The mission of this meeting was to facilitate communication and collaboration among scientists from around the world who are interested in different aspects of bone marrow adiposity in health and disease. The BMA2020 meeting brought together 198 attendees from diverse research and clinical backgrounds spanning fields including bone biology, endocrinology, stem cell biology, metabolism, oncology, aging, and hematopoiesis. The congress featured an invited keynote address by Ormond MacDougald and ten invited speakers, in addition to 20 short talks, 35 posters, and several training and networking sessions. This report summarizes and highlights the scientific content of the meeting and the progress of the working groups of the BMA society (http://bma-society.org/).The 6 The Bone Marrow Adiposity Society (BMAS) conferences are greatly enhanced by the broad research and training backgrounds among conference organizers, speakers, and attendees that promote diverse perspectives and opportunities for collaboration. The field of bone marrow adipose tissue (BMAT) research is growing, which was reflected in the BMA2020 program. Besides a specific focus on aging and osteoporosis, the BMA2020 meeting program included sessions related to the role of BMAT in hematopoiesis, regulation of systemic energy metabolism, cancer development and metastasis, and response to environmental cues including nutrition and exercise  and was co-organized by Drs. Erica Scheller (Washington University), Meghan McGee-Lawrence (Augusta University), and Beata Lecka-Czernik (The University of Toledo). BMA2020 was originally scheduled to take place in Seattle, Washington as the first BMA meeting in the United States. However, due to the global COVID-19 pandemic, the congress was instead hosted entirely online in a mixed live/asynchronous format to promote both networking and accessibility. With great thanks to the dedication of our BMAS members, both established and new, this meeting ended up being our largest event to date with 11 invited speakers, 55 submitted abstracts, and 198 registered attendees from 18 different countries around the world. The congress featured 53 sessions and sub-sessions, 35 posters, and 14 lab highlights that were viewed collectively more than 7,000 times. In direct evidence of the collaborative nature of the meeting, there were also 63 photos shared and 1,391 in-app messages sent between colleagues. In all, despite the change in format, the BMA2020 meeting succeeded in bringing together clinicians and scientists studying all aspects of bone marrow adiposity, contributing to the advancement of the field.The scientific sessions at BMA2020 included bone marrow adipocyte (BMAd) dynamics and bone mass in aging, obesity and malnutrition, as well as BMAd progenitors and lineage tracing, metabolism, hematopoiesis, metastasis, leukemia and myeloma, endocrine regulation, exercise, and advanced methods of BMAd imaging and analysis, as discussed below. A full list of talks and speakers is available in BMA2020 opened with a welcome address from the conference organizers, followed immediately by a keynote presentation by Ormond MacDougald (University of Michigan) entitled “Bone marrow adipose tissue biology, endocrine physiology and metabolism – unique and common traits with peripheral adipose tissue depots”. In his talk, Dr. MacDougald highlighted the basis of BMAd cell biology and physiology as grounded in the broader field of adipose tissue biology. He went on to discuss the nature of regulated and constitutive BMAT clusters , the discovery of which ultimately provided bases for in-depth analysis of the unique metabolic regulation of BMAT relative to other fat depots in the body . Thus, rThe first session featured an invited talk by Sundeep Khosla (Mayo Clinic) that covered aspects of BMAT, aging, senolytics and skeletal health. A key focus of his presentation was that cellular senescence may play a causal role in reducing osteoblastogenesis and increasing adipogenesis during the process of aging, suggesting that senolytic drugs have potential to target this aspect of skeletal aging biology . The invvia β‐catenin  and Janet Rubin (University of North Carolina), followed by a short talk from Piotr Czernik (The University of Toledo). It was moderated by Anne Schafer  and Rebecca Schill (University of Michigan). The session was concentrated on regulators of BMAT volume including nutrition, exercise and gut microbiota. Dr. Fazeli reviewed research focused on the paradox of increased BMAT volume in anorexia nervosa, a clinical condition of chronic undernutrition, with a take home message that BMAT serves different functions in states of nutrient sufficiency as compared to nutrient insufficiency . In addi‐catenin , 12. To  the gut .via mechanisms such as lineage recruitment and lipolysis  and Biagio Palmisano (Columbia University). The first short talk reported the role of the novel adipokine adipsin and its ability to activate the immune complement system in BMAT expansion promoted by caloric restriction or thiazolidinedione treatment . This presentation focused on the role of hormones, especially parathyroid hormone, in the regulation of BMAT ipolysis , 15. Thereatment . The secreatment . The thireatment .in vitro and ex vivo  and Greet Kerckhofs (Université Catholique de Louvain), followed by two short talks from Kisoo Pahk  and Josefine Tratwal . Session IV was moderated by Jean-Francois Budzik (Groupement des Hôpitaux de l’Institut Catholique de Lille) and Ahmed Al Saedi (University of Melbourne). Dr. Duque discussed secreted factors that couple bone marrow adipocytes to the surrounding skeletal cells and their implications for the pathophysiology of osteoporosis. In addition, he provided information about key technical approaches that can be used to study aspects of bone marrow adipocyte function and lipotoxicity both  ex vivo , 20. Aft ex vivo . Next, K density . Last, J density .The invited speakers for Session V were Olaia Naiveras  and Izabela Podgorski (Wayne State University). Short talks were given by Emma Morris (University of Oxford), Sonia Severin (Inserm U1048 and Paul Sabatier University), and Mariah Farrell . The session was moderated by Michaela Reagan  and Josefine Tratwal . Session V focused on mechanisms by which BMAT regulates hematopoiesis and cancer progression. Olaia Naveiras summarized the effects of BMAT on hematopoiesis, including use of MarrowQuant, a new tool for quantification of bone marrow compartments in histologic sections . This prThis session featured an invited talk by Moustapha Kassem (University of Southern Denmark) and three short talks by Russell Turner (Oregon State University), Leilei Zhong (University of Pennsylvania), and Xiao Zhang (Washington University). Session VI was moderated by Michaela Tencerova (University of Southern Denmark) and Sudipta Baroi (The University of Toledo). Dr. Kassem opened the session by reviewing the mechanisms underlying lineage commitment of multipotent bone marrow stromal  stem cells to adipocytes with an emphasis on the role of KIAA1199 . Next, DThe final session started with an invited talk by Courtney Karner , followed by four short talks by Ziru Li (University of Michigan), Ayyoub Salmi (MABlab), Amit Chougule (University of Toledo), and Wei Yu (University of Pennsylvania). The session was moderated by Christophe Chauveau (MABLab) and Thomas Ambrosi (Stanford University). Dr. Karner presented on the role of glutamine metabolism in the fate specification of bone marrow adipocytes from mesenchymal precursor cells, providing support for a model by which inhibition of glutamine metabolism or glutathione biosynthesis increases oxidative stress and promotes adipocyte differentiation . After tPosters consisted of a pre-recorded video presentation of up to 5-minutes in length. Virtual posters were highlighted in the exhibitor center and could be viewed asynchronously by congress attendees. A live poster session was also held on the first day of the conference where attendees and presenters could post and respond to questions in real time. The highlighted topics of the posters fell into several main categories including aging, BMAT dynamics and bone mass, endocrine regulation, imaging and advanced methods, metabolism, metastasis, myeloma and hematopoiesis, obesity and malnutrition, and progenitors and lineage tracing. A detailed list of posters and presenters is available in The Bone Marrow Adiposity Society is committed to fostering collaborations between members and to the development of trainees and fellows to support the growth and advancement of the field. Consistent with this mission, the BMA2020 meeting featured several trainee discussion sessions and networking events. All members were invited to participate in an open discussion with keynote speaker Dr. Ormond MacDougald, a question-and-answer session with leaders from the National Institutes of Health, and a BMA2020 ‘After Hours Trivia’ social event hosted by Don’t Tell Comedy. In addition, there were two trainee-specific sessions focused on topics including publishing, preprints, and open access  and planning for life and job opportunities after research training . The meeting organizers would like to provide special thanks to Andrea Lovdel and Biagio Palmisano for their contributions to the development of the trainee-focused content and trivia event of the BMA2020 meeting.In addition to networking and scientific content, the BMA2020 symposium provided a forum for meetings of the six BMAS working groups (WG). Additional information on the activities of the working groups can also be obtained by following BMAS on twitter (@BMA_Society).WG1 – Nomenclature. The nomenclature working group position paper reporting Standardized Nomenclature, Abbreviations, and Units for the Study of Bone Marrow Adiposity was published in 2020  of BMAS.WG5 – Repositories. The working group on repositories aims to identify currently existing repositories that contain expression data related to BMAd. Ultimately, this information can be distributed among BMAS members to gain access to the BMAd-related repositories for their research.WG6 – Sponsoring. The aim of the sponsoring working group is to find partners in industry and academia to financially liaise with BMAS. This committee is tasked with developing a strategy to ensure stable sponsorships for BMAS.Awards were presented during the conclusion of the BMA2020 meeting for the highest scoring clinical research and basic/translational research short talks and poster presentations. In addition, to promote scientific discourse and interaction during the virtual meeting, awards were also presented for the “audience choice” best poster presentation, a social media-based photo contest, a community engagement award, and a trivia contest. For the abstract-based scientific awards, all abstract submissions underwent blinded review and scoring by three to five independent reviewers. Abstracts were categorized as “clinical research” or “basic/translational research”, and awards were administered proportionally to the volume of abstracts received in each category; seven such awards were presented for basic/translational research, and three for clinical science. For the short talk and poster presentation awards during the meeting, presentations were scored by representatives from the BMAS Scientific Board on the overall presentation quality, the speaker’s responses during the question and answer session, the impact of the data, and the overall