Major depressive disorder (MDD) is a leading cause of disability worldwide. Management of chronic conditions such as MDD can be improved by enhanced patient engagement, measurement-based care (MBC), and shared decision-making (SDM). A user-centered design approach can improve the understanding of the patient journey and care team workflows and thus aid the development of digital health care innovations optimized for the needs of patients living with MDD and their primary care teams.PathwayPlatform, intended to enhance patient engagement, MBC, and SDM.This study aims to use qualitative research methods for the user-centered design of a digitally enabled MDD care platform, Insights were gathered through 2 stages of qualitative interviews by a study team with expertise in qualitative research and user-centered design methods. Thematic analysis was used to generate an overarching understanding of a set of shared experiences, thoughts, or behaviors across a broad qualitative data set, including transcripts of interviews, to allow both inductive and deductive insights to emerge. Thematic analysis of interviews was supported by Dedoose , a qualitative data analysis software tool that enables systematized coding. Findings and insights were presented based on code frequency, salience, and relevance to the research project.Pathway app while also exploring the perceptions about potential additional features and functionality. Feedback about care team workflows and treatment approaches was collected in stage-2 interviews with 36 health care providers at 8 primary care sites. Inductive and deductive thematic analyses revealed several themes related to app functionality, patient-provider engagement, workflow integration, and patient education. Both patients and their care teams perceived the remote tracking of patient-reported outcomes via digital tools to be clinically useful and reliable and to promote MBC and SDM. However, there was emphasis on the need to enhance the flow of real-time data shared with the care team, improve trend visualizations, and integrate the data within the existing clinical workflow and educational programs for patients and their care teams. User feedback was incorporated into the iterative development of the Pathway app.In stage 1, interviews were conducted with 20 patients living with MDD and 15 health care providers from September 2018 to January 2019 to understand the experiences with and perceptions about the initial functionality of the Pathway Platform. Key insights led to further development of the patient-facing and care team–facing visit preparation features, collaborative goal-setting and goal-tracking features, patient-reported outcome summaries, and trend visualizations. The result is an enhanced digital platform with the potential to improve treatment outcomes and provide patients living with MDD additional support throughout their treatment journey.Ongoing communication with patients living with MDD and their care teams provided an opportunity for user-centric developmental iterations of the  Depression is a leading cause of disability worldwide, affecting nearly 300 million people ,2. MajorThe American Psychiatric Association clinical guidelines recommend measurement-based care (MBC) for treating depression. MBC includes the routine use of standardized outcome measures to assess changes in depression symptoms, level of functioning, and quality of life across the treatment course . MBC forAlong with MBC, another critical factor shown to improve treatment outcomes is the involvement of people living with MDD in the decision-making processes of their treatment journey . SeveralAmong people receiving treatment for mental health disorders (including depression), increased adherence to treatments  has been reported when they recognize that their treatments reflect their unique needs and preferences. A strong alignment between the treatment goals of the person living with depression and their treatment provider is another critical factor shown to be important in promoting adherence ,11. SeveDigital tool development that enhances patient engagement, MBC, and SDM has the potential to improve treatment outcomes in MDD . DigitalFrom the patient’s perspective, several studies using smartphone app–based interventions for depressive disorders have shown that depressive symptoms were reduced significantly more with smartphone apps ,18,19 thAchieving this potential of digital tools to improve treatment outcomes requires a nuanced understanding of the desirability and usability of patient-facing and care team−facing digital interfaces alongside the practical requirements for patient and care team adoption. Perceived utility and overall value of the product to care teams and privacy and confidentiality concerns are often cited by care teams as examples of barriers that can limit the adoption of these types of apps . VariousPathway App, was designed with a conversational interface and tested via a pilot feasibility study with 40 patients living with MDD . Pa. Pa30]. with MDD . The stuwith MDD . Buildininsights . In thisPathway Platform into primary care in the AAH system within and around Chicago, Illinois. In stage 1, interviews were conducted with 20 patients with MDD who participated in the pilot feasibility study and 15 HCPs . The stage-1 interview sought to understand the experiences with and perceptions about the initial functionality of the Pathway app . Care teams were interviewed about topics related to workflow, perceptions about and experiences with MBC and SDM, and educational needs of patients with MDD and their care team members. The interviews were conducted until observational and analytical saturation was achieved. Saturation was defined as when no new inductive themes emerged during analysis and a priori or deductive themes were exemplified in the data [This report describes the qualitative research undertaken to understand, iterate, and integrate hway app  while althe data .The qualitative data were first coded and analyzed independently by 2 Ctrl Group researchers using a set of foundational structural codes. A structural coding framework, based on the agreed-upon discussion guide from the qualitative interviews, was created for the “top-down” codes; “bottom-up” codes that organically arose from the data were also used. The top-down and bottom-up coding was then refined collaboratively as the researchers progressed through the data set by, for example, splitting preexisting codes into more specific subcodes and combining existing subcodes where appropriate. Once refined, the codes enabled thematic analysis and identification of recurring themes across participants’ accounts and perceptions. Guided by prior research findings -36, we aThematic analysis of interviews was supported by Dedoose , a qualitative data analysis software tool that enables systematized coding. Audio recordings from the interviews were uploaded to the web-based transcription service, Rev. Transcripts were uploaded to Dedoose , the topThe Standards for Reporting Qualitative Research recommendations were followed in the reporting of the study .Ethics approval from the AAH institutional review board was obtained by making amendments to the existing Advocate Pathway study protocol .Pathway App arm and 11/19, 58% from the usual care arm) participated in the qualitative interviews in stage 1. In addition, 15 HCPs also participated in the stage-1 interviews. Overall, 53% (8/15) of HCPs in the group were previously involved in the pilot study, 25% (2/8) of whom were assigned to the PathwayApp arm and had used the app to derive patient reports. A total of 36 HCPs from primary care medicine with experience in managing people with depression participated in the stage-2 interviews  were Black and 38% (n=14) were Hispanic . Overallterviews . These HPathway App, which included functionality, support, and patient-provider engagement, along with subthemes such as ease of use, utility, reliability, motivation, reducing burden, communication, understanding, and shared vision  trajectories for medication adherence, PHQ-9 scores, and side effects provided a clinically useful view of how each patient’s condition has changed over time, which, in turn, supports better clinical decision-making. HCPs suggested including more information about patient care in the Pathway Platform can support care team workflows. Data about medication adherence, PHQ-9 scores, and side effects were perceived to be the most clinically important PROs. However, there were also concerns that Pathway data would be overwhelming and may lead to key data being missed.Interviews also highlighted the importance of understanding care team needs, such as interpreting PRO measures and trend visualizations, to ensure that Many expressed low familiarity and desire for education regarding PROs other than PHQ-9 and clinical use of cognitive tests. In addition to their own education, the care team members also expressed a desire for patient-directed educational materials. Many care team members spoke about patients living with MDD being provided with educational handouts at their respective practices . Many care team members stated that, from the list of educational topics , they were most interested in accessing materials about helping patients understand their diagnosis and their available treatment options. Care team members also thought that patients would benefit from educational resources about the types of local behavioral health resources that are available to them and information about what type of role they can play in their depression care and how often they should follow-up with their physician.Qualitative research and thematic analyses conducted in this study allowed us to capture the user experiences and perceptions of patients living with MDD and their care teams. These results can guide researchers and app developers in designing effective digital health interventions that will be readily accepted by their intended end users .Pathway App to improve these processes by using features such as visit preparation and collaborative goal setting and tracking. Using the broad insights gathered from our thematic analyses, we were able to understand, iterate, and integrate a digitally enabled platform, Pathway Platform, into a primary care setting in the United States. The first iteration of the Pathway App included PRO measures related to depression, well-being, cognitive symptom tracking, medication adherence, and side effects [Pathway App among patients living with MDD and showed a trend in enhanced patient activation in the app arm, albeit in a small sample size [Pathway Platform was developed to consist of 3 components: the latest iteration of the Pathway App; EHR-integrated, real-time, patient-level data sharing; and educational programming that is both care team and patient facing , along with input from software developers and health-technology product development researchers, to optimize usability, utility, iteration speed, and integrated system performance and to ultimately enable nuanced care focused on SDM and MBC  were clinicians. Future studies would benefit from an even split between clinicians and nurses in the sample. Moreover, this was a single-provider network study, and the results of this study may have limited generalizability. In addition, although the design and development of Pathway Platform is being evaluated in an ongoing large-scale implementation study . The study will include up to 200 patients at 20 primary care clinics. The implementation study aims to test the scaling and integration of Pathway Platform, along with educational interventions, at multiple primary care sites within the AAH system, with the primary objective of determining improvement in adherence to MBC practices [Pathway Platform [Furthermore, although thematic analyses offered the necessary tools for organizing, interpreting, and transforming data without the need for separate theories, the depth of our conclusions may have been increased by additional methods such as modeling and theory building . Howeverractices . Resultsractices . EHR intPlatform .Providing effective care for MDD has become more important than ever, with the prevalence of symptoms of anxiety disorder and depressive disorder having increased more than 3-fold in the United States during the COVID-19 pandemic ,46. FurtMoreover, future research methodologies, analysis protocols, and publications should provide a more explicit account of the impact of people’s social intersectionality on their perceptions about remote MDD monitoring. The imperative for this is heightened by the increasing attention that reimbursement entities are paying to the way any given intervention can help minimize the negative effects that social determinants have on treatment outcomes .Pathway Platform. These insights included the need for rapid communication of updated and current patient data with the care team, integration of the app into the MDD care pathway via the EHR, and education of the care team about the interpretation and use of these data. This cocreation model using qualitative research findings has resulted in fast iterations and optimized system performance and will allow for eventual sustainability outside the research environment. Future development of Pathway Platform will continue, consistent with the evolving needs of people living with MDD and their care teams.Ongoing communication with patients with MDD and their care teams (cocreation) provided an opportunity for continued reassessment and developmental iteration of


