Variant STAT4 and Response to Ruxolitinib in an Autoinflammatory Syndrome.

BACKGROUND: Disabling pansclerotic morphea (DPM) is a rare systemic inflammatory disorder, characterized by poor wound healing, fibrosis, cytopenias, hypogammaglobulinemia, and squamous-cell carcinoma. The cause is unknown, and mortality is high. METHODS: We evaluated four patients from three unrelated families with an autosomal dominant pattern of inheritance of DPM. Genomic sequencing independently identified three heterozygous variants in a specific region of the gene that encodes signal transducer and activator of transcription 4 (STAT4). Primary skin fibroblast and cell-line assays were used to define the functional nature of the genetic defect. We also assayed gene expression using single-cell RNA sequencing of peripheral-blood mononuclear cells to identify inflammatory pathways that may be affected in DPM and that may respond to therapy. RESULTS: Genome sequencing revealed three novel heterozygous missense gain-of-function variants in STAT4. In vitro, primary skin fibroblasts showed enhanced interleukin-6 secretion, with impaired wound healing, contraction of the collagen matrix, and matrix secretion. Inhibition of Janus kinase (JAK)-STAT signaling with ruxolitinib led to improvement in the hyperinflammatory fibroblast phenotype in vitro and resolution of inflammatory markers and clinical symptoms in treated patients, without adverse effects. Single-cell RNA sequencing revealed expression patterns consistent with an immunodysregulatory phenotype that were appropriately modified through JAK inhibition. CONCLUSIONS: Gain-of-function variants in STAT4 caused DPM in the families that we studied. The JAK inhibitor ruxolitinib attenuated the dermatologic and inflammatory phenotype in vitro and in the affected family members. (Funded by the American Academy of Allergy, Asthma, and Immunology Foundation and others.).

Prevalence of Helicobacter pylori infection among resettled refugees presenting to a family medicine clinic in the United States.

BACKGROUND: Although endemic to much of the global population, few studies have examined Helicobacter pylori (H. pylori) in US refugee populations. This study investigates the prevalence of H. pylori infection and barriers to treatment in the International Family Medicine Clinic (IFMC), a primary care refugee clinic, in central Virginia. MATERIALS AND METHODS: We conducted a chart review of 188 refugee patients of the IFMC who were referred for an H. pylori test between January 1, 2019, and December 31, 2020. Recorded measures included patient demographics, H. pylori test result, treatment of initial infection, completion of test of cure (TOC), TOC results, salvage therapy, and barriers to treatment. Binary logistic regression was performed to examine the association between demographic factors and H. pylori test results. RESULTS: Of the 171 patients who completed an H. pylori test, 94 tested positive (54.9%). Of the 93 patients that were subsequently treated, 76 were treated with clarithromycin triple therapy (82%). Forty-eight patients (52%) completed a TOC after completing treatment, and 21 (43%) of these patients remained positive, indicating persistent infection. Eighteen patients (90%) who remained positive for H. pylori were subsequently treated with quadruple therapy. Patients under 18 (OR = 0.25, p < 0.01) and patients with a history of previous H. pylori (OR = 0.44, p < 0.05) were less likely to have positive results on initial H. pylori testing. Common barriers to treatment included pregnancy, religious observance (e.g., fasting), and health system complications (e.g., prior authorization for medications, cost of treatment). CONCLUSIONS: The prevalence of H. pylori among refugees at the IFMC was higher than the overall prevalence estimate for the United States, which is consistent with previous studies. This work represents an updated picture of H. pylori prevalence among refugees in the United States and contributes to the identification of treatment barriers.

Improving Depression Screening in Primary Care: A Quality Improvement Initiative.

The increase in depression during the COVID-19 pandemic underscores the importance of systematic approaches to identify individuals with mental health concerns. Primary care is often underutilized for depression screening, and it is not clear how practices can successfully increase screening rates. This study describes a quality improvement initiative to increase depression screening in five Family Medicine clinics. The initiative included four Plan-Do-Study-Act cycles that resulted in implementing a standardized workflow for depression screening, collaborative efforts with health information technology to prompt providers to perform screening via the medical record, delivering educational materials for providers and clinic staff and conducting follow-up education. Between September 2020 and April 2021 there were 23,745 clinic encounters with adult patients that were analyzed to determine whether patients were up-to-date on depression screening following their visit. A multi-level logistic regression model was constructed to determine the changes in likelihood of a patient being up-to-date on screening over the study period, while controlling for patient demographics and comorbidities. The average proportion of up-to-date patients increased from 61.03% in September 2020 to 82.33% in April 2021. Patients aged 65+ and patients with comorbidities were more likely to be up-to-date on screening; patients with telemedicine visits had lower odds of being up-to-date on depression screening. Overall, this paper describes a feasible, effective intervention to increase depression screening in a primary care setting. Additionally, we discuss lessons learned and recommendations to inform the design of future interventions.

