Imaging is increasingly being integrated into clinical practice to improve diagnosis, disease control and outcome in children with juvenile idiopathic arthritis. Over the last decades several international groups have been launched to standardize and validate different imaging techniques. To enhance transparency and facilitate collaboration, we present an overview of ongoing initiatives. Juvenile idiopathic arthritis is the most common chronic rheumatic disease in childhood. The diagnosis is based on clinical features, including onset before 16 years of age, persistence of arthritis in the same joint(s) for at least 6 weeks and the exclusion of other causes of arthritis.In recent years, imaging has become increasingly important to confirm diagnosis, monitor disease activity and predict the disease course and outcome in children with juvenile idiopathic arthritis. Several criteria or filters, such as those outlined in the Thornbury pyramid and in the OMERACT  filters, are being used to determine whether an imaging technique holds sufficient quality for accurate interpretation. The efficacy criteria of Thornbury  provide During the last decades great efforts have been made to improve the quality of diagnostic imaging and to reach consensus on which method and scoring systems to use. This is particularly important when performing and comparing the results of clinical trials. We give an overview of ongoing international initiatives addressing imaging in juvenile idiopathic arthritis, their main focus and achievements Table .Table 1OThe American College of Rheumatology (ACR) Pediatric Rheumatology Imaging Study Group was established in 2010 with the aim to promote imaging in pediatric rheumatology. The study group follows ACR guidelines and provides updates on current topics and advances in imaging research in pediatric rheumatology on a yearly basis to pediatric rheumatologists and allied health care professionals. Regularly, different specialists and researchers deliver new research data on a certain topic from different perspectives . The study group promotes research and wide participation of interested colleagues in current and future research projects. The study group also provides a link between other pediatric imaging working groups in rheumatology . The future scope of the study group is to continue to link interested health care providers to imaging research in pediatric rheumatology and crosslink various working groups.A European League Against Rheumatism (EULAR)–Pediatric Rheumatology European Society (PRES) task force was convened in 2013 to establish recommendations on the use of imaging in the diagnosis and management of juvenile idiopathic arthritis in clinical practice. The task force comprises pediatric rheumatologists, rheumatologists experienced in imaging, radiologists, methodologists and patients from nine countries. Initially, the task force performed a detailed systematic search of the published literature on the use of imaging in juvenile idiopathic arthritis. Included studies were evaluated for risk of bias and applicability using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool . The tasIn 2003 the European Society of Musculoskeletal Radiology (ESSR) launched its arthritis subcommittee. The committee promotes the standardization of the use of imaging in arthritis assessment. It proposes structured protocols for performing, interpreting and quantifying imaging findings. Recommendations are written concerning the use of MRI in musculoskeletal rheumatic diseases including juvenile idiopathic arthritis  and, morThe Health-e-Child radiology group was established in 2006, emerging from a large longitudinal multi-center project  aimed at combining clinical, laboratory and radiologic data of a large number of children with juvenile idiopathic arthritis. The development of an MRI scoring system for wrist and hip involvement in juvenile idiopathic arthritis was among the principal objectives of this work, which involved the collaboration of four large pediatric centers: Great Ormond Street Hospital, London (GOS); Hopital Necker Enfants Malades, Paris (NEM); Ospedale Gaslini, Genoa; and Ospedale Bambino Gesu, Rome. During 2010, Norwegian centers joined the group, focusing on normative standards for wrist MRI. Standards for wrist ultrasound are underway. To date, the group has made contributions of MR-wrist scoring systems , normatiThe Imaging Working Party was initiated in 2015 at the Paediatric Rheumatology European Society (PRES) annual meeting in Belgrade, as a response to the emerging need within the PRES membership to share experiences with and expectations of imaging. The aim of the PRES Imaging Working Party has been defined as the promotion of knowledge, research and education on imaging within the PRES frame. The group is open to all PRES members and people who share its aim and activities, summarized as “meet and work.” Initially 9 people from 5 European countries met, increasing to 22 colleagues from 13 countries at the PRES meeting in 2016. An update on the most recent advances in research and clinical applications of imaging in pediatric rheumatology is provided at every annual meeting. The group actively encourages international courses of imaging in children. Further, it promotes collaborative research projects with involvement of pediatric rheumatologists, pediatric radiologists, care-givers and scientists interested in imaging in children with rheumatologic diseases.MD Paedigree, a model-driven European pediatric digital repository, is a clinically led virtual physiological human multicenter project 2012–2016) funded by the European Union 7th Framework Programme for Research and Technological Development (EU FP7). MD Paedigree develops patient-specific computer-based predictive models of various pediatric diseases, including juvenile idiopathic arthritis, thus providing newly defined workflows for personalized predictive medicine at the point of care. The management of juvenile idiopathic arthritis has changed dramatically over the last two decades with the development of new therapeutic agents and the shift toward early aggressive interventions. Early identification and treatment of patients at higher risk to develop joint destruction and serious functional impairment has become a high priority. In the frame of this project clinical, immunological, metagenomic and imaging data have been collected in a prospective cohort of new-onset juvenile idiopathic arthritis patients. The potential role of an extensive ultrasound assessment  in predicting disease severity and response to treatments has been explored. Patients with clinical ankle involvement were also investigated by MRI, gait cycle analysis and whole-body MRI. MD Pedigree integrated the data from these evaluations to build a patient-specific finite element model of the joints to explore the role of the biomechanical determinants on the disease severity and structural damage progression [ funded bThe Norwegian Juvenile Idiopathic Arthritis Study uses a cross-disciplinary, longitudinal prospective design and includes pediatric radiologists, rheumatologists, pedodontists , maxillo-facial surgeons, and physicists from Norway, with input from colleagues in Denmark and Canada. It combines clinical, laboratory and radiologic data from a large number of children with juvenile idiopathic arthritis, to validate, refine and further explore different imaging techniques used for the assessment of temporomandibular joint involvement in children with juvenile idiopathic arthritis. The focus is on advanced MRI techniques and image analysis .In 2011, prior to the Outcome Measures in Rheumatology (OMERACT) 11 meeting, a special interest group on MRI in juvenile idiopathic arthritis was formed. During the OMERACT 11 meeting, participants agreed that the special interest group would concentrate on the development and further refinement of MRI scoring systems. Because juvenile idiopathic arthritis includes different subtypes with a different clinical picture, it was decided that the special interest group would focus on the development of MRI as an outcome measure in juvenile idiopathic arthritis at three joint levels: (1) large joints (knees and ankles), (2) small joints (wrists and hands) and (3) temporomandibular joints . RecentlThe different subgroups are focusing on the establishment of standardized imaging protocols, definitions and MRI scoring systems. Also, reliability studies have been performed following face-to-face meetings. Especially the small joints subgroup has close collaboration with other international initiatives .Future steps of the special interest group on MRI in juvenile idiopathic arthritis will be: (1) to further refine and validate the different MRI scoring systems (including reference atlases), (2) to develop an MRI atlas of healthy joints at different ages and (3) to perform studies on the correlation between MRI and clinical characteristics of disease status in juvenile idiopathic arthritis (“truth”).The Amsterdam November Meeting (ANOME) was established in 2013 and is held annually. It includes pediatric rheumatologists, pediatric radiologists, musculoskeletal radiologists and research fellows/students from different initiatives mentioned in the current paper . ANOME aims to “find the truth” in imaging juvenile idiopathic arthritis, through literature reviews and research projects. Currently, the main focus is wrist and knee imaging, using the principle “describe, not explain” , 19, 22.www.espr.org).The group was established in 2004, aiming to promote evidence-based musculoskeletal imaging in children. The group plays an advisory role with respect to imaging strategies for juvenile idiopathic arthritis within the pediatric radiology society  Ultrasound Group, a pediatric subgroup, was formed several years ago. The goals of the pediatric subgroup are to foster the dissemination of ultrasonography in pediatric rheumatology practice through education and presentations at professional meetings. In 2016 the group started to contribute to international efforts of standardization in pediatric musculoskeletal ultrasonography through the dissemination, evaluation and further refinement of definitions, acquisition standards and scoring systems for the various structures relevant in pediatric rheumatologic disease.The Childhood Arthritis and Rheumatology Research Alliance (CARRA) is a well-established group of pediatric rheumatologists in North America focusing on collaborative research to improve standards of care for patients with pediatric rheumatic diseases.The increasing importance of musculoskeletal ultrasound as an outcome measure in research and for clinical care is reflected in the establishment of a musculoskeletal ultrasound group within CARRA in 2015. The goals of this group are to enhance ultrasound skills among CARRA members through training and the validation of ultrasonography as an outcome measure. The first validation project was started in 2016, is ongoing and is focusing on acquisition standards as well as scoring of the knee joint.The overview provided in this paper gives insight into the different ongoing international initiatives working on imaging in juvenile idiopathic arthritis. To date, each individual collaborative initiative has had important influence on improving our knowledge and thereby patient outcomes in juvenile idiopathic arthritis. The overview further enhances transparency and enables groups to combine their forces to reach the universal goal: improving the quality of imaging in children with juvenile idiopathic arthritis in order to improve their quality of life.


