The Government of Kerala in 2017 launched the Aardram Mission with the aim to revamp public health delivery in the State. A key strategy under the mission was its focus on comprehensive primary health care to achieve equitable health care delivery through the Family Health Centre (FHC) initiative. Given this, the current study aims to examine the primary health care policy discourse for their perspectives on caste-driven inequities.The study undertook a Critical Discourse Analysis (CDA) of the primary health care policy discourse in Kerala. This included CDA of spoken words by senior health policy actors and policy texts on Aardram Mission and FHC.Though equity was a major aspirational goal of the Mission, related policy discourse around equity failed to acknowledge caste as a potential axis of health marginalisation in the State. The dismissal of caste manifested in three major ways within the policy discourse. One, the ‘invisibilisation’ of caste-driven inequities through strategies of (un)conscious exclusion of Dalit issues and ‘obliteration’ of caste differences through the construction of abstract and homogenous groups that invisibilise Dalits. Secondly, locating caste as a barrier to primary health care initiatives and health equity in the state, and finally through the maintenance of an ‘apoliticised’ social determinants discourse that fails to recognize the role of caste in shaping health disparities, specifically among Dalits in Kerala.Given Kerala’s renewed commitment to strengthening its public health provisioning, the acknowledgment of caste-driven inequities is invariable in its path toward health equity and social justice. That Dalits (Scheduled Castes or SC in administrative parlance) are one of the most marginalised social groups in contemporary India is not something new to Indian academia and policymakers. While many countries have had similar hierarchisation of societies, none was as complex, pervasive, and long-lasting as the caste system that exists in India. The resilience of caste in the face of myriad historical changes including feudalism, colonial rule, and modern-day capitalism is proof enough of its adaptability and the complex grip it wields over Indian society , 2. ThisThe Indian state of Kerala despite its low economic performance is often hailed for its achievements within human development indices. The State is often considered a model, even for the third-world regions burdened with the history of colonialist exploitation and chronic developmental inequality. The developmental landscape of Kerala is marked by its impeccable achievements in the social sector reflected as high levels of life expectancy, literacy, and low levels of maternal and infant mortality . An achiThe continuing presence of health inequities along caste lines in the state is often argued as the product of deep-rooted and historically shaped caste norms leading to social exclusion and denial of opportunities of social development for Dalits including education, landownership, and employment amongst others, despite the strident growth in terms of poverty reduction and human development post the 1980’s in Kerala . The expWhile Kerala achieved significant improvements over the years in human development indicators and in the domain of health, its achievements in health post the economic liberalisation of the ‘90 s have often been argued as unimpressive. Reflected through the reversal of its achievements within indicators like infant mortality rate, and childhood anaemia during the period between 2003 to 2012 . In additranslated as ‘New Kerala’) Mission conceived by the incumbent government (led by the Communist Party of India (Marxist)), that sought course corrections in terms of the historical exclusion of various social groups within the state’s developmental trajectory. The Nava Kerala mission within its umbrella consisted of four key sub missions 1) The Aardram mission, 2) Life mission , 3) mission to revamp public education and 4) ‘Haritha Keralam’ mission . These missions were part of the Left government’s aspiration to ensure a developmental model that is much more equitable and inclusive of the underprivileged and marginalised sections in the state [In full recognition of the widening gaps within the health landscape in terms of reduced public presence and growing distrust in the public health system, the Government of Kerala initiated the Aardram Mission in 2017 [he state .The Aardram mission through its approaches, therefore, also aligned itself with the new national policy roadmap set out by the National Health Policy, 2017 that sought to achieve Universal Health Coverage. These included initiatives such as ‘Ayushman Bharat’ that aimed at the transformation of Primary Health Centres and Sub-Centres as Health and Wellness Centres (HWCs) with the specific aim of delivering Comprehensive Primary Health Care that is easily accessible for communities at the grassroots , 23. On The policy affirmation on comprehensive primary health care through the Aardram mission along with the other three missions under the ‘Nava Kerala’ Mission, therefore, presents itself as a unique opportunity for the state to take cognizance of unaddressed health inequity gaps that continue to exist in Kerala. The current study, therefore, locates itself within this context of revived commitment on the part of the Government of Kerala on comprehensive primary health care, reflected through the Aardram and FHC initiative and aims to examine how it problematise the situation of Dalits and the ways to overcome their health challenges.Health policy and systems research (HPSR) has over the years gained substantially from its engagement with the construct of power and its analysis, specifically to gather a nuanced understanding of the mechanisms and structures that generate health inequities and disparities. Application of theories on power and deeper empirical examination of its dimensions does hold significance in the attempts to locate health policies as also a product of wider social, political, and historical contexts and to drive potential revisions and improvements to generate equitable health outcomes through them. Power here is defined as the capacity ‘to do something or act in a particular way’ and ‘to direct or influence the behaviour of others or the course of events. Quite crucial, as power relations do hold the ability to shape societies and societal interactions and thereby also in the process shape health and related policies and subsequent health outcomes. The current study specifically draws from the idea of analysing power and how it may flow through societal expressions in the context of health policies and systems. To analyse how power manifests and expresses itself within health policies reflected through their unique positionalities and expressions of social relations and in turn how they may also engender health disparities .One of the suggestive methods to undertake the analytical examination of words both written  and oral  is using a Discourse Analysis approach. It facilitates a deeper examination of oral and written acts of communication to bring to the fore the subtle yet shared ways of perceiving the world around us and what may be considered normal , 27. DisThe application of CDA was guided in the current study using the four-phased approach to CDA Fig.  suggesteThe formal policy documents related to Aardram and FHC were sourced from multiple sources. The Aardram document on FHC was collected from the office of the State Health Systems Resource Centre, Department of Health, Government of Kerala in Thiruvananthapuram. In addition, documents on the Aardram mission available from the website of the National Health Mission, Kerala were also sourced. The policy officials’ narratives on primary health care and their ideas on various marginalised communities in Kerala were prepared through in-depth interviews with seniormost policy officials at the Directorate of Health Services (DHS), Department of Health, Government of Kerala (GoK). This involved interviews with officials from the Directorate of Health, District Medical Officers (DMO) as well as District Program Managers (DPM) under the National Health Mission and senior officials of the State Aardram mission Table . The finA central idea within CDA is the fact that social actors from different social locations see and express the world differently and exploring the use of language within discourse could be a way to bring out these differences . This isThe analysis of the policy discourse on primary health care in the current study primarily pivoted itself to the dimension of equity from a caste lens. Specifically, through the examination of how equity and its dimensions are being expressed within the policy discourse on Primary Health Care. This has been undertaken by examining how the policy discourse problematise health vulnerabilities in the state and subsequently examining the nature in which caste is being discussed within the discourse on health inequities in the State. The CDA of the policy discourse in this regard points to three related aspects. Firstly, the discursive strategies adopted by policy actors that aimed at Dalit ‘invisibilisation’ within the policy discourse. These include methods such as the overt exclusion of references to caste as a potential axis of health vulnerability and/or through subtle ways of obliterating caste differences and thereby mobilising health vulnerabilities to inexistent social groupings that further invisibilise Dalits. Secondly to locate caste as a barrier to effective primary health care strategies and thirdly through ‘apoliticised’ discourse on social determinants that is devoid of the consideration to caste-driven health disparities in the State.A common theme within the discourses on marginalised social groups was the ways in which they carefully avoided references to caste as a probable axis of marginalisation in Kerala, where dimensions of caste remained obvious through their unignorable absence. Discourse that excludes caste-related marginalisation also by extension remain blind to the situation of Dalits in the state and prioritised efforts in the context of primary health care initiatives in the State.The policy official Table , Quote 1Dalit exclusion was also found shaped within the policy discourse through their discursive subsumption under abstract and homogenous social categories.One of the ways in which the policy narratives discursively obliterated caste differences was through the construction of an abstract ‘general community’ and limiting ideas of marginalisation exclusively from the point of geographically and religiously tangible social groups Table , Quote 1A second way of discursively obliterating caste differences is through the forceful imposition of logics of economic inequality over caste-driven inequities in Kerala Table , Quote 2Yet another way caste was found subsumed within other categories is through the homogenous category of ‘SC/ST’ Table , Quote 3Within the policy document, the word SC appears 5 times, yet in all these instances it is never used or defined in its own right as a specific social class but always as ‘SC/ST’. Although a possible fallacy in the argument here would be the unique contexts in which these terms may be appearing within the policy document justifying the clubbing of SC and ST. While it may not be completely wrong to argue so, the document however without delineating the unique social realities and health needs of two completely different social groups, such homogenising narratives can only further reinforce the existing discursive patterns of subsuming caste groups under the abstract category of ‘SC/ST’. One that may do justice, neither to Dalits nor to Aadivasis in terms of recognising their differential health needs and thereby pre-empting the possibility of providing equitable primary health care services.To be read along with the patterns of caste invisibilisation achieved through its subsumption within constructed abstract social groups is the perception of caste as a barrier to novel primary healthcare strategies in the State. The discourses on marginalisation largely perceived caste as a fractural construct that can negatively influence the implementation of primary health care strategies, and by implication renders consideration of caste within primary health care modalities as a negative idea.The narratives related to primary health care innovations often tend to iterate the need to approach the community as a homogenous group Table , Quote 1The narrative also further considers the exclusion of certain social groups as normalised and a taken-for-granted requirement in the context of primary health care innovations anywhere. This is established through the statement that ‘it is always difficult to consider only a small section’ and ‘there is always the barrier of some sections not accepting innovations.’ This view by extension is also normalising and legitimising exclusions that continue to exist in the case of various marginalised sections of the community including Dalits in Kerala as a given within local primary health care-related projects.Yet another way caste was excluded and located as a barrier was through the relegation of caste as an irrelevant grouping when it comes to the idea of primary healthcare Table , Quote 2However, even this narrow take on social groups evidently turned problematic, upon pointed inquiries of caste as an axis of marginalisation Table , Quote 2The analysis of the State Government’s Aardram Policy document too points to a discourse that is blind to the existing caste-driven disparities in the State. The policy document on Aardram and Family health centre specifically stood out in terms of its unique representation of Dalits and in its complete absence in terms of not recognising caste as an axis of inequity and a social determinant of health marginalisation in the State.Most striking is the way in which the FHC document locates the word Scheduled caste within its considerations for health care priority Table , Quote 1While the policy also suggests the idea of marginalised communities and specific care for them, here too it fails to speak explicitly about social groupings based on caste in its discourse on marginalisation in Kerala Table , Quote 3The Aardram mission and the FHC initiative clearly suggest Kerala Government’s commitment to reviving the primary health care provisioning in the State. This is also reiterated by the fact that it pivots itself on comprehensive primary health care as its approach to achieve the larger goals of equity and social justice for the state. However, the analysis of the policy suggests the persisting gaps in its conceptualisation and articulation of equity and underprivileged specifically from a caste lens. The existing discourse on marginalisation within the primary health care policy in Kerala is characterised by a blindness to caste-driven inequities and the existing social realities of Dalits as a marginalised social group. One that is also curious given its acknowledgment of Adivasis and coastal communities as marginalised, groups which too are historically marginalised in the State , 37–39. A good place to start here would be, therefore, to problematise the nature of representation of caste as a possible axis of marginalisation in Kerala as well as the ways in which the policy engages with Dalits. The primary health care policy discourse examined in the study was evident in its dismissal of the caste question or in recognizing caste as a potential axis of marginalisation. The policy narratives were characteristically evident with an ominous reluctance to mention the word caste or scheduled castes related to discourses on marginalisation and health inequity in the state. Beyond the recognition of Adivasi and coastal communities, the marginalisation narratives in the current study almost exclusively existed along the axes of biomedical markers of age and sex, access to drinking water, and hygiene. The palpable need to dismiss any reference to caste within marginalisation discourses within the current study alludes to a conscious or unconscious yet strong repugnance towards discussions on caste. Quite similar to what sociologist Satish Deshpande argued in his thesis on ‘castelessness’, where he discusses how various historical legal, and policy decisions on the issue of caste and reservation in India have shaped a new ‘common sense’ of caste in India. He argues that the word caste is almost often immediately reinterpreted as ‘lower castes’ within the collective discourses. This also has parallels to similar recontextualizations within other universal categories of gender and race. Gender is almost often construed as women from a conventional patriarchal common sense and race as people of colour from a white supremacist sense .The reductionist logic of caste as ‘lower caste’ has significant relevance in the current study too, since dismissing caste also by extension suggests the exclusion of Dalits themselves as a marginalised social category. Through the avoidance of discussions on caste, there is an uncanny resemblance of the Brahminic logics of purity and impurity being carried over to the realm of social discourses on health and by extension exclusion of Dalits. An evident contempt to even discuss caste among the ruling elites, leading to the existing caste blindness within policies. This is also in line with the ‘Social Nausea’ argument by sociologist Awanish Kumar, where he argues that Indian policy today suffers from the potent combination of social isolation backed by the regressive notion of Brahminical caste and that of social nausea of elite castes towards utterances of caste and Dalits. The result is the inability of public policies on health to effectively address the real issues of the masses in India . The facThe discursive ostracization of Dalits also seems to have been facilitated by the differences in the geographical attributes of Aadivasis/coastal communities and Dalits in Kerala. Historically Aadivasi and fisherfolk communities have remained distinct from their non-Aadivasi/coastal counterparts in Kerala. Specifically, in terms of the almost exclusive geographical presence of Aadivasi communities along the Western Ghats and fisherfolks within the long coastal belts of Kerala with their own distinct socio-cultural identities , 47, oneth report of the Administrative Reforms Commission of the Kerala government, majority of the state’s slum population is constituted by marginalised Dalit sections and is characterised by poor housing status, subpar infrastructural facilities, and sanitation services amongst a host of others [What’s also not helping is the adversarial position historically adopted by the political left including Communist parties in India and in Kerala towards caste and caste-identity politics. The urgency in declaring caste-identity politics as an antithetical force to Marxian class politics has often contributed to the political left’s inability to accommodate the struggles of various historically marginalised social groups in India including Dalits . The subf others . Besidesf others . The resf others . HoweverAn obvious corollary being the stark contradictions within the state’s health policy that is adamantly caste blind despite chronic disparities both in terms of access to basic determinants of health as well as health outcomes among Dalits. A toxic contrast, arguably drawn from the ‘Savarna (upper caste) gaze’ that is relentless in its attempt to normalize Dalit invisibilisation within its discourse on health inequities. Achieved in this case through clandestine ways of shaping discourse on health inequities that is quick to deny the spotlight on caste-inequities either through dismissal or by ‘mobilising health vulnerabilities’ to amorphous social groupings that shall never have a Dalit focus as its priority. A rather lucid demonstration of how caste continuously arranges and rearrange itself to find ways and means to continue its status quo and maintain the social order of caste hierarchies in Indian societies . These pI, therefore, argue that as a first step it is important to deconstruct current policy discourses on development in the state by carefully breaking them down to their individual contradictions that constitute their exclusive positions and subjecting them to deeper understanding and subsequent problematisation . InsightWhile there is a renewed rhetoric against health inequities under the Aardram mission and FHC initiative, the Kerala health system’s policy discourse on primary health care suggests the persisting presence of a ‘Savarna gaze’ that is quick to dismiss the role of caste-related social hierarchies in shaping health disparities among Dalits in the state. Through a discourse that is silent about existing caste-driven health inequities, the renewed policies on comprehensive primary health care under the FHC initiative also stand to engender social practices of primary health care at the grassroots in the state through various Local Self-Government Institutions (LSGIs) that are also similarly blind to caste inequities. This is crucial as a key anchor point for the implementation of the Aardram mission and FHC initiative is the ability of decentralised LSGIs across Kerala to pro-actively undertake and implement the strategies envisioned through the mission at the level of communities at the grassroots . The pol


