Capsular contracture is one of the most common complications of implant-based breast reconstruction or augmentation surgery. Despite advanced molecular biology, the exact mechanism of this complication is not fully understood. PubMed was searched for studies, published from 2015 to 2020, focused on potential risk factors and preventions of capsular contracture (CC) in patients who underwent implant-based breast surgery. A total of 533 articles were identified from PubMed, and 13 articles were selected ultimately for our review after eligibility screening and quality appraisal. Common risk factors of CC include biofilm, surgical site infections (SSI), history of prior CC or fibrosis, history of radiation therapy, and implant characteristics. Interventions that decrease the rate of CC include antibiotic prophylaxis or irrigation, acellular dermal matrix (ADM), leukotriene (LTE) inhibitors, surgical techniques, and others. Multiple risk factors are proposed to be a component of the pathophysiology of CC. However, there is inconsistent evidence supporting these risk factors, and the current data was based on broad heterogeneous studies. While efforts are being undertaken to solve this complication with improved technologies and surgical practices, CC remains to be unsolved. Our objective was to provide a summary of the current data of contributing risk factors as well as preventative and treatment measures for CC. Breast cancer is the most frequently diagnosed cancer in women around the world, and up to 41% of patients who undergo mastectomy receive breast reconstruction . The maiStaphylococcus epidermidis and S. aureus, Escherichia, Pseudomonas, Propionibacterium, and Corynebacterium [CC is a distressing complication of breast implant surgery and often requires revision operation. Up to half of the patients develop CC, and 30% of them suffer from CC with Baker rates III and IV following implant-based breast reconstruction . Risk faacterium ,10.While the procedures for breast surgery and pre- or postoperative interventions are being improved, the causes and prevention methods for CC remain unclear. This study aims to review the risk factors associated with CC and to outline the available preventative and treatment measures to reduce the rate of CC.MethodsProtocolThe protocol of this systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) 2009 guideline.Search Strategy, Study Selection, and Data ExtractionElectronic databases PubMed Central (PMC) and Medical Subject Heading (MeSH) were searched for articles. The keywords included in the search strategy include: "Implant Capsular Contracture/microbiology" OR "Implant Capsular Contracture/prevention and control" OR "Implant Capsular Contracture/statistics and numerical data"; "Mastectomy/complications" OR "Mastectomy/mortality" OR "Mastectomy/psychology"; AND "Surgical Wound Infection/analysis" OR "Surgical Wound Infection/microbiology" OR "Surgical Wound Infection/mortality" OR "Surgical Wound Infection/prevention and control" OR "Surgical Wound Infection/statistics and numerical data". No language restrictions were applied.Three authors screened the titles and abstracts using the inclusion and exclusion criteria to identify the eligibility of the studies. Reference duplicates were manually checked by one author. The inclusion criteria were studies within the last five years (2015-2020) and studies with only human subjects that focused on CC and SSIs following breast surgery. We included various types of studies except for letters to the editors, animal and in vitro studies. Two authors extracted the following data from each study independently: study title, publication date, study design, sample size, mean follow-up, and mean age of the patients.We identified 533 publications total from PubMed PMC and MeSH search and excluded 520 publications due to duplication, ineligibility, incomplete data, and irrelevance to our topic. Thirteen studies were ultimately selected and included in our review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart diagram of literature retrieval is shown in Figure Quality of the Studies and Risk of Bias Within StudiesFour authors assessed the quality of included studies and risk of bias using the Newcastle-Ottawa Scale (NOS) for observational studies; A Measurement Tool to Assess Systematic Reviews (AMSTAR 2) for systematic reviews and meta-analysis; and Cochrane risk of bias tool for randomized controlled trials (RCTs).ResultsStudy CharacteristicsThe 13 selected articles include two RCTs, one controlled trial (CT) without randomization, two cohort studies, one systematic review, one meta-analysis, one cross-sectional study, three retrospective studies, and two traditional reviews. Patients in the included studies are women who underwent either mastectomy followed by implant-based reconstruction surgery or implant-based breast augmentation only. The study characteristics are summarized in Table Overall Results and Recommendations of the StudiesMultiple risk factors are mentioned to be associated with CC across studies. The number of studies discussed each topic include 14 studies about infection with biofilm-producing bacteria and SSIs; six studies about radiation therapy and previous fibrosis; nine studies about antibiotics and irrigations; six studies about implant surface, size, and placement; three studies about acellular dermal matrix (ADM); three studies about leukotriene antagonists (LTE); one study about toll-like receptor 4; and one study about Thy1(CD90) expression. The suggested risk factors and preventions for CC are summarized in Table SSISSI is a major postoperative complication that can cause CC formation. The risk of SSI is higher with reconstruction performed during the primary surgery, and the incidence rate of acute infection is higher than that of late infections ,8,9. A rAntibiotics and IrrigationsPreoperative skin antiseptic agents are known to reduce postoperative complications. CC rate is reduced with povidone-iodine and antimicrobial irrigations ; howeverStaphylococci species are the most common axillary flora, and antibiotics targeted at these species do not show a significant impact on SSIs . PreoperRadiation Therapy and Implant SurfacePost-mastectomy radiation therapy leads to higher rates of CC . SeveralBreast implant characteristics especially implant surface seem to play a role in CC. Studies have analyzed that smooth implants, compared to textured implants, are significantly associated with CC, and the choice of the textured implant may reduce the risk of CC ,30. MoreADM and Leukotriene (LTE) AntagonistsLong-term study has shown that the incidence of CC remains low in patients who had implant-based breast reconstruction with ADM with or without radiation therapy and states that it may truly prevent early-onset CC . Due to LTE antagonists have been known to prevent and treat CC. Multiple studies have found that the patients who used LTE antagonists, either montelukast or zafirlukast, have significantly decreased rate of CC compared to the control group -39. AlthDiscussionCC remains the most frequently recorded complication and cause of reoperation following breast implant surgery; yet, the pathophysiology of CC has not been clearly defined, and the prevention remains to be unresolved . MultiplRisk Factors of CCMicrobial biofilm is challenging to treat and can cause chronic inflammation and the formation of capsular fibrosis ,5. WhileSSIs are a common cause of breast reconstruction failure following breast surgery . The assImplant surface may or may not affect biofilm formation. The textured implants may cause higher rates of biofilm formation compared to smooth implants, but a study also found no difference between textured and smooth implants in biofilm formation . A recenAll the studies support that post-mastectomy radiation therapy is a strong risk factor for postoperative complications including CC and SSIs ,29,34. TManagement Approaches to CCADM is a popular intervention to reduce the rate of CC. An RCT has found that ADM does not reduce postoperative pain , but anoLTE antagonists are used by many plastic surgeons to some extent for the treatment of CC, but there is no clear evidence of the benefit of these medications currently. The available information on how LTE antagonists work on the pathogenesis of CC is limited. Several studies have shown favorable outcomes with LTE antagonists in decreasing the incidence of CC and support the use of these medications in a safe way -39. HoweA recent study demonstrated fat grafting in women with the previous CC to restore the soft tissue thickness and found that it significantly reduces pain and tension due to CC . The stuCurrently, the gold standard treatment of CC is capsulectomy to remove the capsule and replace it with a new implant. Surgeons performed open capsulotomy, which does not remove the capsule from the body and reinserts the intact implant, more often in the past. A retrospective study suggests that an open capsulotomy is a safe treatment and there is no significant difference between capsulectomy and open capsulotomy in the CC recurrence rate . HoweverLimitationsThere are several limitations to our study. First, the studies included in this review were obtained from a single database and were mixed studies with heterogeneity in terms of sample size, follow-up duration, control groups, and randomization, which may create bias in reporting the development and different stages of CC. Second, we selected studies from 2015 to 2020, except one study in 2012 , to haveFuture DirectionsGiven the limited number of studies with evidence-based medicine on this topic, well-designed studies are indicated in the future. According to the current literature, the incidence of SSI and CC has decreased with antibiotic prophylaxis, textured implant, ADM, leukotriene antagonists, and an open capsulotomy; however, these interventions have not been proved. The important question to be addressed should be more focused on the pathogenesis of CC, which has been debatable. What exactly is the cause of CC? Is it multifactorial? What is the biggest factor contributing to the pathogenesis of CC among other factors? Focusing on these questions will help further studies to search for strategies about particular preventions and treatment approaches for CC.CC is most likely to be multifactorial, and the exact mechanism of pathogenesis of CC formation is unknown. The available evidence on risk factors associated with CC is weak and inconclusive. Our review suggests that infectious cause may be the strongest risk factor of CC etiology, and further studies on this aspect are required. The current literature data on prevention and treatment of CC is heterogeneous, and results are controversial. Greater efforts in developing modern imaging and technologies will continue to provide advanced tools to understand the pathophysiology of CC in depth and further develop preventative and treatment interventions.


