The presence of lymph node metastasis is a key prognostic factor in colorectal cancer and lymph node yield is an important parameter in assessing the quality of histopathology reporting of colorectal cancer excision specimens. This study assesses the trend in lymph node evaluation over time in a single institution and the relationship with the identification of lymph node positive tumours. It compares the lymph node yield of a contemporary dataset compiled from the histopathology reports of 2178 patients who underwent surgery for primary colorectal cancer between 2005 and 2012 with that of a historic dataset compiled from the histopathology reports of 1038 patients who underwent surgery for colorectal cancer at 5 yearly intervals from 1975 to 2000. The mean lymph node yield was 14.91 in 2005 rising to 21.38 in 2012. In 2012 92.9% of all cases had at least 12 lymph nodes examined. Comparison of the mean lymph node yield and proportion of Dukes C cases shows a significant increase  in lymph node yield while there is no corresponding significant trend in the proportion of Dukes C cases . This study shows that there is increasing yield of lymph nodes from colorectal cancer excision specimens. However, this is not necessarily associated with an increase number of lymph node positive cancers. Further risk stratifying of colorectal cancer requires consideration of other pathological parameters especially the presence of extramural venous invasion and relevant biomarkers. Detection of metastasis in tumour-associated lymph nodes has a highly significant effect on prognosis in patients with colorectal cancer. All patients with one or more lymph nodes displaying metastasis are upstaged to Dukes C/stage 3 disease. This has important therapeutic consequences for a patient, as all these patients are considered for treatment with adjuvant chemotherapy. It is generally considered and accepted that examining more lymph nodes in a colorectal cancer excision specimen increases the likelihood of identifying involved lymph nodes and thus upstaging the cancer. However, recent studies have provided some contrary evidence. Data collected from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database for 86,394 patients showed that while the number of lymph nodes being evaluated increased over time but that this did not significantly increase the detection of node positive cancers. These recent studies appear to contradict the hypothesis that examining more lymph nodes increases the detection rate of node positive disease. Nevertheless the studies by Parsons et al., Despite the variation in the published evidence, guidance and standards on lymph node yield have been introduced as a quality performance indicator for the histopathology reporting of colorectal cancer resections. Professional and regulatory bodies including The Royal College of Pathologists UK, Healthcare Improvement Scotland and American College of Pathologists have recommended the identification of a minimum number of lymph nodes from colorectal cancer resections as a standard and also as a quality performance indicator. This study assesses the trend in lymph node evaluation in a large cohort of over a thirty seven year period in a single centre and focuses on the trend in lymph node yield in comparison with the proportion of lymph node positive cases.This study included 3216 patients who had their colorectal cancer pathology reported by the Department of Pathology, Aberdeen Royal Infirmary from 1975–2012. The Department of Pathology at Aberdeen Royal Infirmary is the regional pathology centre serving three health authorities and four acute hospitals namely NHS Grampian , NHS Orkney  and NHS Shetland . Approximately 75% of the total volume of colorectal cancer surgery is performed at Aberdeen Royal Infirmary. Relevant pathological data was extracted from the pathology reports of the resected colorectal cancer excision specimens and two databases were constructed.The first database was compiled using prospectively collected histopathological data from colorectal cancers resected between 2005 and 2012. The information recorded in this database includes age, gender, year of operation, administration of neoadjuvant therapy, whether the tumour was screen detected, tumour site, tumour differentiation, tumour (T) stage, extramural venous invasion (EMVI), total number of lymph nodes examined, number of lymph nodes involved by metastatic tumour, nodal (N) stage and Dukes stage. Information for each parameter was available for every patient. This database is referred to as the contemporary dataset and the distribution of cases in this series is shown in The second database was compiled retrospectively from cases of colorectal cancers identified by searching the Department of Pathology computer database using the search terms ‘colon’, ‘rectum’ and ‘carcinoma’. Histopathology reports of colorectal cancers excised at 5 yearly intervals 1975, 1980, 1985, 1990, 1995 and 2000 were identified and reviewed. Information on patient age and gender, tumour site, tumour differentiation, T stage, N stage, total number of lymph nodes examined, total number of lymph nodes involved and Dukes stage were extracted from these reports (when stated) and used to assemble the database. When not explicitly stated Dukes stage was inferred from the information stated in the histopathology report regarding the depth of tumour invasion and lymph node involvement. This database is referred to as the historic dataset and the distribution of cases is shown in Both databases were compiled in Excel 2007 and then imported into IBM SPSS version 21 for Windows 7™  to perform data analysis. Linear trends for changes in lymph node yield and proportion of Dukes C cases with time were determined using Excel 2007 .The project was carried out using anonymised data and within the remit of ethics approval (ref. nos. 08/S0801/81) from the North of Scotland research ethics committee.The clinico-pathological parameters collected for the contemporary and historic datasets are summarised in The lymph node yield in the contemporary series of colorectal cancers is summarised in The frequency distribution of tumour stage in both the historic dataset and the contemporary dataset is shown in In the contemporary data set comparison of mean lymph node yield and proportion of Dukes C cases shows a highly significant year on year increase  in lymph node yield in contrast there is no significant trend in Dukes cases . This is true both for all colorectal cancers and also when potential confounding factors are excluded from the analysis including administration of neoadjuvant therapy, bowel cancer screening detected cases . Figure This large study from a single centre assesses the trend in lymph node evaluation over a thirty seven year period. It utilises both a contemporary dataset and a historic dataset to compare the effect of time and recent advances in colorectal cancer treatment, screening and pathological reporting on lymph node yield and involvement. It examines in detail the effect lymph node yield has on the detection of lymph node positive disease and hence colorectal cancer staging. All the data has been compiled from one centre thus minimising potential data collection and reporting bias.Factors that influence lymph node yield include patient, surgeon oncologist and pathologist and in designing this study it was important to consider key confounding factors to allow meaningful comparison of data especially between the historic dataset and the contemporary dataset. Histopathological reporting of colorectal cancers has greatly improved over the last 15 years driven by the introduction of guidelines and datasets for the reporting of colorectal cancer excision specimens and the parallel requirement for high quality pathology reporting as adjuvant and neoadjuvant therapy became recognized and established therapeutic options in the treatment of colorectal cancer. One of the key quality parameter in colorectal cancer histopathology is lymph node yield. The current Royal College of Pathologists UK colorectal cancer dataset recommends a mean of 12 lymph nodes and Healthcare Improvement Scotland quality performance indicator for colorectal cancer pathology is that greater than 80% of colorectal cancers should have 12 or more lymph nodes identified. Our data from the historic database shows that from 1975 to 2000 there is a higher proportion of Dukes B tumours and a lower proportion of Dukes C tumours compared to the tumours excised between 2005 and 2012 and this reflects the low lymph node yield per case and supports the concept of understaging of colorectal cancers when there is a low yield of lymph nodes. However in the current data set while there is a significant trend to increase lymph node yield this has not been reflected in an increasing proportion of Dukes C cases even when the confounding factors of neoadjuvant therapy and bowel cancer screen detected cases have been excluded from the analysis. The reasons for this are not apparent and have been observed in other series. Age distribution and anatomical site distribution of tumours within the colon both of which are other potential confounding factors do not appear to have significantly altered with time. Over the period of time from 2005–2012 pre-operative staging protocols have also remained constant. This may suggest that there may be a threshold for lymph node yield above which there is marginal benefit in identifying further lymph nodes.


