finding means of sustainable nutrition for the growing population across all countries. The emphasis is on identifying low-resource strategies acceptable to communities that do not put an unnecessary burden on the environment (Food and Agriculture Organization 1993). One suggested approach is the adoption of an ecosystem approach in agricultural management with an emphasis on traditional and indigenous coping strategies. Traditional foods are those which indigenous peoples have access to locally, without having to purchase them, and within traditional knowledge and the natural environment from farming or wild harvesting , agricultural fields or bunds, gardens (bari or kitchen garden) or water resources such as man-made ponds (pokhar), dams or even from market (haat). The foods identified were categorized under various food groups based on their edible parts.Free listing and focus group discussions (FGDs) were used to assess the range of available foods and the contribution of indigenous wild foods to the regular diets of the Oraon community. Adult women and men and village elders were requested to join in FGDs. The research team started with a free listing exercise and explored various issues related to seasonal availability and access to these local foods. The participants identified indigenous or “This ranking method which compares pairs of elements helps prioritize preferences for needs, problems, food items etc and normally leads to analysis of the decision making rationale . Samples of identified items were either provided by participants (if available) or were collected by the research team; these samples were then sent for classification to a team of experts at the Botany department of Birsa Agricultural University, Ranchi. The photographed food item  was collected, wrapped in paper towels, placed in a well perforated polythene bag and sent to the botanists for identification/confirmation of the botanical classification. Subsequent to the botanical classification, the Indian Food Composition tables were checked for availability of the nutritive values of the classified foods and finally a list of the items not available in the Indian food composition tables was prepared for collection for nutrient analysis.The food samples short listed for nutrient analysis and available at the time of survey/sampling were collected from the field site or procured from the local market . Flesh foods were not analysed in this study.Each of the procured samples was weighed, wrapped in clean paper towels, placed in well perforated polythene bags, and placed in a laboratory travel cooler box lined with freezer packs for transportation to the site of interim storage. Five hundred grams of each of the vegetables/fruits/green leafy vegetables collected was sent to the National Accreditation Board for Testing and Calibration Laboratories (NABL) certified laboratory for analysis.1), riboflavin (vitamin B2), niacin (vitamin B3), vitamin C, calcium, iron, zinc, sodium, and folic acid.The nutrient analysis was done according to standard reference protocols. The specific methodology is listed in saag) was reportedThe qualitative enquiry revealed that rice was the staple food for the community. Rice in the form of puffed rice and rice flakes were also commonly consumed. Meals consisted of rice with green leafy vegetables (GLVs). Pulses use was reportedbut they were not being consumed daily. Consumption of roots and tubers both cultivated and from the wild were also reported. The availability and consumption of a large variety GLVs  activities were limited and were pursued only during the festival season. The indigenous foods (n = 136) identified through the FGDs are listed in in all the discussions. The participants differentiated between GLV which are grown in the Beng (Centella asiatica) and Kudrum (Hibiscus cannabinus); Hirmichiya (Enhydra fluctuans), Bathua , Phutkal (Ficus geniculata), Chiniya (Brassica campensis pekinensis) and Bhaji (Amaranthus viridis) were the most preferred and consumed indigenous varieties. In case of other vegetables, roots and tubers, no indigenous variety was commonly consumed or preferred.Out of the foods listed, the ones commonly consumed under each food group and preferred by the community were listed through pairwise ranking. A demonstration of the outcome of pair wise ranking done through the FGDs for different food groups is given for preferred rice variety and green leafy vegetables (GLVs) in n = 30) for which classification was unavailable were collected and sent for identification by an expert at the Birsa Agricultural University (Botany Department). Finally, the taxonomic classification provided was verified from other literature sources . For the rest of the foods identified but not having nutritive values available in the Indian food composition tables, samples (n = 8), were procured based on their availability. These were then sent for nutrient analysis to a NABL certified laboratory in New Delhi. Of all the foods identified in this study, the nutritive values (based on taxonomic classification) were available for 55 foods in