The quality of maternal healthcare training is the most optimal degree of health in the delivery of effective, efficient and quality healthcare in midwifery discipline. Student accoucheurs studying at the Free State School of Nursing are faced with resistance, discrimination, rejection and unacceptability by pregnant women during their clinical placement at the Free State maternal healthcare institutions. This results in poor quality of training of student accoucheurs in maternal healthcare. Considerable studies have been conducted on males in midwifery nursing, but no guidelines have been developed to facilitate student accoucheurs' acceptance and improvement of the quality of training in maternal healthcare, hence the purpose of this study.n = 32) were conducted through purposeful sampling method. Data was analysed thematically.A descriptive, explorative qualitative design was used in this study. Qualitative focused group discussions (Three main categories emerged: student accoucheurs' related factors with social interactions and relations as a theme; maternal healthcare users’ related factors with transcultural diversity and socio-economic status as themes; nurse training institutions and maternal healthcare institutions service providers-related factors with gender inequality in the work place as a theme. Ultimately, the guidelines to facilitate acceptance and improvement of quality training of student accoucheurs in maternal healthcare institutions were developed and recommended for implementation.The paper developed guidelines to facilitate acceptance and improvement of quality training of student accoucheurs in Free State maternal healthcare institutions. The quality of education and training of nurses, midwives and accoucheurs are low and poor in many countries including South Africa, resulting in a health workforce ill-prepared to effectively respond to rapidly changing and complex existing, and future health systems including maternal healthcare challenges. The training of males in nursing specifically in midwifery has met various challenges worldwide.Over time, however, nursing and midwifery evolved to include males, men have been prominent in the nursing profession during the Middle Ages and Renaissance, the modern image of an “ideal nurse” is feminized. This is primarily because of the Nightingale system for nurse training, wartime and economic factors . The auMidwifery, however, may be one of the most exclusively and disproportionately female specialties in the field of nursing, it is time to acknowledge the presence of accoucheurs, the challenges they face and the positive attributes they bring to the profession . This cIn the eighteenth century, childbirth in most parts of the world remained informal and exclusively managed by women, and in the nineteenth century respectively, midwifery began to change based on the revised curriculum which allowed men to enter into maternal healthcare discipline . R.425 In South Africa, chapter 2 of the Constitution stipulates the upholding of gender equality at all times. Hence, the percentage of student accoucheurs training in midwifery has steadily risen and continues to do so in the country. Although the numbers of men who choose nursing midwifery as a profession have increased significantly, it remains difficult for men to practice in this area of nursing despite being trained as accoucheurs.Gender diversity and inequality occurring in the nurse training institutions and clinical workplace contributes towards the phenomena. Segregation, rejection and discrimination projected by pregnant women towards student accoucheurs during their clinical placement in maternal healthcare institutions have a negative impact towards goal achievement to become accoucheurs . SimilaAccording to the World Health Organization (WHO), 800 women die per day globally owing to pregnancy-related complications . While The nurse training institutions are constantly producing registered midwives/accoucheurs on an annually basis to enter the working force in a healthcare sector. According to the policy on gender in Malawi, an equal number of males and females should enter tertiary education. However, this is not the case with nursing due to the historical background of nursing being “feminine,” and the challenges men face in nursing, impact negatively on those intending to enter the profession . PredomIt is evident that student accoucheurs are faced with difficulties during their training specifically in midwifery discipline. These difficulties maybe contributed by rejection, segregation, discrimination by pregnant women based on their gender including lack of support from their lectures and midwives in maternity units among other factors contribute to these difficulties. This was confirmed byA descriptive explorative design was used to explore the views of student accoucheurs' experiences encountered during their third and fourth levels of training in maternal healthcare institutions. The main focus of this study was on the acceptance of student accoucheurs by pregnant women during their clinical placement in the maternity units. Therefore, a descriptive explorative design was chosen to invent the full nature of the phenomena, the way it is manifested and establishing the clear picture of the situation as it is naturally happening without manipulation of any variables . The inThe total of 32 student accoucheurs between the ages of 20 and 24 years studying in the Free State School of Nursing were purposively selected to be included in the study. Purposive sampling is a method often used when the researcher wants a sample of experts . FurtheAll student accoucheurs registered at the Free State School of Nursing at their fourth year of training placed at post-natal units were purposively selected.All student accoucheurs over the age of 18 years at their fourth year level of training who were willing to participate in the study and who signed the consent form were purposively selected.All student accoucheurs not studying at the Free State School of Nursing and not in their fourth-year level of their study and who are below the age of 18 years of age.All student accoucheurs who meet the inclusion criteria but not willing to participate in the study.Five focus group discussions consisting of four to five members in a group were conducted. Additional two focus group discussions were added to ensure that data has been saturated. The focus group discussions were conducted with the fourth year student accoucheurs only based on the aim of the study which was to explore the experiences of student accoucheurs regarding their acceptance by pregnant women during their clinical placement at maternal healthcare in the Free State Province. Ground rules and information about the scope of discussion which assisted the participants to understand what is expected from them were laid . All foAs outlined inQualitative data was transcribed from the voice-recorder into a written format, organised and stored using Atlas TI 8. version programme. This programme helped the researcher to systematically organised data into themes and sub-themes with codes to evaluate and interpret qualitative texts . Tesch'Lincoln and Guba criteria of credibility, transferability, dependability and conformability were used to establish trustworthiness . ConforPrior to the commencement of the study, the approval of the study was obtained from the University Ethics Committee (IREC Number: 10/17) and the Free State Department of Health. Information letters detailing the purpose of the study were given to the participants. Confidentiality was assured, anonymity guaranteed and participants were allowed to withdraw from the study at any point. All participants gave informed consents agreeing to take part in the study.The analysed data was grouped into three categories of factors from which four major themes and six sub-themes emerged . These As males, we are challenged on how to build good relationships with women in maternity units. Most women come with preconceived ideas that they expect to be treated by female midwives that's how they were socialised […] .Most procedures are invasive such as vaginal examination […] and women refuses to be examined by us. I need help and support to interact and gain women's trust […] .Most participants stated that the quality of their training in midwifery is based on good interactions with pregnant women. According to them, such interaction alleviates woman's preconceived ideas and fears about pregnancy, labour, delivery and the midwife that will be assisting them. Hence building a nurse–patient relationship was important in the maternity units, but this could be a challenge because most women are socialised into building sound relationships with other females. Therefore, the provision of quality training by the training institutions will empower them with knowledge, skills and support to build good nurse–patient relationships with pregnant women:Sometimes I feel shy to ask a woman to push in SeSotho as this word sound vulgar if used by male to a female […] .I need to be taught how to give instructions to women without embarrassing them […] .Moreover, participants associated lack of communication skills as a contributing factor to women not accepting maternal healthcare rendered by them. Vernacular words used to give instructions to women during delivery could sound vulgar and embarrassing when are said by a male to a female:I was denied the opportunity by a Muslim family to assist during delivery as this was seen as taboo. I had to respect the patients' rights you know […] .Married women do not want to be seen naked by another man other than their own husbands. Despite this, culturally it is unacceptable to undress for a younger person of opposite gender […] .Some women will tell you that in their culture, men should wait for the period ten days before they can be allowed to see them during and after delivery […] .Most participants stipulated that the training institutions should empower them with transcultural nursing in midwifery. Participants said women who are from traditional rural areas are religiously, socially and culturally sensitive regarding pregnancy as this is regarded as sacred to them hence, they become sceptical about maternal healthcare services rendered by males:I have forfeited the chance of learning and fulfilling my required objectives other day when I was refused to deliver a lady teacher whose husband was a taxi owner […] and the Unit Manager did not intervene […] .Whereas financially unstable women are forced to attend public hospitals. Although some women do not express their views about student accoucheurs' presence in maternity units. Their resistance and non-co-operation can be detected when taking care of them which contribute to poor quality of their training in midwifery while increasing risks of maternal mortality:Some women who are unemployed do not actually tell you that they do not want you as a male to assist them depriving us from quality training in midwifery, but they will resist your commands during examination and during labour putting themselves and the babies at risk […] .It emanated from the participants that financially stable women are at liberty to choose the midwife of their preference, whether to attend private or public hospital for maternal healthcare services. Their voices in a public hospital regarding their choice of care is more respected. Therefore, they indicated that the training institutions should capacitate them with skills and knowledge in managing women attending their maternal healthcare services in the public hospitals irrespective of their financial statuses:Accoucheurs are allocated in casualty, intensive care, theatre and other general wards except in maternity units […] .Student accoucheurs indicated that in clinical areas where they were allocated for maternal healthcare services in the province, no accoucheurs were placed in maternity units:In some other few institutions you will find one or two community service accoucheurs working for either a week to a month […] and they are constantly taken to assist in other units if there is shortage