Working with children with cortical visual impairment who use augmentative and alternative communication: implications for improving current practice.

The aim of this study was to describe how professionals from multiple disciplines (e.g., speech-language pathologists, teachers, occupational therapists) in the United States reported challenges they face in delivering services to children with cortical visual impairment (CVI) who use augmentative and alternative communication (AAC). Three surveys were utilized to identify barriers to and priorities for improving educational and clinical services and in-service and preservice education from the perspectives of professionals in school, community, and university settings. Results suggest that current service delivery models may not be meeting the needs of either children with CVI who use AAC or the professionals whose job it is to provide them with services. Professionals in community-based settings appeared to encounter more barriers. Findings help to support a discussion about approaching AAC interventions for children with CVI who use AAC by adopting interprofessional collaborative practice (IPCP) and interprofessional education (IPE) models, which reflect long-standing best practice guidelines for AAC service delivery and are encouraged by multiple professional organizations.

Lessons for the AAC field: a tribute to Dr. David Beukelman.

On February 5, 2022, the field of augmentative and alternative communication (AAC) lost a giant when Dr. David "Dave" Beukelman passed away. As the readership of this journal is aware, Dave was one of the principal founders of the AAC field and devoted his career to providing a voice to those without one. Before AAC became a field, people who could not talk were invisible or seldom noticed, unless they were in the way. For more than 40 years, he was a catalyst for change in AAC clinical practice, research, dissemination, teaching, and public policy development. This tribute aims to honor Dave's lifelong mission of serving others by sharing some of his most timeless and valued lessons. Each lesson begins with one of Dave's most enduring quotes that is then followed by a brief synopsis of the lesson Dave hoped to convey.

Systematic evaluation of nine monogenic autoinflammatory diseases reveals common and disease-specific correlations with allergy-associated features.

BACKGROUND: Monogenic autoinflammatory diseases (AID) are caused by mutations in innate immune genes. The effects of these mutations on allergic inflammation are unknown. OBJECTIVES: We investigated allergic, immunological and clinical phenotypes in FMF (familial Mediterranean fever), CAPS (cryopyrin-associated periodic syndrome), TRAPS (tumour necrosis factor receptor-associated periodic syndrome), HIDS (hyper-IgD syndrome), PAPA (pyogenic arthritis, pyoderma gangrenosum and acne), DADA2 (deficiency of adenosine deaminase 2), HA20 (haploinsufficiency of A20), CANDLE (chronic atypical neutrophilic dermatosis, lipodystrophy, elevated temperature) and SAVI (STING-associated vasculopathy of infancy). METHODS: In this cross-sectional study, clinical data were assessed in 425 patients with AID using questionnaires and chart reviews. Comparator data were obtained from public databases. Peripheral blood mononuclear cells obtained from 55 patients were stimulated and CD4+ cytokine production assessed. RESULTS: Clinical laboratory features of Type 2 immunity were elevated in CAPS but reduced in most AID, particularly DADA2. Physician-diagnosed allergic diseases were prevalent in multiple AID, including CAPS and DADA2. T helper 2 (Th2) cells were expanded in CAPS, TRAPS and HIDS; Th9 cells were expanded in HA20. CONCLUSIONS: CAPS is characterised by an enhanced Type 2 signature, whereas FMF and CANDLE are associated with reduced Type 2 responses. DADA2 is associated with reduced Type 2 responses but a high rate of physician-diagnosed allergy. Therefore, NLRP3-driven autoinflammation may promote Type 2 immunity, whereas AID like DADA2 may manifest clinical phenotypes that masquerade as allergic disorders. Further investigations are needed to determine the contribution of autoinflammation to allergic clinical and immunological phenotypes, to improve the treatment of patients with AID.

College student attitudes and strategies for intervention with a hypothetical peer exhibiting disordered eating.