Emergencies can threaten human rights by disrupting societies, increasing vulnerabilities, and instigating exceptional measures from governments and other actors. As independent institutions mandated to protect and promote the human rights embedded in Canada's federal, provincial and territorial legislation, Canada's human rights commissions (HRCs) have mobilized to advocate for human rights during the COVID-19 public health emergency. Emergencies can threaten human rights by disrupting societies, increasing vulnerabilities, and instigating exceptional measures from governments and other actors. As independent institutions mandated to protect and promote the human rights embedded in Canada's federal, provincial and territorial legislation, Canada's human rights commissions (HRCs) have mobilized to advocate for human rights during the COVID-19 public health emergency.Based on an original dataset and content analysis of HRCs’ official statements regarding COVID-19, this research note examines the points of consistency and variation in HRCs’ advocacy for human rights during the COVID-19 crisis. This represents the first systematic analysis of advocacy by Canada's HRCs. HRCs have elucidated key human rights issues, particularly various forms of discrimination, in the context of COVID-19. HRCs also have advocated for governments and other actors  to adopt policies and practices during the crisis that address individuals’ vulnerabilities and promote human rights. In a crisis generally framed in terms of public health and safety, comparatively analyzing Canadian HRCs’ assessments of human rights issues and obligations provides a foundation for deliberating whether and how a human rights approach to COVID-19 response should be pursued.Canada has a long history of struggling to uphold human rights during emergencies. Human rights violations under the War Measures Act during the World Wars and the 1970 October Crisis Lindsay,  contribuDiscussion of human rights and COVID-19 in Canada has centred on the Charter  could be considered a disability with antidiscrimination protections. HRCs highlighted the prohibition of discrimination based on family status and the duty to accommodate the impacts of COVID-19 on individuals’ work and care responsibilities. Discussions of age discrimination generally focused on the vulnerability of the elderly, particularly in long-term care homes.A narrow majority of HRC statements did not discuss any conditions for limiting human rights . Nine HRSeven HRCs noted that the duty to accommodate protected grounds  in areas such as employment, housing and services only extends up to the point of undue hardship  for those making accommodations. Employers, for instance, should accommodate employees’ absenteeism or additional care responsibilities during quarantine or self-isolation orders, unless employers can prove that accommodations (such as flexible telework options) would involve costs or health and safety concerns amounting to undue hardship (see, for example, OHRC, Further emphasizing the importance of evidence for human rights accountability during the crisis, HRCs targeting governments repeatedly stressed governments’ responsibilities for monitoring and reporting on the human rights dimensions of COVID-19 response. HRCs, for instance, advocated that governments should factor protected grounds, such as a race, age and disability, into their data collection, and governments should increase human rights oversight by consulting with relevant experts, stakeholders and representatives of vulnerable groups.Federal, provincial and territorial HRCs, based on their institutional authority for protecting and promoting human rights, have been strong advocates for upholding human rights protections during the COVID-19 public health emergency. Aggregating and comparing their advocacy statements reveals how far-reaching and multidimensional a human rights approach to COVID-19 response could be. Given the diversity of rights and responsibilities discussed by the various HRCs, there is room for debate regarding whether and how to reconcile the imperatives of responding to the COVID-19 emergency and protecting human rights. The broad point of consensus among all HRCs, however, is that this unprecedented crisis requires that governments and other societal actors consider threats to not only health and lives, but also a wide range of human rights.


Synergy paper request for applications]. This paper describes opportunities for collaborative opioid research at CTSA hubs and NIDA–NCATS opportunities that build capacity for best practices as this crisis evolves. Results of a Landscape Survey (among 63 hubs) are provided with descriptions of best practices and ideas for collaborations, with research conducted by hubs also involved in premier NIDA initiatives. Such collaborations could provide a rapid response to the opioid epidemic while advancing science in multiple disciplinary areas.The opioid crisis in the USA requires immediate action through clinical and translational research. Already built network infrastructure through funding by the National Institute on Drug Abuse (NIDA) and National Center for Advancing Translational Sciences (NCATS) provides a major advantage to implement opioid-focused research which together could address this crisis. NIDA supports training grants and clinical trial networks; NCATS funds the Clinical and Translational Science Award (CTSA) Program with over 50 NCATS academic research hubs for regional clinical and translational research. Together, there is unique capacity for clinical research, bioinformatics, data science, community engagement, regulatory science, institutional partnerships, training and career development, and other key translational elements. The CTSA hubs provide unprecedented and timely response to local, regional, and national health crises to address research gaps [Clinical and Translational Science Awards Program, Center for Leading Innovation and Collaboration,  Collaborative and institutional infrastructure grants funded by the National Institutes of Health (NIH) offer unprecedented opportunities to address multiple issues affecting population health locally, regionally, and nationally. The opioid crisis is one major health issue significantly affecting the US population that could be urgently addressed utilizing resources and infrastructure of a national network. To address a crisis of this magnitude, a holistic approach is needed that covers the entire spectrum of clinical and translational research, from basic science and animal models to community engagement science . ProgramNIDA is the NIH institute that funds the majority of research on substance use disorders and opioids in particular. The opioid epidemic has been responsible for an economic cost of at least $630Bf from 2015 to 2018. One-third of the cost is attributable to healthcare, 40% is attributable to early mortality, and 6% is from the criminal justice system with another 6% from child and family assistance. Finally, 15% is attributable to lost productivity  while maintaining each hub’s local/regional context –22. In tThis paper describes the landscape of opioid research with CTSA Program hubs with the goal of creating opportunities to build capacity to promote best practices and innovative collaborative research related to opioids and eventually other substances or crises requiring a synergistic approach. This “synergy” paper offers ideas for collaborative growth and science as this crisis progresses and different trends emerge. The hope is that the NIH, foundations, industry, and other entities will facilitate research and the development of new therapeutic options for opioid (and other disorders) research to improve population health.To move the needle forward, NIDA and NCATS leadership and hub scientists outlined gaps and initiatives that hubs could strengthen together. These initiatives were planned in three phases.NIDA leadership spearheaded three conference meetings in summer 2017 that focused on medication development for OUD and overdose (OD), the development of safe and non-addictive medications for pain relief, and neurobiological mechanisms of pain. In June 2018, the Center for Leading Innovation and Collaboration (CLIC), the CTSA Program coordinating center at University of Rochester, hosted a consortium-wide “Un-Meeting” on the opioid crisis with scientists and external stakeholders across the translational spectrum . The eveIn Phase 2, the CTSA Program Steering Committee focused on the crisis in July 2017. Subsequently, NCATS and NIDA held a 2 hour virtual meeting August 2017 with representatives from the CTSA Program hubs with expertise in substance abuse and/or pain. NIH Directors Drs. Volkow (NIDA) and Austin (NCATS) presented data and facilitated a discussion on potential collaborations, which was followed by the formation of an opioid interest workgroup October 2017 with representatives from CLIC, NCATS, NIDA, and eight CTSA Program hubs; they planned a Landscape Survey of activities and capacity to address the opioid epidemic.To build and strengthen research capacity between hubs, the CTSA Program Steering Committee Opioid Workgroup, facilitated by CLIC, developed the HIPAA compliant online Landscape Survey using an iterative pretesting process involving experts and other stakeholders.The goal of the Survey was to generate a broad landscape analysis of current opioid-related programs representing either best practices or innovative programs underway across the CTSA Program hubs, individually and with diverse partners. Principal investigators (PIs) at each hub asked the person most knowledgeable at their site to complete the Survey by April 30, 2018.Procedures were established to systematically and iteratively code the qualitative findings from the open-ended text-based survey item data. All quotes and passages provided by respondents were structurally organized by the study team . Two codAfter coding, review, and regular peer debriefing, themes that emerged were further organized within broader domains when applicable and compared among and between domain areas during additional meetings . FinallySeveral gap areas were outlined during the study phases Table . These in = 17), Administrators at the hubs , and Managers, Evaluation Specialists, Researchers, and Program Directors . After data cleaning and direct confirmation of sites regarding specific information, a final dataset reflected responses from 45 of 63 hubs active during FY17, including those both currently funded and in a no cost extension phase, representing a 70.3% response rate [Results of the Landscape Survey from the Phase 3 consolidation uncovered numerous ideas to fill the knowledge gap, identify models to disseminate, and provide opportunities for collaborations. The Survey casts a wide net in that the 47 respondents were inclusive of PIs of the CTSA Program hubs  clinical research on the development of innovative approaches and best practices to identify, recruit, and retain populations with OUD more effectively. This also included clinical trial networks that could be utilized for specific studies with surgical, adolescent, pain management, primary care, or neonatal populations, among others; (3) community engagement efforts that highlighted outreach, active partnerships with Departments of Health, Emergency Departments, community members, and others; (4) computational science and data informatics, distilled to “data science” which included effective approaches and epidemiological tools to affect the use of clinical data to address OUD and/or OD; and (5) training approaches to assess and address high risk use of opioids within the medical setting, under the umbrella of workforce development