the Indian food composition tables ,Saru (Colocasia anti-quorum), Karmi (Ipomea reptans), Gandhari (Amaranthus spinosus), and Kudrum leaves were seen to have high levels of beta carotene  and calcium (110–800 mg/100 g). The iron content of Chakod, saru, Bhaji, Lal bhaji (Amaranthus gangeticus), Gandhari, Khapra (Trianthema monogyna), and Kanda leaves (Ipomea batata) wereMany indigenous GLVs for which nutritive value was available in the Indian food composition tables namely Chakod, Saru, Karmi, Gandhari, Kudrum, Khapra, kanda leaves, were high (12 to 82 mg/100 g). Bhaji was found to have exceptionally high vitamin C content (179 mg/100 g). The GLVs Lotni, (Brassica juncea), Hirmichiya, Chiniya, Lahsun (Allium sativum) were found to be rich sources of calcium (mg) (range 221 to 389 mg/100 g of edible portion), iron (mg) (range 5.95 to 19.77 mg/100 g) and beta carotene . Beng saag (Centella asiatica) was found to be exceptionally rich in iron (55.66 mg/100 g) and dietary fiber (7.5 mg/100 g). Mandua (Eleusine coracana), a millet was found to have high levels of calcium (344 mg/100 g) and dietary fiber (11.5 mg/100 g). The pulses consumed, namely Khesari dal (Lathyrus sativus) and Barbatti (Vigna catjang), were rich sources of thiamine  and iron . The indigenous rice variety, Lalhat desi was found to be high in folic acid (14.09 mcgm/100 g). A dried variety of GLV, Phutkal was also analyzed and found to be rich in calcium (672 mg/100 g), iron (8.89 mg/100 g), zinc (4.63 mg/100 g), and dietary fiber (45.1 mg/100 g).in the range of 3.49 to 38.5 mg/100 g. The vitamin C content of GLVs like Singhi fish (Saccobranchus fossilis), and crab consumed by the community were seen to be rich sources of protein and calcium .Flesh foods like snail and fresh water mussel, Indigenous plants used for medicinal purposes were identified by the FGD participants. In general, majority of the plants were useful for easing stomach ailments, management of pain and fever and in improving overall health.Beng saag was the most versatile medicinal plant identified by the participants and was highly preferred among the GLVs as well. Beng was reported to ease stomach ailments and jaundice, maintain blood pressure and keep the heart healthy, reduce blood sugar, and improve mental capacity.tulsi (Ocimum tenuiflorum), katai (Vangueria spinosa), tamarind (Tamarindus indica), phutkal, and the fruit of the sarai (Bambusa arundinacea) plant were used to treat stomach ailments such as diarrhea, and vomiting.The leaves of the beng, kulthi (Dolichos biflorus), neem (Azadilrachta indica), and the bark of the charaigodwa (Vitex peducularis) were believed to improve immunity and induce healing. The participants explained that these plants increased one’s appetite and kept the body cool. Beng, charaigodwa, and munga (Moringa oleifera) were believed to maintain blood pressure.GLVs such as kariya haldi (Curcuma caesia) or the rare black turmeric was used for treating chest pains. Bhuineem (Andrographis paniculata) leaves were considered blood purifiers and were used for fevers or malaria. Papaya leaves (Carica papaya) were also used to cure fever in children.The tuber chakod plant were used to treat tuberculosis. The participants identified the use of koraiya bark (Holarrhena antidysenterica) as a local treatment for heat stroke. They mix koraiya with hadiya or fermented rice wine. Charaigodwa and mahua fruit were used to relieve pain and swelling. Katai leaves could be applied to cuts.The seeds of the bakla) or seeds were boiled or grounded and consumed as tea for deriving their medicinal use. These plants were mostly cultivated in the bari or foraged from the forests. Freshly prepared GLVs were used for most of the medicinal uses, with the exception of the tamarind and neem leaves, which were dried and then later consumed.Barks from trees  will help protect this treasure trove of traditional knowledge and sustain biodiversity. Some villages inhabited by the Oraon are in difficult terrain and remote areas; use of this indigenous knowledge about medicinal benefits may potentially be used as a first line of management for minor ailments before accessing standard health care. Supporting and advocating for the consumption of indigenous plants for their medicinal properties through local policy interventions or knowledge and behavior change communication could present opportunities for improving community health outcomes.Some of the indigenous foods identified in the study also reportedly had medicinal properties which was known to the local community based on practical knowledge and traditional wisdom. Based on some of our findings and evidence from previous literature, there is likely a scientific basis to these beliefs. For example, the nutrient analysis of While studies have documented the various uses and immense diversity of the flora and fauna in Jharkhand (Pradhan, Mishra, and Mohapatra Research into indigenous foods and the nutritional practices related to these foods are gaining momentum for many reasons. Firstly, the scope of these foods to provide a nutrient rich diet by virtue of their