of staff […] .Most participants attested that even community health service accoucheurs were placed for the short period of time in this units. Therefore, women have limited exposure to maternal healthcare services rendered by accoucheurs; hence they reject and unaccepting to be taken care by them during their clinical placement in maternity units:I have never saw even a single male Unit Manager or Assistant Director Nursing Manager where I was placed for my maternal healthcare rotation for the past two years […] and all our lecturers are females .Moreover, all Unit Managers, Assistant Director Nursing Managers responsible for maternal healthcare units were females including Lecturers teaching midwifery at the Free State School of Nursing. Although they render quality services in students training in midwifery, but gender diversity is not represented:I like midwifery nursing […] and I prefer to work in maternity units rather than in other units […] .Most student accoucheurs chose midwifery nursing science as their preferred discipline:The study finding was based on the categories emerged during data analysis. The first category was based on student accoucheurs' related factors. The nurse training involves an active social interactions and relations with the patient. This enhances building a good nurse–patient relationship which promotes effective communication and provision of quality maternal healthcare to pregnant women. According to the Department of Health as cited byA gap was identified from the student accoucheurs discussion that they lack communication skills in assessing women and giving instructions effectively during delivery without causing discomfort to them and feeling embarrassed. The key facets of constructive communication in maternity care include an empathetic communication style, willingness to respond to questions and allowing enough time to discuss the woman's concerns . The NGT gathers information by asking the participants to respond to questions posed by the researcher and then asking the participants to prioritise the ideas of all group members .Table A policy which incorporates cultural or religious sensitivity of pregnant women to student accoucheurs' presence in the maternal healthcare institutions should be developed and implemented.A policy that integrates cultural and religious sensitivity in maternal healthcare in the curriculum of the Free State School of Nursing to ensure that student accoucheurs are taught about pregnant women's religious and cultural diversity.The policymakers in the Free State Department of Health need to ensure that maternal healthcare services rendered at the maternal health institutions cater for all pregnant women despite their cultural or religious backgrounds, whilst ensuring effective and quality training of student accoucheurs in midwifery. Therefore, the following recommendations for the implementation of this guideline should be taken into consideration:Nurse Managers should allocate accoucheurs on a rotational basis in the maternal healthcare units to improve the visibility of accoucheurs in these units.Nurse Managers should consider accoucheurs when vacant positions for Unit Managers in maternal healthcare become available to ensure gender equity in the work place.Placement of accoucheurs in maternal healthcare units will improve the quality of student accoucheurs' training by providing support and encouragement in midwifery discipline.The Nurse Managers places accoucheurs in all other nursing units within the organisations except in the maternal healthcare units' despite being trained to work in this discipline. This deprives pregnant women an opportunity to experience the maternal healthcare services rendered by accoucheurs. Hence the recommendations for implementation of the developed guideline by Nurse Managers.Nurse Managers should ascertain accoucheurs' preferred discipline and negotiate placement on a rotational basis with them to promote gender equity in maternal healthcare institutions.Accoucheurs requesting to be placed in maternal healthcare units should be granted the opportunity to practice midwifery.Accoucheurs who have an interest in improving their career by furthering their studies in advanced midwifery should be given the relevant opportunities by Nurse Managers.Accoucheurs should be given opportunities to mentor and supervise student accoucheurs in the maternal healthcare institutions to improve the quality of their training in midwifery discipline.Nursing Managers need to consider how accoucheurs are allocated in the Free State healthcare institutions. The random allocation of accoucheurs in general units except for maternity units, despite their preference, deprives them of the opportunity to explore and grow their careers in maternal healthcare. It is recommended that the developed guideline should be implemented by Nurse Managers:A programme designed to teach pregnant women in ANC, labour wards and postnatal wards about gender and its importance in nursing, and to equip pregnant women and their families with knowledge about the nursing profession.Involve the relevant training stakeholders in the implementation of the teaching programme about gender diversity and equity in nursing to ensure correct implementation of the programme at the Free State maternal healthcare institutions.Involve student accoucheurs in teaching pregnant women and their families about their roles in maternal healthcare to promote gender diversity and equity in nursing.Encourage pregnant women to verbalise their concerns and uncertainties about student accoucheurs in maternal healthcare and to give clear and accurate responses.Student accoucheurs undergo the same training as their female counterparts' despite being rejected and discriminated by women in maternal healthcare units due to their gender. It is recommended that a career exposure programme that will focus on teaching pregnant women and their family members about career choice and the contribution of student accoucheurs in maternal healthcare is required. Hence the researcher made recommendations to implement the developed guideline:Lecturers at the Free State School of Nursing should develop and integrate communication skills in their teaching objectives to equip student accoucheurs with effective communication skills in maternal healthcare.Translation of culturally sensitive terminologies, used in midwifery, into a less embarrassing and non-offensive form so that student accoucheurs and pregnant women are not embarrassed.Lecturers should encourage student accoucheurs to implement the taught communications skills, acquired in their training, during their clinical placement at the Free State maternal healthcare institutions.Student accoucheurs should give feedback regarding the effectiveness of implemented communication skills programme to lecturers on a regular basis.The development of a programme that will integrate communication skills specifically in maternal healthcare for student accoucheurs in their third- and fourth-year level of training is necessary. This programme will facilitate effective communication skills for student accoucheurs as the key facets of constructive communication in maternity units (Create, advertise and approve posts with specific requirements for clinical instructors while considering gender diversity and equity to be allocated in various maternal healthcare institutions in the Free State Province, employed by the Free State School of Nursing.Enrolment of clinical instructors in a simulation course for health professionals to equip them with needed skills and knowledge on clinical accompaniment of students including student accoucheurs to improve the quality of training in maternal healthcare.Allocation of clinical instructors in the Free State maternal healthcare institutions accredited for placement of student accoucheurs in midwifery discipline to ensure prompt and active supervision of student accoucheurs to improve the quality of their training.Clinical instructors should actively utilise the simulation skills laboratory at the Free State School of Nursing in demonstrating skills and feedback from student accoucheurs to ensure quality of training in midwifery discipline.Clinical instructors at the Free State maternal healthcare institutions should frequently give feedback to lecturers about challenges, progress and proposed solutions regarding student accoucheurs placed in these institutions.The Free State School of Nursing should consider hiring clinical instructors to be stationed in the maternity units. The developed guideline and the proposed implementation is aimed at improving the supervision of student accoucheurs by clinical instructors stationed at the Free State maternal healthcare institutions. It is imperative that the Free State School of Nursing consider the recommendations below for implementing the developed guideline:A designed programme with stipulated time frames for clinical skills demonstrations and feedback for student accoucheurs to improve the quality of training in maternal healthcare.Compulsory attendance and supervision of student accoucheurs during clinical practice in the skills laboratories.Use simulated patients in the skills laboratory for maternal healthcare history taking to teach student accoucheurs effective communication skills improve their confidence in maternal healthcare.Giving constructive feedback, either negative or positive to student accoucheurs after the performance of their clinical tasks to encourage them to improve their skills and knowledge.Debriefing sessions after each clinical task should be conducted to ensure that student accoucheurs express their fears and concerns which should be addressed by clinical instructors.Counselling sessions and referrals to student counsellors those student accoucheurs with difficulty in maternal healthcare clinical practice in the skills laboratory.Compulsory briefing sessions by lecturers for student accoucheurs on what to expect and how to deal with rejection by pregnant women prior to their clinical placement in the Free State maternal healthcare institutions.The Free State School of Nursing should design and equip clinical skills laboratory with the high and low fidelity manikins designed for midwifery teaching purposes. This skills laboratory should be fully utilised for midwifery clinical practice to enhance skills and knowledge of student midwives and student accoucheurs enabling them to render quality maternal healthcare services. The Free State School of Nursing academia should consider the following recommendations for implementation of this guideline:The study was conducted in the Free State Province maternal healthcare institutions accredited by SANC for student nurse training purposes which may restrict transferability.The study is in line with nursing education in the midwifery discipline and human resource management. The developed guidelines are intended for implementation by the policymakers in the Free State Department of Health, Free State School of Nursing and the Nurse Managers in their respective maternal healthcare institutions in the Free State Province including to other relevant maternal healthcare institutions involved in midwifery student nurse training. The researcher contends that this is the first comprehensive study that has researched and developed guidelines regarding the phenomena. According toThe literature review and data analysis from the study participants confirmed that there were gaps in the training of student accoucheurs and that there were no developed guidelines with respect to improving the quality of training and support of student accoucheurs during their clinical placement in maternal healthcare institutions. The main aim of the current study was realised in that the guidelines to facilitate acceptance and improve the quality of training of student accoucheurs in midwifery clinical practice at the Free State maternal healthcare institutions were developed. Recommendations for implementation of the developed guidelines were suggested for stakeholders involved in the training of student accoucheurs in midwifery discipline.