communication of the message. A full list of scientific awards and recipients is provided in th International Meeting of the Bone Marrow Adiposity Society. This was an important forum for discussion within the diverse, growing field of bone marrow adiposity research. The success of the transition to a virtual format has prompted discussions regarding the future integration of both in-person and virtual events to support the attendance of those that are not able to travel to the on-site destination. Moving forward, the BMAS meetings will be held once every 2-years with the next BMA2022 meeting currently scheduled to take place in Greece under the direction of Eleni Douni. In addition to this, several trainees and members within BMAS have come together to organize a virtual training seminar entitled “BMAS Summer School 2021”. This training seminar will take place over three half-days in September of 2021 and feature topical lectures from international experts, skill-based workshops, group discussions, and presentations that will promote the career development of trainees in the field. In conclusion, we are thankful for the overall success of the BMA2020 symposia and the connections made between colleagues despite the global COVID-19 pandemic. Though bone marrow adipocytes are gaining increasing attention as an endocrine cell and key component of the skeletal niche, much remains to be discovered to harness their potential in anti-osteoporotic, metabolic, cancer, hematological, or regenerative therapies. The research highlighted at this meeting and the new collaborations formed between colleagues will undoubtedly contribute to these efforts.BMA2020 was the 6ES, MM-L, and BL-C served as co-organizers of the BMA2020 meeting and worked together to develop the conference report herein. All authors contributed to the article and approved the submitted version.The authors declare that this research conference received funding from Radius Heath Inc., Kubtec, The Jackson Laboratory, Progen, Washington University Musculoskeletal Research Center, and BioQuant. The funders were not involved in the conference design, the writing of this article or the decision to submit it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.The reviewer WC declared a past collaboration with one of the authors ES to the handling editor.


Tobacco smoking is associated with significant morbidity and premature mortality in individuals with serious mental illness. A 2-year pragmatic clinical trial (PCORI PCS-1504-30472) that enrolled 1100 individuals with serious mental illness in the greater Boston area was conducted to test 2 interventions for tobacco cessation for individuals with serious mental illness: (1) academic detailing, which delivers education to primary care providers and highlights first-line pharmacotherapy for smoking cessation, and (2) provision of community health worker support to smoker participants. Implementing and scaling this intervention in other settings will require the systematic identification of barriers and facilitators, as well as the identification of relevant subgroups, effective and unique components, and setting-specific factors.This protocol outlines the proposed mixed methods evaluation of the pragmatic clinical trial to (1) identify barriers and facilitators to effective implementation of the interventions, (2) examine group differences among primary care physicians, and (3) identify barriers that stakeholders such as clinical, payor, and policy leaders would anticipate to impact the implementation of effective components of the intervention.Qualitative interviews will be conducted with all study community health workers and selected smoker participants, primary care providers, and other stakeholders. Measures of performance and engagement will guide purposive sampling. The Consolidated Framework for Implementation Research will guide qualitative data collection and analysis in accordance with the following framework approach: (1) familiarization, (2) identifying a thematic framework, (3) indexing, (4) charting, and (5) mapping and interpretation. Joint display analyses will be constructed to analyze and draw conclusions across the quantitative and qualitative data.The 3-year cluster-randomized trial has concluded, and the analysis of primary outcomes is underway. Results from the pragmatic trial and this mixed methods implementation evaluation will be used to help disseminate, scale, and expand a systems intervention.The results of this mixed methods implementation evaluation will inform strategies for dissemination and solutions to potential barriers to the implementation of interventions from a smoking cessation trial for individuals with serious mental illness.DERR1-10.2196/25390 Tobacco smoking is associated with significant morbidity and premature mortality in individuals with serious mental illness. People with serious mental illness in the United States have physical diseases at a young age and die approximately 28 years earlier than those without mental illness, primarily from diseases that are directly attributable to tobacco smoking ,2. PremaIn a pragmatic clinical trial (PCORI PCS-1504-30472) conducted from November 2016 to February 2020, our research group tested the effectiveness of a 2-year intervention that involves (1) academic detailing, which involves the delivery of targeted smoking cessation education to primary care physicians and (2) community health worker support for tobacco abstinence among those with serious mental illness. Over 1100 smokers with serious mental illness—hereinafter referred to as “smoker participants”—enrolled in the trial in 2016. Primary quantitative analysis of study outcomes is underway.Academic detailing is a provider-level educational intervention in the form of targeted, practical, action-oriented information, which is designed to educate providers on current best practices in a particular area. During this intervention, education is provided to primary care providers by doctoral-level (MD and PhD) study staff who are focused on the safety and tolerability of first-line pharmacotherapy for smoking cessation treatment in those with serious mental illness. The impact of academic detailing on the provision of smoking cessation pharmacotherapy to providers, and the resulting cessation outcomes, has not been studied.Community health workers assist patients with accessing services and provide health education and outreach in their communities. Utilization of community health worker support has been demonstrated to be useful in reducing the length and number of hospitalizations, improving posthospitalization follow-up, and improving mental health in the general medical setting ,17. To dDissemination, scaling, and expansion of a systems intervention in a pragmatic clinical trial to other settings is greatly aided by the systematic identification of barriers and facilitators to implementation, and identification of relevant subgroups, effective and unique components, and setting-specific factors ,19. ThisWe aim to conduct a mixed methods evaluation of the aforementioned pragmatic clinical trial to (1) identify barriers and facilitators to effective implementation of the interventions described by community health workers, smoker participants, and primary care providers in qualitative interviews; (2) examine how primary care providers, grouped at the clinic level, differ by quantitative performance and engagement level and how their experiences with the intervention components, barriers, and facilitators compare across these groups; and (3) identify barriers that stakeholders such as clinical, payor, and policy leaders would anticipate to impact the implementation of effective components of the smoking cessation intervention tested.We propose a mixed methods evaluation  utilizinThe Consolidated Framework for Implementation Research provides a basis for qualitative data collection and analysis . This “mThe quantitative data for this evaluation will be derived from the pragmatic clinical trial and process data from both interventions . Enrolled smoker participants were asked to complete three surveys: a baseline survey conducted at enrollment, followed by 2 surveys administered annually. Survey questions assessed self-reported current tobacco use, behaviors related to smoking cessation medications , smoking-related health issues, and rating of overall health. Demographic data were collected in the baseline survey. Additionally, smoker participants were asked to provide expired-air carbon monoxide measurements at each survey, which is used as biological confirmation of tobacco abstinence. Relevant process data include goal attainment during sessions with community health workers, the number of sessions with community health workers per smoker participant, attendance of the cessation group in cognitive behavioral therapy sessions, visits among primary care providers to address smoking cessation, and the attendance of primary care providers in academic detailing presentations.Using these existing quantitative data, we anticipate creating matrices using 3-level measures  of intervention engagement and performance to inform our purposive sampling for qualitative testing and future hypothesis testing. We will conduct quantitative analyses appropriate to establish thresholds for each measure of engagement and performance for community health workers, smoker participants, and primary care providers. We also anticipate conducting additional quantitative data analysis in testing hypotheses generated from the results of the qualitative data analysis.All community health workers paired with smoker participants in the trial (n=12) will be recruited to participate in qualitative interviews. Those eligible for qualitative interviews include smoker participants who provided consent to work with a community health worker and provided smoking behavior data at the year 2 survey (n=201). Primary care providers from clinics randomized to receive academic detailing, who treat smoker participants who provided information regarding prescriptions for smoking cessation medications at baseline and year 2 surveys, will be eligible to participate in the qualitative interviews (n=459). We intend to recruit stakeholder interviewees who are considered key opinion leaders in policy, payor, and clinical administration. Interviews will be conducted in person or in the community setting, depending on interviewee preferences.Purposive sampling involves the intentional selection of study participants based on preselected criteria that relate to the research questions of interest; that is, barriers and facilitators. As described above, we will establish matrices based on 3-level categorical measures of engagement and performance, which will be used to frame our qualitative purposive sampling and ensure representation from a range of qualitative interview participants .Basic concepts and the purpose of the study will be reviewed with all interviewees by a doctoral-level qualitative interviewer. Study staff will review the consent form with all interviewees and provide an opportunity to the participants to ask questions before signing the form. Additionally, smoker participants from the pragmatic clinical trial will be required to successfully complete a competency assessment in the form of a short quiz on facts about participation in the research qualitative interview. All individuals who complete the qualitative interview will receive US $15 as compensation