and implementation science.Five domains emerged and included: (1) In the pre-clinical domain, there were multiple mentions of research projects/programs related to chronic pain, from proteins to nociceptive mechanisms (eight hubs). The next most salient theme was related to biomarkers/imaging studies with three east coast hubs mentioning work in this area, followed by basic science studies relative to genetics (two hubs); other approaches were related to brain plasticity and brain–computer interfaces (two hubs each).clinical research area, a number of key programs were enumerated. Most salient was research infrastructure related to recruitment, retention, and screening methods especially for high-risk populations. This effort included cohort discovery through social media, electronic health records, wearable technologies, and community outreach (mentioned by 13 hubs). This was followed by pain management research (11 hubs), MAT such as buprenorphine or methadone treatment (MAT-5 hubs), perinatal/obstetrics research (3 hubs), and HIV-related efforts (1 hub). The pain management programs ranged from research on nutritional and herbal remedies to alternatives to opioids.In the Community engagement was a key focus of the hubs—especially reaching diverse populations. Nearly every site that responded mentioned their Community Advisory Board. Many other innovative efforts are underway, including Our Community, Our Health—a national town hall meeting series pertaining to issues that are a priority to the community—spearheaded by the University of Florida—involving 23 hubs to date. Along these same lines are the regional conferences on opioids and hub involvement in their state’s opioid response. Hubs are also conducting needs assessments, Community Engagement programs such as HealthStreet, Science Cafes, and harm reduction efforts, such as needle exchange and distribution of naloxone and medication deactivation pouches [ pouches . In thisData Science. It has introduced the required need for data warehouses, honest brokers, querying tools for cohort identification, computable phenotypes, and predictive modeling. This area has involved the contributions of numerous and varied disciplines from computer science, bioinformaticians, mathematicians, statisticians, epidemiologists, and IT teams.The CTSA Program has also transformed the culture at most hubs to conduct highly innovative computational bioinformatics research in the area of workforce development for translational research within the CTSA Program hubs. This key component provides training and continuing education on best practices to address public health issues. The information provided in this area was particularly difficult to codify because it varied so greatly. Training practices focused on clinical training, research training, or both. Clinical training included health professionals across a number of disciplines and specialties, including internal medicine physicians, psychiatrists and other prescribers, nurses, pharmacists, dentists, and public health professionals. It also included training for partners operating outside the university sector, including community-based agencies and law enforcement professionals. CTSA training activities covered topics such as general knowledge about the opioid crisis, treatment strategies, OD management/naloxone administration, MAT, pain management, and safe prescribing practices. Training activities encompassed a number of formats, including face-to-face, online (distance learning) formats, team science approaches, and collaborations with external entities, such as Project ECHO from the University of New Mexico, which provides tele-mentoring and training to community providers in the treatment of complex conditions [Finally, there is an extraordinary capacity for nditions . ResearcAs noted in Table with and for a number of important diverse populations, many of which are underrepresented in clinical and translational research. These are identified in Table Data from the survey also highlighted that the CTSA Program hubs work n = 24) but no CTN tended to be in the Midwest, the southeast, and northeast. The hubs with at least one other NIDA project (CTN/T32)  were considered to have maximal synergy for SUD research.Lastly, to indicate the capacity of the CTSA Program to train the next generation of scientists, and to develop and promote translational science, we mapped the location of NIDA NRSA Training Grants (T32s) and NIDA Clinical Trial Networks (CTNs) in relation to the academic centers awarded a CTSA. Among the 62 CTSAs listed in the NIH Reporter (those in NCE and those awarded), 28 (45%) of the CTSA hubs had no CTN or T32; 24 (39%) had a T32 but not a CTN; 7 11%) were the recipient of both a CTN and T32, and 3 (5%) of CTSA hubs had a CTN. As shown in Fig. 1% were tAdditionally, there are 21 sites across the country, most of which are also aligned with CTSA Program hubs, with NIH funding for the “ABCD study”—the NIH funded Adolescent Brain and Cognitive Development longitudinal study of over 11,000 children enrolled at 9–10 years of age, who are being followed for 10 years . These sThis first synergy paper from the NIH CTSA Program indicates a high degree of opportunity relevant to a serious scientific response to a national drug abuse crisis. NIDA and NCATS worked together to evaluate the gaps in the field, and the capacity at the CTSA hubs to field studies focused on opioids and eventually other drug trends.Through three phases of initiatives that spanned conferences, working group calls, and a Landscape Survey, including an NIH Reporter analysis of built capacity through NIH awards, it was heartening to see that the CTSA Program has begun to change the landscape and reached out to improve the health of all through activities included in important domains: pre-clinical, clinical, community engaged, data science, and workforce development domains, with multiple themes in each. It must also be noted that many of these discussion points are the focus of conferences in which the researchers may or may not even know that the research is related to a CTSA Program hub. Of course, the Association for Clinical and Translational Science (ACTS) meetings is CTSA focused; however, the College on Problems of Drug Dependence hosts many scientists and numerous scientific contributions, in which an NCATS CTSA project might not be reported. If researchers acknowledged all funding sources during their conference presentations, it could foster collaborations across hubs and raise awareness of CTSA programs.Additional discussion points relate to our metrics for success which we could adopt and monitor in an ongoing manner to track capacity building, close the gaps, and make headway toward reducing ODs, finding satisfactory alternatives to opioids, and treating OUD. Now that the capacity for research focused on many critical aspects of the OUD epidemic has been identified, it can be translated to focus on other SUDs.Hubs could eventually evaluate their achievements in some of these areas: (1) hubs working together on both externally and internally funded initiatives, including cooperative agreements from NCATS as well as Un-Meetings on Rural Health or Regional Hub meetings; (2) the number of collaborative networks established and sustained over time; (3) the number of investigators, research coordinators, and others trained to conduct opioid research through the Translational Workforce Development programs; (4) specific models of care at each CTSA hub; (5) investigators trained in SUDs through K and T programs that have a NIDA T32 and how integrated the T32 is at each hub; (6) the mentoring mosaics that were established include an investigator from another hub; (7) increased pilot studies funded by hubs that are relevant to SUDs, in addition to opioids, and their risk factors; (8) the number of educational certificates launched that are relevant to OUD; (9) the number of grants that are submitted as well as funded that are pertinent to OUD and other SUDs; (10) community involvement regarding solutions related to OD; (11) the number of town hall meetings that involve discussions about substance use and its harm, and (12) an increase in the percentage of people with substance use or SUDs who are both recruited into and retained in health research. Metrics such as these as well as other morbidity and mortality statistics could be evaluated and tracked , 36. MorCollaboration could also be facilitated through the Trial Innovation Network (TIN), established by NCATS in 2016. The TIN focuses on research to establish methods to improve the clinical trials process and enhance the network capacity of the CTSA Program. Three Trial Innovation Centers, one Recruitment Innovation Center, and the CTSA Program hubs comprise the TIN. The TIN offers resources to support investigators and their research teams, such as single IRB reviews, assistance setting up master clinical trial agreements, advice on protocol design, participant recruitment and retention plans, help finding additional CTSA clinical sites for studies, and serving as the data coordinating center for funded studies. The TIN multisite clinical research infrastructure can provide targeted support for studies that need to be implemented in a rapid and efficient manner, such as studies that address the opioid epidemic.An important limitation must be noted. Some hubs may have identified only CTSA activity while others may have provided information about all activities at their home institution regardless of funding. This discrepancy reflects a conservative outlook as to the complete universe of capacity at each site. Benefit of the doubt should be given to all hubs—they should each be viewed as worthy partners in any collaborative approaches. In fact, now that the domains have been established, it is feasible for the Workgroup to repeat the survey in an informed context and with intentionality to plan for multisite studies.This limitation notwithstanding, there were a number of strengths found through this landscape analysis, primarily the robust enumeration of the capacity available at each site. While sites may not have known until this time of all the initiatives available to them at each site, or even their own, they can now be fully aware of the initiatives to be brought to bear to address this topic locally, regionally, and nationally. In fact, the NIH Helping to End Addiction Long-term (HEAL) and its initiative offers additional, multiple mechanisms for CTSA Program hubs to consolidate efforts and collaborate.It is critical to marshal the efforts of the scientific community to deliver effective and sustainable solutions to this formidable public health challenge. Congress added $945M to the base appropriation of the NIH starting in fiscal year 2018 to invest in resources to support science that advances addiction and pain research. This new trans-NIH initiative—HEAL—is focused on identifying new treatments for addictions and non-addictive treatments for pain, better understanding of the mechanisms underlying pain and optimizing the use of effective treatments for addiction, including the development of new models of care . The HEA