Extensive research has demonstrated the effectiveness of physical activity interventions for middle aged and older adults (MAOA). Despite this effectiveness, the actual reach of the target population participating in these interventions in a real-world setting remains relatively low. This demonstrates the urgent need for further implementation research. In the Netherlands, this need has been recognized earlier, leading to the foundation of the ZonMW financed Implementation Network Sports and Physical Activity: the presenters in this symposium are all members of that network.The aim of this symposium is to describe barriers and facilitators regarding implementation that were determined by qualitative studies among MOAO and stakeholders. In addition, the development of a practical tool that stimulates implementation by stakeholders is presented. These studies were grounded in relevant scientific frameworks such as Consolidated Framework for Implementation Research (CFIR) and Implementation Mapping. This symposium also provides recommendations for future research and practice in the shape of potential strategies that can be applied when implementing interventions.


Managed care pharmacists are faced daily with choices regarding how to deliver the best care with finite resources. Whether it is through encouraging appropriate utilization of medications via formulary management and drug utilization evaluation or through chronic diseasemanagement programs, pharmacists are guiding patient care with effectiveness, quality, and an eye toward value. It is with these goals in mind that pharmacists can benefit from the research produced by the Agency for Healthcare Research and Quality (AHRQ).


Klippel–Trenaunay syndrome (KTS) is a very rare vascular malformation syndrome also referred to as a capillary–lymphatic–venous malformation with unknown aetiology. The aim of our paper is to highlight interesting images, regarding a rare case of foetal Klippel–Trenaunay syndrome diagnosed prenatally in our department and confirmed postnatally with a favourable evolution during the gestation and neonatal periods. This case was diagnosed at 26 weeks gestation and characterised through ultrasound by the presence of superficial multiple cystic structures of different sizes spreading over the left leg with hemihypertrophy and reduced mobility. The cystic lesions were spreading to the left buttock and the pelvic area. The right leg and upper limbs had normal appearance with good mobility. There were no signs of hyperdynamic circulation or foetal anaemia, but mild polyhydramnios was associated. The ultrasound findings were confirmed postnatally, the left leg presented multiple cystic lesions and port wine stains, and there was hypertrophy and fixed position, with favourable evolution at 6 months of life, when the size of the lesions began to decrease and the mobility of the leg improved.