diversity is considered important for maintaining a holistic health status through natural means. Secondly, the propagation of the consumption of these foods provides a buffer against the increasing displacement of traditional dietary patterns by marketed, processed foods. Though the Food and Agricultural Organization has been involved in the support and promotion of knowledge regarding indigenous foods across the Americas and Africa, data in the form of a comprehensive biorepository of indigenous foods is very limited in India (Bhattacharjee et al. Our study is step towards documenting the nutrient rich indigenous foods in this tribal community which could be used for quantification of nutrient intake in this community. To the best of our knowledge, no previous study has looked at the anthropological, dietary and nutritional aspects of the indigenous foods in the tribals of Jharkhand in an integrated manner. We would also like to highlight the immense scope of further study in this geographical area with such tremendous environmental biodiversity. Data on these aspects could be a repository of information for botanists, agriculturists and nutritional experts alike and form a valuable resource for researchers and for the community to build upon and preserve.The authors acknowledge the contribution of all Oraon respondents in the study villages for sharing their knowledge about their rich heritage of indigenous and traditional foods. They thank Professor R. P. Singh “Ratan” and his team from Birsa Agricultural University for carrying out the taxonomic classification of the food samples. They also acknowledge the contribution of Ms. Keya Chatterjee, Mr. Alok Kundu, and their team at “Ekjut,” a local NGO, for providing support for data collection and facilitating an excellent team of fieldworkers; thank all the field staff, and anganwadi workers in the study villages, for their support; and acknowledge the contribution of Intertek Laboratories in analyzing the food samples.This study was funded by the Wellcome Trust Capacity Strengthening Strategic Award to the Public Health Foundation of India and consortium of UK universities.


The goal of these analyses was to determine whether there were systematic differences in Emergency Severity Index (ESI) scores, which are intended to determine priority of treatment and anticipate resource needs, across categories of race and ethnicity, after accounting for patient-presenting vital signs and examiner characteristics, and whether these differences varied among male and female Veterans Affairs (VA) ED patients.We used a large national database of electronic medical records of ED patients from twenty-two U.S. Department of Veterans Affairs ED stations to determine whether ESI assignments differ systematically by race or ethnicity. Multi-level, random effects linear modeling was used to control for demographic characteristics and patient’s vital signs , as well as age, gender, and experience of triage nurses. The dataset included 129,991 VA patients presenting for emergency care between 2008 and 2012  and 774 nurses for a total of 359,642 patient/examiner encounters. Approximately 13% of the variance in ESI scores was due to patient characteristics and 21% was due to the nurse characteristics. After controlling for characteristics of nurses and patients, Black patients were assigned less urgent ESI scores than White patients, and this effect was more prominent for Black males compared with Black females. A similar interaction was found for Hispanic males. It remains unclear how these results may generalize to EDs and patient populations outside of the U.S. VA Health Care system.The findings suggest the possibility that subgroups of VA patients receive different ESI ratings in triage, which may have cascading, downstream consequences for patient treatment quality, satisfaction with care, and trust in the health equity of emergency care. Emergency Severity Index (ESI) scores and similar triage categorization systems have been widely used to determine the urgency and priority of patient treatment in the emergency department (ED). These systems are intended to rely on objective vital signs and presenting symptoms such as pain to prioritize care and anticipate resource needs for ED patients at the time of presentation, according to the severity of patients’ conditions. ESI scores have been shown to reliably predict hospital resources needed by ED patients, as well as the probability and location of hospital admission ,2. NumerSeveral studies have shown that African Americans and Hispanic ED patients, in particular, tend to wait significantly longer, are less likely to receive opioids, and are less likely to be prescribed analgesics on discharge than White patients presenting similar conditions . TherWe used a national database of U.S., Veteran’s Affairs (VA) ED patients to calculate whether race and ethnicity independently influenced the ESI scores assigned by triage nurses during visits between January 2008 and December 2012. The study was approved by the University of New Mexico Institutional Review Board and the