A significant proportion of patients experiences poor response (i.e. no or little improvement) after total knee arthroplasty (TKA) because of osteoarthritis. It is difficult to quantify the proportion of patients who experiences poor response to TKA, as different definitions of, and perspectives (clinician’s and patient’s) on poor response are being used. The aim of this study was therefore to review the literature and summarize definitions of poor response to TKA.A systematic search was performed to identify and review studies that included dichotomous definitions of poor outcome after primary TKA. The type, amount and combination of domains (e.g. functioning), outcome measures, type of thresholds , values and moments of follow-up used in definitions were summarized.A total of 47 different dichotomous definitions of poor response to TKA were extracted from 2163 initially identified studies. Thirty-six definitions incorporated one domain, seven definitions comprised two domains and four definitions comprised three domains. Eight different domains were used in identified definitions: pain, function, physical functioning, quality of life (QoL), patient satisfaction, anxiety, depression and patient global assessment. The absolute cut-off value was the most common type of threshold, with large variety in value and timing of follow-up.Our inventory review shows that definitions of poor response to TKA are heterogeneous. Our findings stresses the need for an unambiguous definition of poor response to draw conclusions about the prevalence of poor-responders to TKA across hospitals and countries, and to identify patients at risk. Total knee arthroplasty (TKA) is considered to be a cost-effective intervention for the treatment of advanced knee osteoarthritis (OA). Nonetheless, increasing evidence shows that a significant proportion of patients experiences a poor response to TKA (i.e. show no or little improvement) in terms of chronic knee pain , 2, funcThe comparison of research findings on the effectiveness of TKA across studies and countries is hampered by the fact that different concepts for (poor) response for outcome after TKA are being used . VariousCurrently, it is unclear which definitions of poor response to primary TKA are used in the literature. This insight can help to reach consensus on an unambiguous definition of poor response. The need to use a combined endpoint incorporating relevant constructs, and a relevant amount of change based on multiple, clinical outcome perspectives (including physicians’ and patients’ outcome perspective) to accurately describe poor-response to TKA , has beeThe aim of this study was to review and summarize dichotomous definitions of poor response as dichotomous definitions allow to make inferences about the prevalence of poor outcome and comparisons of TKR outcome across hospitals, countries and over time.We expect a variety of definitions and outcomes used to define poor response after primary TKA. Therefore this study systematically map definitions of poor response to primary TKA in the literature.An electronic search strategy was performed to retrieve systematic reviews (SRs) until 2016 in the PubMed Database, EMBASE and PsycINFO, on the outcome of TKA using search terms as “knee, arthroplasty, replacement, prosthesis, outcome measures, score and failure”. A detailed search strategy can be found in Fig. To include more recent publications, articles from 2016 or later, were searched for definitions of poor outcome of TKA using the same search terms as for the SRs.Duplicates were excluded and search results were screened on title and abstract.All reference lists of included SRs were hand searched for relevant articles.Studies were assessed for eligibility by the in-and exclusion criteria.Subsequently, full texts screening of the eligible studies was carried out, for definitions of poor outcome after primary TKA.Previously used definitions for poor outcome after TKA in the literature, from 2000 up to October 2019 were identified and reviewed. We followed the following strategy to systematically identify definitions of poor outcome:Two reviewers  independently selected eligible SRs and eligible recent publications from 2016 or later, describing a dichotomous definition for poor outcome after TKA in a certain domain or combination of domains. The reviewers  independently selected eligible studies from the references lists of the, based on their titles, SRs and thereafter the eligibility criteria for studies.Selected studies were assessed by the following eligibility criteria: 1) TKA patient population diagnosed with osteoarthritis; 2) primary TKA; 3) incorporating a dichotomous definition of poor outcome after primary TKA. 4) utilizing a controlled or prospective observational design (cohort and registry studies).There were no restrictions on 1) sample size; 2) the type of primary implant; 3) follow-up moment of outcome; and 4) studies with missing data regarding primary- and secondary outcomes.Studies with other TKA procedures  as study intervention, studies not written in the English language and articles without an abstract and/or access to the full text manuscript, were excluded.Full text evaluation of the eligible studies was carried out by one reviewer (MtM), to select eligible dichotomous definitions. When eligible studies used definitions from other articles, data on the definition was extracted from the original article. Criteria for definitions to be included in the review were: 1) included a threshold for dichotomizing; and 2) related to the concept of poor, worse or non-responder outcome as stated by the authors of that publication. Any uncertainty about the final selection of definitions and the extraction of data on the definitions was discussed with the second reviewer (CvdE) to achieve consensus.Study characteristics: author names, date of publication and length of study follow-up.Characteristics of the definition of poor outcome after primary TKA: number of domains, type of domains, outcome measure(s) used, type of threshold , value and time points).Additional background information on selected definitions of poor response provided by authors.We extracted all dichotomous definitions of poor outcome after TKA using a data extraction form. Definitions were grouped according to outcome domains , the following data were extracted:After removal of duplicates, a total of 329 SRs and 1834 articles after 2016 were screened on title and abstract , physical functioning (N = 17 different definitions) and patient satisfaction (N = 13 different definitions) domains were most frequently used in identified definitions of poor outcome after TKA. Patient satisfaction was only measured as unidimensional definitions with wide variation in wording of questions and answering categories. An absolute cut-off value of a certain outcome measure (N = 42 different definitions) was the most common type of threshold.There were 36 different unidimensional definitions, seven different definitions included two domains and four different definitions incorporated three domains. Eight different domains were identified in the 47 different definitions: pain, function, physical functioning, QoL, patient satisfaction, anxiety, depression, and patient global assessment. Pain (N = 11 different dichotomous definitions) and the Visual Analogue Scale (VAS) (N = 5 different dichotomous definitions) were the most frequently used measurement instruments after the single item questions.In the 47 different dichotomous definitions of poor outcome after primary TKA, we identified 14 different single item questions, two different self-composite question, one physician-assessed outcome measure, eight different PROMs and five different mixed outcome measures (combination of physician-assessed and patient reported). Single item questions measure one construct by asking for example the following question: ‘How satisfied are you with the outcome after TKA?’ Self-composite questions refer to composite questions of multiple items: ‘Overall limitations was defined as moderate/severe, if a patient had ≥ activities  with moderate or severe limitations ’. The Western Ontario and McMaster University Osteoarthritis Index (WOMAC) , patient satisfaction, anxiety, depression and patient global assessment. Patient satisfaction was used as single domain with a wide variation in wording of questions and answering categories. The absolute cut-off value was the most common type of threshold, with large variety in value and timing of follow-up. Our review stresses the need for an unambiguous, dichotomous definition for poor response after TKA to enable comparisons of the effectiveness of TKA among studies and among countries.A remarkable finding of our review was that the majority of definitions used to describe poor outcome incorporate only one or two outcome domains. This finding does not seem to correspond with the conclusions by the OMERACT-OARSI initiative and the International Consortium for Health Outcomes Measurement (ICHOM). The OMERACT proposed a simplified set of responder criteria for  treatment of OA in clinical pharmaceutical trials. This set of responder criteria comprises relative and absolute changes in three domains: pain, physical functioning and patient global assessment , 19. AlsA great variety of thresholds is being used to measure poor response, ranging from an absolute cut-off point regarding patient dissatisfaction to composite measures incorporating relative changes or a MCID less than a certain value. Some studies used the inverse of the OMERACT-OARSI responder criteria “nonresponse” as a definition of poor outcome –26. HoweIn our opinion, strict, dichotomous definitions are necessary to interpret data on group level and to compare TKR outcome among hospitals, countries and over time. However, dichotomous data implies reduction of data and is therefore, less suitable for identifying factors underlying poor outcome. In particular, for individual patients, continuous outcomes are more suitable to monitor and evaluate specific health outcomes.Patient satisfaction was used as single domain with a wide variation in wording of questions and answering categories, most frequently measured by single item questions  . HoweverThe variety in definitions of poor outcome used could reflect different perspectives of physician, patient and clinical researcher. There are many studies reporting on the disagreement between the patient and physician in terms of their satisfaction with surgery , 29, 30.In 27 of the 57 selected definitions additional background information was provided to justify the choice for the definition and/or thresholds being used. Background information was extracted from the original publications. In particular, definitions of patient dissatisfaction were not substantiated and arbitrarily dichotomized.This study has some limitations, as our searches for relevant articles were systematic but the data extraction was performed by a single reviewer. Although any uncertainty about the selection of definitions and the extraction of data on the definitions was discussed with the second reviewer (CvdE). This inventory review does provide a complete overview of definitions of poor response after TKA that could be of interest to a large group of physicians and researchers involved in defining outcomes after TKA. Furthermore, only studies published in English language were included. For this reason, it cannot be ruled out that some studies were not identified (language bias).In conclusion, this inventory review shows that many different heterogeneous definitions, incorporating several domains, for poor response to primary TKA are being used in the literature. Future research should focus on the perspectives and perceptions of orthopaedic surgeons and patients about constructs underlying poor response to TKA. Our findings stress the need for an consensus-based unambiguous, dichotomous definition of poor response to draw conclusions about the prevalence of poor-responders to TKA across hospitals and countries, and to identify patients at risk.Additional file 1. Example search terms – for PubMed.Additional file 2. Definitions of poor outcome after primary TKA.Additional file 3. Additional background information about selected definitions.