Neocortex plays key role in diverse brain functions. Understanding this role involves the study of collective neural activity patterns under different situations, and how these patterns relate to the structural and functional organization of neocortex. Here we study the effect of synaptic plasticity on neural spiking activity patterns in a neocortical network model. We measure changes in neural spiking patterns due to changes in the strengths of the synapses connecting neurons and relate them to changes in the functional connectivity of the network as disclosed by graph-theoretic measures.Our neocortical network model was composed of excitatory and inhibitory neurons in the proportion of four excitatory cells for each inhibitory cell. Neurons were described by the Izhikevich model . The parWe determined a set of parameters for which the spiking activity generated in L4 by the external input propagated to the entire network. This network-wide activity was oscillatory, and we found that its mean frequency was higher for the network version with synaptic plasticity than for the version without synaptic plasticity. We also found that the formation of clusters of synchronous neural activity was facilitated in the case with LTS cells as inhibitory neurons. Our results suggest that synaptic plasticity may induce changes in the functional connectivity of the neocortical network with impact on its global activity.


Percutaneous interventions for cardiac disease are on the increase worldwide. Acute complications of interventions include vessel dissection, total occlusion, thrombosis etc. Other than the complications associated with the disease process and the disturbances to the vascular endothelium mechanical complications due to mishandling of or mishaps with the device itself can occur. These complications, though rare do occur and the cardiac surgeon has to deal with them often on an emergency basis.To assess the safety and efficacy of emergent surgery in patients who develop device related complications of PCI.We present 4 patients with coronary artery disease who had complications during angiogram and attempted angioplasty/stenting. In 1 patients the stent was inappropriately deployed and the patient required urgent surgery for stent retrieval. In one the ring tip of the angiography catheter dislodged in the coronary artery requiring emergency surgery and in a further two patients the guide wire broke in the circulation and had to be retrieved along with coronary artery bypass graftingIn another group of 3 patients there was mishandling of the ASD device requiring urgent retrieval and ASD closure. Devices were" lost" in the LA, in the RA and the other in the Pulmonary arteryIn 1 patient undergoing device closure of PDA the device was deployed before proper positioning and was brought down to the femoral artery using a bronchoscopic biopsy forceps and then retrieved surgically. In a further patient a PDA coil was "lost' in pulmonary artery, lodging in a small branch. The child underwent surgical closure of PDA. The coil could not be retrieved.In conclusion, urgent surgery is often required for device related complications of percutaneous devices. Surgery can be safely undertaken in these patients with gratifying results.Emergent surgery is lifesaving in patients with device related complications of PCI and can be safely carried out


Early phase trials of complex interventions currently focus on assessing the feasibility of a confirmatory RCT and on conducting pilot work. These trials are not designed to enable a formal assessment of potential efficacy. As a result, guidance recommends any statistical analysis of treatment effects conducted in these trials should be treated with extreme caution and not used in deciding if a confirmatory trial of the intervention is warranted. Phase II trial designs developed in the drug context offer a potential solution, providing methods for selecting sample size parameters for feasibility and pilot trials which will enable formal assessments of potential efficacy to be carried out. In this paper we will outline the challenges encountered in extending ideas developed in the phase II drug trial literature to the complex intervention setting. The prevalence of multiple endpoints and clustering of outcome data will be identified as important considerations, having implications for timely and robust determination of optimal sample size parameters. The potential for Bayesian methods to help to identify robust trial designs and optimal decision rules will also be explored.


In this session I will review the clinical and imaging features of the most common pediatric bone and soft tissue sarcomas and several benign lesions that may mimic them. These malignancies often have unique features that can help narrow the differential diagnosis. The material will be presented in an informal manner and audience participation is encouraged. A review of the appropriate diagnostic work-up will also be presented, including the role of various imaging modalities to detect local-regional and distant metastatic disease. At the end of this session participants should be able to identify clinical features  and imaging features that are suggestive of the correct diagnosis.


The main factor related to gingival/periodontal problems in disabled individuals is the inadequacy of the plaque removal from the teeth. Motor coordination problems and muscular limitation in neuromuscularly disabled individuals along with the difficulty in understanding the importance of oral hygiene in mentally disabled individuals have resulted in the progression of inflammatory diseases.This report describes a case of cerebral palsy child who developed gingival hyperplasia due to poor oral hygiene practices which remarkably improved by proper motivation and adaptation of oral hygiene measures.It is important that the caretakers especially mother is informed about the importance of maintaining proper oral hygiene and the harmful effects of not doing so. It forms our duty to guide them towards maintaining good oral hygiene and thereby help in improving overall health of these children. There are no differences in prevention of the diseases and the treatment modalities between these groups. The main factor related to gingival/periodontal problems in disabled individuals is the inadequacy of the plaque removal from the teeth. Motor coordination problems and muscular limitation in neuromuscularly disabled individuals along with the difficulty in understanding the importance of oral hygiene in mentally disabled individuals have resulted in the progression of inflammatory diseases.6Handicap is the loss or limitation of opportunities to take part in the normal life of the community on an equal level with others due to physical and social barriers.The following report describes a case of cerebral palsy child who developed gingival hyperplasia due to poor oral hygiene practices which remarkably improved by proper motivation and adaptation of oral hygiene measures.A male patient aged 6 years reported to Department of Pedodontics and Preventive dentistry, VS Dental College and Hospital, Bengaluru. Patient’s mother complained of severe bleeding from gums from past 1 week and inability of the child to eat. The child is known case of cerebral palsy with microcephaly and mental retardation with developmental age of only a few months . PatientOn intraoral examination, erythematous gingival overgrowth was noted on labial and palatal aspects of 54  and labiA detailed case history was taken and it was noted that the patients teeth were cleaned once daily by mother by wiping with a wet cloth. No brushing or use of any dentifrice was done from the beginning.Depending on clinical examination and based on the oral hygiene status of the patient, a provisional diagnosis of inflammatory gingival hyperplasia due to poor oral hygiene was obtained.Pediatric opinion on general state of patient was obtained and after performing all the necessary blood investigations, excision of hyperplastic gingiva in relation to 54 was planned and done under local anesthesia . The excMeanwhile, mother was educated regarding the importance of oral hygiene, method of brushing and other oral hygiene practices. Chlorhexidine mouth rinse was also advised and the surgical excision of the tissue in relation to 64 was deferred till the final diagnosis was obtained.The histopathological examination confirmed the diagnosis of inflammatory gingival hyperplasia secondary to poor oral hygiene status.Patient was recalled after 1 week for excision on the other side, i.e in relation to 64 but it was observed that there was spontaneous healing of the gingival tissues probably due to the oral hygiene measures adopted  and 6. T7 Thus, poor oral hygiene is perhaps more prevalent among mentally retarded persons compared to other indi-viduals.8 Many studies have found an inverse relationship between the levels of mental retardation and oral hygiene status; the lower the IQ score, the higher the oral hygiene index score.910 The provision and/or supervision of oral hygiene by parents have been reported to be lower for disabled children than for nondisabled children.11 This may lead to various complications like gingival and periodontal diseases, dental caries thereby affecting the nutritional status of the child.Oral hygiene practices are voluntary physical activities that have at least two requirements: Motivation and manual dexterity.1213 and also the lack of parental education and motivation leads to the development of gingival and periodontal diseases which thereby affects the nutrition status of these children. In this case report, the parents were from low socioeconomic background and were unaware of the importance of oral hygiene practices. No oral hygiene measures were being used or have been used which can be accounted for the gingival hyperplasia.The mechanical control of dental plaque in disabled individuals generally causes some difficulties, is found to be time-consuming, and sometimes ineffective14 As a result, chemical plaque control has been recommended as an alternative and adjunc-tive to mechanical plaque control in these special patient groups.15 The effectiveness of chlorhexidine (CHX) have widely been investigated in various patient populations, including the disabled, and the results have led CHX to be defined as the “gold standard.”20 The combination of mechanical and chemical plaque control seemed to be even more beneficial than only using a mouthwash.2122Various studies have shown that the effectiveness of manual and electric toothbrushes is limited by the manual dexterity and skill of the user.In the present case, spontaneous healing of the gingival hyperplasia was noted in just 1 week after the adoption of chemical (CHX) and mechanical plaque control measures.Particularly the education and motivation of parents, especially mother can be considered to be the main factor for the adoption of oral hygiene measures and improved oral hygiene status of the patient.Oral health problems in mentally disabled children may be because of the parental belief of a reduced importance of oral health in comparison to the over all scheme of health management or maybe more time is devoted to assist these children in other daily activities which are seen to be more important compared to their nondisabled counterparts. It is important that the caretakers especially mother is informed about the importance of maintaining proper oral hygiene and the harmful effects of not doing so. It forms our duty to guide them towards maintaining good oral hygiene and thereby help in improving overall health of these children.


