To effectively deliver child and adolescent mental health (CAMH) services in resource-constrained settings, it is vital to be smart in utilizing such resources efficiently, and this requires strategic planning. Of paramount importance is in-service training of primary care professionals aimed to consolidate existing knowledge and employ evidence-based strategies to manage child mental health care and to successfully integrate further these services into other mainstream healthcare facilities.•Enthusiasm from health professionals/ CAMHS team lead by a child psychiatrist and CAMHS team as the service provider is a key determinant of sustainability•Perseverance and patience are the salient qualities necessary to secure commitments and resources from relevant authorities•Liaising effectively and cultivating cooperative and communicative networks between primary care professionals, educators, child-care and social care professionals, as well as non-governmental organisations is essential for effective service network•In-service education and training as well as ‘task-shifting’ methods to optimise human resource development can be potent strategies to sustain CAMH service in limited resource environmentsThe establishment of CAMH services in Terengganu and the East Coast of Malaysia has resulted in better skills in assessing and managing young people with mental health problems by medical practitioners and mental health workers. It has had a positive impact on young people with mental health issues and their families around the East Coast and particularly in Terengganu.The implementation of CAMH services in Terengganu has served to facilitate numerous improvements such as promoting and increasing awareness of young people with mental health problems within their general practices. Furthermore, planning and implementing fully integrated child mental health service in Terengganu and the East Coast of Malaysia has served to enhance our understanding and yielded valuable insights which include:Child psychiatry services in Terengganu, Malaysia were initiated in 1997 as part of services provided by the department of Hospital Sultanah Nur Zahirah Hospital (HSNZ) which has been gazetted to manage psychiatric patients in Terengganu since early 70’s. The service was led initially by a general psychiatrist who has a deep interest in working with young people with mental health problems. A specific day was allocated for children and adolescents with mental health issues to attend the general psychiatric clinic.The service development has progressed with the integration of child psychiatric unit specially designed and included during the planning of Day Treatment Complex in the 8th Malaysian Plan. This complex which also housed the psychiatric clinic was finally completed in April 2003. Sadly, the service was temporarily discontinued when the specialist was transferred to serve a different hospital. All children and adolescent patients were then relocated to the general adult clinic to be managed by medical officers and general psychiatrist.In December 2004, the child psychiatry clinic was re-established and re-branded with a new name Child and Adolescent Mental Health service (CAMHS) and managed by a child and adolescent psychiatrist who was posted to the hospital. The CAMHS was moved to the existing Day Treatment Complex. There were, however, multiple challenges faced during the initial implementation of CAMH service. Among those, we encountered various constraints involving inadequate funding to provide effective training and crucial posts to set up a multidisciplinary team to facilitate the assessment and management of mental health needs of children and adolescents. Inadequate support received including a vague understanding to allocate appropriate staff namely occupational and speech therapists, clinical psychologist/counsellor dampened the proper assessment and effective interventions upon arriving at the diagnosis. It was more of ‘a one-man show’ type of approach; i.e. existing occupational therapist focused mainly on the physical deformities while speech therapists are based in the ORL department; primary health care providers were not managing the cases adequately.•Encouraged more specialists to subspecialise in child psychiatry with ongoing training of Masters in child psychiatry as well as a training base for those planning to subspecialize in child psychiatry abroad•Provided an opportunity for staff to further their study or doing an attachment in child and adolescent mental health programmes and activities•Made sure that all training modules, guidelines and protocol on child and adolescent mental health have been made available to all schools, primary care clinics and communities.•Collaborated with the Education Department in organising courses and workshops related to mental health for school children and teachers in Terengganu.Since 2005, great efforts were made. A series of training courses and workshops were carried out both by the department and by other agencies. Specific issues were identified and funding was appropriately explored to materialise such plans. The primary focus was on improving knowledge and useful skills among mental health practitioners in the care of children and adolescent mental health patients. We have:Despite such constraints and being the only CAMH service in Terengganu, the team has endeavoured to provide an efficient service that will give an impact to the state of Terengganu and East coast. As demonstrated in Table CAMH service in Terengganu and the East coast of Malaysia has resulted in better skill reinforcement in areas of assessment and management of young people with mental health problems among medical practitioners and primary health care workers. Through receiving continuous funding and appropriate training, staff have achieved more confidence and are more able to care for their clients in their settings. This CAMHS establishment is believed to have an encouraging impact in the improvement of mental health among children, young people and their families in the East coast particularly Terengganu.To date, there is no standardised service evaluation in our CAMHS to assess patient clinical and service outcome measurement that may indicate the impact of CAMHS to the population of Terengganu and also the east-coast. This standardised routine outcome measurement is still mostly unexplored not only in Terengganu but Malaysia in general. These future research findings may help us to provide useful information for improvement in the quality of treatment planning as well as the implementation of standardised outcome measurement for local and national benchmarking of CAMHS service in this country.National Institute of Health (NIH), Ministry of Health (MOH), Malaysia.Application of approval for publications and presentations from Director General (DG) of Health Malaysia has been submitted to the NIH .No potential conflict of interest was reported by the authors.