Evaluate evidence of the efficacy, safety, acceptability and cost-effectiveness of outpatient parenteral antimicrobial therapy (OPAT) models.A systematic review.MEDLINE, EMBASE, CINAHL, Cochrane Library, National Health Service (NHS) Economic Evaluation Database (EED), Research Papers in Economics (RePEc), Tufts Cost-Effectiveness Analysis (CEA) Registry, Health Business Elite, Health Information Management Consortium (HMIC), Web of Science Proceedings, International Pharmaceutical Abstracts, British Society for Antimicrobial Chemotherapy website. Searches were undertaken from 1993 to 2015.All studies, except case reports, considering adult patients or practitioners involved in the delivery of OPAT were included. Studies combining outcomes for adults and children or non-intravenous (IV) and IV antibiotic groups were excluded, as were those focused on process of delivery or clinical effectiveness of 1 antibiotic over another. Titles/abstracts were screened by 1 reviewer (20% verified). 2 authors independently screened studies for inclusion.128 studies involving >60 000 OPAT episodes were included. 22 studies (17%) did not indicate the OPAT model used; only 29 involved a comparator (23%). There was little difference in duration of OPAT treatment compared with inpatient therapy, and overall OPAT appeared to produce superior cure/improvement rates. However, when models were considered individually, outpatient delivery appeared to be less effective, and self-administration and specialist nurse delivery more effective. Drug side effects, deaths and hospital readmissions were similar to those for inpatient treatment, but there were more line-related complications. Patient satisfaction was high, with advantages seen in being able to resume daily activities and having greater freedom and control. However, most professionals perceived challenges in providing OPAT.There were no systematic differences related to the impact of OPAT on treatment duration or adverse events. However, evidence of its clinical benefit compared with traditional inpatient treatment is lacking, primarily due to the dearth of good quality comparative studies. There was high patient satisfaction with OPAT use but the few studies considering practitioner acceptability highlighted organisational and logistic barriers to its delivery. This review provides the most comprehensive picture of outpatient parenteral antimicrobial therapy (OPAT)-related research in recent years, bringing together available evidence on the clinical and cost-effectiveness, safety and acceptability of community-based antibiotic delivery.Much of the work in this area is based around service evaluation and many studies provided only basic descriptive findings, making it difficult to grade the quality and robustness of the evidence.Although many studies were identified and included in the review, the definitiveness of its conclusions related to the clinical benefit of OPAT over traditional inpatient treatment is limited by the lack of good quality comparative studies.Nonetheless, the synthesis provided by this review provides much needed evidence to inform the design and commissioning of OPAT services.Delivery of intravenous (IV) antibiotics outside of the hospital setting ) is widely accepted as standard practice in many countries, including the USA and Australia.In recent years, OPAT services have also been developed in the UK, both in the National Health Service (NHS) and private sectors.The failure to realise the full potential of OPAT in the UK is due in no small part to the paucity of information related to optimal delivery, most notably evidence of effectiveness, associated risks and patient preferences for this form of treatment. The purpose of this review was to evaluate existing evidence in relation to the efficacy, safety, acceptability and cost-effectiveness of different models of OPAT delivery.A comprehensive search strategy was developed by an experienced information specialist (JW) and a range of bibliographic sources were searched for the period 1993 to March 2015: MEDLINE, MEDLINE in process, EMBASE, CINAHL, International Pharmaceutical Abstracts, the Cochrane Library, the NHS Economic Evaluation Database (EED), Research Papers in Economics (RePEc), Tufts Cost-Effectiveness Analysis (CEA) Registry and Health Business Elite (HBE). This time frame was selected to take account of the substantial changes in the organisation of the NHS and the shift towards more community involvement that have taken place following publication of the NHS and Community Care Act 1990.Supplementary searches of Web of Science Proceedings, the Health Information Management Consortium (HMIC) and the website of the British Society for Antimicrobial Chemotherapy were conducted to identify relevant unpublished work. In addition, the reference lists of included studies were reviewed for potentially relevant papers  or practitioners involved in the delivery of OPAT. Any form of IV antibiotic drug delivery system  was included. Studies of any research design were considered (with the exception of single case reports), and no language restrictions were applied.Studies were excluded if they considered the costs related to a model of delivery but did not consider patient benefit alongside these, or if they made reference to costs and benefits but did not report specific cost-effectiveness data . Similarly, studies that made reference to clinical effectiveness without reporting specific patient outcomes were also excluded. Studies that included children or that involved multiple routes of antibiotic delivery were reviewed but excluded if they did not differentiate between outcomes for adult patients or for patients receiving IV treatment, and those of other participants. Studies that focused only on the method or process of delivery or on the clinical effectiveness of a single treatment or of one class of antibiotic over another were excluded, as were abstract only, descriptive or commentary pieces and guidance documents.Titles and abstracts of all identified studies were screened for eligibility by one reviewer (EDM) with a random selection (20%) independently screened by a second. Full-text versions of papers not excluded at this stage were obtained for detailed review and independently assessed by two reviewers  to determine whether they met the inclusion criteria. Differences of opinion were discussed until a consensus was reached, with validation sought from a third reviewer where necessary.Data extraction was carried out by one experienced reviewer (EDM) using a standardised pro forma. Data for a sample of studies were extracted independently by a second reviewer (CCM) in order to validate the items being collected. Information was collected on study purpose and design , setting, duration, population and clinical characteristics, models of delivery , outcome area , antibiotic parameters , outcome measures, follow-up and key findings.Studies were assessed for bias by two reviewers (EDM and CCM), where possible using previously developed scoring systems. The Cochrane Risk of Bias assessment tool was used for experimental studies , and the Newcastle-Ottawa scales for cohort and case–control studies.7A method of assessing the strength of evidence of other observational studies—developed for previous reviews on early diagnosis of cancer10.1136/bmjopen-2016-013560.supp2supplementary appendixSTRONG+ ; STRONG− (study graded strong in two areas and moderate in the third); MODERATE ; INSUFFICIENT .Four categories were then used to weight the evidence: Many of the papers included in this review used methodologies that did not lend themselves to the scoring systems outlined. Many studies included all patients in receipt of OPAT since its establishment at a particular institution or over a specified time period, and simply reported conditions treated and therapies used, along with limited outcomes data. Case-series such as these, which were to all intents and purposes service evaluations that included little or no analytic content, were not subject to formal quality assessment.In keeping with accepted good practice, studies at risk of bias were not excluded from the review, but an appraisal of the strength of existing evidence has been reported, and findings interpreted in light of this.The main characteristics of included studies and findings relating to clinical effectiveness, cost-effectiveness, patient safety, acceptability and study quality have been summarised in narrative and tabular form. Substantial heterogeneity in clinical characteristics—condition treated, treatment duration, definition of a successful outcome —and methodology precluded pooling of study data for meta-analysis.This review formed one work stream of a larger National Institute for Health Research (NIHR)-funded study that included qualitative interviews and economic modelling. The research team included a lay co-applicant who commented on study design prior to submission of the funding proposal, including the focus of the systematic review and the outcomes to be included. In addition, a Patient Advisory Group (PAG) was established to input at key phases throughout the project including the design of patient recruitment materials, interview topic guides and health economics aspects of the study. An Expert Panel was convened to discuss emerging findings from each work stream, and a representative of the PAG was a member of the panel. A project dissemination event was held in April 2016 to which both patients and professionals were invited.The search strategy identified 7214 articles of which 589 met the inclusion criteria for detailed review . The ful11–138Three-quarters of studies were undertaken in Europe n=53; 41%) and North America n=45; 35%). Almost two-thirds of the European studies were UK based. Two studies involved centres in more than one country,% and Nor; 35%. Al133The most commonly reported reason for treatment was osteomyelitis n=68, 53%), followed by endocarditis , skin and soft tissue infection , cellulitis , and septic arthritis . Most studies involved multiple conditions ; 7 