Psychotic disorders are severe, debilitating, and even fatal. The development of targeted and effective interventions for psychosis depends upon on clear understanding of the timing and nature of disease progression to target processes amenable to intervention. Strong evidence suggests early and ongoing neuroprogressive changes, but timing and inflection points remain unclear and likely differ across cognitive, clinical, and brain measures. Additionally, granular evidence across modalities is particularly sparse in the “bridging years” between first episode and established illness—years that may be especially critical for improving outcomes and during which interventions may be maximally effective. Our objective is the systematic, multimodal characterization of neuroprogression through the early course of illness in a cross-diagnostic sample of patients with psychosis. We aim to (1) interrogate neurocognition, structural brain measures, and network connectivity at multiple assessments over the first eight years of illness to map neuroprogressive trajectories, and (2) examine trajectories as predictors of clinical and functional outcomes. We will recruit 192 patients with psychosis and 36 healthy controls. Assessments will occur at baseline and 8- and 16-month follow ups using clinical, cognitive, and imaging measures. We will employ an accelerated longitudinal design (ALD), which permits ascertainment of data across a longer timeframe and at more frequent intervals than would be possible in a single cohort longitudinal study. Results from this study are expected to hasten identification of actionable treatment targets that are closely associated with clinical outcomes, and identify subgroups who share common neuroprogressive trajectories toward the development of individualized treatments. Psychotic disorders, including schizophrenia (SZ), schizoaffective disorder (SZA), and bipolar disorder with psychosis (BDP) are severe, debilitating, and even fatal  and are Evidence of early and ongoing disease-related changes in brain and neurocognitive measures in psychosis, often referred to as “neuroprogression,” including cognitive dysfunction, gray matter reduction and ventricular enlargement, and regional structural and connectivity alterations, have been described using multiple modalities including neurocognitive testing, PET, CT, and fMRI imaging techniques, and post-mortem brain studies  5–93]. –93. 5–93The years after illness onset represent a critical period where early intervention strategies may be most effective, before irreversible brain alterations take place. Effective treatment after a first episode of psychosis (FEP) not only improves functioning but may actually alter illness trajectories placing patients on a path toward recovery . DiseaseAbnormalities of gray and white matter volume, network connectivity, and cognition are well-described in patients with established psychosis, and longitudinal research suggests that neuroprogression may continue well into chronicity in some patients ,67,99. HNeuroprogressive changes are related to disease course. Cognitive deficits are predictive of functional disability ,24, and Together, findings suggest that neuroprogressive changes in the years following psychosis onset occur rapidly in many areas during an important neurodevelopmental window , with coHeterogeneity of premorbid adjustment, illness course, and outcomes is the rule rather than the exception in psychotic disorders, , and idEvidence strongly indicates that neuroprogressive changes occur across brain and cognitive measures in patients with psychosis at the time of first episode and throughout the early course of illness. Nonetheless, no studies to date have undertaken the systematic characterization of neuroprogression throughout the early course of illness at a granular level using multimodal assessments in a transdiagnostic sample. Thus, our objective with this project is the systematic, multimodal characterization of neuroprogression through the early years of illness in a cross-diagnostic sample of patients with psychosis. We hypothesize that (1) by interrogating neurocognition, structural brain measures, and network connectivity at multiple assessments across the first eight years of illness we will identify clear neuroprogressive trajectories along our primary outcome variables, and (2) neuroprogressive trajectories will be predictive of clinical and functional outcomes. To accomplish this objective within the project timeline, we will use an accelerated longitudinal design  modeling multiple neuroprogressive markers by duration of illness, and in association with key clinical and functional measures. A central aspect of this project is that it builds upon the rich neuroimaging, cognitive, and clinical data being collected by the Human Connectome Project in Early Psychosis . Data collection for this longitudinal study will occur across the Boston HCP-EP sites, and it is estimated that approximately 75% of baseline data for the present project will be drawn from existing data collected in the context of the HCP-EP.192 patients with DSM-V non-affective  or affective (major depression with psychosis or bipolar disorder with psychosis) psychosis as determined by SCID-5-RV for DSM-V-RV interview  will be In order to capitalize on existing data and maximize comparability between data sets, we will use identical materials and procedures to those currently implemented by the HCP-EP. Participants will be reassessed at the same site as their original assessment, including MRI scans.Behavioral measures include the NIH Cognition Toolbox , psychosMedications represent an important covariate in the study of progressive changes in brain and behavior. We will collect detailed information about mediation use at each assessment, and account for medication effects using analytic models of antipsychotic, Lithium, and total medication load both as moderators and confounders in order to examine the potential role of medications in neuroprogression.Imaging data will be collected on two Siemens MAGNETOM Prisma 3T scanners, one at McLean and one at Brigham and Women’s Hospital. Both use a 32-channel head coil and are actively collecting HCP-EP data using the same sequence employed here. This protocol is similar to the original HCP Lifespan protocol , but witThis project employs an accelerated longitudinal design (ALD) in order to cover the desired timeframe within the constraints of the project. ALDs follow enrollment cohorts longitudinally and thus model both within subject longitudinal and between subject group effects. While most ALDs use age to define cohorts, we will use duration of illness (DOI), which will allow us to estimate DOI-related trends in our primary outcomes. The timing of repeated assessments will be calibrated to each individual’s DOI resulting in measures that span the range from 0 to 88 months after illness onset. We selected a “balanced ALD”, meaning equally spaced measurements across the study, the same number of measurements per cohort, and equal overlap between successive cohorts , and traveling human subjects. Scanner reliability was assessed both between scanners and using test-retest assessments within scanners. Intraclass correlations (ICC) were computed on Freesurfer outputs including total GM volume, subcortical GM volume, cortical WM volume, brain segmentation volume, and total ICV, and regionally specific measures based on our primary outcomes. We found ICCs of 0.98–0.99 for broad measures, and 0.90–0.99 for regional measures.Our primary aim is to map neuroprogression across the first 8 years of illness. We will fit latent growth curve models to the repeated measures of our cognitive and MRI measures on the full sample using techniques that permit the functional form of the trajectories to be determined by the data. Each model will include initial DOI as a covariate to separate between-subject differences from within-subject changes as a function of current DOI at each assessment point ,130; theTo evaluate