for their participation.Community health worker interviews will be conducted by authors DA, MCM, and KS, who are trained in qualitative interviewing techniques. Smoker participant interviews will be conducted by authors MCM and KS to minimize bias, as author DA interacted with many smoker participants during smoking cessation groups. Immediately following each qualitative interview, interviewers will document and organize field observations into 3 categories—“context, content, and concepts”—as described by Fetters and Rubenstein in 2019 . This apAll audio-recorded interviews will be transcribed verbatim. All transcripts will be checked for accuracy and completeness and edited where necessary. Final transcripts will be uploaded to NVivo software  for organizing the text and supporting the analysis.We will use a theory-driven approach in which we will explore the relationship between the findings and the Consolidated Framework for Implementation Research. Our study will be carried out in 5 stages outlined in the framework approach to qualitative analysis : (1) famAll analyses will follow procedures to ensure robust qualitative data analysis, including the establishment and training of the coding team and ongoing recalibration meetings to ensure reliability and to reduce coding drift. Interrater agreement will be assessed using a second rater coding a subset of interviews during initial data analysis until a high level of reliability (κ≥0.80) is established. Weekly consensus meetings will be held to resolve disagreements. The analytic process will be documented, and all coding decisions will be recorded for further review. Field observations will be reviewed to develop a macroscopic view of the data, assist the process of coding, and explore emerging hypotheses .We will conduct joint displays analysis, in which quantitative and qualitative concepts will be merged and displayed together in an organized structure known as a “joint display” -35. CombThe COVID-19 pandemic and resultant social distancing measures took effect during preparation for qualitative interviews. Consequently, the protocol has been adapted to allow for interviews to be conducted via telephone or videoconferencing. All in-person team meetings have been transitioned to videoconferencing platforms.The 3-year cluster-randomized trial has concluded, and the analysis of primary outcomes is underway. Results from the pragmatic trial as well as this mixed methods implementation evaluation will be utilized to facilitate dissemination, scaling, and expansion of a systems intervention. The results of this evaluation will be published in a peer-reviewed journal and presented at scientific conferences.This study aims to evaluate barriers and facilitators in implementing a smoking cessation intervention for individuals with serious mental illness. This study will also broadly evaluate the real-world implementation of academic detailing and community health workers in the role of smoking cessation and provide insights into engagement strategies and the smoking cessation process for individuals with serious mental illness. Through close examination of outcomes and particular challenges by subgroup, identification of effective and unique intervention components, and setting-specific factors in this study, our analysis will inform future health interventions for those with serious mental illness as well as the general population.


To examine mental health outcomes of unaccompanied refugee minors during global policy shift. Additionally, to consider mental health service delivery and placement type for this group.A rapid systematic search of research published since 2018 which related to mental health outcomes of unaccompanied refugee minors. Data extracted, risk of bias assessed and outcomes reviewed qualitatively.We found 181 papers, of which 14 met inclusion criteria. This review found consistently high levels of PTSD and PTSS among URMs in various contexts. Exposure to trauma, being unaccompanied (compared to accompanied), being female and being older are associated with poor outcomes. Depression and anxiety were consistently high among URMs and associated with discrimination, limited language attainment and daily hassles.High rates of mental illness and symptoms among unaccompanied refugee minors were consistent across national and settlement contexts but the quality of the evidence is variable with significant heterogeneity of assessment. We relate persistence of poor mental health outcomes with problems accessing mental health services and discuss the role of key post-migration factors influencing outcomes—in particular placement type and the use of detention centres. Unaccompanied refugee minors are among the rising numbers of forcibly displaced people  2]. In . In 2]. It is well documented that refugees are at an increased risk of various mental illnesses  7–9]. W–9. W7–9]Refugee children have often experienced a range of traumatic events, such as death/persecution of family members, war, forced recruitment and personal persecution and then must manage the dual stressors of traumatic past with resettlement , 12. BeyAs a major contextual dimension to this paper, we have noted an increasingly punitive response to refugees and migrants in many Western countries, likely to have worsened the health outcomes for refugees; for example in the USA, the increase in use of detention centres and separation of children from families for Mexican migrants has been attributed to increased vulnerability for poor mental health outcomes . In AustIn this review, we have identified and examined recent literature on the prevalence and associated factors for mental health disorders in unaccompanied refugee minors. We also discuss the recent evidence base and service delivery for this group and consider post-migration predictors of mental health outcomes and the key issues of placement type and use of detention centres.Peer reviewed materialReview only material published since 2018Published in English language journalsProvide data on mental health outcomes of unaccompanied refugee minorsPrimary research, quantitative, otherwise not design restrictedFor this rapid review, we searched for potential articles that could be included on PubMed, Medline and socINDEX databases on the 13/03/2021. We used principles recommended by the WHO, and PRISMA reporting guidelines were adhered to , 20. We Qualitative studiesIf mean age of sample was over 18If article focussed on interventionIf no specific outcomes for URMs providedExclusion criteria:Duplicates were removed. In the first stage, two independent researchers (JB and MF) screened titles and abstracts for papers identified. In the second stage, the same researchers screened the full texts of all remaining studies to assess eligibility for data extraction and analysis. At either stage, any queries or disagreement on eligibility were remedied via discussion with GL.The authors then extracted data about the following from eligible articles: publication year, country of study, URMs characteristics , design, assessment method, time period and main results on mental health outcomes in keeping with review processes . We asseDatabase search identified 181 articles in total, of which an eventual 14 met inclusion criteria, further details are provided in Fig. Table Most studies solely had only URMs as participants, some had a heterogeneous group of accompanied and unaccompanied youth, often comparing outcomes between the two. As seen in Table Following assessment for risk bias, we concluded that most of the 14 studies were of moderate quality. A small number were of high quality, and a small minority were of low quality. Low quality often related to poor consideration of confounding variables and inadequately described samples.Estimates of post-traumatic stress disorder (PTSD) and post-traumatic stress symptoms (PTSS) were generally higher among URMs compared to those of accompanied minors. Some studies measured PTSD, often via a cumulative measure of PTSD-related symptoms and a defined cut-off for caseness or via clinical interview by a trained practitioner. Other studies measured the symptoms associated with post-traumatic events, namely avoidance, hyper vigilance and mistrust. Studies referred to the development of these symptoms as PTSS. There is significant overlap in the symptoms defining PTSD and PTSS , 37, 38.In a prospective cohort study in Germany, PTSS among URMs remained high at follow-up, with 37.5% still experiencing symptoms while other psychopathology tended to improve at follow-up . MoreoveA comparison of rates of depression and anxiety between accompanied and unaccompanied minors show fairly consistent findings across studies. A Norwegian study  using thThe study by Hanewald et al.  used a sIn Odepal et al.’s Norwegian study, longer length of residence in Norway, and greater heritage and cultural identity among URMs were protective for depression , 25. SymWhile young refugees experience high levels of mental health problems and symptoms, predominantly PTSD, PTSS, depression, anxiety and behavioural problems , 41, theAgain, some caution is needed in assessing the evidence. As with other reviews on refugee mental health, we found considerable heterogeneity across studies . Many ofWhile high rates of mental health problems have been consistently observed, the evidence on long-term psychiatric outcomes is limited. Other longitudinal studies indicate that poor mental health may persist over years . HoweverFurthermore, in recent research conducted among UMRs in the Netherlands, among the sample, 61% had made use of healthcare services; however, when asked about mental healthcare services, this dropped to 17%. Although most attendees understood the importance of mental health support and felt they received good care, poor therapist understanding of their situation was cited as the main reason for dissatisfaction with care .Another key determinant of poor mental health outcomes for URMs may relate to children’s own perceptions of mental health and healthcare systems and the implications of a psychiatric diagnosis. Their perceptions may deter engagement with mental health services . This isThe current review found evidence that post-migration factors are important determinants of mental health outcomes for URMs, as opposed to simply pre-flight exposure to trauma. Studies found that poor social support, poor language proficiency of resident country, reduced resources, experience of discrimination, asylum status and increased daily hassles were all key predictors of outcomes , 32, 33.There is growing novel evidence of increased burden of psychiatric disorders and symptoms among URMs; however, the studies are heterogeneous in design and population. This review shows that recent studies indicate that post-migration factors are important predictors of mental health outcomes. Namely we found that poor social support, poor language proficiency of resident country, experience of discrimination and experience of daily hassles influence outcomes for URMs. We found some evidence that the process of detention is extremely damaging for URMs’ mental health outcomes, and that strong rearing environments in host countries are protective for mental wellbeing. Future studies should employ a longitudinal design to follow up URMs and their outcomes, and explore how best to address post-migration determinants of well-being such as addressing social support, language proficiency and discrimination.