Patient recruitment to clinical research is an important metric used to assess the effectiveness of research departments and decide resource allocation. The Mobile Workforce (MW) has been put in place to increase recruitment to haematology studies across the North Thames region.The NIHR North Thames division three has provided funding to employ a group of clinical trial practitioners and data managers. The team are employed by and based at large teaching hospitals and travel to other sites within the North Thames region to open and manage research studies with a high anticipated recruitment.The MW has recruited over 200 patients to research projects in its first year of operation. This has contributed to a rise in the North Thames LCRN's haematology recruitment from 512 in 2013-2014 to 851 in 2014-2015. The MW has encouraged senior clinicians to participate in research and has facilitated the set-up of new research projects. The MW has reduced the need for staff training and has allowed for greater flexibility in meeting staffing requirements.The MW has achieved a significant increase in study accrual during its first year. The MW has allowed previously unsupported sites to participate in research and has caused an increase in investigator interest in research. The NIHR seeks to replicate the approach across divisions and regions to provide an efficient and cost effective approach to study recruitment.


Ever since the first hematopoietic cell transplantation (HCT) was performed in 1960s, thousands of studies have elucidated the impact of patient and donor factors  on outcomes after the procedure. Fewer studies have looked at the role of center specific factors such as procedure volume, center experience or accreditation status in influencing the outcomes . MacroecIn this issue of EBioMedicine, Baldomero et al. present a retrospective population level analysis that examines the interplay of patient-, center- and country level factors on outcomes of allogeneic and autologous HCT using data from the European Society of Blood and Marrow Transplantation (EBMT) database . The autThe findings about the differential impact of macroeconomic factors on survival after autologous and allogeneic HCT are novel, but not surprising as these are two different types of procedures with different degree of medical complexity, risk and resource requirement. Even though the study is about HCT in Europe, it has wider implications. An important question it raises is ‘if one size fits all?’ for worldwide practice of HCT or for that matter, any expensive medical technology. Should the benchmarks for assessing the success of an expensive technology be different amongst different countries at diverse stages of socioeconomic development with different resource capacity ? The authors suggest streamlining and consolidation of the transplant activity to help maintain the quality of care and strengthening the overall health infrastructure to provide optimal pre- and post-HCT care. This proposition and a long term vision for the growth and sustainability of a transplant program may be more important for the poorer countries than the richer countries to help optimize the best utilization of the scarce resources. This is because the spending on health care especially on high cost medical technology is more likely to strain the government as well as individual household budgets in poorer countries as opposed to affluent countries. The bigger question is if the poorer countries should spend their limited resources to improve outcomes of expensive procedures that benefit only a few or focus on providing basic necessities and preventive care for a larger population?The authors highlight the role of professional medical societies worldwide in improving the quality of care and scaling up transplant systems through education and training that fit within the economic framework of individual countries across the globe. This will need to be supplemented with other measures such as international aid, advocacy efforts, partnerships and investment in research in the affluent countries to develop affordable technologies. Bidirectional knowledge transfer is important because the evolution of a technology developed in a richer country may follow a more cost-effective route when implemented in developing countries. This may provide an opportunity for the affluent countries to learn a less expensive way to do things as long as it doesn't impact short- and long-term outcomes . Finally


Over the past two decades finite element (FE) analysis has become a popular tool for researchers looking to simulate the biomechanics of the foot in people with diabetes. The ultimate aims of these simulations have been to improve understanding of the complicated nature of mechanical loading and to inform interventions designed to prevent plantar ulceration. This review is intended to provide a systematic review of these FE analysis based computational simulations.PUBMED, ScienceDirect and Web of Science databases were searched for relevant peer reviewed articles using the keywords “diabetic foot”, “finite element” and related synonyms. This review considered original research studies that utilised FE models of the foot or part of the foot to simulate function, tissue behaviour, or structural deformities associated with the diabetic foot. In addition, studies using FE to study footwear, insoles or surgical interventions intended to reduce ulceration risk in the diabetic foot were eligible for inclusion.Thirty relevant articles were found covering three primary themes: investigations of the characteristics of the diabetic foot (10 articles); design of interventions to reduce ulceration risk (17 articles); and methodological aspects for modeling the diabetic foot (3 articles). Several FE studies have provided estimates of external and internal soft tissue loading, and suggested that internal stresses may often be considerably larger than those measured at the plantar surface and are proportionally greater in the diabetic foot compared to controls. A series of results that inform the design of insoles, footwear and corrective surgery have been presented with the goal of defining the modes of action for these intervention strategies. FE analysis has also been applied to simulate the effect of changes associated with the diabetic foot on factors such as blood supply to local tissues.Existing models have not yet adequately captured the complexity of foot anatomy or the changes in tissue properties and structural factors associated with diabetes. Further work is required to improve the validity and credibility, of FE models and to standardize reporting. The development of patient-specific models is an extremely time-consuming process and reported run times are long. Progress in these areas is needed to ultimately move the technique beyond the research domain to allow it to become a clinically relevant tool at the patient level.


To discuss the practicalities of setting up MRgFUS service for uterine fibroids and in particular the challenges of formulating an effective business plan in a time of financial austerity and curtailment of health service budgets.The authors, an interventional radiologist and a gynaecologist, have worked together closely for 10 years delivering a comprehensive service for the treatment of uterine fibroids in both the state and private health sectors. Despite recognising the clinical potential of MRgFUS and its undoubted appeal to patients we encountered difficulty in engaging any hospital partner to make the necessary capital investment.We describe the business planning process and arguments put forward to support our strategy. Close interdisciplinary working between specialities is fundamental to success as is the nurturing of links in both healthcare management and industry. Challenges include not only the capital costs of equipment purchase but also the opportunity cost of lost scanning time on MRI scanners also used for diagnostic imaging. The requirement for a particular make of MRI scanner can also hinder business plan progress due to manufacturer representation within a particular national market. Reluctance of both government health services and private health insurers to reimburse innovative treatments is a further hindrance to overcome.We share our experience of several unsuccessful and one ultimately successful bid to set up a service with a hospital partner and to provide MRgFUS as an addition to our repertoire of minimally invasive fibroid treatment options. We outline the ground work and business planning processes and arguments in terms of clinical quality, patient choice and health economics used to support our service development strategy.There are undoubtedly logistical and economic obstacles to overcome in setting up a new MRgFUS service but these are not insurmountable. With clarity of purpose, perseverance, an understanding of the health economic arguments and a level of persuasive skills these obstacles can be overcome.


Medical education is tedious and takes both a physical and psychological toll on medical students. Stress could lead to burnout which research has shown that is prevalent among medical students and can lead to other significant dangers if it continues into residency and beyond . Aims: AInterviews and a self-administered anonymous survey of 55 final year medical students by a 2 part questionnaire assessing demographics and support system were carried out.35 final year medical students responded equating to a response rate of 76%. 54% were male mirroring class demographics. The majority (69%) were more than 25 years old and unmarried (89%). We observed that majority of students relied on family, friends and classmates for support when stressed and very few relied on mentors, faculty and school administration for support.The major support systems relied upon by the students has been identified and a void of support from mentors, faculty and school administration discovered. Further research for the cause of this might be helpful to distinguish between the lack of support provision or lack of use on the part of students. This is important as healthy support systems are necessary to cope with the stress ahead in the field of medical practice.