The concern relates to the provenance of this article as brought to our attention by Faisal Alhawaj, who denies authorship of this article and others published in Cureus. These articles were submitted and subsequently published purportedly as an effort coordinated by Imam Abdulrahman Bin Faisal University to ensure all medical interns publish at least one peer-reviewed article in order to qualify for enrollment in a postgraduate residency program as stipulated by The Saudi Commission for Health Specialties (SCFHS).The journal has not been presented with enough evidence to warrant the formal retraction of these articles as both Imam Abdulrahman Bin Faisal University and The Saudi Commission for Health Specialties have failed to respond to numerous communications requesting additional information regarding these allegations. While we acknowledge that the provenance of these articles is very much in question, we cannot act until these claims have been investigated by the appropriate institutions with the results of said investigation communicated to Cureus.The concern and this note will remain appended to the above-mentioned article until Cureus is provided with official confirmation from Imam Abdulrahman Bin Faisal University or The Saudi Commission for Health Specialties.


There is an error in the Funding statement. The new statement should be: “Supported by the national social science fund project Research on Path Design and Policy Support for Rural Tourism in Ethnic Areas to Consolidate the Achievements of Poverty Alleviation (20BSH062), the Fundamental Research Funds for the Central Universities (SWU2109207).”The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.


There is a large gender gap in critical care medicine with women underrepresented, particularly in positions of leadership. Yet gender diversity better reflects the current critical care community and has multiple beneficial effects at individual and societal levels. In this Viewpoint, we discuss some of the reasons for the persistent gender imbalance in critical care medicine, and suggest some possible strategies to help achieve greater equity and inclusion. An explicit and consistent focus on eliminating gender inequity is needed until gender diversity and inclusion become the norms in critical care medicine. Medicine has traditionally been a male-dominated profession. Despite women medical trainees outnumbering men medical trainees in many countries, there are still more men than women in clinical and academic leadership positions around the world . Recent Publication of research is considered essential for academic career advancement in medicine, and the number of publications influences the authors’ visibility as researchers, their success as grant applicants  and theiThe reasons for the persistent gender imbalance in critical care medicine have been studied extensively over recent years. Societal ideas pertaining to the roles traditionally occupied by men and women have likely contributed. In a survey of 115 faculty and 122 undergraduate students at large, research intensive universities, agentic traits  were thought to be more important than communal traits  for success in science . Other bParsons Leigh and colleagues described institutional (lack of flexibility and limited job prospects) and interpersonal (bias against women) factors as key drivers of the gender gap in critical care medicine . At the Another important area that needs to be addressed is the tension that many women experience between the different roles they hold at work and at home. The challenges of taking time away from medicine for maternity leave have been widely recognized and discussed , 18. TheWithin national and international critical care societies, several initiatives have been introduced to encourage gender balance, including selective endorsement of meetings that have gender diverse speakers. The Canadian Critical Care Society Diversity Policy strives to achieve at least 30%  women speakers. A similar policy developed by the Australia New Zealand Intensive Care Society aims to include 50% women speakers by 2022. The European Society of Intensive Care Medicine (ESICM) has introduced several task forces to address gender inequality. In the absence of international registries, it remains challenging for critical care societies to benchmark or compare their diversity metrics to those of others.The focus of this Viewpoint has been to highlight the need to promote gender equity and inclusion in critical care medicine and suggest some possible strategies to help achieve greater equity and inclusion. It is our collective responsibility, as a critical care community, to identify and address barriers that perpetuate inequities in critical care. Diversity and code of conduct policies have been adopted by several critical care societies and the World Federation of Societies of Intensive and Critical Care Medicine. Widespread adoption of such policies will help eliminate inequity and enhance inclusion. Training and mentorship programs for women intensivists will enable promotion of women to higher academic ranks and leadership positions. Acknowledging the existence of implicit and explicit biases is an essential first step. We believe that an explicit focus on eliminating gender inequity will help to gradually change societal views of the roles played by women and men critical care physicians so that it will become the norm for women and men to be both critical care physicians and leaders in critical care.


With our work we want to support better, evidence‐based decisions by: (a) supporting rigorous synthesis of evidence on key questions; (b) further improving the quality of climate change research through critical appraisal of primary research; and (c) improving the efficiency of the scientific process through enhanced oversight of, and less duplication in, secondary research efforts. We further believe that our work strengthens the IPCC and other climate change assessments by supporting the completion of its evidence pyramid  in resource constrained contexts like the Global South. Our aim is, therefore, to provide accessible and functional training in climate evidence synthesis that works across settings .3It is an exciting and important task to build a thriving  community that tries to learn what climate solutions work under what conditions, for whom, and why, using rigorous systematic review and evidence (gap) map methodologies. Beyond the core remit of the group to promote rigorous evidence synthesis as an important pathway to more evidence‐informed climate policy, CSCG will further try to advance evidence synthesis methodology more generally in four priority areas.Promote the adaptation and application of qualitative and mixed methods evidence synthesis methodologies: The social science of climate change provides a very diverse body of evidence. Only a small part of this literature is directly on impact evaluations of climate solutions based on experimental or quasiexperimental research designs IPCC, . In partEncourage the development and application of novel evidence synthesis technology: Climate change is not only one of the most pressing policy issues of our time, but also a very prolific area of research with tens of thousands of studies being published every year. In such an age of big literature with a vast and fast‐growing evidence base, traditional manual tools of evidence synthesis are being pushed to their limits (Callaghan et al., Integrating the evidence synthesis traditions of the climate and the systematic review communities: It is clear that comprehensive learning on climate solutions must be rooted in a systematic exploration of alternative future pathways as well as systematic evaluation of past policies. The CSCG brings together two evidence synthesis communities with complementary strengths in ex‐ante and ex‐post assessments of climate solutions. We are convinced that there is great scope for mutual learning and that sharing and integration of these distinct traditions will ultimately lift evidence synthesis and the resulting scientific policy advice to a higher level.Promote the application of formal assessment of confidence in evidence within syntheses of climate solutions: Assessment of uncertainty and confidence in evidence is a critical component of climate change assessments (Janzwood, Climate change is one of the most pressing problems that humankind faces. We need to urgently and rapidly learn from the best available evidence on climate solutions. The CSCG warmly invites registrations and submissions to Campbell Systematic Reviews from climate experts across diverse disciplines and evidence synthesis practitioners.


The aim of the study was to assess the attitudes and perceptions of parents towards child and adolescent psychiatric consultation, diagnosis and treatment.The hypothesis of the study was there are significant problems in the domains of attitude and perceptions of parents towards child and adolescent psychiatric consultation, diagnosis and treatment.Parents are an important stake holder in child and adolescent psychiatry and mental health care service models. There is scarce literature from developing countries regarding attitudes and perceptions of parents towards child and adolescent psychiatric consultation, diagnosis and treatment.This study was conducted at the Child and Adolescent Psychiatry Clinic, Department of Psychiatry at a Tertiary Care Institution. Eligibility criteria comprised of parents of children and adolescents who had come for consultation. The parents were provided information of the study and those willing to participate were included in the study. A convenience sample of 100 parents was considered for the study. The parents were interviewed using a specially designed survey comprising 30 questions with Yes/No response developed by the authors for the purpose of the study. Informed consent and Institutional Ethics Committee Clearance was obtained. Data were analysed using SPSS.We found that the majority of parents were from urban area (72%) and mothers comprised 68%. We found that 46% of parents did not want a psychiatric diagnosis and 35 % parents felt stigmatized for seeing a psychiatrist for their child. Sixty nine percentage of parents preferred counseling as the first line of treatment and 31% preferred medicines as the first line of treatment. We found that 33 % felt additional psychological tests could be useful and 54% of parents felt brain imaging and blood tests could be useful for their child. Majority of parents expected basic improvement for their child within 1 week(32%) and expected full improvement by 1 month(82%). Fifty three percent of parents had searched online information prior to consulting and found useful information. However, 38% of the parents felt confused after reading online information and 69 % of parents were more worried about giving medications after referring online information.Our study provides useful key insights from parent's perspective in child and adolescent psychiatric services. Implications exist for future research as well as policy perspectives on the role, attitudes and expectations of parents as vital stake holders in child and adolescent psychiatry.


