Barriers To Dissemination Research Articles

Structural Integrity of the Alveolar–Capillary Barrier in Cynomolgus Monkeys Challenged with Fully Virulent and Toxin-Deficient Strains of Bacillus anthracis

Inhalational anthrax, a disease caused by inhaling Bacillus anthracis spores, leads to respiratory distress, vascular leakage, high-level bacteremia, and often death within days. Anthrax lethal toxin and edema toxin, which are composed of protective antigen (PA) plus either lethal factor (LF) or edema factor (EF), respectively, play an important yet incompletely defined role in the pulmonary pathophysiology. To better understand their contribution, we examined the structural integrity of the alveolar-capillary barrier in archival formalin-fixed lungs of cynomolgus monkeys challenged with the fully virulent B. anthracis Ames wild-type strain or the isogenic toxin-deficient mutants ΔEF, ΔLF, and ΔPA. Pulmonary spore challenge with the wild-type strain caused high mortality, intra-alveolar hemorrhages, extensive alveolar septal sequestration of bacteria and neutrophils, diffuse destabilization of epithelial and endothelial junctions, increased markers of coagulation and complement activation (including tissue factor and C5a), and multifocal intra-alveolar fibrin deposition. ΔEF challenge was lethal and showed similar alveolar-capillary alterations; however, intra-alveolar hemorrhages, bacterial deposition, and markers of coagulation or complement were absent or markedly lower. In contrast, ΔLFor ΔPA challenges were nonlethal and showed no signs of alveolar bacterial deposition or alveolar-capillary changes. These findings provide evidence that lethal toxin plays a determinative role in bacterial dissemination and alveolar-capillary barrier dysfunction, and edema toxin may significantly exacerbate pulmonary pathologies in a systemic infection.

4340 Piloting Implementation and Dissemination of Best Practice Guidelines Using BPM+Health

OBJECTIVES/GOALS: Clinical translational studies inform clinical practice patterns through dissemination of clinical practice guidelines (CPG). In EM practices change to rapidly for timely local EHR implementation. We test the OMG BPM+Health specification for rapid deployment of best practices relevant to EM. METHODS/STUDY POPULATION: The OMG Business Process Management for Healthcare (BPM+Health) specification combines BPMN™ with Case Management Model and Notation (CMMN™) and Decision Model and Notations (DMN™) to “disseminate and leverage evidence-based best-practices at the point of care.” The American College of Emergency Physicians (ACEP) Board-certified Emergency Physicians modeled practice guidelines in the BPM+ modeling language during on-line meetings. Two common emergency conditions were selected for initial pilot testing: 1) evaluation and treatment of first trimester bleeding in pregnant patients, and 2) the evaluation and treatment of non-traumatic low back pain. RESULTS/ANTICIPATED RESULTS: The protocols were successfully modeled during four on-line meetings in less than 2 months. Process steps from initial evaluation to disposition were implemented using BPMN™. When clinicians need to evaluate the patient to collect data for decision making the inputs and outputs were modeled in CMMN™. Decision logic is represented as DMN™. The software tool linked the components for easy browsing and authoring the logic. The Physicians easily followed the displayed logic. The practice recommendations from each policy were successfully modeled, using the standard BPM+ notation to support rapid implementation in EHRs. Detailed implementation specifications will be shared. DISCUSSION/SIGNIFICANCE OF IMPACT: This pilot project demonstrated the feasibility of the OMG approach to solving Clinical Practice Guideline Implementation and Dissemination Barriers. Ongoing work by involved specialty societies will be necessary to demonstrate the scalability and sustainability of this approach.

Characterizing health researcher barriers to sharing results with study participants.