Recent epidemiological research has identified alarming trends in drinking patterns of girls and women in the United States. In recent years, the amount and frequency of alcohol use are increasing in White and Hispanic girls and young women in contrast to decreasing patterns of heavy alcohol use in boys and young men.Alcohol Research: Current Reviews (ARCR) seeks to close these knowledge gaps and identify important areas for future research directions.These epidemiological trends have increased the urgency of sex-specific, gender-focused research on alcohol.“Gender Differences in the Epidemiology of Alcohol Use and Related Harms in the United States” provides an update on the diminishing sex differences in alcohol consumption, related health problems, hospitalizations, emergency department visits, and death across the life span.ARCR topic series, many alcohol-related sex differences—including development and maintenance of alcohol misuse, alcohol-driven cognitive and medical problems, and even psychiatric comorbidities—derive from key differences in the neurobiology of men and women. In “Sex Differences in the Neurobiology of Alcohol Use Disorder,” Flores-Bonilla and Richardson explore preclinical and human research on neural differences using a three-stage framework of addiction.9As illustrated in articles throughout this In “The Endocrine System and Alcohol Drinking in Females,” Finn extends this neurobiological review by examining the multidirectional interactions of alcohol, stress, and key gonadal sex steroid hormones and stress steroid hormones.In “Alcohol’s Unique Effects on Cognition in Women: A 2020 (Re)view to Envision Future Research and Treatment,” Fama, Le Berre, and Sullivan provide a wide-ranging update on the interrelationships between alcohol and cognition, including effects of acute and chronic alcohol consumption across the drinking continuum.It is well established that women experience higher prevalence of mood and anxiety disordersGiven differences between women and men in risk factors, developmental course, and health and psychosocial consequences of alcohol misuse and AUD, tailored approaches to alcohol identification, prevention, and intervention for girls and women may be necessary to maximize treatment outcomes. Indeed, specialized screening instruments that are more sensitive and specific to women are available to improve case identification.In “Maternal Substance Use: Consequences, Identification, and Interventions,” Chang reviews prevalence and addresses the importance of early identification and intervention for substance use among pregnant women, with emphasis on alcohol, tobacco, cannabis, and opioid exposure.18In “Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Girls and Women,” Hammock, Velasquez, Alwan, and von Sternberg provide a comprehensive review of the effectiveness of this evidence-based, public health approach to identifying and intervening in heavy/harmful alcohol use across the life span, specifically examining SBIRT for girls, women of childbearing age, and older women.20“Treatment Interventions for Women With Alcohol Use Disorder” examines women’s barriers to treatment seeking and referral, program services to address these barriers, and efficacy of women-specific services relative to traditional mixed-gender care.21Although much of the research discussed in this topic series addresses sex-specific findings, it is critical to bear in mind that this literature often obscures important differences among women as a group. In “Alcohol-Related Disparities Among Women: Evidence and Potential Explanations,” Mulia and Bensley address key foci of diversity research, including race, ethnicity, socioeconomic and social status, and sexual orientation.22Finally, we have known for decades that women are more vulnerable to many of the negative health consequences of alcohol consumption, in part, due to their higher blood alcohol levels achieved at comparable alcohol doses compared with men. Now, research is providing system-specific findings of the interplay of alcohol and health in women. Indeed, this topic series addresses sex-specific health effects of alcohol in four key areas. In “Alcohol and Liver Function in Women,” Maddur and Shah address the increasing rates of liver disease in women, the key role that estrogen plays in the greater vulnerability and more rapid progression to alcohol-related liver disease in women compared with men, and sex differences in liver transplant availability and outcomes.24In “Alcohol’s Effects on Breast Cancer in Women,” Freudenheim highlights the compelling evidence that any alcohol use increases breast cancer risk and that risk increases as total consumption increases, emphasizing the importance of targeting this modifiable risk factor for public education and intervention.25Cardiovascular (CV) diseases  are the leading cause of death in women.27Women are more likely to experience insomnia and other common forms of sleep dysregulation compared with men and, in turn, sleep disruption has more severe health consequences for women compared with men.30All of the articles in this topic series highlight critical, ongoing, sex-specific knowledge gaps in our understanding of the epidemiology of alcohol use, the interplay of physiology and alcohol, and best approaches to prevention and treatment. This research supports the importance of the National Institutes of Health mandate not only to include female subjects in research, but also to include them in sufficient numbers to permit sex-specific analyses of findings. As evidenced by these articles, the National Institute on Alcohol Abuse and Alcoholism has successfully targeted many of these areas for support in recent years, yet much remains to be learned as we confront the rapidly changing characteristics of women’s alcohol misuse and harms.


This study focused on gender education for medical and nursing students, because gender competency is essential for them to provide effective and appropriate healthcare and to promote equal rights to health. A questionnaire was administered to 50 health care professionals to explore the gender concepts and gender knowledge that they deem imperative and often teach to medical and nursing undergraduate students in class. Sexism, gender awareness, sexual harassment, the topics of three acts related to gender equity, and patriarchy are the gender concepts participants deemed most crucial for students to learn and understand. However, disparities were noted between the gender concepts frequently taught by the participants and the gender knowledge they considered essential for students. The 50 experts emphasized teaching the concept of patriarchy and the cultivation of students’ structural competency in addition to identifying directions for gender, medical, and health care education. By highlighting the key gender-related concepts, the present research findings may benefit teachers who intend to integrate gender into the curriculum but are limited by time constraints. The results offer a professional development direction for teachers endeavoring to incorporate gender into the curriculum and their teaching. Awareness and knowledge of gender has been acknowledged to constitute a key competency among medical and healthcare professionals. The value of integrating gender into professional health education is therefore recognized ,2,3. HowMedicine and healthcare are specialist areas, and so is gender education. In addition to the proper delivery of professional knowledge, communications between doctors and nurses and patients often require understanding of and sensitivity to gender, necessitating some gender knowledge and gender competency. Studies have shown that lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) people, having lived in a heterosexual society for a long time, tend to accumulate mental stress. When they face medical staff, they often feel awkward and difficult to reveal their true self . Some LGThis study asserts that the right to equal health is a matter of concern in medicine and healthcare, as well as a topic to be addressed through education because changes in culture and in values are required rather than mere systematic and policy changes. Education is always crucial in the training of healthcare professionals. This is why multiple scholars have advocated the incorporation of gender into medical and healthcare education ,9,10,11.Undergraduate education is the preliminary stage in the career paths of various professionals. To promote equal health rights, crucial professional competencies for medical and nursing students should include, but not be limited to, gender competency. Eliminating health disparity and practicing gender-friendly medical care requires undergraduate gender education for medical and nursing students. For medical and nursing students, exploration and construction of the core gender-related concepts facilitate the development of gender competency.This study surveyed medical and nursing teachers and healthcare professionals to determine what gender knowledge they deemed crucial for medical and nursing undergraduate students and which gender-related concepts they most frequently taught. This study provided answers to the research question “Which gender-related concepts should be incorporated into curricula to prepare students for the future?”Curriculum reform is the core of education reform. Multiple studies have explored the effectiveness of incorporating sex and gender into medical and healthcare courses ,11,12,13Experiences of integrating gender into medical and healthcare education in Australia, Sweden, the United States, Canada, Taiwan, and other countries and territories also demonstrates the benefits of gender courses and the manner in which they contribute to students’ understanding. For example, after studying gender, students can: recognize gender differences; address medical problems from a gender perspective; demonstrate awareness of the influence of social and cultural factors on individual health, which is generally believed to be affected only by biomedicine; and demonstrate increased sensitivity to the healthcare needs of LGBTQI patients ,16,17,18The following measures were adopted during medical education reform in Taiwan: In 2002, the Ministry of Education published the White Paper on Medical Education in which “enhancing gender equity in medical education” was declared to be an objective. In 2007, the Ministry of Health and Welfare revised the Regulations Governing Practice Registration and Continuing Education of Doctors to incorporate gender issues into the curriculum. In 2013, the Taiwan Medical Accreditation Council added gender to the educational evaluation criteria of the new accreditation standards and demanded cooperation between teaching hospitals and universities to provide students with education and training regarding gender equity regulations and to ensure their understanding of key gender issues .Development of the aforementioned national education policies has resulted in administrative measures and regulations in relation to the incorporation of gender into the education system and curricula. However, key topics in relation to gender require identification. Studies have proposed that the integration of gender into curricula and professional health education is challenging for the following reasons: problems achieving conceptual clarity; lack of time and space to accommodate gender in the curriculum; skepticism regarding the incorporation of gender into the curriculum; lack of time or willingness to learn about gender among teachers; gender blindness in the medical system and knowledge; treatment of women’s issues as gender issues and negligence of the existence of multiple genders; the categorization of gender in childbirth