The new regulations offer an important springboard for further progress, in order to preserve the efficacy of existing antimicrobials, which are a critical international resource.New regulations on veterinary medicines and medicated feed will substantially influence antimicrobial prescribing and usage throughout Europe into the future. These regulations have been informed by a very large body of work, including the substantial progress towards reduced antimicrobial usage in food animal production in a number of member states of the European Union (EU). This paper seeks to summarise European perspectives on efforts to reduce antimicrobial usage in food animal production. Work within the EU is informed by the global action plan of the World Health Organization, which includes a strategic objective to optimise the use of antimicrobial medicines in human and animal health. There is ongoing measurement of trends in antimicrobial usage and resistance throughout the EU, and detailed information on strategies to reduce the need to use antimicrobials in food animal production. Substantial scientific progress has been made on the measurement of antimicrobial usage, including at herd-level, and on the objective assessment of farm biosecurity. In a number of EU member states, monitoring systems for usage are well-established, allowing benchmarking for veterinarians and farms, and monitoring of national and industry-level trends. Several countries have introduced restrictions on antimicrobial prescribing and usage, including strategies to limit conflicts of interest around antimicrobial prescribing and usage. Further, a broad range of measures are being used across member states to reduce the need for antimicrobial usage in food animal production, focusing both at farm level and nationally. Veterinarians play a central role in the reduction of antimicrobial usage in farm animals. Ireland’s National Action Plan on Antimicrobial Resistance 2017–20 ( New regulations on veterinary medicines (Regulation (EU) 2019/6) and medicated feed (Regulation (EU) 2019/4) will enter into force within the European Union (EU) from 28 January 2022  etc) which precludes comparison between studies. Collineau et al. [In recent years, there have been a number of scientific studies of antimicrobial usage in food animal production in Europe. At times, however, different usage indicators have been used , tou et al. , to allou et al. .Some explanation is needed for the terms DDDvet and ‘defined course dose for animals’ (DCDvet), which are increasingly used as technical units of antimicrobial usage. These units are calculated for a particular animal species and based on the assumed average dose administered per kg per day, noting that a standardised list of DDDvet suitable for use across all EU member states is now available . The folEstablished in 2017, the AACTING consortium has focused on the quantification of veterinary antimicrobial usage at herd level . It has assembled information about existing farm-level systems for the collection of antimicrobial usage data, available at their website . These iThe University of Ghent have developed Biocheck.UGent™, which is an online, freely available, risk-based tool to allow herd- or flock-level biosecurity to be objectively measured . The tooThe new EU regulations on veterinary medicines and medicated feed have been preceded by a series of earlier relevant policy initiatives. In 2007, the European Commission adopted a new Animal Health Strategy, this being the first time that the Commission had set out its strategic aims and objectives for animal health. With a primary focus on ‘prevention is better than cure’, the strategy was structured around four main pillars  .The most-recent EU One Health Action Plan against Antimicrobial Resistance was adopted in 2017 . The actSubstantial efforts have been made by a number of EU member states to reduce the overall use of antimicrobials in food-producing animals, including the creation of national usage & reduction targets, the measurement and benchmarking of prescribing and usage by veterinary practices and individual farms respectively, and through strategies to encourage antimicrobial stewardship . ActionsSince 1996, the Danish Programme for surveillance of antimicrobial consumption and resistance in bacteria from food animals, food and humans (‘the DANMAP project’) has produced a detailed report, produced annually, of antimicrobial usage and resistance in humans and farm animals in Denmark . SummaryIn those countries where national usage data are available, these data are used for multiple purposes including benchmarking of farms and veterinarians and monitoring national and industry-level trends. Using the Netherlands as an example, there is ongoing benchmarking of livestock farms and veterinarians. Several different thresholds  are used to differentiate between moderate, high and very high users (farmers) and prescribers (veterinarians) . Action In a number of countries, national targets have contributed to a broader strategy to limit antimicrobial usage in food animal production. In Belgium, for example, national 2020 targets include a 50% reduction (compared to 2011) in antimicrobial usage, 75% reduction in CIA usage and 50% reduction in use of medicated feed . TargetsSeveral countries have introduced restrictions on antimicrobial prescribing and usage. Further to recommendations from the WHO in 2009 , the NetRecognising the potential for conflicts of interest around antimicrobial usage, several countries have introduced restrictions on veterinarians and farmers, including each of the following. In the Netherlands, farmers are obliged to procure veterinary services and veterinary medicines from a single veterinary practice, to reduce competition between veterinary practices and ensure that the prescribing veterinarian has a comprehensive understanding of the farm . In DenmConsistent with the findings of the RONAFA opinion, a broad range of measures are being used across member states to reduce the need for antimicrobial usage in food animal production.Farm-level practices were considered in a recent study investigating alternatives to the use of antimicrobial agents in pig production . DrawingAt a broader scale, there has been a long history in Europe, and elsewhere, of infectious disease control and prevention in food animal production. These efforts initially focused on regulatory diseases , such as bovine tuberculosis. Increasingly, however, there is increase focus on non-regulatory diseases, such as, for cattle, the control and eradication of bovine viral diarrhoea (BVD), salmonellosis and infectious bovine rhinotracheitis (IBR). This work is frequently coordinated by non-government bodies, such as AHI, Royal GD  in the Netherlands and La Fédération nationale des Groupements de Défense Sanitaire (GDS France), which are playing a key role in coordinating eradication efforts.Quality assurance (QA) programmes have become increasingly common, offering the potential to positively impact on animal health and antimicrobial usage. Generally independent of government, QA programmes are a direct response to societal and consumer demands for assurance of high standards in animal welfare and food quality . RetaileVeterinarians play a central role in the reduction of antimicrobial usage in farm animals. Studies have highlighted major country differences in usage patterns based on sales data –69 whichiNAP) provides an overview of Ireland’s commitment to the development and implementation of a holistic, cross-sectoral ‘One Health’ approach to the problem of antimicrobial resistance [Ireland’s National Action Plan on Antimicrobial Resistance 2017–20 (sistance . Strategsistance ), includRelevant to food animal production, a policy on the use of HP CIAs has been developed, indicating that these products should not be used prophylactically or as first line of treatment . IndustrIn conclusion, this paper highlights some of the work that has been conducted throughout Europe in support of reduced antimicrobial usage in food animal production. In some EU member states, a broad series of changes have been implemented and progress has been substantial. The new regulations offer an important springboard for further progress, in order to preserve the efficacy of existing antimicrobials, which are a critical international resource.