Research participants want to receive results from studies in which they participate. However, health researchers rarely share the results of their studies beyond scientific publication. Little is known about the barriers researchers face in returning study results to participants. Using a mixed-methods design, health researchers (N = 414) from more than 40 US universities were asked about barriers to providing results to participants. Respondents were recruited from universities with Clinical and Translational Science Award programs and Prevention Research Centers. Respondents reported the percent of their research where they experienced each of the four barriers to disseminating results to participants: logistical/methodological, financial, systems, and regulatory. A fifth barrier, investigator capacity, emerged from data analysis. Training for research faculty and staff, promotion and tenure incentives, and funding agencies supporting dissemination of results to participants were solutions offered to overcoming barriers. Study findings add to literature on research dissemination by documenting health researchers' perceived barriers to sharing study results with participants. Implications for policy and practice suggest that additional resources and training could help reduce dissemination barriers and increase the return of results to participants.

Disseminating Cultural Neuropsychology Research: Five Key Recommendations for Skill Development

Abstract Objective Cultural neuropsychology has been called upon to meet the demand for more empirical tools and frameworks to use with our diverse populations. While much is being done, we have largely been “playing a game of catch-up” (Manly, 2008) and researchers have been encouraged to reinvent their approaches (Suchy, 2016). In this regard, one area of opportunity is promoting the development of cultural neuropsychology research dissemination. Method Relevant literature and professional experiences were used to identify cultural neuropsychology research dissemination barriers and solutions. Outcomes (1) Researches should use empirically supported knowledge dissemination frameworks to guide their approaches (Wilson et al., 2010). (2) Care should be taken to report study variables in internationally compatible/meaningful units (e.g., education, socioeconomic status; UNESCOIS, 2012). Researchers are also encouraged to find opportunities to comment on the purposeful exclusion of “North-American” variables (e.g., ethnicity) as well as the lessons learned from research “failures” (Hruschka et al., 2018). (3) Findings should be presented in ways that make clinical application easily comprehensible and implementable, even for those not specializing in cultural neuropsychology (e.g., use clear titles, clarify “insider” knowledge). (4) Researchers can and should negotiate with journals to make available the translated manuscripts and supplemental materials to improve research accessibility. (5) Professional collaboration and research visibility are fundamental to the success of dissemination (Tripathy et al., 2017). Discussion Neuropsychologists are eager for more culturally informed and clinically applicable research. Thus, cultural neuropsychology researchers focusing on developing their dissemination skills in these five highlighted areas are well positioned to increase the impact of their work and promote growth within cultural neuropsychology specifically, and neuropsychology broadly. References Hruschka, D. J., Munira, S., Jesmin, K., Hackman, J., & Tiokhin, L. (2018). Learning from failures of protocol in cross-cultural research. Proceedings of the National Academy of Sciences, 115(45), 11428-11434. Manly, J. J. (2008). Critical issues in cultural neuropsychology: profit from diversity. Neuropsychological Review, 18(3), 179-183. Suchy, Y. (2016). Population-based norms in crisis. The Clinical Neuropsychologist, 30(7), 973-974. Tripathy, J. P., Bhatnagar, A., Shewade, H. D., Kumar, A. M. V., Zachariah, R., & Harries, A. D. (2017). Ten tips to improve the visibility and dissemination of research for policy makers and practitioners. Public Health Action, 7(1), 10-14. UNESCO Institute for Statistics. (2012). International Standard Classification of Education: ISCED 2011. Montreal: UNESCO Institute for Statistics. Wilson, P. M., Petticrew, M., Calnan, M. W., & Nazareth, I. (2010). Disseminating research findings: what should researchers do? A systematic scoping review of conceptual frameworks. Implementation Science, 5(1), 91.

