Cancer treatments have the potential to cause infertility among women of reproductive age. Many cancer patients do not receive sufficient oncofertility information or referrals to reproductive specialists prior to starting cancer treatment. While health care providers cite lack of awareness on the available oncofertility resources, the majority of cancer patients use the internet as a resource to find additional information to supplement discussions with their providers.Our aim was to identify and characterize Web-based oncofertility decision aids and health education materials accessible for women of reproductive age with a diagnosis of any cancer.We searched five databases and the gray literature for the years 1994-2018. The developer and content information for identified resources was extracted. Each resource underwent a quality assessment.We identified 31 open access resources including 4 decision aids and 27 health educational materials. The most common fertility preservation options listed in the resources included embryo , egg , and ovarian tissue freezing . Notably, approximately one-third  contained references and 5 (16%) had a reading level of grade 8 or below. Resources were of varying quality; two decision aids from Australia and the Netherlands, two booklets from Australia and the United Kingdom, and three websites from Canada and the United States rated as the highest quality.This comprehensive review characterizes numerous resources available to support patients and providers with oncofertility information, counseling, and decision making. More focus is required to improve the awareness and the access of existing resources among patients and providers. Providers can address patient information needs by leveraging or adapting existing resources to support clinical discussions and their specific patient population. Many life-saving cancer treatments, including chemotherapy, radiation, and surgery, have the potential to impair reproductive function in women -3. Even The decision to pursue FP is preference-sensitive. There is no “best” option for everyone; rather, the weighting of the risks and benefits of each FP option depend on personal values ,7. For oDecision aids and health education materials could be of great use to women diagnosed with cancer and a valuable tool for providers. However, many providers cite lack of awareness on the available resources as a barrier to information provision and fertility discussions with patients -23. ReceNo protocol was registered for this study. Information specialists conducted a search of MEDLINE, PsycINFO, CINAHL, Cochrane Central and Database of Systematic Reviews, and EMBASE from January 1, 1994, to April 4, 2018, to capture open access decision aids and health education materials available on the Web. Key words and their synonyms were used in the search strategy:  AND  . The incWe included decision aids and health education materials. Decision aids are defined as “evidence-based tools designed to help patients make specific and deliberate choices among healthcare options” . They prTwo reviewers independently screened the websites, publication abstracts, and full texts. Criteria for inclusion included the following: (1) publication/website is in English and describes or is a decision aid or health education material on oncofertility or describes the development and/or evaluation of such a resource, (2) full decision aid or health education material is openly accessible at the time of the search, (3) website contains printable oncofertility information defined by the Patient Education Materials Assessment Tool (PEMAT) as “printed booklets, brochures, and materials that can be printed from websites ”  or are nTwo reviewers independently extracted descriptive information into a data extraction table created in Microsoft Excel 2010. Information included author, publication date and date of last update, target population, classification of decision aid or health education material and sections included, number of pages, development country, fertility options before treatment and parenthood options after treatment, and specific content pertaining to fertility . Analysis of the decision aids and health education materials involved synthesizing descriptive characteristics and tabulating the results.Since no single quality assessment tool was appropriate for the evaluation of the different decision aids and health education materials identified, we used three separate quality assessment tools based on the type of resource. The International Patient Decision Aid Standards Collaboration (IPDAS) checklist (V.4.0) is internationally approved and recognized as the most credible measure to evaluate the quality of decision aids ,38. The Two reviewers (SM and CD) independently assessed the quality of each decision aid, and two reviewers (BS and TL) independently assessed the quality of each health educational material. The Cohen kappa score was obtained to determine the level of interreviewer agreement .The Web-based search in 2014 yielded approximately 11,000,000 results and this increased over twofold in 4 years to approximately 26,600,000 results in the 2018 search. From the Web-based search and consultation with experts in the field of oncology, an additional two decision aids and 27 health education materials were identified. We also identified four decision aids in development, including one in Switzerland by Tschudin et al , one in This review identified four decision aids categorized as two traditional decision aids (6.5%) and two option grids (6.5%). In 2011, Peate et al developed a decision aid in the form of a booklet for women with early-stage breast cancer in Australia . The AusAn additional 27 health educational materials were identified and categorized as 10 printable handouts , 15 printable website sections dedicated to oncofertility , and 2 non-printable interactive websites dedicated to oncofertility. All resources identified provided information on embryo and egg freezing. Most resources provided information on ovarian tissue freezing  and many provided information on ovarian suppression . Less than half of resources provided information on other FP options including ovarian transposition , fertility-sparing surgery , ovarian shielding , and in vitro maturation . The Australian and Dutch decision aids as well as the PMH pamphlet, MSKCC website, Breast Cancer Care booklet, and Cancer Council Australia booklet  were the only resources to included information on the option of not pursuing FP or “wait and see.” Nine resources (29%) provided no additional information on parenthood options after cancer treatment. The most commonly described parenthood options after treatment included egg donation , surrogacy , adoption , natural conception/having fertility testing completed , and embryo donation . Few resources listed no more children  or foster parenting  as parenthood options after cancer treatment. The Australian decision aid and Cancer Council Australia booklet were the most comprehensive resources covering a range of topics and included sections. These resources also contained the most pages, with 37 and 84 pages of content respectively. Only the decision aids from Australia and the Netherlands contained explicit values clarification methods. The values clarification method in the Australian decision aid is a personal worksheet with questions and a pros/cons list to identify the drawbacks and advantages for each fertility option . The DutFew resources contained information on fertility in women , with more focusing on infertility in women . Most resources included information on cancer treatments , an explanation on how the treatment impacts fertility  and fertility outcomes after treatment  . Many resources also listed sources for patients to access more information . Finally, 11 resources (35%) contained references detailing the sources of evidence and 7 resources (23%) had a glossary of medical terms. Each resource underwent a quality assessment . The CohThe decision aid quality assessment revealed that the Australian and Dutch decision aids met all the qualifying criteria, while the two option grids met most qualifying criteria . The Dutch decision aid met all certification criteria, while the Australian decision aid and Canadian option grid met most applicable certification criteria, , and the LIVESTRONG option grid met only one certification criteria . All decision aids met at minimum three of the applicable quality criteria, including the ability to compare features of available options, inclusion of outcome probabilities, and the event rates for the outcome probabilities. The Australian and Dutch decision aids met the most quality criteria, , when compared to the option grids.Using PEMAT, five of the printable handouts and printable website sections dedicated to oncofertility shared the greatest actionability score  , including the Cancer Council Australia booklet, the Leukemia and Lymphoma Society factsheet, the Breast Cancer Care booklet, and the Breastcancer.org, Canadian Cancer Society, MD Anderson Cancer Center, and MSKCC websites. Six materials rated 80% or above on understandability , including the Cancer Council Australia booklet , American Cancer Society , Breast Cancer Care booklet , Canadian Cancer Society website , the MSKCC website , and the National Cancer Institute website . More than half (64%) of the printable handouts and printable website sections dedicated to oncofertility scored 50% or below on the actionability, and 52% of these resources scored below 70% on the understandability. However, all materials used the active voice for most sentences, did not expect users to complete any calculations, did not contain material that distracted from the resources purpose, and presented the information in a logical sequence.The interactive oncofertility dedicated websites had variable quality, meeting between 23 (47%) and 38 (76%) of the 49 possible criteria. Both websites contained technical elements such as information on the ownership of the site, clear statement about their objectives and target audience, transparency on funding, compliance with advertising rules, and geographic location of the site. Additionally, each website contained design elements such as scroll bars, subheadings and grouping of information, a menu with listings, proper layout and typography, and correct presentation of content when viewed in a partial webpage window. For readability and usability, the websites had appropriate sentence construction, use of active voice for most sentences, and road signs to indicate next/previous topics, minimal downloading time, appropriate functionality to support content, and ease of navigation in finding the desired content. However, some aspects that neither website displayed included the date of creation/last update/technical maintenance, message alert when leaving the secure site, clear statement about the editorial review process, hierarchy of evidence clearly displayed, and interactive learning tools .Only five (16%) of the decision aids and health education materials were assessed at a reading level of grade 8 or below. All other resources ranged from a grade 8 to grade 12 and above readability level .This review identified and characterized 31 open access decision aids and health education materials of varying quality for use by women of reproductive age diagnosed with cancer and their providers. Of the identified resources, two decision aids from Australia  and the While the number of resources has increased, this review found the quality of these resources could be enhanced. While more information is of benefit to patients and providers, developers should adhere to best practices, such as the IPDAS  when creThe Australian decision aid by Peate et al  and bookWomen of reproductive age want fertility information and desire participation in discussions around FP prior to starting fertility-risking cancer treatment . The risThrough the exploration of Web-based sources, the review was strengthened by the discovery of decision aids in development and resources not identified in previous reviews ,27,68. TWe also conducted the Web-based search using one search engine (Google) in one location . Although different results may have been obtained with other search engines and in other geographic locations, the search was conducted at three different time points capturing search engine index changes. Additionally, the review of approximately 50 websites during each search ensured a broad range of potentially eligible websites and aimed to replicate the searching strategy of a patient recently diagnosed with cancer. Our search did not include fertility clinic information as the search strategy was not designed to capture fertility clinics globally and a targeted search of fertility clinic information was out of scope for this review.This review allowed for the comparison and quality assessment of decision aids and health education materials potentially accessed by women of reproductive age with a diagnosis of cancer or used by providers as an adjunct to clinical discussions. Applicable resources that align with the clinical population, local context, and patient information needs can be identified from this review. As such, we need to focus on enhancing the awareness and the access of these resources to ensure use and promotion of high-quality resources to patients who desire more information before fertility decision making and cancer treatment. The identified decision aids and health education materials can also be modified to enhance their quality and to meet the local needs of a clinic and patient population.Fertility preservation prior to cancer treatment is an important topic of discussion for women of reproductive age, and resources can help facilitate patient-provider discussions prior to fertility-risking treatment. This review identified 31 oncofertility decision aids and health education materials that are publicly available. The quality assessments revealed the resources are of varying quality, which indicates that there is room for improvement for many of these resources. As further resources are developed to fill an information gap, developers should adhere to patient education best practices during development to ensure a high-quality tool. Field testing should also be completed by stakeholders of the resource prior to publication of the content on the Web.