The Competing Interests statement published incorrectly. The publisher apologizes for the error. The correct statement is as follows: The authors have read the journal’s policy and the authors of this manuscript have the following competing interests: JT discloses a consulting relationship with Genetika, and JKW discloses paid employment with the Center for Translational Bioethics and Health Care Policy at Geisinger during the conduct of this study but no active competing interests at the time of publication. The authors have declared that no other competing interests exist and that the authors have no financial interests  related to this study to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials.


The review by Hurst et al.  is a comProgressive vision loss in adults is escalating worldwide, as the incidence of macular degeneration and diabetic retinopathy are expected to exceed 300 million and 642 million, respectively, by 2040 (Mitchell et al., in vitro and organotypic platforms have been developed to examine native stem cell behaviors within microscale environments (reviewed in Greene et al., Contemporary cell replacement therapies offer exciting promise to restore vision by replacing damaged neurons with transplanted stem cells. Numerous platforms have been developed to elucidate the cellular mechanisms able to promote stem cell integration within mature retinal hosts (Wu et al., Initial hybrid models  culturedSM developed and wrote the manuscript. MV wrote and provided edits to the manuscript. All authors approved the final manuscript version 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.


The COVID-19 crisis has revealed the deep technological and production dependencies of the EU on third countries in sectors deemed as particularly strategic and has thus fuelled the debate on (the lack of) European technological sovereignty in critical fields. This article argues that in the light of a renewed interest in relaunching a European industrial policy, technological sovereignty considerations must be fully incorporated into policy objectives and instruments.


Somaliland is a de facto state in the horn of Africa. It unilaterally declared independence from rest of Somalia in 1991. Medical education in Somaliland started in the year 2000.Aim of the study is to explore the feasibility of teaching program for the country by its future potential psychiatry educators. The initiative started in 2019 to seek trainees with interest in academic psychiatry and support them with medical education skills. This is intended to prepare them for leading future teaching roles in both undergraduate and residency/fellowship in psychiatryAmoud University wanted to empower junior doctors at the university to have teaching skills needed to set up residency program. The Somaliland government asked Ethiopian ministry of health to offer psychiatry residency program for general practitioners in Somaliland to have future residency and fellowship in psychiatry. Several psychiatry trainees worked with the visiting professor from the United Kingdom who joined Somaliland medical school as visiting professor in psychiatryThe visiting professor supported the trainee in setting up a psychiatry undergraduate training curriculum in line with Somaliland medical school curriculum. Before the teaching methods were didactic and role play based. The faculty introduced different teaching methods including flipchart, small/large group teaching which was student centered education. Students received a online survey to reflect on psychiatry teaching they received. post course survey was conducted at the end of the teaching to evaluate the teaching initiative.Survey revealed interesting pattern that students preferred class room based teaching in comparison to online teaching. 90 percent of the attendees showed interest in flipchart teaching compared to didactic model. They expressed increasing understanding of the subject matter when they read and discuss among themselves instead of lectures. 70% of students prefer more clinical teaching compared to online sessions.52% liked the new teaching module compared to the lecturing sytle.Supervision of early career psychiatrists to undertake future academic psychiatry roles is an important step in building psychiatry faculty in medical schools. As the case of Somaliland this retains trainees in teaching roles in the future to teach undergraduates mental health courses. The other benefit is empowering them to set up psychiatry training program to close the service delivery gap with skilled psychiatrists in the future. Somaliland plans to set up its psychiatry residency/fellowship programs soon after this initiative.


We need a Green Tax Reform which focuses on the Pigouvian approach and can correct the distortions of different climate hurting activities. Through tax policy tools, the price structure should be drastically changed and serious incentives should be provided to change the behaviours of the consumers and producers to achieve green policy goals.Climate crisis is becoming higher on the agenda of the decision makers of the world. A huge amount of resources have been dedicated to green projects, however far less emphasis has been put on tax policy opportunities. Carbon pricing can increase the burden of CO


One emerging dyadic concept is the experience of family caregivers when their care partner dies and their dyadic relationship comes to an end. This study qualitatively examined and characterized the loss of the dyadic experience for the caregiver after the death of their care partner. Data was accrued as part of a randomized clinical trial in 29 older hospice caregivers. Iterative thematic analysis focused on dyadic processes before, during and post death. Using two relational parameters from Relational Turbulence Theory resulted in a preliminary characterization of a new concept - dyadic dissolution as a cognitive and affective process whereby a remaining member of a dyad experiences relational uncertainty and partner interference while adapting (or not) to the death of their care partner. Findings suggest that asking several open-ended questions about the dyadic relationship will enable assessment for any continuing impact of relational uncertainty and partner interference on bereaved caregivers.


This study assesses the relationship between indicators of early childhood disadvantage and later-life multimorbidity within a nationally representative sample of Brazilians aged 50 and over . Data come from the baseline assessment (2015/2016) of the Brazilian Longitudinal Study of Aging (ELSI). We employed survey-weighted Ordinary Least Squares regression to estimate the effects of individual and combined measures of childhood disadvantage on the total number of chronic conditions in later life. Mediation analysis assessed whether adult socioeconomic status (SES) mediated the relationship between childhood disadvantage and chronic conditions. We found that individual and combined measures of childhood disadvantage were associated with the total number of chronic conditions, even after controlling for potential confounders. Mediation analysis suggested that part of the effect of childhood adversity is mediated by higher SES in adulthood (~10%). A formal strategy of sensitivity analysis showed that omitted variable bias is extremely unlikely. To rule out the observed effect, an unobserved hypothetical confounder would need the explanatory power of the residual variance of both the independent and the dependent variables that is at least 30 times larger than that of BMI or 5 times larger than the explanatory power of age. Results should inform efforts to strengthen interventions targeting early childhood development and to improve other key inputs (such as education) to enhance adult SES and lessen the impact of early life stressors on health in older adulthood.


Plant life cannot exist without programmed cell death (PCD). Both plant developmental processes and responses to environmental factors are modulated by highly controlled, localized cell death events  and the proteases involved in execution of cell death process . Burke et al. highlights the role of transcription factors (TFs) in the regulation of plant PCD occurring in response to abiotic and biotic environmental triggers, complementing a recent publication by Cubría-Radío and Nowack  and degradation of cellular components (effector caspases) . We expect that the application of increasingly accessible proteomics-based approaches will test this hypothesis in the near future.The two review articles of this Topic discuss critical aspects of plant cell death pathway: its transcriptional control . These authors used the root hair assay (Kacprzyk et al., The Earth's changing climate is leading to increased frequency of extreme weather events that may lead to severe crop damage. Thankfully, plants have developed diverse strategies to deal with environmental stresses, and PCD is part of this defense repertoire (Kacprzyk et al., Collectively, the contributions from the Research Topic emphasize the progress in the field of PCD research and its potential to deliver solutions from the laboratory to the farm. They also highlight the still unanswered questions about the death of plant cell—and hence the exciting opportunities for further research!All authors listed 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.


Surgical procedures alter tissue integrity; are associated with pain and activation of the sympathetic nervous system; and sometimes, cause exposure to foreign materials used during the surgery or implanted perioperatively. Those factors have been demonstrated to induce a number of inflammatory reactions ,2,3. DepCardiovascular risk stratification has become an essential dimension in the standardization of clinical pathways and has significantly improved the overall quality of care . HoweverThis Special Issue aims to provide insights in current developments and mechanistic discoveries regarding the impact of surgical and interventional procedures on organ systems and the potential of specifically monitoring biomarkers and cellular responses in perioperative medicine.


Conduct an environmental scan of Marion County (Indianapolis) neighborhoods using electronic medical record data, state health data, and social and economic dataDevelop strong network of community collaboratorsConduct a thorough assessment for each targeted neighborhood by listening and understanding the pressing health issues in the community and working together to design and deliver solutionsOBJECTIVES/GOALS:Identify measures in the 3 domains of vulnerability, health and assets for the targeted neighborhoods and conduct bivariate descriptive statistics and multivariable regression analyses to investigate association between measures of vulnerability and health outcomes.Initiate relationships with leaders and residents in targeted neighborhoodsLocate organizations working in targeted neighborhoods through online mapping software and word-of-mouth at neighborhood events, and created a spreadsheet with contact information.Conduct multidisciplinary assessment  of the targeted neighborhood.Iteratively synthesize assessments to develop areas of interest and relevance to the community.Develop a road map for solutions identified by the community.METHODS/STUDY POPULATION:RESULTS/ANTICIPATED RESULTS: The results from the environmental scan conducted will be displayed in a report and visual “map” of health outcomes and health determinants, including assets and barriers for the targeted neighborhoods. The research team will use results from the environmental scan coupled with listening activities including attendance at community events, key informant interviews and focus groups to develop relationships and strong collaborations with the targeted neighborhood stakeholders. The relationship building between the research team and community will provide increased trust and engagement that will further enhance the effectiveness of the assessments completed with the targeted neighborhood. The assessments will help to empower communities to develop sustainable solutions and drive future work that will lead to future grant applications and larger-scale implementation in other community impact hub neighborhoods. DISCUSSION/SIGNIFICANCE OF IMPACT: Through the community impact hub work, we will develop collaborative efforts with targeted neighborhoods with the greatest health inequities in the Marion County area. In partnership with these neighborhoods, we will build a foundation – a network of community collaborators and a focused plan – upon which we will improve the health outcomes of residents while learning best practices on how to do so.