Health navigators are healthcare professionals who specialize in carecoordination, case management, navigating transitions, and reducing barriersto care. There is limited literature on the impact of health navigators oncommunity-based palliative care for people experiencing homelessness.We devised key performance indicators in nine categories with the aim toquantify the impact of a health navigator on the delivery of palliative careto patients experiencing homelessness.Data were collected prospectively for all patient encounters involving ahealth navigator from July 2020 to 2021 and reviewed to determine thedistribution of the health navigator’s role and the ways in which patientcare was impacted.This study was conducted in Toronto, Ontario with the Palliative Educationand Care for the Homeless (PEACH) Program. At any one time, the PEACH healthnavigator served a total of 50 patients.We identified five key areas of the health navigator role including (1)facilitating access (2) coordinating care (3) addressing social determinantsof health (4) advocating for patients, and (5) counselling patients andloved ones. The health navigator role was split evenly between activitiespertaining to palliative care for structurally vulnerable populations andcommunity-based palliative care for the general population. To achieve highimpact outcomes, a considerable investment of time and energy was requiredof the health navigator, speaking to the importance of adequate andsustainable funding.These findings underscore the potential for health navigators to add value tocommunity-based palliative care teams, especially those caring forstructurally vulnerable populations. What is already known about the topic?Health navigators positively impact the patient experience of palliative carethrough coordination of care, case management, navigating transitions, andreducing barriers to care.What this paper adds?A professional health navigator can improve access to care and help meet thesocial needs of palliative care patients experiencing homelessness, and theimpact of this can be measured.Implications for practice, theory or policyCommunity-based palliative care teams may consider incorporating aprofessional health navigator into their model to improve access to care,and doing so may lead to wider societal impacts to support structurallyvulnerable populations. Research has clearly shown that people experiencing homelessness are atincreased risk for illness and mortality, and there are significant systemicbarriers to them receiving good palliative care at the end of life.25Amongst individuals experiencing homelessness, specific groups are overrepresented,including Indigenous and racialized individuals, people who first experiencedhomelessness in their youth, people who have experienced foster care, andindividuals who identify as 2SLGBTQ+.614 Multiple studies havedemonstrated the positive impact of social workers on palliative care teams,including their capacity to improve quality of care, facilitate discussions aboutadvance care planning, educate patients and families, help patients achieveprognostic alignment, screen for bereavement needs, and lead teamdiscussions.1521 Moreover, there is researchdemonstrating that health navigators can improve the health care of underserved patients. However, there is little research to date on the potential for social workersas health navigators to facilitate equitable access to palliative care amongststructurally vulnerable populations, and to our knowledge there are no studiesdemonstrating the impact of a professional health navigator in community-basedpalliative care for individuals experiencing homelessness.A health navigator is a healthcare professional or peer who specializes incoordination of care, case management, navigating healthcare transitions, andreducing barriers to care. At the beginning of the COVID-19 pandemic, PEACH received funding toestablish a health navigator role with the aim of providing social care throughaddressing the housing, income, food security and access to health care needs ofthis patient population. An individual with a Master of Social Work was hired forthis role given their specialized skills in systems navigation, interdisciplinarycollaboration, and evaluating and meeting the social needs of their clients.The Palliative Education and Care for the Homeless (PEACH) program is acommunity-based palliative care program in Toronto, ON developed in response to aneed for the delivery of equity-oriented palliative care to individuals experiencing homelessness.In this study, we sought to characterize the activities of health navigator with aMaster of Social Work delivering palliative care to individuals experiencinghomelessness, and evaluate the impact of a health navigator on the delivery ofcommunity-based palliative care to people experiencing homelessness in Toronto, ON.We hypothesized that over a 1-year period the addition of a health navigator to thePEACH program would facilitate access to palliative care and social services as wellas help overcome structural barriers to health and well-being for peopleexperiencing homelessness while receiving palliative care.1524 A total of nine KPIcategories and 51 individual KPIs were included  were devisedfor the purposes of evaluation and categorized into one of two domains,including KPIs applicable to (1) palliative care for people experiencinghomelessness and (2) general community- and home-based palliative care, or“mainstream” palliative care. KPIs in Domain One were derived from the PEACHhealth navigator job description, while those in Domain Two were derived fromcurrent literature pertaining to the role of a health navigator in generalpalliative care settings, including both community- and home-basedsettings.included .This study was conducted in Toronto, ON, with study approval granted by the InnerCity Health Associates research oversight committee. The PEACH health navigatorposition was occupied by one individual throughout the duration of the study. Atany one time, the health navigator served a total of 50 patients experiencinghomelessness. While there are many definitions of homelessness, PEACH considersan individual to be experiencing homelessness if they are sleeping outside,couch-surfing, living in shelter, or vulnerably housed in temporary or permanenthousing.KPIs were tracked prospectively by the PEACH health navigator between July 2020and July 2021. Each time the health navigator carried out an activity orachieved an outcome corresponding to a KPI, it was logged in an anonymized excelspreadsheet for tabulation. These encounters were also documented in thepatients’ electronic medical record.All data points were tabulated to calculate the total number of times eachindividual KPI was achieved as well as the total number of occurrences loggedper KPI category. KPIs were further categorized by rate of completion, includingthose completed at low frequency (0–1 times), moderate frequency (2–9 times) andhigh frequency (10+ times) during the study period.Supplemental File 1). KPIs are considered a direct reflection ofthe health navigator’s activities, and are therefore referred to as “activities”in both the results and discussion sections.Collated data were then interpreted to understand the distribution of the healthnavigator’s role and examine its impact on the delivery of palliative care toindividuals experiencing homelessness. The health navigator role was furthercharacterized using three distinct methods of analysis, which are detailed inthe supplementary material , accompaniment to medical appointments(72), housing (60), patient advocacy and health outcomes (59), income (51), accessto interdisciplinary care (35), counselling and psychosocial support (25), food(in)security (19), and capacity building and partnership development (9) .Specific activities completed most often by the health navigator included booking ataxi or medical transportation (10), applying for transportation coverage (11),applying for a medical necessities benefit through provincial social servicesprograms (12), advocating for a patient in their application for housing (14),connecting individuals to a local hospice grocery program (17), coordinating withspecialists (23), providing counselling to patients and their loved ones (25),picking up and delivering medication (32), attending case conference meetings (52),and attending an appointment with a patient (69) .This study adds to a growing body of literature characterizing the role of a healthnavigator in community-based palliative care and fills a gap in the area of impactmeasurement. We highlight the ways in which a health navigator with a background insocial work can take a focused approach to the social determinants of health tofacilitate access to equitable care at the end of life.323 including throughharm-reduction strategies2529 and better integration ofsocial services with health care services.3032 We argue that addressing thesocial needs of patients and providing a person-centered approach to care is ofconsiderable value not only in the field of socially-oriented palliative care forstructurally vulnerable populations but in all fields of healthcare delivery. Infact, it is now widely recognized that addressing the social determinants of healthis vital for improving overall health and reducing health disparities.34 Forcommunity-based palliative care teams that identify a gap in meeting the socialneeds of their patient population and wish to establish a health navigator position,we also provide an objective framework for evaluating the impact of a professionalhealth navigator in community-based palliative care settings with the use of keyperformance indicators (KPIs).Emerging research offers similar emphasis on addressing the social determinants ofhealth to improve access to palliative care for people living with life limitingillness and experiencing structural vulnerability,18 In contrastto the existing literature, our study is unique in its measurement of outcomespertaining to the social determinants of health. By examining the rates at whichthese outcomes were completed during the study period, we found that a high degreeof output was required from the health navigator to achieve meaningful outcomesrelated to social needs . For instance, the completion of 28 activitiesrelated to housing (i.e. housing applications and related advocacy) led to twosuccessful housing applications during the study period, which althoughrepresentative of a small number of outcomes, presumably led to considerable impacton the health and wellbeing of those patients who were housed in the context of alife-limiting illness. Given the well-documented challenges of overcoming structuralbarriers to facilitating dignifying and equitable end-of-life care, we encourageteams to acquire adequate and sustainable funding for a professional healthnavigator to maximize their potential impact.31Previous studies examining the impact of social workers and health navigators on thedelivery of palliative care have focused primarily on outcomes such as painmanagement, advanced care planning documentation, and hospice utilization.This study was limited by the fact that we had no baseline data or control group forcomparison. Therefore, although we can postulate that a professional healthnavigator had a positive impact on access to palliative care delivered to thispopulation, we cannot comment on the degree to which various outcomes related to thesocial determinants of health would have been achieved in the absence of a healthnavigator. Likewise, these findings may not be broadly applicable to othercommunities within a different health network if the specific needs of thepopulation in question differ considerably from the population we studied. Certainoutcomes were achieved at a lower rate than anticipated, which may speak to thedifficulty of measuring these outcomes, highlight an area for role development, orit may indicate that a longer study period is needed to capture outcomes that wereachieved at low frequency over the course of 1 year of data collection.This study opens the door for future avenues of research to enrich our understandingof the potential for a health navigator to enhance the delivery of palliative careto structurally vulnerable populations as well as those accessing “mainstream”community-based palliative care services. Future directions may include measuringthe impact of a health navigator on quality of care, patient outcomes, survival, andcost savings for the healthcare system as a result of addressing the socialdeterminants of health.Click here for additional data file.Supplemental material, sj-pdf-1-pmj-10.1177_02692163221146812 for Assessing theimpact of a health navigator on improving access to care and addressing thesocial needs of palliative care patients experiencing homelessness: A serviceevaluation by Lilian Robinson, Leeann Trevors Babici, Alissa Tedesco, DonnaSpaner, Trevor Morey and Naheed Dosani in Palliative Medicine