Recent physiological studies revealed that the strength of the synaptic connections changes in a short period of time with short-term plasticity (STP) mechanism; these synapse is called dynamic synapse . The synIn the present study, we further explore the dynamical properties of the associative memory network with stochastic binary neuron model. Changes in the synaptic transmission efficacy can be modeled with variables that represent the releasable neurotransmitter and the utilization parameter reflecting the calcium concentration on presynaptic terminal. We drive the dynamical mean field model that allows to analyze detailed bifurcation structure of network dynamics of the stochastic model. We evaluate the memory retrieve performance with applying external input.In the associative memory network with dynamic synapses, the network shows variety of dynamical state including memory retrieved states and transitive states among the memory patterns.


Batson’s venous plexus is a system of paravertebral veins that connect pelvic and thoracic vessels to the intraspinal  veins. It was first described in 1940 to explain a route for spread of metastases and infection that was separate to the lymphatic system. Its role in the retrograde venous spread of malignancy is now well-described, but not widely demonstrated on imaging.We present a detailed pictorial review of imaging of patients from our oncology centre showing retrograde venous spread to the paravertebral vessels specifically in cases of renal, rectal and breast carcinoma.We demonstrate expansion of the paravertebral vessels containing tumour and associated vertebral body metastases.We also review and illustrate the spinal venous anatomy.Radiologists should be aware of the implication of Batson’s venous plexus as a route of metastatic dissemination. Our pictorial review highlights the importance of the paravertebral vessels as a review area.


The human auditory brainstem faithfully represents the acoustic structure of sounds  ? Assessing both young and aging amusic populations who speak tonal or non-tonal languages will shed further light on this issue. Longitudinal studies are also needed to elucidate the time course of the mechanism that sharpens or detunes the brainstem response and more clearly dissect the relative contribution of cortical structures in driving this type of plasticity.If limited exposure to music listening or making can have negative effects, this would support the idea that music has a role in rehabilitation and in education more generally. Recent studies suggest that music training accelerates neuro-development in children (Skoe and Kraus, In summary, the inherent plasticity of the auditory system primes it for being sensitive to the acoustic environment in a way that can either positively or negatively affect how sound is encoded subcortically. We believe that experience-dependent detuning of the auditory system may explain variations in auditory acuity in both typical and atypical populations, making it a topic ripe for future investigations.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.


As human genomics moves into a mass-scale era, whereby millions of genome sequences will soon become available, new opportunities are opening up to use these very large samples better to understand the relationship between genotype and phenotype.A fundamental problem for such studies in the past has been lack of standardization in the description of the phenotypes used. Not only have disease concepts often been confused with phenotypes , but the concepts used have at times been vague   approach, has been developed . It therefore provides an underpinning component for the computational study of genotype-phenotype relations in humans and model mammals. At the same time it provides a valuable set of terms and relations to facilitate more systematic annotation and searching of phenotype terms across human and model organism databases. This opens up exciting new opportunities for the unified analysis of human and mouse disease and phenotype data.An important addition to the armory of ontological frameworks that can be used to describe phenotypes is provided by Shimoyama et al.  who descThe author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Diabetic foot ulcers (DFU) are a leading cause of diabetes-related hospitalisation and can be costly to manage without access to appropriate expert care. Within Queensland and indeed across many parts of Australia, there is an inequality in accessing specialist services for individuals with DFU. Recent National Health and Medical Research Council (NHMRC) diabetic foot guidelines recommend remote expert consultation with digital imaging should be made available to people with DFU to improve their clinical outcomes. Telemedicine appears to show promise in improving access to diabetic foot specialist services; however diabetic foot telemedicine models to date have relied upon videoconferencing, store and forward technology and/or customised appliances to obtain digital imagery which all require either expensive infrastructure or a timed reply to the request for advice. Whilst mobile phone advice services have been used with success in general diabetes management and telehealth services have improved diabetic foot outcomes, the rapid emergence in the use of mobile phones has established a need to review the role that various forms of telemedicine play in the management of DFU. The aim of this paper is to review traditional telemedicine modalities that have been used in the management of DFU and to compare that to new and innovative technology that are emerging.Studies investigating the management of DFU using various forms of telemedicine interventions will be included in this review. They include the use of videoconferencing technology, hand held digital still photography purpose built imaging devices and mobile phone imagery. Electronic databases  will be searched using broad MeSH terms and keywords that cover the intended area of interest.It is anticipated that the results of this narrative review will provide delegates of the 2015 Australasian Podiatry Conference an insight into the types of emerging innovative diagnostic telemedicine technologies in the management of DFU against the backdrop of traditional and evidence based modalities. It is anticipated that the findings will drive further research in the area of mobile phone imagery and innovation in the management of DFU.


Dear editorMehta et al recently reported removal of dystrophic calcification on the posterior surface of a silicone intraocular lens (IOL) in a patient with asteroid hyalosis.We have recently tried unsuccessfully to use PPV to treat an 86 year old patient with calcification of a silicone IOL in the presence of asteroid hyalosis. We chose to avoid IOL exchange due to a history of Fuchs endothelial dystrophy and glaucoma in the left eye, and a failed corneal graft in a rubeotic eye on the right. Our patient did not have an intact posterior capsule having been treated with Nd:YAG capsulotomy 2 years previously, before the calcification occurred. A 25 gauge pars plana vitrectomy was performed after attempting to remove the deposits unsuccessfully from the posterior surface of the IOL with Nd:YAG laser. It was felt that PPV would be less likely to cause corneal decompensation than IOL exchange. In contrast to the experience of Mehta et alMehta et al reported that initially their patient underwent an unsuccessful Nd:YAG capsulotomy, however it was not made clear whether the posterior capsule remained intact.A similar case of this condition has been published recently by Ullman and Gupta.We believe that vitrectomy and surgical capsulectomy should be considered as an alternative to Nd:YAG capsulotomy where IOL calcification is not yet established. It is likely that opening a significantly calcified posterior capsule by Nd:YAG capsulotomy in the presence of asteroid hyalosis will lead to significant future IOL dystrophic calcification. In established calcification of a silicone IOL we feel that vitrectomy is of limited value and IOL exchange should remain the standard treatment. We appreciate Drs Rainsbury and Lochhead sharing their experience and insight into the treatment of dystrophic calcification of silicone intraocular lenses (IOL). As they point out, it intuitively makes sense that the presence or absence of a posterior capsule changes the natural history and management options of this pathologic calcification.In our case,In the setting of monocular patients (as in our case) or those with compromised capsular support (as in the case described by Drs Rainsbury and Lochhead), we believe it is reasonable to attempt vitrectomy prior to IOL exchange in these cases of dystrophic calcification. Though vitrectomy might not be successful in every case, removing the vitreous alone may make subsequent IOL exchange safer, and prevent recurrence of dystrophic calcification.