In 1994 Alcohol Health & Research World  last devoted a full issue to the topic of fetal alcohol syndrome (FAS) and other alcohol-related birth defects (ARBD). This introductory article provides readers with information on how the field has advanced since then. In addition to tracing the development of the terminology used in the field, it describes the difficulties involved in determining the true prevalence of FAS and ARBD; the mechanisms that may play a role in alcohol-derived fetal injuries; approaches to preventing drinking during pregnancy; and strategies for assisting people who have been born with FAS and ARBD. Alcohol Health & Research World  last devoted a full issue to the topic of fetal alcohol syndrome (FAS) and other alcohol-related birth defects (ARBD) . Selected by the National Association of Government Communicators as first prize in the technical publications category, that issue of the journal provided an excellent overview of the existing knowledge on alcohol-derived prenatal injury and still remains a valuable resource for readers. Since the publication of that issue, however, research in the ARBD field has advanced significantly. This current issue of Alcohol Research & Health presents a selection of these new, important findings.In 1994 Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention, and Treatment  to prepare a comprehensive report on FAS. In response, NIAAA commissioned the Institute of Medicine (IOM) of the National Academy of Sciences to conduct a study. The resulting seminal report, reatment a, criticThe term “fetal alcohol syndrome” was introduced in 1973 by The IOM developed five diagnostic categories (see textbox). The first two pertain to FAS itself. The other categories address various aspects of the spectrum of alcohol-related disorders. Researchers previously had disagreed whether an FAS diagnosis could be made without evidence of maternal alcohol use. Some investigators had argued that the phenotype  of FAS appeared to be sufficiently unique to permit the diagnosis to be made even in the absence of information on maternal drinking; other investigators, however, felt uncomfortable about making an FAS diagnosis without a confirmation of maternal drinking. The issue of drinking history as one of the diagnostic criteria is important, because maternal drinking history is frequently unknown. Because no validated objective biological marker currently exists to confirm maternal drinking during pregnancy or alcohol exposure of the fetus , researchers must rely on maternal self-reports as well as reports from the mother’s collateral acquaintances. However, many affected children are in foster care or adopted, and accurate drinking information for the birth mother, even from her collaterals, is not readily available for these children.Category 1. FAS With Confirmed Maternal Alcohol ExposureConfirmed maternal alcohol exposure*Characteristic pattern of facial anomalies, including short palpebral fissures, and abnormalities of the premaxillary zone Growth retardation, such as low birth weight, lack of weight gain over time, disproportional low weight to heightNeurodevelopmental abnormalities of the CNS, such as small head size at birth; structural brain abnormalities with age-appropriate neurological hard or soft signs Category 2. FAS Without Confirmed Maternal Alcohol ExposureCharacteristics 2–4 as in Category 1Category 3. Partial FAS With Confirmed Maternal Alcohol ExposureConfirmed maternal alcohol exposure*Some components of the FAS facial patterneither 3, 4, or 5 below:Growth retardation as in Category 1CNS neurodevelopmental abnormalities as in Category 1Complex pattern of behavioral or cognitive abnormalities inconsistent with developmental level and unexplained by genetic background or environmental conditions Category 4. Alcohol-Related Birth Defects (ARBD)Confirmed maternal alcohol exposure*One or more congenital defects, including malformations and dysplasias of the heart, bone, kidney, vision, or hearing systemsCategory 5. Alcohol-Related Neurodevelopmental Disorder (ARND)Confirmed maternal alcohol exposure*CNS neurodevelopmental abnormalities as in Category 1and/orComplex pattern of behavioral or cognitive deficits as in Category 3*Maternal alcohol exposure is defined as a pattern of excessive alcohol intake characterized by substantial, regular intake or by heavy episodic  drinking. Evidence of this pattern may include signs of alcohol dependence.CNS = central nervous system; FAS = fetal alcohol syndrome; IOM = Institute of Medicine.SOURCE: not occur, a diagnosis of FAS would not be made, even if the affected person appeared to have all the signs of FAS.The IOM addressed this problem by creating two FAS categories that differed from each other only on whether maternal alcohol exposure could be confirmed. At-risk maternal drinking during pregnancy was defined as “a pattern of excessive intake characterized by substantial, regular intake or heavy episodic drinking” a, p. 77.The other elements of the FAS diagnosis in the IOM definitions do not deviate significantly from the original descriptions provided by The other three IOM diagnostic categories describe conditions that do not meet the FAS criteria. All require a confirmation of substantial maternal alcohol use because the phenotypes for these diagnoses are not considered unique enough to be ascribed to prenatal alcohol exposure without evidence of maternal drinking.Category 3 includes partial FAS with confirmed maternal alcohol exposure—in other words, some, but not all, of the facial characteristics required for an FAS diagnosis must be present as well as confirmed evidence of maternal alcohol exposure. In addition, at least one of the three following indicators also must be present: growth deficits normally characteristic of FAS, neurodevelopmental abnormalities, or behavioral and cognitive problems consistent with those observed in FAS. The latter indicator includes a complex pattern of deficits in learning, school performance, impulse control, and the cognitive functions involved in guiding behavior. Category 4 encompasses ARBD and was proposed for people with heart, bone, kidney, vision, or hearing defects who had been prenatally exposed to alcohol. Such organ abnormalities are not uncommon in FAS, although they are not observed as consistently as other FAS features. When the behavioral and cognitive problems of FAS and partial FAS are present, but the facial features are normal, the affected individual is assigned to category 5, alcohol-related neurodevelopmental disorder (ARND). Because ARND and ARBD can co-occur, a person may receive a dual diagnosis.The terminology introduced by the IOM provides flexibility for clinical applications and more precision for research applications. However, as new knowledge about the nature of the deficits accrues, further refinements in the defining categories will likely occur.“fetal alcohol spectrum disorders” (FASD) for inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). FASD describes the full range, from mild to severe, of disturbances of physical, behavioral, emotional, and/or social functioning attributable to in-utero alcohol damage. These terms may prove useful in some circumstances, provided that conflicting definitions for FAS, ARBD, and ARND are not introduced.Among other terminology that has been introduced since the IOM study, Riley and colleagues use the term “prenatal exposure to alcohol ” in their research e.g.,  to descrOne of the biggest challenges in determining the true prevalence of FAS and the associated disorders is how to recognize the syndrome, which depends in part on the age and physical features of the person being diagnosed . SeveralInvestigators have used three different approaches in attempting to measure the prevalence of FAS: passive surveillance systems, clinic-based approaches, and active case ascertainment in a segment of the general population. May and Gossage discuss in their article in this issue, pages 159–167, both the advantages and disadvantages of these approaches. Based on recent findings, May and Gossage estimate that the prevalence of FAS in the United States during the 1980s and 1990s was 0.5 to 2.0 cases per 1,000 births.Not every woman who drinks during pregnancy will give birth to a child with FAS or even ARND. Clearly, no single mechanism is responsible for the array of alcohol-derived fetal injuries. However, some putative mechanisms are particularly significant in early pregnancy, such as excessive cell death in a special population of embryonic cells that give rise to facial structures and certain peripheral nerves  , whereasThe conundrum confronting efforts to prevent FAS, ARND, and ARBD is obvious to everyone who has attempted to address this issue. As the IOM noted in its report, the problem may appear simple on the surface: “Women who drink excessively while pregnant are at high risk for giving birth to children with birth defects. Therefore, to prevent these defects, women should stop drinking alcohol during all phases of pregnancy” b, p. 1. Universal prevention targets an entire population group and can include such components as health advisories, public service announcements, and health articles and brochures distributed through a variety of outlets. For example, NIAAA issued a health advisory in 1977  are described by Coles on pages 199–203. Lastly, Mennella (pages 230–234) discusses how alcohol exposure through lactation may affect aspects of child development, particularly motor development.Efforts are under way to obtain a full understanding of the specific neurocognitive functions that are impaired or spared among people with FAS and ARND. Several articles in this issue of The new knowledge on FAS highlighted in this issue should help clinicians and researchers in developing approaches for assisting people in overcoming behavioral and cognitive deficits and thereby improve the quality of their lives. New approaches to amelioration, such as dietary supplementation  and specAlthough great strides have been made in identifying and characterizing the physical and neurobehavioral problems of FAS and ARND, further research is needed to accomplish the following important objectives:Improve the clinical recognition of women’s at-risk drinking behavior before and during pregnancyIntervene more effectively to modify drinking behavior during pregnancyDevelop in-utero approaches derived from basic research to prevent or minimize alcohol-induced prenatal injuryDetermine more effective ways to identify FAS and ARND across the life span, especially in infants and childrenDevelop strategies to address the neurodevelopmental and learning problems of children with FAS andARND, including the use of appropriate behavioral and cognitive therapies, medications, and special education programs.Multidisciplinary approaches encompassing basic laboratory animal research, human clinical research, and epidemiology will pave the way for translating scientific knowledge into practical approaches for preventing and treating FAS, ARND, and ARBD.