To determine the influence of breathing maneuver and sitting posture on tidal volume (TV), respiratory rate (RR), and muscle activity of the inspiratory accessory muscles in patients with chronic obstructive pulmonary disease (COPD).Twelve men with COPD participated in the study. Inductive respiratory plethysmography and surface electromyography were used to simultaneously measure TV, RR, and muscle activity of the inspiratory accessory muscles  during quiet natural breathing (QB) and pursed-lips breathing (PLB) in three sitting postures: neutral position (NP), with armm support (WAS), and with arm and head support (WAHS).Two-way repeated-measures analysis of variance was employed. In a comparison of breathing patterns, PLB significantly increased TV and decreased RR compared to QB. Muscle activity in the SM and SCM increased significantly in PLB compared to QB. In a comparison of sitting postures, the muscle activity of the SM, SCM, and PM increased in the forward-leaning position.The results suggest that in COPD, PLB induced a favorable breathing pattern (increased TV and reduced RR) compared to QB. Additionally, WAS and WAHS positions increased muscle activity of the inspiratory accessory muscles during inspiration versus NP. Differential involvement of accessory respiratory muscles can be readily studied in COPD patients, allowing monitoring of respiratory load during pulmonary rehabilitation. Breathing training  and a siRelief from dyspnea is often experienced in patients with COPD by assuming a forward-leaning position . SittingHowever, the effects of a forward-leaning position on inspiratory muscle activity remain unclear. A previous study showed decreased activity of the scalene and sternocleidomastoid muscles in a forward-leaning position . In contThus, this study was performed to compare the TV, RR, and activity of respiratory accessory muscles during quiet natural breathing (QB) and PLB in three different sitting positions: a neutral position (NP), with arm support (WAS) in a forward-leaning position, and with arm and head support (WAHS) in a forward-leaning position in patients with COPD.2) diagnosed with COPD were recruited from the Division of Pulmonary Medicine, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea. All subjects were classified as stage 2 or 3 COPD (forced expiratory volume in 1 s percent predicted (FEV1 %pred) (50.75 ± 9.27)) by the GOLD criteria [Twelve male subjects  to enable the simultaneous acquisition and recording of respiratory parameters and surface electromyographic measurements.TV and RR were measured by inductive respiratory plethysmography . The system consisted of two bands (Teflon-coated inductance) that measured changes in the cross-sectional area of the rib cage and abdomen, allowing determination of the respiratory phase (inspiration and expiration).For surface electromyography, three pairs of Ag/AgCl electrodes and a reference electrode were affixed on the patient’s inspiratory accessory muscles, the scalene muscle (SM), sternocleidomastoid muscle (SCM), and pectoralis major (PM). The EMG unit of the Embla N7000 (Embla Systems) was used to measure the muscle activity of the inspiratory accessory muscles. Data are expressed as percentages of the reference voluntary contraction (%RVC). Muscle activity was measured during the inspiration phase. The inspiration phase was determined from the nasal pressure curve, measured using a nasal cannula and respiratory analysis software for inductive respiratory plethysmography, and Origin 8, a program that calculates the root mean square .Prior to enrollment in the study, all subjects received a training session for PLB. For the quiet natural breathing (QB) maneuver, patients were instructed to breathe in their normal habitual comfortable breathing style with no specific training. Breathing maneuvers and sitting postures to be tested Figure  were selpost hoc test was performed. In all analyses, p values < 0.05 were considered to indicate statistical significance.The SPSS software  was used for statistical analyses. Two-way (2 × 3) analysis of variance with repeated measures was employed to compare the two breathing maneuvers  and three different positions . In the case of significant differences between test positions, Bonferroni’s The mean and standard deviation of tidal volume and respiratory rate for each respiratory maneuver and sitting posture are presented in Table post hoc test showed that the muscle activity in WAHS was significantly increased compared to that in NP (p = 0.017). Muscle activity was not significantly different between WAHS and WAS (p = 0.070) or between WAS and NP (p = 0.495). For sternocleidomastoid muscle (SCM) activity, there was no interaction between breathing pattern and position , but significant main effects of breathing method  and position  were observed. Muscle activity in PLB was significantly greater than that in QB. Bonferroni’s post hoc test showed that the muscle activity in WAHS was increased significantly compared to that in NP (p = 0.001), and the muscle activity in WAS was increased significantly compared to that in NP (p < 0.001). No significant difference in muscle activity between WAHS and WAS (p = 0.154) was observed. For pectoralis major (PM) muscle activity, the results showed no interaction between breathing pattern and position  and no significant main effect of breathing method , but a significant main effect of position  was observed. Bonferroni’s post hoc test showed significant muscle activity differences among the three sitting positions used in this study. Muscle activity in WAS was increased significantly compared to that in NP (p = 0.025) and in WAHS (p = 0.029). Muscle activity in WAHS was increased significantly compared to that in NP (p = 0.039).The mean and standard deviations of %RVC for each respiratory maneuver and sitting posture are presented in Table The findings of this study show that TV was significantly greater in PLB than in QB and that RR was significantly lower in PLB than in QB, supporting the research hypothesis. These results are consistent with previous studies indicating beneficial effects of PLB compared to QB for increasing TV  and decrThe increased TV during PLB was probably due largely to the increased pressure in extra-thoracic airways and thus to a reduced cost of breathing due to decreased intrinsic positive end-expiratory pressure (PEEP). Many patients with COPD use PLB in an attempt to produce extrinsic PEEP to reduce lung hyperinflation and dyspnea . The incA, and IIB/X), and the types of fiber vary in function with aging, type of exercise, and chronic respiratory load in patients with COPD [The diaphragm contains three types of muscular fibers , maximum inspiratory pressure (MIP), maximal expiratory pressure (MEP), diaphragmatic movements during tidal breathing, or forced breathing in the sitting or supine positions, or sitting leaning forward with hands supported on the knees (tripod position) in patients with COPD. Kera and Maruyama [In contrast to PLB, TV and RR did not differ significantly with sitting position. Thus, the research hypothesis regarding breathing position was not supported by the results of this study. These findings are consistent with a recent study by Bhatt et al. , who fouMaruyama  reported1, and peak expiratory flow compared to upright postures [Posture can influence the degree of limitation on expiratory tidal flow according to changes in functional residual capacity (FRC) . Recent postures ,27. Anotpostures .Patients with severe COPD frequently lean forward, bracing their arms. A position bracing the elbows on a table increased ventilatory capacity significantly in four healthy men, and this effect could be helpful information for COPD patients, whose diaphragms are flattened and ineffective, as such patients depend more on the inspiratory muscles of the rib cage . In contSince the muscular force-generating capacity of the diaphragm is decreased in COPD and the effects of elbow bracing have differed among the past studies, in the present study we focused on changes in inspiratory accessory muscle activity related to changes in posture with or without elbow bracing to identify postural effects.Although both the WAS and WAHS postures, characterized by the trunk leaning forward, might increase intra-abdominal pressure and decrease diaphragmatic excursion toward the abdominal cavity during inspiration, many patients with COPD adopt a sitting posture with the trunk leaning forward during conditions of an increasing sense of dyspnea ,31, and TV and RR did not differ significantly in relation to sitting position in this study. We had no data on inspiratory duty cycle or FRC according to different sitting posture; thus, our results do not provide complete information about postural changes in lung volumes.The muscle activities of the SM and SCM in PLB were significantly greater than those in QB in this study. The fact that the SM and SCM attach between the cervical spine and the upper two ribs increased muscle activity in these muscles during inspiration in patients with COPD can be interpreted as an attempt to increase intrathoracic volume by elevating the upper ribs and sternum . IncreasIn this study, muscle activities of the SM and SCM in a forward-leaning position, both WAHS and WAS, were greater than those in NP, even though the increased muscle activity of the SM in WAS relative to NP failed to reach statistical significance. Several mechanisms may explain these results. First, it is possible that increased activity of the SM and SCM overcame restricted downward movement of the diaphragm. The forward-leaning position results in increased intra-abdominal pressure by approximating the ribs to the pelvis, making it difficult for the diaphragm to descend caudally during inspiration ,32. A seIn this study, the PM showed the greatest muscle activity in WAS, followed by WAHS, and the lowest PM activity was observed in NP. These results may be explained by reversal of muscle contraction. When the distal limb segment is stabilized, the proximal limb segment can be mobilized. Decreased activity of the PM in WAHS, compared to that in WAS, may be attributable to increased SM and SCM activity in WAHS. However, muscle activities of the major muscles of respiration, including the diaphragm and intercostal muscles, were not measured, so the effects of changes in the activity of accessory muscles during different breathing maneuvers and of various positions on major muscle activity could not be determined in this study. Additionally, the effects of breathing maneuvers and sitting postures on pulmonary function in patients with COPD remain unclear because of limitations in the measurement of lung volume and dyspnea according to breathing maneuver and sitting posture. Further studies are required to measure the major muscles of respiration, including examination of various activities and conditions of ventilatory insufficiency, using various pulmonary parameters and dyspnea scales.In conclusion, these results suggest that in COPD patients PLB induced a favorable breathing pattern (as assessed by TV and RR) in comparison to QB. Additionally, WAS and WAHS induced increased activity of inspiratory accessory muscles during inspiration compared to NP in COPD. Differential involvement of the accessory respiratory muscles can be readily studied in COPD patients, allowing monitoring of respiratory load during pulmonary rehabilitation.Ki-song Kim and Min-kwang Byun contributed equally to this work.The authors declare that they have no competing interests.