Workers in the informal economy often incur exposure to well-documented occupational health hazards. Insufficient attention has been afforded to rigorously evaluating intervention programs to reduce the risks, especially in artisanal and small-scale gold mining (ASGM).This systematic review, conducted as part of the World Health Organization’s Global Plan of Action for Workers’ Health, sought to assess the state of knowledge on occupational health programs and interventions for the informal artisanal and small-scale gold mining (ASGM) sector, an occupation which directly employs at least 50 million people.We used a comprehensive search strategy for four well-known databases relevant to health outcomes: PubMed, Engineering Village, OVID Medline, and Web of Science, and employed the PRISMA framework for our analysis.programs for this sector although target interventions addressing specific hazards exist. Major areas of intervention—education and introduction of mercury-reducing/eliminating technology were identified, and the challenges and limitations of each intervention taken into assessment. Even for these, however, there was a lack of standardization for measuring outcome or impact let alone long-term health outcomes for miners and mining communities.Ten studies met the inclusion criteria of a primary study focused on assessing the impact of interventions addressing occupational health concerns in ASGM. There were no studies evaluating or even identifying comprehensive occupational health and safety There is an urgent need for research on comprehensive occupational health programs addressing the array of hazards faced by artisanal and small-scale miners. The term informal economy was first coined by British anthropologist Keith Hart in observing the work of rural migrants in Ghana in 1971 3. In 2012ASGM operations are responsible for a quarter of all gold extracted globally and is often seen as a livelihood alternative for poverty-stricken communities worldwide 89. Thoug81011What is the evidence that comprehensive occupational health programs established to address the hazards of ASGM are beneficial (or harmful)?any occupational health interventions in this sector are beneficial (or harmful)?If there is no evidence regarding comprehensive programs for ASGM, what is the evidence that A broad approach was taken to gather data. Initially, a search was conducted through search engines: PubMed, OVID Medline (1946 to present), Web of Science (1900 to present), and Engineering Village which includes journals in the field of mining engineering such as Compendia, GEOBASE, and GeoRef (1884 to present) for peer-reviewed journal articles. Search terms relating to occupational health and artisanal or small-scale mining (Appendix 1) were adapted for each search engine and broadened as needed with the help of a health research librarian. The search syntax was verified with the assistance of a second librarian using WHO guidelines. Studies that were purely observational with no interventions implemented were excluded 181920 as18192122232425One reviewer (VWLT) extracted all relevant data from eligible studies and included information such as: study properties , health concerns addressed, intervention methods , methods of evaluation , and challenges for replication and expansion. This information was confirmed by another reviewer (KL) who also identified any additional studies missed on initial compilation Tables  and 4. AInitially 3,546 articles were identified in four different search engines . The titles of these articles were screened for relevance and 3,390 articles were excluded. Abstracts of 156 articles were then screened for relevance and 23 articles remained after this process. After full text screening, 10 peer-reviewed articles were included for analysis  and Africa 4) (Table  (Table 4and health impacts as well as educational campaigns. While pre and post intervention assessment constituted a necessary inclusion criterion in this systematic review, studies that reported monitoring results, but without describing specific hazard reduction interventions, were excluded.The interventions studies were summarized into two loose categories: education and technological improvements Table , albeit 2728Six studies that discussed technological improvements introduced equipment such as homemade retorts, wet-spray misting, sluice boxes, and modified speaker magnets in lieu of mercury amalgamation 2829, Thr282930Some studies discussed creative modifications to existing mining tools and infrastructure, including homemade retorts 30, mercuOliveira et al.’s study evaluated interventions in the Poconé region that were in effect since the 1990s , includiOne local creative approach that deviates from the common use of retorts and amalgamation techniques was offered in Mozambique . As oppoThe only non-mercury focused study was of wet-spray misting nozzles and wet-stream machines to reduce lead and silica dust in ASGM operations, decreasing both direct respiratory and take-home exposures . This waEducational campaigns were a clear focus in the articles that discussed interventions within the Global Mercury Project 303233 bu303215162818It was reported in various studies that many traditional ASGM practices are driven by beliefs embedded within the gold-mining process; for example, in one study, dialogue with miners in Antioquia, Columbia revealed beliefs that recovering mercury used in amalgamation processes would cause a portion of gold to be lost . Measuri3 to 10ug/m3 after the installation of retorts, bringing levels below the recommended upper limit of 25 ug/m3 set by the WHO for long-term exposure to metallic mercury [One study evaluated a three-day workshop in 2013 where train-the-trainer strategies were employed  with top mercury . A previ mercury  studied Initial pioneers, Sousa and Veiga, performed assessments in Brazil in 2002 where extensive integration and observation of mining communities were conducted by trainers over periods of three to five months to navigate cultural and behavioural contexts which allowed them to cater suggestions to improve gold recovery. A balanced scorecard method  using 20Considerable attention has been devoted to occupational hazards in the mining sector overall 48495051 484950Uptake of mercury-free techniques has been slow, due to large sum of funds needed upfront to install machinery, buy equipment, or alter operational procedures. However, studies have documented that simple devices such as homemade retorts and education about proper mercury disposal can effectively reduce mercury exposure, and educational interventions such as workshops and training sessions that supplement the introduction of new mining equipment can help. The use of magnets in lieu of mercury amalgamation is reasonably scalable, and efforts can be put into sharing best practices with other mining operations. However, systematic documentation and evaluation of long-term impacts  has beenSaldarriaga-Isaza et al.  stress t40A framework for training miners in ASGM can be employed to improve efficacy and streamline education interventions for miners , for exa12other than mercury [Lastly, our finding of only one study of interventions reducing exposures to hazards  mercury  underlin mercury .The databases used in this study focus on English language articles. However, no studies were found in a non-English language using the aforementioned broader search strategy.Few peer-reviewed studies exist that evaluate occupational health interventions for this population. This is not because of the lack of documentation of the hazards in this sector. The establishment of treaties like the Minamata Convention on Mercury coupled with new innovations in technology will undoubtedly help reduce mercury use, as will promote other preventive measures in ASGM. However, the lack of documentation of the effectiveness of interventions is problematic. Whether the dearth of literature reflects lack of occupational health interventions and services, or rather absence of studies thereof, cannot be determined by our review.Moreover, even beyond exposures to mercury, lead, mercury and other toxic substances, occupational hazards in ASGM include concerns about hygiene and sanitation, and the rise of sex workers and associated reproductive health problems in mining communities. Whether interventions exist to address these concerns exist but have not been evaluated, or rather have not been implemented at all, cannot be determined by this study. What we can conclude is that there remains a lack of meticulous pre- and post-intervention health assessments to facilitate the objective measurement of success in improving health and wellbeing for this sector. While efforts to find alternate livelihoods for those working in precarious and hazardous situations is imperative, research is urgently needed now as to how to offer occupational health interventions, if not full programs, to mitigate the risks.The additional file for this article can be found as follows:10.5334/aogh.2592.s1Appendix 1.Search Criteria.


Microscopic and molecular events related to alveolar ridge augmentation are less known because of the lack of experimental models and limited molecular markers used to evaluate this process. We propose here the chick embryo chorioallantoic membrane (CAM) as an in vivo model to study the interaction between CAM and bone substitutes (B) combined with hyaluronic acid (BH), saline solution , or both, aiming to point out the microscopic and molecular events assessed by Runt-related transcription factor 2 (RUNX 2), osteonectin (SPARC), and Bone Morphogenic Protein 4 (BMP4). The BH complex induced osteoprogenitor and osteoblastic differentiation of CAM mesenchymal cells, certified by the RUNX2 +, BMP4 +, and SPARC + phenotypes capable of bone matrix synthesis and mineralization. A strong angiogenic response without inflammation was detected on microscopic specimens of the BH combination compared with an inflammatory induced angiogenesis for the BS and BHS combinations. A multilayered organization of the BH complex grafted on CAM was detected with a differential expression of RUNX2, BMP4, and SPARC. The BH complex induced CAM mesenchymal cells differentiation through osteoblastic lineage with a sustained angiogenic response not related with inflammation. Thus, bone granules resuspended in hyaluronic acid seem to be the best combination for a proper non-inflammatory response in alveolar ridge augmentation. The CAM model allows us to assess the early events of the bone substitutes–mesenchymal cells interaction related to osteoblastic differentiation, an important step in alveolar ridge augmentation. Alveolar ridge augmentation represents a preliminary step in dental implant procedures. Several studies and highly heterogeneous data have been reported regarding the techniques applied and biomaterials used for alveolar ridge augmentation. The most controversial issue in the field is the nature of the biomaterials used for augmentation ,2,3, andDespite the fast development of alveolar ridge augmentation techniques, bone substitutes are still largely used for this procedure. Bone substitutes commercially available as Bio-Gen or Bio-Oss are spongy or cortical bone of equine or bovine origin, fully enzyme deantigenised, able to be resuspended in sterile saline solution and to be used as a scaffold for alveolar bone augmentation. The osteoconductive properties of these bone substitutes are widely recognized, but the most frequent criticism of these materials is that they only have osteoconductive properties, but not osteoinductive properties . In contSeveral animal experimental models are used to test different bone substitutes and their interactions with alveolar bone and periodontal tissues. Tests usually performed on dogs, rabbits, and rats have the main disadvantage of lacking early assessment of the effects of bone substitutes on periodontal tissues. Additionally, in this experimental model, the interaction between mesenchymal stem cells and bone substitutes is hard to quantify. This happens because the biopsies are harvested three to six months after experimental alveolar ridge augmentation ,12, and Chick embryo chorioallantoic membrane (CAM) is well known as a powerful experimental tool for the study of normal and pathologic angiogenesis, because of its high vascular network ,14. AddiBased on the versatility of CAM given by its immature mesenchymal structure and its ability to have no immune system, we propose here CAM as a model for testing one of the bone substitutes usually used for alveolar ridge augmentation. We used three different resuspension media to assess if different resuspension media may influence bone substitute behavior. The main objectives of the present study were focused on: (1) The identification of a possible osteoinductive effect of the bone substitute on CAM mesenchymal cells, (2) the assessment of inflammatory response induced by the CAM–bone substitute interaction, and (3) the