Biogas development: Dissemination and barriers

Biogas as alternative energy has long been developed in Indonesia since 1970, however, the utilization of biogas as fuel has not been optimum even can be said is still low compared to the potential. Biogas can be produced from wastes (agriculture, household, farm, etc.), but from various studies and experiments, the best biogas is produced from livestock manure. Initially, the biogas produced from livestock manure was not approved by the community because of the public’s perception that cow dung/manure is dirty and inappropriate to be used for lighting and cooking. Over time these perceptions have changed and biogas is more accepted, but the utilization of biogas is still not optimal, various obstacles arise. This paper provides an overview of the barriers in biogas dissemination in West Java-Indonesia, among others, the investment is expensive, the process is considered complicated, the reluctance to manage the digester like filling cow dung, etc. Knowledge of these barriers can be used for designing the method in disseminating also the pattern/model of biogas development and application in a community to be accepted and sustainable. Information was extracted by observation and survey, interview and learning from various studies and reports. In addition, action research was also conducted in Subang, Sumedang, Bandung of West Java. Results from the studies and action research, show that biogas is actually needed by society, especially in rural areas, if its price is affordable and its operation is easy or not complicated, and also supported by policy.

Scaling up a tobacco control intervention in low resource settings: a case example for school teachers in India.

Research on processes of bringing effective tobacco control interventions to scale to increase quit rates among tobacco users is uncommon. This study examines processes to bring to scale one such intervention for school teachers, i.e. Tobacco Free Teacher-Tobacco Free Society (TFT-TFS). This intervention provides a foundation for an effective and low cost approach to promote cessation through schools. The present study was conducted in the states of Bihar and Maharashtra in 2014 using quantitative and qualitative methods. Focus group discussions (FGDs) were analysed using immersion crystallization method. The data presented are from a survey of 291 principals and seven FGDs. This study examined characteristics of principals and teachers, organizational environment, external environmental factors and program characteristics to determine facilitators and barriers for successful dissemination and implementation of the TFT-TFS program. Some facilitators were, incorporation of the program in existing channels like staff meetings and trainings, certification and recognition by the department of education; while some barriers were routine time bound duties (mainly teaching) of teachers and prevalence of tobacco use among teachers and administrators. Principals and teachers expressed a need and high level of interest in the adoption and implementation of the TFT-TFS program in their schools.

Transcriptome profiling of whitefly guts in response to Tomato yellow leaf curl virus infection

BackgroundPlant viruses in agricultural crops are of great concern worldwide, and over 75% of them are transmitted from infected to healthy plants by insect vectors. Tomato yellow leaf curl virus (TYLCV) is a begomovirus, which is the largest and most economically important group of plant viruses, transmitted by the whitefly Bemisia tabaci. The circulation of TYLCV in the insect involves complex insect-virus interactions, whereas the molecular mechanisms of these interactions remain ambiguous. The insect gut as a barrier for viral entry and dissemination is thought to regulate the vector specificity. However, due to its tiny size, information for the responses of whitefly gut to virus infection is limited.MethodsWe investigated the transcriptional response of the gut of B. tabaci Middle East-Asia Minor 1 species to TYLCV infection using Illumina sequencing.ResultsA total of 5207 differentially expressed genes (DEGs) between viruliferous and non-viruliferous whitefly guts were identified. Enrichment analyses showed that cargo receptor and ATP-binding cassette (ABC) transporters were enriched in DEGs, and might help the virus to cross gut barrier. TYLCV could perturb cell cycle and DNA repair as a possible result of its replication in the whitefly. Our data also demonstrated that TYLCV can activate whitefly defense responses, such as antimicrobial peptides. Meanwhile, a number of genes involved in intracellular signaling were activated by TYLCV infection.ConclusionsOur results reveal the complex insect-virus relationship in whitefly gut and provide substantial molecular information for the role of insect midguts in virus transmission.

Coping with the Stress in the Cardiac Intensive Care Unit: Can Mindfulness Be the Answer?