OBJECTIVE: The present study assesses stigma, attitudes, and strategies of college students in intervening with peers demonstrating disordered eating behaviors. METHOD: Four hundred and eighty nine college students (384 women) completed questionnaires that assessed eating disorder symptoms and bystander attitudes adapted for disordered eating. Participants read one of three vignettes of a 20-year-old hypothetical peer displaying symptoms of disordered eating aligned with bulimia nervosa, anorexia nervosa, or binge-eating disorder; participants then described whether the vignette subject had a problem, what the problem was, and strategies for intervention. Relationships among eating disorder history, bystander attitudes, demographics, and intention to intervene in disordered eating were assessed using descriptive and regressive analyses; peer intervention strategies were organized and evaluated for frequencies of responses. RESULTS: Demographics (female-identification) and familiarity with disordered eating were associated with likelihood to intervene in disordered eating. Most students recognized that the peer had a problem, but fewer than half believed the problem was disordered eating; nearly a quarter (22%) of the students stated that they would be uncomfortable talking to a peer about disordered eating. The majority of students cited vague or nonproblem-related intervention strategies (62%), followed by emotion-focused strategies (22.5%), or body and behavior-focused strategies (15%). DISCUSSION: College students, particularly women and those with previous exposure to eating disorders, are likely to intervene peers disordered eating. However, students tend to use vague or body-focused intervention strategies. Bystander intervention training that provides rationale and rehearsal for supportive communication strategies is needed to address students' lack of intervention skills, particularly among men.

Depression, burnout, and professional outcomes among PAs.

OBJECTIVE: This study examined the effect of depression and burnout on PA professional fulfillment and medical errors. METHODS: Eight hundred eighty PAs completed an online survey containing the Professional Fulfillment Index, PHQ-2, GAD-7, and demographic questions. Two serial mediation models examined the relationship between depression, burnout, and professional outcomes. RESULTS: Burnout fully mediated the relationship between depression and outcomes in both models and the present research indicates that burnout plays a stronger role in job satisfaction than symptoms of depression. CONCLUSIONS: Understanding the underpinnings of professional satisfaction may mitigate clinician turnover, which in turn may lead to cost savings for the organization, better resilience and mental health for clinicians, and potentially better patient outcomes.

Application of the Consolidated Framework for Implementation Research to examine nurses' perception of the task shifting strategy for hypertension control trial in Ghana.

BACKGROUND: The burden of hypertension in many low-and middle-income countries is alarming and requires effective evidence-based preventative strategies that is carefully appraised and accepted by key stakeholders to ensure successful implementation and sustainability. We assessed nurses' perceptions of a recently completed Task Shifting Strategy for Hypertension control (TASSH) trial in Ghana, and facilitators and challenges to TASSH implementation. METHODS: Focus group sessions and in-depth interviews were conducted with 27 community health nurses from participating health centers and district hospitals involved in the TASSH trial implemented in the Ashanti Region, Ghana, West Africa from 2012 to 2017. TASSH evaluated the comparative effectiveness of the WHO-PEN program versus provision of health insurance for blood pressure reduction in hypertensive adults. Qualitative data were analyzed using open and axial coding techniques with emerging themes mapped onto the Consolidated Framework for Implementation Research (CFIR). RESULTS: Three themes emerged following deductive analysis using CFIR, including: (1) Patient health goal setting- relative priority and positive feedback from nurses, which motivated patients to make healthy behavior changes as a result of their health being a priority; (2) Leadership engagement (i.e., medical directors) which influenced the extent to which nurses were able to successfully implement TASSH in their various facilities, with most directors being very supportive; and (3) Availability of resources making it possible to implement the TASSH protocol, with limited space and personnel time to carry out TASSH duties, limited blood pressure (BP) monitoring equipment, and transportation, listed as barriers to effective implementation. CONCLUSION: Assessing stakeholders' perception of the TASSH implementation process guided by CFIR is crucial as it provides a platform for the nurses to thoroughly evaluate the task shifting program, while considering the local context in which the program is implemented. The feedback from the nurses informed barriers and facilitators to implementation of TASSH within the current healthcare system, and suggested system level changes needed prior to scale-up of TASSH to other regions in Ghana with potential for long-term sustainment of the task shifting intervention. TRIAL REGISTRATION: Trial registration for parent TASSH study: NCT01802372. Registered February 27, 2013.

Novel MALT1 Mutation Linked to Immunodeficiency, Immune Dysregulation, and an Abnormal T Cell Receptor Repertoire.