To review and discuss important topics regarding periodontal treatment pre- and post-radiotherapy for head and neck cancer in human patients; to discuss the references for adequate techniques, the appropriate moment for tooth extractions and periodontal management; and to discuss the prevention of osteoradionecrosis.Thirty-nine studies including original studies, randomized clinical trials (RCTs) and reviews were searched in online databases MEDLINE (PubMed) and the Cochrane library. No year of publication restriction was applied.Language was restricted to English, and the following Medical Subject Heading terms were used: radiotherapy, radiation therapy and periodontal treatment. Studies regarding periodontal treatment and tooth extraction that involved clinical management of irradiated patients were selected.The treatment of periodontal diseases before radiotherapy is mainly required to avoid future dental extraction and to reduce the development of osteoradionecrosis. Periodontal treatment in irradiated patients mostly includes scaling and root planing, extraction of condemned teeth and topical and systemic antimicrobial therapy. Tooth removal should be planned at least 14 days before the first day of radiation treatment. Particular care and mouthwashes should be taken during and after radiation.The management of irradiated patients represents a challenge for health professionals, including dentists. It is important to establish recommendations for clinicians concerning dental and periodontal management in irradiated patients before, during and after treatment. Key words:Head and neck cancer, radiotherapy, periodontal treatment, periodontitis. Radiotherapy (RTX) is one of the treatment options for head and neck cancer, and it is also indicated as an adjuvant after tumour resection in association with chemotherapy or as palliative treatment for unresectable late-stage tumours . ManagemIn addition to the side effects described above, oral cavity morbidities related to RTX also include increased susceptibility to dental caries, tooth decay and periodontal disease ,4. PatieThe effect of radiation on periodontal health is dose-dependent and is associated with poor periodontal health before radiotherapy initiation. The prevalence of periodontitis in adults is frequent and is likely to get worse with oncology treatment . The aggRecently, RTX has been applied through the use of three-dimensional (3D) irradiation techniques, such as 3D conformal radiation therapy (3DCRT) or intensity-modulated radiation therapy (IMRT). Both techniques have been shown to preserve adjacent tissues and provide a more precise assessment of high-irradiation and high-risk areas .With the action of clinicians within dentistry, it is possible to propose a prevention-based approach, with control over the source of dental infection adapted to a patient’s situation before administering RTX. Pre-treatment assessment and management, accompanied with maintenance of oral hygiene, have already been shown to be effective methods of preventing oral and systemic complications following RTX treatment ,9. Oral Thus, the aim of this study was to review and discuss important topics regarding periodontal treatment pre- and post-RTX for head and neck cancer in human patients. In addition, this study seeks to establish recommendations for clinicians concerning dental and periodontal management in irradiated patients before, during and after treatment. Lastly, this study includes a discussion of references for adequate techniques, the appropriate moment for tooth extractions and periodontal management, and the prevention of osteoradionecrosis.Twenty four original studies, 1 randomized clinical trial (RCT) and 12 reviews were included, being the studies searched in online databases MEDLINE (PubMed) and the Cochrane library, all of them selected by means of the focus on the patient attendance and care. No year of publication restriction was applied. Language was restricted to English, and the following Medical Subject Heading terms were used: radiotherapy, radiation therapy and periodontal treatment. Studies regarding periodontal treatment and tooth extraction that involved clinical management of irradiated patients were selected, with an emphasis on updated guidelines and protocols.- Pre-radiation procedures• Clinical evaluation – what is important to consider?Current recommendations indicate that irradiated patient examination and treatment should account for the cancer treatment. The clinician should examine the oral condition before, during, and following cancer therapy. Additionally, a lifelong commitment by the physician to promote preventative oral health management is recommended. Preventive maneuvers should be done in order to minimize the risk of worsening periodontitis, which could require tooth extraction with the associated risks of ORN . PeriodoTooth extraction recommendations defined before RTX should determine the right moment to perform this clinical procedure and which teeth should be extracted . Apical • Tooth extraction and soft tissue management – reducing the risk of ornThe most followed guidelines and recommendations concerning tooth removal before radiation is based on the orientations of the German Society of Dental, Oral and Craniomandibular Sciences, which include the following: (1) periodontal probing depth equal or greater than 5 mm; (2) furcation involvement; (3) carious lesions that reach the pulp; (4) impacted and retained teeth; (5) large fillings, fractures, or significant occlusal wear; (6>) teeth positioned in a region of that is expected to receive more than 55 Gy; (7) teeth that are non-vital and without sufficient root canal filling; and 8) teeth that are painful, sensitive to percussion, or show apical radiolucency  and gingival indices (GI) than healthy patients. The use of fluoride products and chlorhexidine rinses are beneficial in patients after RTX . It is cAdvances in cancer treatment have increased patient overall survival, though treatment usually requires aggressive management of oral toxicities related to the side effects of oncology therapies. To ensure long-term oral health and overall well-being, advances in oral care will need to reduce oral complications, which is unavoidable for these patients. The significant impact of long-term complications can be reduced through adequate prevention tasks. Prevention and management are best provided through multidisciplinary and integrated health care teams, including the dentist, in order to provide timely, coordinated treatment .Hyposalivation and an increase in microorganisms after RTX associated with changes in diet and oral hygiene difficulties  increase the deve-lopment of dental caries and periodontal disease . The effAdvances in radiotherapy techniques, such as the use of IMRT, allows high-dose irradiation of tumours with small volumes of exposed mandibular bone and has been observed to reduce the incidence to less than 5% ,34. AddiAfter IMRT for treatment of head and neck cancer, teeth can be preserved for longer time periods. This fact explains the increase in the depth of periodontal pockets, because preserved teeth remain in contact longer with periodontal pathogens. Although IMRT reduces the risk of xerostomia, a study with a one-year follow-up showed that opportunistic pathogens still increase over time . Oral anStudies including case reports have indicated that periodontal surgery can be performed on select patients after radiotherapy. A careful evaluation of the previous RTX conditions must be performed, including whether the irradiation included the maxilla or mandible, the total dose, the fractionation and the source of radiation. Late tissue changes due to radiation should be evaluated to reduce the risk of osteoradionecrosis ,10. PeriInfectious diseases result in significant morbidity and mortality in cancer patients. During and after cancer therapy, patients may continue to experience some degree of compromised immunity and suboptimal lymphocyte function, which in turn facilitates the development of oral infections. Treatment of periodontal diseases includes scaling and root planning, tooth extraction, and topical and systemic antimicrobial therapy, usually with agents targeting oral anaerobic bacteria, such as penicillin, clindamycin, or metronidazole .Radiation therapy increases oxidative damage in infected periodontal tissues. Recently, melatonin has been more frequently evaluated in research studies because of its anti-inflammatory, antioxidant and free radical scavenging properties. Melatonin use has been observed to significantly reduce regional alveolar bone resorption in rats. However, the data do not distinguish whether melatonin improved the effects of radiotherapy or of periodontitis alone .- Final recommendationsFinal recommendations to tend to irradiated patients should be based on procedures and clinical findings specific for the following time periods: pre-radiation, during and after radiation Figure .• Pre-radiation procedures- The evaluation of the patient should be done by a multi-professional team that includes the dentist. The dentist should also help plan RTX with the implementation of intra-oral devices and/or other orientations concerning future rehabilitation plans.- The clinical examination should assess the patient’s oral, periodontal and dental conditions for the purpose of addressing individual health problems. Clinical  and radiographic  examinations should be performed for pe-riodontal evaluation.- Patients should be advised about the importance of maintaining oral hygiene and nutritional intake and should receive information about the deleterious effects of smoking and alcohol consumption. Oral hygiene instructions may include a description of the Modified Bass brushing technique, use of dental floss and interdental brushes, tongue cleaning methods and chemical plaque control.- The treatment of periodontal diseases before RTX includes scaling and root planing, extraction of condemned teeth and topical and systemic antimicrobial therapy. Tooth removal should be planned at least 14 days before the first radiation treatment.- For the prevention of ORN, the evaluation of the patient must be done by an experienced clinician considering the field to be irradiated, the total dose, the fractionation and the source of radiation, all of which will influence the indication for tooth extractions.• During radiation therapy- Prevention and cleaning of the oral cavity should be performed by a trained professional during RTX. When painful conditions make it difficult to brush the teeth , other actions should be discussed and implemented. Chemical control with chlorhexidine 0.12% should be prescribed, as well as daily mouthwashes with fluoride 0.05%.- Urgencies, scaling and root planing can be performed if platelet and white blood cell counts are within acceptable limits.• Post-radiation therapy- Post-RTX treatment involves prevention to reduce long-term complications, such as caries, periodontal diseases and osteoradionecrosis. Oral rehabilitation should be planned considering the loss of attachment that usually occurs in irradiated patients.- Mechanical control of plaque/biofilm should be performed by the patient and by the professional.- Chemical plaque control should include daily mouthwashes with fluoride 0.05% and chlorhexidine 0.12%.- Periodontal therapies should be conservative, and bone surgical procedures should be avoided because of the risk of osteoradionecrosis. When these procedures are necessary, care should be taken, and tooth removal should be planned as a traumatic surgery, while switching to intra-oral sites for different tooth removal at different times should be considered.- It is possible to perform periodontal surgery on irradiated bone, as in some cases this management can be tolerated more easily than extraction. This procedure should be discussed with the patient’s medical staff.