did not specify indications for treatment. These included two qualitative studies and one survey of patient acceptability,, 53%, fo17Of the five outcome areas evaluated in the review, the most commonly considered were patient safety  and clinical effectiveness . Just over a quarter of studies involved some aspect of patient acceptability , but few determined cost-effectiveness (n=5) or practitioner acceptability (n=6). Most investigated multiple areas (70%).Twenty-two of the 128 studies (17%) either did not indicate the type of OPAT delivery model used, or reported that home treatment was used without providing any additional detail. In the remainder, the most frequently reported model across studies was self (or carer) administration , followed by visits from a specialist nurse , outpatient treatment  and visits from a general nurse . Just over half of these studies evaluated a single model of delivery . Other less common delivery methods and locations included infusion centres, home infusion or home care companies, hospital in the home units (HHU), prison and doctor visits ; a small number of others carried out secondary analysis of national or international OPAT registries. Satisfaction surveys, either by questionnaire or telephone completion, were frequently used, while interviews  and visual analogue scales were also well represented. Less common methods of data collection included clinic or ward diaries, direct observation, and data from previous studies or the published literature. It was often unclear who collected data, and few studies reported on how this was carried out. A substantial number provided little or no detail on the methods used. Twenty-one of the 128 (16%) studies received full or partial funding by pharmaceutical companies, while 72 others (56%) did not report the funding source.Three of the 14 included trials were assessed as having a low risk of bias,132All five included case–control studies (three of them retrospective) rated low for potential bias .76In the majority of observational studies, the data analysed were derived from OPAT databases or medical records review. Many studies also involved questionnaire surveys. Only five included a comparator (inpatient care),Only 21 of the 89 studies evaluating the clinical effectiveness of OPAT included a comparator which, with few exceptions, was inpatient treatment . Five of137Regardless of the particular OPAT model used, most studies assessing duration of treatment found little difference compared with inpatient therapy81Evidence of the effect of OPAT on cure rate, however, was less conclusive. When findings from all delivery models were considered, OPAT appeared to produce superior results to those seen for inpatient treatment. This may reflect heterogeneity in the population groups, with inpatients being thus because they required more intensive care. However, it is also undoubtedly influenced by the inclusion of positive studies that reported on multiple or unspecified OPAT treatment models.131In the remaining studies that considered clinical effectiveness for OPAT models only, rates of cure or improvement ranged from 61.1% to 100% . When the various OPAT models were considered individually, the highest mean cure/improvement rate was found for self-administration (91.3%), followed by specialist nurse (90.6%), general nurse (90.0%) and outpatient treatment (88.3%). Few studies reported on bacterial eradication, but those that did saw rates of between 57.1% and 100%  indicated that for both 1 course and 1 year of treatment, IV antibiotic treatment administered mostly in hospital was more effective but more costly than treatment administered mostly at home.Only 4 of the 36 studies considering patients' acceptability of OPAT involved a comparison of inpatient and outpatient therapy , or did not specify the model(s) under study. For the most part, satisfaction with treatment was very high,67Two studies determined patients' willingness to pay to have treatment in their preferred location, and although differences did not reach statistical significance, patients reported that they would pay more for the home-based than hospital-based treatment, including giving up slightly more of their remaining life to ensure this.120Only six studies included assessment of practitioner acceptability: one involving general practitioners (GPs), one involving nurses and four involving infection specialists  of this mode of therapy compared with traditional inpatient IV treatment is lacking. Acceptability of OPAT appears to be high among patients, who appreciate the greater freedom that it provides, particularly in relation to being able to resume daily activities (such as going to work or school), having greater control over their illness and not having to attend hospital but being able to stay at home with family. Disadvantages identified most commonly related to the use of infusion equipment. Few studies considered practitioner acceptability, but those that did found some concerns related to the logistics involved in providing an OPAT service, including cost and who would assume clinical responsibility for patients.et alThe results of this review should be used by clinicians in the context of their patient populations and the types of infection being treated. Results from ongoing research studies, such as work being done by Scarborough Although many studies were identified and included in this review, its conclusions are limited by the lack of studies involving a usual care comparison, or comparison with other models of OPAT delivery. In addition, few studies employed a rigorous study design. Much of the work in this area appears to be based around service evaluation and, as such, many of the studies provided only basic descriptive findings, with no estimates of variance and limited data related to patient outcomes. As a result, it is difficult to grade the quality and robustness of the evidence, even in the few randomised controlled trials that have been conducted. Similarly, substantial clinical and methodological heterogeneity precluded pooling of data for meta-analysis. The majority of studies included a varied case-mix and did not differentiate their results between conditions treated. In addition, there was variation across studies in relation to what constituted a successful outcome , as well as a lack of consistent treatment duration. Although this undoubtedly reflects real-world practice, it meant that it was not possible to pool the results of individual studies to provide estimates of true effect size when using OPAT for different patient groups, or even for comparing OPAT as a whole with inpatient treatment. Although identified as part of the search strategy, time constraints meant that non-English language papers were not assessed beyond the abstract screening stage, and it is possible that this may have resulted in some language bias . However, given the lack of robust, conclusive studies that were included, this is unlikely to have significantly influenced the findings of the review.It is likely that the increased use of OPAT in the UK in recent years is due, in no small part, to clinicians' expectations that it should increase hospital inpatient capacity while delivering non-inferior patient care and improved patient experience. However, this review has demonstrated that the evidence related to care is not strong. Few studies reported on the different levels of service required to account for the complexity of patient cases encountered, including those with comorbidity and those requiring ‘one off’ or longer term treatment. In addition, many studies provided aggregated results and it was not possible to disentangle these either for individual OPAT models or for the specific conditions treated. This, combined with a lack of detail on the delivery models actually used, makes it difficult for clinicians and policymakers to be able to replicate existing practice  even from positive studies. OPAT services have the potential to deliver significant cost savings and increased patient satisfaction for the NHS, and it is crucial that this information is reported in future studies in order to identify best practice and help support decision-making at a local level. We would recommend, that as a minimum, authors fully describe the specific method of OPAT delivery studied , include and report on a comparator when determining the impact of OPAT on clinical outcomes (only 21/89 studies in this review did so), report all numerators and denominators, avoid reporting pooled data (where possible), report on case complexity and average duration of treatment to achieve cure, and adhere to CONSORT guidelines when reporting trials.Commissioning healthcare services in England is increasingly complex and has been subject to much change in recent years.There is a need for further research to address significant gaps in knowledge about the cost-effectiveness of different IV antibiotic services, and to ascertain which services patients prefer and which aspects of the services are most important to them. This would help identify the most appropriate configuration of services in terms of value for money and patient preference, as well as future research priorities. Since OPAT services are now established in many areas of the UK, conducting a definite randomised controlled trial of different models of care is unlikely to be feasible. Individual centres would not be able to provide all of the necessary comparator services for randomisation, and there would be difficulties related to the heterogeneous nature of the patient population, and consequent decisions about the most relevant outcome measure. Other, more pragmatic, study designs should therefore be considered, including large-scale, prospective observational studies designed to collect robust data on outcomes, adverse events and the costs of OPAT (including mixed models of care). This, together with high standards of reporting to ensure that delivery models and their results are fully described and reported individually, would go some way to bridging the current information gap.