MALT1 (mucosa-associated lymphoid tissue lymphoma-translocation gene 1) is an intracellular signaling protein that activates NFκB and is crucial for both the adaptive and innate immune responses. Only 6 patients with immune deficiencies secondary to inherited mutations in the MALT1 gene have been described. PURPOSE: To provide clinical and immunological insights from 2 patients diagnosed with MALT1 immunodeficiency syndrome due to a novel MALT1 mutation. METHODS: Two cousins with suspected combined immunodeficiency underwent immunological and genetic work-up, including lymphocyte phenotyping, lymphocyte activation by mitogen stimulation, and next-generation sequencing (NGS) of T cell receptor gamma chain (TRG) repertoire. Whole exome sequencing was performed to identify the underlying genetic defect. RESULTS: Clinical findings included recurrent infections, failure to thrive, lymphadenopathy, dermatitis, and autoimmunity. Immune work-up revealed lymphocytosis, low to normal levels of immunoglobulins, absence of regulatory T cells, and low Th17 cells. A normal proliferative response was induced by phytohemagglutinin and IL-2 but was diminished with anti-CD3. TRG repertoire was diverse with a clonal expansion pattern. Genetic analysis identified a novel autosomal recessive homozygous c.1799T>A; p. I600N missense mutation in MALT1. MALT1 protein expression was markedly reduced, and in vitro IL-2 production and NFκB signaling pathway were significantly impaired. CONCLUSIONS: Two patients harboring a novel MALT1 mutation presented with signs of immune deficiency and dysregulation and were found to have an abnormal T cell receptor repertoire. These findings reinforce the link between MALT1 deficiency and combined immunodeficiency. Early diagnosis is crucial, and curative treatment by hematopoietic stem cell transplantation may be warranted.

'I believe high blood pressure can kill me:' using the PEN-3 Cultural Model to understand patients' perceptions of an intervention to control hypertension in Ghana.

OBJECTIVES: Currently in Ghana, there is an on-going task-shifting strategy in which nurses are trained in hypertension management. While this study will provide useful information on the viability of this approach, it is not clear how patients in the intervention perceive hypertension, the task-shifting strategy, and its effects on blood pressure management. The objective of this paper is to examine patients' perceptions of hypertension and hypertension management in the context of an on-going task-shifting intervention to manage blood pressure control in Ghana. DESIGN: Forty-two patients participating in the Task Shifting Strategy for Hypertension program (23 males, 19 females, and mean age 61. 7 years) completed in-depth, qualitative interviews. Interviews were transcribed, and key words and phrases were extracted and coded using the PEN-3 Cultural Model as a guide through open and axial coding techniques, thus allowing rich exploration of the data. RESULTS: Emergent themes included patients' perceptions of hypertension, which encompassed misperceptions of hypertension and blood pressure control. Additional themes included enablers and barriers to hypertension management, and how the intervention nurtured lifestyle change associated with blood pressure control. Primary enabling factors included the supportive nature of TASSH nurses, while notable barriers were financial constraints and difficulty accessing medication. Nurturing factors included the motivational interviewing and patient counseling which instilled confidence in the patients that they could make lasting behavior changes. CONCLUSIONS: This study offers a unique perspective of blood pressure control by examining how patients view an on-going task-shifting initiative for hypertension management. The results of this study shed light on factors that can help and hinder individuals in low-resource settings with long-term blood pressure management.

Evaluating antenatal care in Liberia: evidence from the demographic and health survey.

Liberia has one of the highest maternal mortality ratios worldwide. Using quality antenatal care (ANC) can prevent maternal mortality. Indicators of quality ANC include: (1) timing of care initiation; (2) number of ANC visits (4+); and (3) ANC with recommended components. The purpose of this study was to examine factors associated with quality ANC in Liberia. Data from the 2013 Liberia Demographic and Health Survey were used (n = 5,348). Factors associated with quality ANC were assessed using multiple logistic regression. The majority of women attended at least four ANC visits (76.13%) and initiated care in the first trimester (66.5%); however, only 30% received care with all recommended components. Intended pregnancy, contraceptive use, and receiving ANC at a health facility with skilled providers were significantly associated with quality care. The lack of quality ANC may contribute to the high maternal mortality in Liberia. Facilitating access to health facilities and skilled ANC providers could improve the quality of care and potentially improve maternal outcomes over time. Additionally, focusing on empowering women with respect to access to birth control and control over pregnancies may increase the use of quality care.

Impact of a Hand Hygiene Curriculum and Group Handwashing Station at Two Primary Schools in East Africa.