topics or obstetrics, strengthening of the link between women’s health and reproduction ,20,21,22Studies have also shown that the lack of concrete gender-related curricula, gender-related theories, or comprehensively addressed gender-related topics has rendered gender education in medicine difficult ,3. RisbeThe aforementioned research revealed that, although policies and curricula are being reformed to incorporate gender into professional health education, additional efforts are required for further improvement. To achieve further improvement, the curriculum must be reorganized and the structure of gender-related knowledge reformed to identify the gender-related concepts and concerns that should be taught in health professions education as well as enhancing teachers’ professional knowledge of gender.The women’s health movement emerged in the 1990s, originating from the awareness of gender bias in a male-dominated medical enterprise . In suchThe central tenet of both feminism and gender theory is how to end sexism, sexist exploitation, and oppression ,25. FemiInfluenced by feminism, gender theories, and the women’s movement, Taiwan passed the Gender Equity Education Act in 2004, implementing gender equity education in schools at all levels through institutionalization. Stromquist  examinedKnowledge of Gender Equality in Employment Act and of gender-related regulations is mandatory in the education and training of medical and nursing students during internships governed by the Taiwan Medical Accreditation Council and in the gender curriculum for the continuing education of doctors and nurses, per Ministry of Health and Welfare guidelines. Both education and training programs focus on developing medical and nursing students’ and medical personnel’s awareness of power structure relationships and of the right to work and medical rights. Sharma  noted thIn this study, a questionnaire survey enrolled 50 medical or nursing teachers and healthcare professionals. Taiwan’s policies, systems, and organizations in relation to gender equality education have contributed to gender education, as reflected in the reform of university curriculum structures, professional certification, and professional continuing education. Many medical universities or medical/nursing programs have established gender-related courses or have integrated gender into their curricula. The government also requires that courses on gender be included in continuing education for medical personnel.The design of this questionnaire was based on research purposes and questions. The questionnaire items queried respondents on the gender-related concepts that they frequently teach and consider essential for students’ learning and knowledge. Respondents were asked to consider medical/healthcare specialties and occupational competency in completing the self-administered questionnaire. The research team mailed or emailed the questionnaires to the participants for them to complete independently.1.Please list at least three gender concepts or gender knowledge that you often teach in your course or at work.2.Among the 25 items (the 25th item is “other”), please select 15 gender concepts or gender knowledge that university students must learn .3.Continuing from Question 2, please rank the 15 gender concepts or knowledge according to the following three major categories: most important and highest priority, second most important and second highest priority, and least important and lowest priority; please also explain your reasons for the ranking.4.Taking the department you teach in or work competency into consideration, among the 25 items, what do you think are the 15 gender concepts or gender knowledge that students must learn to succeed in future workplaces and in their social life?5.Continuing from Question 4, please rank the 15 gender concepts or knowledge according to the following three major categories: most important and highest priority, second most important and second highest priority, and least important and lowest priority; please also explain your reasons for the ranking.6.Please provide any further opinions or suggestions on the gender concepts or related knowledge that students must learn and know.The questionnaire was prepared, and expert validity was used to test the content validity of each item. Three gender education experts and scholars tested the validity of, reviewed, and revised the questionnaire. The revised questionnaire included two parts: (1) demographic data; and (2) questions on gender education for students. The second part of the questionnaire was composed of open-ended questions, multiple choice questions, and sequential questions. The sequential questions involved prioritizing and ranking multiple items by their perceived importance. The second part’s questions were as follows:This study employed purposive sampling and ensured the representativeness of expert opinions by establishing a sampling standard, which addressed the professional knowledge or experience of the participants in the professional fields of gender, medicine, and healthcare. The inclusion criteria required that participants demonstrate gender awareness and possess years of teaching or practical experience in medicine and healthcare, in addition to meeting any of the following requirements regarding professional knowledge: (1) they were teaching courses on gender and medicine or healthcare at universities or had incorporated gender into medicine or healthcare courses; (2) they had published works related to gender and medicine or healthcare; (3) they had conducted research projects on topics related to gender and medicine or healthcare; or (4) they had promoted gender education for medical personnel or gender-friendly medical care.Participants were recruited through the following channels: (1) the researcher’s interpersonal network; (2) professional associations or gender-related nongovernmental organizations; (3) a search for university professors teaching courses related to gender and healthcare; (4) a search for researchers implementing gender- and healthcare-related research projects commissioned by national institutes; and (5) a search of the various agendas of gender-related conferences/seminars to establish a list of authors who had published papers on gender, medicine, and healthcare. This study used the snowball sampling technique to send invitation emails to those satisfying the sampling criteria.This study recruited 50 participants, 35 of whom were teachers and 15 of whom were healthcare professionals. Regarding the sex of participants, 18 were males . Of the participants, 4, 14, 13, 15, and 4 people were aged 20–30 years, 31–40 years, 41–50 years, 51–60 years, and 61 years or older, respectively. Notably, many of the participants teaching in the department of medicine were also licensed doctors. Twenty eight of the participants specialized in medicine, whereas the remainder specialized in nursing.For data coding, the following methods were adopted separately according to the nature of the open-ended questions: (1) Record participants’ answers. For example, for the sixth question in For data analysis, this study used different methods for qualitative and quantitative data. Clustering, counting strategy, and thematic analysis were used for qualitative data; descriptive statistics and correspondence analysis were used for quantitative data. For sequential questions, the study adopted a weighted scoring method to assign 15, 10, and 5 points for items deemed most important (top priority), less important (secondary priority), and least important (third priority), respectively. The importance and priority scores for the multiple choice questions were compared. For correspondence analysis, 30 items were combined and divided into four groups through an expert validity test: (1) patriarchy and heterosexuality: heterosexual hegemony, heteronormativity, patriarchy, misogyny, homophobia, male-centeredness, male-dominance, male-identification, objectification, patriarchal dividend; (2) sex and gender: LGBTQI, gender awareness, sexual and gender identity, gender traits, sexism, gender role stereotypes; (3) gender violence: sexual harassment, sexual and gender-based bullying, domestic violence, oppression and gender oppression, abuse of power; and (4) gender politics: exploitation, Taiwan’s three acts on gender equity, autonomy, emotional labor, body politics, feminism, gender mainstreaming, and intersectionality.This research complies with the basic principles of research ethics, including informed consent, privacy, autonomy, and protection from harm. The invitation letter clearly explained the research purpose, research questions, questionnaire survey method, and data processing method, including the anonymity of the survey, the number of questionnaire items, the estimated completion time, and the steps required for the termination of participation. Only after consent was obtained from potential participants would the questionnaire and informed consent form be sent out. Therefore, the invitees fully understood the use of and processing methods for research data  before deciding, with full autonomy, whether to participate in the study. The National Cheng Kung University Human Research Ethics Committee approved the anonymous questionnaires.Based on medical and healthcare specialties and occupational competency, the 50 experts identified the top 15 gender concepts essential to medical and nursing students’ learning and knowledge, with the top 10 being sexism, sexual harassment, gender awareness, patriarchy, the three gender equity acts, LGBTQI, sexual and gender-based bullying, sexual identity and gender identity, autonomy, objectification, and oppression/gender oppression . Up to ≥The top three gender concepts considered essential for medical and nursing students to learn and understand were the same for male and female participants: sexism, sexual harassment, and gender awareness. The top 10 gender concepts proposed by male and female participants were relatively similar, with the only difference being that female participants included objectification and body politics, whereas male participants did not. The top three gender concepts proposed by teachers and healthcare professionals varied; the concepts highlighted were sexism, gender awareness, and sexual harassment and patriarchy, sexism, and sexual harassment, respectively. Among the top 10 gender concepts proposed by teachers and healthcare professionals, objectification and body politics were ranked as crucial only by teachers, whereas “oppression and gender oppression” was ranked as crucial only by healthcare professionals.Notably, up to 93% of healthcare professionals believed that students must learn and understand the concept of “patriarchy.” Eighty percent of the participants working as teachers or healthcare professionals identified the gender concept of “sexism” and “sexual harassment” as essential for medical and nursing students to learn and understand.Correspondence analysis was used for this study to explore the relationship between demographic variables and concept combinations; the variable of age was added to identify whether generational differences existed. Regarding “gender politics” , the majMale and female participants generally had the same opinions concerning the top-priority gender-related concepts; participants of both genders agreed that teaching sexism, gender awareness, sexual harassment, and three gender equity acts were priorities, but male and female participants respectively mentioned LGBTQI and patriarchy as top-priority gender-related concepts. Teachers and healthcare professionals both identified the following gender concepts as crucial for medical and nursing students: gender awareness, sexism, sexual harassment, three