The idea of animals possessing personalities was once dismissed by the scientific community, but has since gained traction with evidence for potential application to improve captive animal management and welfare. Although domestic cats are popular companion animals, research has tended to overlook the value of personality assessment for management and care of pet cats. The aim of this study was to investigate personality in a large sample of pet cats with a view to understanding practical implications for pet cats in the home. Personality of 2,802 pet cats, from South Australia and New Zealand, was rated by their owners utilising a survey measuring 52 personality traits. Five reliable personality factors were found using principal axis factor analysis: Neuroticism, Extraversion, Dominance, Impulsiveness and Agreeableness. Implications for the ‘Feline Five’ are discussed in relation to their potential application to improving the management and welfare of pet cats. Highly Impulsive cats for example, may be reacting to something stressful in their environment, whereas cats with low Agreeableness scores, showing irritability may indicate underlying pain or illness. Thus, the need for a systematic and holistic approach to personality that includes both the individual pet cat and its environment is recommended, and opens the door to future interdisciplinary intervention. Domestic cats have been companion animals for thousands of years , and areIt is possible for cats living in a multi-cat household to time-share favourite places , choose Personality refers to consistent individual differences in behavioural patterns  and is sEarly cat personality studies relied on systematic observation of cat behaviour and coding methods, which involves generating an ethogram, and then systematically recording frequency or duration of behavioural categories , 27, 28,Investigations of cat personality have focused on either: the continuum of one personality dimension, such as dominance-warmth , which mDomestic cat personality research has tended to explore development of behaviour directed at humans, socialisation, and the shy-bold continuum of cat personality in relation to humans , 35, 41.Macaca mulatta), which was modified following behavioural observation of cats in a laboratory over three months. Despite the limited generalizability of the sample , inter-cat social behaviour was observed and recorded, allowing successful validation of initial subjective assessments. Some of the methodological limitations or weaknesses of domestic cat personality studies conducted to date include: (1) lack of information on length of familiarity between cats and the people rating them [A multidimensional examination of personality in cats  served aing them ; (2) lacing them ; (3) smaing them  or 40 caing them , 41, witing them ; and (4)ing them , 41, 43.Another problem concerns the inconsistent nomenclature or labelling used for cat personality trait and factors. The dimension reduction technique principal components analysis (PCA), coupled with exploratory factor analysis (EFA), is recommended to analyse statistical correlations among personality traits that cluster together creating overall components . For exaFollowing identification of personality factors, researchers should assess consistency of these factors across situations , with evFelis silvestris) [Acinonyx jubatus) [Previous research on captive wild felids has led to suggestions of potential application of personality assessment to captive animal management and welfare, such as socially compatible enclosure groupings created for Scottish wildcats (vestris)  and provjubatus) . These aAs an exploratory study, this study aimed to analyse personality in a large sample of pet cats, utilising a personality inventory completed by cat owners about their cats. The study followed on from previous research on felid personality, which has typically found between three  and fiveThe study was conducted in New Zealand and South Australia. The methods and materials used in this study were approved by the University of South Australia’s Human Research Ethics Committee (#33220) and the Victoria University of Wellington Human Research Ethics Committee (#21064) with all cat owners consenting to participate in the study. All issues related to participant recruitment and consent were approved by Human Research Ethics Committees. Data were collected through an online survey instrument. Participants voluntarily self-selected to complete the survey and they were provided with information regarding the project and consent at the beginning of the online survey. It was a requirement for participants to confirm that they consented to being involved in the project and that they met inclusion criteria  before being able to undertake the survey. As an example, a copy of the South Australian participant information for the online survey is provided .The Human Research Ethics Committee approved 16 years and older as a participation criterion for the South Australian research as 16 year olds were able to register cats in some local council areas in South Australia and it was considered important to understand their attitudes to cat management. The Human Research Ethics Committee agreed that a 16 year old could reasonably decide to participate in the social survey and answer the questions.n = 1,687) and New Zealand . This included 1,377 male, 1,387 female and 38 cats of unknown sex, ranging in age from 1–20 years, with a median age of 5 years. Cats under one year of age were excluded and only surveys where respondents had answered all personality items needed for analyses were included.Subjects included 2,802 domestic cats of varying breeds from private homes in South Australia  [The current study utilised a 52-item (variable/trait) survey based on a recent comprehensive Scottish wildcat personality survey , which plodytes) . Minor cThis personality survey was part of a larger online survey (using SurveyMonkey ) createdn = 4,842) were downloaded from SurveyMonkey [n = 1,780) as they did not have a cat, had a cat but decided not to complete the  cat personality section, or had neglected to answer some of the items. Data from those respondents were removed. The survey responses were also checked for unengaged participants , which resulted in two being excluded from analysis. The remaining sample  was analysed in IBM SPSS Statistics V21.0. A filter was applied to conservatively exclude cats less than one year old (n = 258), as personalities may still be developing prior to a minimum age of four months [Survey data from both SA and NZ  and NZ . Initial results .Initial exploratory factor analysis (EFA) utilising principal axis factoring was conducted on two independent samples of personality ratings in pet cats from SA ( results  show the results . The higp < .001), thus the data were considered appropriately correlated for factor analysis. The KMO values for individual items were over .72  and Bartlett’s test of sphericity to determine if the data were appropriate for factor analysis . The oveover .72 , which iInitial analyses were run to obtain eigenvalues for each factor in the data. Ten factors had eigenvalues greater than Kaiser’s criterion of one that cumulatively explained a variance of 56.95% for SA and 57.22% for NZ. For SA and NZ as independent samples, the scree plots display the eigenvalues associated with the components in descending order against the number of the components revealed inflexion points that justified retaining four factors for each data set .The factorability of the 52 cat personality survey items was also examined using several well-known criteria , and basn = 308), female  or did not answer (n = 133). About 60% of participants were aged between 21 and 50 years, with approximately 16% of participants on either side of this age range  were owned by 2,291 survey participants, members of the general public of SA and NZ. Participants were male  and oblique (direct oblimin) rotations were explored and resulted in similar factor extractions, as minimal correlations (< .30) were present between factors ranging from .01 to .28  and build on previous research to fill in a number of methodological gaps. The cross-validation technique analysing data from two independent samples (SA and NZ) strengthened the research providing a reliable and valid measure of pet cat personality upon which future animal personality research can build. Management and welfare implications for pet cats in the home have been largely neglected, and how this research can be used within this field is discussed subsequently. However, there are some limitations of the study which can be addressed in future research. Survey length may affect rater accuracy and engagement if they are too long [This study sought to determine the number of reliable and interpretable factors that depict personality in pet cats and analyse what traits the factors represent. The results suggest that there are five factors of domestic cat personality and that these represent traits related to Neuroticism, Dominance, Impulsiveness, Agreeableness, and Extraversion. This study is the first of its kind to utlilise a transnational sample of this magnitude  [Pet cat personality ratings from SA and NZ revealed five factors with acceptable-high internal consistency: Neuroticism, Extraversion, Dominance, Impulsiveness and Agreeableness. Based on the clusters of traits, previous research and the FFM nomenclature, the labelling of four out of the five cat personality factors was clear, namely: (1) Neuroticism- reflects strongest levels of traits, such as insecure, anxious, fearful of people, suspicious and shy; (2) Dominance- reflects bullying, dominant and aggressive to other cats; (3) Impulsiveness- reflects impulsive, erratic and reckless; and (4) Agreeableness- reflects affectionate, friendly to people and gentle. However, our fifth factor Extraversion also revealed traits normally associated with Self-control in Scottish wildcats  includin abelii) .Our Feline Five factors of Extraversion, Neuroticism and Agreeableness appear generally consistent with the Big Five human personality assessments, along with the addition of Dominance in nonhuman animal personality assessments . The FelThe personality profiles of their cats may not only be interesting to cat owners, but may be used to improve welfare, particularly when an individual cat has unusually high or low scores on a factor. Awareness of results being considered extreme on a scale, compared to a sample of 2000+ pet cats, allows the owner to seek advice and consider changes to the environment or management of their cat. Personality profiling may be particularly useful for managing multi-cat households, ideally before obtaining a new cat. The following information provides specific examples.Cats that score high on Neuroticism (shy) may be stressed and benefit from an assessment of social stress  by obserCats with high scores for Extraversion  may need additional stimulation and more complex environmental enrichment to avoid boredom , such asHigh scores on Impulsiveness  may also indicate a stressful environment , 69, witLoxodonta africana) [Panthera tigris tigris) [High scores for Agreeableness (friendly) are likely to represent cats that are well adjusted and ‘happy’, potentially serving as a source of enrichment for other cats (see captive elephants (fricana)  and tige tigris) ). Owners tigris)  for thei tigris) , and as  tigris) . Low sco tigris) , frustra tigris) , or unde tigris) .Further research is needed to understand how extreme scores for the Feline Five factor of Dominance may be used for improving cat welfare. Most of our knowledge about sociality of domestic cats comes from behavioural observations of free-living  colonies, where related adult females cooperate in raising kittens, while there is competition between adult males . High scIn summary, our Feline Five factors were: Neuroticism, Extraversion, Dominance, Impulsiveness and Agreeableness. Accurate assessment of pet cat personality may help owners manage their cats in a way that optimises cat welfare. Additionally, a greater understanding of cat personality may help owners notice changes in their cat and seek professional assessment by a veterinarian and/or animal behaviour specialist , 17, 77.S1 Appendix(PDF)Click here for additional data file.S2 Appendix(PDF)Click here for additional data file.S3 Appendix(PDF)Click here for additional data file.S4 Appendix(PDF)Click here for additional data file.S5 Appendix(PDF)Click here for additional data file.S6 Appendix(PDF)Click here for additional data file.


Hip and knee arthroplasty are common interventions for the treatment of joint conditions, most notably osteoarthritis. Although many patients benefit from surgery, approximately 1% of patients develop infection afterwards known as deep prosthetic joint infection (PJI), which often requires further major surgery.To assess support needs of patients undergoing treatment for PJI following hip or knee arthroplasty and to identify and evaluate what interventions are routinely offered to support such patients.Systematic reviewMEDLINE, EMBASE, Web of Science, PsycINFO, Cinahl, Social Science Citation Index, The Cochrane Library, and reference lists of relevant studies from January 01, 1980 to October 05, 2016.Observational  studies, qualitative studies, or clinical trials conducted in patients treated for PJI and/or other major adverse occurrences following hip or knee arthroplasty.Data were extracted by two independent investigators and consensus was reached with involvement of a third. Given the heterogeneous nature of study designs, methods, and limited number of studies, a narrative synthesis is presented.Of 4,213 potentially relevant citations, we identified one case-control, one prospective cohort and two qualitative studies for inclusion in the synthesis. Patients report that PJI and treatment had a profoundly negative impact affecting physical, emotional, social and economic aspects of their lives. No study evaluated support interventions.The findings demonstrate that patients undergoing treatment for PJI have extensive physical, psychological, social and economic support needs. The interpretation of study results is limited by variation in study design, outcome measures and the small number of relevant eligible studies. However, our review highlights a lack of evidence about support strategies for patients undergoing treatment for PJI and other adverse occurrences following hip or knee arthroplasty. There is a need to design, implement and evaluate interventions to support these patients.PROSPERO 2015: CRD42015027175 Joint arthroplasty is a common surgical procedure, with over 185,000 primary hip and knee arthroplasties performed in England, Wales and Northern Ireland in 2014 , 4. ThisThe Medical Research Council (MRC) guidance on developing complex interventions suggests that the first step in the development process is “to identify what is already known about similar interventions and the methods that have been used to evaluate them. If there is no recent, high quality systematic review of the relevant evidence, one should be conducted and updated as the evaluation proceeds” . In lineS1 Appendix). We systematically searched MEDLINE, EMBASE, Web of Science, PsycINFO, Cinahl, Social Science Citation Index, and the Cochrane Library from 1980 to October 05, 2016 for observational  studies, qualitative studies, and clinical trials that have reported on the support needs and interventions for patients being treated for PJI or other major adverse occurrences following joint arthroplasty. The computer-based searches combined free and MeSH search terms and combination of key words related to support and care pathways  and adverse outcomes  without language restriction. We adapted the MEDLINE search strategy to the other databases using the appropriate controlled vocabulary. Reference lists of retrieved articles were manually scanned for relevant additional studies missed by the electronic search. Details on the search strategy are provided in S2 Appendix.This review was conducted using a predefined protocol, which was registered in the PROSPERO prospective register of systematic reviews CRD42015027175) and in accordance with PRISMA guidelines [15027175 Studies were eligible if they reported on i) support needs (patient identified needs associated with the outcomes of joint arthroplasty) and interventions  for ii) adult patients (≥ 18 years) iii) undergoing treatment for PJI or other major adverse occurrences  iv) following joint arthroplasty or revision surgery.all of the questions, ‘mainly address SURE questions’ if they attended to most of the questions, or ‘partially address SURE questions’ if they attended to some of the questions.One reviewer (S.K.K.) initially performed screening of abstracts and potentially relevant articles were acquired. We then retrieved full text articles of these studies to determine whether they met all inclusion criteria, which was conducted independently by two reviewers (S.K.K. and A.J.M.). Disagreements and uncertainties were resolved by discussion, with the involvement of a third reviewer (A.D.B) if necessary. A standardized predesigned data collection form was used for data extraction. Data were abstracted, where available, on study design, baseline population characteristics, geographical location, year of recruitment, percentage of males, mean age, description of complication after joint arthroplasty, treatment for complication, and number of participants. For studies with a prospective cohort design, methodological quality was assessed based on the Methodological Index for Non-Randomised Studies (MINORS), a validated instrument that is designed for assessment of methodological quality of non-randomised studies in surgery. For nonIt was not possible to calculate summary measures across studies given the limited number of studies, diversity of the study designs, and the heterogeneous nature of the outcomes. The characteristics of each study were summarised in a table. A narrative synthesis with separate results from each study was therefore performed. For the above reasons, subgroup and sensitivity analyses, and exploration of heterogeneity could not be conducted.S3 Appendix), while four studies met the inclusion criteria and were included in the review .Our initial search of databases and manual screening of reference lists of relevant studies identified 4,213 potentially relevant citations. After screening based on titles and abstracts, 12 articles remained for further evaluation. Following detailed assessments by two reviewers, eight articles were excluded  for patients being treated for PJI or other major adverse occurrences following joint arthroplasty.S3 Appendix. The majority of these articles focused on the impact of preoperative clinical pathways on major outcomes after joint arthroplasty. One was a quantitative review of 22 studies that evaluated the impact of clinical pathways compared to standard medical care, on postoperative complications, quality