This paper addresses recent calls to narrow the micro–macro gap in management research , by incorporating a macro-level context variable (country) in exploring micro-level determinants of board effectiveness. Following the integrated model proposed by Forbes and Milliken (1999), we identify three board processes as micro-level determinants of board effectiveness. Specifically, we focus on effort norms, cognitive conflicts and the use of knowledge and skills as determinants of board control and advisory task performance. Further, we consider how two different institutional settings influence board tasks, and how the context moderates the relationship between processes and tasks. Our hypotheses are tested on a survey-based dataset of 535 medium-sized and large industrial firms in Italy and Norway, which are considered to substantially differ along legal and cultural dimensions. The findings show that: (i) Board processes have a larger potential than demographic variables to explain board task performance; (ii) board task performance differs significantly between boards operating in different contexts; and (iii) national context moderates the relationships between board processes and board task performance. Copyright © 2010 John Wiley & Sons, Ltd. Most previous governance studies have been criticized for either adopting under- or over-contextualized views. On the one hand, literature on corporate governance and boards of directors has primarily applied agency theory to explore the impact of board demographics on firm financial performance  and/or firm specific knowledge and expertise. Boards are usually populated by highly competent and reputed individuals; however, the mere presence of knowledge, we argue, does not per se mean that board members will use their knowledge , leadership style will encourage board participation, and processes will tend to be naturally more effective. As a consequence, however, it may lead to a “ceiling effect” in Scandinavian boards, since relatively less variance is achievable in a good process context. In sum, previous arguments point at the importance of developing effective board processes especially in those settings where autocratic leadership and low participative business styles prevail. In such settings, the greater variance in processes across boards will determine a higher predictive potential of the board processes themselves on board task performance. Thus, we hypothesize the following:Hypothesis 6: Effort norms, cognitive conflicts and the use of knowledge and skills will have a stronger positive impact on both control and advisory task performance in Latin countries vis-à-vis Scandinavian countries.The hypotheses were tested on data collected in Norway (representing Scandinavian countries) and Italy (representing Latin countries). The selection of two countries as proxies of cultures and institutions follows the tradition in cross-cultural organizational behaviour research. In this vein, issues related to cross-national data collection procedures, matching samples and construct equivalence often lead scholars to a choice of comparing two radically different countries . The Norwegian sample consists of the publicly listed firms and the one thousand largest industrial firms based on total turnover in 2002, totalling 1140 firms. The Italian sample consists of the 2000 largest Italian industrial firms ranked by turnover in the same year, including all the 240 industrial firms listed in that year at the Italian Stock Exchange. We obtained 379 answers from Norway, with a response rate of 33 per cent, and 301 answers from Italy, with a response rate of 15 per cent, which is in line with previous research on board of directors  controls that activities are well organized; (ii) establishes plans and budgets for the firms' operations; (iii) establishes guidelines for the operations of the firms; (iv) keeps itself informed about the financial position of the firm and (v) oversees that the operations are properly controlled  Management issues ; (ii) financial issues ; (iii) technical issues ; (iv) market issues  and (v) legal issues and taxation , defined as the net operating income before extraordinary items divided by total assets. ROA is a well understood and common measure used in several studies on the impact of boards and top management teams on firm performance, and is particularly appropriate for manufacturing firms , considering the year following the one in which the survey was administered  operationalization of conflicts, and relying on Forbes and Milliken's  and to assess the influence of the national context on board task performance, as well as its moderating effect on the board processes and task performance relationship. Similar to what the majority of cross-cultural studies do . Our firm age variable was a logarithmic transformation of the age the firm.At the board-level, we controlled for CEO tenure and the traditional board demographic variables. CEO tenure may have an influence on board task performance across life cycle evolution Shen, . The CEOIn order to deal with potential common method bias , and the average variance extracted range from 76 to 90 per cent  were assessed simultaneously in one confirmatory factor analysis (CFA) using MPLUS Version 5.21. The CFA results showed a good model fit . We assessed reliability by calculating a composite reliability for each construct  > 3.84 was exceeded in all cases). In addition, we tested for the invariability of the constructs and their measurement across the two national contexts. A multi-group analysis was conducted to validate the factorial structure of the proposed constructs and test whether the regression coefficients were invariant across the two populations  to 0.41 (model V). Further, the most significant F-changes are between model II and model III (27.2***) and model III and model IV (81.3***), indicating the relevance of board processes and the country variable to predict control task performance. Table The first set of regressions was performed considering the control task performance as dependent variable. As evident from Table R2 range from 0.01 (model I) to 0.32 (model V), and the most significant F-change is between model II and model III (37.5***), indicating the predictive potential of board processes on board task performance in advice. Further, the R2 change and the F-change statistics between model IV and model V are stronger than the previous set of regressions, indicating that interactions are more relevant for advisory tasks than for control. Detailed results are presented in Table The second set of regressions refers to the board advisory task performance. As Table l III 37.***, indiThe third set of regressions tests for the hypothesized positive effects of board effectiveness in performing its tasks on firm's financial outcomes. Table Return On Assets in year t + 1; and (ii) the positive effects of board task performance (both control and advice) remain significant even after introducing board processes in the regression equations 2. Overall, these results provide evidence that there is a relationship between self-reported performance measures of board tasks and firm performance, and that this relationship is robust  Board performance in both control and advisory tasks predict firm financial performance measured as The different sets of regressions above provide support for hypotheses 1 and 3, respectively, on effort norms and the use of knowledge and skills, while they do not provide supporting evidence for Hypothesis 2. The results also provide support for Hypothesis 4 on the relationship between task performance and firm financial results. Furthermore, our results provide support for Hypothesis 5 on the higher board performance in both control and advisory tasks in Norway. With respect to Hypothesis 6, results show support for effort norms related to both board performance in control and advisory tasks, while cognitive conflicts show positive interaction with control task performance only. The use of knowledge and skills, however, shows no interactions at the country level with either control or advisory task performance. All the significant relationships are graphically presented in Figures We performed an additional set of analyses in order to further validate our main results. Specifically, in order to account for potential perceptual biases of CEO respondents being also Chairs of their boards, we performed the same full set of regression analyses without considering responses of “dual” CEOs . While separate CEO and Chair positions may indicate CEOs as both “clients” of board advice and “targets” of board control, dual CEOs may be evaluating at least to some extent the quality of his or her own leadership of the board. Empirical analyses showed identical results for analyses excluding dual CEOs . Results also show that dual CEOs are not positively biased in their ratings.The main purpose of this study is to introduce a macro-level variable (country) to the boards and governance research on micro-level behavioral processes , it opens up for debate at both the micro- and the macro-level of analysis. At the micro-level, De Dreu and Weingart  notice tA second set of results shows the impact of macro-level institutional context on board task performance. According to institutional theory, human and social behaviors are driven by the pervasive influence of institutions such as norms, rules, routines and historical patterns , since processes tend to be naturally higher in such cultures. Consequently, the relatively lesser variance in the good process context of Scandinavian boards will lower the predictive power of board processes on task performance.Finally, the use of knowledge and skills shows similar patterns in both contexts, with moderating effect being non-significant. Contrary to previous findings, our results show that using knowledge and skills in highly interdependent groups is predictive of group task performance regardless of the country context. As such, our findings point to the use of knowledge and skill as a more universalistic practice, which corporate boards should carefully follow. Overall, our results support theoretical predictions that effective board processes are likely to be stronger predictors of tasks in highly individualistic power distance cultures. Our findings may also relate to the greater variance in processes that individualistic cultures experience The paper is not without limitations, which may provide opportunities for future research. First, in line with the majority of previous cross-national studies  explanations into the boards and governance research. To this end, we focused on board effectiveness in its tasks to investigate how macro-level determinants (context) influence micro-level relationships. Our analyses offer evidence of how both micro- and macro-level variables influence board task performance, and show how the macro-level country variable moderates relationships between board processes and task performance. As a result, the paper provides a preliminary answer to recent calls to bridge under-contextualized agency theory approaches and over-contextualized views of institutional theory (Aguilera et al.,