Brain-computer interfaces (BCIs), or brain-machine interfaces (BMIs) involve real-time direct connections between the brain and a computer Kubler, . BidirecThe user of a BCI can execute an intention to perform a motor task through changes in the system caused by electrodes detecting signals in, for instance, the motor cortex mediating the intention. Success in operating the system depends on a combination of unconscious operant conditioning of brain responses and conscious goal-directed expectation of the subject. These depend in turn on how effective the practitioner is in training the subject how to operate the system. As in other cases of traumatic brain injury, goal-directed thinking in some patients with tetraplegia may be impaired if there is significant damage to neural networks in frontal regions mediating planning and decision-making. This may also impair the subject's capacity to understand the benefits and risks of the technique and give informed consent to participate in BCI research and treatment , electrodes are implanted epidurally or subdurally (Leuthardt et al., EEG- and fMRI-based BCIs might enable individuals to reliably communicate when they are unable to communicate behaviorally (Birbaumer et al., Some investigators have claimed that fMRI-guided BCIs could enable minimally conscious patients with a high level of cognitive function to make these decisions (Peterson et al., This last point may be overly optimistic. Even advanced BCIs that could detect neural activity correlating with complex semantic processing might not be sufficient to show that the subject had the cognitive and emotional capacity to make an informed and autonomous decision about life-sustaining treatment. Some form of behavioral interaction may be necessary to confirm that the subject had this capacity. Medical professionals and caregivers must be cautious not to read too much into BCI-enabled responses and interpret them as having a meaning they lack.BCIs can benefit individuals by restoring varying degrees of motor control and possibly the ability to communicate. But expectations of some subjects and their caregivers may exceed what they can reasonably achieve with the technology and result in psychological harm. Selecting candidates with higher levels of preserved cognitive function for BCI research and treatment and educating them on the potential benefits and limitations of the technique is advisable to prevent or at least minimize harm. The fact that a particular BCI system is more invasive than others does not imply that it has an unacceptable degree of risk and may instead indicate a more favorable benefit-risk ratio if it does more to enable the execution of intentions in actions and promote neuroplasticity. Perhaps the most significant application of BCIs would be in enabling minimally conscious or completely locked-in patients to communicate. Yet it is questionable that even the most sophisticated system alone could demonstrate that these subjects have the ability to clearly and meaningfully communicate their wishes and make informed decisions about life-sustaining treatment. Decision-making capacity falls along a continuum correlating with a continuum of cognitive and emotional capacities, and there is no algorithm providing a definitive answer to the question of where the threshold at which one has a sufficient degree of these capacities lies. All relevant parties need to be cautious and not infer that a BCI indicating certain levels of brain activity and semantic processing in a subject is evidence of an understanding of the ethical magnitude of life-and-death decisions and the ability to make them.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Hierarchical processing is key to understanding vision. The visual system consists of hierarchically organized distinct anatomical areas functionally specialized for processing different aspects of a visual object  is missing. The advent of optogenetics and neuroimaging has provided additional remarkable investigative tools. How these recent techniques will contribute to the prevailing arguments of feedforward and feedback projections in vision is still open. We hope this issue will inspire the readers and act as a catalyst for future work on the issues of feedforward and feedback processes in vision.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.


Pain perception is subject to powerful modulatory influences that can increase or reduce subjective responses in the short and long term. Nociceptive circuits can become sensitised causing both innocuous and noxious inputs to be amplified and their intensity and other sensory characteristics to be increased. Both central and peripheral mechanisms of sensitisation are recognised. Nociceptive mechanisms are immature at birth, undergoing both structural and functional change during normal development that can have important consequences for the maintenance, management and prognosis of chronic pain in children.The neurophysiology of pain in children will be briefly described with special reference to sensitisation in the context of non-inflammatory musculoskeletal pain and pain amplification syndromes. A mechanisms based approach to the medical management of chronic pain in children will be discussed.None declared.


In the final version of our article entitled, " Lessons from sexual and reproductive health voucher program design and function: a comprehensive review" the authors inadvertently failed to acknowledge the role of International Union of Scientific Study of Population (IUSSP). IUSSP colleagues kindly reviewed early drafts of the manuscript presented at an IUSSP workshop in Bangkok August 2012 and had specifically requested that we recognize their feedback. We therefore feel obliged to acknowledge IUSSP.


Diabetes is considered as a risk factor for atrial fibrillation and patients with a co morbidity of diabetes and atrial fibrillation have an increased risk of cardio-vascular complications like stroke. However, paroxysmal atrial fibrillation often is not recognized and therefore stroke is a frequent and severe complication of diabetes and atrial fibrillation. The objective of the study is a screening of patients with diabetes mellitus type 2 for atrial fibrillation and as a consequence an individually adjusted risk management regarding glucoses levels, anticoagulation and blood pressure.To detect atrial fibrillation ECGs of diabetes patients will be evaluated by an automated AF episode detection algorithm that already has proven superiority in the detection of atrial fibrillation. The software uses an algorithm that detects QRS complexes of the ECG data and then classifies them as being of atrial or ventricular origin and finally creates a list of R-R-intervals. To detect episodes of AF, the software performs a time series analysis of multiple mathematical parameters that are typical for an absolute arrhythmia during AF. Based on this analysis, the system creates a report on whether episodes of AF are present . The proThe study is expected to give detailed information on the increased prevalence of atrial fibrillation in patients with type 2 diabetes and provides the data base for an optimized therapy regime in order to avoid cardio-vascular complications.The detection of atrial fibilation as a major risk factor for cardio-vascular complications of diabetic patients will have to be improved. This strategy can be combined with other strategies of detection of complication risks  and improve personalized treatment of diabetic patients.


Dermatological conditions form a significant number of consultations seen by general practitioners on a daily basis. There is a lack of training and formal assessment of dermatology during medical school and we propose that there should be a mandatory component in OSCEs for dermatology during medical school to enhance one's diagnostic and clinical reasoning skills which will ultimately lead to better care for the patient and efficacious use of NHS resources. Dermatology forms an essential part of a medical student's specialty training. Inflammatory skin diseases  and infective diseases  are some of the most commonly encountered conditions in primary care; it is estimated that the prevalence of skin diseases in primary care setting is around 12.4%  target sThere are many different forms of assessment used in medical schools throughout the United Kingdom. The most popular forms of assessment which have shown great validity in a medical student's performance as a competent and safe clinician are EMQs (extended matching questions), SBAs (single best answers), and the OSCEs . These forms of assessment have been widely adopted by many medical schools across the United Kingdom , 5. The Tomorrow's Doctors’ provides a clear framework for medical schools to design curricula. The fact that there has been a lack of practical clinical examination for dermatology considering the vast number of cases presenting in general practice on a daily basis itself is a cause for concern  and can have a significant impact on social and psychological wellbeing . The Gen concern .On the other hand, it could be argued that as most universities blueprint the quantity of questions going to be asked across all different types of examinations by the number of weeks of the specialty placement itself; it can be understandably difficult for examiners to test candidates in dermatology . At BartWe believe that practical training in dermatology should begin at an early stage in medical school, and that practical dermatological clinical examinations should be compulsory. It is paramount to implement the core skills required for a competent and confident diagnosis and management of dermatological problems leading to a better outcome for all patients and an effective use of the NHS resources . One of


Prevalence of allergenic plants varies by geographic region and climate, which affects the level of allergen exposure experienced by patients in different parts of the country. Because of these variations in exposure it is recommended that allergy practices use customized regional diagnostic panels based on the prevalence and significance of various aeroallergens. However, gathering this information can be difficult for new physicians. The purpose of these recommendations is to provide a foundation for new physicians to begin building a custom aeroallergen panel for all regions of Canada.Clinical, geographical and botanical references were evaluated and compiled to determine the prevalence and impact of various aeroallergens across Canada. These recommendations were discussed with regional allergy practices and other clinical authorities for consensus on recommendations.Aeroallergen recommendations were compiled into a prevalence map and table that was organized by the major geographic regions of Canada. Allergens were categorized as (1) high allergenicity & high prevalence, (2) high allergenicity & low prevalence, (3) low allergenicity & high prevalence, or (4) low allergenicity & low prevalence. A significant degree of allergen similarity across all regions was recognized although specific differences in species selection and general distribution patterns were identified for each region.Gathering clinical and botanical prevalence data for aeroallergens across different regions can be time consuming and difficult. These recommendations were compiled from many years of industry experience working with allergy specialists across the country and were verified by the literature. It is hoped that this knowledge can provide a foundation for new physicians trying to understand which aeroallergens to target for allergy diagnostic panels specific to their region.


The arcOGEN Consortium should be listed as an author of this article. They contributed to the genome-wide association study results presented in this work. They should be listed in the author byline at position 292 and affiliated with The Arthritis Research UK Osteoarthritis Genetics Consortium. They should also be included in the footnote designating consortia which is underneath the author affiliation list in the PDF version of the article, and in the S2 Text(DOCX)Click here for additional data file.