New Mexico VA Health Care System Research and Development Committee and patient records/information was anonymized and de-identified prior to analysis. Data tables were sourced from the VA Corporate Data Warehouse, the operational database that houses the electronic medical records of US VA patients. Information from the patients and nurses who assigned the ESI scores to the patients were managed and combined via VA Informatics and Computing Infrastructure (VINCI); see n = 22) using identifiable ESI scores were included in the analyses  had been treated for an inflammatory or a musculoskeletal condition (broad pain-related categories); 3) were processed by a VA staff member with a nursing license ; and 4) had complete vital signs and demographic data and information about their triage nurse. Only patients with an ESI score between 2 (representing time sensitive and high risk patient conditions) and 5 (low acuity and low anticipated resource needs) were considered in the analyses. Visits in which patients were assigned an ESI score of 1 were excluded, because this score is usually restricted to patients who require immediate resuscitation , and in such cases there is little to no discretion to assign any but the most emergent ESI rating.Only VA hospitals  codes indicating a current alcohol or substance-related diagnosis (behavior problems), and the vital signs: heart rate, respiratory rate, and patient-reported pain score . Nursing characteristics consisted of gender, age, and number of years of experience working for the VA. Visits with any missing patient or nurse information were removed from the dataset prior to analysis. Visits with outlying vital measurements for patients  were also excluded from analyses (see Patient ethnicity was dummy-coded (using White as the reference group), as were patient and nurse gender (with women as the reference group in both cases). Continuous predictors were centered at the mean across visits , except for problem behaviors , which was left centered at the modal value of 0.The goal of these analyses was to determine whether there were systematic differences in ESI scores across categories of race and ethnicity, after accounting for other patient and examiner characteristics, and whether these differences varied among male and female ED patients. We used linear cross-classified, random-effects (multilevel) models  in orderIn our models, each ESI score is nested under a specific nurse and a specific patient. This allows for the mean ESI score to vary across nurses  and patients (who may vary in their presenting complaints and communication styles). We estimated a model for all patient encounters that met our inclusionary criteria. In M = 58.3yrs, SD = 15.7). Each patient was seen between 1 to 157 times on separate visits by one of 774 nurses  across a total number of 359,642 visits/triage assignments . The staff who assigned the ESI scores to the patients ranged in age from 21 to 75 years  and assigned multiple ESI scores over the 5-year period analyzed . At the time of each assessment, the staff had between 0 and 43 years of experience  since their initial employment with the VA Health Care System.In total, the sample consisted of 129,991 patients with complete (patient and examiner) data for inclusion in the study. Since all patients were veterans, most patients (91% of the sample) were males. Patient age ranged from 18-103yrs  than among female patients , not among female patients .Characteristics of nurses accounted for a greater proportion of variability in ESI (21%) than demographic characteristics and vital signs of patients (13%). In the full sample, there was an interaction between patient gender and the dummy code representing Black patients . A simplAmong the other patient characteristics, patient age, heart rate, respiratory rate, problem behaviors, and pain score were all negatively related to the patient’s ESI score; patients with higher levels of these characteristics during visits were given more urgent ESI scores. Among the nurses’ characteristics, and despite the substantial proportion of variance in ESI scores attributable to their characteristics, neither nurses’ gender, age, or years of experience significantly predicted ESI scores in the full sample , emerged as a statistically independent and significant predictor of ESI scoring assignments, in addition to patient’s vital signs (i.e. objective factors that are explicitly intended to influence ESI scores). This study cannot determine whether the observed effects contribute to measurement error, as there was no practical way to qualify the validity of ESI assignments in a study this size. Conventional protocols for establishing optimal treatment decisions such as relying on the subjective judgments of so-called experts  are also subject to individual factors  that likely affect how experts stylistically report their judgments [As expected, patients’ vital signs  independently predicted more urgent ESI scores, as did patients’ age and problem behaviors . By comparison, the influence of Black ethnicity on ESI scores, though small in absolute