BackgroundMothers of infants with complex congenital heart disease are exposed to increased stress which has been associated with numerous adverse health outcomes. The coping mechanisms these mothers use critically effect the familial illness adaptation and most likely infant outcomes. Currently no data-based strategies have been developed for mothers to facilitate their coping, and proactively promote their adaptation in the critical care settings. A potential strategy is mindfulness which is currently used in other clinical settings with stress-reduction effects. Purpose(1) To investigate coping mechanisms of mothers whose infant with complex CHD is admitted in the CICU, and (2) to explore the acceptability and feasibility of mindfulness as a potential stress-reduction intervention for these mothers. Design and MethodsA descriptive qualitative study obtained perspectives from 14 mothers during three focus groups. A qualitative conventional content analysis was performed using ATLAS.ti. ResultsIn congruence with the Stress and Coping framework, themes identified mostly emotion-regulatory coping mechanisms including both active and passive strategies such as positive thinking, denial, distraction, relying on support systems, and focusing on baby. Mindfulness was an acceptable and feasible approach for most participants, however, practice unfamiliarity, time and space concerns, and personal preferences were identified as potential barriers for future dissemination. ConclusionsMindfulness can potentially promote illness adaptation by utilization of active coping mechanisms. Early interventions can provide immediate, and potentially long-term stress relief. Intervention settings, format, and time-frame should be flexibly tailored to the trajectory of parental distress and familial adjustment.

Bridging the Gaps Between Basic Science and Cognitive-Behavioral Treatments for Anxiety Disorders in Routine Care

Abstract. As a core component of cognitive-behavioral therapies (CBT), behavioral exposure is an effective treatment for anxiety disorders. Still, recent treatment studies demonstrate relatively high rates of treatment dropout, nonresponse, and relapse, indicating a substantial need for optimizing and personalizing existing treatment procedures. In the present article, we aim to address current challenges and future demands for translational research in CBT for the anxiety disorders, including (a) a better understanding of those mechanisms conferring behavioral change, (b) identifying important sources of individual variation that may act as moderators of treatment response, and (c) targeting practical barriers for dissemination of exposure therapy to routine care. Based on a recursive process model of psychotherapy research we will describe distinct steps to systematically translate basic and clinical research “from bench to bedside” to routine care, but also vice versa. Some of these aspects may stimulate the future roadmap for evidence-based psychotherapy research in order to better target the treatment of anxiety disorders as one core health challenge of our time.

Quantifying family dissemination and identifying barriers to communication of risk information in Australian BRCA families.

PurposeRecommendations for BRCA1 and BRCA2 mutation carriers to disseminate information to at-risk relatives pose significant challenges. This study aimed to quantify family dissemination, to explain the differences between fully informed families (all relatives informed verbally or in writing) and partially informed families (at least one relative uninformed), and to identify dissemination barriers.MethodsBRCA1 and BRCA2 mutation carriers identified from four Australian hospitals (n=671) were invited to participate in the study. Distress was measured at consent using the Kessler psychological distress scale (K10). A structured telephone interview was used to assess the informed status of relatives, geographical location of relatives, and dissemination barriers. Family dissemination was quantified, and fully versus partially informed family differences were examined. Dissemination barriers were thematically coded and counted.ResultsA total of 165 families participated. Information had been disseminated to 81.1% of relatives. At least one relative had not been informed in 52.7% of families, 4.3% were first-degree relatives, 27.0% were second-degree relatives, and 62.0% were cousins. Partially informed families were significantly larger than fully informed families, had fewer relatives living in close proximity, and exhibited higher levels of distress. The most commonly recorded barrier to dissemination was loss of contact.ConclusionLarger, geographically diverse families have greater difficulty disseminating BRCA mutation risk information to all relatives. Understanding these challenges can inform future initiatives for communication, follow-up and support.