effects of the bone substitute on CAM vessels and angiogenesis. The specimen survival rate was over 95%, and those who died before the end of the experiment were most likely influenced by daily manipulation rather than by the implant. Significant macroscopic changes were dynamically observed during the experiment, as shown in Hyaluronic acid (H) alone induced a discrete increase of CAM vascularization, which started early on day 1 a; was maBSH produced different specific changes compared to the previous compounds. The bone particles remained dispersed within the silicone ring, where they were implanted m,n. The CAM biopsies harvested on day 13 were histopathologically and immunohistochemically evaluated. The microscopic examination of the H samples highlighted a large number of blood vessels, confirming a vascular reaction in the CAM, while for the samples treated with saline solution (S), the number and distribution of the blood vessels was similar to that of normal CAM.The morphology of the mesenchymal cells from CAM chorion in H-treated specimens was significantly changed compared with control specimens. We observed that CAM chorion cells became elongated with a spindle like shape and a tendency to be grouped as compact structures just below CAM epithelium. The same aspect of stromal cells reorganization was also observed in BH treated specimens.For the BSH samples, a large inflammatory infiltrate was detected around the implant. At the end of the experiment, resorption areas prevailed, detrimental to the compact areas. In compact areas, resuspended bone cells showed an intense acidophilic cytoplasm and were poorly interconnected. At the end of the experiment, the BH complex showed the lowest resorption rate. Around BH samples, there was an angiogenic response in the absence of inflammation.Microscopically, on specimens treated with BH complex, compact structures were observed, composed of tightly interconnected cells able to create a continuous, well-defined layer, tightly attached to the internal surface of the CAM a. New blA panel of antibodies involved in osteoblastic differentiation (RUNX2), bone matrix synthesis (SPARC), and ossification (BMP4), were applied and different results obtained.Mesenchymal cells from samples treated with hyaluronic acid (H) alone were negative for RUNX2, BMP4, and SPARC a, b. SpeBS samples showed a positive but inconsistent reaction for RUNX2, and SPARC was not expressed in these types of samples, nor BMP4. The BSH complex was also reflected in the expression pattern of the three markers included in the study, and completed the morphological characterization of BSH-treated samples. Thus, RUNX2 was expressed in the mesenchymal cells of the CAM adjacent to the implant. The expression was mild regarding the density and intensity of immunohistochemical reaction in the implant areas c. The stThe BH complex induced significant changes, both morphological (previously described) and molecular, characterized by the expression of RUNX2, BMP4, and SPARC. A particular aspect was encountered in the case of the BH complex and was represented by stratification of RUNX2 positive cells a.The stratified organization induced by the BH implant was characterized by heterogeneity in the distribution of RUNX2 positive cells. The highest density was recorded inside the BH implant, giving the appearance of a compact structure b. The condensed stroma adjacent to the BH implant represented the second layer composed of spindle cells with positive nuclei for RUNX2 c. Cells The other two markers were strongly positive for the BH treated samples too. SPARC was expressed in all three layers with cytoplasmic expression and some scattered nuclear expression, more intense in the implant areas and moderately weak in the CAM modified chorion a–c. BMP4A comparative assessment of the results is summarized in Alveolar ridge augmentation was developed at the beginning of the 1980s by Tatum and Boyne, and made possible the rehabilitation of implantology and increased the success rate of the dental implants by restoring alveolar bone atrophy and preparing it for the future dental implant ,32. The The diversity of biomaterials used, respectively organic or inorganic materials of animal or synthetic origin, as well as the heterogeneity of the resuspension media of these materials, are the basis of the controversial results in the literature, as well as the failure of dental implants following these interventions. Moreover, the characterization of the early stages of bone augmentation behavior, both at the morphologic and molecular level, are rare and incompletely studied. It is well known that any natural bone material used as xenograft in alveolar ridge augmentation has osteoconductive properties, and few of them have osteoinductive effects. The alveolar bone has a particular histological structure, consisting of compact bone and spongy bone, which is why the materials used should contain both cortical bone and spongy bone particles.Experimental studies for alveolar bone substitutes are extremely limited at this time. Relatively recent studies have tested the efficacy of the BioGen Bioteck bone equine implant for experimental fractures induced in rabbits, sheep, or rats ,36,37,38The experimental model based on the chorioallantoic membrane allows the observations of bone substitute effects starting from the early stages, an aspect that cannot be studied in other experimental models, due to the failure of daily microscopic assessment. Other experimental models do not allow the dynamic follow-up of the bone implant and adjacent stroma interactions, nor the molecular differences involved in these stages of the implant. Bone grafts on CAM are rarely cited in the literature. Most bone graft models use bone fragments stored in tissue banks , and so ®, Bioteck, Vincenza, Italy), and resuspended in three different excipients: Hyaluronic acid (H), , sterile saline solution (S) , and a combination of hyaluronic acid and sterile saline solution (HS). Based on our previous observations regarding the diversity of the clinical response to the different types of excipients used for resuspending bone particles, we tested the chorioallantoic membrane reaction to bone granules (B) combined with saline (BS), hyaluronic acid (BH), and both hyaluronic acid and saline (BSH). Four types of resuspension media were tested on CAM: H, S, BH, and BHS. Details regarding these substances and their combinations are summarized in For the purpose of this study we used granules of spongy and cortical bone of equine origin, fully enzyme deantigenised (B)  and four test groups (with 5 eggs each). H, S, BH, and BHS were applied inside the silicon ring. The experiments ended on day 13 of incubation. For all procedures the ethical European rules regarding the use of animals for experimental purposes were respected. Because the CAM experimental method does not apply direct traumatic methods to chick embryos, and no pain occurs due to the lack of nerve fibers in the CAM, ethical approval was not mandatory for this type of experimental model. The experiments were stopped by in ovo fixation of CAM with 10% buffered formalin for 30 min. Then, CAM and the corresponding implants were removed and continued to be fixed for 24 h, followed by the paraffin embedding procedure. Three micrometer serial sections were performed, and routine hematoxylin and eosin stain was performed for histopathologic evaluation. Corresponding sections from each specimen were selected for immunohistochemistry. Immunohistochemistry helped us assess the osteoblastic commitment of mesenchymal cells, osteoblastic differentiation, and bone formation. Three different antibodies were selected. We used rabbit polyclonal anti RUNX2 (Runt-related transcription factor 2) antibody , well known as the key transcription factor associated with osteoblast differentiation; rabbit polyclonal anti SPARC (osteonectin) antibody , a bone glycoprotein secreted by osteoblasts; and rabbit polyclonal anti BMP4 (bone morphogenic protein) antibody , a polypeptide specifically involved in bone repair. Incubation with primary antibody for 30 min at room temperature was followed by the use of the visualization system Novolink Max Polymer/DAB. All immunohistochemistry steps were fully controlled using Max Bond Autostainer . All CAM specimens were daily evaluated in ovo using an Axio CAM Stereo Microscope , and pictures from different moments of the experiment were obtained and processed with ZEN software . Microscopic evaluation of the specimens was performed using an Axio Zoom 2 Observer Microscope (Zeiss).This study is the first CAM experimental model testing biomaterials used in bone augmentation. Undifferentiated CAM mesenchymal cells can be considered as an in vivo platform of cells with a high potential of differentiation, similar to those found in alveolar bone, which are able to differentiate into the osteoblastic lineage. The BH complex induced CAM mesenchymal cells differentiation towards osteoprogenitor and osteoblastic lineage. Based on our experimental results, the BH complex is an ideal combination for alveolar ridge augmentation, because it does not induce inflammation, and its osteoinductive effect on mesenchymal cells was certified in the present study by RUNX2 +, BMP4 +, and SPARC + phenotype capable of bone matrix synthesis and mineralization. Additionally, our study supports the use of mesenchymal cells combined with bone substitutes and hyaluronic acid in alveolar ridge augmentation.


Avian avulavirus 1. Here, we describe the molecular epidemiology of Latin American NDVs, current control and prevention methods, including vaccines and vaccination protocols, as well as future strategies for control of ND. Because the productive, cultural, economic, social, and ecological conditions that facilitate poultry endemicity in South America are similar to those in the developing world, most of the problems and control strategies described here are applicable to other continents.Newcastle disease (ND) infects wild birds and poultry species worldwide, severely impacting the economics of the poultry industry. ND is especially problematic in Latin America  where it is either endemic or re-emerging. The disease is caused by infections with one of the different strains of virulent avian Newcastle disease virus (NDV), recently renamed The online version of this article (10.1007/s11250-019-01843-z) contains supplementary material, which is available to authorized users. T 1) Mayo . The vir 1) Mayo , and inf 1) Mayo .Based on genetic characteristics, NDV has been classified into class I and class II viruses. Class I NDV have been isolated predominantly from wild birds, are mostly of low virulence, and their presence is only rarely reported in poultry species. Classification of class II NDV strains has been thoroughly reviewed elsewhere , Nicaragua (2001), and Belize (2008) suggesting that this genotype may have become established in some unknown reservoir  and Brazil in 1953  was obtained in May of 2008 from a commercial pullet flock presenting high mortality rates and clinical signs of ND  employed most commonly as seed strains for live, and inactivated vaccines are applied worldwide  chickens that have no maternal antibodies to NDV under laboratory conditions, they do not prevent replication and shedding of virulent challenge virus into the environment and into eggs , smaller eggs with rough, thin, and whiter “bleached” shells and poor-quality contents (whites and yolks)  vaccine and a recombinant genotype seed strain vaccine are also often used in Mexico. The rP05 vaccine contains a complete recombinant NDV of low virulence expressing the F and HN proteins of a genotype V NDV. Most of the oil emulsion type inactivated vaccines for the prevention of ND are mixed with two to four additional infectious antigens to decrease the number of times the birds have to be handled, resulting in less stress for the birds and decreased costs for vaccine administration. For example, in addition to the NDV genome, most vaccines also contain fowl adenovirus , infectious bronchitis virus, avian influenza virus (H5N2), and infectious bursal disease virus (Gumboro)  expressing one of the genes encoding the antigenic proteins of NDV, mostly the fusion protein gene, are available and reviewed by Dimitrov et al. (Layers have extended vaccination programs to provide protection during their longer (compared with broilers) lifespan. For example, in Mexico during breeding (0 to 18 weeks of age), hens receive at least four vaccines against NDV (2 live/2 inactivated)  are also included. HVT is a persistent apathogenic virus for chickens that induces long-term immunological protection, and is therefore, considered a good viral vector for use in poultry. In addition, HVT also induces protection against Marek’s disease virus, so these vaccines are capable of inducing protection against both viruses  in comparison with 90.5% survival in the experimental farm  Hoerr . ImmunosStressful rearing situations, in addition to live agents, may contribute to immunosuppression Hoerr , and proNDV is capable of increasing the concentration of corticosterone up to sixfold in the serum of infected birds .Prevention and control strategies for Newcastle disease in endemic countries need improvement. Ideally, these would include measures that include culling, active surveillance, improved biosecurity, and stringent vaccination programs. Any strategy needs to be accompanied by measures that ensure strict compliance of policies and procedures, which would include adequate record keeping and control of movement and disposal of infected animals. As with the outbreaks in the USA , the measures might include control of the viruses replicating in backyard and pet species, together with control of viruses in commercial birds. The current reliance on the use of vaccines formulated from seed strains from older genotypes that are less antigenically similar to the virulent challenge viruses may not eliminate the continuing persistence of the virus in farms due to viral excretion from the vaccinated-but-infected birds or prevent egg drops in vaccinated layers