terms  studies showing minimal influence of personal characteristics of nurses ,23,24 anOne significant limitation of our study therefore was the unavailability of additional clinical characteristics of patients, information about contextual factors and personal attributes of the examiners, including the nurses’ ethnicity/race. It is likely that controlling for patient-presented vital signs does not provide an adequate sense of the overall clinical “severity” of any given patient presenting to the ED. Another feature that may limit the generalizability of the findings is that the sample included VA Medical Center patients who are predominantly male and older than the general population, and the lower power associated with the substantially smaller sample of female patients may have affected some of the results. Although the VA health care system provides a rich national database of ED records using relatively uniform and standardized procedures, many VA staff are veterans themselves and may have additional characteristics not representative of community EDs. Finally, there may be alternative techniques for analyzing the current data, including multilevel logistic regressions which could account for the ordinal nature of ESI scores .We do not know whether the differences in ESI scores given to Black males and females and Hispanic males in this study caused those patients to receive less timely or lower quality care. However, triage scores have been shown to be reliable predictors of hospital admission and death , and somOur study controlled for illness severity by using vital signs  measured in triage. Additional research is needed to unpack all the factors that contribute to health disparities in treatment delivery including regional differences in population density  and grouIn light of these factors, it is reasonable to assume that normative and reflexive (involuntary) social psychological reaction styles operate alongside reflective, induction-based judgments  to influAn ethics statement was not required for this work.S1 Supplemental Materials(DOCX)Click here for additional data file.


Background: Developmental periods in early life may be particularly vulnerable to impacts of environmental exposures. Human research on this topic has generally focused on single exposure–health effect relationships. The “exposome” concept encompasses the totality of exposures from conception onward, complementing the genome.Objectives: The Human Early-Life Exposome (HELIX) project is a new collaborative research project that aims to implement novel exposure assessment and biomarker methods to characterize early-life exposure to multiple environmental factors and associate these with omics biomarkers and child health outcomes, thus characterizing the “early-life exposome.” Here we describe the general design of the project.n = 150) will collect data on biomarker variability, use smartphones to assess mobility and physical activity, and perform personal exposure monitoring. Omics techniques will determine molecular profiles  associated with exposures. Statistical methods for multiple exposures will provide exposure–response estimates for fetal and child growth, obesity, neurodevelopment, and respiratory outcomes. A health impact assessment exercise will evaluate risks and benefits of combined exposures.Methods: In six existing birth cohort studies in Europe, HELIX will estimate prenatal and postnatal exposure to a broad range of chemical and physical exposures. Exposure models will be developed for the full cohorts totaling 32,000 mother–child pairs, and biomarkers will be measured in a subset of 1,200 mother–child pairs. Nested repeat-sampling panel studies : project rationale and design. Environ Health Perspect 122:535–544;  The fetus and infant are particularly vulnerable to such potential hazards . Environtabolism . Such chtabolism . Neurodetabolism . Up to nThe exposome. The “exposome” concept was first proposed by The HELIX (Human Early-Life Exposome) project has as its general aim to implement tools and methods , to characterize early-life exposure to a wide range of chemical and physical environmental factors and associate these with data on major child health outcomes , thus developing an “early-life exposome” approach. The project takes pregnancy and childhood periods (“early life”) as the starting point for developing the life-course exposome. In this review we describe the general design of HELIX and its main challenges. In this manner, we aim to illustrate how the exposome concept may be implemented in a feasible epidemiological study design.HELIX will develop the early-life exposome approach and database in three overlapping steps containing six research areas . A firstTo obtain estimates of exposure to persistent and nonpersistent pollutants in food, consumer products, water, and indoor air, during pregnancy and in childhood.To obtain estimates of chemical and physical exposures in the outdoor environment during pregnancy and in childhood: ambient air pollution, ambient noise, ultraviolet (UV) radiation, temperature, and built environment/green space.To