the predictive utility of neuroprogressive change on clinical and community functioning, we will conduct a second set of latent growth curve analyses on clinical and functional measures. We will then build predictive models of our clinical and functional outcomes based on within-subject changes in neuroprogressive markers. We will also explore the possibility that subgroups of subjects demonstrate distinct neuroprogressive trajectories, and differences in clinical and functional outcomes based on these groups using growth mixture models (GMMs). GMMs, an extension of multiple-group growth curve models in which the grouping variable is not specified a priori, can be used to identify subgroups within the data and describe differences in longitudinal trajectories between subsamples. Finally, we will conduct explicit tests of fully dimensional models and combined dimensional and categorical models based on the latent class trajectories groupings.Determining the timing and course of neuroprogressive changes over the early course of psychosis is essential to the development and implementation of targeted, individualized treatment during a critical time period in which treatments may be maximally effective and the potential for preventing further decline and chronic loss of functioning is at its greatest. Results from this study will (1) hasten the identification of actionable treatment targets that are closely associated with clinical outcomes in order to capitalize on islands of preserved plasticity and maximize their clinical utility, and (2) provide guidance for individualized treatment.This project includes several key innovations. First, these data will be the first to characterize multiple markers of neuroprogression throughout the early course of psychosis, including inflection points, stabilization points, and associations with clinical course, in a transdiagnostic sample and within a single study paradigm covering the critical years between first episode and established illness. These findings will not only elucidate neuroprogressive processes that are as yet unknown, but will hasten our ability to design treatments in the early course of illness that target actionable mechanisms, potentially preventing further decline and chronic loss of functioning. For instance, if neurocognitive decline predates and predicts structural brain degeneration in associated regions, early treatments targeting cognition for patients with cognitive deficits may improve cognition and halt progression of gray matter loss. Indeed, Eack et al.  found th


Chronic rheumatic diseases can commonly lead to significant physical disability, reduced health-related quality of life and high economic burden for the societies. In the last decades and despite the availability of novel, effective medical treatment for specific rheumatic diseases, rehabilitation interventions do have a pivot role in improving function and psychological status in these conditions. Several systematic reviews and evidence based management recommendations suggest nonpharmaceutical rehabilitation management as an adjunct to medical therapy. The composition of rehabilitative interventions may extensively vary including therapeutic exercise, patient education, occupational therapy, orthoses, assistive devices, work rehabilitation and physical modalities. Exercise therapy is the main component of non-pharmacological treatment and strongly recommended in international guidelines but currently there is no consensus regarding intensity, frequency, or type of rehabilitation program for patients with rheumatic diseases. So, rehabilitation should be designed on a patient-centered basis in the context of multidisciplinary approach. A recent study demonstrated that work disability is a major consequence of rheumatic diseases and occurs in about 49% of patients with rheumatoid arthritis (RA), 39% of patients with psoriatic arthritis (PsA) as well as 41% of patients with ankylosing spondylitis (AS).3The worldwide prevalence of rheumatic diseases ranges from 12–24%,6whilst the estimated prevalence of RA in many Mediterranean countries varies between 0.2–5%.8On the other hand, Behçet’s disease and Familial Mediterranean fever are more common in this area compared to Europe and America.11Rheumatic diseases are commonly leading to a significant impairment of physical function and health-related quality of life. Subsequently they are associated with a high economic burden on society with a total cost of $321.8 billion reported by the Medical Expenditure Panel Survey in patients with arthritis and other rheumatic conditions.12In the literature, there is limited reported data available to assess rehabilitation interventions for rheumatic disease in the Mediterranean region. This might be attributed to the lack of rehabilitation services, economic difficulties, inadequate knowledge amongst rheumatologists for the beneficial effects of non-pharmacological treatment strategies as well as underestimation of the role of allied health professionals in the management of rheumatic diseases across Mediterranean countries.Rehabilitation work areas show significant differences within the Mediterranean countries. While neurological rehabilitation is primarily implemented in Israel, France and to some extent in Italy, rheumatology and orthopaedic rehabilitation are primarily implemented in Turkey and Spain.13More interestingly Staalesen Strumse et al14compared the effectiveness of the same rehabilitation program between two settings with different climatic conditions, namely Mediterranean and Norwegian settings in patients with AS. When the rehabilitation was performed in the former setting, the improvement in health status and spinal mobility outcomes were much better and sustained for longer. In addition, the proportion of ASAS20 and ASAS40 responders were higher in the Mediterranean group than in the Norwegian group. These results suggest that specific groups of patient rehabilitation may be more beneficial in a warm climate setting such as the Mediterranean region, providing the rationale for better designed studies in these countries.Until now, a few studies have assessed the effect of climatic variables such as temperature, humidity and barometric pressure on rheumatic diseases including RA, AS and osteoarthritis (OA) in Mediterranean countries. A prospective study showed that low temperature and decreased atmosphere pressure increase the risk of joint pain in Spanish patients with RA and OA respectively.16Rehabilitation in rheumatic diseases is a difficult task that requires knowledge, expertise and patience, as most of these conditions are progressive and vary in clinical course with periods of remission and exacerbation. In rheumatic diseases, disease consequences such as pain, loss of range of motion, joint instability, muscle weakness, and fatigue accompanied by loss of function result in marked and severe impairments in daily activities and limit participation in society, family and working life.20Moreover, last updated evidence based treatment recommendations including European League Against Rheumatism (EULAR) recommendation on early arthritis as well as American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network (ACR/SAA/SPARTAN) recommendation on AS and non-radiographic axial spondyloarthritis (nr-axSpA) indicate of non-pharmacological interventions as an adjunct.22Rheumatic diseases usually require lifelong treatment. Despite the availability of effective medical treatment, the adverse outcome of chronic rheumatic disease on patients’ lives is still substantial. So, effective and comprehensive multidisciplinary treatment strategies are crucial. In fact, rehabilitation programs combined with pharmacologic therapy can improve patient’s physical, psychological and social functioning and well-being, reducing in parallel the disability and health care costs associated with underlying conditions.The aim of rehabilitation intervention for rheumatic disease can be summarized in the following terms: reducing