Balance and core stabilization exercises have often been associated with improved athlete performance and/or decreased incidence of injuries. While these exercises seem to be efficient in the prevention of injuries, there is insufficient evidence regarding their role in sport-specific performance and related functional movements. The aim of this scoping review is (1) to map the literature that investigates whether currently available variables of postural and core stability are functionally related to athlete performance in sports with high demands on body balance and spinal posture and (2) to identify gaps in the literature and suggest further research on this topic. The literature search conducted on MEDLINE, Scopus, Web of Science, PubMed, and Cochrane Library databases was completed by Google Scholar, SpringerLink, and Elsevier. Altogether 21 articles met the inclusion criteria. Findings revealed that postural stability plays an important role in performance in archery, biathlon, gymnastics, shooting, and team sports . Also core stability and strength represent an integral part of athlete performance in sports based on lifting tasks and trunk rotations. Variables of these abilities are associated with performance-related skills in cricket, cycling, running, and team sports . Better neuromuscular control of postural and core stability contribute to more efficient functional movements specific to particular sports. Training programs incorporating general and sport-specific exercises that involve the use of postural and core muscles showed an improvement of body balance, back muscle strength, and endurance. However, there is controversy about whether the improvement in these abilities is translated into athletic performance. There is still a lack of research investigating the relationship of body balance and stability of the core with sport-specific performance. In particular, corresponding variables should be better specified in relation to functional movements in sports with high demands on postural and core stability. Identifying the relationship of passive, active, and neural mechanisms underlying balance control and spinal posture with athlete performance would provide a basis for a multifaced approach in designing training and testing tools addressing postural and core stability in athletes under sport-specific conditions. Postural and core stability is critical to almost all movements in sport , particuThe core that involves lumbopelvic–hip region maintains the vertebral column equilibrium within its physiological limit by reducing postural displacement after unexpected perturbations . This reRecently, widely promoted spine stabilization and core strengthening exercises have been seen to improve postural and core stability and/or reduce back problems in athletes . These eCurrently, motion analysis and accelerometry recordings allow monitoring of head, trunk, and limb movements and provide useful data for a complete assessment of postural and core stability during a variety of functional movements. Measurement of postural sway using accelerometry is strongly related to task-based variables . The accIn the study by Usually, postural and core stability have been compared among athletes of different sports, their age, and/or performance level. For instance, the best body balance is found in gymnasts, then in soccer players, swimmers, physically active controls, and basketball players . BalanceBalance is also associated with performance measures . Body swIn general, practicing any kind of sport is associated with better postural stability . The cenInvestigating the relationship of passive, active, and neural mechanisms underlying balance control and spine stabilization with sport-specific performance would provide a basis for a multifaced approach in designing training and testing tools addressing postural and core stability in athletes. The aim of this scoping review was (1) to review the existing literature that deals with sports with high demands on body balance and spinal posture and to investigate whether currently available variables of postural and core stability are functionally related to athletic performance and (2) to identify gaps in the literature and suggest further research on this topic.This article was proposed as a scoping review . The purAn electronic literature search was provided to analyze existing studies dealing with the role of neuromuscular control of both postural and core stability in functional movement and/or athlete performance. Studies were searched on Scopus, Web of Science, PubMed, MEDLINE, and Cochrane Library databases. This search was completed on Google Scholar, Elsevier, and SpringerLink. The articles in peer-reviewed journals were considered for analysis. References included in review articles were also searched to identify further relevant studies. If articles included overlapping data from the same or similar study, the one with the most recent publication date was analyzed. Articles or abstracts published in conference proceedings, theses, case studies, and books were excluded. Articles were also excluded if they did not contain original research or were incomplete. The inclusion criteria involved research articles that specified participants, experimental protocols, and measures relevant to this review. The literature search was limited to the English language. Articles published after 1990 were preferred. Articles were excluded if they failed to meet the eligibility criteria.The initial search was confined to research articles closely related to the main purpose of this scoping review, that is, those dealing with the relationship between neuromuscular control of either postural or core stability and functional movement and/or athlete performance. However, this approach revealed only a limited number of articles that met the eligibility criteria. The search was, therefore, widened to investigations dealing with the effects of sport-specific and balance or the core-related exercises on functional movements and skills within a particular sport. In particular, neuromuscular mechanisms underlying these relationships were studied. This together helped us to identify gaps in the literature and formulate recommendations for further studies in this field of research.The search and appraisal of selected studies on the basis of exclusion and inclusion criteria were performed by both authors of this review. Some concerns were related to sample size and its representativeness, incomplete information about the methods used, variables analyzed, and/or non-controlled compliance of experiments. The target population was athletes of a team and individual sports where balance and core stability play an essential role in their performance. Proposed sports were combined with the following keywords.A combination of these terms was included in the search strategy: “postural stability” AND “core stability” AND “core endurance” AND “core strength” AND “core training” AND “body balance” AND “postural control” AND “spinal posture” AND “lumbopelvical stability” AND “athletes” AND “sport-specific exercise” AND “athletic performance” AND “functional movement,” AND “neuromuscular control.”Further searches were conducted by using words from subheadings that specified the contribution of postural and core stability on performance in highly skilled athletes in comparison with those at a lower level of sport-specific skills. Following an initial screening of articles identified through database searching and assessing for their eligibility, those that failed to meet inclusion criteria were removed. Articles that investigated neuromuscular control of postural (14 out of 29) and core (7 out of 13) stability in association with functional movements and/or athlete performance were included in this scoping review. The search process phases are displayed in Analysis of the literature revealed  that posThe majority of studies investigated postural stability in association with shooter performance. Postural stability and stability of hold were identified as the main factors influencing air rifle shooting performance . High poVertical holding ability and cleanness of triggering are also important for shooting performance in the biathlon . PosturaThe synchronization of bow and body sway plays a role in shot accuracy, which indicates that combined bow stability and balance exercises would contribute to better archery performance . ReducedFurthermore, specific postural stability control plays an essential role in acrobatic sports. Gymnastic experience during childhood is beneficial for the development of proprioceptive reweighting processes that lead to a more mature form of controlling and coordinating posture similar to adults . AnthropThe sport-specific task  is more sensitive in differentiating the level of expertise in young gymnasts than the simple task  . While bSpecific postural control in gymnasts’ skills  is not transferred to basic upright stances . GymnastPostural stability control is also important for performance in team sports and may vary among athletes of different competition levels. Both dynamic and static tests should be used for the assessment of balance as postural control performance in these two cases is not related . For insThe hockey skating performance significantly correlates with balance and sprint tests, which demonstrates the important role postural stability plays in skating speed in young players . ImproviSoccer players have superior postural control when compared to those involved in contact sport and no sport at all . ContactThe contribution of vision in the maintenance of balance is less important in the professional national-level than amateur regional-level soccer players . BalanceExperienced team-handball players exhibit better balance performance, which is more associated with the maturation of the motor system than their performance level . It seemFurthermore, balance, core strength and stability, flexibility, and peripheral muscle strength are associated with golf performance . Using cHowever, some studies found no significant relationship between postural balance control and athlete performance. For instance, both the isokinetic core power and a one-legged static balance do not correlate