The implications of the COVID 19 pandemic signal both tragedy and possibility.This reflective paper considers the amplification of the concurrent pandemics ofviolence against women and children and anti-black racism during the responsesto COVID 19 and renewed calls to action. The enforced ‘pause’ as a result ofsocial isolation or distancing measures in response to COVID-19, has led manypeople to re-imagine a different world and ignited social movements across theglobe. Education must inspire a vision of what our world could be and definewhat action is needed and the steps required to implement change. The criticalreflection that characterizes most social work educational programs can provideopportunities to harness such imaginings in redefining ‘the possible’ in thequest for a more equitable and safer world. This article describes the potentialof the pandemic to subvert the pervasive influence of neoliberalism by promotingcollective notions of care. The implications of the COVID 19 pandemic signal both tragedy and possibility. Thisreflective paper considers the amplification of the concurrent pandemics of violenceagainst women and children and anti-black racism and renewed calls to action. Theenforced ‘pause’ as a result of social isolation or distancing measures in response toCOVID-19, has led many people to re-imagine a different world and ignited socialmovements across the globe. The critical reflection that characterizes most social workeducational programs can provide opportunities to harness such imaginings in redefining‘the possible’ in the quest for a more equitable and safer world. At no other time inrecent history has the call for social justice been so insistent.During the first few months of the pandemic the media posted news stories of the largestmass shooting in Canadian history, depicted images of global marches against anti-blackracism and described marked increases in violence against women and children all whilesocial isolation or distancing measures were enforced. These early months of thepandemic were characterized by hoarding and fear and at the same time acts of generosityand a swiftness of innovative responses unimagined before the pandemic. Examplesincluded new housing options for the homeless, releasing inmates from prisons and arenewed call for equitable access to a living wage for all. This article describes theseinnovative responses as disruptions and discusses the potential of the pandemic tosubvert the pervasive influence of neoliberalism by promoting collective notions ofcare.The guiding political philosophy in Canada since the 1980’s has been neoliberalism. It has been described as a regime change that facilitated a transitionto corporate rule in which it is assumed that increased productivity and economic growthwill improve human well-being . RelyingIt is difficult to quantify the pervasive influence of neoliberalism and the myriad waysin which it gets ‘under our skin’ to order our thoughts about what constitutes oursuccess and in turn influence our behavior; monitoring our appearance, employment andaccumulation of possessions. As one student shared in class this past year, she feltpressure to be perfect and believed this pressure contributed to high rates of anxietyamong her peers. But how is perfection defined? If we turn to Foucault’s concept ofpanopticism, in which he described the ways inmates in prison are constantly visible,subjected to surveillance and controlled seemingly by invisible authority figures, itcan serve as an analogy regarding the impacts of neoliberalism. Facebook, twitter andother forms of social media comprise mechanisms of visibility evident in the consumerculture spaces, images and screen culture . InvisibGlobally, at least one third of women experience physical or sexual violence . Over haThe call to end anti-black racism also includes the subversion of neoliberal ideologiesand practices to redress years of neglect and indifference by providing support andresources to African Canadian communities. Canadian Senator Wanda Thomas The murder of African American George Floyd by police officer Derek Chauvin has awokencollective rage that demands action. As the fall university term begins it is moreimperative than ever that the individualism that marks neoliberalism be replaced bycollective concern and action. Education should inspire a vision of what our world couldbe and define what action is needed and the steps required to implement change. Thepairing of reflection followed by implementation of action is required. This moment ofsubversion of neoliberalism compels a re-imagining of what our social and community lifecould be if a more just and peaceful world was the measure of success.


Family caregivers of hospice patients faced additional challenges in the context of the COVID-19 pandemic where social isolation and loneliness that are often observed among those taking care of a loved one at the end of life, were exacerbated by social distancing rules and workflow changes introduced by hospice agencies. The use of telehealth technologies has the potential to facilitate the delivery of supportive services for family caregivers. We conducted a study examining the use of telehealth for the delivery of a supportive intervention based on problem solving therapy and positive appraisal theory designed specifically to support family caregivers of hospice patients during the COVID-19 pandemic. We recruited 248 caregivers who each participated in three telehealth sessions over a month; caregivers reported higher levels of quality of life and lower levels of anxiety post intervention. Specific recommendations for inclusive telehealth design are discussed based on lessons learned.


The concern relates to the provenance of this article as brought to our attention by Faisal Alhawaj, who denies authorship of this article and others published in Cureus. These articles were submitted and subsequently published purportedly as an effort coordinated by Imam Abdulrahman Bin Faisal University to ensure all medical interns publish at least one peer-reviewed article in order to qualify for enrollment in a postgraduate residency program as stipulated by The Saudi Commission for Health Specialties (SCFHS).The journal has not been presented with enough evidence to warrant the formal retraction of these articles as both Imam Abdulrahman Bin Faisal University and The Saudi Commission for Health Specialties have failed to respond to numerous communications requesting additional information regarding these allegations. While we acknowledge that the provenance of these articles is very much in question, we cannot act until these claims have been investigated by the appropriate institutions with the results of said investigation communicated to Cureus.The concern and this note will remain appended to the above-mentioned article until Cureus is provided with official confirmation from Imam Abdulrahman Bin Faisal University or The Saudi Commission for Health Specialties.


Resilience is described as the ability to respond to acute forms of stress and recover to normal homeostasis. There is growing evidence that biology of resilience is entwined with the biology of aging. With increasing age, resilience decreases and is a likely contributor to increased morbidity, frailty and susceptibility to death with age. Conversely, increased resilience across numerous physiological markers of function is associated with longevity and healthy aging. The variation in resilience in populations suggests biological and molecular regulatory mechanisms that might provide insight into interventions to improve resilience, healthy aging and longevity. In this session, speakers will provide insight regarding short-term assays of resilience in animal models that prove useful both in delineating these biological mechanisms as well as inform on potential translational models to better understand biological resilience in human populations. The sessions focus is on defining these assays and discussion of the biological relevance each resilience assay in terms of the regulation of aging. The goals of these studies range from identifying potential predictors of individual lifespan within markers of functional resilience to leveraging geroscience to define whether markers of resilience can be modified through interventions to the aging process. Moreover, better understanding of the biology of resilience could assist in defining novel interventions that improve resilience and thereby enhance longevity.


Rupture of ascending thoracic aortic dissection mimicking pulmonary thromboembolism due to pulmonary artery occlusion is rare and should be considered in hypoxic patients with aortic dissection. We describe a case of an 88-year-old male who presented with shortness of breath and hypoxia. Chest radiograph demonstrated airspace opacification in the right lung mainly involving the mid and lower zones . TransthCT demonstrated a dissection flap at the ascending thoracic aorta extending caudally to the aortic root and cranially to the origin of left common carotid artery . The braUnfortunately, the patient deteriorated soon after the CT scan and passed away within 24 h after the CT.The ascending thoracic aorta and the PT are invested in a common sheath of serous visceral pericardium. Occlusion of the RPA from rupture of ascending aortic dissection into the common sheath shared by the aorta and pulmonary artery is rare. It can mimic pulmonary thromboembolism and it is important to distinguish from this as anticoagulation is contraindicated.1 had similar imaging findings mimicking thromboembolism. They describe the susceptibility of compression of the RPA by pathology of the ascending aorta due to the anatomical relationship with the aorta at this level and the common tunica adventitia shared by the aorta and PT. Buja et al2 described medial rupture of an ascending aortic aneurysm resulting in adventitial haematoma compressing the PT. A case of pulmonary hypertension caused by compression of the pulmonary arteries by dissecting ascending aortic haematoma was reported by Kim et al3 Another case of transient pulmonary hypertension caused by extrinsic compression of the pulmonary trunk was reported by Okiwelu et al4, due to a contained rupture of proximal ascending aorta, likely from a penetrating atherosclerotic ulcer.One case of an ascending aortic dissecting aneurysm causing RPA occlusion described by De Silva et alIt is important to consider rupture of ascending aortic dissection into the common sheath as a cause of pulmonary artery occlusion. Occlusion can mimic pulmonary thromboembolism and it is important to distinguish from this, as anticoagulation is contraindicated.CT should be considered in cases of dissection, even when a dissection flap is clearly visible on TTE. CT will demonstrate extension of the dissection in the ascending aorta, aortic root and possible involvement of pulmonary artery, which cannot be assessed on TTE.