pain and discomfort, improving or maintaining current physical, psychological and social functions, compensating for loss of function, preventing or slowing disability, increasing independence and health-related quality of life, providing social integration and decreasing cardiovascular risk.24A number of studies have demonstrated that MTC programs have a favorable effect on disability, disease activity, physical and psychosocial outcomes in patients with a wide range of rheumatic diseases.27In daily practice, such rehabilitation interventions can be provided in inpatient rehabilitation units, outpatient rehabilitation centers or long-term self-care management. Several studies have suggested that inpatient MTC delivered better health outcome in the short-term in patients with RA, AS, OA, as well as other non-inflammatory musculoskeletal diseases, including low back pain (LBP) and chronic widespread pain compared to outpatient MTC.28In contrast, others have demonstrated equivalent clinical effects between inpatient and daycare or outpatient team care programs.30Long-term effect of the treatment on disability or other health outcomes is yet unclear in patients with rheumatic disease. In a systematic review, it was suggested that either inpatient or outpatient MTC had limited effect on disability at 12 months, <12 months or 2 years of follow-up in patients with RA.23More recent reviews also indicated that after receiving inpatient MTC, mild as well as short-term improvements were observed in most clinical outcomes in patients with inflammatory rheumatic disease.24So, there is a strong need for studies to explore the long-term clinical effectiveness of MTC care on functional status, disability and other disease outcome in patients with rheumatic disease.Rehabilitation program can be applied in many different ways according to the patient’s needs and availability of health care professionals in rheumatology clinics. Lately, a more holistic approach is preferred and the most commonly implemented rehabilitation strategy for people with rheumatic disease is comprehensive multidisciplinary team care (MTC) including psychologists, podiatrists, dieticians, social workers, nurses, vocational, physical and occupational therapist under the supervision of a rheumatologist and/or rehabilitation specialist.31This approach consists of two parts that have several components including body functions and structures, activities and participation and contextual factors . Within the field of rheumatology, the ICF model is accepted to fit well in assessing the adverse long terms outcomes in several rheumatic diseases including RA, AS, OA and osteoporosis.33Thus, these structural approaches can contribute to the implementation of appropriate rehabilitation interventions which can eventually meet patient’s expectations and health professionals’ goals for optimal level of functioning.In the modern treatment era, the rehabilitation program should be designed as patient-centered using a multi-disciplinary approach. All patients should be assessed systematically for disease consequences, and individual goals of therapy should also be clearly defined before the rehabilitation intervention. To address these requirements, a structured approach towards rehabilitative management has been proposed by the World Health Organization International Classification of Functioning, Disability and Health (ICF).-Therapeutic exercise: In general, exercise is considered the cornerstone of the rehabilitative management of rheumatic disease. The primary aim of exercise programs is to maintain or increase joint range of motion, muscle strength, bone mineralization as well as aerobic capacity. Moreover, according to recent studies, exercise should be prescribed to improve cardiorespiratory fitness and reduce cardiovascular risk in patients with RA and other rheumatic diseases.34Although there is growing evidence on the effectiveness and safety of exercises in most rheumatic diseases,35there is still insufficient evidence to suggest the optimal type of exercise as well as the intensity, the duration, the number of repetitions or the frequency of the program. Such interventions could be performed through different types of exercise including land-based, water-based, home-based, individual and supervised exercises.36According to the ACR/SAA/SPARTAN treatment recommendation for AS and nr-axSpA, active physical therapy interventions such as supervised exercise is strongly recommended compared to passive physical therapy interventions including massage, ultrasound or heat. Taking into account the similar effectiveness of aquatic and land-based physical therapy with regard to disease outcomes as well as the fact that land-based therapy is more easily accessed than aquatic therapy, land-based physical therapy interventions is primarily recommended.21A Cochrane review article analyzed the effectiveness of physiotherapy interventions in the management of AS. Eleven studies were included in the data analysis. It was reported that, supervised exercise program was more effective than individualized home exercise programs and also group exercise combined with spa was superior compared to group exercise alone in patients with AS.37But, several factors including disease activity, joint damage, comorbidity or physical inactivity may represent barriers for patients to participate in exercise programs. Therefore, exercise prescription in RA should be tailored according to the patient’s functional ability, performance and cardiorespiratory fitness.39In RA, more recent reviews have indicated that dynamic exercises (aerobic and/or muscle strength training) exert a positive effect on function, quality of life, fatigue, psychological status and pain without any adverse influence on disease activity and/or radiologic damage. Currently, aerobic exercise combined with muscle strength training as routine practice should be recommend to patients with RA.41In the recent Cochrane review, high to moderate-quality evidence has reported moderately relief of knee pain and slightly improvement in physical function and quality of life in patient with knee OA.42Similarly, in patients with hip OA, the positive effects of the exercise program on hip pain and physical function has been supported by high quality evidence. But there is only low-quality evidence from three small studies supporting that exercise has small favorable influence on quality of life.43On the other hand, little evidence concluded benefit of exercise for patients with hand OA.44In patients with OA, exercise therapy including strengthening and aerobic exercise is the main component of non-pharmacological treatment and strongly recommended in most evidence-based international guidelines.38For example, some patients enjoy aquatic exercise but others do not; therefore, besides the disease related factors, the patient’s preference and expectations should be taken into consideration before prescribing the exercise program.Taken all together, the increasing amount of evidence suggests the effectiveness and safety of exercise in most rheumatic diseases. However, there are difficulties in the interpretation of these studies. Currently no guidance regarding the more effective type of exercise intervention per disease phenotype is available. Moreover, exercise duration, frequency, type  vary widely between the reported studies. Therefore, optimal therapeutic exercise programs for patients with rheumatic diseases should be prescribed on an individualized basis, taking into account the level of pain, disease activity, functional limitations, baseline levels of cardiorespiratory fitness as well as the shared decision between the patient and doctor.17Another study showed that intensive group exercises combined with TNFi was more efficient in term of spine mobility and physical function in patients with AS.19These results suggest that intensive rehabilitation intervention is more efficient in patients previously stabilized with biological therapy.Tumor necrosis factor inhibitors (TNFi) can be accepted as a major breakthrough in the treatment of several rheumatic diseases. So far, a few studies have examined the effect of TNFi therapy combined with exercise program on disease outcome in patients with AS. One study by Yigit S et al. suggested that home exercises combined with TNFi had better outcome for a variety of parameters  compared with TNFi therapy alone.Work rehabilitation: A number of studies suggested that vocational rehabilitation programs can reduce job loss, absence and sick leave as well as increase work participation, productivity and job retention rates.45Therefore, early identification of work problems is of outmost importance to prevent work disability.