Ebola virus infection kinetics in chimeric mice reveal a key role of T cells as barriers for virus dissemination

Ebola virus (EBOV) causes severe systemic disease in humans and non-human primates characterized by high levels of viremia and virus titers in peripheral organs. The natural portals of virus entry are the mucosal surfaces and the skin where macrophages and dendritic cells (DCs) are primary EBOV targets. Due to the migratory properties of DCs, EBOV infection of these cells has been proposed as a necessary step for virus dissemination via draining lymph nodes and blood. Here we utilize chimeric mice with competent hematopoietic-driven immunity, to show that EBOV primarily infects CD11b+ DCs in non-lymphoid and lymphoid tissues, but spares the main cross-presenting CD103+ DC subset. Furthermore, depletion of CD8 and CD4 T cells resulted in loss of early control of virus replication, viremia and fatal Ebola virus disease (EVD). Thus, our findings point out at T cell function as a key determinant of EVD progress and outcome.

University of California Center for Health Quality and Innovation: experiences from a system approach to scaling up effective interventions

The challenge of improving outcomes, costs, and access in health care among academic health systems is not a dearth of innovative research; but the difficulties encountered when attempting the dissemination and implementation of effective interventions throughout health systems. The University of California (UC) Center for Health Quality and Innovation (CHQI) was established to mitigate barriers to improvements among UC academic health systems. UC recognizes that engagement by leadership, strong evaluation processes, and innovator champions are key to overcoming dissemination and implementation barriers within large health systems. CHQI, led by five UC health system CEOs, six medical school deans, and the UC Senior Vice President of Health Sciences and Services, integrates evidence-based interventions by supporting a collaborative approach to innovative research and spreading best practices through grants, leadership, change management training, and convening task forces to facilitate system-wide change. CHQI employs a tactical and methodical performance-monitored approach to disseminating and implementing proven models of care, including quantifying the ROI (in quality and costs) of all programs prior to initiating a spread program. Once the ROI is assessed for scale and feasibility, a team of senior UC researchers provides guidance by reviewing program implementation and process measures with a focus on spreading best practices, as well as ongoing cost and outcome analyses. Since 2011, CHQI has funded 50 innovation projects, and trained and supported 23 fellows who additionally manage their own innovation projects. This panel presents CHQI's approach and experiences with scaling up effective interventions, through 3 of its multi-site programs that demonstrated a proven ROI before integrating and spreading evidence-based interventions across 5 UC health systems. The panelists will discuss barriers, challenges and successes of project design, evaluation, and implementation, such as data integration issues, organizational barriers (including culture and policies) among health systems, institutional impediments (workflow, workforce), and future plans.

Streptolysin S Promotes Programmed Cell Death and Enhances Inflammatory Signaling in Epithelial Keratinocytes during Group A Streptococcus Infection.

Streptococcus pyogenes, or group A Streptococcus (GAS), is a pathogen that causes a multitude of human diseases from pharyngitis to severe infections such as toxic shock syndrome and necrotizing fasciitis. One of the primary virulence factors produced by GAS is the peptide toxin streptolysin S (SLS). In addition to its well-recognized role as a cytolysin, recent evidence has indicated that SLS may influence host cell signaling pathways at sublytic concentrations during infection. We employed an antibody array-based approach to comprehensively identify global host cell changes in human epithelial keratinocytes in response to the SLS toxin. We identified key SLS-dependent host responses, including the initiation of specific programmed cell death and inflammatory cascades with concomitant downregulation of Akt-mediated cytoprotection. Significant signaling responses identified by our array analysis were confirmed using biochemical and protein identification methods. To further demonstrate that the observed SLS-dependent host signaling changes were mediated primarily by the secreted toxin, we designed a Transwell infection system in which direct bacterial attachment to host cells was prevented, while secreted factors were allowed access to host cells. The results using this approach were consistent with our direct infection studies and reveal that SLS is a bacterial toxin that does not require bacterial attachment to host cells for activity. In light of these findings, we propose that the production of SLS by GAS during skin infection promotes invasive outcomes by triggering programmed cell death and inflammatory cascades in host cells to breach the keratinocyte barrier for dissemination into deeper tissues.