Given the dynamic nature of health systems, with multiple complex relationships between subsystems, an intervention seemingly limited to one element often has system-wide implications.5 Viewing CBD implementation through a systems lens can help develop parallel interventions and inform policy and management direction. By taking advantage of interconnected subsystems within the health system it is possible to mitigate unintended consequences while simultaneously identifying areas that can be strengthened.5,6Medical specialist education in Canada is transitioning from a time-based model to a competency-based one, called Competence by Design (CBD).4 Frenk et al. (2009) provide a comprehensive overview of the transformational capacity of health care professional education reform on health systems.6 They offer an adaptation of the Health System Framework for use in conceptualizing the education system.6 In 2014, the Royal College published an in-depth report of recommendations for the reform of postgraduate medical education in Canada, going beyond curriculum to consider several aspects of the overall system.2The following analysis applies CBD implementation as a case study, using the World Health Organization (WHO) Health System Framework for Action to illustrate potential implications and related opportunities of medical health education reform for health system functions, from my perspective.7 Given the close interactions between elements, some Building Blocks of the Framework will be discussed together, while discussions of Governance will be interspersed throughout.I hope to offer a unique reflective analysis of a specific reform feature in educating specialist medical doctors (referred to as residents), early in implementation and with a health systems perspective. The focus is on selected immediate and mid-term consequences of CBD in Canada. Not all health system implications or opportunities will be covered, nor will the education of general practitioners, who are overseen by a separate college.Health financingMost residents in outcome-based programs like CBD are expected to progress to independent practice earlier.8,9 Paradoxically, given that CBD is projected to better detect competency deficiencies, some learners may have a longer duration of training than in the current model.9,10 Regardless of the net effect, the length of time spent as a learner will not be as well-defined as before. Additionally, with an emphasis on diverse learning settings, CBD may result in greater movement of residents between hospitals, clinics, and even provinces.2 Annual variation has potential budgeting implications for faculties, hospitals, and ministries of health — all of which currently finance aspects of postgraduate medical education.2,7 This variation will make it necessary to seriously consider how best to adapt current financing models and resident salary negotiation procedures. This may include pooling funds among disciplines or academic centres, and greater coordination among stakeholders. Ultimately, CBD implementation brings opportunities to strengthen financing structures by reducing fragmentation and duplication and increasing transparency.2,711 Currently, there is significant variation among incentive and remuneration schemes for clinicians involved in teaching or serving on committees. Alongside CBD implementation, residency programs must deliberate as to whether committee members will be remunerated. As a result, calls to standardize teacher remuneration and incentives across the province or country may arise, particularly since a greater number of sites not affiliated with a university may supervise resident physicians. In the current economic climate, remuneration may be scaled back, which could have an effect on the supply of clinician teachers.CBD requires direct resident supervision and the formation of competence committees, which will be responsible for assessing eligibility to progress.Health workforce and service delivery Canadian academic hospitals rely heavily on specialist residents to staff clinics, operating rooms, medical wards, and overnight shifts.2,7 With a shorter duration of residency and more off-site rotations, academic hospitals may experience doctor shortages and a negative effect on patient care. If tasks now carried out by residents are shifted to attending physicians , some physicians may leave the academic setting. The additional direct supervision and workplace assessment requirements of CBD may have a similar consequence. With medical schools appropriately emphasizing the societal need for generalists rather than specialists, it is both anticipated and desired that fewer students will choose a specialist career.3 These effects could synergize with CBD implementation, creating doctor shortages and service delivery and clinical teaching impacts across academic health sciences centres.12 Improved coordination can help resolve the current imbalanced proportions of medical school graduates to residency entrance spots; specialists to employment opportunities; specialists to generalists; and urban to rural physicians. As Maudsley et al. (2014) insightfully highlighted, if academic health science centres remain the principal regulator of the number of specialists trained, without regional or national coordination, the needs of academic institutions will continue to take priority.12 They additionally offered, “we need to move away from the notion that students and residents have an inalienable right to practise in the specialty and scope of their choosing without regard to societal need.”12 Although restrictions on resident positions have evolved since then, Maudsley et al. illuminate the importance of considering diverse perspectives in a balanced manner during regulatory decision- making. A coherent strategy would also better coordinate the human resource management (and training) of physicians with international medical graduates, nurse practitioners, registered nurses, physician assistants, and midwives.2,7 Such cohesion has great potential for ultimately positively affecting the health of individuals, communities, and populations.One approach to both adapt to this potential consequence and strengthen the underlying processes is to design a more coordinated health human resource (HHR) management strategy across different strata — academic institutions, regionally, provincially and at the inter-professional level.13 Perhaps coordination and strategic planning can begin within current structures, rather than being deferred until the government creates a new and separate agency.Strengthening HHR management processes is difficult to put into operation. Several stakeholders are involved and students’ preferences cannot be entirely disregarded. The Royal College has emphasized HHR coordination in several submissions to the Federal Advisory Panel on Health Innovation and the House of Commons Standing Committee on Health.Information and technology Ideally, CBD implementation will be monitored closely and evaluated in real time. Choosing indicators to determine its impact and developing the capacity for measurement will prove challenging. Thus, opportunities to strengthen monitoring and interpretation of learner outcomes will be plentiful, as well as the links to patient and population outcomes. The Royal College already works closely with organizations such as the Canadian Institutes of Health Information to collect and analyze important data related to specialists. CBD implementation will push the frontiers of harmonization; for example, by streamlining the creation of “Health Intelligence Units”14 — a type of agency not yet in existence, but proposed as being charged with the surveillance and analysis of the health of a population and its corresponding human resources.14Governance and leadership It is clear that CBD implementation has several implications for governance and leadership. As explored above, this includes impacts on medical education financing models, HHR management, and the alignment of data collection and analysis. CBD implementation will test current structures, and likely propel adaptation. Organizations such as the Royal College may find they are taking on leadership roles and encouraging better coordination without being given a specific mandate or designation from the government. Through innovation, assertiveness, grassroots collaboration, and removal of duplication, CBD implementation can act as a catalyst for visionary leaders to create a stronger health system.10,15 The College of Family Physicians of Canada began implementation of a competency-based curriculum in 2011.16,17 Reflections on learning from this diverse group, in particular regarding any experience with strengthening health systems functions, are invaluable for Canadian decision-makers and front- line clinicians alike. There are still questions regarding how to ensure widespread participation in the generation of such knowledge and its systematic dissemination and application throughout CBD rollout.The effects of CBD implementation across all specialty programs in Canada are not yet known. This brief analysis is informed by a health systems conceptual framework, stakeholder perspectives, and a limited amount of experience; but primarily represents my opinions as the sole author. Such limitations are expected because of time lag and the nature of opinion-based analysis, but also reveal the importance of sophisticated evaluation, intentional consultations, and reflection on learning throughout CBD rollout. Many academic centres have experience with competency-based medical education, both internationally and within Canada due to staggered implementation. The orthopedic surgery residency program at the University of Toronto, for example, transitioned to a competency- based model in 2009, and have shared their learning beyond the direct impacts of curriculum.5 The comprehensiveness of this analysis counters that perspective, as using the Health System Framework systematically exposes interactions between subsystems.3,5 Perhaps the value in applying a health systems lens, then, is not to attempt to predict the outcomes of CBD implementation with a high degree of accuracy; but rather, to build capacity in analyzing systems-wide impacts of an intervention. Such capacity can in turn be used to unearth opportunities for strengthening health systems functions.Some may view a health system lens as not necessary for CBD implementation, given it is relatively less complex than some other outlooks when considering the full spectrum of health system interventions.Going beyond identifying the system-wide implications and possibilities accompanying CBD implementation will prove essential. Next steps include consensus-based priority-setting and feasibility assessment by stakeholders, including community partners. Not every opportunity can or should be acted on, but each merits serious reflection. Given the broad scope of opportunities explored, several distinct but cohesive stakeholder deliberations should be considered. Specific representatives may be invited from: faculties of medicine, postgraduate medical education, regional public health authorities, registered nurse associations, ministries of health, hospital associations, patient advocacy groups, community organizations, the Royal College, the College of Family Physicians of Canada, and the Canadian Institutes of Health Information.Medical education reform in Canada is long overdue to ensure that physicians’ competencies will continue to adapt to the evolving health needs of society. This period of transition to a competency- based model provides a unique opportunity for parallel changes to strengthen the related health system processes.Viewing CBD implementation through a health system lens has allowed for a systematic examination of its implications for Health System functions and relationships. I explored opportunities for strengthening the system, including restructuring the financing of medical education, designing a coherent HHR management strategy, standardizing teaching incentive schemes across geographical regions, and improving capacity for data collection and analysis. Given that stronger governance leads to greater efficiency and a more responsive system as a whole, it is not surprising that the majority of opportunities are closely linked with governance processes.Since all reforms share the objective of improvement, we must not inadvertently create restrictions of scope. The commitment and coordination of a number of agencies is required to act on the potential that CBD brings. Using a Health Systems Framework at multiple stages of implementation will help. Returning to the question, Are we ready?, the answer is simple: we must become ready. It is time for action.