--Occupational Therapy: A beneficial effect of occupational therapy programs including lifestyle changes, joint protection, environmental modification, energy conservation, usage of orthoses and adaptive device on physical function has been demonstrated in a number of studies in rheumatic disease.46A Cochrane review demonstrated strong evidence for positive effect of occupational therapy on functional ability in patients with RA.47Also, more recently occupational therapy, dynamic exercises and hydrotherapy have been recommended in addition to pharmacological treatments by update of the EULAR recommendations for the management of early arthritis.22Physical Modalities: Despite extensive clinical experience with physical modalities including thermotherapy, therapeutic ultrasound, low-level laser therapy and TENS in patients with rheumatic disease, evidence-based data about their affectivity is scarce.48More high-quality studies are warranted to demonstrate the effect of physical modality intervention on functional ability and other disease outcomes in patients with rheumatic diseases.-Future rehabilitation intervention: Recent studies have explored alternative tools to improve active participation of patients to rehabilitation intervention. A few small studies described good short-term efficacy of virtual reality intervention on pain reduction in patients with RA.50Also, another study reported that routine exercise was performed more effectively by using the virtual reality intervention in patients with AS.51A more recent review article concluded that smartphone applications may have positive effect on self-management application in patients with rheumatic disease.52Therefore, web-based and mobile health interventions may contribute to an increased adherence to rehabilitation intervention in patients with rheumatic disease.-The composition of rehabilitative interventions may vary, but, recently, in the rheumatology setting, therapeutic exercise, patient education, occupational therapy, orthoses, assistive devices, work rehabilitation and physical modalities are most often included in rehabilitation intervention. Although in daily practice these interventions can be applied as a single treatment modality, usually combination therapy is preferred.22Moreover, rehabilitation programs have reported synergistic effects when used with medical treatments.19Hence, rehabilitation intervention is still considered as the mainstay of management of rheumatic disease, even in the era of new and effective pharmacotherapies.53In this respect, comprehensive and multidisciplinary rehabilitation interventions should become available and should be implemented as early as possible in the course of disease. Future research agenda should focus on the adequate description of early rehabilitation interventions to prevent deformities and disease progression, and their significance when used in combination with conventional and biologic disease-modifying drugs. In addition, particular care should be taken in the design of rheumatology rehabilitation facilities, the prioritization of patients and their needs, as well as the level and structure of service delivery organization in order to achieve better long-term outcomes for patients with systemic rheumatic diseases.In the last decade, the availability of new and effective medical treatment for specific rheumatic diseases is increased. However, rehabilitation interventions have a pivotal role in improving function and psychological status in this population. Several systematic reviews and also evidence-based management recommendations suggest rehabilitation management as an adjunct to medical therapy.


The aim of this systematic review was to investigate current penetration and educational quality enhancements from digitalization in the dental curriculum. Using a modified PICO strategy, the literature was searched using PubMed supplemented with a manual search to identify English-language articles published between 1994 and 2020 that reported the use of digital techniques in dental education. A total of 211 articles were identified by electronic search, of which 55 articles were selected for inclusion and supplemented with 27 additional publications retrieved by manual search, resulting in 82 studies that were included in the review. Publications were categorized into five areas of digital dental education: Web-based knowledge transfer and e-learning, digital surface mapping, dental simulator motor skills , digital radiography, and surveys related to the penetration and acceptance of digital education. This review demonstrates that digitalization offers great potential to revolutionize dental education to help prepare future dentists for their daily practice. More interactive and intuitive e-learning possibilities will arise to stimulate an enjoyable and meaningful educational experience with 24/7 facilities. Augmented and virtual reality technology will likely play a dominant role in the future of dental education. The implementation of digital technologies in dental curricula has started globally and reached varying levels of penetration depending on local resources and demands. One of the biggest challenges in digital education is the need to continuously adapt and adjust to the developments in technology and apply these to dental practice . Most deThe introduction of intraoral optical scanning (IOS) allows the current anatomic situation to be digitized, enabling chairside or laboratory fabrication of restorations, to plan oral rehabilitations with a set-up , and/or 3D education programs have been introduced to enhance students’ spatial ability, their interactivity, critical thinking, and clinical correlations with the integration of multiple dental disciplines. Augmented reality in 3D visualization allows insights in tooth morphology, and also facilitates treatment planning with fixed or removable partial denture (RPD) programs . DigitalA recent review on the application of augmented reality (AR) and virtual reality (VR) in dental medicine demonstrated that the use of AR/VR technologies for educational motor skill training and clinical testing of maxillofacial surgical protocols is increasing . It was Overall, digitalization seems to have had a major impact on dental education, addressing various aspects, such as e-learning and Web-based knowledge transfer, but also related to diagnostics using 3D imaging and digital radiography, and practically oriented trainings in terms of dental simulator motor skills including IOS with 3D printing, prototyping, and digital surface mapping. Digital applications can provide additional opportunities to evaluate and improve education, implementing evidence-based surveys related to the penetration and acceptance of digital education.The aim of this systematic review was: (i) to investigate the current level of implementation of digital technology in dental education; and (ii) to outline the educational quality enhancements that result from digitalization in main focus areas within the dental curriculum.Journal of Dental Education and the European Journal of Dental Education was conducted.This systematic review was conducted in accordance with the guidelines of Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) . A systeThis systematic review focused on randomized