The translation of evidence based practice to clinical care in rehabilitation settings has been limited , 2. It cDespite such challenges, the effective implementation of evidence based cognitive rehabilitation treatments is essential and the process of clinical implementation for cognitive rehabilitation has been specifically investigated –7. In anboth before and during the implementation of the intervention are integral to delivering flexible interventions in practice. Additional modifications that may occur in clinical practice include applying an intervention to a clinical population that was not included in the empirical research or to an individual who may not have met inclusion criteria in the research studies associated with the intervention  approach in inpatient stroke rehabilitation, was conducted at five rehabilitation hospitals in Canada . In thisIt is likely that increased integration of implementation science and knowledge translation paradigms in the area of cognitive rehabilitation will allow for increased communication and collaboration between cognitive rehabilitation researchers and practitioners and will contribute to increased development of flexible evidence-based protocols that can flow from the research lab to the more fluid demands of the treatment environment. Such flexibility will allow for guided modifications to evidence-based cognitive rehabilitation treatment protocols and data driven application of cognitive rehabilitation which aligns with clinical recommendations. Formal tracking and documentation of needed and implemented modifications, as well as improved dialogue between researchers and clinicians are necessities. Such dialogue will encourage a common language through which to communicate about cognitive rehabilitation concepts  and to d


Comprehensive sexuality education is a scientifically accurate global program that encompasses the variable aspects necessary for achieving healthy sexual and reproductive health in children of school-going age. It provides a holistic approach to developing sound knowledge and a positive attitude in a manner that does not blatantly refute the established sociocultural norms but rather delicately treads around them to bust unhealthy practices through age-appropriate measures. It is deemed necessary for health professionals to be appropriately trained to better convey sensitive information regarding sexual and reproductive well-being in a manner that is acceptable and effective, especially in the context of orthodox communities. The available guidelines of CSE help to explore the very sensitive aspects of sexuality without becoming flustered and without imposing ideas upon the recipient. The need for health professionals to receive formal training to be able to answer potential queries in an effective manner would help relieve the enormous health burden arising from mere ignorance.5In 2018 Comprehensive sexuality education (CSE) was defined by United Nation Educational, Scientific and Cultural Organization (UNESCO).6 Being thus backed up by the scientific community we felt much more confident in putting our plans into action.During our internship, we proposed to conduct a health awareness program in a local government school targeting school-going children between grades 8 and 10. At the end of our session, we hoped to better equip our target group with the basic information needed to make informed choices regarding their sexual behaviour, strengthen their relationships with their friends and family and respect and appreciate their interpersonal differences. Being medical students gave us a scientific edge in addressing the anatomical and physiological aspects of adolescence. But we understood a sensitive topic like itself would require us to be strong yet approachable to break the ice with our participants. It would be challenging to overcome reservation and shyness on both ends. There was also the risk of coming across as being "vulgar" or instigating risky behaviour by "putting ideas in one's head". We felt the need to find established and tested age-appropriate norms in communicating sexual information to the impressionable young minds of children. In doing so we discovered the CSE program by UNESCO along with several studies conceding to the efficacy of this program in perpetuating much of the same goals as ours. Opposed to the common misconception that such programs encourage young adults to engage in risky sexual acts studies showed that two in three CSE programs provided evidence of a decrease in risky sexual behaviour and encouraged responsible decision-making like the use of contraception.Before the main event, we decided to conduct a mock session amongst our own team to better apprehend the questions that could arise on an actual day. Surprisingly many of us had strikingly different views on the same topics. This instigated extensive debates and arguments among ourselves making us realise that it was necessary to recognize our goals clearly and not impose our personal beliefs or practices onto others in order to succeed. This persuaded us to seek formal training from certified CSE trainers. We felt it was important to avoid imprinting personal opinions particularly regarding grey areas into the minds of the young children and only deliver facts in the form of a clear message. Recalling our own school days brought to us the revelation that hardly any of us had any definite knowledge on a lot of sexual and reproductive topics as adolescents. Much of what young adults know is theoretical and the little practical knowledge they do have is borrowed from social platforms or from conversations with their peers. Even in medical school much of what is taught describes unhealthy sexual behaviour and hardly any literature is found painting a healthy sexual relationship. This later poses problems in the form of unclear concepts and inadequate vocabulary. Overcoming the uneasiness with our own friends and discussing openly during our training made us realize that knowing earlier what we knew then could have saved us from tremendous anxiety and uncertainty while growing up. The training proved very insightful and we realized that even after medical school there was much to learn.7We conducted our pilot program as a tutor-based peer-to-peer learning with two tutors, a male and a female, assigned to a total of 20 trainees. It comprised health education, demonstration, information exchange and active question-and-answer sessions. Young adults are naturally inquisitive and have the ability to soak up information like a sponge. But even so, as anticipated talking about anything even remotely associated with sex caused them to initially show inhibition and shyness. But once they overcame the awkwardness we found them to be remarkably inquisitive and brimming with queries. The open and casual discussion enabled us to unmask traditional firmly rooted beliefs like menstruation being a time of "ridding body of impure blood" and the lack of clarity regarding bodily processes like "menstrual blood flows from the same opening as that for urine". Busting myths in a delicate yet affirmative manner was the most challenging of all tasks but our formal CSE training had prepared us for that part. Above everything we had learnt that it was necessary to respect our subjects for them to reiterate our teachings. In several instances, we felt that the training had prepared us to avoid potential controversies and grey moral grounds while still providing an appropriate and acceptable response. The receptiveness and kindness that the children demonstrated were a fresh breath of air. We were truly overwhelmed with how fulfilled we felt towards the end of the program and this has only fuelled us to conduct more such programs thereafter. We understand that a limitation to CSE programs, especially in South Asian settings due to cultural normative patterns can be the elimination of dialogue regarding pleasure and sexual fluidity. This may be due to the portrayal of sex as problematic behaviour and not as a natural entity.Available literature from the last three decades offers strong evidence for the effectiveness of CSE. School programs can be framed to be initiated early on and delivered successively over increasing grades to build up knowledge in a manner that is age appropriate and essential. Health professionals should seek to be better informed regarding the aspects of CSE to delve better into prevention medicine. The need for formal training on CSE is necessary to better reiterate learning objectives without potentially harming the existing cultural sentiments and dissuading the participants. It would also help in acquiring clear concepts and an appropriate vocabulary to interact without becoming flustered while remaining respectful to the target audience. As medical professionals, we are capable of sending out enormous ripples of positive changes. Only through formal training and indulgence in research can we equip ourselves for the battle against ignorance. It is upon ourselves to seek to become adequate before we begin to address inadequacies. While there may be limitations to what can be comfortably included in our discussions, it is time we start where we stand and begin the climb to a better view.


We thank the authors  for elevBecause meat intake is often at the crux of scientific debate on optimal healthy, sustainable diets for the population , this reThe DGA model dietary patterns that are intended to provide examples of healthy dietary patterns use food groups and subgroups rather than individual foods and beverages to avoid being prescriptive . The modWhile the authors  compare


We read the article by Theodoraki K and colleagues entitled ‘Colloid Preload versus Crystalloid Co-Load in the Setting of Norepinephrine Infusion during Cesarean Section: Time and Type of Administered Fluids Do Not Matter’ with interest . The aimThere are some possible related concerns worth being discussed further.1. The intraoperative use of hydroxyethyl starch (HES) solutions remain controversial regarding that the perioperative use of HES have increasingly been reported to both the US Food and Drugs Administration and the European Medicines Agency (EMA) . Accordi2. According to an international consensus statement, maternal hypotension following spinal anesthesia should be treated or prevented routinely with vasopressors . In this3. In a study aiming to determine the effects of in vitro hemodilution with HES on the coagulation status of women, it was concluded that an HES solution causes significant hypocoagulable changes in the thromboelastographic profile . From an4. The safety category of HES during parturiency and breastfeeding is C, which means ‘the effects on fetus is unknown and adverse effects were obtained in animal reproduction studies on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks’. There are not enough data to recommend the use of HES for children, and it is widely accepted that administration of HES to pregnant and breastfeeding women must be limited to emergency cases only .Given the abovementioned concerns and the relevance of coagulation abnormalities that might eventually result into extensive bleeding and a hysterectomy and the limitations provided by EMA, is it worth using HES instead of using vasopressors as the first-line therapy in patients undergoing cesaren delivery without any hemodynamic instability?We believe that clarification of these issues will result in better deductions and improve the anesthetic management of parturients with safety concerns.