with overall World Cup points in competitive snowboarders . FurtherAnalysis of the literature revealed  that outThe remaining six studies (46%) evaluated the effects of various core or neuromuscular training programs on core stability, functional movement, and athletic performance . Three oRegarding the sport, eleven studies (85%) were conducted in team sports, such as baseball, basketball, cricket, football, handball, soccer, and touch ball  and two Among seven studies, six investigated the association of core stability with variables of athletic performance  or both The most investigated characteristics of core stability  were corT-test, agility test, shuttle run, medicine ball throw . Correlations between core stability and strength or power, and sprints or shuttle run were moderate to weak but significant. This indicates that core strength contributes to power and strength performance and therefore should be taken into account . HoweverThe second type of study represents relationships between core stability and bowling speed in cricket, walks, hits per innings pitched and total innings pitched in baseball and functional movement in cycling. Cricket players with well-developed stability of the core manifest high quality in the kinetic chain of movements when bowling that probably results in increased bowling speed. They can better control their trunk position and motion over the pelvis and leg. This allows optimum generation and transfer of force to the terminal segment in the kinetic chain of specific movements. Core stability provides integration of proximal and distal segments in increasing bowling speed . LumbopeTraining programs were usually aimed at the increase of athletic performance factors  or variaThe duration of intervention was from 4 to 6 weeks  or 8 weeCore stabilization training programs included core exercises , or coreThe assessment of athletic performance or measurement of functional movement variables was focused on throwing velocity  and jumpCore stability and core strength training have been used for the improvement of functional movement and consequently also athletic performance. The purpose of core stability exercises is to control the lumbar spine, whereas core strength exercises improve the transfer of muscle power, activation of local stabilizers, and global mobilizers . The tra2max, vVO2max, or running economy at speeds of 60, 70, 80, or 90% vVO2max . Also, core stability and strength represent an integral part of athlete performance in sports based on lifting tasks and trunk rotations. Variables of these abilities are associated with performance-related skills in cricket, cycling, running, and team sports . Better neuromuscular control of postural and core stability contribute to more efficient functional movements specific to particular sports. Training programs incorporating general and sport-specific exercises that involve the use of postural and core muscles showed an improvement of body balance, back muscle strength, and endurance. However, there is controversy about whether the improvement in these abilities is translated into athletic performance. Identifying the relationship of passive, active, and neural mechanisms underlying balance control and spinal posture with athlete performance would provide a basis for a multifaced approach in designing training and testing tools addressing postural and core stability in athletes under sport-specific conditions.Both authors have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Journal indexing by global bibliographic databases has numerous implications for research and development in the era of digitisation. Researchers and authors employ bibliographic searches to comprehensively and systematically analyse relevant articles in their research and reviews. They consult lists of indexed sources at multidisciplinary and specialist databases to target relevant journals offering global visibility and dissemination of their own work. Research and academic institutions are also concerned with bibliographic records of their affiliated faculty and strive to expand indexing of their own periodicals to achieve and maintain ranking in the global competition.1 To better serve their contributors’ and readers’ interests, editors should better organise their work and regularly consult experts with interest in bibliographic databases. Professional advice on instructions for authors, publication ethics statements, internationalisation, and digitisation pave the way toward expanded indexing.2 Such advice is particularly helpful for prioritising editorial tasks and applying to bibliographic databases in an organised way, when certain indexing criteria are met.3 The sequence of journal applications to information aggregators, digital repositories, and bibliographic databases is critically important. Failure to realise the importance of planning relevant activities may result in 2 to 4-year application embargos imposed by databases. Initial archiving by PubMed Central and listing by information aggregators such as EBSCO often allows garnering citations and acquiring journal metrics required for the coverage by prestigious abstract and citation databases such as Scopus.3 Over the past decade, Scopus has gained immense importance because of its constantly improving functionality, expanded coverage of quality sources, and scrutinised selection and deselection criteria. Launched in 2004 as an Elsevier database, Scopus has succeeded in outperforming many other indexing systems, with 22,794 active titles and more than 78 million bibliographic records.4 Equipped with advanced analytical tools and integrated with the social-media aggregator Plum Analytics, Scopus offers enriched scientometric and altmetric data at the level of individual articles. Scopus searches allow mapping science dynamics across academic disciplines and synthesising new scientific evidence. Accordingly, experts advise its inclusion in search strategies of narrative and systematic reviews.6 To ensure independent and comprehensive evaluation of journal application, the Scopus Content Selection and Advisory Board was established in 2009. The Board chairs monitor the multi-step evaluation procedure that facilitates acceptance of trustworthy sources with established quality controls, digitisation, and recognition by the international community. Re-evaluation mechanisms are also in place to analyse and delist sources with skewed metrics, un-ethical publishing practices, and diminishing value for the scientific community. Unsurprisingly, academic ranking systems such as the Times Higher Education (THE) and QS World University Rankings currently process Scopus data,7 motivating academic institutions to set goals for improved performance on this highly reputable database. Scopus coverage immediately boosts a journal’s influence on other indexed sources’ citation metrics. As such, validating and formatting article reference lists is crucial for entering and maintaining in the database. The indexing itself facilitates comprehensive and transparent impact calculation and journal ranking in a relevant subject category. Scopus-based metrics are publicly available on the database and the SCImago Journal & Country Rank platforms. Since June 2020, Scopus displays improved CiteScore values that cover a 4-year indexing window and distinguish journals with fast citation growth.8 All newly indexed journals with a publication history of 1 year have their monthly updated CiteScore values.9 In 2018, annual CiteScore values were available for 23,350 journals.9Improved understanding of the journal indexing and its implications for all stakeholders motivates authors and editors to draft, edit, and publish quality work.https://www.scimagojr.com/journalrank.php?-category=2745&page=1&total_size=64), including 16 in the highest quartile of the SCImago Journal Rank (SJR) with the most prestigious citations. The top 3 journals in this category are Annals of the Rheumatic Diseases (SJR 6.142), Arthritis and Rheumatology (4.113), and Nature Reviews Rheumatology (3.390). These flagship journals publish evidence-based articles of importance to the global community of rheumatologists and allied health professionals. Each of these journals has a long publishing history reflected in their h-index values of 228, 305, and 126, respectively. Such impressive metrics may stimulate editors of all other rheumatology journals to improve their adherence to the best standards in the field, solicit more evidence-based items such as practice guidelines, clinical trial reports and cohort studies, and gain more influence by attracting numerous relevant citations and the attention of respective professional communities.The SCImago Journal & Country Rank platform currently displays much-desired metrics of 64 rheumatology journals  for indexing, recognising the value of the new addition to the Scopus database and motivating the editorial team to achieve new highs. The acceptance for coverage is indeed a great achievement for the Journal editorial team, the Greek Rheumatology Society and Professional Association of Rheumatologists, and for the many rheumatology societies endorsing the Journal’s activities. Over the past few years, MJR has consistently upgraded its instructions and publication ethics statement, instituted posts for a Research Integrity Officer and Independent Statistician, internationalised its Board, expanded cooperation with numerous rheumatology societies, integrated with CrossRef and received Digital Object Identifiers (DOI), joined the Directory of Open Access Journals (DOAJ), and got archived by PubMed Central.10 Also, it signed the San Francisco Declaration on Research Assessment (DORA) and established a Social Media Coordinator post to diversify impact evaluation and accelerate dissemination of rheumatology research in the Mediterranean region and far beyond.In October 2020, the Scopus Content Selection and Advisory Board accepted the The indexing status is yet another major milestone for the MJR. With this and previous achievements in mind, the Editorial Team, supported by numerous authors, reviewers, and readers, anticipates an increased flow of great submissions and publication of truly influential articles of interest to all stakeholders.