controlled trials, cohort studies, case–control studies, observational trials, and descriptive studies that investigated the application of digital technologies in dental education. Reports without an underlying study design and studies not involving dental students were not included. Furthermore, the vast body of literature about the transition from glass to digital slide microscopy was also excluded. Four reviewers  independently screened the titles, abstracts, and the full texts of the identified articles to select those for inclusion in the review. Disagreements were resolved by discussion. Duplicates or preliminary reports that were followed by original publications were excluded. A total of 211 titles were identified by the electronic search . After sWeb-based knowledge transfer/e-learning (22 studies);Digital surface mapping (20 studies);Dental simulator motor skills including IOS (23 studies);3D printing and prototyping (2 studies);Digital radiography (5 studies); andSurveys related to the penetration and acceptance of digital education (10 studies).The publications were categorized into six areas of digital dental education:Fifteen studies reported the use of Web-based learning tools in the dental curriculum, comprising orthodontics ,13, tootVisual inspection of students’ work is known to have shortcomings in inter- and intra-examiner reliability, whereas standardized digital surface mapping of abutment tooth preparations facilitates objective evaluation and feedback  34,35,3,44,45,46A high level of interest and acceptance was documented among undergraduate students for simulator training in cavity preparations ,55,56, oImproved student performance in crown digitization and framework design was observed when CAD/CAM (Computer-Aided Design/ Computer-aided manufacturing) courses were introduced in dental education . While sTwo studies evaluated training models created by 3D rapid prototyping ,78. SuchFour studies dealt with diagnosing radiographic changes ,80,81 orSix surveys evaluated students’ perception and acceptance of digital technologies  84,85,8,87,88,89Four surveys analyzed the penetration of and attitudes towards digital technologies at dental schools in the UK , U.S. 9, North ADespite a high acceptance of digital technologies in dental education by faculty  and studThe systematic review aimed to investigate current penetration and educational quality enhancements from digitalization in the dental curriculum. Heterogeneous study types addressing various fields of digital applications were found. While a meta-analysis was not feasible, a descriptive approach for identified publications was conducted. Digitalization in dental education is frequently used to enhance the accessibility and exchange of documents and to facilitate the collaboration and communication among students, teachers, and administrative staff. Digitalization enables cloud-based records, evaluation, and feedback, as well as the provision of e-learning modules . StudentEspecially in the field of motor skills training, digital software tools can be used to evaluate the manual abilities of potential candidates for the dental curriculum, to analyze students’ preclinical preparations, to enable self-assessment, and to enhance the quality of education. The objective and exact nature of these digital evaluations helps to improve students’ visualization, provides immediate feedback, and enhances instructor evaluation and student self-evaluation and self-correction ,94. StudWhile undergraduate students today have to be prepared for digital dentistry, they still need to acquire the knowledge of conventional treatment strategies and processes. Growing up in the digital world, they will easily adapt to digital features. Digital dentistry offers several options for an objective standardized evaluation of students’ performance, which should be used for quality enhancement. It is currently a “teaching transition time”, and new standards have to be defined for dental education in general. Open questions remain, such as: (i) in which phase of the dental curricula should digital technologies be introduced as the routine tool; (ii) which analog techniques can be omitted; and iii) which digital content should be taught in which disciplines? Several studies indicated that personal instruction and feedback from faculty cannot be replaced by simulator training and feedback ,65,85. IIt should be emphasized that there are still no uniform standards in dental education with regard to the digital tools applied. Such standards are essential to ensure uniformity in teaching, which is particularly important for an international exchange. Society as well as dentistry is currently undergoing a digital transformation. It is necessary to clarify learning contents, to what extent conventional workflows should still be taught, and what can be done digitally. While digital tools and applications in knowledge transfer are a general challenge for undergraduate education in all disciplines, the field of dentistry with its high degree of practical training units is specifically demanding. Just because training units are designed digitally does not mean that students learn on their own. Continuous training with supervision and feed-back is still the key to good dental education. In this context, digitization is certainly a great opportunity to convey the learning content with more joy and newly awakened enthusiasm.Following the rule, “you can only teach what you are able to perform yourself”, a highly motivated faculty is needed that is willing to embrace the latest digital technologies. Besides personal motivation, the financial aspect of implementing the various digital tools and applications has to be managed at dental universities. Collaborations with industry would be helpful here. This is a classic “win–win situation”—the dental school would be equipped with the latest products and updates, and the industry would get access to the youngest target group of potential customers. In the event of such collaborations, it is vital that universities maintain their objectivity by offering a variety of products from diverse companies; otherwise, there is a risk of unduly influencing dental students and biasing them towards one particular technological option. The rapid pace of change in dental technology must also be considered. Dental technology companies are constantly introducing new products and workflows. While this provides exciting opportunities for dental research, to test and analyze those new developments, it complicates the implementation of digital workflows in dental education programs. New job descriptions are also necessary at dental schools in order to maintain the technical infrastructures required for these new technologies and to guarantee a smooth operation in clinical practice. In future, the best dental schools will be ranked according to their digital infrastructure combined with the level of innovation of the teaching faculty. Digital tools and applications are now widespread in routine dental care. Therefore, this trend towards digitization and ongoing developments must be considered in dental curricula in order to prepare future dentists for their daily work-life. There is a need to establish generally accepted digital standards of education—at least among the different dental universities within individual countries. Digitalization offers the potential to revolutionize the entire field of dental education. More interactive and intuitive e-learning possibilities will arise that motivate students and provide a stimulating, enjoyable, and meaningful educational experience with convenient access 24 h a day.At present, digital dental education encompasses several areas of teaching interests, including Web-based knowledge transfer and specific technologies such as digital surface mapping, dental simulator motor skills including IOS, and digital radiography. Furthermore, it is assumed that AR/VR-technology will play a dominant role in the future development of dental education.