The rate of infection of health care workers in the recent Ebola Virus Disease (EVD) outbreak in West Africa, including Nigeria has shown that the disease can be transmitted and amplified in healthcare settings especially when infection prevention and control (IPC) procedures are ineffective or ignored.The aim of this study was to evaluate the level of infection control measures operating in health facilities in Rivers state as at the time of the Nigerian 2014 EVD outbreak.th and 11th 2014. Each response was scored between 0-3. An overall score of ≥75% was graded as good while <75% was poor. Data was analysed with SPSS Version 20. Ethical statement; this study was conducted during the outbreak of EVD in Nigeria as part of response activities by the members of the Ebola Emergency Operation Center.The descriptive cross sectional study was done in Rivers state one of the two states that experienced the EVD outbreak in Nigeria. Information on IPC materials and practices in health facilities in the state was collected using the Infection Control Assessment Tool (ICAT) between September 4Two tertiary, twenty four public secondary and sixty six private secondary health facilities were studied. Only one of the tertiary healthcare facilities had an IPC committee in place with a focal officer in charge. Only one hospital had an IPC policy which was not operational. None of the health facilities had a good score for both IPC materials availability and practice.Gaps existed in IPC in health facilities in Rivers State, Nigeria at the outbreak of EVD. It is recommended that appropriate policy for maintaining and sustaining infrastructure and supplies essential to IPC in health facilities be developed and implemented in all health facilities. Regular surveillance should be put in place to ensure that these items are always available, while hospital administrators and departmental heads must provide the necessary resources to facilitate compliance.None declared.


Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) scan are the two ubiquitous imaging sources that physicians use to diagnose patients with Cystic Fibrosis (CF) or any other Chronic Obstructive Pulmonary Disease (COPD). Unfortunately the cost constraints limit the frequent usage of these medical imaging procedures. In addition, even though both CT scan and MRI provide mesoscopic details of a lung, in order to obtain microscopic information a very high resolution is required. Neither MRI nor CT scans provide micro level information about the location of infection in a binary tree structure the binary tree structure of the human lung. In this paper we present an algorithm that enhances the current imaging results by providing estimated micro level information concerning the location of the infection. The estimate is based on a calculation of the distribution of possible mucus blockages consistent with available information using an offline Metropolis-Hastings algorithm in combination with a real-time interpolation scheme. When supplemented with growth rates for the pockets of mucus, the algorithm can also be used to estimate how lung functionality as manifested in spirometric tests will change in patients with CF or COPD. Patients with chronic obstructive pulmonary disease (COPD) or cystic fibrosis (CF) have chronic lung inflammation which causes airflow limitation and the scarring of lung tissues. Their airways are generally inflamed and produce excess amounts of mucus that impair the flow of air into and out of their lungs.Our hypothesis is that the scarring, and ultimate remodeling of a CF lung is mostly due to the contact between the lung lining and the mucus. Inflammatory cytokines induce scars in lung tissue Spirometry, the measurement of a patient's breathing, is the standard clinical tool for monitoring lung disease. The two most common spirometric indicators are the forced expiratory volume in one second, FEVMRI was first introduced as an alternative imaging tool for patients with CF in 1987 There have been research studies on mesoscopic modeling of Cystic Fibrosis one configuration is of this form. In fact, however, repeated MRI measurements separated by small challenges such as coughing or even just taking a few deep breaths reveal that mucus inside the lungs of CF patients show small but discernible movements in response to such challenges. Given this dynamic picture, the possibility that all of the configurations of mucus would avoid the configurations that can be realized the largest number of ways is extremely unlikely. We describe below how to construct such distributions that best represent the state of airways corresponding to the patients lung functionality test values , we first have to define how mucus is distributed in a voxel's binary tree structure. There is an astronomical number of configurations for filling a binary tree of 10 generations with a given amount of mucus. Approximately, it is given by Hence if a voxel contains In order to expedite the computational process; Dulcinea computing clusters from the Computational Science Research Center at San Diego State University were used for collecting almost 54 million samples. The Dulcinea computing clusters contains 12 workstations each with Dual-Quad Xeon central processing unit (CPU) (E5520 2.27GHz) and Dual Tesla graphic processing unit (GPU) (M1060) which provides the total of 96 CPU cores. The cluster system utilizes 3GB of memory per CPU core for nodes 1 to 10 and utilizes 6GB of memory per CPU core for nodes 11 and 12. After obtaining these samples the probability distributions for different amount of mucus are calculated. In order to spatially locate each bronchiole in a human airway tree we used Kitaoka et al.'s three-dimensional model At this stage we have mapped the voxels from imaging data into our model in a way that the total rate of airflow and the accessible alveoli of the lung model resemble the corresponding patient's FEVIn this section we use the mucus distribution and growth model presented in This method can even be applied to follow a patient's progress with out fewer imaging tests. Since most CF patients take spirometry test more often than any imaging tests, we can use our model without recourse to imaging data. This time the model takes only the FEVSince the mean mucus growth rate was estimated based on years of data from many CF patients, such predictions should work reasonably well for a patient between exacerbations. Our model can also be used to predict the progression during exacerbations, albeit with voxel specific growth rates informed by much more data than we currently possess. Using one mean mucus growth rate is a shortcoming not of our algorithm but rather of the paucity of data to which our predictions have been applied. There is every indication that soon we will have reasonable metagenomic We can improve the accuracy level of the model by extending the resolution of our PDFE-2D distributions. The current PDFEs were constructed with With current research studies about cystic fibrosis, CF treatment is poised for great strides. Non-genetic treatments such as Ivacaftor  only works on patients with a certain mutation of cystic fibrosis which accounts for 4–5% of cystic fibrosis cases While an eventual cure for the disease by replacement of the defective gene is likely, we expect such treatment not to be available anytime soon. Rather we anticipate that new observational tools such as metagenomics, transcriptomics, metabolomics and MRI imaging coupled with our modeling approach will give the clinician unprecedented ability to follow and treat the disease. The models will provide quantitative predictions of responses to various drug regimens and prescribe adaptively implemented optimal controls for treatment. Predicting the impact of mucus growth on lung functionality will correlate the current stage of the disease with how infection has been propagating throughout different generations of lung. This will enable the physician with a tool to track this propagation of infection.The various sub-models required here will soon be informed by data characterizing the microbial communities present. Such data comes from metagenomic and transcriptomics analyses of sputum samples and metabolomic analyses of exhaled air. In our current model we predict the dynamic distribution of mucus in a CF lung in the absence of treatment as a stepping stone for eventually eventual treatment and microbial community specific modeling of the treatment response.According to a research study done by Willner et al. 3 for the size of one voxel was for illustration. Any resolution scale however forces estimation of the distribution on spatial scales below this resolution. Since estimation of the distribution on finer spatial scales would perforce need the solution of an inverse problem with many possible solutions and since the movement of mucus hinted that the “right answer” would in any case not be a unique distribution, we were led naturally to using Monte Carlo estimation methods for the most likely distribution and the corresponding spirometric observables. The resulting models and algorithms form a clinically useful tool with which to reassess the various simplest possible sub-models and assumptions used in our work so far. These models can play a crucial role in future treatments of the disease.Our methods are completely scalable – the 1.0 cmFile S1The supporting file Psudo.pdf contains the psudo code of the algorithms and models mentioned in this manuscript.(PDF)Click here for additional data file.