This is the authors’ response to peer-review reports for “Information Technology Ambidexterity, Digital Dynamic Capability, and Knowledge Processes as Enablers of Patient Agility: Empirical Study”Comments and Responses by the Authors MethodsDescribe the study [Move the highlighted (in the reviewed manuscript) content under Data Collection Procedures to a new subsection under subsection heading Study Population (see comments in the reviewed manuscript)The highlighted content should be under a new subsection heading Study DesignProvide content on another two subsection headings:Sampling TechniquesSample SizeSeparate content under Data Collection Procedure into two new subsection headingsData Collection Tool and ProcedureData Analysis and ManagementMove Table 1 to Analyses & Results sectionProvide content under two new subsection headings: Inclusion and Exclusion CriteriaEthics ConsiderationsAuthors: The sections mentioned in this review  are esseInclusion and exclusion criteria were combined with sample size, as we described how we got the final sample and why we included respondents (and why not).AbstractDo not begin a sentence with abbreviation of figureUse past tense under Methods See comments in the reviewed manuscriptIntroductionUse physicians in lieu of doctorsUse health care providers not other medical professionalsKeep in-text citation to the end of sentenceAdd health information management professionals among the key stakeholdersConsider reducing the whole of section 2  to 1-2 paragraphs and keep it within the Introduction section just before your study objective. This is to reduce readers’ boredom.Compress the content under research models and hypothesesResultsMake your findings more visible hereMake your writing more readable to known and unknown readersDiscussionPlausible and insightful discussion but not a reflection of the content under the Results. Make the Results section more readable and meaningful to your audience.FigureUse Fig not FigureAcknowledgement It is scientifically necessary that you acknowledge the numerous (n=107) participants, who are the major stakeholders in your research.ReferenceList at least 3 authors before et al Follow the Referencing Style consistentlyOthersUse participants not respondentsAuthors: We adjusted this accordingly.Thank you for the opportunity to review this paper on the lesser known topic of information and communications technology ambidexterity. The paper is well cited, uses appropriate methods, and discusses the concepts and findings in a clear and thorough manner. The paper should appeal to a broad audience. It is a good example of the underrepresented information and communications technology–centered literature in health care.Authors: We would like to thank this reviewer for these kind words . We hopeWell thought out study design with specific hypotheses and methods of analysis spelled out. Interesting conclusions drawn out that would be fruitful for further discussion and analysis to replicate on a broader sample of hospital systems outside of the current reviewed sites.Authors: We would also like to thank this reviewer for these kind words . We agre


Reply to the Editor:The authors reported no conflicts of interest.Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.The We thank the author for his interest in our article titled “Conventional Versus Miniaturized Cardiopulmonary Bypass: A Systematic Review and Meta-Analysis.”It is well known that cardiopulmonary bypass induces a systemic inflammatory response due to the contact of the patient's blood with nonendothelial surfaces and air, which is accompanied by an increase in cytokine levels. The attenuation of this inflammatory response is associated with a reduction of morbidity and mortality after cardiac surgery.We note that the author reported the formation of a colloid film as an incidental finding during the administration of polygeline (Emagel) for volume integration in the establishment of cardiopulmonary bypass. The use of a colloid film as a solution to temporarily reduce air–blood contact in optimized open circuits has both potential benefits and risks.,The elimination of the air–blood interface reduces contact activation of blood components when exposed to air, especially with longer perfusion times . However,Colloid solutions are effective in increasing circulatory blood volume and maintaining colloid osmotic pressure in cardiopulmonary bypass. However, the use of such solutions increases the cost of cardiac surgery and may cause adverse reactions such as histamine release, resulting in hypotension, bronchospasm, and skin rash.The hemodilution effect caused by large amounts of colloids could result in an increased risk of stroke or other neurological events through cerebral hypoperfusion.Although the formation of a colloid film reduces air–blood contact for a short period of time, the clinical benefits of this are not well investigated. The use of solutions to limit air–blood contact in optimized open circuits is thought provoking, and more research is needed to fully evaluate its effectiveness and safety.


BackgroundPost-operative complications present a challenge to the healthcare system due to the high unpredictability of their incidence. However, the socioeconomic factors that relate to postoperative complications are still unclear as they can be heterogeneous based on communities, types of surgical services, and sex and gender.MethodsIn this study, we conducted a large population cross-sectional analysis of social vulnerability and the odds of various post-surgical complications. We built statistical logistic regression models of postsurgical complications with social vulnerability index as the independent variable along with sex interaction.ResultsWe found that social vulnerability was associated with abnormal heart rhythm with socioeconomic status and housing status being the main association factors. We also found associations of the interaction of social vulnerability and female sex with an increase in odds of heart attack and surgical wound infection.ConclusionsOur results indicate that social vulnerability measures such as socioeconomic status and housing conditions could be related to health outcomes. This suggests that the domain of preventive medicine should place social vulnerability as a priority to achieve its goals.The authors would like to note that Mohamed Abdelhack and Sandhya Tripathi contributed equally to this work.


A more dynamic school day that includes less sitting and more physical activity throughout the day may support health in primary school children. In this mixed methodologies study, we assessed which physical activity possibilities are incorporated in the school policies of Dutch primary schools and if this translates into more physical activity in pupils.Seven primary schools were included in the study. The head teachers completed a questionnaire on the incorporation of physical activity in the school policy. Physical activity policy was assessed for physical education, physical activity during breaks, scheduling of physical activity during lessons, after school physical activity and active transport to school. In each school, actual physical activity was objectively measured using accelerometers in pupils in two classes and planning and logging of PA by teachers.We will assess the impact of the school policy on physical activity in pupils using logistic regression. We will assess the impact of the several school policies on total physical activity in pupils, and on the three  modalities of physical activity.The results of this study will give us more insight in the current role of physical activity in Dutch primary schools. The potential impact of the school policy on physical activity levels in pupils can be used as a starting point for a more integral dynamic school day approach.This study was partially funded by “Stichting Westelijke Tuinsteden’.


Chicken breast meat is one of the most sustainable and affordable sources of animal protein making it one of the most popular protein sources globally. As such, maintaining consistency in product quality is of the utmost importance. Over the last decade three novel myopathies have been identified in broilers (White striping (WS), Wooden breast (WB) and Spaghetti breast (SB)) ; there hThe exact aetiology of the myopathies is still not fully understood however a wide range of studies have used gene expression , proteomGenetic selection for broiler performance traits such as bodyweight (BW) and breast yield (BY) has been a core theory as a cause of the myopathies. Published data of large populations of broiler pure lines have estimated low genetic correlation between the three myopathies and performance traits (BY and BW), this indicates there is little shared genetic background between the myopathies and broiler performance traits ; 2020. HThere are many non-genetic factors that can influence broiler growth rates such as incubation, brooding, nutrition, temperature and ventilation . A key aOxidative stress and hypoxia have been highlighted as a key feature of all three myopathies  thereforWhilst genetic correlations indicate that there are no significant links between the myopathies and bird growth at the genetic level, phenotypically it is often the larger birds in a flock which express the myopathies. This phenotypic relationship is not always the case however, as some studies report that WS and WB are not linked to bird weight . Wooden One approach to influencing growth is reducing nutrient intake by diluting or limiting the availability of feed; these methods ultimately impact upon the efficiency of production through poor bird growth or the birds compensate by eating more food and thus do not offer a suitable solution . By targvia the intermediate guanidinoacetic acid (GAA)   but thisid (GAA) . Exogenoid (GAA) ; 2018b.Increasing dietary antioxidants such as vitamin E and selenium have been used to reduce oxidative stress and myopathies but results have been mixed and may depend upon the quality of fat in the diet . A novelpost mortem, the authors stated that SB was not and thus not described fully due to the uncertainty; this raises the question of whether SB is present in the live bird (post mortem change in the muscle. Immediately post mortem, muscle pH drops as a result of lactic acid production which is accompanied by the release of proteolytic enzymes (post mortem changes in the muscle and thus increase SB incidence in a flock. The rate of cooling of carcases post mortem has an influence on the rate of lactic acid production and the activity of the proteolytic enzymes (Spaghetti breast is probably the least understood myopathy  and its ive bird  or only  enzymes . This pr enzymes  and, in  enzymes —the slow enzymes . The useBreast myopathies remain an important focus for the poultry industry and the poultry science community, and it is clear that there is still a lot to understand. The reduction in breast myopathies relies on a holistic approach to control: Balanced breeding by poultry breeders can target the genetic component but the larger influence from non-genetic factors remains an important focus area. Understanding the biological needs of the muscle and ongoing physiology in the modern broiler provides key time-points for strategies to reduce the myopathies and gain more insight into their aetiology .


Due to a production error, an incorrect Conflict of Interest statement was provided. The correct Conflict of Interest statement appears below. The publisher apologizes for this mistake.“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.®. After investigation, the journal has no reason to believe that the scientific conclusions of the article are affected in any way.”A reviewer of this manuscript, Devan Mehrotra, is a biostatistician at Merck & Co., Inc., known as MSD outside the United States and Canada. The pharmaceutical ivermectin studied in this manuscript is manufactured and marketed by Merck & Co., Inc. in the United States under the brand name STROMECTOLThe original article has been updated.