Given the lack of progress in breast cancer prevention, the California Breast Cancer Research Program (CBCRP) plans to apply current scientific knowledge about breast cancer to primary prevention at the population level. This paper describes the first phase of Californians Linking Action with Science for Prevention of Breast Cancer (CLASP-BC). The foci of Phase 1 are building coalitions and coalition capacity building through community engagement in community-based participatory research (CBPR) and dissemination and implementation (D&I) research training. Based on the successful implementation and evaluation of Phase 1, the foci of Phase 2  will be to translate the California Breast Cancer Prevention Plan overarching goal and specific intervention goals for 23 breast cancer risk and protective factors strategies into evidence-informed interventions (EIIs) that are disseminated and implemented across California. CLASP-BC is designed to identify, disseminate and implement high-impact, population-based prevention approaches by funding large scale EIIs, through multi-jurisdictional actions, with the intent to decrease the risk of breast cancer and other chronic diseases (sharing common risk factors), particularly among racial/ethnic minorities and medically underserved populations in California. Breast cancer is the most common cancer in women and the largest cause of cancer deaths among women worldwide: there were an estimated 2.1 million new cases and 626,679 deaths in 2018  indicatiGiven the lack of progress in breast cancer prevention, the California Breast Cancer Research Program (CBCRP)  applies CLASP-BC was informed by six years of funded dissemination and implementation (D&I) research and program evaluation conducted by the Canadian Partnership Against Cancer (CPAC)  through CLASP-BC is designed to support the dissemination, implementation, and evaluation of evidence-informed intervention (EII) strategies from the BCPPP by leveraging existing community cancer and chronic disease prevention efforts and focusing on identified risk factors for breast cancer. CLASP-BC will also be implemented in two phases. As detailed in the future directions for research section of this paper, Phase 1 will focus on: (1) understanding the breast cancer concerns and prevention priorities of community leaders , researchers, practitioners, and policy experts across California; (2) engaging community and opinion leaders, research, practice, and policy specialists in regional California meetings to identify opportunities for working together in breast cancer prevention coalitions based on shared concerns and priorities; and (3) supporting  building, strengthening, and enhancing community-based participatory research (CBPR) and D&I research capacity, as well as research engagement within these coalitions. The conceptual framework underpinning the first phase of CLASP-BC incorporates the multi-disciplinary model to broaden participation in community problem solving through collaborative practice and research , conceptFollowing the implementation and evaluation of Phase 1, Phase 2 will focus on: (1) providing D&I research grant support for interested and eligible coalitions demonstrating in their funding applications collaborative, evidence-informed (both practice and science-based) breast cancer prevention approaches from the BCPPP across two or more California jurisdictions ; (2) working through a cooperative agreement funding mechanism, successful applicants will share the knowledge gained on quarterly video conference calls and annual meetings to exchange ideas for how to meet the challenges and take advantage of the opportunities to sustain the breast cancer prevention approaches beyond the funding period: and (3) integrating the lessons learned from science with the lessons learned from practice and policy to reduce the risk of developing breast cancer.CLASP-BC is designed to disseminate and implement high-impact, population-based prevention approaches by funding large scale EIIs, through multi-jurisdictional actions, with the intent to decrease the risk of breast cancer and other chronic diseases (sharing common risk factors), particularly among racial/ethnic minorities and medically underserved populations in California. Examples of medically underserved communities in California include black populations in counties such as Tuolumne and Mariposa counties where 56.3% and 49.1% of families respectively live below the poverty level; Alpine county where 62.5% of Hispanic families live below the poverty level; and Lake County and Glenn counties where 40.9% and 40.3% of Native American families respectively live below the poverty level . Thus, gIn addition, engagement of indigenous communities may require working with tribal leaders and elders in ensuring acceptability of proposed partnerships. In California there are 109 federally recognized tribes . MoreoveA comprehensive strategy to breast cancer prevention assumes that through multi-sector , academia, and the private sector) and multi-jurisdictional approaches, working together will be more effective than when each organization, sector, or jurisdiction works on its own. By working together, partners share each other’s skills, knowledge, and resources, as well as the risks and rewards, to more quickly and effectively reach breast cancer and chronic disease prevention goals and objectives.This paper describes in detail the plans for implementing CLASP-BC Phase 1. A separate paper in this special issue describes the Phase 2 elements of CLASP-BC predicated on the successful implementation and evaluation of Phase 1.Much of the literature on coalition and partnership building ,21,22 caOne of the most important challenges faced today in social movements for change is how interactions and intersections of race, class, gender, sexuality, and power come together . CommuniCommunity-based partnerships and coalitions also provide benefits to scientific and public health institutions. They allow for the opportunity for researchers and academics to hear about specific barriers and knowledge gaps faced by various populations and regions. They also provide rich environments to move from theory and observation to deep contextual knowledge, which in turn improves theory. The demands of academia incentivize academic researchers to prioritize expediency, efficient scientific designs and publication over the qualities required for true collaboration with communities such as relationship- and trust-building, equitable service delivery, social change, advocacy, negotiation and recognition of the power imbalances between team members.Negotiating this balance is not a skill taught in research training, and failure can lead to worsened academic-community relations. To successfully build relationships that foster collaboration and shared lived experiences requires time, listening to and understanding the needs and barriers of communities and how their environment may pose unique risks for increased breast cancer rates as well as opportunities to reduce risk. It also requires communities to have a clear understanding of academic needs, and to build skills on negotiating a common scientific agenda . The infEstablishing strong community-based coalition partnerships that are responsive to community needs and priorities, and help to foster research by providing a good understanding of community needs , are necMechanisms and principles for building multisector partnerships for population health and health equity that can be sustainable have been described . While oOne key finding that permeates many of these studies is the factor of “synergy.” Partnership synergy, combining the individual perspectives, resources, and skills of coalition partners to create something new and valuable, has been examined and a practical framework developed for studying and strengthening the collaborative advantage . MechaniTo engage diverse constituencies at meetings, they must be accessible to all participants and be perceived as worth the investment in time. Some best practices include offering translated materials and simultaneous interpretation upon request, facilitating a safe space for all participants. Facilitating a safe space means cultivating and upholding community agreements and inviting all participants and facilitators to share their pronouns. Events and venues must be accessible and centrally located for various members with sufficient parking or public transit access. Consideration of the times of the day when members meet, may be necessary, as well as offering food, parking, and child-care on the premises.During COVID-19, connection is necessarily virtual and remote, creating barriers for many underserved and vulnerable communities that lack access to reliable Wi-Fi and the necessary technology. These barriers may further limit access to