A scarcely studied consequence of urbanization is the effect of temporal stabilization of the environment on bird communities. This alteration is thought to dampen environmental variations between day and night, seasons and years, promoting a temporal persistence of bird composition in urban areas. The aim of this study was to review current evidence of temporal stabilization of biotic and abiotic factors in urban environments and the potential effects of such stabilization on temporal variation of bird species presence at different temporal scales.I selected the literature by searching published articles and book chapters using Scopus and Google scholar. I only included articles that compared the temporal variation of bird composition or resources between different levels of urbanization.In general, there is evidence of temporal stabilization of abiotic and biotic factors at the three time scales considered. At the diurnal scale, the main factor considered was artificial light in the context of light pollution. At the seasonal and interannual scales, several case studies found a smaller temporal variation of primary productivity in urban than in natural and rural areas. Bird species composition showed more stabilization in urban environments at the three temporal scales: (1) several case studies reported bird activity at night, associated with artificial light; (2) studies in urban parks and along urbanization gradients showed smaller seasonal variation of bird composition in the more urbanized areas; and (3) in general, case studies along urbanization gradients showed smaller interannual variation of bird composition in the more urbanized areas, although some studies showed no relationships or opposite trends than expected.The published evidence suggests that urban areas dampen the natural cycles at several temporal scales. The stabilization of biotic and abiotic factors, such as light, temperature, food and habitat structure, is desynchronized from natural diurnal, seasonal and interannual cycles. However, there is a dearth of long-term comparisons of bird composition and studies that simultaneously analyze the relationship between resources and bird composition stabilization at the seasonal and interannual scales. More research is needed in the Southern hemisphere, where there is a lack of studies dealing with the seasonal and interannual variations of primary productivity along urbanization gradients and nocturnal activity of bird species. A future research agenda should include differentiation of spatial and temporal homogenization of avifaunas. Urbanization has many impacts on natural and semi-natural environments; urban expansion promotes fragmentation of ecosystems, perforation through the creation of different urban areas, alteration of biogeochemical cycles, the occurrence of the urban heat island phenomenon and pollution . These eBirds are one of the most widely studied taxa in urban environments because they are easily observable and respond to environmental changes . Birds cIn natural areas, biotic factors such as predator presence or food availability, and abiotic factors, such as the variation of light throughout the day or seasonal changes in rain or temperature, induce temporal changes in species composition, favoring the coexistence of species through temporal segregation and an increase in beta diversity . For exaPeucaea aestivalis) is related to fire disturbance, and a decline in its numbers is predicted due to projected urban growth  avoided illuminated areas when selecting nest sites  through the day and night  showed that in urban areas, wind speed was significantly reduced, contributing to increased plant growth and accumulated biomass . This inBiotic factors stabilized by urbanization at the seasonal scale included vegetation, abundance of arthropods and food supplied by humans. Abiotic factors, such as temperature and irrigation, also affected the extended growing season of vegetation.Evidence of altered seasonal patterns of resources came mainly from data of leaf and flowering phenology and vegetation indices obtained from remote sensors; those data are mainly indicators of the net primary productivity. Most studies were conducted in the Northern Hemisphere, mainly in USA and China; and were concentrated in the 2010–2018 period (10 out of 12 studies) . The mosAmbrosia artemissifolia flowered earlier in urban than in rural habitats of Minneapolis (USA), and attributed this asynchronous flowering to genetic differences between populations. On the other hand, Pinus sp. and Eucalyptus sp. may stabilize the seasonal dynamics of primary productivity in urban areas compared to agricultural and natural areas Pinus sp.al areas . Therefon = 20) and were equally distributed in North America, Europe, Asia, and South America Fig. 1). Natural disturbances that strongly impact vegetation structure and bird communities, such as hurricanes, tornados or fire , may be Case studies that analyzed the interannual variation of temperature in urban areas are scarce. A study from China showed that interannual variation in LST was higher in urban areas than in forests .A few studies from North America provided remote sensing data and suggested that urban areas have a lower interannual variability of primary productivity than natural areas . TherefoActivities such as maintaining vegetation or using fertilizers and pesticides may stabilize the interannual habitat structure and primary productivity of residential areas  Fig. 1)Fig. 1). However, several authors argue that urban areas may be unstable in the long term. Physical, social and vegetation changes associated with advances in urban technology, urban decay, urban redevelopment and socioeconomic fluctuations may influence biotic communities . On the Turdus merula). In general, most studies found more bird activity at night in areas with more artificial light. Other factors such as day length and cloud cover may influence bird activity at night , whereas the Great Horned Owl (Bubo virginianus) and the Eastern Screech Owl (Otus asio) did not exhibit responses to urbanization.The stabilization of bird composition between day and night can also be promoted by the extinction of nocturnal species. For example, Falco columbarius, Erithacus rubecula, Junco hyemalis, Passer domesticus, Turdus merula, Sylvia atricapilla) in Europe  in suburban habitats compared with bushland. Most of studies related community composition stability to urban attributes, such as impervious cover or human density.Most of the eight studies analyzed were conducted in the Northern Hemisphere, and during the 2010–2018 period (six out of eight studies). Five studies were long term (>5 years). In general, studies showed that urbanization stabilized the interannual variation of community composition . HoweverColumba livia or Turdus sp., food resource does not seem to be a limiting factor at night. Moreover, without artificial light, it is difficult that diurnal species could find food. At the seasonal and interannual scales, the stabilization of biotic factors seems to be the dominant determinant of bird composition stabilization. However, this stabilization of biotic factors is usually mediated by the effect of abiotic factors, such as water or the urban heat island phenomenon during winter.The role of stabilization of biotic and abiotic factors seems to vary at the different temporal scales. At the diurnal scale, stabilization of abiotic conditions such as light seems to be the most relevant, inducing nocturnal activity of birds. On the other hand, artificial light can increase food availability for nocturnal birds, especially insectivores. However, in the case of species that feed on human food waste or earthworms, such as Studies suggest that nocturnal activity is mainly regulated by artificial light, which alters melatonin secretion . MelatonCiconia microscelis) were provided supplementary food by humans year-round in KwaZulu-Natal (South Africa), and humans were motivated by pleasure  in Dunedin  complemented their seasonal foraging on insects by using exotic and native trees (Quercus robur) had the highest abundance of arthropods. The advance of reproductive phenology in the Abert ’s Towhee (Melozone aberti) in Phoenix was related to predictability and limited change of food resources in urban areas  presented a uniform use of carrion throughout the year, whereas rural vultures showed a fluctuation in diet composition from arthropods to carrion  was lower in the city of Warsaw than in a nearby forest, mainly due to predation on the resident House sparrow (Passer domesticus)  .In my opinion, spatial and temporal homogenization acts at different spatial scales and has different underlying processes. On the one hand, spatial homogenization is the increase of taxonomic similarity between two or more biotas over a specified time interval . The maiAre both processes simultaneous? The spatial homogenization of bird composition promoted by urbanization seems to be scale-dependent. While at a global scale or when comparing different biomes, there is a higher taxonomic similarity in the most urbanized areas than in less urbanized and non-urban areas , at the Published evidence suggests that urban areas dampen the natural cycles at several temporal scales. The stabilization of biotic and abiotic factors, such as light, temperature, food and habitat structure, are desynchronized from natural diurnal, seasonal and interannual cycles. These changes induced by urbanization are expected to influence the temporal dynamics of bird composition. In fact, the reviewed literature showed that bird composition was temporally most stable in the most urbanized areas, leading to a temporal homogenization of bird communities . As a reCalypte anna), the Allen’s Hummingbird (Selasphorus sasin sedentarius) and the White-throated Hummingbird  have expanded their range sizes and are highly associated with residential areas, which provide supplementary food resources such as nectar, year-round flowering plants and nesting sites (Psittacula krameri) and the Monk Parakeet (Myiopsitta monachus) in Europe and the Rainbow Lorikeet (Trichoglossus haematodus) in Australia, expanded their distributions associated with food and nesting resources provided in urban areas  of bird abundance between weekdays and weekends in sandy beaches of California and a significant interaction between weekends and seasons, suggesting that the effect of human density may depend on the period of the year and bird phenology. Therefore, we may expect significant changes in bird composition between weekdays and weekends in urban green spaces, because a massive number of people usually visit them on weekends.An overlooked aspect of urban environments is the possible creation of rhythms in bird communities as a response to massive movement of people between weekdays and weekends. Car traffic may promote weekly cycles of pollutants, wind speed and noise, which may cause changes in bird activity . Along aThe dampening of temporal variation in bird composition may be another aspect of the so-called extinction of experience , i.e., hRecently, a collaborative project that encompassed six metropolitan areas of varied climatic regions of the USA aimed to elucidate the ecological homogenization of urban areas compared to natural areas, showing convergences of soil moisture, amount of organic matter and microclimate among residential areas . In my o10.7717/peerj.6056/supp-1Supplemental Information 1Search terms used, number of scanned papers and number of selected papers.Click here for additional data file.10.7717/peerj.6056/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.6056/supp-3Supplemental Information 3Click here for additional data file.10.7717/peerj.6056/supp-4Supplemental Information 4Click here for additional data file.