Each year, 287,000 women die from complications related to pregnancy or childbirth, and 3.8 million newborns die before reaching 28 days of life. The near totality (99%) of maternal and neonatal deaths occurs in low- and middle-income countries (LMICs). Utilization of essential obstetric care services including postnatal care (PNC) largely contributes to the reduction of maternal and neonatal mortality and morbidity. There is a strong need to evaluate the evidence on the unmet needs in utilization of PNC services to inform health policy planning. Our objective is to assess systematically the socioeconomic, geographic and demographic inequalities in the use of PNC interventions in low- and middle-income countries.The Cochrane Handbook for Systematic Reviews. Our systematic review will identify studies in English, French, Spanish, Portuguese and Chinese – provided inclusion of an English abstract - from 1960 onwards, by searching MEDLINE (PubMed interface), EMBASE (OVID interface), Cochrane Central (OVID interface) and the gray literature. Study selection criteria include research setting, study design, reported outcomes and determinants of interest. Our primary outcome is the utilization of PNC services, and determinants of concern are: 1) socioeconomic status ; 2) geographic determinants ; and 3) demographic determinants . Screening, data abstraction, and scientific quality assessment will be conducted independently by two reviewers using standardized forms. Where feasible, study results will be combined through meta-analyses to obtain a pooled measure of association between utilization of PNC services and key determinants. Results will be stratified by countries’ income levels (World Bank classification).The current protocol adopts a strategy informed by the guidelines of Our review will inform policy-making with the aim of decreasing inequalities in utilization of PNC services. This research will provide evidence on unmet needs for PNC services in LMICs, knowledge gaps and recommendations to health policy planners. Our research will help promote universal coverage of quality PNC services as an integral part of the continuum of maternal and child health care. This protocol was registered with the Prospero database (registration number: CRD42013004661). Each year, 287,000 women die while pregnant, during childbirth or within 42 days of termination of pregnancy . Materna. The fifth United Nations Millennium Development Goal aims to achieve universal access to reproductive health services by 2015, including coverage of obstetrical care services [It is largely acknowledged that utilization of essential obstetric care services - including but not limited to antenatal care, skilled attendance at birth and postnatal care - contribute to the reduction of maternal and neonatal mortality and morbidity in LMICs ,7. The fservices . In thisThe World Health Organization WHO, 2010) stated that the postnatal period begins immediately after the birth of the baby and extends up to six weeks (42 days) after birth . The pri stated tPNC of the newborn covers screening and treating infections , jaundice and postnatal growth restriction, as well as dispensing immunization services and umbilical cord care . PretermThe number and timeliness of postnatal consultations are being studied at present by WHO to update clinical guidelines . Some suThere are important unmet needs in PNC in LMICs, where more than 70% of all babies born outside the hospital do not receive any PNC services . In a stScientific evidence exists on inequalities in the use of antenatal care (ANC), location of childbirth (home or facility delivery) and skilled birth attendant (SBA) at delivery across socioeconomic status ,21, educOur objectives are to: 1) systematically identify and assess studies and reports on the utilization of PNC services in LMICs; 2) synthetize evidence on the determinants of PNC services and inequalities in the use of PNC interventions in LMICs; and 3) provide evidence to policy planners in order to address unmet needs for PNC services in LMICs. This systematic review is guided by the following research questions: is PNC service utilization associated with 1) socioeconomic, 2) geographic and 3) demographic determinants?Cochrane Handbook for Systematic Reviews) [The current protocol outlines a strategy informed by the guidelines of The Cochrane Collaboration (Reviews) . The sysReviews) .CRCHUM), and an expert librarian (DZ) of the Documentation Center of the University of Montreal Hospital Centre (CHUM). Filters for bibliographic research will include publication date - from 1960 onwards - and languages, with consideration of English, French, Spanish, Portuguese and Chinese articles, conditional on the provision of an English abstract. We will use specific medical subject headings (MeSH) and text words to identify studies by searching MEDLINE , EMBASE  and Cochrane Central . We will hand-search relevant abstracts in the Cochrane Neonatal Group, Cochrane Pregnancy and Childbirth Group, and Cochrane Public Health Group. As per the Peer Review of Electronic Search Strategies (PRESS) recommendation, we will include the ‘explode’ option to the Emtree terms in the EMBASE research [Literature search strategies will be implemented by the research team  of the Research Centre of the University of Montreal Hospital Centre (research . The exaOur search strategy will combine terms related to the following categories: 1) postnatal or postpartum care; 2) utilization or accessibility; 3) determinants or inequalities; and 4) low- or middle-income countries. We will combine in a complete Endnote file all the scientific articles and reports retrieved through the identification phase, and then extract duplicates.We will retrieve studies implemented in LMICs, as defined by The World Bank Group’s classification  and cluster-randomized trials (CRTs); quasi-experimental studies including quasi-randomized trials, controlled before-after studies (CBAs) and interrupted time series studies (ITSs); and observational studies including cohort, case–control and cross-sectional studies.WHO Technical Consultation on Postpartum and Postnatal Care (2010), a scientific panel agreed that adopting the single term ‘postnatal’ would aid clarity and should be used for all issues pertaining to the mother and the baby after birth [We will include studies reporting outcomes of postnatal/postpartum care services utilization. Although some studies underline that ‘postpartum’ refers to issues pertaining to the mother and ‘postnatal’ refers to those concerning the newborn or the baby, we will use the terms interchangeably, in accordance with WHO’s conceptualization  . In a reer birth . Our priDeterminants of concern are: 1) socioeconomic status - assessed by income, expenditure, household characteristics and/or assets, occupational or contractual status ,21,31,32Demographic and Health Surveys (DHS) for consecutive years in the same country, we will only consider the most recent [We will consider quantitative results of the association between potential determinants and the utilization of PNC services. Published results must include an association measure, frequency ratio/difference, or statistical test comparing utilization of PNC services across two or more groups. If these results are not explicit, we have to be able to estimate them with the information provided in the paper. We will consider relative comparisons – for example, relative concentration index (RCI) or relative index of inequality (RII) - to a reference group, along with absolute differences in PNC services utilization, such as absolute concentration index (ACI) or slope index of inequality (SII). Such reported disparities will be useful in making comparisons over time or across geographical areas, populations or indicators, in light of the Centers for Disease Control and Prevention (CDC)’s guidelines ,37. StudA team of researchers, MM  and EVL (PhDc), will identify articles by first analyzing titles and abstracts for relevance and compliance with the selection criteria, based on research setting, study design, reported outcomes and determinants of interest. Relevant articles will be classified as: 1) included; 2) excluded; or 3) uncertain. After exclusion of records not relevant to the systematic review, full texts of selected abstracts (records categorized as included or uncertain) will be extracted systematically for further eligibility analysis.Full-text screening will be conducted independently by the reviewers (MM and EVL) using a standardized form with explicit inclusion and exclusion criteria. Discrepancies will be resolved by discussion between the two reviewers, and persisting disagreement will be resolved by discussions with two experienced researchers (IK and MVZ). We will compute the inter-rater agreement using the intraclass correlation coefficient (ICC) .SD, parity, health literacy, women’s decision making power); outcomes (PNC utilization); and results of the association between PNC services and potential determinants. In cases where numerous publications report data originating from the same study, the latest outcomes of interest will be assessed. Missing data on key characteristics will be dealt with by contacting the study authors and through complementary research . Reviewers will systematically use a standardized data abstraction form [See Additional file Reviewers will use an explicit data collection form to abstract data items, including but not limited to: study characteristics ; participants’ characteristics  Statement[We will assess the scientific quality of selected studies to ensure internal validity of reported results and avoid analyzing spurious associations - confounded or biased – or type I statistical errors. We will use standardized quality assessment tools for specific types of designs to determine the methodological quality and the risk of bias of the included studies. To assess the quality of RCTs we will use the Cochrane Collaboration’s Risk of Bias Tool (CCRBT) ; for quaStatement. SpecialStatement,45. EVL Statement. DiscrepEvidence tables will be generated to descriptively summarize the included studies and results: 1) authors, 2) study design, 3) objectives, 4) setting, 5) population, 6) outcomes assessed, 7) determinants/predictors, 8) results and 9) scientific quality. Evidence tables will be stratified by countries’ income level (World Bank classification) to provide for different contextual characteristics of low- versus middle-income countries.2 statistic) and corresponding analysis . Data synthesis will be stratified and presented separately for experimental, quasi-experimental and observational studies. Depending on the number of studies, we will further stratify observational studies according to design  and/or association measure - odds ratio, risk ratio, incidence rate ratio, hazard ratio, and prevalence ratio - exploring potential heterogeneity. Where feasible, we will carry out separate meta-analyses of adjusted versus non-adjusted (or insufficiently adjusted) association measures. Should we notice conditions that impede meta-analysis, we will synthetize the data narratively to provide for PNC services inequalities. Particular attention will be paid to assessing results in light of study settings to ensure proper contextualization of evidence and relevance for policy planning purposes in LMICs. Results will be reported according to the PRISMA Statement, with a focus on health equity (PRISMA-Equity 2012 Extension) [Where feasible, data will be combined to obtain a pooled measure of association evaluating PNC services inequalities, through meta-analyses conducted by using The Cochrane Group’s Review