Science, Science Operations, and Technology objectives. This article outlines the BASALT Science Operations background, strategic research questions, study design, and a portion of the results from the second field test. BASALT field tests are used to iteratively develop, integrate, test, evaluate, and refine new concepts of operations (ConOps) and capabilities that enable efficient and productive science. This article highlights the ConOps investigated during BASALT in light of future planetary extravehicular activity (EVA), which will focus on scientific exploration and discovery, and serves as an introduction to integrating exploration flexibility with operational rigor, the value of tactical and strategic science planning and execution, and capabilities that enable and enhance future science EVA operations.Biologic Analog Science Associated with Lava Terrains (BASALT) is a science-driven exploration program seeking to determine the best tools, techniques, training requirements, and execution strategies for conducting Mars-relevant field science under spaceflight mission conditions. BASALT encompasses  Science, Science Operations, and Technology objectives that are being addressed through real (nonsimulated) biogeochemical fieldwork under simulated Mars mission constraints that are based on current architectural assumptions for future exploration missions  program includes et al. (2019).The purpose of this article is to introduce the BASALT Science Operations program. Here, we present (1) an overview of how current (and former) extravehicular activity (EVA) operations will shift for future planetary exploration, (2) the previous analog work that informed the ConOps and capabilities selected for investigation during BASALT, (3) the Science Operations study design, and (4) a detailed description of field test execution. We also report a small subset of Science Operations results from the second field deployment, referred to as BASALT-2, related to EVA execution; the primary set of BASALT-2 Science Operations results are presented in the work of Beaton et al., BASALT-2 took place in the Mauna Ulu region on the Big Island of Hawai'i in November 2016. This field test built on the lessons learned from BASALT-1, which was conducted at Craters of the Moon (COTM) National Monument and Preserve in Idaho in June 2016 .Although communication latencies create new challenges for space-to-ground (SG) interactions, they do not preclude the ability for remote, Earth-based experts to add scientific value to EVA. The high-profile, high-risk, high-reward nature of conducting scientific exploration on Mars, coupled with the fact that no amount of crew training can replace the expertise available on Earth to cover the breadth, depth, scope, and complexity of Mars science objectives, means that incorporating as much knowledge as possible from the Earth will be highly desirable. Hence, future EVA timeline  and traverse  design may benefit from incorporating varying amounts of ground assimilation time  and intravehicular (IV) crew  exploring Mars could enhance their EVA science and operations through the integration of capabilities , such as position mapping, navigation aids, handheld science instruments, and the transmission and receipt of audio, video, and text data. Likewise, Earth-based mission support personnel could benefit from not only monitoring transmissions from the EV and IV crew, but also incorporating tools that allow them to rapidly ingest and analyze the incoming data and to interact with the crew, thereby providing meaningful input to the explorers. A challenge lies in determining not only what future work practices and responsibilities will be needed for future domain operators, but also which capabilities are most enabling to these operators for different Mars operational concepts, whose missions are constrained by communication latencies and bandwidth restrictions.The extravehicular (EV) crew  will need to be addressed before sending humans to Mars. Strategies to do so have been investigated in various Earth-based spaceflight analogs . The Exploration Analog and Mission Development (EAMD) team at NASA Johnson Space Center (JSC) has led science operations research for many of these analogs, including the Desert Research And Technology Studies (DRATS), Pavilion Lake Research Project (PLRP), NASA Extreme Environment Mission Operations (NEEMO), and the BASALT program. This section highlights some of these previous analog missions and associated capabilities  that were used to inform the ConOps, capabilities, and Science Operations objectives investigated during BASALT.Over the past several decades, NASA, along with its international, commercial, and academic partners, has led numerous analog field tests in Arctic, Antarctic, underwater, desert, cave, and volcanic environments  to assist crewmembers with science and science operations. A MIP can range from a small unmanned robot to a large unpressurized or pressurized human-rated vehicle  when there were two EV crewmembers, as two IV crew enabled more effective management of both the operations and science aspects of the EVA  was found to be borderline acceptable, whereas the high bandwidth condition (6 Mb/s downlink) was found to be acceptable with the differences in the ratings attributed to a decrease in science value due to changes in video frame rate and high-resolution panoramic images downlink rates , were also evaluated and found to be useful.e.g., breathing gases, power, and water), and differences in task performance and duration between suited and unsuited operations. These results served as the basis of understanding EVA resource requirements that could, for example, be used to maximize scientific exploration range while reducing fatigue and injury risk to the crew   to examine microbialite formation and growth  scientific exploration under simulated deep space exploration ConOps. Over the 10-year project (2004–2014), a combination of SCUBA divers, remotely operated vehicles, autonomous underwater vehicles, and piloted DeepWorker 2000 submersibles (Nuytco Research Ltd.) conducted series of scientific research dives  further evaluated and refined the exploration ConOps and capabilities identified during DRATS and PLRP. During these missions, NEEMO crewmembers lived inside the Aquarius underwater habitat  back to the crew. In addition, the concept of a tactical EVA timeline management tool was developed and evaluated. The tool successfully provided the IV crew with the ability to manage the EVA by tracking the EV crew's progress against the planned timeline, projecting deviations in the start and end times of future tasks based on the actual durations of prior tasks, and notifying the crew of key milestones when they could expect guiding input from the science backroom team.Cursory capabilities for i.e., beyond the precursor data) will be obtained through contextual and presampling surveys of each location of interest that may modify traverse plans, science tasks, and/or science priorities  will have collected imagery and precursor data to plan science exploration EVA traverses to be conducted by human crew NASA, . On execet al., et al., intra-EVA SG interactions) and between EVAs (inter-EVA SG interactions). ConOps that incorporate intra-EVA interactions are important and advantageous when science objectives drive the exploration of as many different regions of interest as possible  or when science objectives limit the number of visits to a particular site .Second, as noted in * Note that although substantial science data analysis and EVA re-planning occurred daily between EVAs, this strategic element of mission operations was not a focus for evaluation of the BASALT project. The tactical, intra-EVA SG interaction ConOps directly addresses the presumption that latency and bandwidth constraints associated with deep space missions preclude meaningful “real-time” communication with Earth and, hence, demand nearly complete crew autonomy .The ConOps investigated during BASALT focuses specifically on EVAs that integrate tactical, intra-EVA expertise from Earth while promoting scientific productivity, operational efficiency and safety, and minimal crew idle time.et al., From an EVA perspective, this translates into an assumption that intra-EVA SG interactions, especially in the form of scientific guidance, become more challenging as communication latency increases and bandwidth allowance decreases. This challenge can be addressed through deliberate traverse and timeline design and management, as described in the paragraph below and in Beaton et al., e.g., contextual audio descriptions, still imagery, and video footage of candidate sampling locations identified by the EV crew) and a corresponding sampling task at a particular location of interest. The EV crew could complete a presampling survey and send that data to the Mission Support Center (MSC), which the MSC could then analyze and interpret to guide sampling recommendations. While the MSC is receiving the data across latency and formulating their recommendations, the EV crew could complete a second presampling survey or a separate independent  task. With sufficient understanding of EVA task dependencies, task durations, communication delays, and necessary GAT, timelines and traverses can be created that allow for Earth input on many tasks while minimizing or avoiding crew idle time and promoting flexibility in the EVA objectives based on new information arriving from the EVA crew  personnel include two EV crewmembers in the field completing science exploration and sampling tasks and two IV crewmembers working from an IV workstation (inside a simulated rover or habitat) supporting the EV crew. The IV crew communicate with an Earth-based MSC that provides scientific expertise and operational guidance across communication latency and bandwidth limitations (Lim The use of the word “support” in MSC rather than “control” (as in the MCC that has been used for low Earth orbit operations) reflects the advisory role that the MSC assumes when working under communication latency. et al., 1.Real-time (between EV and IV crew) and delayed (between the EVA crew and MSC) voice data.2.Real-time and delayed text messaging.3.Real-time and delayed transmission of video data from EV crew chest-mounted video cameras and an SA camera.4.Real-time and delayed transmission of high-resolution still imagery from EV crew handheld point-and-shoot cameras.5.et al., Real-time and delayed transmission of scientific data from EV crew hand-held instruments [including a Fourier transform infrared spectrometer, visible-near infrared spectrometer, portable X-ray fluorescence spectrometer, and forward-looking infrared camera  instrument, and communication network relay  software package  and critical task times, and provides a sophisticated science operations management platform and repository for scientific data, imagery, and field notes  and corresponding justification(s).An understanding of how results will be used  related to the questions being tested.The development of functional requirements, objectives, and hypotheses  and the provision of sufficient training so that the subjects understand the objectives and methods for collecting their input.The selection of test subjects that are representative of the target population  utilizing a consistent set of operational methods and metrics to enable the iterative development, testing, analysis, and validation of evolving exploration architectures. This approach ensures that the required level of rigor and consistency is applied before, during, and after the operational field tests so that the data collected remain relevant to NASA's strategic architecture and technology development goals and provide data-driven, actionable