To gauge the breadth of current inflation and prospects for inflation returning to target, we consider disaggregated measures of CPI infl ation to evaluate trends and then consider diff erent scenarios for the realisation for wages and prices.


The authors regret that in the original article an incorrect email address was given for the corresponding author Sang-Wha Lee. The correct email address is shown here.The Royal Society of Chemistry apologises for these errors and any consequent inconvenience to authors and readers.


COP cells have been identified as having a potential role in the pathogenesis of tissue loss syndromes such as osteoporosis and frailty. This is based on the hypothesis that their dysregulation may cause a decrease in bone and muscle formation, which also increase the risk of adverse outcomes such as frailty and disability. Whereas high numbers of COP cells have been associated with osteoporosis and fracture healing, a low percentage of COP (%COP) cells have been associated with frailty and disability. In addition, low expression of lamin A (a protein of the inner nuclear envelope) in COP cells has also been associated with frailty and disability in older persons. In this session, the evidence on quantification methods for COP cells in clinical settings and the potential clinical use of COP cells in tissue loss syndromes will be discussed. This discussion will include current evidence supporting the use of COP cells as a biomarker or as a novel therapeutic approach to these age-related conditions.


Health technology has the potential to support behavior change by measuring performance and providing users with visualizations of this performance as feedback. Such visual feedback has had limited success in changing health behaviors, but it is not clear why. We conducted a systematic review of the visual feedback literature to develop an organizational framework representing the visual feedback-action process. We identified the components that have been investigated in the context of visual feedback. These components are classified into four categories: visualization types  and variables ; feedback characteristics ; psychological processes  and action . The insights will inform the design of feedback visualizations in a smartphone application to support medication adherence for older adults. More broadly, this integrative perspective will yield principles of feedback visualization techniques and components that influence the behavior change process and develop a roadmap to facilitate the design.


The National Institute for Health and Care Excellence (NICE) has been applying the principles of evidence-based medicine to public health problems for over twelve years. This application is in effect the practice of evidence-based public health (EBPH) . NICE asInfrequently is it practical to assess the effectiveness of interventions for complex public health problems by traditional gold standard randomised control trials. The importance of context, wider determinants, subpopulation variability and the role of the non-human biology element often mean that specific high quality evidence is unavailable. There is often a lack of good outcome studies answering the specific ‘what works’ question. There are often fewer studies still that answer the questions what works for whom and under what circumstances? The evidence is also often too imprecise to determine the relationship between the intervention and the outcome.The public health evidence base is rarely perfect, if it were it would likely negate the need for, or change the approach and role of organisations such as NICE. Perhaps more importantly the question asked in the evidence interrogation at NICE is ‘What is the best available evidence to answer the specific question being addressed?’ We know public health questions may benefit from exploration of a broader range of evidence including that which is further down the hierarchy of evidence. By taking a transparent and systematic approach and pulling from evidence from a range of disciplines, NICE has been able to review and synthesise evidence for complex public health problems .The evidence used to generate NICE guidelines is diverse and consists not only of the traditional scientific published evidence but also stakeholder comments, grey literature, real world evidence and expert testimony . The defThis presentation will aim to describe the approach taken by NICE in interrogating the evidence base to develop national public health guidelines. The key challenges and some solutions will be illustrated through examples from evidence synthesis to support guidelines for non-communicable diseases.


Brandenburg’s federal state framework agreement (LRV) on the implementation of the national prevention strategy according to section 20f of Book 5 of the German Social Code specifies the structural and organisational bases for the further development of prevention and health promotion strategies. The targets and fields of action defined by the federal framework recommendations form part of the established structures of health target processes. The Alliance for Growing up Healthy in Brandenburg (BGA) therefore defines health targets with regard to the objective Growing up healthy stated in the federal framework recommendations. LRV partners thereby have agreed to develop activities sustainably and uphold the current quality standards. This includes a commitment to answering the needs revealed by health and social reporting.In 2018, the roundtable Starke Kinder – Starke Familien  focused on ‘child health and poverty’. This year the thematic focus will be on applying the LRV as a basis for co-operative strategies to improve health equity for children and adolescents at the district and municipal levels.The planned report on the health and social conditions of children in Brandenburg aims to reveal the causes of health inequality and provide a basis for measures. To evaluate health and social conditions, the report will build on previous reports on child health in Brandenburg. This combined form of health and social reporting references multiple activities in Brandenburg and in addition to the efforts in the context of the Strong children, strong families roundtable, aims to further develop integrated municipal level prevention strategies, as well as implement Germany’s National Prevention Strategy. The report matches health findings to the health targets of the growing up healthy alliance. The Koordinierungsstelle Gesundheitliche Chancengleichheit Brandenburg  accompanies the establishment and implementation of co-operation projects at the district and municipal level.Brandenburg’s health and social reporting provides comprehensive data and thereby a basis for monitoring the health and social conditions of children and adolescents. A key challenge remains improving the implementation of these findings in municipal level health planning.


In the UK, people with severe mental illness at a greater risk of poor physical health and have higher premature mortality than the general population, highlighting the importance of responding to physical health problems among patients suffering from psychiatric conditions. However, training for staff on inpatient psychiatric units to meet patients’ physical health needs is sometimes overlooked and has not always been effective.According to NICE Clinical Guideline 25 (2005) and NPSA Rapid Response Report (2008/RRR010), staff on any psychiatric inpatient setting must be capable of monitoring, measurement, and interpretation of vital signs. They must have both adequate information and skills to identify signs indicating worsening of patients’ health and respond effectively to severely ill patients.Hence, we aim to re-audit the results of a similar audit carried out in 2016 to review the level of medical emergency training (in terms of life support training) of clinical staff across the inpatient psychiatric wards at our local hospital - Stepping Hill Hospital- in Stockport.Our hypothesis is that there will be a gap in meeting the required standards for training.A questionnaire including 6 questions  was given to staff on acute inpatient psychiatric units in Stepping Hill Hospital.The sample included 49 staff members from all the 3 wards included in the audit. The level of training of nursing staff on the 3 wards was meeting standards except for nursing staff who were new to the wards or coming back to work from prolonged leaves. There was also a gap identified in the level of training of other staff members on the ward as well as on the remaining standards measured by the audit.A gap was identified in meeting the required standards of training on the inpatient psychiatric units. Reasons identified for this gap are mainly due to the fact that new or bank staff are asked to cover the wards without providing them with appropriate training and without orientating them about the location of different equipments and policies on the ward.


Residents of care homes across the globe are affected by the spread of SARS-CoV-2 as they have been identified as a high-risk group and because they experienced strict social isolation regulations during the first wave of the pandemic. Social isolation of frail older people is strongly associated with negative health outcomes. The aim of this research project was to investigate how residents in care homes experienced social isolation during the first phases of contact ban in Germany. This paper draws on structured interview data collected from 22 residents in two care homes during early June 2020 in Frankfurt/Main. The findings show that their experiences were shaped by three factors: care home staffs’ approach to handling the contact ban; biographical sense of resilience; and a hierarchy of life issues. The findings highlight the importance of locally specific response mechanisms in care homes, and the need to contextualize residents’ experiences.


The origin and cell lineage of stromal cells in the bone marrow is uncertain. Whether a common stem cell exists for both haemopoietic and stromal cells or whether these cell lines arise from distinct stem cells is unknown. Using in situ hybridisation for detection of the Y chromosome, we have examined histological sections of bone marrow from seven patients who received marrow transplants from HLA-matched donors of the opposite sex. Stromal cells  were identified in these recipients as being of host origin. This result is consistent with the concept of a distinct origin and separate cell lineage for cells of the haemopoietic and stromal systems. It also shows that engraftment of marrow stromal cell precursors does not occur and that host stromal cells survive conditioning regimens for marrow transplantation. With the exception of one case, with a markedly hypocellular marrow, mixed chimaerism was seen in haemopoietic cells, indicating that this is not a rare event after marrow transplantation.