gender equity acts, and patriarchy. That is, these concepts were deemed gender education priorities. Notably, concepts classified as “other” were considered less important (of secondary priority) according to participants’ responses, regardless of gender and occupation. This phenomenon is subsequently explained further with reference to the qualitative data for participant responses.The majority of the participants stated that basic gender knowledge required for medical professionals is the most important gender concept that should be prioritized in students’ education. Advanced learning is implemented after students master basic gender-related concepts and knowledge. They are of secondary importance or even lower priority, and are only taught when the class schedule or time permits. Specifically, some gender concepts are ranked low priority by some teachers because these concepts are more advanced and abstract, such as the concepts of heteronormativity and body politics.Thematic analysis results showed that participants listed certain gender concepts as the highest priorities in gender and medicine education for students for the following three reasons:(1) Learner orientation : Participants, whether in the field of medicine or nursing, believed that the purpose of their professions and jobs were to serve people. Therefore, an understanding of certain basic gender-related concepts, such as sexism, gender awareness, and sexual harassment is equally crucial to students and to their future care receivers. Participants responded that emphasizing gender knowledge enhances personal and medical profession–related gender competency in students as well as facilitates the establishment of a gender-inclusive medical environment. For example, Ada, a female teacher in the department of nursing stated, “I teach a course entitled “Gender and Nursing.” My students are about to conduct internship in hospitals, so I teach them manifestations of sexual harassment prevalent in the nursing workplace, thereby preparing them for their internships at hospitals.” Another female teacher, Betty, in the department of nursing also responded, “Nursing students should be more sensitive to and possess more understanding of gender issues in the clinical care of patients, including potential sexual harassment incidents and sexism in spoken language.” Cathy, a female teacher teaching in a medical school remarked, “I teach in a medical school, and a notable gender gap exists both in school and in the future workplace. I hope to clarify the causes of such a phenomenon for students.”(2) The value of understanding structural inequality: Participants emphasized that medical and nursing students must understand the inequality in social structures and gender relations and their effects on gender culture and gender interaction. This also explains why the majority of participants ranked “patriarchy” as the most crucial gender concept to be prioritized in students’ education on gender. A female teacher, Daisy, in the nursing department stated, “The top priority is for students to perceive the existence of gender inequality in social structures and to recognize the comprehensive influence of patriarchy on culture and society. Particular attention should be devoted to inequality between men and women, which renders women relatively vulnerable. Such awareness is the first step for understanding gender-related concepts or for acquiring gender education.” The only transgender participant, Terry, in this study responded “Patriarchy deeply influences all aspects of daily life. I believe that it is the main cause for gender inequality and the existence of oppressive and dominant relationships in society. Therefore, I will prioritize [the learning] of it [patriarchy].”Furthermore, gender inequality, power structures, and power relations in clinical practice, as well as their potential influence on students in their future workplaces, are the main reasons for which participants listed “patriarchy” as the most crucial gender concept in gender education. A male doctor, John, remarked on the value of understanding patriarchy, saying that “This gives undergraduate students an overall picture of their future workplaces, enabling them to quickly grasp gender dynamics within it.” A female doctor, Ella, mentioned, “The surgical department is a patriarchal working environment… It’s male-centered….homosexuality is…highly frowned upon in such a work environment.”(3) By prioritizing certain gender concepts in undergraduate education, participants hope to improve students’ understanding of gender-related regulations to protect their rights and their patients’. This objective is also related to the aforementioned two reasons. A female teacher, Erica, in the long-term care profession said, “Acts guarantee fundamental rights, so the three acts on gender equity are must-knows… Students must also learn about sexual harassment, which is common in the care industry.” A nursing department teacher, Fanny, said, “We can start fostering gender equality on campus or in the workplace by teaching the three acts on gender equity. Specifically, the Gender Equality in Employment Act targets the prevention of sexual harassment in the workplace, and the Gender Equity Education Act focuses on the prevention of sexual harassment incidents on campus.” Paying particular attention to the effect of Taiwan’s same-sex marriage legalization on LGBTQI medical rights and medical decision-making, another nursing department teacher, Gail, indicated that students must understand policies and measures related to LGBTQI medical rights.Overall, the interrelated connection among the aforementioned three reasons indicates that the participants planned a bottom-up learning approach to gender education by imparting the fundamental concepts first. This study also reveals a notable phenomenon: Although the participants were asked only to provide reasons for how they prioritized and ranked gender-related concepts, most participants also explained how they should or would teach crucial gender concepts that should be prioritized in education. For example, a male doctor highlighted the importance of learning the three gender equity acts and stated, “I think that studying gender-related regulations is necessary. Interactive case-based discussion, debate, and dialectic can be employed to avoid the dullness of learning regulations. After all, the real purpose of education is to address the values behind each article, rather than mere memorization and lecturing.”Most participants reported that the gender concepts they frequently imparted to students were basic gender concepts or knowledge requiring prioritization in learning. However, considerable disparities and contradictions were noted in this study between the aforementioned statistical results and the qualitative responses provided by participants.Because participants provided various types of answers to the question regarding gender concepts they imparted most frequently, a counting method was used to organize these. A total of 58 gender concepts were identified, none of which was simultaneously mentioned by ≥50% of the participants. Only the following four gender concepts were simultaneously mentioned by ≥20% of the participants: gender diversity, patriarchy, gender role stereotypes, and sexual harassment (in descending order).The analysis results demonstrated that the gender concepts and knowledge frequently taught by participants did not converge on specific concepts. Although most participants provided more than three gender-related concepts, their answers—which were widely dispersed—rarely overlapped or intersected. Gender diversity, the most frequently mentioned gender-related concept, was mentioned by only 24% of the participants. Concepts of patriarchy, gender role stereotypes and sexual harassment, LGBTQI, and sexism were frequently taught by 22%, 20%, 16%, and 14% of the total participants, respectively.Gender knowledge comprises either “one or several gender concepts” or “a specific conceptual category or theme relating to gender,” such as gender medicine. In this study, only two female teachers reported “gender medicine” to be a gender-related concept that they often imparted to students. Both taught in the department of medical humanities and specialized in feminism, gender sociology, and gender research. To enhance medical students’ competency in social sciences and humanities, medical universities in Taiwan recruit teachers with medical humanities backgrounds and establish courses on medical ethics and social sciences. The only female teacher who mentioned “gender oppression” and “power relations” as concepts she frequently teaches served as a medical humanities teacher at a medical university and was one of the few teachers integrating feminism into the curriculum.The 50 medical and nursing professionals appeared to have a clear idea of the gender knowledge that medical and nursing students should learn. They also achieved a high level of consensus on gender concepts that should be prioritized in gender education for students: sexism, gender awareness, and sexual harassment. Simply put, participants identified sexism, gender awareness, and sexual harassment as core gender knowledge for medical and nursing students, and as essential for students to learn and understand.The gender concepts of patriarchy, patriarchal dividend, and heterosexual hegemony were also mutually identified by respondents as essential for students’ learning and knowledge. The male-centeredness or male-dominated organizational structure and culture of the medical workplace were the reasons for which participants selected patriarchy or sexism, gender awareness, and sexual harassment as crucial gender knowledge requiring prioritization. A female teacher in the medical department said, “Medical students must understand the power relations between doctors and patients, recognize the patriarchal structure of society, respect autonomy, and avoid sexism in the process of caring for patients.” The three concepts in question were also emphasized in the conclusion of Metzl and Hanse , who indQualitative data from the survey revealed that participants were mutually concerned regarding the development of gender awareness in students to prevent them from becoming victims or perpetrators of sexism or sexual harassment. In particular, female participants showed more concern in their qualitative data regarding gender discrimination and sexual harassment that medical and nursing students might have encountered in their future workplaces as well as regarding the corresponding gender education and learning. The correspondence analysis result showed that female participants preferred students to study the following gender concepts and knowledge: objectification, body politics, and gender mainstreaming.In response to the question “Is gender or gender education a woman issue?” this study asserts that gender matters in medical school and in clinical practice. In Taiwan’s medical field, female nurses have a minority status despite being the majority, whereas female doctors are the minority in both number and status. To exacerbate matters, severe gender division exists in both the medical and nursing departments. Numerous studies have addressed the influence of gender bias and sexism on the learning, work, and career development of female medical students. Female medical students and teachers continue to experience sexism in medical school and clinical practice ,31. MaleGender bias and sexism in medical schools and the workplace require attention and redress. The elimination of sexism, the improvement of gender awareness, and the reformation of patriarchy are the core tenets of feminism and gender theory ,25,36. LThe aforementioned