The diuretic bumetanide failed to treat acute seizures due to hypoxic ischemic encephalopathy (HIE) in newborn babies and was associated with hearing loss (NEMO trial, Pressler et al.,  The diuretic bumetanide is one such drug that specifically blocks the NKCC1 chloride importer thereby reducing (Cl−)I levels and restoring GABAergic inhibition in many neuronal types in physiological and pathological conditions. The recent failure of the NEMO trial aimed at treating seizures in newborn babies with bumetanide  neurons GABA provides most of the inhibitory tone, in immature neurons it depolarizes and often excites due to higher levels of intracellular chloride ((Cl−)I in immature and adult cochlear hair cells, and effects of hypoxic injury and toxicity of aminoglycosides that are aggravated by bumetanide I levels was found to be highly seizure history dependent. Bumetanide neither prevented the formation by recurrent seizures of an epileptogenic mirror focus nor efficiently reduced their generation I levels and attenuated electrical and behavioral parameters I levels and excitatory GABA I levels I levels notably oxytocin attenuate schizophrenia symptoms , striatal medium spiny neurons generated Giant GABAergic Currents that are readily blocked by L–Dopa and lesions of the sub thalamic nucleus suggesting that they constitute relevant signatures of PD I levels in pain pathways I levels paving the way to a common therapeutic strategy to many disorders. Therefore, neither the severe side effects of bumetanide on the hearing system of newborn with hypoxic ischemic encephalopathy (HIE) nor its lack of efficacy in the NEMO study bear relevance to many other disorders. High (Cl−)I levels and excitatory GABA play a fundamental role in the pathogenesis of many disorders, generating aberrant activities that perturb the operation of behaviorally relevant oscillations. Bumetanide and other drugs acting on chloride co-transporters can restore low (Cl−)I levels in these disorders but may be contraindicated in newborns because chloride co-transporters are still operative.In several instances, encouraging preclinical data fail in clinical trials and the reasons for these failures are not always straightforward. They might also lead to the abandon of the animal model although heterogeneity of the clinical data might also be a factor. Yet, with bumetanide, the situation is of particular interest as the convergence of animal and human data is reinforced by a fundamental conceptual series of observations stressing the impact of a wide range of insults on (ClPD and EL contributed to the summary on Parkinson disease and autism respectively and YB performed the analysis of the literature and wrote the paper.Experimental work on autism of YB-A was financed by the Bettencourt-Schuller Foundation but grants rejected by the European Research Council. Clinical trials on autism were supported by the Simons Foundation but grants rejected by the Agence Nationale de Recherche.YB is CEO and share holder of Neurochlore 2 and B&A Therapeutics biotech companies dedicated to the development of treatments to autism and parkinson disease. EL and PD are respectively share holders of Neurochlore and B&A Therapeutics.


Contemporary psychology does not question the existence of psychological processes that operate outside human conscious awareness, such as implicit stereotypes  used different exposure durations of affective primes as operationalization of salience of affective stimulation. Confirming the predictions, the results showed assimilation effect when the exposure duration of primes was shorter—4 ms—and the contrast effect, with the longer duration of 16 ms  affective stimulation. Thus, the nature of nonconscious affective priming may be more complex that was originally assumed and may be mediated by automatic processes of implicit emotion regulation  emotion regulation may appear automatically and modify the influence of affect on subsequent processes, as when we observe the contrast effect. This is one more argument for the substantial role of implicit processes in human life.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.


Health Logistics Association (HLA) is an association of logistics professionals committed to humanitarian logistics effectiveness by creating opportunities for dialogue and cooperative relationships with its members and partners to build a community of practice for advancing the humanitarian logistics profession through the promotion of cross organisational learning and collaboration. IAPHL is a professional association dedicated to improving public health supply chain management by promoting the professional development and recognition of those who work with health supplies.Under the Enhanced Learning & Research for Humanitarian Assistance professionalization umbrella, the HLA has joined an inter-agency project to define a framework and system for recognising relevant humanitarian logistics experience and training. Initial research will be required to ensure that any framework is relevant, inclusive and aligned with other initiatives. The project will build on training program achievements in the humanitarian logistics (and emergency nutrition) sector and support the emerging suite of competence based qualifications.Humanitarian assistance partners recognize the importance of effective humanitarian logisticians in the planning and delivery of aid. More humanitarian assistance professionals and academics see the need to hone specific competencies and skills for these programs so certifications build a portfolio of evidence. A key challenge is to ensure that individuals successfully completing these and other relevant qualifications gain the recognition they require from aid agencies. There is also a need to define a recognised career pathway within the sector with clear routes for progression. IAPHL is investigating professional certification requirements and seeks to learn from HLA’s experience.The current system for recognizing knowledge and skills of humanitarian workers strongly favours international staff. Limited professional development funding for national staff is often wasted, as there is no accepted system to measure competencies or training effectiveness. A new system to capture, recognise and certify the skills, learning and development of aid workers is needed. It’s proposed that an internationally recognized Learning and Development Passport for humanitarian logisticians be development, and extended to include other related sectors such as public health logisticians.Given HLA’s experience, the next steps for professionalizing the humanitarian logistics workforce are to stimulate greater advocacy, buy-in, recognition and endorsement for certification in the mainstream. HLA’s experience can be applied to other sectors like public health; IAPHL and PtD can build on and formalize the methods for professional certification and standards that have worked for HLA.


Herpes Zoster also known as Shingles is an acute viral infection which is an extremely painful and incapacitating ailment. It results from the reactivation of the varicella zoster virus. The triggering factors for the onset of an attack of Herpes Zoster include some form of immunosuppression. The diagnosis of Herpes Zoster can be made on proper medical history and a thorough clinical examination. Here is the report of a male patient affected by Herpes Zoster infection which followed after extraction of a lower first molar. Herpes Zoster is a painful acute infectious viral disease caused due to the inflammation of dorsal root ganglia or extramedullary cranial nerve ganglia, leading to vesicular eruptions of the skin or mucous membrane in an area supplied by the affected nerve. The most commonly affected dermatomes are the thoracic (45%), cervical 23%), and trigeminal 15%) 3%, and tThe primary infection of varicella zoster virus (VZV) is the chicken pox and, due to the characteristic of latency of the herpes group of viruses, VZV gets reactivated to cause Herpes Zoster infection in later age.The incidence of latent Herpes Zoster increases 5–10-fold after the age of 80 years .A male patient of 49 years reported to the Department of Oral Medicine and Radiology, C.S.I. College of Dental Sciences and Research, with the chief complaint of pain and ulceration on left side of face and mouth for four days. Patient gave the history of extraction of the tooth 5 days ago after which multiple vesicles formed on the left side of the face and inside the mouth which made him uncomfortable while ingesting food. He had visited a dentist who diagnosed the condition as angioedema and prescribed antihistamines for three days but they did not alleviate any of the symptoms and the pain and ulcerations worsened. He did not have any relevant medical history. He is not a smoker but occasionally consumes alcohol.On examination, unilateral multiple vesicles with few of them ulcerated were found on the left side of the face and facial asymmetry due to diffuse swelling which extended superiorly to the upper eyelid was evident . On intrUlcerations were also evident on left buccal mucosa and alveolar mucosa in relation to 36 . The ulcPatient was subjected to few investigations to rule out any immunocompromised status. The hemogram and serum glucose levels were within normal limits. ELISA for HIV was negative. Patient was referred to a general physician for hydration and ophthalmic evaluation. A dose of antivirals and steroids which included Valacyclovir 1000 mg 3 times a day and Prednisolone 20 mg 3 times a day and topical acyclovir for 1 week was prescribed.The patient responded to antivirals and steroids well within a week and showed considerable healing. Patient was evaluated every week and steroids were tapered over four weeks and stopped. Gradual healing was observed in phases Figures .By fourth week the patient was seen only with scars on the left side of face Figures  and 6.Systemic steroids could have prevented complications as it has been 3 months and the patient is apparently healthy at present.Herpes Zoster has an estimated life time incidence of 10–20% and gets reactivated with some form of immunosuppression. Herpes Zoster infection is common in elder persons, HIV-positive individuals, and patients affected by malignant blood dyscrasias or malignant tumours or undergoing immune suppressive therapy and radiotherapy .The most noted point of our case report was that there was no previous history of any herpetic simplex infection in childhood or recurrent herpes labialis in later stage. It is believed that the patient could have contracted chicken pox early in his life as the incidence of chicken pox in a tropical country like India is very high. Also the unilateral distribution of the erosions and the lesions pertaining only to the oral and maxillofacial region with involvement of ophthalmic, maxillary, and mandibular division of trigeminal nerve is suggestive of Herpes Zoster rather than a herpes simplex infection. The infection was triggered by a traumatic extraction of left mandibular lower first molar. El Hayderi et al. postulated that HSV reactivation occurs during surgical procedures involving trigeminal nerve in 50% of patients and an anaesthetic block may irritate the nerve leading to reactivation and recrudescence of herpes lesion , 7. ThisInvolvement of the second and third branches of the trigeminal nerve results in vesicular lesions in oral cavity. The vesicular lesions develop 2–4 days after prodromal period of fever, weakness, fatigue, and stiffness of the neck . Our patThe duration of healing of Herpes Zoster lesions and the severity of pain associated with the disease have been shown to be considerably less with prompt administration of antiviral agents. However these benefits have been found in patients who received antiviral agents within 72 hours after the onset of the rash . But ourThe early diagnosis of Herpes Zoster and prompt treatment can avoid further complications. Herpes infection following extractions has been reported very rarely. Herpes Zoster infection must also be considered as one of the complications after extraction. The patients must be asked to report to the dentist if there is any symptoms of the disease after extraction. The patient should be under medication and periodically reviewed. Misdiagnosis should be avoided as far as possible unlike this case where herpes infection was misdiagnosed as allergy.