It is much more important to know what sort of a patient has a disease, than what sort of disease a patient has.William Osler1Despite powerful narratives echoing a purported existence of meritocracy in our society, major racial and ethnic disparities in health and healthcare have persisted for hundreds of years. Yet a clear understanding of structural societal inequities and not innate group differences underlying the racial disparities in health was articulated nearly 200 years ago by Dr. James McCune.It was not until the 1985 Report of the Secretary's Task Force on Black and Minority Health, led by Dr. Margaret Heckler, that the nation could accept such disparities as a problem worthy of consideration. Soon thereafter, the 2003 Institute of Medicine report entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” sought to not only codify racial and ethnic group differences in health outcomes, but emphasized these were due to how people were treated and not due to innate attributes. It also identified how this mistreatment led to differences in the quality of and access to health care.AHRQ Equity Agenda and Action Plan that was created to help guide priorities to advance health equity. This commentary addresses two interrelated articles, written by Chisholm et al.The emerging focus on the quality of and access to health care at the turn of the 21st century was embraced by the Agency for Healthcare Research and Quality (AHRQ) who in 2003 started to formally track disparities in health care delivery as it relates to racial and socioeconomic factors in priority populations. This formal tracking of disparities played a critical role in developing the evidence base for health systems to improve and advance their ability to provide the best care to all of us. Spurred by the Coronavirus 2019 (COVID‐19) pandemic and the 2020 murder of George Floyd, the US health care system faced a social and health equity justice movement. This movement emphasized the role of racism and the inequitable distribution of the social determinants of health (SDoH), the broad set of forces and systems shaping the conditions of daily life, as major driving forces in health disparities and major root causes in the racial and ethnic disparities in the access to and quality of health care. In 2022, AHRQ sponsored a Health Equity Summit to bring together multiple working groups from the 2021 2Chisholm et al.Jindal et al.Together, these articles reflect the importance of how addressing inequities in access to and quality of health care must be done with consideration of systemic racism and intersectionality, and emphasize the importance of high‐quality research to inform equitable health care delivery.These outcomes and recommendations from the AHRQ's 2022 Health Equity Summit help to more optimally position AHRQ to address inequities in access to and quality of health care, created and once again perpetuated by legal decisions during this time of potential new limits in tools we have available to achieve equity. The importance of a focus on the SDoH as a pathway through which racism works is critical given the potential implications of the new Supreme Court rulings, which state that universities can consider “an applicant's discussion of how race affected his or her life, be it through discrimination, inspiration, or otherwise.”3AHRQ's Health Equity Summit was prescient in its timing, preceded two major landmark events with major implications for the health equity landscape—the recent Supreme Court rulings , which have ended affirmative action in college admissions and yet allowed discrimination based on free expression despite public accommodation laws. These rulings do not mean that racial and ethnic or other identity‐based inequities no longer exist, particularly with regard to health. However, these rulings limit the approaches that can be used to address health inequities, particularly those focused on health workforce composition or regulations requiring equal provision of service. We will collectively need to innovate to ensure that health systems have the appropriate research findings and data to implement requisite solutions to reduce health disparities and improve health equity. This is why a focus by AHRQ explicitly on equity in access to and quality of health care will be critical, as AHRQ can be the driver for necessary health equity innovation through its research agenda and funding priorities.Some have argued that health care organizations are not well equipped to take on many of the root causes of health disparities such as inequities in the allocation of social determinants of health (SDoH).However, to truly reverse many of the structural and longstanding issues that underpin health inequities, AHRQ will need to directly partner more closely with affected communities.4Ensuring health equity is critical for all of us in the care we receive from health care delivery systems, especially the components that affect our ability to access care. Implementation of these proposed approaches for AHRQ to infuse its research agenda would be important steps toward achieving health equity.Dr. Ong receives relevant funding from the Agency for Healthcare Research and Quality (K12 HS026407) and the Department of Veteran Affairs Health Services Research & Development (CIN 13‐417). Dr. Norris receives relevant funding from the National Institutes of Health .


Rapid assessment of avoidable blindness (RAAB) is a population-based survey methodology that is designed to provide a simple and affordable – yet reliable – estimate of the prevalence and causes of vision impairment and blindness among people aged 50 years and older in a defined population. RAAB is therefore an important tool in achieving the global eye health priorities set out by the World Health Organization's World Report on Vision and the Lancet Global Health Commission on Global Eye Health.,RAAB surveys provide the majority of the data used to estimate the global and regional prevalence and causes of vision impairment, as well as data which are vital for tracking progress towards eye health within universal health coverage, such as effective cataract surgical coverage and effective refractive error coverage.www.raab.world) collates RAAB survey results and datasets and makes them available for secondary analyses; data from 118 of the 330 RAABs carried out since 2000 have has been made available for this purpose. We encourage more RAAB survey principal investigators and data owners to share their data via the repository, so that the global eye health community collectively can have a more comprehensive and powerful evidence base for research and advocacy.The RAAB repository (


In our study  we reconVariations in monsoon moisture supply are a crucial physical process to disentangle, and isolating the influence of atmospheric black carbon  is a welWhile the study of Yang et al.  demonstrThe rapid decline of glaciers in the Southeastern Tibetan Plateau threatens the sustainability of its water resources, and understanding these two complementary drivers will help to design mitigation measures and refine projections of glacier and hydrological changes.


Standardization Is Necessary in the Methods to Assess the Value of Electronic Prescribing Systems In the May 2005 issue of JMCP, we reported that an electronic prescribing system with integrated clinical decision support was effective at improving prescribing behavior and lowering prescription costs. In contrast, Ross et al. reported in the June 2005 issue of JMCP that a different electronic prescribing system  had no impact on generic drug utilization or formulary compliance.


Individuals with schizophrenia exhibit severe speech and Theory of Mind (ToM) deficits creating substantial handicaps for them on the level of communication and interpersonal skills. Consequently, these individuals cannot adequately take part in social life, and are exposed to marginalization in all aspects of life. Hence, communication impairments associated with schizophrenia are a central issue to investigate in order to optimize their quality of life and functioning in society. The study being part of an interdisciplinary research is based on guided interviews related to a short story by Hemingway. The analysis of person deictic expressions related to social emotions and social interactions combined with the most frequently used mental state terms  identified in the corpus may not only describe the severity of linguistic disturbances indicating ToM deficits but can also help understand patients’ social dysfunction and difficulties in the context of social cohesion.The primary task of the functional linguistic research is to identify and classify the occurrence of linguistic disturbances during mentalizing processes expressed via mental state terms. The study particularly focuses on interpersonal relations expressed with person deictic forms that may indicate the difficulties of this patient group with social cohesion.The End of Something. The interviews were digitally recorded and transcribed in Hungarian. The qualitative analysis was performed with Sketch Engine corpus analysis tool, which assisted in the identification and classification of collocations associated with the interviewees’ mental processes directed at interpersonal relations expressed by person deictic forms.The corpus involves 40 guided interviews including 20 individuals with schizophrenia treated at the Department of Psychiatry of the University of Pécs and 20 controls. The interviews were conducted by a PhD student of Psychology in Hungarian and centred around Hemingway’s short story entitled ‘I don’t know’ combined with person deictic expressions revealed that individuals with schizophrenia have difficulty attributing mental states to a specific linguistic utterance during a social situation (e.g. ‘I don’t know why somebody said that’). These examples show that their communicative and interpersonal skills are substantially impaired.Pragmatic processes including the communicative aspect showed severe deficiencies. The most commonly used mental state term The findings can offer some possible indications for psychotherapists how to detect pragmatic impairments in schizophrenic speech and interpret mental state terms with reference to social interaction, thereby contributing significantly to therapeutic success enhancing the social reintegration of individuals with schizophrenia.None Declared