define multiple exposure patterns in the individual and outdoor environment, describe their predictors, and describe uncertainties and variability in the exposures assessed.To measure molecular signatures associated with environmental exposures through analysis of profiles of metabolites, proteins, transcripts, and DNA methylation in biological samples from the children in the cohorts. Biological pathway analyses will be used to inform analyses of the relationship between multiple exposures and child health.To develop a novel multistep statistical approach for the analysis of the association of patterns of multiple and combined exposures and child health outcomes, using agnostic environment-wide association study (EWAS) analysis, structural equation modeling (SEM), and Bayesian profile regression.To provide exposure–response estimates for the association of multiple and combined exposures with child health, focusing on fetal and childhood growth and obesity, neurodevelopment, and respiratory health.To estimate the burden of common childhood diseases that may be attributed to multiple environmental exposures in Europe.To strengthen the knowledge base for European policy in the area of child and environmental health by engaging with, and effectively disseminating HELIX knowledge to stakeholders including those responsible for risk management and mitigation and prevention strategies.The birth cohorts. Six existing longitudinal population-based birth cohort studies in Europe form the basis of the project: BiB  (a) they each have a large set of existing longitudinal data from early pregnancy through childhood; b) they can implement new follow-up examinations of the children at similar ages (6–9 years), old enough for accurate measurement of the phenotypes of interest for HELIX; and c) they can integrate new questionnaires, biosampling, and clinical examinations in their new follow-ups using common protocols. The cohorts have worked together intensively and have pooled data as part of other European Community (EC) projects (Kingdom) , EDEN (ÉKingdom) , INMA (IKingdom) , KANC (KKingdom) , MoBa (NKingdom) , and RheKingdom)   . The cohStudy populations. In general, exposure estimates can be obtained in cohort studies for very large numbers of subjects by exposure models and questionnaires, whereas exposure and omics biomarkers can, for cost reasons, be obtained only in smaller numbers of subjects. Assessment of individual exposure variability and validation of exposure models require very intensive data collection that is feasible only in an even smaller number of subjects. For these reasons, HELIX uses a multilevel study design, drawing on nested study populations for four different levels of data collection  air pollution land-use regression (LUR) models , water da) age 6–9 years, 7–8 years, if possible; the age range should be as narrow as possible for comparability of omics analyses and exposure-related behavior; b) stored pregnancy blood and urine samples available, and available sample volume sufficient for the analysis of exposure biomarkers detailed in research area 1; c) complete address history available from first to last follow-up point; d) no serious health problems that, in the opinion of a local clinician, may affect the performance of the clinical testing  or affect the volunteer’s safety . In addition, the selection will consider whether data on important covariates  are available. Cohorts with more than the required number of mother–child pairs that meet these criteria will invite subjects at random from the eligible pool. The new follow-up examination will include the collection of new biological samples suitable for all planned biomarker and omics analyses . The collection of two urine samples (one before bedtime and one first morning void) will better capture short-lived biomarker metabolites and provide more stable metabolome coverage than would be achieved with one spot urine sample. Collected blood samples will be processed into appropriate matrices  and storage media (for RNA and DNA extraction), and will be rapidly deep frozen under optimized and standardized processing procedures. Variables that can affect omics profiles, such as use of drugs, time of last meal, or physical exercise, will be collected. Trained nurses will carry out health examinations of the children. Examinations include measurements of weight, height, waist circumference, skin folds, blood pressure, and spirometry, and will follow standard operating procedures. Standardized computer-assisted interviews with the mothers will collect information on exposure sources , physical activity, time activity, diet, social factors, stress, and asthma and allergy. Neurodevelopmental outcomes will be assessed through a battery of internationally standardized, nonlinguistic, and culturally blind computer tests  will be used to identify biological pathways affected by the exposures. Identification and representation of biological–toxicological pathways will be done using software such as Ingenuity Pathway Analysis (http://www.ingenuity.com/), Cytoscape  health impacts? In