Manager Software (RevMan 5.1) . Data witension) .Oral consent was obtained from the women for the publication of the accompanying image.et al. (2010) underlined that a focus on health equity in systematic reviews improves their relevance for public policy making [et al. (2012) stressed that systematic reviews are a valuable source of scientific evidence on inequities in health outcomes, resource allocation and use [This systematic review will provide: 1) knowledge on existing inequalities and unmet needs for PNC services in LMICs; 2) pragmatic recommendations to health policy planners for improving access to, and utilization of, quality PNC in LMICs; and 3) an overview of knowledge gaps and future research needs. Results of the systematic review will be published in a peer-reviewed international journal and presented at conferences and symposia in relevant fields . Further knowledge dissemination will involve communicating results to the governments of LMICs and to organizations active in promoting access to maternal and child health services . The utmost relevance of systematic reviews to inform health systems policymaking is increasingly recognized . Tugwelly making . Welch e and use . Our revANC: Antenatal care; CBAs: Controlled before-after studies; CDC: Centers for disease control and prevention; DHS: Demographic and health surveys; EBF: Exclusive breastfeeding; EPHPP: Effective public health practice project; ICC: Intraclass correlation coefficient; ITS: Interrupted time series; LBW: Low birth weight; LMICs: Low- and middle-income countries; MeSH: Medical subject headings; PNC: Postnatal care; PRISMA: Preferred reporting items for systematic reviews and meta-analyses; RCT: Randomized controlled trial; SBA: Skilled birth attendant; WHO: World Health Organization.The authors declare that they have no competing interests.EVL, IK, MM and MVZ contributed to the conception and design of the review. EVL and DZ developed the search strategies. EVL drafted the manuscript. IK, MM and MVZ were actively involved in critically revising the protocol for important intellectual content. DZ made a substantial contribution to the ‘Information sources and literature search’ section, and to Additional file Search strategy MEDLINE, EMBASE, and Cochrane Central.Click here for fileData collection form.Click here for file


To describe an approach to the development of manualized protocols for Ayurveda as a whole system of medicine; to characterize an Ayurvedic perspective on the pathophysiology, etiologies, and supportive treatments for an allopathic diagnosis of cancer.Hour-long, digitally recorded interviews were conducted with experienced Ayurvedic clinicians from both the USA and India. Eligible clinicians had an advanced degree in Ayurveda and clinical experience with a minimum of 50 patients with a diagnosis of cancer. All interviews were transcribed verbatim and coded for major themes using principles of qualitative content analysis. At least two investigators coded each interview. Variations in interpretation were reconciled through refined definitions and recoding.Ten participants, with an average of 23 years of clinical experience, were interviewed. Several themes emerged from the data: (1) The Ayurvedic description of the pathophysiology of cancer uses traditional concepts translated into the modern context. ( 2) Although the allopathic treatment of cancer is considered necessary, from an Ayurvedic perspective, it results in degeneration and depletion. (3) In cases where Allopathic treatment has stopped working or is not feasible, an Ayurvedic approach focusing on strengthening digestion, burning toxins, reducing growth, and improving tissue metabolism is viewed as useful. (4) An Ayurvedic approach to cancer supportive care focuses on restoring equilibrium, building mental and physical strength, and rejuvenation. Qualitative data were used to develop a study manual focusing on an individualized, multi-modality Ayurvedic intervention for breast cancer survivorship.A methodology for whole systems research that starts with a qualitative approach can be used to develop a manualized Ayurvedic intervention. Although derived from an ancient, but living tradition, Ayurvedic medicine offers a unique perspective on the modern allopathic diagnosis of cancer that emphasizes restoring wholeness and integrity to the mind and body; using natural remedies; including a focus on emotional health; and instituting prevention strategies.


As part of an effort to address shortages in the cancer workforce, C-Change developed competency standards and logic model-driven implementation tools for strengthening the cancer knowledge and skills of non-oncology health professionals. These standards and tools were applied by four diverse grant programs to yield gains in the management of pain and palliative care, thereby improving the quality of care for individuals experiencing or recovering from cancer treatment. The results from the four grant sites and tools used to achieve them are described in this article. Our Nation’s capacity to fight cancer and improve the quality of care for patients depends on the quality and quantity of the cancer workforce—the number of health professionals and the adequacy of their training. Nearly all of the professional disciplines who play a role in the delivery of comprehensive cancer services are experiencing a shortage including physicians, nurses, social workers, pharmacists, public health workers, researchers, technologists, and cancer registrars. The rising incidence of cancer, an aging population, and an increase in cancer survivorship all predict an increased demand for health services. These trends threaten our ability to provide timely and comprehensive cancer care.The current physician shortage is approximately 8 % and is projected to be greater than 20 % in 2025 The supply of oncologists is only predicted to increase by 14 % by 2020, creating a shortage of 2,500 to 4,080 oncologists [More than 20 % of the US population lives in areas deemed by the federal government as health professions shortage areas without access to adequate medical care One third of critical access hospitals lack a surgeon living in the county By 2020, the shortage of registered nurses will be greater than 1 million Only 33,000 of 120,000 registered nurses who specialize in oncology are certified , 8The social work labor force is older than most professions, with nearly 30 % of licensed social workers over age 55 Currently, the U.S. has approximately 4,400 hospice and palliative medicine physicians, but 6,000 to 18,000 are needed to meet the gap between supply and demand By 2015, 81,000 additional clinical laboratory technologists will be needed to replace retiring staff and another 68,000 to fill newly created positions The projected shortage of more public health workers by 2020 is 250,000 While 25 % of the U.S. population is comprised of African Americans, Hispanics, and Native Americans, medical training programs are comprised of fewer than 7 % of underrepresented minorities The supply of cancer-related research, clinical, and public health professions is inadequate and is projected to worsen among nurses, social workers, oncologists, radiation oncologists, pharmacists, researchers/scientists, and imaging technologists while the current and projected demand for cancer care is expected to increase. This imbalance between supply and demand is quantitatively exemplified below:Founded in 1998, C-Change is the only organization that assembles the Nation’s cancer leaders from the three sectors—private, public, and not-for-profit—and from across the cancer continuum—prevention, early detection, treatment, to palliative care and survivorship. The mission of C-Change is to eliminate cancer at the earliest time possible by leveraging the expertise and resources of its members. The cancer workforce shortage is one challenge that C-Change’s members identified as an important priority for collaborative action. In an effort to address this shortage, the C-Change Cancer Core Competency Initiative was developed to equip non-oncology professionals with the knowledge and skills to better meet the needs of an aging and increasingly diverse population of people at risk for or living with cancer.Convened by C-Change, a national, multi-disciplinary panel of leaders and experts developed competency standards that define the knowledge and skills needed by all healthcare providers. The competency standards can be applied in any healthcare setting, by any health discipline, and address issues spanning the continuum of care, cancer science, and care coordination and communication. Implementation tools include a logic model and curriculum validation template. Defining core competencies is a widely recognized approach to developing and maintaining key knowledge and skills in the workforce, and is one important approach toward expanding the cancer workforce.www.cancercorecompetency.org.As discussed in previously published work, the competency standards, coupled with a model for planning, implementation, and evaluation were successfully pilot-tested in four diverse healthcare settings targeting different professional populations and cancer topics , 2. The Building on the pilot grants, C-Change awarded four additional cancer core competency grants that were focused on identifying, treating, and managing cancer pain, and the benefits of palliative care. Cancer pain and symptoms can manifest in many different forms, and can also be a telling indication that cancer has returned, or that the care an individual is receiving or being offered is not sufficient to manage the effects of the disease or the side effects of treatment. Research shows that 26 % of unscheduled hospital admissions are due to uncontrolled pain , and neaTo adequately address cancer pain and accompanying psycho-social aspects of cancer, the entire healthcare workforce should ideally be armed with the knowledge and skills necessary to identify, treat, and refer patients for appropriate pain and palliative care services. In July of 2009, C-Change invited any healthcare organization, association, or comprehensive care control coalition to apply for a grant aimed at strengthening the cancer pain and palliative care knowledge, skills, and attitudes of non-oncology health professionals. C-Change convened an Advisory Committee of pain and palliative care experts, received 18 proposals, and awarded grants to four sites to develop competency-based pain and palliative care programs. The programs were developed and implemented based upon the below pain and palliative care competency standards to improve the pain management knowledge, skills, and attitudes among non-oncology health professionals:Define palliative and end of life care.Assess that resources for palliative and end of life care and insurance coverage are consistent with current recommendations.Refer patients to community palliative and end of life care and support resources.Explain the role of hospice care.Manage symptoms of the cancer patient.Incorporate end of life comfort strategies for the dying cancer patient.GeneralDescribe the methods used to diagnosis pain throughout the progression of the disease.Differentiate between acute and chronic pain symptoms.Describe the characteristics used to assess pain: frequency, intensity, and site.Perform a pain assessment.Explain the different treatment options for pain.Perform a pain-related history