Frontiers in Cell and Developmental Biology presents an exciting series of articles encompassing significant developments in the application of Pluripotent Stem Cells (PSCs) to the treatment of ophthalmological diseases. Diseases affecting the retina and its associated innervation present significant societal challenges since treatments are frequently limited to symptom management and slowing the progression of the disease rather than affecting a complete cure. Conditions such as Age-Related Macular Degeneration (AMD) characterised by declining functions of both the retinal pigment epithelium and neural retina, and Glaucoma which involves dysfunction of retinal ganglion cells and the optic nerve, currently affect approximately 280 million individuals worldwide. Without the means to repair the damage to retinal structures, the impact of these diseases will worsen as the numbers of older individuals in the global population increases; thus the costs of disease management are likely to rise significantly. In view of these sobering observations, the number research efforts aimed at increasing our understanding of retinal degeneration and developing methods to ameliorate the decline are encouraging.Rohowetz and Koulen in this Research Topic is exciting since it provides a highly informative review of the current state of the art in RPE transplantation. A key point arising from this publication is that the safety of RPE transplant seems to be promising and that adverse events arising during the procedure are more likely related to surgery induced damage or to the need for immunosuppression which indicates the need for more precise HLA matching; however, an alternative strategy to eliminate the need for immunosuppression might be to generate RPE cells from “hypoimmunogenic” iPSC lines in which the assembly of the MHC-I major histocompatibility complex at the cell surface is inhibited by homozygous knockout of the gene encoding β-2-microglobulin . Of particular value is the light responsiveness of organoid photoreceptors (in vivo retinogenesis and restate disease phenotypes seen in patients (Völkner et al. to this series is valuable because it further optimises the process of retinal organoid generation which will be of considerable use to other groups in this field. The last publication in this series published by Wahlin et al. explores early retinal development by introducing markers of eye field development that may be used to distinguish those cells that have committed to a retinal development fate from those that may be forming cells that contribute to other regions of the CNS.The remaining two papers in this series add to our understanding of pluripotent stem cell derived retinal organoid development. This is an important enquiry since many of the cell types generated in 3D retinal organoids show more advanced maturity than those generated by 2D differentiation protocols (with the exception of eceptors  which unpatients . NaturalOverall, we have enjoyed reading these incisive articles and we hope that the reader will draw the same level of inspiration and enjoyment from this special series highlighting the great contributions of pluripotent stem cells to the understanding and potential treatment of eye diseases.


In a review of UK-supported clinical trials more than half of the investigators asked the funding agency for an extension and a third did not hit their recruitment targets . Study fPreviously we investigated the requirements of clinical and protocol development experts for a system to support trial design and recruitment. We developed a software architecture which addresses their primary concerns: preservation of consent for consent; improving the efficiency of the trial design process and automation of as much as possible of the recruitment workflow . The FARWe have worked with local clinical research organisations to evaluate FARSITE, running recruitment criteria for on-going clinical trials through FARSITE and comparing our estimates of numbers of patients eligible for the trial with the trials’ actual recruitment rates. A strong correlation was observed between protocols with a low FARSITE recruitment estimate and trials struggling to recruit participantsWe have shown that FARSITE can improve the speed and efficiency of clinical trials feasibility, allowing researchers to quickly assess the feasibility of trials in advance.


Crude and fractionated Xenopus egg extracts can be used to provide ingredients for reconstituting cellular processes for morphological and biochemical analysis. Egg lysis and differential centrifugation are used to prepare the crude extract which in turn in used to prepare fractionated extracts and light membrane preparations. Current Protocols in Cell Biology.The complete text protocol for this experimental approach is available in


This research is concerned with the peristaltic flow of third order nanofluid in an asymmetric channel. The governing equations of third order nanofluid are modelled in wave frame of reference. Effect of induced magnetic field is considered. Long wavelength and low Reynolds number situation is tackled. Numerical solutions of the governing problem are computed and analyzed. The effects of Brownian motion and thermophoretic diffusion of nano particles are particularly emphasized. Physical quantities such as velocity, pressure rise, temperature, induced magnetic field and concentration distributions are discussed. Peristaltic motion is now an important research topic due to its immense applications in engineering and physiology. This type of rhythmic contraction is the basis of peristaltic pumps that move fluids through tubes without direct contact with pump components. This is a particular advantage in biological/medical applications where the pumped material need not to contact any surface except the interior of the tube. The word “peristalsis” comes from a Greek word “Peristaltikos”which means clasping and compressing. The peristaltic flow has specific involvement in the transport of urine from kidney to the bladder, chyme movement in gastrointestinal tract, movement of ovum in the female fallopian tubes, blood circulation in the small blood vessels, roller and finger pumps, sanitary fluid transport and many others. Latham Heat transfer in cooling processes is quite popular area of industrial research. Conventional methods for increasing cooling rates include the extended surfaces such as fins and enhancing flow rates. These conventional methods have their own limitations such as undesirable increase in the thermal management system's size and increasing pumping power respectively. The thermal conductivity characteristics of ordinary heat transfer fluids like oil, water and ethylene glycol mixture are not adequate to meet today's requirements. The thermal conductivity of these fluids have key role in heat transfer coefficient between the heat transfer medium and heat transfer surface. Hence many techniques have been proposed for improvement in thermal conductivity of ordinary fluids by suspending nano particles in liquids. The term “nano” introduced by Choi The aim of present study is to venture further in the regime of peristalsis for fluids with nanoparticles. Therefore we examine here the mixed convective peristaltic transport of third order nanofluid in an asymmetric channel. Channel asymmetry is produced by peristaltic waves of different amplitude and phases. Mathematical modelling involves the consideration of induced magnetic field, Brownian motion and thermophorsis effects. Numerical solution of nonlinear problem is obtained using shooting method. Limiting case for viscous nanofluid in symmetric channel is also analyzed. Detailed analysis for the quantities of interest is seen.Extra stress tensor Consider third order nanofluid in an asymmetric channel of width To facilitate the analysis, we introduce the following transformations between fixed and wave framesThe dimensionless boundary conditions are given byOur main interest in this section is to examine the velocity (This subsection illustrates the behavior of emerging parameters The variations of or  and  –13.Effect of heat transfer on peristalsis is shown in the Influence of mass transfer on peristalsis is shown in the The variations of Trapping phenomenon is shown in the A detailed analysis is presented for peristaltic transport of third order nanofluid in an asymmetric channel with an induced magnetic field and mixed convection. The main findings of the presented study are listed below.Pumping rate increases with Velocity distribution is increasing functions of Deborah number at the centre of channel. Absolute value of axial velocity and pressure rise in third order nanofluid is larger than viscous nanofluid.Influence of Temperature distribution is an increasing function of Brownian motion parameter (Induced magnetic field increases with


The recent development and implementation of a catheter-based approach to denervate the renal sympathetic nerves in patients with resistant hypertension has ensured that the sympathetic nervous system (SNS) remains on center stage in cardiovascular medicine (Krum et al., Sympathetic neural drive is dependent on a range of factors including race, sex, and age. This idea is developed further in the review of Fu  who poinThree articles acknowledge the limitations of multiunit MSNA and emphasize the increased information associated with recording single unit MSNA. Single unit recording is technically more difficult; however, it provides a more precise description of the way vasoconstrictor neurons behave during a sympathetic burst. Upon our previous findings, we (Lambert et al., The SNS has long been recognized to play a central role in cardiovascular regulation, and targeting sympathetic activity is certainly a therapeutical approach in the treatment of many cardiovascular diseases. Thus, a reliable tool to assess SNS activity such as microneurography remains essential in order to comprehend the physiological mechanisms underlying disturbed SNS activity and to assess the effects of therapeutical strategies. It is anticipated that assessment of both multiunit and single unit will remain central in future investigations related to cardiovascular health.


In humans the two cerebral hemispheres have essential roles in controlling the upper limb. The purpose of this article is to draw attention to the potential importance of ipsilateral descending pathways for functional recovery after stroke, and the use of non-invasive brain stimulation (NBS) protocols of the contralesional primary motor cortex (M1). Conventionally NBS is used to suppress contralesional M1, and to attenuate transcallosal inhibition onto the ipsilesional M1. There has been little consideration of the fact that contralesional M1 suppression may also reduce excitability of ipsilateral descending pathways that may be important for paretic upper limb control for some patients. One such ipsilateral pathway is the cortico-reticulo-propriospinal pathway (CRPP). In this review we outline a neurophysiological model to explain how contralesional M1 may gain control of the paretic arm via the CRPP. We conclude that the relative importance of the CRPP for motor control in individual patients must be considered before using NBS to suppress contralesional M1. Neurophysiological, neuroimaging, and clinical assessments can assist this decision making and facilitate the translation of NBS into the clinical setting. Reaching forward with the arm to manipulate objects with the hand is a quintessential function for higher order primates. Upper limb movements involve a fine balance between proximal stability and distal dexterity, presenting a unique motor control challenge to the central nervous system. There is a growing body of evidence that skilled upper limb function is under the control of both contralateral (cM1) and ipsilateral (iM1) motor cortices  provide objective information about corticospinal tract integrity. TMS and DWI can be used in combination with clinical measures to predict the potential for recovery of function with rehabilitation (Stinear et al., It is becoming increasingly clear that skilled function of the upper limb relies on the balance of excitability of cM1 and iM1 in healthy adults. In this article we propose a neurophysiological model of ipsilateral neural control of the proximal upper limb via the CRPP. The model highlights the importance of understanding how the degree of compensatory activity in the contralesional hemisphere after stroke contributes to paretic upper limb function across a range of impairment levels. It is proposed that NBS protocols are not “one size fits all” and should be carefully selected based on individual patient characteristics. Research has targeted the development of structural and functional biomarkers that can be combined with clinical tests to allow NBS to be individually prescribed as an adjuvant to therapy after stroke. These methods of patient stratification based on objective measures of impairment should be used to determine the optimum intervention in future studies of NBS in stroke. Individualization may increase effectiveness of NBS in clinical trials and expedite translation from research laboratory to the clinical setting.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.