Canada’s vast geography, and centralized delivery of cancer care and clinical trials create barriers for trial participation for patients in remote and rural settings. The development and implementation of a framework that enables safe and regulatory compliant trial participation through local healthcare providers would benefit Canadian patients, clinicians, trial sponsors and the health care system. To address this issue, representatives of Canada’s cancer clinical trial community met to identify key challenges and develop recommendations for remote patient participation in trials. A structured literature review identified remote/rural trial delivery models. A panel of expert stakeholders reviewed the models and participated in a workshop to assess health system readiness, identify needed processes, tools and mechanisms, and develop recommendations for a Canadian framework for decentralized clinical trial conduct. The Canadian Remote Access Framework for clinical Trials (CRAFT) represents a risk-based approach used by site investigators to delegate responsibilities for a given trial to satellite health centres within a hub-and-spoke “trial cluster”. The Framework includes specific recommendations to ensure research experience, capacity, regulatory compliance and patient safety. Canada’s cancer care and telemedicine systems can be leveraged to enable broader access to clinical trials for patients who are geographically remote from cancer centres. CRAFT’s risk-based framework is based on other successful models of remote trial patient management and is in the pilot implementation phase in Canada. Clinical trials are vital to improving standards of cancer care, yet participation in clinical trials is low in Canada. For cancer trials, the reported rates of trial participants to new incident cancer cases are 4.7% overall, and as low as 1% in some Canadian provinces, as compared to 14% in the UK . This diThere are strong ethical, scientific, and medical reasons that cancer patients should have access to trials. The ethical principle of respect for persons and equity, including the just distribution of resources and of risk and benefit, requires that people, regardless of where they live, should have the opportunity to participate in clinical trials . It alsoTelecommunication advances and health care delivery models have enabled cancer patients to be managed closer to their homes. Telemedicine for patient assessments and extending cancer care delivery to include clinical teams at health care facilities remote from cancer centres have become standard across Canada. In addition, remote trial participation during the COVID-19 pandemic was enabled through evolving Canadian and international regulatory guidances ,11,12. PIn line with its objective to support the conduct of academic sponsored clinical trials, the Canadian Cancer Clinical Trials Network (3CTN) convened a steering committee of academic, public, government and industry stakeholders with expertise and knowledge of Canada’s clinical trial environment. The committee was charged to review existing models for remote access to trials; assess national health system readiness; identify needs and enabling mechanisms; and to develop recommendations that would serve as a framework for a Canadian approach  and the Pediatric Oncology Group of Ontario (POGO) Satellite Program. Both leverage telemedicine technologies and health care collaborations and provide guidelines to enable participation of remote and rural patients in clinical research ,20. Australia has made a significant investment in developing and implementing a model to address the low population density and vast geography to enable trial participation ,22. An iA formal evaluation of trial conduct for centres participating in the randomized Phase III trial, monarchE found that the data produced was acceptable for commercially sponsored research destined for marketing applications and regulators. Furthermore, it showed successful recruitment and management of rural and remote patients to trials closer to their homes and increased clinical trials capability and training of regional sites in Good Clinical Practice (GCP) . These fParticipation in multi-centred trials is a core component of childhood cancer care. Given the small numbers of children with cancer, community hospitals cannot independently obtain and maintain the expertise, capacity or infrastructure for clinical trial activities. Since 1998, POGO’s Provincial Pediatric Oncology Satellite Program has enabled the transfer of certain aspects of a child’s clinical care, including clinical trial research activities, to community hospitals closer to the children’s homes. The POGO model is a networked, shared-care system partnership of Ontario’s five tertiary hospitals and POGO Satellite community hospitals that enables some clinical trial activities to be conducted in community settings. Industry and academic trial sponsors such as the Children’s Oncology Group (COG) and the US National Cancer Institute (NCI) endorse the model for conduct of their trials ,25. Similarities between Canadian and Australian population distributions, national cancer centre networks, regulations and health system funding arrangements suggest the COSA ATM “hub and spoke” of lead cancer centre linked with community health care facilities and personnel is a feasible option for Canada. The model is conceptually straightforward, applicable to a wide variety of trials and scalable across regions and trial populations. When tested, it showed that patient recruitment, retention and national trial capacity was enhanced. With agreement of a study sponsor and participating institutions, a regional or metropolitan centre serving as the primary site holds overall responsibility for supervision and coordination for a hub-and-spoke “trial cluster” comprised of one or more local satellite site(s) see . Satellite sites are delegated responsibilities and collaborate on activities such as recruitment, consent, treatment and/or follow-up using a risk-based approach that considers trial complexity, patient safety, site research capacity and professional competencies. Trial procedures can be streamlined and in-person patient visits can be conducted at the cancer centre, local health centre, via telemedicine, or through compliant remote data collection platforms. Protocol-specific and core research training  needs are determined based on defined research roles and provided to those personnel with identified research responsibilities. Training requirements would not necessarily formally extend to allied healthcare or administrative personnel performing duties that fall within professional education, accreditation or standards of care. The CRAFT framework provides recommendations in eight areas, summarized in The CRAFT steering committee recommends the following be conducted to evaluate the remote access framework and guide its implementation in Canadian settings. Conduct pilot studies to evaluate the model and share findings. Pilot implementation projects should build upon existing regional networks of shared clinical care with personnel that are supportive of improving trial participation. Pilot clusters would extend care delivery to include trial delivery, leveraging existing regional patterns of care and telemedicine capacity across site networks. The cluster could begin by participating in a trial of interventions of lower risk and complexity, such as a trial assessing different standard of care treatments or supportive care measures. Such a trial experience would establish the cluster, and the processes to ensure trial oversight and conduct .Identify agreement terms among investigators, sub-investigators, healthcare providers (or their representatives), insurers and sponsors that can address research responsibilities, professional liability, and indemnity. Ideally, a core set of template documents could be developed to be used by those interested in implementing the model and framework.Identify feasible and cost-effective options for establishing linkages between centres that consider professional capacity, existing workflows, and scheduling requirements. Research activities should be distributed to efficiently and effectively ensure optimal engagement of personnel and resources.Continue to consult with Health Canada to ensure recognition and support of models of trial conduct within a cluster across regulations, guidance documents, review of clinical trial applications and site/sponsor inspections.The CRAFT initiative aims to develop a model for Canada that would address the geographic barriers to trial participation. Although development of the framework was initiated in 2019, prior to the COVID-19 pandemic, transformational changes in healthcare services since have helped address access restrictions imposed by the pandemic and allowed many of the key concepts of decentralized trial conduct to be implemented. For example, there is now more widespread use of distributed care models and virtual platforms for healthcare and for trial conduct, along with new regulatory measures that enable leveraging virtual care models for decentralized clinical trial (DCT) activities ,27. TeleThe POGO and Australian experiences and the approaches adopted to ensure continued trial participation during the pandemic showed that remote or decentralized participation in clinical trials is feasible and preferable for many patients, health care providers and trial sponsors. The CRAFT model provides practical recommendations that if implemented, would ensure successful trial conduct. Fundamental to adoption would be recognition by sponsors, regulators, ethics boards and participating health care institutions of a “cluster” as an organizational unit for trial conduct. Trial complexity, capacity and capabilities within the cluster will determine the scope of delegated activities. Access to and sharing of trial participants’ health information as part of the “the circle of care” within the cluster is also a key consideration. The extent of training required by remote practitioners and staff should be based on whether the proposed trial activities fall within the scope of routine standard practice or are research-specific. Additional communication, oversight, SOPs and training within the cluster and provision of resources to support the activities of personnel at participating sites are needed to assure patient safety, research quality and regulatory compliance. Decentralized trial activities require added commitments for tools, infrastructure, communication frameworks and funds along with added time investments for site personnel. New agreements, training, study drug distribution and handling, new workflows for trial management, oversight and monitoring are implementation costs to be factored. Costs may be mitigated by improved recruitment and retention, reduced patient travel, better patient quality of life, and broader health system and economic benefits of a decentralized approach to trial delivery. Additional benefits may include more rapid trial completion, trial results that are more representative of outcomes of the intended “real world” population, and a broader health care workforce with expertise in clinical research. Higher trial accrual rates would improve trial feasibility, particularly for rare diseases. Improved overall participation rates across all trials would serve to reduce the disparity in outcomes for geographically dispersed populations.There is a unique and timely opportunity to implement, evaluate and improve CRAFT across all regions of Canada. 3CTN plans for demonstration of CRAFT proof of concept pilot among member cancer centres. The pilot will be enabled by the CRAFT framework and the 3CTN collaborative network of clinicians, patient representatives, industry sponsors, Health Canada and other stakeholders. Scaled implementation of CRAFT across the Canadian clinical trial system will be informed by evaluation of pilot outcomes, further knowledge exchange and would also benefit from health system policy development that recognizes and enables equitable access to clinical trials as a fundamental component of standard of care delivery.