recommendations. Key points include:et al. . The EVAs were designed and conducted under two different communication latencies and two different bandwidth conditions:Latency: 5- and 15-min OWLT, which fall within the 4–22-min OWLT delays experienced between Mars and the Earth.Bandwidth: low = 0.512 Mb/s uplink and 1.54 Mb/s downlink (representing a conservative and lower-cost flight data rate), and high = 5.0 Mb/s uplink and 10.0 Mb/s downlink  NRC, .The BASALT-2 field test consisted of ten simulated EVAs in which scientifically significant samples of basalt were extracted from “Mars” (These communication delays and bandwidth conditions formed four communication study conditions: (1) 5-min latency/high bandwidth, (2) 5-min latency/low bandwidth, (3) 15-min latency/high bandwidth, and (4) 15-min latency/low bandwidth. All simulated EVAs were conducted under one of these four conditions. For BASALT-2, two EVAs were planned per study condition with two additional reserve EVAs for contingencies, such as inclement weather or technical difficulties. Premission estimates of data product sizes were calculated and post-EVA network analytics were completed to ensure that bandwidth traffic stayed within the study condition limits.Three EVA teams were established based on the key roles described in ® imagery at a resolution of 0.15 m/pix, multispectral imagery at ∼2 m/pix, and digital elevation models at 10 m/pix. Scientists used these data to identify candidate locations of interest, referred to as “EVA stations”, relevant to their science research objectives  to best meet the overall BASALT-2 science goals. In the end, BASALT-2 consisted of nine completed EVAs, whose planned traverses are depicted in Each EVA consisted of five phases: station approach, station contextual survey, sample location search, presampling, and sampling. Timelines were strategically designed to minimize the potential for crew idle time by delineating EVA tasks that could be conducted independent of Earth input and tasks that either were dependent on or could substantially benefit from Earth input. Because three stations were visited during each EVA, the MSC was able to consider data from at least two stations before their first transmission of presampling recommendations was needed (regardless of whether the EVA was being conducted under 5- or 15-min OWLT communication latency). A representative EVA timeline is provided in et al., At the beginning of each EVA, the EV crew provided a brief local report, which included the current time, wind speed and direction, percentage cloud cover, sun angle, temperature, and amount of precipitation. During the station approach phase, the EV crew described the surrounding terrain and recorded still imagery and video along the traverse, noting important features that characterize the area and that relate to that day's science objectives. The EV crew also looked for, described, and imaged targets of opportunity that might be relevant to other science objectives and be worth visiting later in that day's EVA or returning to on a separate EVA  positioned the SA camera with guidance from the IV crew; (2) gave a verbal contextual report that included the orientation, shape, general condition, and color of the station, details regarding the presence of water, fluids, and biomass within the station, and any additional information relevant to that EVA's scientific objectives; and (3) recorded relevant still imagery and video footage. After the contextual survey, the EV crew conducted a candidate sample location search where they searched for, labeled with candidate sample markers, verbally described, and imaged candidate samples of basalt that met that EVA's science objectives  interacted with a tactical EVA management tool  and reported relevant timing information to the EV crew, (2) tracked GPS positions of the EV crew relative to the planned traverses and provided heading and distance information to the EV crew on request, (3) posted operationally relevant information to the Mission Log, (4) verified incoming still imagery and added tags and notes to each image within xGDS, and (5) monitored and responded to simulated EVA telemetry (including spacesuit consumable) data  distilling and communicating presampling and sampling priorities between the EV crew and MSC, (2) clarifying scientific queries between the MSC and EV2, and (3) providing both general and specific scientific guidance while observing the EVA in real-time  to track and rank candidate samples relative to one another and against the science objectives for the current EVA and overall mission , (2) relative priority ranking information that expressed how much greater priorities were over one another , and (3) rationales associated with each priority ranking.Throughout the EVA, the MSC monitored and reviewed incoming data from the field across delay, recorded additional field notes in Minerva  support personnel in the field and in the MSC. These individuals coordinated the start and stop of the EVAs, were on standby to assist with communication network troubleshooting, and took the place of mission critical capabilities (or aspects of capabilities) whose hardware and/or software designs were outside the scope of the BASALT project itself. For example, x-sim personnel replaced some of the MIP capabilities, including manually maneuvering the SA camera in the field and acting as containment units to carry sampling tools and extracted samples. Training was implemented to ensure in-sim and x-sim personnel maintained adequate simulation fidelity throughout all aspects of the EVA; detailed simulation quality results are presented in the work of Beaton et al. .The field support team (FST) assisted the EV crew in the field. The FST lead was responsible for coordinating all pre-, during-, and post-EVA x-sim activities. The instrument aide provided the EV crew with technical scientific instrument support, including carrying and handing over instruments to the crew at the appropriate times and troubleshooting malfunctions. The biology sterilization aide assisted the crew with critical biological sampling tasks to maintain sterilization. The field stenographer/runner recorded detailed field notes in the event of communication dropouts and assisted the FST lead as needed.et al., Two members of the BASALT communications and backpack team were responsible for maintaining communication coverage among the EV crew, IV crew, and the MSC and for providing EV informatics backpack  coordinated the start, end, and any pauses within the EVA with the FST lead. The MSC was further staffed with additional communications infrastructure support, Minerva technical support, a science operations stenographer , and a science stenographer .Shuttle and ISS EVA operations have generated a vast array of engineering and hardware flight rule constraints on system configurations NASA, . Howeveret al., BASALT-2 flight rules were established to govern all aspects of field operations and to provide the operating guidelines with respect to safety, mission management and authority, EVA management and authority, troubleshooting, and ground rules . The safThe troubleshooting flight rules defined the conditions under which the EVA could continue in the event of hardware, software, and/or communication malfunctions. Finally, the ground rules mandated an exclusion area around the EV crewmembers to facilitate quality in-sim operations. A mission management team (MMT) that included the leads of each BASALT sub-team  was established to address concerns and necessary amendments to field operations during the field test and to ensure adherence to the flight rules.acceptability, capability assessment, and simulation quality  of interactions, (2) the timing of these interactions relative to the EVA timeline, (3) GAT available, (4) GAT utilized, and (5) EV crewmember idle time. The GAT available was defined by the EVA timeline and the communication latency under which the EVA was being conducted. The GAT utilized was derived from the timing of dynamic leaderboard updates sent to the crew.Objective task performance data and subjective ratings of et al., Network usage data, which parsed total bandwidth usage by data type , were also collected  “deadlines” in which MSC input regarding presampling and sampling recommendations had to be sent to the EVA crewmembers so that they would not incur idle time waiting on ground input. These NLT deadlines were based on the communication latency and assumed that the EV crewmembers would conduct the remaining EVA tasks according to the planned timeline. Hence, the MSC needed to send presampling and sampling guidelines NLT 5 or 15 min before the start of these phases. However, with the dynamic leaderboard approach, the MSC was encouraged to send multiple presampling and sampling priority rankings. Multiple updates to the crew in advance were important for minimizing idle time if the crew got ahead in the timeline and were critical in the event of communication network dropouts.In Typically, however, multiple presampling and sampling leaderboard updates were sent. As the EV crew continued to gather information in the field and the MSC assimilated these data across latency, the MSC regularly updated their leaderboards and sent several amendments to the crew. The crew understood the dynamic nature of these leaderboards, but because the MSC provided rationales and comments along with their priority rankings, the crew could use their best judgment as to how likely certain priorities might be to change.et al.  the Station C candidate sample location search. The used GAT is how much time the MSC actually used to send their first leaderboard recommendation to the crew.GAT is presented in phase-elapsed time (PET), which is the total time since the start of the EVA. The GAT for both presampling and sampling is derived from the NLT times, that is, 5 or 15 min before the end of the Station C candidate sample location search. The et al., et al., The number of candidate samples identified by the EV crew varied little across the EVAs, whereas the number of presampling leaderboard inputs from MSC varied more . The difference in the number of presampling leaderboard inputs could be associated with the variation in the science objectives across the EVAs and with the number of candidates identified that met those objectives that needed to be considered . Even though it is recognized that the traverse distances and durations during BASALT are not necessarily representative of operations in spacesuits and with rovers  and for correlation with other objective data related to execution of the ConOps. Thus, actual EVA traverses were recorded for each of the nine BASALT-2 EVAs. As an example, As discussed in The contextual surveys tended to take longer than the 5 min allocated in the planned EVA timelines. Although these EVA phases were intended to provide quick, high-level overviews of the station, the EV crew tended to give more detailed terrain descriptions. For the most part, the crew did not traverse much during the contextual surveys, although some crew occasionally circumnavigated the stations to facilitate more thorough descriptions; this was especially true when the stations incorporated terrain that was difficult to see around.Traverse distances associated with Station C were the most variable. The EV crew or the MSC often adjusted the duration of this phase based on the quality of the candidates found at the previous stations. If adequate candidates to meet that EVA's objectives had been found at Stations A and B, then time spent searching for candidates at Station C was usually shortened; if inadequate candidates were found at Stations A and B, then time spent searching at Station C was typically extended. If insufficient candidates