How iCBT is designed and delivered differs across programs. Although iCBT is considered an effective approach for treating child and adolescent anxiety, rates of program use  are highly variable for reasons that are not clear. As the extent to which users complete a program can impact anxiety outcomes, understanding what iCBT design and delivery features improve program use is critical for optimizing treatment effects.Internet-based cognitive behavioral therapy (iCBT) is a The objectives of this study were to use a realist synthesis approach to explore the design and delivery features of iCBT for children and adolescents with anxiety as described in the literature and to examine their relationship to program use outcomes.A search of published and gray literature was conducted up to November 2017. Prespecified inclusion criteria identified research studies, study protocols, and program websites on iCBT for child and adolescent anxiety. Literature was critically appraised for relevance and methodological rigor. The persuasive systems design (PSD) model, a comprehensive framework for designing and evaluating persuasive systems, was used to guide data extraction. iCBT program features were grouped under 4 PSD categories—Primary task support, Dialogue support, System credibility support, and Social support. iCBT design (PSD Mechanisms) and delivery features (Context of use) were linked to program use (Outcomes) using meta-ethnographic methods; these relationships were described as Context-Mechanism-Outcome configurations. For our configurations, we identified key PSD features and delivery contexts that generated moderate-to-high program use based on moderate-to-high quality evidence found across multiple iCBT programs.A total of 44 documents detailing 10 iCBT programs were included. Seven iCBT programs had at least one document that scored high for relevance; most studies were of moderate-to-high methodological rigor. We developed 5 configurations that highlighted 8 PSD features  associated with moderate-to-high program use. Important features of delivery Context were adjunct support  and whether programs targeted the prevention or treatment of anxiety. Incorporating multiple PSD features may have additive or synergistic effects on program use.The Context-Mechanism-Outcome configurations we developed suggest that, when delivered with adjunct support, certain PSD features contribute to moderate-to-high use of iCBT prevention and treatment programs for children and adolescents with anxiety. Standardization of the definition and measurement of program use, formal testing of individual and combined PSD features, and use of real-world design and testing methods are important next steps to improving how we develop and deliver increasingly useful treatments to target users. Cognitive behavioral therapy (CBT) is recommended as a first-line treatment for children and adolescents with anxiety -4. Trainpersuasive system .-34.30-34Journal of Medical Internet Research, Internet Interventions, Journal of Cyber Therapy & Rehabilitation, and Journal of Telemedicine and Telecare, and a review of reference lists of included documents and reviews .We used 3 main strategies to identify literature for iCBT programs. The first search strategy involved an information specialist conducting a systematic and comprehensive search of 8 electronic databases: MEDLINE, EMBASE, ERIC, PsycINFO, CINAHL, Cochrane Library, ProQuest Dissertations & Theses Global, and PubMed for the period 1990 to 2017. The second strategy involved a manual search using Google, an internet search engine, and gray literature repositories  to identify conference proceedings, program evaluations, and government or technical reports. For both search strategies, MeSH terms and text words were based on mental health condition (anxiety and phobias), intervention modality (internet-based and mobile app), intervention type (prevention and treatment), and therapeutic approach CBT; . The thiWe employed the search strategies on an iterative and recurrent basis until November 2017 to ensure the review was up to date and inclusive. Before discontinuing the literature search, a test of saturation was applied to the search strategies, which involved verifying that further searching would not yield any new results .In this study, 2 independent, trained reviewers (authors ADR and LW) screened the identified documents for eligibility using a 2-stage approach. During this process, reviewer discrepancies were resolved by consensus or third party arbitration (author ASN). At stage 1, all documents were screened for eligibility using the title and abstract. During this stage, we randomly selected 100 citations to assess inter-rater agreement for inclusion or exclusion decisions; Cohen kappa was 0.74 between raters, reflecting substantial agreement . All docFor an iCBT program to be included in this synthesis, supporting documents needed to be published in English and provide information on treatment Context, program design (PSD) and delivery features, and program use Outcomes. Each document did not need to provide details on all 3, but all 3 needed to be represented in the total documents for an iCBT program. In addition, at least one published study on the iCBT program needed to be available for inclusion so that we could assess the methodological quality of the study providing program use outcome data.Intervention studies  were eligible for inclusion if they evaluated iCBT anxiety programs with children (aged <14 years) or adolescents (aged 12-19 years). As some iCBT programs were designed for and evaluated with participants from a broader age range , only those studies that provided separate data for participants aged ≤19 years were included. We also required that the type of iCBT program under evaluation be designed for an anxiety disorder(s) or anxiety symptoms associated with a disorder as classified according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition  such as low if little or no information was provided, medium if some information was provided, and high if information was well described. Exemplar documents with a high level of contribution across the 3 domains informed decision rules for the rating of all other documents.Documents were assessed for relevance and rigor based on consensus between 2 reviewers (authors ADR and LW). Relevance was assessed based on the level of contribution a document provided for an iCBT program in 3 domains: (1) underpinning theory and/or the context and sequence for delivery (Context), (2) PSD features (Mechanism), and (3) program use outcomes (Outcomes). The level of contribution for each domain was rated The methodological quality (rigor) of research studies was assessed using the Mixed Methods Appraisal Tool (MMAT) ,39. The Documents for each iCBT program were grouped together during data extraction and coding. Two reviewers (ADR and LW) cross-referenced extraction and coding decisions, with a random subset of 10 documents; the remaining documents were coded by 1 reviewer (ADR). In addition to document characteristics (type and year of publication), iCBT program data were extracted for the following:Participants: eligibility criteria and participant demographics.iCBT program Context: number of modules, module workflow and sequence, delivery setting, adjunct support, and level of prevention according to the Institute of Medicine model .Theory or proposed Mechanisms: program features, content and components, including PSD features, and information on why the iCBT program was designed a certain way or how the program was proposed to work.Program use Outcomes: information related to how many Web-based modules, exercises, or activities were completed by users or how many users completed certain aspects of the program, measured at posttreatment.Adjunct support details were coded when human-derived technological or therapeutic communication was provided to users to complement iCBT program delivery.Therapeutic content in programs was coded according to the 5 main CBT components found in the American Academy of Child and Adolescent Psychiatry (AACAP) practice parameter : psychoeAs most authors did not use PSD terminology or concepts, program descriptions were coded as PSD features using a codebook and glossary  Multime. PSD feaWe found inconsistent and heterogeneous measurement and reporting of program use Outcomes—such as program adherence, compliance, and completion. These limitations have been noted by others .program use. As no applicable cut-off scores have yet been established, when possible, Outcomes were converted into percentages (based on quartiles) to assist with interpreting program use. We used the following parameters to summarize program use: high use (≥75%), moderate use (50%-74%), low use (25%-49%), or very low use (≤24%). Study dropout or attrition data were not included in the analysis because these data may not directly reflect program use , but rather rates of study participants who did not fulfill the research protocol  [For each study, program use Outcomes are reported as published by original authors and are collectively referred to in this study using the umbrella term nnaires) . CorrespWe used a multistep approach to data analysis that was structured according to Pawson’s techniques ,28 and mThe second step in the analysis involved reciprocal translation analysis, a meta-ethnographic technique that involved reviewing the Context-Mechanism-Outcome configurations across iCBT programs ,45. ConfIn the final step, we used lines-of-argument synthesis, a theorizing technique  that invThe literature search and selection progress are presented in All programs described themselves as CBT-based and contained at least 3 of the 5 AACAP-recommended CBT components . The workflow of the programs presented the more foundational and simpler treatment components  before more challenging skills . Many programs also integrated interpersonal therapy skills , such asThe frequency of the PSD features used in the iCBT programs is shown in high for level of contribution for program Context, Mechanisms, and Outcomes. We evaluated 29 research studies (found in 25 documents) for methodological rigor. A total of 19 studies met all 4 MMAT criteria (100%), 7 met 3 criteria (75%), and 3 met 2 criteria (50%). Lower ratings reflected an unclear description of: processes for recruitment, selection, randomization, or allocation; how group differences (if any) were controlled for; the percentage of outcome data obtained; or withdrawal or dropout rates were not within acceptable limits.Details of the quality appraisal are provided in high or moderate program use.When finalizing our proposed configurations, we considered both what program Contexts and Mechanisms were combined using  and 3 anKey Contexts and PSD Mechanisms that may have led to moderate-to-high iCBT program use Outcomes are described in Evidence from 8 iCBT programs suggested that indicated prevention and treatment programs that provided adjunct support along with Tailoring and Personalization resulted in greater program use. Studies supporting this configuration had a mean MMAT score of 90.2%.Tailoring and Personalization were used to provide users with more information to increase the individualized feel of the program and portray that the program knew and could meet the user’s needs. Programs most commonly tailored content  based on the user’s age or mental health condition . User information was often collected by the adjunct support person during study enrollment . Personalization was a feature that could be initiated through program automation  or via program communications . The adjunct support person acted as an extension of the Tailored or Personalized program experience through their contact with users within  oEvidence from 6 iCBT programs suggested that indicated prevention and treatment programs that provided adjunct therapist support along with Reminders also resulted in greater program use. Studies supporting this configuration had a mean MMAT score of 92.1%.The programs contributing to this Context-Mechanism-Outcome configuration involved multiple modules or activities (the number of modules ranged from 6-11 or app use