general, environmental health studies have considered single exposures or single families of exposure . Notable exceptions of studies that have provided risk estimates for multiple exposures include a cross-sectional EWAS of diabetes , 2013 anFurther, the exposome includes evaluation of multiple exposures, omics markers, and outcomes, each with very different temporal scenarios. A challenge in the development of the statistical analysis protocols is to takes these complexities into account. For example, spatial models for the outdoor exposures are constructed for a specific year and can then be extrapolated to relevant time periods  backward or forward in time using available monitoring stations data. For persistent pollutants we may assume that biomarkers give estimates over a relatively long time period, whereas for nonpersistent pollutants biomarkers will reflect only very recent exposures; in some cases we may assume a fairly constant exposure pattern depending on the habits underlying the exposure , whereas in other cases exposure variations may be largely seasonal . Neurodevelopment, growth and obesity, and asthma and allergies are each driven by extremely complex multistage developmental processes that take place prenatally and during the first years of postnatal life. Commonly used statistical techniques for high-dimensional data, such as machine learning, dimension reduction, and variable selection techniques, need to be adapted to the longitudinal context by accommodating issues such as time-varying exposure effects, delayed effects, and effects of exposure trajectories over time on outcome trajectories .Research area 5: linking the exposome to child health. Research area 5 aims to develop a multistep approach that is based on several tools and methods and will produce risk estimates for different types of exposure variables:a priori information, in which all pairs of exposure–outcome associations will be quantified , appropriately controlling for false discovery rate (FDR), as is done in GWAS and in the only published EWAS  and NO2, and carrying out manual work  and personal measurements  in the panel studies. As a preliminary step, a simulation study aimed at comparing the efficiency of various study designs and statistical approaches to characterize the impact of the exposome on health will be conducted. With a sample size of 1,200 (subcohort), the agnostic EWAS analysis with control for FDR will have a power of 80% to detect a 3-point difference in a continuous outcome variable with a standard deviation of 15 (as in common neurodevelopment indexes), considering that 15% of the tested exposures will show an association . Higher a) We will center all exposures using the cohort mean. Analyses conducted with mean-centered variables will remove differences between cohorts and only consider within-cohort differences in exposure. b) We will document heterogeneity between cohorts, applying random effects models where applicable, and conduct sensitivity analyses excluding one cohort at the time.Heterogeneity between cohorts in terms of study design can play a role in the results of these analyses, but it will not be possible to separate these effects from true differences between populations. We will address the issue of cohort differences in two ways: Research area 6: health impact of multiple exposures. Finally, research area 6 will estimate the burden of common childhood diseases that may be attributed to multiple environmental exposures in Europe. It will construct scenarios for the health impact assessment, working from traditional one-exposure–one-outcome assessments  to more complex benefit–harm scenarios. For example, given increasing obesity rates, children are encouraged to walk or cycle to school, which may lead to increased energy expenditure and possible reduction in weight and improvement in mental health. However, at the same time, longer duration of exposure to air pollutants, noise, and UV may lead to adverse health effects and higher risks of accidents  with common, centrally established QA/QC procedures. Mechanisms to transfer and hold data from across cohorts and other partners will include the identification of agreed data sets, specifications for the data warehouse, data validation, cleaning and harmonization procedures, and the establishment of robust data security mechanisms. Data analysis protocols will be established and performed centrally by a statistical analysis task force. Further, the data warehouse will be established in a format that will allow future uses beyond the project as an accessible resource for researchers external to the project. Procedures for external access will be developed and made public by the end of the project; these will include information regarding data collection, data content, and procedures for data requests.There is a strong consensus that new integrative tools and approaches for human exposure and risk characterization are needed to significantly advance environmental risk and health impact assessment and health protection . Specifi(167 KB) PDFClick here for additional data file.