events, complicate outreach efforts and pose challenges to community partners joining virtual meetings. To overcome these barriers, event organizers should send out meeting information ahead of time, by mail if necessary, and by email, including simple instructions for joining on-line platforms and telephone call-in options. Creating accessible meetings allows for more intersectional attendance and creates a space for individuals to share their lived experiences. Community members’ stories highlight the complex intersections that can contribute to breast cancer risk factors and are an essential tool for tailoring breast cancer prevention efforts to the needs of different communities. Additionally, community involvement and coalition-building create another avenue to share information about breast cancer prevention and empower community members to share information within their communities that are culturally and linguistically appropriate.CLASP-BC is expected to have wide reach and involvement across the entire public health and medical spectrum of those engaged with breast cancer. It is expected that participants involved in outreach, engagement, evaluation and/or dissemination of the activities of this program may include, but are not necessarily limited to: practitioners, public health specialists, community health workers, citizen scientists, patient advocates, patients and their families, social service agency leaders, policy makers, opinion leaders, business leaders, civic leaders, researchers, cancer centers, cancer registries  program, local hospitals, local clinics, local public health agencies, governmental and non-governmental organizations, community based organizations, academic units, regional municipalities, jurisdictions and district offices, coalitions, faith-based organizations, and interested citizens who can form part of data-gathering, strategies and solutions proposed.There are both similarities and significant differences between CPAC’s CLASP initiative and the proposed CLASP-BC initiative. In terms of the population focus, while Canada (37.6 million in 2019) and California (39.8 million in 2019) have similar sized populations, they have radically different population densities . Both Canada and California have high percentages of their populations living in urban areas . In California, 39% of state residents are Latino, 37% are white, 15% are Asian American, 6% are African American, 3% are multiracial, and fewer than 1% are American Indian or Pacific Islander, according to the 2018 American Community Survey. Latinos surpassed whites as the state’s single largest ethnic group in 2014 . In CanaCPAC’s pan-Canadian CLASP framework focused on engaging communities from 10 Canadian provinces and 3 territories. The proposed CLASP-BC initiative would be focused on engaging communities across the state  prioritizing those communities with the highest percentage of racially and ethnically diverse and medically underserved populations that bear the greatest burden of breast cancer diagnoses.Throughout the CLASP experience in Canada, two key challenges were encountered consistently with respect to community engagement:In providing multidisciplinary knowledge to action research opportunities, a key learning from the Canadian CLASP initiative was the importance of considering equity in capacity across the partner disciplines . ResearcMany coalitions included First Nations partners—either organizations or communities—and a key challenge was fostering respectful and meaningful engagement and aligned partnerships . IndigenIn light of the COVID-19 pandemic, in the California context, conduct pre-planning prior to capacity building to determine when the timing is appropriate to engage community partners in coalition capacity building focused on breast cancer prevention and how best to engage community participants if the opportunities for face-to-face meetings remain limited.Engage community leaders, including elected officials, from culturally diverse and medically underserved California communities to understand their breast cancer prevention priorities in relation to other community health priorities (including COVID-19).Engage research, practice, advocacy and policy specialists to understand their breast cancer prevention priorities in relation to the dissemination and implementation of evidence informed interventions.(a)develop and sustain community, research, practice, and policy partnerships and conduct research using CBPR methods.(b)create a shared vision for partnerships.(c)develop model team agreements and tools for conducting partnership self-assessments.(d)identify benefits and challenges of participating in CBPR for their own partnership and identify potential solutions to challenges.Foster equitable coalition partnerships to conduct successful CBPR/D&I research by providing training and technical assistance to:(a)identify the various scientific methods that may be used in innovative intervention/adaptation research leading to D&I research.(b)identify community concerns and potential solutions regarding which research methods best fit their contexts.(c)identify and select best practices that will be utilized in creating a strong  and sustainable measurable methods plan, using theoretical frameworks.Assist teams in creating a pathway from vision to research project consideration by providing training and technical assistance to:The overall purpose of CLASP-BC is to link the lessons learned from science (Knowledge to Action) with the lessons learned from practice and policy (Action to Knowledge). In doing so, it will broaden the reach and deepen the impact of EIIs on breast cancer and chronic disease prevention initiatives across California, focused on common risk factors, and will expand their impact. The foci of Phase 1 are building coalitions, coalition capacity building through community engagement, and cooperative and collaborative CBPR and dissemination and implementation research training. The specific aims of phase 1 are as follows:For the purposes of CLASP-BC, the definitions of community representatives and patient advocates, as well as research, practice, and policy experts, who will be invited to participate in the meetings described below, are as follows:Community representatives and patient advocates—these are individuals who live and work in the engaged communities and/or are leaders in community-based organizations providing vital social, economic and health service support in the engaged communities. As such, these coalition partners are vital in contributing their knowledge and expertise as community leaders. In Canada, they often referred to as community champions. US examples are “promotores de salud” , serving as citizen scientists who are engaged in supporting research at different levels in the community. These individuals can be trained in research and can be engaged from conceptualization through implementation, evaluation and dissemination of findings for research and practice projects.Research experts—individuals with an advanced degree  who have actively participated in and contributed to the research enterprise as evidenced by peer-reviewed research grants and/or publications. Researchers who have such a demonstrated research background may or may not be affiliated with an academic institution  but could also serve in an NGO, government, or other organizations with research as part of their mission.Practice experts—individuals who manage and/or provide programming and/or services that influence directly or indirectly  population health. Practitioners in the funding agreement applications could represent NGOs, government, or other organizations with demonstrated knowledge and skill in the topic under consideration for the funding application.Advocacy and policy experts—individuals who work on making or influencing policy decisions in or outside of government  that influence directly or indirectly population health. Policy can include legislative or executive decisions that work through taxation, regulation, and related policy instruments that impact populations. This may also include advocacy groups that advocate for informed policy decision making and help to educate and inform policy-makers, disseminating scientific findings.In Phase 1, interested parties will be invited to participate in a state-wide concept mapping  activitySubsequently, two-day CBPR and D&I training workshops will be organized for existing or emerging coalitions interested in applying to a future Phase 2 D&I research funding initiative. These meetings will provide CBPR and D&I research tools and guidance as well as coalition exercises to help potential applicants develop a shared common understanding of the opportunities and challenges of working together collaboratively on EII for breast cancer prevention.For the past