ranged from daily-weekly activities); therefore, users were required to log into the program over numerous instances. Reminders were used to encourage the user to take program action, either by promoting skills practice  or by “pEvidence from 4 iCBT programs suggested that programs and mobile apps that provided adjunct support along with Rewards resulted in greater program use. Studies supporting this configuration had a mean MMAT score of 85.0%.A total of 3 iCBT programs regularly incorporated Rewards into modules to encourage ongoing program use and promote the completion of essential treatment exercises ,47,51. TEvidence from 6 iCBT programs suggested that indicated prevention and treatment programs with adjunct Web- or email-based therapist support that also provided a Social role component, and conveyed Authority, Expertise, Trustworthiness, resulted in greater program use. Studies supporting this configuration had a mean MMAT score of 91.3%.The Social role component of iCBT programs was often fulfilled by a therapist or coach . Therapists engaged in regular, Web- or email-based communication with the user and served 2 roles by (1) facilitating program delivery by providing technical support and answering users’ questions and (2) promoting program completion by providing reminders and encouragement, reinforcing program concepts, and ensuring accurate comprehension and application of CBT skills. Together, the Social role feature and therapist emails complemented (had overlap with) other PSD features such as Reminders, Praise, and Suggestion. Therapists had secure access to users’ written responses or logged data so that they could send specific communications to users, demonstrating therapists’ credibility and competence with both the therapeutic process and individual responsiveness . Moreover, 3 studies measured child-reported therapeutic alliance with their iCBT program therapist and found it to be strong and program use to be high ,81. One Evidence from 5 treatment programs suggested that iCBT programs with adjunct therapist and parent support that also included a Social role component, and conveyed Authority, Expertise, and Trustworthiness, had greater program use. Studies supporting this configuration had a mean MMAT score of 90.8%.Treatment-based iCBT programs were designed to be child-parent combined or parent-supported child-based interventions. Combined interventions required parents to complete parent-specific modules  either before or alongside their child as they completed their own child-directed modules. In parent-supported interventions, parents may have also been responsible for explaining program instructions and assisting their children with their modules ,54,76, cpersuasiveness and its potential to assist the user with their goals of the program [The role of technological, persuasive components in iCBT programs is an understudied aspect of program design and evaluation. The extent of iCBT program use may be a fundamental indication of its  program ,88-91. TThe 5 Context-Mechanism-Outcome configurations provide support for several persuasive strategies to improve iCBT program use: Tailoring and Personalization as Primary task supports; Rewards, Reminders and Social role features in programs serving as Dialogue supports; and Trustworthiness, Expertise, and Authority features serving as System credibility supports for a program. Traditionally, PSD features that stimulate human-computer communication, such as Dialogue supports, have been the most widely used and studied features for improving program use ,89,92,93necessary for program use , whereas others may be complementary to program use (have an impact by enhancing the design framework of iCBT); although both types of features together may influence program use. In this realist synthesis, all 10 iCBT programs described a purposeful design that incorporated Reduction and Tunneling (Primary task supports) and Similarity and Liking  to create a logical, incremental, relevant, and aesthetically pleasing experience for users—these may be the necessary PSD features for iCBT for children and adolescents with anxiety. The PSD features described in our configurations are hypothesized to be complementary—building on the persuasiveness of necessary PSD features to further improve or optimize iCBT program use.Moreover, we suspect that not all PSD features may have equal influence on program use. Depending on the program, some PSD features may be real world and from the user’s perspective [A meta-analysis of PSD features used in internet-based interventions for mental health demonstrated that determining the amount and type of persuasive principles to include may be a delicate balance, as some principles seem to work together, whereas when other principles co-occur, they may have an unapparent or diminishing effect . As was spective ; therefospective .In this synthesis, 3 important potential relationships were identified: (1) adjunct support seemed to improve program use even when input or support was minimal  or when it was provided by a nonexpert  ,25; (2) This realist synthesis not only provides support for incorporating some of the well-studied and highly used PSD features into iCBT activated or present.Although this synthesis and other recent reviews have been helpful for identifying PSD features of interest for improving program use of internet-based interventions ,89,90, tThis is the first study to examine PSD features as they relate to program use in iCBT for children and adolescents with anxiety. A strength of this synthesis is the inclusion of diverse and high-quality evidence  from boprogram use. Adoption of a recent standardized definition and calculation of adherence [effective dose in different delivery settings. Finally, like others [The lack of operationalization of how PSD features and aspects of Context and program use Outcomes were defined, described, and measured by authors affected our data extraction and coding strategies. As adherence to recent recommendations  and repodherence  can clare others -121, we e others ,122), the others ), or pere others )—factorsThe Context-Mechanism-Outcome configurations identified by this realist synthesis provide an initial understanding of how, why, and for whom iCBT programs for children and adolescents with anxiety work from a persuasive systems’ perspective. Appreciating that the effectiveness of iCBT programs may hinge on whether and to what extent programs are used, this study is an important step toward successfully implementing and integrating iCBT into routine clinical care. Recognizing that multiple PSD features are incorporated in iCBT program designs and that individual features may affect each other differently, further knowledge and testing of the purpose and function of these features will help determine the number and combination to use in certain delivery contexts . As PSD features are modifiable, iCBT program designers and developers can look to create more persuasive programs that promote greater use and improved treatment outcomes.


In this data article, a robust data exploration is performed on daily Internet data traffic generated in a smart university campus for a period of twelve consecutive (12) months . For each day of the one-year study period, Internet data download traffic and Internet data upload traffic at Covenant University, Nigeria were monitored and properly logged using required application software namely: FreeRADIUS; Radius Manager Web application; and Mikrotik Hotspot Manager. A comprehensive dataset with detailed information is provided as supplementary material to this data article for easy research utility and validation. For each month, descriptive statistics of daily Internet data download traffic and daily Internet data upload traffic are presented in tables. Boxplot representations and time series plots are provided to show the trends of data download and upload traffic volume within the smart campus throughout the 12-month period. Frequency distributions of the dataset are illustrated using histograms. In addition, correlation and regression analyses are performed and the results are presented using a scatter plot. Probability Density Functions (PDFs) and Cumulative Distribution Functions (CDFs) of the dataset are also computed. Furthermore, Analysis of Variance (ANOVA) and multiple post-hoc tests are conducted to understand the statistical difference(s) in the Internet traffic volume, if any, across the 12-month period. The robust data exploration provided in this data article will help Internet Service Providers (ISPs) and network administrators in smart campuses to develop empirical model for optimal Quality of Service (QoS), Internet traffic forecasting, and budgeting. Specifications TableValue of the data•The data provided in this data article can be used to accurately predict Internet data traffic in a smart campus environment. Predictions of Internet data traffic will help network engineers to improve the Quality of Service (QoS) of computer networks and also ensure efficient utilization of the networks in a smart university campus •Availability of dataset on Internet data traffic obtained from real scenarios will facilitate more empirical research in the areas of computer networking and Internet traffic engineering •This dataset is made available to give correct facts and figures on Internet data traffic in a Nigerian university campus that is driven by Information and Communication Technologies (ICTs) •Free access to daily Internet data traffic of a period of one year will facilitate the development of empirical prediction models that can be used by Internet Service Providers (ISPs) and Internet subscribers in a smart university campus for effective network planning and traffic forecasting •Robust data exploration that is performed in this data article will help the university network administrators to gain useful insights about the traffic peak and off-peak periods. Also, the descriptive statistics, frequency and probability distribution plots, correlation analysis, ANOVA test and multiple post-hoc test results will give better understanding of the relationships between the Internet data download traffic and the Internet data upload traffic in a smart campus 1Ubiquitous access to reliable Internet services is pivotal to achieving sustainable smart education in university campuses For each month, descriptive statistics of daily Internet data download traffic and daily Internet data upload traffic are presented in tables. The mean, median, mode, standard deviation, variance, kurtosis, Skewness, range, minimum, maximum, and sum of the daily Internet data traffic download and upload for January–December, 2017 are presented in 2A robust data exploration was performed on daily Internet data traffic in a smart university campus for a period of twelve consecutive 12) months . For each day of the one-year study period, Internet data download traffic and Internet data upload traffic at Covenant University, Nigeria were monitored and properly logged using an open source software, FreeRADIUS, Radius Manager web application, and Mikrotik Hotspot Manager. FreeRADIUS software was installed in Linux Operating System (OS) for authentication, authorization, and accounting services. Radius Manager Web application was used to add users, to edit and create cards, and to harvest data in a more user-friendly format. Mikrotik Hotspot Manager was used to integrate the smart campus network to the enterprise edge. Statistical computations were done using the Machine Learning and Statistics toolbox in MATLAB 2016a software. Boxplot representations of the daily download traffic and the daily upload traffic for the 12-month period are shown in  months  of 0.8791. A linear regression equation that represent the relationship is provided in the scatter plot shown in Furthermore, Analysis of Variance (ANOVA) and multiple post-hoc tests are conducted to understand the statistical difference(s) in the Internet traffic volume, if any, across the 12-month period. The results of the ANOVA test and the multiple post-hoc test conducted on download data traffic are presented in