of care, and direct costs after hip and knee joint arthroplasties.The list of excluded studies after full text evaluation is provided in Using a systematic review approach, we have assessed evidence on the support needs and support interventions for patients being treated for PJI and other major adverse occurrences following joint arthroplasty. In a comprehensive search of several databases, only four studies were eligible and were included in the review. While all included studies focussed on support needs for patients with PJI, one study also included patients with adverse outcomes such as aseptic component loosening and component instability . OverallOur results are relevant and provide new insight into the limited evidence available regarding support needs and provision for patients undergoing treatment for PJI and other adverse events after joint arthroplasty. Our review clearly identifies gaps in the literature. Although for many people, hip and knee arthroplasty are highly successful and cost-effective interventions for alleviating pain and disability associated with advanced joint disease, arthroplasty is also associated with uncommon but serious complications, such as PJI , 29. PatThis is the first review to identify a lack of evidence on support needs and interventions for patients undergoing treatment for prosthetic joint infection or other major adverse occurrences following hip or knee arthroplasty. With a comprehensive literature search across multiple databases, we identified 4 studies which provide evidence on the support needs of patients being treated for PJI or other major adverse events following hip or knee replacement and appropriate support interventions. The review was limited by the small number of heterogeneous studies that were identified. While the evidence is limited the general objective of a systematic review is to identify best evidence and to evaluate it where it exists, as well as to identify important gaps within the research evidence. These studies highlight the considerable negative impact that these adverse events have on patients and identify their unmet needs, while the lack of evidence also suggests there is a lack of service provision for this patient population that needs to be addressed.The eligible studies from the review were conducted in a diverse group of countries, which may affect the generalisability of the findings; however, surgical practices around hip and knee arthroplasty in these countries is similar, and our findings suggest that PJI has a similar negative impact on patients in each of these countries. In addition, none of the studies in each of these countries evaluated existing support interventions for patients being treated for PJI or other major adverse events after joint arthroplasty. There was a potential for biases in the study designs used for the eligible studies as they employed observational and interpretive designs. The findings cannot be generalised to other complications after joint arthroplasty as all of the studies focused on surgical site infection.In summary, our review shows that prosthetic joint infection can have a devastating impact on patients and that patients need more physical, psychological and social support. There is a lack of evidence on support strategies for patients undergoing treatment for PJI and other adverse events. The limited evidence available suggests that there is a worrying lack of service provision for these patients. This review highlights the need for the design, implementation, and evaluation of integrated care pathways to support patients undergoing treatment for prosthetic joint infection and other adverse outcomes following hip or knee replacement. Hip and knee arthroplasty are common interventions for the treatment of painful joint conditions and the increasing number of operations being performed means the number of prosthetic joint infections and other complications will remain significant. The development of care pathways that address the psychological, social, emotional, and economic needs of patients experiencing complications after hip and knee arthroplasty should be a research priority. Work is currently underway within our research group to develop and implement a care pathway to address the unmet needs of this patient group .S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S3 Appendix(DOCX)Click here for additional data file.


MundoComm is a current NIH-funded project for sustainable public health capacity building in community engagement and technological advances aimed at improving maternal health issues. Two to four teams are selected annually, each consisting of three healthcare professionals and one technical person from specific low and middle income countries (LMICs) including Costa Rica, Dominican Republic, Honduras, and other LMICs. MundoComm is a course with three parts: in-person workshops, online modules, and mentored community engagement development. Two annual 1-week on-site “short courses” convened in Costa Rica are supplemented with six monthly online training modules using the Moodle® online platform for e-learning, and mentored project development. The year-long course comprises over 20 topics divided into the six modules - each module further segmented into 4 week-long assignments, with readings and assigned tasks covering different aspects of community-engaged interventions. The content is peer reviewed by experts in the respective fields from University of Rochester, UCIMED in Costa Rica, and faculty from Costa Rica and the Dominican Republic who maintain regular contact with the trainees to mentor learning and project progress. The purpose of this paper is to report the first year results of the MundoComm project.Both quantitative and qualitative feedback (using online data capturing forms) assess baseline and post-training knowledge and skills in public health project strategies.The course currently has one team each in Costa Rica, the Dominican Republic, and Honduras for a total of 12 trainees. The course and modules include best practices in information and communication technologies (ICTs), ethical reviews, community engagement, evidence-based community interventions, and e-Health strategies. To maximize successful and culturally appropriate training approaches, the multi-media didactic presentations, flexible distance learning strategies, and the use of tablets for offline data collection are offered to trainees, and then feedback from trainees and other lessons learned aid in the refinement of subsequent curricular improvements.Through remark and discussion, the authors report on 1) the feasibility of using a globally networked learning environment (GNLE) plus workshop approach to public health capacity training and 2) the capacity of LMIC teams to complete the MundoComm trainings and produce ICT-based interventions to address a maternal health issue in their respective regions. In many low and middle income countries (LMICs) where health is improving more slowly compared to wealthier countries, international health disparities increase. Improvements in child and maternal mortality, for example, have stagnated in several countries and, although a trained workforce of health professionals is essential to successfully address this, there is currently a lack of adequate capacity .Costa Rica, which has emerged as a regional hub for technology and health in Latin America , 3 serveElsewhere such technological innovations as m-Health and internet-based technologies have improved maternal health , 9. Our To develop a mentored training program for community-based public health applied research teams from high-need areas of Costa Rica, the Dominican Republic, Honduras and elsewhere in Latin America to learn about ICT applications, with specific reference to maternal health;To test specific training team ICT innovations in field settings to demonstrate feasibility and appropriateness for local context;To create a “Collaboratory” environment where teams, faculty, experts, and others to share developing material, comment on plans, suggest alterations and developments, discuss barriers, and provide support for trainees in the innovation process; and,To stimulate development of a professional network of ICT, medical, public health, and community students, faculty, researchers, and practitioners devoted to supporting ICT for Maternal Health in Latin America.MundoComm’s primary aims are:The theoretical orientation of MundoComm blends Team Learning Theory (TLT) , 11 withThe objective of the present analysis is to explore and report upon the first year results of the MundoComm project. GNLEs  are highly goal-based learning environments that incorporate innovation and technological change. The feasibility of combining a GNLE and workshop approach to public health capacity training, and the capacity of LMIC teams to complete the Mundocomm trainings and produce ICT-based interventions to address a maternal health issue in their respective regions is useful not only to the current project team, but hopefully exportable to other project teams in other LMIC settings. The University of Rochester’s Research Subjects Review Board reviewed the project and determined that the project does not qualify as human subjects research (45 CFR 46.102) in that the activities do not meet the federal definition of research.The aims of MundoComm are to create a “Collaboratory”  – with bIn the Collaboratory context described above, MundoComm is implementing 1) workshops, 2) online training, and 3) a mentored community