The in vitro activity of the novel chloroethylating agent, Clomesone, was investigated in a panel of established murine and human tumour cell lines. In vivo anti-tumour activity was examined against three transplantable adenocarcinomas of the mouse colon and in vivo bone marrow toxicity was assessed using a spleen colony forming unit assay. The pharmacokinetic behaviour of the drug in vivo and drug stability in vitro was analysed by gas chromatography with electron capture detection. Clomesone exhibited no activity in vitro against the majority of cell lines derived from solid human colorectal carcinomas. Anti-tumour activity against the murine tumours in vivo was not impressive and was accompanied by myelosuppression. Pharmacokinetic data suggested that the lack of in vivo activity was due to the failure to achieve effective anti-neoplastic drug concentrations at the tumour site. It was concluded that this study found no evidence to suggest that Clomesone was toxicologically more selective than the chloroethylnitrosoureas.


The haemodynamics of the uterine arteries and myometrium were assessed using Doppler ultrasound in forty consecutive patients requiring treatment for invasive mole and choriocarcinoma. The investigations were performed prior to the commencement of chemotherapy and the subjects followed prospectively. The Doppler waveforms from the uterine arteries were analysed using the pulsatility index. It was found that patients with a pulsatility index of 1.1 or less were significantly more likely to develop drug resistance than those with a higher value (P < 0.04). There was no significant association between the pulsatility index and metastatic disease or uterine bleeding. Five out of eight patients who developed drug resistance could have avoided initial inadequate treatment if the Doppler findings were included in the scoring system for selecting chemotherapy for these tumours. It can be concluded that assessment of the uterine arteries using the pulsatility index prior to the treatment of patients with invasive mole and choriocarcinoma is of help in predicting those who will develop drug resistance.


We measured immunoreactive EGF and TGF alpha in prostate tissue extracts obtained from 19 patients with benign prostatic hyperplasia (BPH) and 19 with cancer of the prostate (CaP). Whilst both BPH and CaP expressed EGF  and TGF alpha  in equal concentrations, the levels of EGF in any tissue extract were on average twice those of TGF alpha. Furthermore analysis of the individual growth factor data revealed a direct correlation between EGF and TGF alpha in both BPH  and CaP . When the tumours were classified according to their Gleason score, a slight but significant increase in growth factor concentrations was noted as the tumour became less differentiated. We also measured the concentrations of testosterone and dihydrotestosterone (DHT) in prostate extracts with a view of elucidating the relationship between androgen and growth factors in this gland. There was a small positive correlation only between testosterone and EGF  and testosterone and TGF alpha  in CaP. The absence of any similar correlation in BPH where DHT becomes the predominant hormone may suggest an indirect role for testosterone in the regulation of growth factor production.


Study of the distribution of the p21 ras oncogene product as demonstrated by monoclonal antibody Y13-259 shows this protein to be apparently present in all epithelial populations of both premalignant and malignant tumours and throughout the normal foetal and adult epithelial crypt population in the colorectum. Metastatic tumour in liver shows a similar staining pattern which is less intense however than in the surrounding normal hepatocytes. Our results suggest that the presence of this protein is a widespread feature of normal cellular metabolism in certain cell types and is not restricted to those actively involved in cellular proliferation. It appears, furthermore, that neither cells at different stages of carcinogenesis nor those representing variants of a malignant phenotype can be identified using this particular antibody.


Neither testis nor epididymis was found to be invaded by L1210 leukaemic cells in spite of widespread dissemination through other organs and tissues. The same applied to animals in relapse after protracted remissions induced by cyclophosphamide. Prior damage to the gonadal vascular endothelium by Cd++ did enable leukaemic cells to enter the testicular interstitium, but not the depleted seminiferous tubules. Injection of cells into the lymphatic sinus system of the testis led to rapid peritubular proliferation and systemic dissemination but the seminiferous tubules were not penetrated. The histological appearance resembled that of human ALL. The results suggest that the L1210 system, using the intratesticular route for inoculation can be used to examine the susceptibility to drugs of leukaemic cells in this environment. The potential of drugs to damage the vascular endothelium of the gonad and perhaps contribute to the development of testicular relapse could be assessed following intramuscular inoculation of cells.


The pattern of spontaneous screening for cervical cancer by general practitioners and gynaecologists in The Netherlands is compared with an efficient screening policy resulting from a cost-effective study. Spontaneous screening tends to start and stop too early in a woman's life, and leaves too many women overscreened or unprotected. The combination in young age of a low incidence of invasive cancer and a high incidence of regressive lesions explains relative ineffectiveness and harmfulness of present screening practice. When screening would take place between ages 30 and at least 60, with intervals of about 5 years, as many lives could be saved for half the costs and with only 60% of the unnecessary referrals and treatments. Much attention should be paid to the coverage of the target population. Therapeutic follow-up policies for dysplastic lesions should be restrained.