High prevalence and two dominant host-specific genotypes of Coxiella burnetii in U.S. milk

BackgroundCoxiella burnetii causes Q fever in humans and Coxiellosis in animals; symptoms range from general malaise to fever, pneumonia, endocarditis and death. Livestock are a significant source of human infection as they shed C. burnetii cells in birth tissues, milk, urine and feces. Although prevalence of C. burnetii is high, few Q fever cases are reported in the U.S. and we have a limited understanding of their connectedness due to difficulties in genotyping. Here, we develop canonical SNP genotyping assays to evaluate spatial and temporal relationships among C. burnetii environmental samples and compare them across studies. Given the genotypic diversity of historical collections, we hypothesized that the current enzootic of Coxiellosis is caused by multiple circulating genotypes. We collected A) 23 milk samples from a single bovine herd, B) 134 commercial bovine and caprine milk samples from across the U.S., and C) 400 bovine and caprine samples from six milk processing plants over three years.ResultsWe detected C. burnetii DNA in 96% of samples with no variance over time. We genotyped 88.5% of positive samples; bovine milk contained only a single genotype (ST20) and caprine milk was dominated by a second type (mostly ST8).ConclusionsThe high prevalence and lack of genotypic diversity is consistent with a model of rapid spread and persistence. The segregation of genotypes between host species is indicative of species-specific adaptations or dissemination barriers and may offer insights into the relative lack of human cases and characterizing genotypes.

Exploring facilitating factors and barriers to the nationwide dissemination of a Dutch school-based obesity prevention program “DOiT”: a study protocol

BackgroundThe evidence-based Dutch Obesity Intervention in Teenagers (DOiT) program is a school-based obesity prevention program for 12 to 14-year olds attending the first two years of prevocational education. This paper describes the study protocol applied to evaluate (a) the nationwide dissemination process of DOiT in the Netherlands, and (b) the relationship between quality of implementation and effectiveness during nationwide dissemination of the program in the Netherlands.MethodsIn order to explore facilitating factors and barriers for dissemination of DOiT, we monitored the process of adoption, implementation and continuation of the DOiT program among 20 prevocational schools in the Netherlands. The study was an observational study using qualitative (i.e. semi-structured interviews) and quantitative methods (i.e. questionnaires and logbooks). Eight process indicators were assessed: recruitment, context, reach, dosage, fidelity, satisfaction, effectiveness and continuation. All teachers, students and parents involved in the implementation of the program were invited to participate in the study. As part of the process evaluation, a cluster-controlled trial with ten control schools was conducted to evaluate the effectiveness of the program on students’ anthropometry and energy balance-related behaviours and its association with quality of implementation.DiscussionThe identified impeding and facilitating factors will contribute to an adjusted strategy promoting adoption, implementation and continuation of the DOiT program to ensure optimal use and, thereby, prevention of obesity in Dutch adolescents.Trial registrationCurrent Controlled Trials ISRCTN92755979.

On Automation in the Verification of Software Barriers: Experience Report

We present an experience report on automating the verification of the software barrier synchronization primitive. The informal specification of the primitive is: when a thread calls the software barrier function, the thread halts until all other threads call their instances of the software barrier function. A successful software barrier call ensures that each thread has finished its portion of work before the threads start exchanging the results of these portions of work. While software barriers are widely used in parallel versions of major numerical algorithms and are indispensable in scientific computing, software barrier algorithms and their implementations scarcely have been verified. We improve the state of the art in proving the correctness of the major software barrier algorithms with off-the-shelf automatic verification systems such as Jahob, VCC, Boogie, Spin and Checkfence. We verify a central barrier, a C implementation of a barrier, a static tree barrier, a combining tree barrier, a dissemination barrier, a tournament barrier, a barrier with its client and a barrier on a weak memory model. In the process, we introduce a novel theorem proving method for proving validity of formulas containing cardinalities of comprehensions and improve the capabilities of one of the verification systems. Based on our experience, we propose new challenges in the verification of software barriers.