This article introduces the concept of ‘cognitive comorbidity,’ which lays emphasis on common cognitive deficits that cut across different disorders. The concept is illustrated with the help of two commonly reported overlapping conditions (autism and epilepsy). It is further explained by concentrating on two important cognitive processes of facial emotional recognition and emotional memory, shown to be compromised in both conditions; and their underlying neural substrates. Cognitive comorbidity is then contrasted with ‘comorbidity,’ a term which is more commonly used for describing cognitive disorders. The paper closes by providing directions for rehabilitative and theoretical efforts that could be inspired by the newly introduced concept. This article aims to introduce and understand the concept of ‘cognitive comorbidity’ and differentiate it from the more common usage of the term ‘comorbidity’. The current paper strives to achieve this aim by describing the overlapping symptoms of autism and epilepsy. These two disorders are chosen as examples because of the high rate of association between the two . This article is not an attempt to discuss the comorbidity between these two disorders in the technical sense of the word “comorbidity,” as it is described in scientific literature but to discuss and highlight the overlap of cognitive deficits. All through, the focus will be on cognitive processes and references to brain/neural structures are provided to advance understanding of the concept. This way of explanation is hoped to be a better method from the viewpoint of theoretical formulations and would also help to throw light on the issue of “comorbidity,” the way it is described in the scientific literature. Therefore, first the description of comorbidity is given, which is followed by a brief introduction to the disorders.Fried, Ferrucci, Darer, Williamson & Anderson (2004) explain comorbidity as, “the concurrent presence of two or more medically diagnosed diseases in the same individual, with the diagnosis of each contributing disease based on established, widely recognized criteria”.The DSM-IV defines autism as a disorder with impairments in socialization, imagination and communication with stereotyped repetitive interests . Autism is a prototypical example of autism spectrum disorders (ASD). The term ASD is used to define life-long developmental disorders of the brain with variable severity . Approximately one-third of the children on the autism spectrum are shown to develop epilepsy .Epilepsy is defined as two unprovoked seizures of any kind that result from genetic defects, due to diffuse or focal pathology in the brain, or due to an unknown cause. Thus seizures due to trauma, infection or metabolic illness are not defined as epilepsy .et al. 2004; Beversdorf et al. 1998; Paesschen et al. 1996). Two most important tasks that have been conducted to demonstrate the cognitive deficits are facial emotion recognition and emotional memory task. Facial emotion recognition and emotional memory are hypothesized to be dependent upon the integrity of functional connections between amygdala and the fusiform cortex  and between amygdala and the hippocampus respectively . Consistent with the hypothesized relations, Brierley et al. (2004) showed inefficient performance by patients suffering from epilepsy and amygdala damage on the two tasks. Their emotion recognition task dealt with perception of affect from faces and voices while the emotional memory tasks dealt with narratives and novel word recognition. There was also a lack of association between the emotional memory and the emotion recognition tasks, thus showing that these two are different cognitive processes.The neurobiology of autism and epilepsy, especially temporal lobe epilepsy, can be similar; that is, the integrity of the amygdala has been found to be compromised in both the disorders; and various cognitive tasks conducted on people inflicted by both of these separately reflect this compromised integrity  also proposed two different neural connections responsible for supporting performance on the two tasks where deficits in facial emotion recognition could arise due to disruptions of connections from the amygdala to the fusiform cortex, and problems on the emotional memory task could arise due to disruptions of connections from the amygdala and hippocampus. Similar performance deficits are also shown by the autistic subjects of Beversdorf et al. (1998) on an emotional memory task. Beversdorf and colleagues presented emotional sentences and coherent/incoherent stories and word lists to their autistic and normal subjects. Autistic and normal individuals showed comparable performance on recalling coherent/incoherent word lists and stories but differed only with respect to recalling emotional sentences, with the autistics remembering lesser number of emotional sentences. Deficits of emotional facial recognition have also been observed for autistics where they showed normal performance on a facial discrimination task but impaired performance on emotional facial recognition task . These results put together show that the two cognitive processes can be disturbed in both the disorders.Brierley This paper makes an initial attempt to highlight the common cognitive processes that might be disturbed in both the conditions giving a possible clue to the comorbidity, in this case, cognitive comorbidity. The paper does not go into the details of different types of autistic spectrum problems or different types of epilepsies as the aim is to highlight broad cognitive processes that could be disturbed. It only concentrates on the common neural and cognitive substrates. By highlighting the issue of cognitive comorbidity, the paper is a step in the direction of encouraging researchers to investigate such issues by looking at the overlap of cognitive deficits between disorders and not to emphasize “comorbidity” based on the incidence rate of the disorders.The previous sections show that emotional memory and emotional facial recognition could be disturbed in a similar manner in both the disorders despite the fact that these two disorders are totally different from each other. In order to provide direct support for the concept of cognitive comorbidity, we need studies that concentrate on examining the performance of both autistics and individuals with epilepsy on these tasks in the same study so that direct comparisons could be drawn. In its current state, the concept of cognitive comorbidity could only be indirectly supported with findings from separate studies and thus future studies need to be planned not only on these two disorders but other similar cases of disorders that have been reported in the literature as comorbid or associated disorders; for instance, attention deficit hyperactivity disorder (ADHD) and tics.Research directed at theories of cognitive disorders and cognitive rehabilitation would save precious efforts if guided by the concept of cognitive comorbidity as this would discourage separate research attempts focusing on different disorders and would definitely go a long way in encouraging coordinated efforts at understanding the overlapping cognitive deficits that cut across the different categories of disorders. It becomes a lot easier to explain the nature of cognitive functions that are disrupted in a similar manner across different disorders but it is difficult to explain these disruptions across two different disorders especially when the current thrust of the field is to place disorders into separate categories. Emphasizing on cognitive comorbidity also helps one apply precious successful attempts of rehabilitation designed to address an underlying cognitive deficit across the disorders but this can only be done when it is known that similar cognitive processes are disturbed. To come up with different rehabilitation programs for different disorders can be very costly, especially if one follows the strategy of placing these into different categories as this can happen at the cost of ignoring the common underlying cognitive substrates.Current article highlights the concept of cognitive comorbidity by elucidating the differences and similarities between autism and epilepsy. The hypothesis still requires direct comparison of patients suffering from both autism and epilepsy on the commonly disturbed processes that support emotional memory and emotional facial recognition. Direct comparison in this manner will not only be helpful in providing support for the cognitive comorbidity hypothesis but will also help us understand the common underlying symptoms that might be important and hence could be targeted commonly across the disorders. This will help us save previous time and resources deployed for treating different disorders separately. For instance, if research shows that emotional memory and facial emotional discrimination are commonly disturbed in both autism and epilepsy, one single intervention strategy (e.g. cognitive rehabilitation program) could be easily designed for autistics and patients of epilepsy. Providing support for cognitive comorbidity might not work well with researchers and clinicians who are looking for more discrimination among the disorders for the purpose of classification and distinction among various categories but this concept could potentially work well for therapists who deal with many patients and suffer from time constraints. Efforts directed at cognitive comorbidity will work well with patients and their families who are not happy to be tagged by some diagnostic label or the other.It is hoped that future work in this direction can be instrumental in stimulating research and highlighting other such overlaps that will be ultimately useful in constraining theories about cognitive processes and also trimming diagnostic criteria and saving precious resources geared towards interventions.This article makes an attempt to highlight the cognitive comorbidity between autism and epilepsy where the structural and the functional integrity of the amygdala is compromised. Hence, there are similar cognitive deficits in both the disorders observed on two tasks, namely, facial emotion recognition and emotional memory, which are supported by the amygdala. Work also shows that these two cognitive processes are not correlated with each other and either both or one of them can be disturbed in autismNone declared.This work or parts of it are not published anywhere else.How can the concept of cognitive comorbidity be extended to other cognitive disorders?How can clinicians save on precious resources by developing the concept of common disturbance among disorders and develop intervention techniques accordingly?How well can this concept of cognitive comorbidity be integrated into popular classifications like the DSM?Should we altogether abolish placing cognitive disorders into various classifications and only focus on overlapping cognitive profiles? http://www.jspsciences.org and as the editorial member of the New School of Psychology Bulletin www.nspb.netNeha Khetrapal is currently a graduate student at the Centre of Excellence “Cognitive Interaction Technology” (CITEC) and the Faculty of Psychology and Sport Sciences, investigating the interaction of spatial processes and language and is supported by Deutsche Forschungsgemeinschaft (DFG) grant managed through the Graduate School of CITEC, Germany. She has been a holder of various awards, and the most important recognition earned by her is from Marquis Who’s Who in the World for 2009. The author also serves currently as the reviewer for Journal of Social and Psychological Sciences