Gynaecological cancers are among the most prevalent cancers worldwide, with profound effects on the lives of women and their families. In this critical review, we explore the impacts of these cancers on quality of life (QOL) of women in Asian countries, and highlight areas for future inquiry.A systematic search of the literature was conducted in six electronic databases: Web of Science, Scopus, Global Health (CAB Direct), PsycINFO (Ovid), EBMR (Ovid), and Medline (Ovid). Screening resulted in the inclusion of 53 relevant articles reporting on 48 studies.Most studies were conducted in high and upper-middle income countries in East Asia and used quantitative approaches. Women had predominantly been diagnosed with cervical or ovarian cancer, and most had completed treatment. Four key interrelated domains emerged as most relevant in shaping QOL of women affected by gynaecological cancer: support, including identified needs, sources and forms; mental health, covering psychological distress associated with cancer, risk and protective factors, and coping strategies; sexual function and sexuality, focused on physiological, emotional and relational changes caused by gynaecological cancers and treatments, and the impacts of these on women’s identities; and physical health, covering the physical conditions associated with gynaecological cancers and their impacts on women’s daily activities.QOL of women affected by gynaecological cancer is shaped by their mental and physical health, support, and changes in sexual function and sexuality. The limited number of studies from lower- and middle-income countries in South and Southeast Asia highlights important knowledge gaps requiring future research. Multiple factors shape the quality of life of women affected by gynaecological cancers in Asian countries as elsewhere. We identified 53 articles reporting on 48 studies, most conducted in high- and upper-middle income East Asian countries, with much less attention to women in lower income countries in South and Southeast Asia. Most studies used quantitative research methods to gain an understanding of the impact on women diagnosed with cervical or ovarian cancer who had completed treatment. Women’s quality of life was shaped by their mental and physical health, their support needs, and the changes they experienced in sexual function and sexuality. In 2020, the International Agency for Research on Cancer reported that gynaecological cancers represented 7.29% of all new cancer cases globally, with 1,398,600 women newly diagnosed in the preceding year [Cervical cancer is responsible for over 50% of all gynaecological cancers globally; this is followed by ovarian and uterine cancers, most often endometrial . VaginalThe concepts of QOL and health-related QOL are often used to discern the impact of gynaecological cancers on women , 8. HealThe suitability of tools and their psychometric qualities for measuring QOL related to gynaecological cancers has been explored in several recent reviews –14, predIn the studies included in this review, 44 standardised instruments were utilised across 36 articles ; three symptom ; and one global health and QOL scale [A three-step approach was applied to evaluate validity. The first involved correlations among various scales; the second, clinical parameters, treatment toxicity and patient ability to perform certain daily life activities; the third, responsiveness of the instrument to temporal changes in respondent health status . The QLQThe HADS was designed in the United Kingdom to screen for clinically significant anxiety and depression in non-psychiatric patients . It has The FSFI , initialWomen affected by gynaecological cancer reported on the significance of social support in shaping QOL in 26 articles , 32–56, Economic support for women undergoing cancer treatment, and their families, was emphasised in studies in Hong Kong, Thailand and China , 42–45. Women’s intimate partners were not always a source of support, and at times cancer resulted in the breakdown of relationships , 39. In Women’s family members, friends and colleagues—usually other women—were important sources of support –49, 55. Studies in Hong Kong, China, Taiwan and Japan reported on support from health care providers, other women affected by cancer, and patient groups , 51, 55.Emotional support offered by women’s peers was described in three studies , 47, 48.Studies in Hong Kong, Taiwan and Thailand identified involvement with religious communities as providing spiritual support , 53, 55.Studies in China, Thailand, Japan, Indonesia and Hong Kong emphasised the provision of information to support women , 54, 56.The relationship between gynaecological cancer and mental health was discussed in 30 articles (29 studies) in the country contexts of Thailand, China, Hong Kong, South Korea, Indonesia, Taiwan and Japan , 57–73. Six generalised risk factors compromised women’s mental health: age, in some research being younger , 63, 67,Factors protective of women’s mental health and QOL included younger age at diagnosis , 70; beiSeveral studies included a qualitative component that elaborated on how women coped with the psychological burden and changes experienced while living with gynaecological cancer. Taiwanese women reported changing priorities and developing new interests post treatment . ChineseIn 31 articles, women reported that having gynaecological cancer, and its treatment, altered sexual function and dampened sexual desire and response , 73–81. Certain treatment regimens had a pronounced impact on sexual function , 79–81. A sexual health intervention in Indonesia with women who had completed treatment for cervical cancer, and their partners, highlighted the potential for women’s sexual experiences to be improved through education , 41. ParThe impact of gynaecological cancer and treatment on fertility was raised in one study in Hong Kong , 37. ThiWomen across studies reported that compromised sexual function shaped their perceptions of sex and their sexual identities. In studies in Taiwan, Hong Kong, China and Thailand involving women with low to medium levels of education, participants avoided or had less frequent sex because they feared this would cause recurrence of the cancer , 73, 77,Two studies in Hong Kong and China reported that women did not necessarily seek health care regarding their sexual function because they felt uncomfortable discussing their sex life with health care providers , feared Numerous articles addressed gender identity and delved into women’s intimate relationships , 69, 77.Two studies in Hong Kong and Thailand emphasised relationship changes due to gynaecological cancer. Some had separated from their husbands , 39; andTwenty-one articles described the impact of gynaecological cancer and treatment on women’s physical health , 81–84. Women’s daily lives, including work and leisure activities, were affected by cancer symptoms, treatment, and side effects , 42, 51.Women were not passive in face of side-effects and the management of illness. Living with gynaecological cancer motivated some women in Hong Kong to become more physically active post-treatment . SimilarOf the 25 Asian countries included in our initial search, only nine are represented in this review, indicating the limited literature published in English on QOL among women living in these countries and affected by gynaecological cancer. Of the nine countries represented, five are classified as high income, three as upper-middle income and one as lower-middle income; no low-income Asian countries were represented. This may reflect the higher research capacity of high-income countries in the region, but it is of concern in terms of representation and because the incidence and mortality rates of gynaecological cancers are significantly higher in the middle-income Asian countries included in the review . There iA key finding was that high levels of support typically improved women’s QOL, and lower levels of support were reflected in poorer QOL. The strong relationship between support and QOL was mirrored in other studies of QOL, for instance, among breast cancer survivors in Asian societies, and so was not specific to women affected by gynaecological cancers , 87. WhaAsian women affected by gynaecological cancer relied on various people for support including: husbands and intimate partners; family and friends; health workers and peers; and religious communities. The nature of support was: financial; emotional and psychological; informational; physical; spiritual; and practical . Consistent with a review on QOL among women affected by breast cancer, we found social support, financial support and support in accessing information to be key components of women’s QOL . While rGaps in information were identified as a support deficit impacting negatively on women’s QOL. This highlights the need for greater attention to the provision of comprehensive patient education by health care professionals engaging with women and their families. The need for financial support for women living with gynaecological cancer confirms findings from a recent multi-country study in eight Asian countries, in which women survivors of cancer  with low socio-economic status experienced lower QOL . The higStrong links exist between mental health and QOL, and between mental health and the degree of support women received. Manifestations of poor mental health included: depression and anxiety; irritability; frustration; negative rumination; suicidality; compromised self-esteem; and social withdrawal. Similar impacts in terms of psychological distress have been observed in other studies on mental health, including of women living with gynaecological cancer in Australia  and womeBoth risk and protective factors associated with psychological distress were reported. Risk factors independent of women’s cancer status and experiences were linked to either age at diagnosis or structural disadvantage. Risk factors for poor mental health directly associated with women’s experiences of gynaecological cancer included: being diagnosed at an advanced