decade, CBCRP has conducted NIH-supported proposal development workshop programs to help new and existing community-academic teams build partnerships and develop fundable research projects focused on breast cancer environmental causes and disparities. Based on this experience, the following draft see  of the pBox 1Topic and Learning ObjectivesThe California Plan to Prevent Breast Cancer[t Cancer,7,37Learning Objectives:Understand Concepts of Population Primary PreventionUnderstand the complexity of breast cancer causation and methods to reduce incidenceIntroduction to Implementation Science[ Science,39,40Learning ObjectivesUnderstand broad objectives of the fieldDefine and understand key terminologyUnderstand types of research questionsIdentify what is (and is not) implementation scienceFinding Your Research Question and Framing Your Questions[uestions,42Learning ObjectivesLearn the elements of effective research questionsUnderstand the key components of specific aims in implementation scienceSmall Group ActivityDefining the problem, crafting the research question and identifying aimsEngaging Your Community and Forming Your Coalition[oalition,44Learning ObjectivesLearn the concentric circles of community engagementLearn how to use best practices and tools to develop coalitionsSmall Group ActivityTheories, Frameworks, and Models[d Models,46Learning ObjectivesUnderstand the importance and role of theories, frameworks, and modelsUnderstand how these theories, frameworks, and models inform study componentsCBPR in Practice[PracticeLearning Objectivesunderstand the benefits and challenges of CPPR for both the community and academic partnersbe able to identify benefits and challenges of participating in CPPR for their own partnershiplearn methods to mitigate barriersStudy Designs in Dissemination and Implementation Research[Research,49,50Learning ObjectivesLearn about study design options for implementation scienceUnderstand basic measures, outcomes, and analyses in implementation scienceMeasurement, Epidemiology, and Evaluation[aluation,53,54,55Learning ObjectivesUnderstand the importance of measurement and evaluation issuesConsider measurement issues in designing studiesLearn about resources for selecting implementation science measuresSmall Group ActivityChoosing a study design, defining outcomes and measuresTools and Technical AssistanceConclusionAll potential Phase 2 D&I research coalition applicants  will be invited to attend the CBCRP-sponsored two-day CBPR & D&I research training workshops described above.In addition to the peer-reviewed publication of Phase 1 meetings data, media and social media presentations of the concept mapping findings by region will be developed and disseminated to increase interest and possible in engagement in Phase 2 CBPR/D&I research coalitions. In addition, CBCRP will share the findings from the concept mapping and regional meetings with potential Phase 2 co-funding agencies which are unable to attend all or any of the regional engagement meetings as observers.explore the strength of the science behind known and suspected risk factors for breast cancer;explore potential interventions to address these risk factors;identify strengths, weaknesses and gaps in scientific research; andwork with the broad array of stakeholders to disseminate and implement the plan.The California Breast Cancer Primary Prevention Plan (BCPPP) , was basThe process was guided by a multi-stakeholder advisory committee that included some of California’s leading breast cancer, public health, social and environmental justice and disease prevention experts. The project culminated in the creation of the Comprehensive Breast Cancer Primary Prevention Plan for California, which will serve as a road map for legislators, local and state regulators, and community.Update state, city and county zoning and permitting laws, as well as city and county General Plans, to prevent polluting industries from being located near schools or concentrated in communities of color or low-income communities.Develop safe walk-, bike- and public transit-friendly cities to enhance physical activity opportunities and reduce pollution, both of which impact breast cancer risk and health in general.Create breastfeeding-supportive workplaces for all workers, regardless of employment classification or status.Establish standards of best practices for all occupations where workers might be exposed to ionizing radiation.Develop workplace policies, with worker involvement, to reduce, eliminate or mitigate unnecessary exposures to light at night.In accordance with California’s recognition of the human right to water, expand the state’s capacity to ensure safe , adequate and affordable water for all California residents, regardless of whether they live in cities, towns or unincorporated areas.The plan outlines a series of 16 overarching goals along with specific interventions that would support the accomplishment of these goals. The following are selected examples of intervention strategies from the Plan:Evidence-informed interventions (EIIs) to prevent breast cancer linked to these strategies include but are not limited to: limiting alcohol intake; promoting physical activity, healthy eating for healthy weight ; promotiHelping to operationalize the intervention strategy priorities identified in the BCPPP, and providing resources for community-level interventions, guidelines are published by many governmental and non-governmental agencies. These resources use an evidence-informed process and consensus, with varying degrees of rigor. For example, the Guide to Community Preventive Services (the Community Guide) is a systematic review that summarizes what is known about the effectiveness and cost-effectiveness of population-based interventions designed to promote health, prevent disease, injury, disability and premature death . RelatedWhile policy dissemination research is relatively under developed in the field of health, policy dissemination research in other areas is not a new field and is more developed in countries outside the United States . The lesThis paper describes a planned research funding initiative by the California Breast Cancer Prevention Program entitled Californians Linking Action with Science for Prevention of Breast Cancer (CLASP-BC). CLASP-BC is informed by CBPR and D&I research and is designed to translate the California Breast Cancer Prevention Plan overarching goal and specific intervention goals for 23 breast cancer risk and protective factors strategies into evidence-informed interventions (EIIs) that are disseminated and implemented across California. CLASP-BC is designed to disseminate and implement high-impact, population-based prevention approaches by funding large scale EIIs, through multi-jurisdictional actions, with the intent to decrease the risk of breast cancer and other chronic diseases (sharing common risk factors), particularly among racial/ethnic minorities and medically underserved populations in California.CLASP-BC was informed, in part, by the Coalitions Linking Action and Science for Prevention (CLASP) D&I research and program evaluation initiative funded by the Canadian Partnership Against Cancer (CPAC). Like the Canadian CLASP, CLASP-BC will be rolled out in two phases. Phase 1 will focus on: (1) understanding the breast cancer concerns and prevention priorities of community leaders , researchers, practitioners, and policy experts across California; (2) engaging community and opinion leaders, research, practice, and policy specialists in regional California meetings  to identify opportunities for working together in breast cancer prevention coalitions based on shared concerns and priorities; and (3) supporting  building, strengthening, and enhancing CBPR and D&I research capacity, as well as research engagement within these coalitions.Phase 2 will focus on: (1) providing D&I research grant support for interested and eligible coalitions demonstrating in their funding applications collaborative, evidence-informed (both practice and science-based) breast cancer prevention approaches from the BCPPP across two or more California jurisdictions ; (2) working through a cooperative agreement funding mechanism, successful applicants will share the knowledge gained on quarterly video conference calls and annual meetings to exchange ideas for how to meet the challenges and take advantage of the opportunities to sustain the breast cancer prevention approaches beyond the funding period: and (3) integrating the lessons learned from science with the lessons learned from practice and policy to reduce the risk of developing breast cancer.This paper describes in detail the plans for implementing CLASP-BC Phase 1. The Phase 2 elements of CLASP-BC, predicated on the successful implementation and evaluation of Phase 1, are described elsewhere in this special issue.