were found at any of the three stations, the EV crew were encouraged to extend the Station C candidate sample location search well outside of the Station C boundary.The presampling survey distances traversed were dependent on three aspects: (1) the number of candidates selected for presampling, (2) the distances between the candidates, and (3) the priority order in which the candidates should be re-visited for presampling. In some cases, sample candidates were spread across all three stations and the priority rankings from the MSC leaderboards recommended that the crew traverse farther to ensure that the highest priorities were presampled first. In other instances, the candidates were closer together or the crew had more flexibility to decide which order to re-visit the priority candidates for presampling data collection. Finding the right balance between optimizing science objectives, which includes targeting the highest priorities first, while simultaneously minimizing EVA risks, including considerations for potential fatigue/injury or loss of SG communication, is a challenge for future exploration EVA that needs to be investigated further.et al.  expertise et al., First, the science objectives were conducive to incorporating intra-EVA recommendations from the MSC. The primary aim of each EVA was for the EV crew to search for and collect samples of basalt that met certain levels of alteration and temperature  and baseline procedures for each were implemented to relay information from the field to the IV crew and the MSC and to accommodate SG interactions. Two SG loops were used to prioritize EV-IV conversations (SG-1) and to allow the crew and the MSC to interact (SG-2).et al., Third, individual roles and responsibilities within the EV crew, IV crew, and the MSC were defined to enhance effectiveness and efficiency; adequate training in these roles with the relevant capabilities was provided. The split responsibilities within the EVA crew, with EV1 and IV1 focusing primarily on operations and EV2 and IV2 focusing on science, enabled timeline management, navigation, and science to be conducted simultaneously. The IV crewmembers were the critical liaisons between the EV crew in the field and the MSC on Earth. The IV crew closely tracked the progress of the EV crew against the planned timeline and used their understanding of that day's science objectives to engage in an effective dialog with the MSC across latency regarding the candidate samples identified by the EV crew  coordinated among one another and reported to their subteam leads, who, in turn, reported to the overall Science Team Lead. CAPCOM (capsule communicator) and SCICOM clearly and concisely relayed critical information to the EVA crew at the appropriate times. The EVA planner tracked timeline progress and reminded the MSC of upcoming bingo times for relaying important recommendations  to the EVA crew. Further details regarding individual roles and responsibilities, and their importance for tactical and strategic planning, are presented in the works of Kobs Nawotniak et al.  about the stations and candidate sample locations to the MSC. This allowed the MSC to meaningfully and effectively integrate into the science being conducted by the EV crew. Although many factors affected the GAT available to the MSC, the MSC was successful in utilizing the training and tools  may be best served by the this ConOps, certainly some will be. For those that can, it is a significant advantage to know that expertise on the Earth can be used to inform decisions relatively quickly , even under communication latencies or bandwidth constraints. Future work should seek to understand the wider variety of planned Mars science EVA objectives and associated SG timing requirements for their achievement.The success of a unique exploratory EVA ConOps is science objective dependent. The BASALT-2 science objectives paired with the baseline ConOps and capabilities enabled the investigation of an Earth-based science team's ability to effectively and efficiently interact with crewmembers within an EVA. Although not all Mars science objectives  than that which occurred during BASALT-2. Therefore, the overall effectiveness and efficiency of the ConOps under investigation may differ from what was found during BASALT-2. Future work should be dedicated to studying each of these factors, taking advantage of the strengths of different analog environments. With a more complete understanding, science objectives could be mapped to various potential ConOps, and future analog work could be focused on evaluating their effectiveness. For all ConOps, the design of EVA timelines that match the necessary tasks and level of required Earth–Mars interaction will be a key to their success.Any factor that modifies task duration or phasing may result in sending more or less science-related data to the Earth , could be combined to inform exploration EVA operations concepts, technology design requirements, and human health and performance drivers for EVA.Hence, future work could incorporate (1) analog field testing that includes rover operations, (2) parallel suited testing using partial gravity offload systems with test subjects conducting relevant science tasks while wearing pressurized spacesuits and outfitted to capture relevant physiological parameters, and (3) modeling efforts that account for rover traverse capabilities  and that extrapolate shirtsleeve field test data to that conducted in a pressurized suit. These efforts, along with complementary standalone technology research  analogs to guide follow-on research objectives, implementations, and testing. Ultimately, these analog field tests should result in scientific, operational, and technological capabilities that will serve to inform the next generation of human-robotic planetary exploration.


We report a case of Barmah Forest virus infection in a child from Central Province, Papua New Guinea, who had no previous travel history. Genomic characterization of the virus showed divergent origin compared with viruses previously detected, supporting the hypothesis that the range of Barmah Forest virus extends beyond Australia. Togaviridae (genus Alphavirus) that comprises several human arboviruses, including Ross River virus (RRV), Sindbis virus, and chikungunya virus. BFV was first isolated in 1974 from Culex annulirostris mosquitoes collected in the Barmah Forest within the state of Victoria and simultaneously from mosquitoes collected in southwest Queensland, Australia  and Ae. camptorhynchus (Victoria), found in salt marshes and from the midge Culicoides marksi in Northern Territory (––Barmah Forest virus (BFV) is an arbovirus that is pathogenic to humans and is traditionally considered to be endemic only to Australia  who had no history of international travel came to an outpatient health clinic in a coastal village northwest of Port Moresby, Central Province, Papua New Guinea, because of an undifferentiated fever. Rash, muscle pain, and polyarthralgia were not noted at that time. Blood samples (containing EDTA anticoagulant) were collected as part of ongoing febrile illness surveillance and transferred to the Port Moresby laboratory of the Papua New Guinea Institute of Medical Research, where extraction of nucleic acids was performed.Orientia tsutsugamushi, Leptospira sp., and Rickettsia sp. All test results were negative, except for a BFV TaqMan RT-PCR, which showed a positive result.We screened eluates by using a real-time reverse transcription PCR (RT-PCR) for a range of pathogens known to cause febrile illnesses, including BFV, chikungunya virus, dengue virus, Japanese encephalitis virus, RRV, West Nile (Kunjin) virus, Zika virus, We isolated BFV by inoculating 100 μL of patient serum onto cultured Vero cells (strain PNG_BFV) and extracting and assessing the nucleic acid content of the harvested cell culture material by using a BFV-specific real-time RT-PCR. The result was positive, suggesting viral replication in culture and confirming the presence of BFV within the specimen of the patient.http://www.epibio.com), and subjected this library to whole-genome sequencing by using the MiSeq System (https://www.illumina.com). We obtained 32 million paired-end reads and mapped them to the only available full-length  BFV reference genome sequence   and an isolate from Victoria (M4208_16/17) with the newly generated PNG_BFV envelope (E2) protein gene sequence of 1,263 nt.To determine the evolutionary relationship of the PNG_BFV strain with those detected in Australia, we estimated their phylogenetic relationships by using the maximum-likelihood method and the time to most recent common ancestor of each node by using Bayesian methods. We aligned the complete envelope (E2) sequences of all currently available BFV strains (n = 7) in the Virus Pathogen Resource database . The wide CIs suggest that sampling was inadequate to provide a precise estimate of the time of divergence and evolutionary rate, which would be greatly improved with access to additional BFV whole-genome sequences and full-length E2 gene sequences, which are currently not available for public access.Subsequently, we estimated the molecular clock for the final dataset of 8 complete E2 protein sequences with a sampling range of 1974–2016, under a stick clock model; a constant coalescent population size and the Hasegawa, Kishino, and Yano substitution model by using the Bayesian Markov chain Monte Carlo method in BEAST version 1.8 , panel BWe report a case of infection with BFV in a child who had no travel history from the Central Province of Papua New Guinea. BFV has been traditionally believed to be endemic only to Australia. Whole-genome sequencing, followed by phylogenetic analysis, showed that this strain was highly divergent from known strains from Australia. These findings placed the Papua New Guinea virus strain within its own clade and supported the hypothesis that the range of BFV extends beyond Australia. Molecular clock analysis indicates that the virus strains from Papua New Guinea and Australia probably diverged during or before the early 1900s, raising questions on the origins and the overall genetic diversity of BFV. On the basis of currently available data, the probable origins of these viruses, either from Australia or neighboring northern countries, such as Papua New Guinea, are inconclusive.The timeline of divergence suggests that this divergence could have occurred by movement of humans, livestock, or mosquitoes from or to Australia during the early 1900s by trade routes or movement of troops during World War I. Increased mosquito surveillance and serosurveys of the population in Papua New Guinea is needed to determine the endemic nature of BFV, which is likely to extend beyond the single detection noted within the Central Province.


In 2015 the Rhode Island Geriatric Education Center (RIGEC) was one of 44 organizations funded by HRSA to implement the Geriatrics Workforce Enhancement Program (GWEP). A primary objective was to develop and deliver Alzheimer’s Disease and Related Dementias (ADRD) education to patients, families, caregivers, and health professionals, with a focus on special populations. Concurrently, Seven Hills Rhode Island, a nonprofit agency that serves people with disabilities, received a grant from the Administration for Community Living (ACL) to provide education and resources to health professionals and caregivers of people with I/DD. As goals for both projects aligned closely, they worked together, fostering a strong partnership, amplifying the opportunity to offer high-quality educational programs and reach target audiences. Lessons learned from this networked approach are critical to informing sustained improvements to the I/DD and health care systems in subsequent GWEP projects.