The prone leg extension (PLE) is commonly used to identify dysfunction of muscle recruitment patterns. The prone leg extension is theorized to identify proximal muscle disturbances which are a result of distal injury or dysfunction (i.e. an ankle sprain). This case study compares the trunk and hip muscle  timing during a PLE of a 27 year old female runner during a healthy state (pre ankle sprain) and 2 and 8 weeks post ankle sprain.The gluteus maximus muscle onsets at 8 weeks post injury appeared to occur earlier compared with 2 weeks post injury. The Right Erector Spinae at 8 weeks post injury was also active earlier compared with the participant's non-injured state. A large degree of variability can be noted within trials on the same day for all muscle groups.An acute ankle injury did not result in a delay in gluteus maximus muscle activation. The utility of the prone leg extension as a clinical and functional test is questionable due to the normal variability seen during the test and our current inability to determine what is normal and what is dysfunctional. The prone leg extension (PLE) test is used by therapists who manually palpate the posterior muscles and observe trunk kinematics in an attempt to identify deviations from a supposed optimal. A dysfunctional firing pattern is assumed to exist when postural muscles (hamstrings and erector spinae) initiate the movement and a delay in gluteus maximus firing is evident . As wellBullock-Saxton et al  investigcause of disturbances in the muscle firing pattern during the PLE. Presented in this case study is a longitudinal quantitative assessment of the muscle onset timing of posterior trunk and leg muscles during the prone leg extension following an acute lateral ankle sprain. This case study will specifically address whether an acute ankle sprain precedes a delay in the muscle activation of the ipsilateral Gluteus Maximus muscle.The Bullock-Saxton study  was a crThis case study is a product of serendipity. A 27 year old female runner was initially part of an experimental study documenting the muscle onset timing of the posterior leg and trunk muscles during the prone leg extension. At the time of the study the participant had no leg or spine injuries. The participant was part of the asymptomatic control group. Five months after the completion of the study this participant suffered an inversion right ankle sprain during a rainstorm while leaping into a camping tent filled with children. At 2 and 8 weeks post ankle sprain the PLE extension test was performed while recording the posterior muscle activation EMG to determine if an ankle injury influences the timing of muscle activation during the PLE as compared with an injury-free PLE onset timing pattern.Twenty seven year old female distance runner  suffered a right ankle inversion sprain. X rays revealed no fractures. Informed consent to participate in this study was received from the subject. In the initial study the participant read and signed an information and consent form that was approved by the Research Ethics Board of CMCC. For the second half of the study the subject was notified of the risks and benefits of the study which complied with the World Medical Association declaration of Helsinki on the ethical conduct of research using human participants within a private practice and agreed to have her results published.No passive therapy was received by the participant. The participant was encouraged to perform daily weight bearing exercise and range of motion exercises. The participant was running within two weeks of the injury with pain and not at her pre injury level. At two weeks post injury the participant reported that she felt she was functioning at 60% of her optimum. At 8 weeks post injury the participant reported that she was running 95% pain free with little loss of function.An identical testing protocol was used across the 3 experimental days . The muscle activity of the right gluteus maximus, bilateral lower erector spinae, and right hamstring muscle groups was recorded during right prone leg extension while lying prone on a manual therapy table. The position of the leg was controlled in all planes  visually by the experimenter. A rig restricting movement or a kinematic analysis system to ensure an identical movement across trials was not used as this is not similar to what occurs during practice. The control of proper form was limited to a visual assessment as this most resembles clinical practice.Disposable bipolar Ag-AgCl disc surface electrodes with a diameter of one cm were adhered bilaterally over the five muscle groups with a centre to centre spacing of 1 cm. Raw EMG was amplified 5000 times. The amplifier has a CMRR of 10,000:1 . Raw EMG was band pass filtered (10 and 1000 Hz) and A/D converted at 2000 Hz using a National Instruments data acquisition system.The prone leg extension exercise was performed five times during each experimental session. The task required the subject to lie prone at complete rest with no movement while the EMG from each muscle was collected for 5 seconds. The subject then extended their straight right leg approximately six inches off the table. The leg was held isometrically for 3 seconds then lowered to the table.The data from each PLE trial was processed in the same manner. The aim of the processing for this study was to determine the order and timing of muscle activation. To determine muscle timing, it is necessary to determine when a muscle is considered active or "on". A muscle was considered "on" when the level of muscle activity was greater than 10% of the peak muscle activity during the prone leg extension. This method of determining muscle onset was used in the previous study by Bullock-Saxton et al . The ordThe data was processed in the following manner: The raw EMG signal was first full wave rectified, then smoothed using a moving average technique which averaged every 100 points of data with an overlap 98 points. The bias was removed from the signal to allow resting activity to be at 0. The peak muscle activity was found and each data point was divided by this peak muscle activity. In this way, muscle onset could be determined by determining the time when the myoelectric signal exceeded 10% of the maximum. The signal was visually inspected to ensure that no artefact occurred or that the results were biologically feasible.Table To the knowledge of the author this is the only prospective case documenting the longitudinal influence of an inversion ankle sprain on muscle activation patterns during the prone leg extension test. The results from this one participant failed to support the idea that lower limb injury leads to a delay in gluteus maximus firing as suggested by the cross sectional study of Bullock-Saxton et al .Conversely, at 8 weeks post ankle sprain there was a decrease in the latency of the gluteus maximus muscle (the muscle fired earlier). This earlier firing is similar to the differences in onset timing of the gluteus medius during lateral ankle perturbations between groups with chronically sprained ankles and controls . BeckmanThe lack of support from this case study and previous research questions the utility of the PLE in determining dysfunctional muscle firing patterns. There is little support in the research literature for the use of the PLE test in assessing muscle onset dysfunction. Further evidence against the use of the PLE in adequately assessing muscle function is found in the conclusions of Pierce and Lee  and Lehmwas not associated with a delay in the gluteus maximus activity. The Gluteus Maximus at 8 weeks post injury fired earlier than 2 weeks post injury and showed a trend to firing earlier than in a healthy state.An interesting trend in changes in muscle activation was earlier muscle activation of the erector spinae activity. Before the injury both erector spinae were active after the hamstring group. Eight weeks post injury the erector spinae preceeded hamstring activation by more than 130 ms. This earlier activation was also seen in the contralateral Erector Spinae at 2 weeks post injury (56.2 ms before hamstring activation). Bullock-Saxton et al [Another weakness of the PLE test is the high variability between trials within one individual (as seen in the current case study) and across individuals. This variability appears normal and limits the use of EMG in producing data which can identify individuals with dysfunction ,4. Last,While this case study failed to support the proposal that distal dysfunction may result in proximal dysfunction manifesting as aberrant muscle onset timing of the gluteus maximus during the PLE, the PLE as a clinical assessment test may still have value. The only means of assessing the PLE has been via muscle onset timing with electromyography. As stated earlier the trunk and hip kinematics of the participant are observed during the performance of the movement. No research to date has measured the kinematics with the aim of identifying and quantifying optimal and dysfunctional movement patterns (as opposed to the motor patterns assessed with electromyography). Quantifying these kinematics may lead to determining the discriminant ability of this test for the identification of dysfunction. The PLE may have more clinical utility as a crude test of function – minor differences in muscle onsets may have no clinical value and may not be easily detected by observation; however, major dysfunctions in muscle activation (i.e. no observable gluteus maximus contraction) would be more easily detected and may be of more clinical value. For example, during the test a patient's buttock may remain flaccid. This is easily seen and may be indicative of inhibition and possible dysfunction. The use of the PLE as a gross detector of dysfunction may be more supportable than being used to questionably detect subtle differences in firing patterns that are within 200 ms of each other.An acute ankle injury did not result in a delay in gluteus maximus muscle activation. The utility of the prone leg extension as a clinical and functional test is questionable due to the normal variability seen during the test and our current inability to determine what is normal and what is dysfunctional.The author(s) declare that they have no competing interests.


The value of the inclusion of doxorubicin hydrochloride (dox) in Cooper type regimens in advanced breast cancer was assessed by performing an overview employing summary statistics derived from published papers of randomised clinical trials comparing Cooper type regimens that contain dox with regimens in which dox was replaced by one or more compounds. Trials were selected which published data on survival, time to treatment failure and response rate. This study suggests that dox confers advantages on all of these endpoints and that the size of such benefits needs to be taken into account when deciding whether to use dox.


Transvenous pacemaker lead implantation is the preferred method of pacing in adult patients. Lead performance and longevity are superior and the implantation approach can be performed under local anaesthetic with a very low morbidity. In children, and especially in neonates and infants, the epicardial route was traditionally chosen until the advent of smaller generators and lead implantation techniques that allowed growth of the child without lead displacement. Endocardial implantation is not universally accepted, however, as there is an incidence of venous occlusion of the smaller veins of neonates and infants with concerns for loss of venous access in the future. Growing experience with lower profile leads, however, reveals that endocardial pacing too can be performed with low morbidity and good long-term results in neonates and infants. Cardiac pacing in infants and children has evolved considerably since the initial implants over half a century ago. Pacemaker generators have become smaller and are now easily accommodated subcutaneously or submuscularly either in the chest or the abdominal wall in the smallest of infants. Improvements in lead technology have enabled lower chronic thresholds with greater mechanical and electrical integrity and longevity of the leads and the pacemaker system. While endocardial leads have consistently proven to be superior to epicardial leads both mechanically and electrically, the development of steroid eluting epicardial leads has improved the effectiveness of epicardial systems . The chiThe choice of the method of permanent pacing is determined by the patient’s size, and presence of structural heart disease. While a large body of opinion holds that neonates and infants should receive epicardial pacing systems -4, experEndocardial leads are increasingly preferred for small infants in other centres as well -16. The Studies specifically comparing pacing via the endocardial route versus the epicardial route in small infants are lacking. The incidence of venous obstruction and occlusion has rarely been addressed. Venous obstruction due to endocardial leads in a small group of newborns and infants was assessed by Stojanov et al . In 12 cStojanov et al promote a cephalic vein cut down rather than a subclavian puncture approach in the very small . It may Endocardial pacing in neonates is not for the faint-hearted as lead replacement is likely to be needed in at least some of the patients. While extracting 11 leads uneventfully in nine patients , Kammeraad et al [Although epicardial leads do not carry a risk of venous thrombosis, there is an increased perioperative morbidity . PatientNeither the epicardial nor the endocardial approach in permanent pacing is free from complications. The experience reported with endocardial pacing in neonates and infants while encouraging is limited and no directly comparative data with epicardial pacing are available. Although the clear advantage of endocardial pacemaker implantation over the epicardial approach has yet to be demonstrated, the growing experience indicates that endocardial pacing is feasible and effective even in neonates and small infants - and it is an acceptable alternative to epicardial systems. The current disadvantages of endocardial leads may be overcome in the future by downsizing of the leads and extraction systems. The ultimate approach in very small children currently will depend on the facilities and experience of the surgeons and cardiologists in each centre.


Fogel's suggestion of a grading system according to the level of peer review (reminiscent of grading systems for "level of evidence" of primary studies) is interesting, but further study is required to determine to what degree the proposed ratings actually correlate with quality or peer review rigor. My suggestion  was to r


Male and female age standardised mortality and incidence rates of colorectal cancer have increased over the most recent 30 years in New Zealand. Among men and women aged 40 to 74, age standardised mortality and incidence rates increased 18 to 105%. However, age standardised mortality and incidence rates among younger men and women have declined from 14 to 69%. Analysis of trends in age specific mortality and incidence rates indicates that the occurrence of colorectal cancer has been declining equally for men and women in successive cohorts born about 1943 to 1953 in New Zealand. This decline in the frequency of colorectal cancer among recent generations was apparent for both the right and left sides of the colon and the rectum. Age-specific trends in coronary heart disease and breast cancer differed from those apparent for colorectal cancer, suggesting that the factors producing the reduction in colorectal cancer risk may affect these diseases among different age groups or may not be of major aetiological importance in these diseases. These trends provide empirical evidence that the occurrence of colorectal cancer can be reduced by at least 50% with a substantial component of the risk being determined before the age of 30. Further study is needed to establish whether changes in risk factors at older ages contribute to the prevention of the disease.