taken during a physical examination.Manage pain and analgesic side effects.Pain managementFocus on professionals who assess, prescribe, and manage care for pain and palliation Promote awareness of a full range of treatment modalities including drugs, devices, and therapiesAddress culture-specific pain management issues and disparitiesEmbrace a multi-disciplinary approach and systems that drive assessment and reassessmentRecognize pain management needs in inpatient and outpatient settings, medical home models encouragedAddress professional practice drivers such as prescribing in the context of the United States Drug Enforcement Agency surveillanceAddress patient-specific insurance policy issues that may impact benefit coverage such as pain classification and documentationPromote patient education and self advocacyWhen applying the pain and/or palliative care competencies, applicants were encouraged to address one or more contemporary pain and palliative care issues:Grant sites were required to develop programs that could measurably improve the patient assessment, treatment, monitoring, and outcomes related to pain and palliative care in the context of cancer; refine program plans based upon the planning and implementation phases of the grant program; disseminate the results; and contribute to C-Change’s online public repository of planning documents, evaluation tools, and lessons learned from various sites.Participate in a 1–2 day project orientation session with the expert Advisory Committee to refine and focus their program plansCollaborate on conference calls with C-Change and other grant sites during the planning processRefine and expand the pain competency definitions as neededForm a site-specific planning committee with the expertise to support the development of curriculum materials, instructional methods, and evaluation toolsIdentify a target professional population and competency topic guided by the Core Competency DefinitionsComplete a needs assessment with the target professional populationUtilize C-Change logic model and curriculum validation templates for program designFulfill the IRB requirements of participating institution if appropriateImplement a program plan within the target professional populationAssure a minimum level of participant accrualEvaluate program impact on learner knowledge, skills, and attitudes regarding the cancer competency topicRecord and share all project data, methods, teaching and communication toolsPublish a final reportWrite and submit an article for publication in a relevant professional journalSubmit a proposal to present program findings at a professional conferenceServe as a program reference for other sitesSelected grant sites were expected to work in collaboration with the C-Change Advisory Committee and staff to:Four of the eighteen applicants were awarded grants: Iowa Cancer Coalition (ICC), University of Florida (UF), Virginia Commonwealth University (VCU), and South Puget Intertribal Planning Agency (SPIPA). Each grant site applied the Cancer Core Competency tools and methods to address cancer topics that specifically met the unique needs of the populations they served, ultimately enhancing the knowledge, attitude, and skills of the targeted health professionals Table . ThroughEach grant site developed unique tools to teach, apply, and sustain the learning process. Teaching methods included didactic lectures, video patient scenarios, and an interactive online learning program. Tools for applying and sustaining improved knowledge and skills included standard order sets, scripts for difficult conversations, patient-symptom journals, and culturally appropriate discomfort barometers in place of traditional pain scales.Each program targeted a specific professional population, defined program goals, developed a unique approach, and achieved measureable results.The Iowa Cancer Consortium (ICC) is dedicated to reducing the burden of cancer in Iowa through priorities set in its State Cancer Plan including the need to improving pain and palliative care and strengthening the cancer workforce. Over 50,000 Iowans live in 840 long-term care facilities, which are often care providers at the end of life. The ICC grant program targeted staff working in long-term care facilities in northeastern Iowa including nurses, social workers, and medical assistants. The educational conference addressed the role of palliative care and hospice, approaches to difficult conversations, and care management techniques. Table Table 2IoThe University of Florida program was a collaborative project with three organizational partners: The University of Florida (UF) Department of Community Health & Family Medicine and the UF-Shands Cancer Center; and the Rural Health Partnership of North Central Florida, Inc. (RHP); all three partners serving residents from nine predominantly rural and underserved counties. This population has the highest cancer mortality rates in the state of Florida, and as a result of the rural setting, these communities are often underserved due to a low concentration of primary care and oncology-specialized healthcare providers and services. Rural health facilities depend on the knowledge and skills of health professionals in outpatient primary care settings to address cancer-related pain management and palliative care, areas where primary care professionals are often under trained. Table Table 3UnVCU Pain Management: An Online Curriculum with a Pediatric Pain Management module.  Medical Center is a comprehensive academic medical center in central Virginia that conducts basic, translational, and clinical cancer research, provides state-of-the-art treatments and clinical trials, promotes cancer prevention and education, and has been designated by the Robert Woods Johnson Foundation as a Palliative Care Leadership Center. Despite advances in pain research and improvements in practice, VCU recognized the continued lack of training resources for students and practitioners to specifically improve pediatric pain management. Their grant program aimed to expand the existing e. Table Table 4ViThe South Puget Intertribal Planning Agency’s (SPIPA) Comprehensive Cancer Control Program serves five Tribes , providing services to over 13,000 Native Americans located in southwestern Washington. Tribal communities served by SPIPA cope with barriers in effective pain management, often associated with cultural, religious, and traditional tribal beliefs, not always compatible with western medical practices, and compounded by a lack of awareness and access to services. To address these issues, SPIPA conducted assessments of elders in the five tribes to develop culturally appropriate trainings for Tribal members on “Recognizing and Documenting Cancer Related Distress and Discomfort.” The programs aimed to strengthen cancer patient and caregiver knowledge, skills, and attitudes regarding emotional distress and physical discomfort, and offered ways to better communicate with caregivers and health practitioners. Table Table 5SoGrant recipients experienced the benefits of a competency-based approach for developing sustainable education programs. The structured, yet flexible approach allowed each site to choose a competency and adapt it to the target audience, allowing individual learners to gain knowledge and skills required to optimize their role in cancer care delivery. Using a competency -based structure forced the program developers to link each learning activity to a measurable outcome that would ultimately improve cancer care in the population they serve.Competency-based programs require significant planning, an investment that is greater than a typical 1-hour continuing education program. Table  While thVoluntary learning opportunities compete with the day-to-day priorities of work and family commitments and must overcome many barriers to fully engage the learners. To foster participation, many grantees provided incentives such as gasoline fuel cards and meals as an additional impetus for participation.An unintended benefit noted by the grant sites was the power of collaboration and the benefits of leveraging individual assets for the common good. Bringing together different partners not only enriched the program itself, but also strengthened relationships in the community, creating partnerships which exist beyond the completion of the programs.As demonstrated above and in previously published sources, the C-Chance Cancer Core Competency Initiative can be applied in any setting, focused on any level of learner, and in any health discipline to improve the competency of the non-oncology workforce. C-Change encourages individuals to access the detailed grant site reports for further information on the programs, and to access the tools and methods when developing a cancer core competency program aimed at improving cancer care. To effectively address the projected demand for cancer care, sustained interventions are needed to recruit, retain, and retrain health professionals. The Cancer Core Competency Initiative represents an effective strategy to better leverage the existing health workforce serving the increasing health care- and services needs of people at risk for and living with cancer Fig. .Fig. 1St


Hemorrhage remains a major cause of potentially preventable deaths. Trauma and massive transfusion are associated with coagulopathy secondary to tissue injury, hypoperfusion, dilution, and consumption of clotting factors and platelets. Concepts of damage control surgery have evolved prioritizing early control of the cause of bleeding by non-definitive means, while hemostatic control resuscitation seeks early control of coagulopathy.Hemostatic resuscitation provides transfusions with plasma and platelets in addition to red blood cells in an immediate and sustained manner as part of the transfusion protocol for massively bleeding patients. Although early and effective reversal of coagulopathy is documented, the most effective means of preventing coagulopathy of massive transfusion remains debated and randomized controlled studies are lacking.Viscoelastical whole blood assays, like TEG and ROTEM however appear advantageous for identifying coagulopathy in patients with severe hemorrhage as opposed the conventional coagulation assays.In our view, patients with uncontrolled bleeding, regardless of it´s cause, should be treated with hemostatic control resuscitation involving early administration of plasma and platelets and earliest possible goal-directed, based on the results of TEG/ROTEM analysis. The aim of the goal-directed therapy should be to maintain a normal hemostatic competence until surgical hemostasis is achieved, as this appears to be associated with reduced mortality. Hemorrhage requiring massive transfusion remains a major cause of potentially preventable deaths. Trauma and massive transfusion are associated with coagulopathy secondary to tissue injury, hypoperfusion, dilution and consumption of clotting factors and platelets and coagulopathy, together with hypothermia and acidosis, forms a “lethal” triad . Also, iThe current transfusion guidelines advocate the concept of hemostatic control resuscitation, i.e., supplementing large transfusions of red blood cells (RBC) with FFP and PLT to critically injured patients in an immediate and sustained manner is proposed -9. The rThe dilution of coagulation factors and platelets is an important cause of coagulopathy in massively transfused trauma