Proper handwashing reduces the transmission of deadly, preventable diseases. Schools, even those with limited resources, have the power to promote handwashing through simple, effective interventions. This study evaluated the impact of a school-based handwashing program consisting of two interventions: a hand-hygiene curriculum and group handwashing station. Quantitative and open-ended pre/postintervention surveys were administered to students at one primary school in Kenya ( n = 38) and at one primary school in Uganda ( n = 57). Matching procedures were followed at each school. Paired ttests for pre/postsurveys demonstrated an increase in students' knowledge ( p < .001) and frequency of handwashing ( p < .001). After 6 months, students were still engaging in daily group handwashing. The curriculum increased knowledge, and the handwashing station enabled students to translate their knowledge into action. This study supports educational interventions combined with built environmental interventions should be used to promote handwashing behaviors and emphasizes the role of group handwashing stations.

A comparison of minimum dietary diversity in Bangladesh in 2011 and 2014.

Improving infant and young child feeding practices is critical for improving growth and reducing child mortality and morbidity. This paper aims to compare predictors of minimum dietary diversity, an important indicator of adequate complementary feeding practices, in Bangladesh in 2011 and 2014. The 2011 and 2014 Bangladesh Demographic and Health Survey were used to examine predictors of minimum dietary diversity among 6-23 months. An additional analysis was conducted for the 18-23-month group, because a significant increase in meeting minimum dietary diversity recommendations was seen in this age group only. Factors found to be associated with practices were compared across time points. In 2011, minimum dietary diversity was 23.8% and increased to 28.8% in 2014. Among children 18-23 months, in 2011, minimum dietary diversity was 32.5% and increased to 42.8% in 2014. Among all children, wealth, education, exposure to media, and antenatal care were significant predictors of dietary diversity. In the 18-23-month age group, significant predictors in 2011 were wealth and decision making. In 2014, significant predictors were education and exposure to media. Demographic trends indicated a significant increase in education and exposure to media between 2011 and 2014. As these were significant for minimum dietary diversity in 2014 overall and for 18-23 months, they might be important targets of future interventions, specifically utilizing media channels and tailoring special strategies for women with low education and limited exposure to media.

Antenatal HIV Testing in Sub-Saharan Africa During the Implementation of the Millennium Development Goals: A Systematic Review Using the PEN-3 Cultural Model.

This study systematically explored the barriers and facilitators to routine antenatal HIV testing from the perspective of pregnant women in sub-Saharan Africa during the implementation period of the Millennium Development Goals. Articles published between 2000 and 2015 were selected after reviewing the title, abstract, and references. Twenty-seven studies published in 11 African countries were eligible for the current study and reviewed. The most common barriers identified include communication with male partners, patient convenience and accessibility, health system and health-care provider issues, fear of disclosure, HIV-related stigma, the burden of other responsibilities at home, and the perception of antenatal care as a "woman's job." Routine testing among pregnant women is crucial for the eradication of infant and child HIV infections. Further understanding the interplay of social and cultural factors, particularly the role of women in intimate relationships and the influence of men on antenatal care seeking behaviors, is necessary to continue the work of the Millennium Development Goals.

Exploring stakeholders' perceptions of a task-shifting strategy for hypertension control in Ghana: a qualitative study.

BACKGROUND: The purpose of this study was to explore stakeholders' perception of an on-going evidence-based task-shifting strategy for hypertension (TASSH) in 32 community health centers and district hospitals in Ghana. METHODS: Using focus group discussions and in-depth interviews, qualitative data were obtained from 81 key stakeholders including patients, nurses, and site directors of participating community health centers involved in the TASSH trial. Qualitative data were analyzed using open and axial coding techniques. RESULTS: Analysis of the qualitative data revealed three themes that illustrate stakeholders' perceptions of the ongoing task-shifting strategy for blood pressure control in Ghana and they include: 1) awareness and understanding of the TASSH program; 2) reasons for participation and non-participation in TASSH; and 3) the benefit and drawbacks to the TASSH program. CONCLUSION: The findings support evidence that successful implementation of any task-shifting strategy must focus not only on individual patient characteristics, but also consider the role contextual factors such as organizational and leadership factors play. The findings also demonstrate the importance of understanding stakeholder's perceptions of evidence-based task-shifting interventions for hypertension control as it may ultimately influence the sustainable uptake of these interventions into "real world" settings.

Training nurses in task-shifting strategies for the management and control of hypertension in Ghana: a mixed-methods study.