Background: Auditory impairment post stroke is common and may be due to both peripheral hearing loss and or central auditory processing disorder (CAPD). When auditory impairment remains untreated, it may impact on patient communication and rehabilitation after stroke. Offering a comprehensive audiological assessment to all stroke patients would be both costly and time-consuming. A brief hearing screening is thus required.Objective: The aim of this study was to determine whether a two-tiered hearing screening approach, with use of a handheld hearing screener and two validated hearing questionnaires could be used as a hearing screening for peripheral hearing loss and CAPD in stroke survivors. The sensitivity and specificity of the screening method was analyzed.Methods: This was a prospective study conducted in a tertiary neurology hospital. Forty-two consecutive stroke patients were recruited and tested within 3–12 months post-onset of their stroke. Three screening tools for the identification of hearing impairment were evaluated in this study: A handheld hearing screener for determination of peripheral audiometric hearing loss and two validated questionnaires (The Amsterdam Inventory Auditory for Disability (AIAD) and the Hearing Handicap Inventory for Elderly (HHIE) questionnaires) for determination of peripheral hearing loss and/or CAPD.Results: The hearing screener had a sensitivity of 92. 59% detecting a hearing loss and specificity of 100%. The greatest test accuracy in identifying a central auditory processing type hearing impairment in stroke patients was found when the handheld hearing screener and the AIAD questionnaire were combined.Conclusion: This study is a first step toward addressing the complex auditory needs of stroke survivors in a systematic manner, with the ultimate aim to support their communication needs and long-term recovery and wellbeing.Registration: Project Identification number 11/0469 and REC ref 11/LO/1675. Stroke can affect all levels of the auditory pathway from the hearing organ to the cortex and manifest with deficits in audiometric thresholds and/or more complex central auditory processing disorder (CAPD) with perceptual difficulties in speech, sound recognition, and localization –3. HowevOffering a comprehensive audiological assessment to all stroke patients would be both costly and time-consuming. A preliminary brief screening assessment to reliably identify perceived auditory difficulties among stroke survivors is thus required. To date, only four studies have attempted to screen hearing in a stroke population , 12–14. Handheld hearing screeners are used to identify the possibility of an individual presenting with peripheral hearing loss who requires full audiological assessment . In addiThe primary purpose of this study was to determine whether a two-tiered screening approach, with use of a handheld hearing screener and two validated hearing questionnaires at the 3-month follow up post discharge from a stroke unit could be used as a hearing screening strategy to facilitate early identification and appropriate referral of auditory impaired stroke patients.This was a study of diagnostic accuracy using sensitivity and specificity. The study was a prospective study where the data collection was planned before the index test and reference standard were performed.The Ethics Committee of the National Hospital for Neurology and Neurosurgery (NHNN) approved the Hearing Evaluation and Auditory Rehabilitation after Stroke (HEARS) study (Project Identification number 11/0469 and REC ref 11/LO/1675). We obtained written informed consent from all the stroke participants. Fifty consecutive stroke patients were recruited and tested at the department of Neuro-otology, NHNN Queen Square London, within 3–12 months post-onset stroke, since auditory impairments are stable at that point . BecauseThe screening tests were completed for each subject in a random order during a single visit, before the administration of the full audiological assessment which aimed to identify and categorize the patient's auditory profile into one of the following: (1) normal, (2) peripheral hearing loss (cochlea to auditory nerve), (3) CAPD (brainstem to cortex and beyond) , 21, andBelow we describe the definition and diagnostic criteria for each category.Threshold assessment was made at 250, 500, 1,000, 2,000, 4,000, 6,000, and 8,000 Hz, and a pure-tone audiometry (PTA) average was calculated. The severity of hearing loss was determined using the British Society of Audiology audiometric descriptors . Also, hThe peripheral hearing loss  was defined as (a) “cochlear type” hearing loss: abnormal pure-tone average, reduced or absent Transient-evoke otoacoustic emission (TEOAEs), present and normal acoustic reflex threshold (ART), and normal auditory brainstem response (ABR) or normal interwave interval ABR ; “neuralThe definition of CAPD adopted by this study was according to the technical report of the American Speech-Language-Hearing Association (ASHA) Working Group (2005) , “deficiThe electrophysiological/electroacoustic test abnormality was not attributable to the presence of hearing loss (see ABR and ART criteria).A semantic test abnormality in the QSTAC without abnormalities in the perceptual spectral and/or apperceptive tests of the same battery was not considered to be evidence of disordered auditory processing.For the purpose of this study, if CAPD and/or an isolated brainstem type ABR and ART test abnormality was detected in the presence of peripheral hearing loss, we defined the pattern as a combination  type auditory impairment.Three screening tools for the identification of hearing impairment were evaluated in this study:Handheld hearing screener  for determination of peripheral audiometric hearing loss.Two validated self-reported hearing questionnaires for determination of hearing disability.– The modified Amsterdam Inventory Auditory for Disability (AIAD) questionnaire : The AIA– The Hearing Handicap Inventory for Elderly (HHIE) questionnaire : The HHIThe screening tests were performed at the department of neuro-otology (NHNN), in a quiet but not soundproofed test room situated next to the outpatient clinic rooms. This room was free of visual and auditory distractions and similar to the clinic rooms of the NHNN stroke follow-up clinic, with the same levels of ambient noise level that did not exceed 50 dBA and was most commonly around 41–42 dBA, as measured with a sound level meter .All the screening tests  were completed for each subject in a randomized order during a single visit before the administration of the full audiological assessment.For the handheld hearing screener test the participants were asked to respond according to the British Society of Audiology recommended procedure for PTA . This teThe AIAD and HHIE questionnaires, that were administered to the stroke patients as self-reported questionnaires, took under 10 min per questionnaire for completion.For the handheld hearing screener, the pure-tone audiogram was established as the “gold standard” according to the ASHA “guidelines for audiologic screening” .the best available method of categorizing participants as having or not having the target condition). All patients received the same set of audiological tests that are described below in brief  the criteria of Ventry and Weinstein study ; patientAIAD questionnaire: Hearing disability was defined by the criteria of Meijer et al. . Pass waCombined handheld hearing screener and AIAD questionnaire for identifying CAPD: For those with CAPD, auditory disability was defined according to the criteria of departmental normative data for CAPD in conjunction with Bamiou's studies in CAPD and stroke patients , 32: FaiPatients were tested in a sound-treated booth with standard clinical procedures including PTA (to determine hearing thresholds), tympanometry and acoustic reflexes threshold to determine middle ear or auditory nerve to lower brainstem problems), transient-evoked otoacoustic emissions (to assess cochlear function), auditory-evoked brainstem responses (to assess auditory nerve & brainstem). A non-verbal auditory processing test battery was used to assess temporal resolution [Gaps-in-noise]  and earlTo evaluate the accuracy of the screening tools for the diagnosis of hearing impairment, calculations of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were performed using the “gold standard” described in Methods. Sensitivities were calculated as the proportions of persons with hearing impairment correctly identified by the tests, while specificities were calculated as the proportions of persons without hearing impairment correctly identified by the tests. PPV is the probability that subjects with a positive screening test truly have the disease, and NPV is the probability that subjects with a negative screening test truly do not have the disease.n = 84 ears). The age ranged from 23 to 80 years old with an average of 58.19 years old (SD = 15.06). Days since stroke ranged between 92 and 360 days . The stroke was haemorrhagic in six and ischemic in 36. See Data from 42 stroke patients were obtained for all screening protocols  and specificity (100%) in detecting a mild or greater hearing loss in stroke patients, similar to previous studies on non-neurological populations , 34. SucThe HHIE yielded low sensitivity (44%) and NPV (23%) but optimal specificity and PPV (100%) for the detection of peripheral hearing loss. Low sensitivity and low NPV indicate that stroke patients tend to under report hearing disability. Several studies show that the HHIE questionnaire is effective for identification of moderate to severe hearing loss , 36–38 rThe AIAD questionnaire gave similar results to the HHIE when used to screen for peripheral hearing loss after stroke. For a cut-off value of >64 , the AIAThe poor sensitivity for detection of peripheral hearing loss of both AIAD and HHIE questionnaires could be attributed to the fact that these measure self-reported auditory disability, which may arise due to impairment at any level of the auditory pathway. In addition, PTA results do not entirely correspond with self-reported hearing loss .To this end, and toward the detection of central auditory deficits corresponding to self-reported auditory difficulties, combined use of the handheld hearing screener and AIAD, gave the best results with a sensitivity of 50% and a high specificity of 89%, PPV of 80%, and NPV of 67%. Similar to the HHIE results for peripheral hearing loss, a significant proportion of stroke patients with a central auditory impairment failed to report it. However, the high specificity showed the ability of the auditory questionnaires to correctly identify patients without central auditory impairments. Their use will potentially limit the number of unnecessary referrals for further central auditory evaluations.The results of our study, albeit preliminary, are promising, in that the handheld hearing screener use yielded reliable information about patients requiring detailed assessment for peripheral hearing loss. Furthermore, the addition of the AIAD self-report measure identified a further proportion of patients in need of further central auditory evaluation, who might not routinely receive such assessment otherwise.This protocol may provide useful information for the rehabilitation team to help identify patients with high levels of perceived deficits and disability who need additional investigation and input on a case-by-case basis. In Clinical implication of the present study is noteworthy. The National Institute for Health and Care Excellence in the UK recommends performing a full medical assessment of the person with stroke including functional ability and communication. However, hearing assessment is not featured in this guideline. Uncorrected hearing loss may affect outcome of speech and language assessment and related therapies , and impThe findings of this preliminary study will require corroboration and development in further pragmatic studies involving larger cohorts, within stroke units and possibly including those with severe aphasia and/or cognitive impairments. However, this study is a first step toward addressing the complex auditory needs of stroke survivors in a systematic manner, with the ultimate aim to support their communication needs, long-term recovery and wellbeing, and thus possibly delay onset of post stroke dementia .To our knowledge, this is the first study to assess the efficacy of a low-cost hearing screening program in the stroke population for both peripheral hearing loss and central auditory impairments. Of the three tools used, the handheld hearing screener had the highest sensitivity (93%) and specificity (100%) in detecting a mild or greater hearing loss in stroke patients, similar to previous studies on non-neurological populations , 34. SucThe raw data supporting the conclusions of this manuscript will be made available by the authors, without undue reservation, to any qualified researcher.NK, DV, NU, DW, and D-EB contributed to the design, results analysis, interpretation, and write-up of the paper. NK and NU conducted the tests. The paper was drafted, finalized and revised by NK and D-EB, and approved by all authors.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.