Tracheostomy is common in the acute care facility today. The care for these patients is challenging for the nurses in the ward where knowledge and skill is tested and often lacking resulting in emergency shift of these patients to ICU. As we found it difficult to care for this group in the wards inspite of continous training, we decided to have a dedicated tracheostomy ward for patient safety and better outcome. As a part of training, this module on tracheostomy care was developed by the medical ICU nurses.Tracheostomy is common in the acute care facility today. The care for these patients is challenging for the nurses in the ward where knowledge and skill is tested and often lacking resulting in emergency shift of these patients to ICU. Often chronic patients tend to be overlooked in Infection control practices (ICP)aspect. This leads increased Health care associated infections (HAI) along with increased morbidity & mortality.To reduce the HAI in tracheostomy patients by ensuring proper infection control practices implementation by effective training module.As we found it difficult to care for this group in the wards inspite of continous training, we decided to have a dedicated tracheostomy ward for patient safety and better outcome. As a part of training, a module on tracheostomy care was developed by the medical ICU(MICU) nurses. Infection control issues are discussed in these patients as they are patients on long term care All the sisters who take care of patients having Tracheostomy are educated with the help of this audio visual medium. Also hands on training is provided with the help of a mannequin.The care is improving in these patients. This is reflected in lower HAI rates and decrease in number of patients returning to the ICU’s from wards with tube blocks and aspirations.Continuous training is the most important part for sustaining ICP in a healthcare setup. We identified the tracheostomy patients as those falling in the high risk category for HAI. We could successfully train our sisters and implement the tracheostomy care practices and bring down the HAI rates.None declared.


Gloucestershire Learning Disability Partnership is a collaborative service of NHS Gloucestershire and Gloucestershire County Council. It serves over 2500 people with a learning disability and is currently working to incorporate telecare and telehealth into its mainstream services. We believe this proposed presentation would fit under the Developing Applications at Scale category. The Partnership Commissioners recognising the internal barriers to effecting telecare and telehealth applications commissioned a service from external providers which substantially improved service and reduced costs as compared with in-house telecare assessments and implementation. A new partnership was established with two external providers: Allied Health care/Tunstall. Their work is exemplified in the attached case study. The Learning Disability Partnership is now able to commission the evaluation of requirements, establishing the baseline and effecting the necessary changes in a continuous stream. This is now being rolled out across the county for learning disability services.The barriers to success: the internal barriers which prevented telecare and telehealth from happening. How we get in our own way to making change happen.How we commissioned around the barriers and achieved success.The case study and other examples of significant service improvements and savings.The next generation:At the front end of services the partnership is now actively using teleprompting, geofencing and GPS systems to facilitate the enablement of people with a learning disability and enhance their abilities to be independent. Service users express delight in having control of their own lives versus having ‘support workers’ follow them around (DVD available).Q and A. The main presenter would be Chris Haynes, an accomplished international speaker winner of the Queens Golden Jubilee Medal for Public Service and currently Joint Commissioner of Learning Disability Services.The presentation would follow the following format:There will be representatives from Allied and Tunstall on hand to discuss their involvement and how it works.


The exhaled breath of more than four hundred patients who presented at the Environmental Health Center – Dallas with chemical sensitivity conditions were analyzed for the relative abundance of their breath chemical composition by gas chromatography and mass spectrometry for volatile and semi-volatile organic compounds. All presenting patients had no fewer than four and as many as eight co-morbid conditions. Surprisingly, almost all the exhaled breath analyses showed the presence of a preponderance of lipophilic aliphatic and aromatic hydrocarbons. The hydrophilic compounds present were almost entirely of natural origin, i.e. expected metabolites of foods. The lipophile, primarily C3 to C16 hydrocarbons and believed to have come from inhalation of polluted air, were, in all cases, present at concentrations far below those known to be toxic to humans, but caused sensitivity and signs of chemical overload. The co-morbid health effects observed are believed to be caused by the sequential absorption of lipophilic and hydrophilic chemicals; an initial absorption and retention of lipophile followed by a subsequent absorption of hydrophilic species facilitated by the retained lipophile to produce chemical mixtures that are toxic at very low levels. It is hypothesized that co-morbid conditions in chemically sensitive individuals can be predicted from analysis of their exhaled breath. All of these patients presented with between four and nine co-morbid conditions. It was anticipated that the chemical compositions and concentrations of these chemicals in the exhaled breath could be predictive of chemical sensitivity and other co-morbid conditions.Of the more than 400 patients, the records of thirty randomly chosen individuals were selected for detailed study. These individuals ranged in age from 12 to 86 years with a median age of 47.7, and 70% were female. Between 40 and 120 chemicals were identified in the exhaled breath of each patient. As the concentrations of all were low ( in the part per billion range), the top 20 in abundance were taken as significant for potential impact. The presenting patients who were analyzed for relative abundance all had between 4 and 9 distinct points of impact of the chemicals in their bodies and all had exhibited signs and symptoms of chemical sensitivity. The breath analysis samples were collected in a less polluted environmentally controlled room by the methods of Rea and Phillips Rea . Air colThe compounds found in the exhaled breath of these patients were almost exclusively exogenous lipophilic C3 to C16 aliphatic and aromatic hydrocarbons. Hydrophilic compounds were almost all endogenous. The concentrations measured were orders of magnitude lower than the known toxic levels of these species. The abundances of the top 6 at times were relatively high, in the 200–1000 part per billion (ppb) range, but still far below the known toxicity levels for these compounds.Since almost exclusively lipophilic exogenous compounds were identified in the analysis and because of the similar toxicological properties of these compounds, the lipophils were considered as additive and treated as such.et al., et al., et al., et al., All presenting patients had nervous systems and immune system impacts and most had respiratory, cardiovascular and gastrointestinal impacts as well. All had a minimum of 4 and a maximum of 9 different systems affected. et al., et al., It should be noted that lipophilic hydrocarbons are not known to attack any of the systems listed above with the exception of the nervous system, but the nervous system is not known to be impacted by these compounds at the low levels found  exhaled butane and one exhaled propane, despite the fact that those species were not present in ambient air.It was anticipated that certain organ/system effects could be associated with specific exhaled chemical species. Though all patients exhibited multiple system effects, this did not turn out to be the case. Essentially no exogenous hydrophilic chemicals were found in the exhaled breaths of the study group. Numerous lipophilic hydrocarbons, however, including the very low molecular weight propane and butane were exhaled by patients despite not being present in the air gradients of the room in which these individuals were studied.et al., et al., It is hypothesized that the finding of lipophilic hydrocarbons in the alveolar air of individuals with zero values recorded for their ambient less polluted room air gradients is indicative of relatively long term retention of these chemicals. This hypothesis is consistent with the known toxicology of these chemicals, i.e. that they are metabolized/eliminated much more slowly than hydrophilic species  and tobacco smoke. The results presented here suggest that chemically sensitive individuals should avoid exposures to these sources as much as possible.Members of the subject study group were found to have numerous systemic ill health effects triggered by chemicals and having one of their diagnoses as Chemical Sensitivity. Their exhaled breath analysis revealed the presence of a preponderance of low level lipophilic hydrocarbon species, that alone are believed to be of very low toxicity, and essentially no exogenous hydrophilic species. The ill health effects induced are believed to be caused by the establishment of a steady state lipophilic layer on body membranes and subsequent exposure to toxic hydrophilic species results in the lipophile facilitated absorption of hydrophilic species that would otherwise not be absorbed. This sequential absorption of chemical mixtures is believed to be responsible for the onset of environmentally induced systemic effects in people. The presence of exogenous lipophilic chemicals in the exhaled breath of chemically sensitive individuals is believed to be predictive of neurological, immunological, respiratory, cardiovascular, gastrointestinal and other health effects in such people.These findings point out the need to limit environmental exposures to lipophilic chemicals even at levels far below their current permissible exposure levels (PELs). It is also recommended that PELs for chemical toxicants be reduced by at least one order of magnitude and that air and water pollution allowable concentrations likewise be significantly lowered.


The purpose of this viewpoint is to provide rationale for the cellular investigation of blood flow restriction (BFR) in the absence of exercise, as this may provide a novel insight into the mechanisms exclusive to the restriction stimulus itself. Most of the research on BFR thus far has been completed with BFR in combination with low intensity resistance training. To illustrate, BFR in combination with low intensity exercise has consistently been observed to result in improvements in muscle size and function  activity observed with low intensity resistance exercise combined with BFR are greater than those observed with resistance exercise alone (Takarada et al., Many hypotheses exist for the mechanism behind the beneficial effects observed with BFR; however it may be necessary to research the effects of BFR in the absence of resistance exercise in order to allow for a clearer picture of what is physiologically occurring with the BFR stimulus itself. We would like to suggest that acute muscle swelling may be the mechanism behind the reductions in muscle size and strength declines observed following surgery or cast immobilization. In addition, this swelling may also help explain the increases in muscle size and strength previously observed from slow walking in combination with BFR (Abe et al.,