training. Two week-long short courses each year are provided to address intervention development and evaluation, health registry development, technology assessment, and ICT project management. These are presented to project teams in-person at the Costa Rica site, and ultimately made available to remote and passive users throughout Latin America. The short courses are supplemented by monthly online training modules (described below). Finally, team mentors meet regularly with the project teams to continually improve program infrastructure and resources.Two to four integrated teams per year, each consisting of three healthcare professionals and one technical  person from a specific Low and Middle Income Country (LMIC), will be trained annually in the development and conduct of community engaged projects aimed at improving locally determined Maternal Health issues in their respective countries .In the first year, the course had 12 enrolled trainees including one team each from Costa Rica, the Dominican Republic, and Honduras. The cohort was composed of nurses, physicians, licensed engineers (technology) and masters’ level hospital administrators. As required for the integrated team approach, each team had three healthcare professionals (including at least one physician), and one IT specialist. The personnel, country, and proposed project are listed in Table The Universidad de Ciencias Médicas (UCIMED), a large medical School in San José, serves as the primary academic base for MundoComm. UCIMED has an active distance-learning portal for continuing education and is especially active in community-engaged service projects. Trainers and mentors included doctoral-prepared faculty from UCIMED, Costa Rica, the Dominican Republic and the University of Rochester. Faculty from Costa Rica and the Dominican Republic speak Spanish as their primary language, and included physicians with additional post-graduate training in community and public health, informatics, and/or clinical investigation. While faculty and mentors from the University of Rochester were not bilingual , all trainings involving non-Spanish speakers and all English materials were presented with Spanish interpretation. University of Rochester faculty disciplines included: Anthropology, Nursing, Psychology, and Informatics.Moodle® (Modular Object-Oriented Dynamic Learning Environment), a freely available and popular open-source learning management system (LMS) or e-Learning platform that serves educators and learners, was developed in 2002 to help educators create online courses with a focus on interaction and collaborative construction of content –18. The MundoComm trainees were asked to create names for their respective teams. This was implemented: 1) to promote the identity, cohesiveness, and effectiveness of each field team, and 2) to promote efficient and tailored faculty-team communication via the LMS. Four named groups were created within this platform, and the course faculty manually enrolled each trainee into his or her respective group. After trainees submitted their completed assignments online, course faculty were able to provide evaluation, instruction, and feedback specific for each team. Additional team-based organization regarding the timing and management of assignments was accomplished by controlling the visibility/accessibility of specific modules, comments, and postings.In tandem with the Moodle® platform, online didactic assignments and evaluations were developed and implemented using REDCap® (Research Electronic Data Capture), which is a software toolset and workflow methodology for electronic collection and management of research and clinical trial data with a secure online format providing an easy-to-use interface for trainees to enter requested information and to provide feedback to the course faculty.The Clinical Translational Science Institute (CTSI) Informatics Core, a unit of the University of Rochester School of Medicine and Dentistry’s Academic Information Technology (AIT) Group, serves as a central facilitator for all data management, including project-specific data and iterative self-documenting processes by all members of the project team. REDCap® was developed in a manner consistent with HIPAA security requirements.In order to create an equivalent and culturally appropriate Spanish language version of initial English versions, materials were first translated into Spanish, and then back translated into English using the Brislin method . The SpaLearning Objectives for the course are to: 1) provide the didactic and mentoring infrastructure to facilitate ICT innovations developed and tested for feasibility in community-based real-life settings; 2) infuse each institution and each of the trainee teams with new insights and strategies for working with diverse partners to create ICTs; 3) aid the teams and faculty to improve the efficiency of the development process via the Collaboratory concept of mentoring and social networking; and 4) strengthen the academic collaboration amongst the partners.To address these Learning Objectives, a core educational plan over a 12-month timeframe was developed Table , and furThe content areas of instruction identified for this population of medical learners include introductory-level skills and topics designed to train health and IT professionals for whom research is not a central job responsibility, but for whom understanding and basic implementation of research principles may help them to be more successful with their maternal health project development. The course was designed to help trainees be more knowledgeable and effective in developing novel technology-based interventions to serve their maternal health populations; to help them understand their project’s data needs and to successfully organize their project from inception to pilot testing.an introductory experience, as appropriate for non-research professionals.During the first week-long short course training in Costa Rica with teams from the Dominican Republic, Honduras and Costa Rica, didactic material was presented in person by United States, Costa Rica, and Dominican Republic faculty covering a wide range of introductory-level areas. The Introductory-level areas of instruction were identified from inspection of methodology courses offered on various online learning platforms, and input from content experts on the core project team, and colleagues within their professional networks. The content areas were then organized into overarching themes of instruction and more specific topics to be addressed via modules, as shown below, and placed either in the in vivo short-course format, or the online distance-learning platform (Moodle®). These themes were identified with the goal of providing Research and ICTs (Information and Communication Technologies) in Latin America.ICTs in Maternal HealthAspects of social, legal and ethical considerations in ICT.Facilitated Global Health Ethics: bioethics program in Spanish.Intelligent databases and data records.Intelligent databases and data records: workshop with Google® Forms.Development of a logic model to address a problem of maternal health.Clinical research and databases.Basics: Epi-Info®How to create a plan for development of an ICT product.Review and analysis tools for the evaluation and accompaniment of projects from the first year of MundoCommCloud (cloud) computing: OwnCloud®, Google Cloud® and Amazon Web Services® (AWS®).Introductory to Word Press® and HTML.Resetting and revision of work plans.Other tools: Open MEAP®, Phone GAP®.Use of social networks and community empowerment: Facebook®, Twitter®, LinkedIn®, Google Analytics®.The sustainability of projects and ICT.Overarching Themes: 1-Week Short Course  share expertise in these ICT areas and will draw upon one another when providing scheduled (and as needed) consultation and mentoring for the teams. Team mentors will assemble annually in Rochester and in Costa Rica to share new approaches, technological ideas, relevant advances in global health and biomedical research, and to continually improve program infrastructure and resources. Throughout the program, teams will collaborate with the mentors to develop their basic ICT intervention which addresses their identified maternal health issue.During the second short course Table  the teamThe evaluation of online training and mentoring included longer-term outcomes  and shorter-term outcomes: whether ICT innovations were developed and tested for feasibility in community-based real-life settings, whether the training program infused each institution and each of the trainee teams with new insights and strategies for working with diverse partners to create ICTs, whether the Collaboratory concept of mentoring and social networking aided the teams and faculty to improve the efficiency of the development process, and whether the academic collaboration amongst the partners strengthened. These outcomes directly relate to the project’s four primary aims, as described above.Using information technology for assessment (e-assessment) includes various strategies to evaluate trainee learning –22. e-AsA pre-training questionnaire and daily post-training evaluations were piloted with the 12 trainees in the first year, using a range of ratings and response choices. A post-training questionnaire was later provided to the first cohort prior to the beginning of their second face-to-face training, to assess the longer term online Moodle® platform experience.n = 8) indicated gaps in knowledge of ICTs , with the highest familiarity reported for