P311 A Survey On The Likely Resources Of Guideline Dissemination And The Perceived Barriers To The Utilization In Korea

BackgroundDissemination resources are very important to utilise Guidelines. To provide useful information to make a strategy for promoting implementation effectiveness, identifying the barriers to the utilisation should be done.ObjectivesTo identify...

Prevalence of urinary incontinence in older Korean women

Worldwide prevalence of any type urinary incontinence (UI) in women 20 years and over is estimated to be over 275 million in 2013 and the 4th International Consultation on Incontinence expects it to increase to over 300 million in 2018. While UI in women is considered to be an aging and public health issue with global implications, most research cited in the UI literature comes from English language sources. The absence of information from many Asian and other countries may be due to reliance on scientific reports written in English by editorial policies, authors of systematic literature reviews and other researchers. Moreover, the financial costs and time constraints associated with translation and dissemination of findings into English language journals could act as dissemination barriers. Therefore, the purpose of this study was to describe the current state of knowledge about prevalence and correlates of UI in Korean older women from non‐English language sources. Twelve research articles, two research monographs and one master's thesis, and data on UI abstracted from South Korea's 2008 National Health Insurance Cooperation Reports were reviewed in full. The prevalence of UI in women 60 years and older ranged from 11·2% to 76·3%. Personal, physical and psychological factors were found to be associated with UI including age, income and educational level, presence of comorbidities, body mass index, depression, anxiety and cognitive impairment. There was little difference between rural and urban dwelling older women in help‐seeking behavior: 93.8% rural and 90.5% urban dwelling older women sought no help for their incontinence. Inclusion of reports from non‐English sources is considered as an important contribution to better understanding of the worldwide epidemiology of UI in older women.

Guideline adherence in ectopic pregnancy management

Evidence-based guidelines have been issued for ectopic pregnancy (EP), covering both diagnostic and therapeutic management. In general, guidelines aim to reduce practice variation and to improve quality of care. To assess the guideline adherence in the management of EP, we developed guideline-based quality indicators and measured patient care in various hospitals. A panel of experts and clinicians developed quality indicators based on recommendations from the Dutch guideline on EP management, using the systematic RAND-modified Delphi method. With these indicators, patient care was assessed in six Dutch hospitals between January 2003 and December 2005. For each quality indicator, a ratio for guideline adherence was calculated. Overall adherence was reported, as well as adherence per hospital type, i.e. academic, teaching and non-teaching hospitals. Out of 30 guideline-based recommendations, 12 quality indicators were selected covering procedural, structural and outcome aspects of care. For 317 women surgically treated for EP, these aspects were assessed. Overall adherence to the guideline was 75%. The highest adherence (98%) was observed for performing transvaginal sonography during the diagnostic workup. The lowest adherence (21%) was observed for performing salpingotomy in case of contra-lateral tubal pathology. Wide variance in adherence (0-100%) existed between academic, teaching and non-teaching hospitals. The overall guideline adherence was reasonable, with ample room for improvement in various aspects of care. Further research should focus on the barriers for guideline dissemination and adherence, to further improve the management of EP.

Energy service companies to improve energy efficiency in China: barriers and removal measures

Since China became the second largest energy consumer and carbon dioxide emitter, Chinese government has put high emphasis on the problem of energy consumption and environmental pollution, and has put the project of energy conservation and emission reducing into practice. Energy service companies (ESCOs), a market oriented mechanism by energy performance contracting (EPC) to improve energy efficiency, had successful experiences in developed countries such as USA and Canada, and developing countries such as South Korea. ESCOs are in nascent stage in China and face several barriers that include market, finance, institutional, technology, risk control, educational and dissemination barriers, and poor energy pricing policies, high transaction costs problems etc. Thus, a series of corresponding countermeasures should be taken effectively to remove these barriers for promoting ESCOs to improve energy efficiency by energy performance contracting (EPC) in China in favor of Chinese economy kept going sustainably.