results revealed considerable disparities between the gender concepts most frequently taught and the gender knowledge deemed crucial to students. Specifically, sexism, gender awareness, sexual harassment, the three gender equity acts, and patriarchy were identified by participants as essential gender knowledge for medical and nursing students. However, only approximately 20% of participants frequently taught concepts of “patriarchy” and “sexual harassment.” Although participants regarded “sexism” as a top-priority gender concept, they rarely taught it in class. The awareness, one of the gender concepts prioritized by participants, was not even included among the gender concepts frequently taught by participants. Only one nursing teacher reported teaching the three acts on gender equity frequently.A significant difference was also observed in the numbers of teachers and of healthcare professionals who selected the concept “other.” Teachers also ranked “other” as a gender concept of less importance (secondary priority) for medical and nursing students. “Other” is a general term for nonrepetitive gender concepts; that is, “other” encompasses various gender-related concepts. This may explain the diverse responses of participants in response to the question regarding which gender concepts they taught most frequently.Integrating gender issues into the curriculum is a common method for medical and health professions education ,11,14. TIn addition, both policy and social changes affect knowledge construction. Medical and healthcare education, which is subject to social trends and contexts, is continually changing. The challenges in relation to the emergence of gender as an area of study also require innovative knowledge and discourse. Gender medicine is an interdisciplinary and relatively new subject that has gained much attention from medical and health educators ,26. HoweSurprisingly, gender stereotypes were ranked as the second most frequently taught gender concept by participants. Undergraduate medical and nursing students in Taiwan grew up after the implementation of the Gender Equity Education Act, which means that they began receiving gender equity education—with gender stereotypes being the first concept they studied—at elementary school. The question meriting discussion is whether imparting such fundamental gender concepts to these undergraduate students stimulates learning motivation and produces favorable learning results.A nursing department teacher, Iris, stated, “Nursing students often face the problem of gender stereotypes in their subsequent professional lives providing clinical care.” A female doctor, Hazel, explained her reason for selecting “gender stereotypes” as a top-priority gender concept priority: “Gender stereotyping and discrimination occur frequently, and relevant education serves as a tool for understanding such phenomena.” Meulen et al.  comparedFurther investigation is required to determine why gender stereotypes are still perpetuated by one-third of teachers or medical professionals. This study uncovered useful clues and meaningful teaching guidance from participants’ responses. If medical and nursing teachers or practitioners still intend to teach gender stereotypes in their curriculum, they may include the concept of unconscious bias to enrich and deepen the teaching and discussion of the concept. In addition, as already stated, participants considered the gender-related problems and concerns of students in school education and in their future workplaces to be crucial and thus emphasized the understanding of sexism, sexual harassment, and gender awareness among medical and nursing students. However, sexism and gender awareness were not reported to be frequently imparted gender concepts. Sexism and sexual harassment may result from gender stereotypes. Gender awareness knowledge covers gender stereotypes. The theoretical basis of the term “gender awareness” originates from Marxism and feminism. Gender awareness denotes gender stereotypes and biases , as wellAndersson et al.  analyzedWith an improved conceptualization of gender knowledge (consisting of gender-related concept combinations), course designers or educators can lead students to explore the gender inequality on campus and in clinical practice in depth. Moreover, they can attend to the different needs of individual courses and students’ gender learning and thereby enhance teaching and learning outcomes.The two limitations to this study are as follows. (1) Constraints in time and research funding prevented further qualitative data collection: In this study, self-reported disparities between gender concepts frequently taught and those deemed of top priority for students were identified. Due to time and research funding constraints, this study failed to gain an in-depth understanding of the qualitative answers provided by the participants. Had interviews or in-depth interviews been conducted, the participants may have been able to explain any contradiction. Further research on this is merited. (2) Due to the established sampling criteria, the number of teachers was twice of the number of healthcare professionals: Initially, this study intended to explore potential discrepancies between school education and medical practice and whether undergraduates are sufficiently prepared to apply their gender education in the medical field. However, because the requirements of the sampling criteria were more biased toward academic specialties, the majority of the participants were university professors. Had different sampling criteria been established for teachers and healthcare professionals, more healthcare professionals might have been recruited as participants, more diversified data collected, and the research horizons broadened. For future research on this topic, recruiting patients of different gender identities as the research participants may also be considered. Because of unique patient medical and healthcare experiences, such research may be able to provide different perspectives and insights into gender in professional health education programs.Education is the first step to promoting equal health rights for people of all genders. Gender competency is the foundation for eliminating health disparity. In the incorporation of gender into medical and healthcare courses, gender education should be regarded as a professional discipline based on theory and practice rather than as a mere perspective or issue of discussion.This study showed that the gender concepts of sexism, gender awareness, sexual harassment, the three gender equity acts, and patriarchy were deemed most crucial or top priorities in medical education by 50 medical or nursing teachers and healthcare professionals. Specifically, sexism, gender awareness, and sexual harassment were considered to be core gender knowledge for medical and nursing students to study. The majority of the respondents prioritized education on sexism, gender awareness, sexual harassment, and patriarchy. This study also demonstrated that female participants, having personally experienced real-world gender phenomena in academic and medical settings, were particularly concerned regarding students’ education on gender. In addition, all 50 experts attached value to the teaching of concepts related to patriarchy, the cultivation of students’ structural competency which pinpoint future directions for gender and medical education. Nonetheless, this study discovered consensus, contradictions, and differences in participants’ opinions regarding the gender concepts and knowledge that should be taught when incorporating gender into the medical care curriculum.Accordingly, this study proposes three practical suggestions. First, according to the gender concepts deemed crucial for medical and nursing students, educators can develop a gender education learning map for medical school students. Course designers or teachers can determine the core gender knowledge required by students and how the learning of other gender-related concepts can be integrated. Second, in response to the diversity in students’ gender knowledge, this study suggests the combination of gender concepts and the use of various categories or themes relating to gender concepts for curriculum design and teaching of gender topics. Designing courses, adopting teaching methods, and planning teaching activities based on combinations of gender concepts enable students with varying levels of gender knowledge to participate in learning activities more effectively.Third, in addition to the curriculum reform requiring that gender be incorporated into courses, medical universities must also pay attention to the professional development of teachers in gender education. This study emphasizes that, to achieve alignment with the concepts in competency based medical education, the integration into education of fundamental gender concepts should focus on core concepts and the imparting of knowledge in relation to gender, providing an instructional scaffold for subsequent or advanced gender topic learning. Such emphasis also contributes to the integration of professional disciplines of gender and healthcare and learning of competency-based integration ability among students. Therefore, professional development for teachers should enhance their knowledge of feminist theory and gender sociology and their ability to apply gender concepts in curriculum planning and instructional design, thereby enhancing the effectiveness of courses integrating gender with healthcare.Overall, an understanding of what aspects of gender to teach in medical and healthcare education enables clarification of gender education goals and content, as well as providing a direction for the professional development of teachers. More notably, these findings may serve as a guide for teachers who intend to integrate gender into the curriculum but are subject to time constraints, helping them to focus on key gender concepts and areas of study. This provides a foundation or a stepping stone for students’ gender education, and students are thereby sufficiently prepared for gender competency practice in their future medical professional areas.


Existing mobility limitations and chronic conditions increase likelihood of adopting mobility-related devices such as canes and walkers. Prior research has not considered how recent acute events such as falls and hospitalizations contribute to the adoption of mobility devices. We studied 4,592 older adults who responded to the 2015 and 2016 National Health and Aging Trends Study surveys, and classified adoption of mobility devices as: (i) Never users (did not use mobility devices either year) and (ii) New users (started using mobility devices in 2016). We determined through chi-square tests, that predisposing characteristics from 2015 that were significantly associated with being a New User in 2016 were: being female, aged 80+, minority race, having a high-school education or lower, living alone, being obese, and having a history of dementia, arthritis, stroke, mobility difficulties, falls, and hospitalization . We used logistic regression to determine the contribution of recent precipitating events on the adoption of mobility devices among older adults after controlling for 2015 characteristics that were significantly associated with being a New user. Precipitating events were significantly associated with being a New user of mobility equipment. Specifically, older adults who, between the 2015 and 2016 interviews, experienced a fall , hospitalization  or increase in mobility difficulties  were more likely to be New users. Study findings reveal the importance precipitating events on the adoption of mobility devices, signaling the importance of assessing for need for mobility devices after these events.