We conducted a mixed-methods process and outcome evaluation for a statewide fruit and vegetable prescription program. The process evaluation assessed program implementation, identified opportunities for quality improvement, and provided recommendations for future programmatic activities. The outcome evaluation measured how the program affected purchases of fruits and vegetables among low-income patients and patient satisfaction with the program.The Washington State Department of Health (WA DOH) partnered with public and private health care systems, public health agencies, a community-based organization, and a supermarket chain to launch a fruit and vegetable prescription program in 2016. The prescription was a $10 voucher redeemable for fruits and vegetables at any one of 169 participating supermarkets. Prescriptions were distributed to eligible low-income patients in clinics and community settings.WA DOH reviewed quarterly reports, meeting minutes and notes, telephone call logs, and email logs to solicit feedback on program implementation processes. We calculated overall prescription redemption rates on the basis of the number of prescriptions distributed by implementing partners and the number of prescriptions redeemed at participating supermarkets. We assessed patient satisfaction through a web-based survey. The study period was July 1, 2016, through June 30, 2018.Best practices for implementation included using the prescription to improve patient engagement and retention and connect patients to additional services, and working in the community to enhance program support and uptake. Overall, $154,810 in fruit and vegetable prescriptions were redeemed during the study period (54.4% redemption rate). Most survey respondents (88.2%) reported eating more fruits and vegetables than previously as a result of the prescription.Fruit and vegetable prescriptions are an effective way to increase affordability of healthy foods for low-income patients. These programs are scalable and translatable across various types of patient–provider encounters. Programs that increase affordability of fruits and vegetables through financial incentives have improved fruit and vegetable consumption and food security among participants. However, program scalability is limited when programs rely on partnerships with farmers markets and small-scale grocers.Through a process and outcome evaluation, this report highlights program implementation successes and barriers of providing fruit and vegetable prescriptions in partnership with a supermarket chain to low-income residents in Washington State.A statewide fruit and vegetable prescription program is scalable and translatable across various types of patient–provider encounters and helps improve affordability of fruits and vegetables for low-income residents.Despite public health efforts, people in Washington State and the United States overall do not eat enough fruits and vegetables to meet national recommendations for a healthy diet –3. This Although in 2017 the overall food insecurity rate in Washington State (11.5%) was lower than the national average (12.5%), intrastate geographic and demographic disparities exist; the rate in some Washington counties is nearly 1.5 times the national average . Howeverwww.doh.wa.gov/FINI). As part of the FINI grant, WA DOH began implementing a statewide fruit and vegetable prescription program in July 2016.The US Department of Agriculture’s Food Insecurity Nutrition Incentive (FINI) Grant Program supports projects that incentivize the purchase of fruits and vegetables among SNAP participants . In 2015The objective of this study was to describe mixed-method process and outcome evaluation results after 2 years of implementation of the fruit and vegetable prescription program, using data collected from July 1, 2016, through June 30, 2018 . The purpose of the process evaluation was to 1) examine strengths and weaknesses of the fruit and vegetable prescription program implementation and 2) gain insight into successful programming activities for fruit and vegetable prescriptions. The purpose of the outcome evaluation was to 1) assess overall effectiveness of the program in improving affordability of healthy foods among low-income patients and 2) assess patient satisfaction with the fruit and vegetable prescription program. Although the program is planned to run through December 2019, the reporting of mid-program evaluation findings, given the current national climate for fruit and vegetable incentives , can helIn July 2016, WA DOH partnered with public and private health care systems, public health agencies, and a community-based organization , and a supermarket chain to launch a fruit and vegetable prescription program in counties where the prevalence of low fruit and vegetable intake, food insecurity, and chronic disease are disproportionately high . The fruProgrammatic planning exercises during the first 15 months of the grant period (April 2015–June 2016) included an in-person meeting, email correspondence, and webinars with implementing partners. Through these exercises, WA DOH and implementing partners identified that they needed flexibility in implementing the fruit and vegetable prescription program.Implementing partners used various types of patient encounters, prescribers, and dosing amounts , which wPatients redeemed the prescription at any one of 169 participating supermarkets in Washington State. Patients presented the prescription at point-of-sale to purchase qualifying items, which included fresh, canned, or frozen fruits and vegetables without added fats, oils, sugars, or salt. No additional purchase was necessary to redeem the prescription, but patients were encouraged to purchase at least $10 of qualifying items per transaction. WA DOH and the supermarket chain provided training to store staff members to prepare for prescription redemption. At the point-of-sale, the prescription was scanned and purchase information was stored in the supermarket’s sales database. The supermarket chain provided data on the number of prescriptions redeemed by PLU, by quantity and characteristics of items purchased, and by dollar amount.Overall, 14 implementing partners participated during the study period. The program began with 9 implementing partners; 3 implementing partners discontinued distributing prescriptions in 2017 and 2018 because of staffing limitations. In 2018, 5 new implementing partners began distributing prescriptions, resulting in 11 implementing partners with 185 prescribers in 86 prescribing sites in the program in June 2018 .To assess the fruit and vegetable prescription program, we conducted a mixed-methods process and outcome evaluation. The process evaluation assessed program implementation, examining strengths and weaknesses of the program and identifying successful programming activities, to identify opportunities for program quality improvement and provide recommendations for future programmatic activities. The outcome evaluation measured program use: how the fruit and vegetable prescription program affected patients’ purchasing of fruits and vegetables and patient satisfaction with the program. We developed the evaluation plan and questions on the basis of extensive stakeholder input through annual in-person meetings and presentations, quarterly telephone calls and webinars, and frequent email communication with implementing partners. The Washington State Institutional Review Board deemed evaluation activities exempt from review.As part of process evaluation activities, we reviewed quarterly reports, meeting minutes and notes, and telephone call and email logs to solicit feedback on program implementation processes. Each quarter, as part of regular reporting required for participation in the program, implementing partners identified key successes in their fruit and vegetable prescription program implementation activities and overall experiences with prescription distribution, including facilitators and barriers to effective implementation. We collected this information electronically through a secure online survey platform. All implementing partners responded to the same open-ended questions on facilitators, barriers, and key program activities. WA DOH staff members reviewed these electronic reports each quarter and tracked responses through a Microsoft Excel 2013 spreadsheet, providing technical assistance as needed for continuous program quality improvement. In all, this review included 89 reports generated during the study period.WA DOH staff members also kept records of telephone calls and emails from implementing partners requesting technical assistance for program implementation and telephone calls and emails that described the steps taken as a result of this assistance. We matched details from telephone call and email logs to implementing partner reporting to identify and confirm quality improvement measures taken. In all, we reviewed records from 20 telephone calls and emails during the study period.In addition to required implementing partner reporting and requests for technical assistance, WA DOH staff members held quarterly meetings, including 6 virtual meetings and 2 in-person meetings, during the study period. These meetings were an opportunity for the study team to ground-truth key themes emerging from reporting and provided a venue for more in-depth knowledge sharing among all implementing partners. WA DOH kept detailed agenda and meeting notes from each of these meetings.Evaluation staff members reviewed all compiled responses from reporting, technical assistance efforts, and meeting notes and closed-coded responses to answer the following questions:What are major facilitators and barriers to 1) program implementation in the clinic setting and 2) patients’ use of a fruit and vegetable prescription?What are key activities and/or resources considered critical to the successful implementation of an incentive program in the clinic setting?Evaluation staff analyzed coded responses and identified patterns across responses by using thematic analysis.Although one-on-one in-depth interviews were originally planned during the study period as part of the process evaluation, staffing limitations led to a change in methodology and approach. Additionally, preliminary review of documents received from implementing partners and sharing of results with key stakeholders showed that information from regular reporting and technical assistance activities was more than sufficient for identifying facilitators and barriers to program implementation and provided more timely information for continuous program quality improvement than would have been possible from interviews.We calculated overall prescription redemption rates for each implementing partner as a measure of program use. Each quarter, implementing partners reported the number of prescriptions distributed each month via a secure online portal. Each month, WA DOH also received point-of-sale transaction details for each prescription redeemed, including the PLU, dollar amount spent, and characteristics of items purchased, from the supermarket’s sales database via secure file transfer. Fruits and vegetables purchased at the point of redemption were categorized according to type  and whether they were eligible to be purchased with the prescription . We calculated redemption rates by dividing the number of prescriptions redeemed by the number of prescriptions distributed over the specified time period. We reported rates to implementing partners each quarter. We assessed redemption rates by quarter and time of month  to determine how timing of SNAP benefit issuance affected prescription redemption. We compared redemption rates from earlier in the month  with the third 10 days to assess whether the fruit and vegetable prescription was helping to stretch participants’ SNAP benefits. We used data on purchases and redemption data to assess program use to answer the following evaluation question: To what extent did patients use the fruit and vegetable prescription?We surveyed patients to assess their satisfaction with the fruit and vegetable prescription program. Because response rates for telephone and mail-based surveys are declining  and becaPatients could complete the voluntary survey