social networking. Although multiple reminders and encouragement were given to all 12 trainees, only six anonymously participated in immediate post-training assessments. Average scores indicated self-reported increases in knowledge across course content areas .”Feedback was also elicited on didactic presentations, on specific technologies and social networks , Twitter®, Facebook®, etc.), distance learning platforms , and on public health models. Daily feedback was also elicited for specific presenters and events relevant to that day. For example, at the end of one of the training days, all of the trainees either “agreed” or “strongly agreed” with the statement: “Other open-ended questions elicited specific feedback. For example:Post-training evaluation of the online Moodle® course included the observations that 1) students completed online course assignments with prompts and encouragement from mentors as needed, and 2) at the end of the online coursework participants responded to overall evaluation questions of the online MOODLE® experience  and e-Health strategies, appropriate ethical review and institutional involvement, proactive community engagement, and community interventions that are evidence-based. Evaluations (in-person and online) involve both quantitative and qualitative feedback. For example, to address “community engagement”, a module specifically addressed maternal health data, community engagement, and project organization via assignments such as comparing their own country’s data with data from other countries, how to conduct semi-structured qualitative interviews, and developing logic models.ICT technologies have emerged rapidly within maternal and child global health communities , 9, and Websites form an important mechanism for dissemination of health information to women  whose usMundoComm therefore focuses on basic training across several technical areas of ICT (prioritizing Open Access and free tools): Databases (REDCap®) and Analytics (EpiInfo®); Electronic Health Records ; HTML/Web Site Design (WordPress®); Mobile App development ; and Social Media . As “Cloud Computing” may provide a paradigm shift in how low-resource communities may access and use a wide range of tools and technical details , the traWith respect to MundoComm’s four aims, described above, the current program has already demonstrated 1) the feasibility of implementing a mentored training program for community-based public health applied research teams in LMICs, with specific reference to maternal health; 2) the implementation of specific training team ICT innovations in field settings ; 3) the creation of a “Collaboratory” environment where teams, faculty, experts, and others to share developing material and processes; and 4) the promising development of a professional network of ICT, medical, public health, and community students, faculty, researchers, and practitioners devoted to supporting ICT for maternal health in LMICs. If ongoing evaluation in this and related projects can provide a “proof of concept”, the present mixed model of training with the use of technology (i.e. online courses for distance learning and mentoring learners with only 2 weeks of face to face contact) is potentially feasible and sustainable in LMICs.As described by Heller et al. , in the Maximizing novel approaches to online training and program management both in the US and country-specific requires experimentation with sophisticated technologies including multi-media presentation of didactic material, distance learning strategies, and the use of iPads for offline data collection in global settings. Although comparing and selecting optimal media, strategies, software and hardware would have been ideal for enhanced project fidelity; this was not fully possible due to the project’s timeline and available resources.Although useful as a qualitative assessment of feedback from this first cohort, the Likert style items will be refined and standardized for future cohorts, incorporating trainee feedback. These will be administered to subsequent cohorts to quantitatively assess measurable pre-post changes in self-rated scores. For the first cohort however, where Likert ranges included both 1–4 and 1–5 response choices, standardized proportional scores (1–10) were calculated from average scores for simple comparison purposes.For faculty there was a steep learning curve, initially, as the online platform had parallel but different features than other LMS systems used previously – coupled with the fact that initial instruction on the use of Moodle® was in Spanish only, and based on the host institution’s online virtual environment/version of Moodle®. Not unexpectedly, there were challenges to creating, implementing, and tracking online systems for both educational and data collection purposes. Preliminary evaluation data indicate overall satisfaction with the course format  and the content presented.The second in-person short course will come in the ninth month of the training program, approximately 5 months after the first short course, described above. By that time, the trainee teams will be entering the last phase of their intervention development. The second short course will be focused more on bringing team projects toward closure and evaluation, and introducing new concepts and technologies. It will also feature more time with mentors and advisors in multiple interactive workshop settings, with a focus on resolving details and expanding on project ideas. Online training will continue with the six modules described above, and will overlap with this second in-person short course. Both the latter online modules and the second short course will continue to be informed by our ongoing iterative curricular developmental process involving evaluation feedback from trainees, project staff, and other stakeholders. The final outcome , will be measured 1 year after the end of the second short course. Given the flexibility and availability of our primary course platforms and tools , future courses can be expanded upon and/or scaled up as appropriate. Such tools can easily accommodate multiple designers, didactic tools (including an increasing variety of multi-media options), and evaluation strategies.As the aims of MundoComm are to train and demonstrate the successful use of ICTs for maternal health improvement in LMICs, evaluation efforts at the conclusion of the training will assess trainees’ perceived learning of evidence-based strategies to decrease maternal health disparities and the degree of incorporation of valid evaluation strategies to assess the impact of each project’s initiative on appropriate measurable health outcomes.Determinants of the reproducibility of the present model include start-up costs and the availability of online technological resources. Costs in the present model can be minimal, as there are advantages to using existing online coursework platforms through partnering institutions , although time was needed for communicating across international teams to address issues related to troubleshooting and access to training models for all faculty, mentors, and trainees. Programs should establish a stable and accessible learning platform and project teams should be able to have ongoing reliable access to the internet.Consistent with the tenets of CBPR (Community Based Participatory Research) and of our previous work –6, 11, tInitial evaluations and feedback during the implementation phase suggest that, in combination with in-person learning, an online training platform and e-assessment strategies can be feasible for delivering targeted didactic material. The present study preliminarily evaluates feasibility, usability and progress towards MundoComm’s aims and learning objectives. The advantages to the type of online strategies employed, such as striving for usability, cultural appropriateness, and the incorporation of a variety of interactive features to enhance the learning experience, can help inform future initiatives towards maximizing flexibility in training. With ongoing feedback from all stakeholders, including trainees, additional functionality and efficacy can be pursued. Lessons learned from this training experience include the development of better practices to ensure more complete evaluations, such as assigning unique user identification credentials to participants to anonymously track their participation and secure evaluation feedback.Our multidisciplinary approach to training with face-to-face didactics and distance learning strategies resulted in the implementation of a model-based course for training maternal health professionals, the process of which can potentially be exportable to other settings. Newer interfaces for online training will help us fully optimize e-learning as a mode of delivery for global learning.The community-engagement process links teams with their primary stakeholders, communities and institutions . By invoFinally, trainees will emerge as thought-leaders who are knowledgeable around issues of ICT in maternal health and, to a broader degree, public health. These individuals are likely to continue their relationships with their mentors and remain involved with MundoComm through its social network of professionals and stakeholders. Given the level and role of trainees in their institutions and in their communities, investing in their training and promoting research partnerships with the major institutions of medicine and technology involved with this project will enhance the project’s ability to continue momentum in the future.