The superiority of the Intensive insulin regimen over the conventional split mix is very well established in Western centres, often considered a prelude to pump therapy. Developing countries find it a challenge to initiate Basal bolus therapy. The main problems include: lack of support systems in school environment to take up the injections and glucose monitoring at school, and difficulties in assessing carbohydrate content of native foods prepared at home (considering the variability in preparation of any given food item). The parental acceptance of five injections a day also remains a challenge. There are numerous extraneous influences and myths in minds of parents that discourage them from accepting this regimen. We present our experience in surmounting these challenges and establishing Intensive insulin therapy as a first line of insulin therapy and also share the advantages in terms of the glycemic control and growth of children on follow-up with us.


Doctors are not short of advice about how to manage their patients. In the case of COPD (Chronic Obstructive Pulmonary Disease) there are a wealth of guidelines, strategies and position papers synthesising an increasing body of data from observational studies and clinical trials into schemes that should help the doctor care for their COPD patients more effectively. In recent years particular attention has been paid to the views of the joint ERS/ATS COPD guidelines  and the 1/FVC ratio of 70% or less to support the diagnosis of COPD and suggest instead that the lower limit of normal (LLN) for this ratio is a more reliable guide. There might have been a little more advice for the busy clinician on the best way of accessing appropriate LLN data and perhaps a little more caution on the usefulness of bronchodilator testing in patient evaluation [Appropriately this new document takes a very wide view of the problems of COPD. It emphasises the need for early accurate diagnosis supported when needed but supplementary physiological investigations such as the measurement of lung volumes and airway responsiveness. It points out the limitations of relying on a fixed FEValuation . HoweverThe authors have avoided some of the controversy and uncertainty surrounding the new GOLD severity assessment scheme , insteadThis new approach to COPD care is needed in Italy now. As the authors point out, COPD remains a major health problem despite much good work to increase smoking cessation rates and improve air quality. International guidelines offer an overview of COPD care in all settings but there is still a need to develop management strategies which work locally and reflect the needs and perceptions of local physicians and patients. This new initiative has achieved both of these goals admirably.


The impact of the chronic pelvic inflammatory state on other organ systems and women's health is unclear. Endometriosis associated chronic inflammation and potential adverse health effects across the lifespan render it imperative for renewed research vigor into the identification of novel biomarkers of disease and therapeutic options. Herein we propose a number of opportunities for research and development of new therapeutics to address the unmet needs in the treatment of endometriosis  The causal relationship regarding which comes first may not be absolutely established  but resewe must develop novel biomarkers of endometriosis for diagnosis, response to treatment, and disease progression;we must ascertain whether the chronic inflammatory process in the peritoneal compartment incurs a significant risk for other systemic (remote) diseases –18;we must strive to identify novel preventative, modulatory, or therapeutic interventions that can take advantage of cellular and molecular mechanisms to mitigate both the primary disease process  and the consequent systemic inflammatory effects.No matter whether the disease etiology depends primarily upon the biomechanics of retrograde menstruation, sex hormone modulation of endometrial tissue proliferation, environmental exposures, genetics, oxidative stress, or inflammatory cell populations, we must address three key themes:A plethora of biochemical differences in the peripheral circulation, peritoneal fluid, and endometrial tissues of women with endometriosis versus healthy controls has been demonstrated –42 many Emerging areas of interest include nerve fiber density, microRNA (miRNA), and neurotrophins. Recent studies report the fact that nerve fiber density in the functional layer of the eutopic endometrium is greater in women with endometriosis compared to controls , 72. AltSeveral recent studies have documented aberrant expression of several different miRNAs in women with endometriosis –82. miRNProspects for development of improved diagnostic and disease-monitoring strategies for endometriosis have recently been advanced by the efforts of a major international research consortium, the international “WERF EPHect” initiative –88. In tContemporary biomarker techniques  are begi per se and systemic adverse effects with durability will mean either long-term continuing usage or repetitive episodic usage with convincing evidence of patient safety and tolerability. Accordingly investigators in this field need to consider the prospects for patient safety with chronic usage of any candidate agents along with evidence of efficacy and reduction in risks of other diseases associated with chronic inflammation [Current therapeutic drugs are primarily directed at suppressing the intraperitoneal activity of the underlying disease. As is the case for other chronic diseases, future novel therapeutics for endometriosis will need to be developed to treat the primary intraperitoneal process , the potammation . Whetherammation  or in teammation  aimed atBeyond the current set of hormonal and anti-inflammatory drugs used to treat endometriosis, what classes of compounds might be safe and effective in the sustained management of this chronic inflammatory process? A modest number of ideas have been suggested by various investigators and we shall consider them plus one new idea that we propose from some recent research in continuous ambulatory peritoneal dialysis (CAPD).Several classes of compounds  have beeα in peritoneal fluid [The second group of compounds that merit research and development for potential application in endometriosis may potentially mitigate both the intraperitoneal and the systemic inflammatory consequences of endometriosis , 34–39. al fluid . Finallyal fluid  and sincIt is our view that there are ample opportunities to pursue research regarding the impact of endometriosis across the lifespan and to pursue development of a number of therapeutics that could plausibly be expected to be both safe and beneficial for women suffering with this disease. This is not an argument for taking our eye off the prize meaning endometriosis as the primary disease; rather we owe it to each of our patients to consider all of the impacts at all times in life that this disease may incur. We urge deeper and broader understanding of such risks and pursuit of safe and effective interventions for the care of our patients.


From February 2012 a multidisciplinary group in a 600 bed tertiary public hospital in Western Australia have worked collaboratively to improve the care of adult patients admitted to an acute medical ward with complications of severe eating disordersThis clinical care journey has gone on to inform a program of staff development and strategic advocacy for a state wide approach to the care of adults with eating disorders.Via demonstration of parallel journeys of patients, staff and the state wide strategy, the authors have identified areas of unmet need, gaps in resourcing and barriers to improving care from a local context.This multidisciplinary collaborative process has now informed a business case for a comprehensive specialist eating disorders service for youths and adults in Western Australia's public health service.Service Initiatives stream of the 2014 ANZAED Conference.This abstract was presented in the