on any electronic device and were eligible to take the survey each time they received a prescription. When the prescription was distributed to an adult on behalf of a child’s participation, the parent or guardian was invited to take the survey on behalf of the child. The survey consisted of 30 questions, including validated questions on demographic and socioeconomic characteristics , food inTo what extent did patients find the fruit and vegetable prescription acceptable to use?How does receipt of a fruit and vegetable prescription change patients’ knowledge, attitudes, and practices toward fruit and vegetable consumption, health behaviors, and perceived access to healthy foods?The survey first became available to patients in September 2017. Each participant received a $3 electronic gift card at each survey completion (maximum 1 per week). We managed and calculated summary statistics  by using Microsoft Excel 2013.Implementing partners identified several key milestones and lessons learned as a result of the prescription program, illuminating potential areas for future program success.Offering the fruit and vegetable prescriptions improved patient visits. Implementing partners consistently reported increased attendance and retention in health care appointments and community-based classes when prescriptions were offered. For example, one implementing partner reported higher-than-average completion rates among patients in the Chronic Disease Self-Management Program as a result of offering the prescription, with 95% of patients completing the 6-week program. Anecdotal evidence also showed that as a result of the fruit and vegetable prescription program, patients scheduled and kept more follow-up appointments with primary care dietitians, and no-show rates for home visiting decreased slightly.Providing a method to identify high-need patients helped connect these patients to additional services. Several implementing partners incorporated food insecurity screening and nutrition wraparound services into their institutional workflows as a result of offering fruit and vegetable prescriptions. One pediatric primary care clinic referred food-insecure families to an outreach organization that helped families determine eligibility for and enroll in SNAP and other food assistance resources. Another implementing partner worked with community health workers who lived and worked in low-income housing sites to distribute prescriptions during nutrition education events. The community health workers were uniquely situated in these low-income housing sites and connected their peers to other health-related screenings and programs that improve food security and other social determinants of health.Working in the community enhanced program support and uptake. Implementing partners reported using several methods to best reach eligible patients in their communities. One such method was having bilingual dietitians, nutrition educators, and other health care providers distribute fruit and vegetable prescriptions. One implementing partner hosted culturally relevant nutrition education classes in Russian and distributed the prescriptions in the Russian-speaking community. Other implementing partners reported efforts to engage with the Spanish-speaking community; however, some patients expressed hesitancy in enrolling in SNAP for fear of negative consequences to their documentation status.Eliminating administrative burden helped ease program implementation. Implementing partners reported difficulty tracking distribution of the paper-based prescriptions for various reasons. First, the prescriptions required a hand-written expiration date, which increased workload on prescribers, as well as time required for distribution, which could affect patients’ perception of the program. Prescribers in many encounters also had to count out each prescription during distribution, which required time and introduced potential human error in the number of prescriptions distributed. Many prescribers distributed prescriptions outside of traditional clinic visits , and they used paper tracking sheets to document distribution because they did not have access to an EMR. Although prescribers could have used technology — for example, tablets or smart phones — for tracking purposes, the use of technology could have been perceived as intrusive to patients or as a barrier to prescribers. Finally, in the few locations where the EMR was available, implementing partners found that introduction of an EMR tracking method was cost-prohibitive because of the involvement of outside vendors or information technology staff.Redemption rates and other characteristics of fruit and vegetable prescription transactions. During the study period, 28,481 prescriptions were distributed, with $284,810 provided to patients to use when purchasing fruits and vegetables. Of these, 15,481 prescriptions were redeemed, for an overall redemption rate of 54.4% . Because each prescription was valid for 1 month from the date of distribution, and the exact date of prescription distribution was not linked with date of redemption, this redemption rate is a conservative estimate; true redemption rates cannot be calculated until one month after the program’s end, in December 2019. Redemption rates varied by quarter , patients spent more than $10.00 on qualifying items . On averPerception of the fruit and vegetable prescription program among patients receiving prescriptions. From September 1, 2017, through June 30, 2018, 144 patients completed the electronic survey. Most respondents  reported the prescription was easy to use. Of the 144 respondents, 74.3% (n = 107) reported food in their home was less likely to run out as a result of the prescription, and 86.8% (n = 125) reported increased ability to afford balanced meals.Patients also reported a perceived increase in fruit and vegetable intake as a result of receiving the fruit and vegetable prescription: 88.2% (n = 127) reported eating more fruits and vegetables than previously and 70.1% (n = 101) reported that they tried a new fruit or vegetable. In addition, 76.4% (n = 110) reported increased fruit and vegetable consumption among family members.Participation in the program also resulted in patients’ perceived health benefits: 71.5% (n = 103) reported managing their health conditions better, and 81.2% (n = 117) reported improvement in meeting nutrition, diet-related, or meal plan goals.Results from the mid-program evaluation affirmed that the fruit and vegetable prescription program improved affordability of fruits and vegetables for low-income patients and helped them achieve their health behavior goals. Our analysis shows patients maximized the full value of the prescription, and stretched limited food budgets to buy healthy foods. Patient-level survey responses showed a perceived improvement in consumption of healthy foods and perceived health benefits as a result of receiving the prescription.Findings from our evaluation highlight several important points. First, our results show that fruit and vegetable prescription programs are scalable and translatable across various patient–provider encounter types in various geographic settings, but they require flexibility for implementing partners to fit into their typical institutional or programmatic workflows. Despite this requirement of flexibility, offering the prescriptions is an effective way to engage patients in educational and counseling sessions. A key reason for its effectiveness is that the prescription simultaneously addresses food insecurity and chronic disease prevention/management by providing financial support for patients to modify purchases and achieve healthy eating goals.Second, our evaluation results show how social determinants of health can be incorporated into patient-provider encounters. Implementing partners can capitalize on fruit and vegetable prescription programs by establishing consistent, holistic enrollment criteria and processes for patients. Although funding for this program requires patients to be enrolled in SNAP, a useful screening tool for other fruit and vegetable prescription programs would be the Hunger Vital Sign , a validThird, minimizing the amount of time required by prescribers to distribute the prescriptions is helpful for effective program implementation. Although streamlining the process of distribution for all implementing partners may not be feasible, one strategy is to move from a paper prescription to a reusable card. Prescribers would issue the card and load it with a certain amount of dollars for fruits and vegetables, and patients would use it just like any other payment card at participating food retailers at point-of-sale. Prescribers could reload cards during follow-up appointments or classes. Although a card-based system may be more expensive than a paper-based system, ultimately it could increase efficiency and improve tracking for distribution and redemption.Implementing partners worked with various populations, including racial/ethnic minority groups, senior citizens, and residents in urban and rural areas. For all implementing partners, redemption rates were 34% or higher. We realize that a statewide fruit and vegetable prescription program may not be feasible for other states to implement because of lack of funding and resources. However, similar programs at any scope or scale can benefit from the lessons learned in our evaluation. Additionally, such programs can play a role in connecting health care with social determinants, which ultimately can improve population health; therefore, funding organizations and legislators should consider investing in programs that support healthy food purchases for low-income patients.This evaluation has several limitations. The diverse implementation of the fruit and vegetable prescription program limited the evaluation design, data collection methods, and subsequently the generalizability of findings. WA DOH supported flexibility in program implementation, which increased the number of patients receiving a prescription; however, this flexibility prevented the clear, concise interpretation and translation of results that is possible under the conditions of a controlled trial. Although a redemption rate of 54% is respectable, 46% of prescriptions were not redeemed. Because of the varied approaches in program implementation, we could not collect information from patients who did not redeem the prescription and better understand reasons for not using it. Data collection was logistically and ethically challenging because of the number of implementing partners and prescribers; for this reason, we collected a minimal amount of patient-level data. Additionally, program implementation hindered the collection of preprogram and postprogram measures, so we could not ascertain causal relationships. Finally, information on perceived benefit was limited to self-report, which is subject to bias. More objective measures, such as biometric measures collected from an EMR, could eliminate potential bias, and will be added to data collection activities in future years, where possible. Although the use of the electronic survey to collect data from patients enhanced data collection and minimized administrative burden, the response rate could be improved, and evaluation staff members will continue to work with implementing partners to improve this rate.Despite these limitations, we believe that these evaluation activities were effective in providing a snapshot of the fruit and vegetable prescription program in Washington State. By using an electronic survey to collect data from patients and having electronic access to implementing partner reports and point-of-sale data, we streamlined the process of data collection, entry, and analysis. Consistent reporting from implementing partners allowed for continuous program quality improvement and provided an easy outlet for partners to report programmatic facilitators and barriers. We also believe that our findings and our approach, compared with those of a controlled trial, more accurately describe best practices for translating a fruit and vegetable prescription program to US settings that would not be appropriate for a controlled trial.