BACKGROUND: Nurses in Ghana play a vital role in the delivery of primary health care at both the household and community level. However, there is lack of information on task shifting the management and control of hypertension to community health nurses in low- and middle-income countries including Ghana. The purpose of this study was to assess nurses' knowledge and practice of hypertension management and control pre- and post-training utilizing task-shifting strategies for hypertension control in Ghana (TASSH). METHODS: A pre- and post- test survey was administered to 64 community health nurses (CHNs) and enrolled nurses (ENs) employed in community health centers and district hospitals before and after the TASSH training, followed by semi-structured qualitative interviews that assessed nurses' satisfaction with the training, resultant changes in practice and barriers and facilitators to optimal hypertension management. RESULTS: A total of 64 CHNs and ENs participated in the TASSH training. The findings of the pre- and post-training assessments showed a marked improvement in nurses' knowledge and practice related to hypertension detection and treatment. At pre-assessment 26.9% of the nurses scored 80% or more on the hypertension knowledge test, whereas this improved significantly to 95.7% post-training. Improvement of interpersonal skills and patient education were also mentioned by the nurses as positive outcomes of participation in the intervention. CONCLUSIONS: Findings suggest that if all nurses receive even brief training in the management and control of hypertension, major public health benefits are likely to be achieved in low-income countries like Ghana. However, more research is needed to ascertain implementation fidelity and sustainability of interventions such as TASSH that highlight the potential role of nurses in mitigating barriers to optimal hypertension control in Ghana. TRIAL REGISTRATION: Trial registration for parent TASSH study: NCT01802372 . Registered February 27, 2013.

WOMEN'S EMPOWERMENT, HOUSEHOLD STATUS AND CONTRACEPTION USE IN GHANA.

Gender inequality is often cited as a barrier to improving women's sexual and reproductive health outcomes, including contraceptive use, in low- and middle-income countries such as those in sub-Saharan Africa. To date there is limited, recent, evidence available regarding women's empowerment, household status and contraceptive use in Ghana. The objective of this study was to investigate whether women's empowerment and status in the household were associated with contraceptive use and unmet need for contraception using the 2014 Ghana Demographic and Health Survey. The study sample consisted of 1828 women aged 15-49. Women's empowerment was measured based on two composite indexes created by the DHS: attitudes towards intimate partner violence and decision-making. Women's status in the home was measured using indicators of work status, relationship to household head, control over monetary earnings and land ownership. Decision-making was found to be positively associated with contraceptive use and not having unmet need for contraception. Women who justified wife beating in one or more instances were less likely to use contraception, and more likely to have unmet need for contraception. Current or past employment and higher levels of male partner education were associated with contraceptive use. This study indicates that women's empowerment and household status are influential for contraceptive indicators. Future interventions aimed at improving contraceptive uptake and use should promote women's empowerment, i.e. decision-making, self-worth and education.

How a diverse research ecosystem has generated new rehabilitation technologies: Review of NIDILRR's Rehabilitation Engineering Research Centers.

Over 50 million United States citizens (1 in 6 people in the US) have a developmental, acquired, or degenerative disability. The average US citizen can expect to live 20% of his or her life with a disability. Rehabilitation technologies play a major role in improving the quality of life for people with a disability, yet widespread and highly challenging needs remain. Within the US, a major effort aimed at the creation and evaluation of rehabilitation technology has been the Rehabilitation Engineering Research Centers (RERCs) sponsored by the National Institute on Disability, Independent Living, and Rehabilitation Research. As envisioned at their conception by a panel of the National Academy of Science in 1970, these centers were intended to take a "total approach to rehabilitation", combining medicine, engineering, and related science, to improve the quality of life of individuals with a disability. Here, we review the scope, achievements, and ongoing projects of an unbiased sample of 19 currently active or recently terminated RERCs. Specifically, for each center, we briefly explain the needs it targets, summarize key historical advances, identify emerging innovations, and consider future directions. Our assessment from this review is that the RERC program indeed involves a multidisciplinary approach, with 36 professional fields involved, although 70% of research and development staff are in engineering fields, 23% in clinical fields, and only 7% in basic science fields; significantly, 11% of the professional staff have a disability related to their research. We observe that the RERC program has substantially diversified the scope of its work since the 1970's, addressing more types of disabilities using more technologies, and, in particular, often now focusing on information technologies. RERC work also now often views users as integrated into an interdependent society through technologies that both people with and without disabilities co-use (such as the internet, wireless communication, and architecture). In addition, RERC research has evolved to view users as able at improving outcomes through learning, exercise, and plasticity (rather than being static), which can be optimally timed. We provide examples of rehabilitation technology innovation produced by the RERCs that illustrate this increasingly diversifying scope and evolving perspective. We conclude by discussing growth opportunities and possible future directions of the RERC program.