disease stage; negative health care experiences; disease symptoms and treatment side effects; impact on sexuality and body image; infertility; and recurrence.Protective factors which supported women’s mental health and QOL included: younger age at diagnosis; diagnosis at an early stage of disease; higher levels of self-esteem and self-efficacy; increased capacity to work; high mobility; a high degree of social support; religious faith; and greater length of time since treatment. Specific coping mechanisms were also described. Some women reported a greater sense of appreciation of their lives and experienced a reorientation of life priorities. Relationships with peers with similar experiences proved important for maintaining mental health. The existing research provides a strong starting point for further research into how specific interventions could be developed to promote the mental health of women affected by gynaecological cancers in different Asian settings.Gynaecological cancers have enormous impacts on sexual function, sexuality and intimate relationships and associated decreases in women’s QOL. Global reviews of sexual function among women affected by gynaecological cancer, and research conducted with women in non-Western contexts other than Asia, confirm that the impacts of cancer and its treatment on women’s sexuality are a crucial determinant of QOL , 93. TheOnly one study reported any interventions to address women’s sexual function and their desire to resume successful sexual relationships. Afiyanti and colleagues’ study , 41 in IWomen with gynaecological cancer in Asia experienced extensive treatment side effects, and these side effects impacted negatively on their QOL and ability to function in their daily lives. The most pronounced side effects were pain, fatigue and gastrointestinal distress. Many women reported side effects that worsened as treatment extended. Specific side effects were associated with specific treatment regimens. For instance, in the studies, women were more likely to report gastrointestinal distress in association with chemotherapy than other modalities of care, and pain was more strongly associated with surgery. For some women, side effects associated with treatment were experienced as akin to having another disease, or as impacting more significantly on wellbeing and QOL than the physical symptoms directly caused by cancer. These findings point to the necessity of dedicated management of treatment side-effects, as well as the initial cancer disease, to protect women’s QOL.Women reported a number of physical conditions affecting their QOL: sleep difficulties; urinary disorders and incontinence; numbness; loss of strength and reduced mobility; hot flushes and other menopausal symptoms. These findings are consistent with Kayl and Meyers’ review of the side-effects of chemotherapy in ovarian and breast cancer patients, in which they described the impact of side effects on women’s quality of life as “tremendous” . Common In the published English-language literature on QOL among women with gynaecological cancers in South, South East and East Asian countries, sexual function and sexuality featured most prominently (31 articles), then mental health (30 articles), support needs (26 articles) and physical health (21 articles). Our findings highlight the need for reforms in the delivery of health and patient care services for women, to address the interrelated domains of psychological health, sexual health and physical health. Such reforms should also attend to the differential support needs of patients across the disease trajectory.Significant gaps exist in the geographical scope of existing research, emphasising the need to expand this research. We identified a dearth of research on QOL of women affected by gynaecological cancer in lower-middle and low income countries, even though women in such settings are both vulnerable to developing gynaecological cancer and have fewer resources to draw upon once diagnosed. The domains of support, psychological distress and mental health, sexual function and sexuality, and physical health should be included in the adaption of QOL scales. The range of gynaecological cancers included in studies of this type in Asian settings also requires extension, and where multiple cancers are included in single studies the reporting of research results should distinguish between the effects of different forms of gynaecological cancer on women’s QOL.The inclusion of qualitative, mixed and quantative studies in this review highlighted the value of mixed methods to understand what constitutes QOL for woman affected by gynaecological cancer and the value of qualitative analysis to explain how the varied components of QOL are shaped by culture. Mixed methods and qualitative approaches are particularly salient in non-Western contexts, given that the standardized instruments typically utilized to measure QOL lack cultural grounding.Further research on women’s sexual function and recovery of sexual health is necessary. Ideally such studies should be linked with appropriate interventions designed to improve women’s sexual function and QOL. The need for further research on mental health as a component of QOL is also evident. We suggest exploring cultural constructions of mental health and wellbeing in different Asian societies to inform interventions relevant to women’s worldviews and sense of personhood. How Asian women manage the side effects of treatment and physical symptoms of gynaecological cancer has also been neglected. Research has the potential to illuminate how and why Asian women use complementary and traditional medicines to promote their physical health and QOL.Research on the long-term impacts of gynaecological cancer on women’s financial status and its resulting impact on QOL in Asian societies is also needed. Likewise, further research focusing on the relationships between social and economic support and psychological distress would enable a better understanding of how women’s QOL is determined by the interaction of social, structural and biomedical factors. Additional inquiry into Asian women’s experiences of cancer-related stigma, including the internalization of stigma, is crucial to address women’s social support needs and to tackle stigma. The significance of religion in promoting QOL and in providing support is another key area for further research, particularly in Asian societies where religious faith and practice remain central to daily life and worldviews. Research into QOL among women affected by gynaecological cancer in Asian societies is in a formative stage, and many gaps still need to be addressed. Filling these gaps has great potential to inform future practices and interventions to promote women’s QOL.


Social isolation is an increasingly critical issue among older adults and has been found to affect several domains of well-being, including physical, psychological, and cognitive health. Research has found that military veterans often experience hardships in the transition back to civilian life including emotional trauma, depression, substance misuse and pain from combat-related injuries, which have been shown to persist well into older adulthood. As such, this study aimed to examine the prevalence of social isolation among older military veterans and determine which veterans are most at-risk of experiencing social isolation, using the Berkman-Syme Social Network Index as a framework. Data were derived from Round 1 of the National Health and Aging Trends Study (NHATS), an annual longitudinal panel survey of adults aged 65 and older living in the United States. Results showed that about 4.5% of veterans in the NHATS are severely socially isolated while another 20.9% are socially isolated. After controlling for other explanatory variables, being White, being 85 and older, having lower educational attainment, being unmarried/unpartnered and having lower income were associated with an increased risk of experiencing social isolation. Interventions aiming to improve the well-being of older veterans should consider employing both preventative and amendatory measures. These may include the creation and administration of a standardized social isolation scale during visits to veterans’ affairs (VA) medical centers and a general effort to address stressors from military service by destigmatizing and improving access to mental health services.


Virtual reality (VR) has long been standard in healthcare education. Recent advances in VR hardware and software applications have coalesced to allow for higher fidelity, more highly realistic simulations that are also deployable at scale -- not just in highly specialized, single location simulation labs. In tandem, there has been an examination in both the corporate and academic sectors around the efficacy of VR training and learning. While VR has been long proven to be effective in training students and workers in hard skills, its lack of realism has been a barrier to explore efficacy in simulations related to soft skills and emotional intelligence. This symposium will discuss the implementation of virtual reality “labs”, where learners embody in a live 360 film environment the first-person point of view of an older adult -- interacting with gaze, voice, and natural hand motions – into four university’s medical and nursing curriculum. Lab outcomes include decreased ageism and stereotyping, and increased empathy, sensitivity, cultural competency, and disease knowledge. The first paper reports outcomes of increased understanding, comfort, compassion and empathy of students and informal caregivers after experiencing various labs. The second discusses comparative data on knowledge and attitudes of medical students experiencing the virtual labs individually vs. the group distance mode. The third reports the results of an initial study on how embodying an older adult with sensory impairment affects participant empathy using a standardized scale. The fourth discusses how one university transitioned to delivering immersive labs to nursing students remotely during COVID19.