patients . The Adv9/l when a hematocrit of 30% is warranted [Furthermore, synthetic colloid resuscitation fluids influence coagulation competence more profoundly than crystalloids. Hydroxyethyl starch (HES) causes efflux of plasma proteins from blood to the interstitial space, reduction in plasma concentration of coagulation factor VIII and von Willebrand factor (vWF), inhibition of platelet function and reduced interaction of activated FXIII with fibrin polymers ,12,15.. arranted .Hypothermia is associated with risk of uncontrolled bleeding and death in trauma patients. Hypothermia induced coagulopathy is attributed to platelet dysfunction, reduced coagulation factor activity (significant below 33°C) ,18, and In trauma patients acidosis is often induced by hypoperfusion and excess administration of ionic chloride, i.e. NaCl during resuscitation . AcidosiBrohi et al. -27 descrWe recently suggested that the coagulopathy observed in trauma patients, which reflects the state of the fluid phase including its cellular elements i.e., circulating whole blood, is a consequence of the degree of the tissue injury and the thereby generated sympathoadrenal activity and importantly, critically related to the degree of endothelial damage, with a progressively more procoagulant endothelium (solid phase) inducing a gradient of increasing anticoagulation towards the fluid phase (circulating blood) . Though Tissue injury secondary to trauma induce immediate activation of the coagulation system through upregulation of tissue factor (TF) expression and extensive thrombin generation. Tissue injury in association with extensive endothelial injury, massive soft tissue damage, and fat embolization from long bone fractures, may be associated with consumption of coagulation factors and platelets and, hence development of coagulopathy. Disseminated intravascular coagulation (DIC) is the most extreme form of consumptive coagulopathy and is characterized by systemic activation of pathways leading to and regulating coagulation, which can result in the generation of fibrin clots that may cause organ failure with concomitant consumption of platelets and coagulation factors that may result in clinical bleeding ,32. We rIncreased fibrinolysis is observed in patients with profound endothelial activation and damage secondary to trauma, surgery and ischemia-reperfusion injury where tissue-type plasminogen activator (tPA) is released from the Weibel-Palade bodies of the endothelial cells. In trauma, increased fibrinolysis has been reported in the most severely injured patients and this correlates with poor outcome ,35-38. TVitamin K antagonists are frequently used by patients with atrial fibrillation or artificial cardiac valves and warfarin has been reported to be associated with about 21,000 visits for bleeding complications per year in the US alone , and theApart from coagulopathy due to iatrogenic heparinization, critically ill patients, including trauma patients, may become endogenously heparinized due to degradation of the endothelial glycocalyx ,46, the An important cause of excessive bleeding in trauma patients is platelet inhibitors, which an increasing proportion of the population today uses as secondary prevention. Currently, the most important are the platelet ADP receptor inhibitors clopidogrel and lately also the even more potent prasugrel that irreversibly inhibits platelet activation through the platelet ADP receptor and confers more potent platelet inhibition than acetylsalicylic acidImportantly, the enhanced antiplatelet activity and greater efficacy seen with prasugrel when compared to clopidogrel in clinical trials has been accompanied by increased bleeding risk and the FDA advisory committee issued guidance to physicians about increased risk in low-weight or elderly patients .Introduction of the cell-based model of hemostasis emphasizes the role of platelets for intact thrombin generation and highlights the importance of the dynamics of thrombin generation influencing the quality and stability of the thrombus formed . ConsequReduced clot stability correlates with clinical bleeding conditions as demonstrated by Plotkin et al.  who, in Different assays evaluating the degree of platelet inhibition secondary to platelet inhibitors exists. Light transmission aggregometry (LTA), previously considered the ”gold standard” for investigation of platelet aggregation , unfortuGoal-directed treatment with blood products and antifibrinolytic pharmacological agents based on the result of the whole blood viscoelastic hemostatic assays (VHA), together with the clinical presentation, was introduced for more than 25 years ago in patients undergoing liver transplantation and cardiac surgery and there are validated algorithms for how coagulopathy is identified and treated in patients with ongoing bleeding, based on VHA . More thWe found that implementation of goal-directed hemostatic resuscitation of massively bleeding patients, including trauma, based on the VHA reduced mortality by approximately 30% in patients requiring more than 10 RBC in the first 24 hours . SystemaIn response to hemorrhage, lowered hematocrit contributes to coagulopathy since erythrocytes promote marginalization of platelets so the platelet concentrations along the endothelium remains almost seven times that of the average blood concentration . In addiIt remains controversial when and in what dose plasma should be transfused to massively bleeding trauma patients-87.The optimal ratio of FFP to RBCs remains to be established although collectively the data indicate that a FFP:RBC ratio greater than 1:2 is associated with improved survival compared to one lower than 1:2 ,80,83-85Platelets are also pivotal for hemostasis ,77 and sA recent meta-analysis of retrospective observational studies evaluating the effect of FFP:RBC and/or PLT:RBC ratios and survival in massively bleeding trauma patients recently reported a significant survival benefit in patients receiving high FFP:RBC and PLT:RBC ratios . A potenSurvivorship bias, however, does not explain the improved survival in studies concerning the introduction of transfusion packages where both FFP and PLT are immediately available i.e. where pre-thawed FFP are available. Cotton et al.  implemenCotton also  reportedA multicentre randomized control study evaluating the effect of different blood product ratios on survival in massively bleeding trauma patients will commence in the USA this year and hopefully this will result in evidence for how best to resuscitate these patients with blood products (http://www.uth.tmc.edu/cetir/PROPPR/index.html).With the implementation of fractionated blood components, routine use of fresh whole blood (FWB) for resuscitation of bleeding patients was abandoned in the civilian setting. In the combat setting, however, FWB has been used in situations where fractionated blood products, and especially platelets were not available. In a report of US military patients in Iraq and Afghanistan from January 2004 to October 2007, those with hemorrhagic shock, a resuscitation strategy that included FWB was associated with improved 30-day survival   and an oIt should be noted that administration of any blood product carries potential risks for the patient including viral and bacterial transmission, hemolytic transfusion reactions, transfusion related acute lung injury and immunomodulation and consequently transfusion of blood products should be reserved to patients who actually needs this therapy .Hyperfibrinolysis contribute significantly to coagulopathy and antifibrinolytics agents reduce the blood loss in patients with both normal and exaggerated fibrinolytic responses to surgery by preventing plasmin(ogen) from binding to fibrin and by preventing plasmin degradation of platelet glycoprotein Ib receptors ,101. In Recombinant factor VIIa (rFVIIa) acts in pharmacological doses by enhancing thrombin generation on the activated platelets independent of factor VIII and IX and is currently approved for episodes of severe hemorrhage or perioperative management of bleeding in patients with congenital factor VII deficiency and hemophilia A or B with inhibitors ,104. DatConversion of sufficient amounts of fibrinogen to fibrin is a prerequisite for clot formation and reduction in the circulating level of fibrinogen due to consumption  and/or dThe four-factor PCC encompasses coagulation factors II, VII, IX and X that all are essential for thrombin generation. Administration of PCC is indicated for the treatment of congenital coagulation disorders and to reverse oral administered anticoagulation by vitamin K antagonists , whereasFactor XIII is important for clot firmness by binding to platelets through the GPIIb/IIIa receptor and by cross-linking fibrin and increasing the resistance of the formed clot against fibrinolysis . NotablyRecently, a new approach to resuscitation of patients with massive blood loss was introduced, employing goal-directed administration of pharmacological agents such as fibrinogen concentrate, prothrombin complex concentrate, recombinant factor VIIa and factor XIII as alternatives to FFP and platelet concentrates together with volume resuscitation with synthetic colloids. Observational studies of limited size of such an approach in injured patients with massive blood loss indicate that it may be feasible to achieve hemostasis with the use of these procoagulant agents .It should be noted, however, and especially in the light of the disappointing results from the trial regarding the use of recombinant factor VII in trauma, that adequately powered double-blind randomized studies are required before routine use of goal-directed administration of procoagulant agents to injured patients with bleeding is recommended. This is especially important with regard to the safety of these agents, which, as opposed to FFP, do not contain relevant concentrations of natural anticoagulant factors such as antithrombin, protein C and protein S, and this may be of importance in the later phase after hemostatic control has been established .Additionally, it remains elusive which fluid that should be used to support the hemodynamic system during massive bleeding treated with the teragnostic approach when plasma not is included in the resuscitation regimen. Crystalloids clearly have not sufficient volume expanding effects and based on the findings of increased bleeding, transfusion requirements and mortality in septic patients receiving synthetic colloids  it couldViscoelastic whole blood assays, such as TEG and ROTEM are advantageous for identifying coagulopathy, and guide ongoing transfusion therapy. From the result of these assays, implementation of a hemostatic control resuscitation strategy to massively bleeding patients seems both reasonable and lifesaving although data from prospective randomized controlled trials are lacking. Until definite proof from such trials is available, retrospective data support a shift in transfusion medicine in regard to early and aggressive administration of plasma and platelets.PJO has received support with analyzers and reagents from Hemonetic Corp, TEM International and Viber Int. PJO has received unrestricted research grants from Novo Nordisk AS and Octaparma GmbH. JS and SRO declare no conflicts of interest.PJ, JS and SRO contributed to the conception and design of the manuscript, literature search, and writing of the manuscript. All authors read and approved the final manuscript.