Not surprisingly given their multi-component nature, initiatives to improve integrated care often evolve to find the best way to bring about change. This paper provides an example of how an evaluation evolved alongside such an initiative designed to better integrate care across primary, community and hospital services in South Auckland, New Zealand.Using the explanatory power of a realist evaluative approach, theories of new ways of working that might be prompted by the initiative were explored in: (i) interviews with stakeholders in 2012 and 2015, (ii) online surveys of general practices and local care organisations, and (iii) a purposive sample of ten general practices.The results highlighted the institutional contexts that led to difficulties in implementing population health initiatives. They also revealed that changes in work practices focussed mostly on activities that improved the coordination of care for individuals at risk of hospital admissions.Multi-component complex interventions can vary in their delivery and be vulnerable to one or more components not being implemented as originally intended. In the case of this intervention, the move towards strengthening local relationships arose when contractual arrangements stalled. Realist evaluative approaches offer a logic that helps unpick the complexity of the relationships and politics in play, and uncover the assumptions made by those developing, implementing and assessing health service changes.Given the multi-component and evolving nature of initiatives seeking to better integrate care, the realist evaluative emphasis on surfacing early the theories to explain how change is expected to occur helps overcome the challenge of evaluating “a moving target”. In recognition that the projected demand for the local hospital was going to outstrip supply, a District Health Board in South Auckland, New Zealand introduced a major change programme focused on shifting the balance of care away from the hospital towards the community . Rather In 2012, in the context of a long standing interest in delivering care better designed around the needs of the local community, Counties Manukau District Health Board in South Auckland, New Zealand grouped a number of interventions together into a major change programme in order to deliver more care outside of the local hospital. An earlier initiative involving case management of patients who were high users of the hospital was extended to primary care to increase the management of patients in the community . Under tInternationally, efforts to better integrate health care have taken many forms  often fu81011The changes being put in place to increase the role of primary care by this District Health Board were informed by evidence that a greater focus on primary care is associated with better health, a more equitable distribution of health in populations, and lower health costs 1415. Fur1417An independent evaluation was commissioned to track progress and evaluate the outcomes achieved from a Strategic Locality Partnership Agreement signed between Counties Manukau District Health Board and the five providers of primary health care within the district. In New Zealand, Primary Health Organisations represent the interests of groups of general practices that generally operate as independent businesses receiving a proportion of their funding from government capitation, and the remainder from patient co-payments. In this district, five Primary Health Organisations representing particular enrolled populations were in operation. In many cases these enrolled groupings cut across the geographical boundaries set up by the Localities initiative.The Partnership between the five Primary Health Organisations and Counties Manukau District Health Board established a global budget for each locality centred on the expectation that if each locality was able to reduce demand across an agreed set of shared services then the savings would be directed towards innovative primary care services. The partnership agreement was the founding document of the Localities initiative.Reviews of new contracting arrangements designed to create savings and reduce utilisation have found mixed outcomes. Potential savings can be limited by the time taken to design and implement new contracts, pricing services and agreeing how performance will be assessed . NeverthThe evaluation team undertook an initial assessment of the outcomes expected to be attributed back to the Localities initiative and were struck by the variety of routes being put in place to achieve an outcome concentrated on reducing demand for secondary health care. These routes included new financial incentives via a risk/gain share contract,Recognising that the Localities initiative was not a fixed thing involving an unchanging set of interventions amenable to a closed system investigation, the following evaluation questions were agreed with the specially created Localities Evaluation Advisory Group:What were the initial theories of how the Localities initiative would achieve change?How is the Localities initiative being implemented, and what are the implications for the initial theories of change?What projects/events/interventions to improve integration most characterise the Localities initiative in health providers’ minds?Using claims made in planning documents and governance meetings, as well as insights from relevant literature 23242526,232425networks theory. When health providers are included in local decision-making networks (context), their knowledge about local issues enables them to improve the design and integration of local services (mechanism), which in turn leads to a reduction in demand for secondary services (outcome).The The early parallels between the Localities initiative and clinical commissioning groups in the NHS, led us to theorise that the proposed risk/gain share contract would employ a similar mechanism of using general practitioners’  frontline knowledge about patient experiences to improve service redesign .planned proactive care theory. When local health providers are resourced to undertake more local coordination activities (context), their confidence in working in a planned proactive way for patients increases (mechanism), resulting in better outcomes for patients and a reduction in demand for secondary care services (outcome).The The District Health Board had a long-term concern with those adult patients who were very high intensity users of hospital emergency departments  and havi26relationships theory. When relationships are strengthened between primary and secondary care health providers, and with social care providers as a result of localities-linked events and activities (context), then increased awareness of who to contact (mechanism) improves the coordination of care for individual patients (outcome).The A growing theme in the integrated care literature stresses the importance of the softer issues of relationship building  in orderBox One). Guidance on developing realist theories suggests that formal theories drawn solely from the literature can end up being too abstract :“As a doctor I can say OK book 30 minutes with me and I spend that time with the patient and then pass on to the practice nurse … it doesn’t reduce the time I spend having the nurse involved but it increases the quality of what patients receive” .Larger practices reported adapting to the At Risk Individuals model of care demands by appointing nurse leads, sharing caseloads across nurses and experimenting with different ways of “pulling nurses off the floor” to cover the extra time involved. These staff were also able to draw on a team-based approach to delivering care in partnership with the doctors in the practice. While the At Risk Individuals model of care did involve more work for the nurses, with the right team dynamic they were able to argue for changes to the way the practice allocated time:“When it first started we were all lost … we did not know what to do … but now as we are going ahead it is more work for us but we are getting more time allocated to do that work as well. We are getting set times. As it is going when we do need more time we are speaking out and we are getting an allocation” (Large-size practice participant).As being part of a new locality network was expected to influence practices to work in a more planned proactive way for those with long-term conditions, the focus group results revealed different locality contexts had much less influence than the team dynamic within each practice. Those practices prepared to change their organisational processes in order to support nurses to confidently take on new responsibilities for those with long-term conditions, were those most likely to embrace the opportunities to work in a planned proactive way.The changes put in place by the Localities initiative were collectively expected to shift the balance of care from the hospital to the community by better integrating services between primary and secondary care, moving from a more reactive to proactive model of care and encouraging the provision of more services in primary care settings. However, an assessment of the high-level trends in secondary care demand across the Auckland region found no evidence of change that could be confidently attributed back to the Localities initiative.Confirming that integrated care “is not a fixed thing but instead is a fluid state that requires constant amending and adapting” , the LocThe original Strategic Locality Partnership Agreement was yoked to an ambitious target of a 20% reduction in the projected standardised use of acute medical in-patient bed days and emergency department services over five years. When the Strategic Locality Partnership Agreement was reshaped into a series of enabling activities across the four localities, the policy target remained. However, using the theory-driven realist approach the evaluation sought to assess progress through the intermediate measures of: (i) whether primary care practices were working more proactively for those with long-term conditions; and (ii) the ways in which relationships were improving in order to deliver more integrated care. It is worth reflecting that this smaller scale of experimentation involving a series of enabling activities was forced on the District Health Board by the different power dynamics between the state  and the non-state .This experience adds weight to broader calls to acknowledge the power dynamics within integrated care  and the Box One outlined ten original propositions of how the initiative was supposed to work. These propositions included both actions that reshaped services for different local populations and actions that improved the coordination of care for individual patients. As time progressed, the Localities initiative became distinguished by the attention paid to the introduction of a new case management programme  and the opportunities to build new working relationships. This finding suggests that of all the propositions in play the ones gaining the most traction were those aiming for improvements for individual patients. Smith’s 2011 analysis of New Zealand’s Primary Health Care directions pointed to unresolved tension between population and patient perspectives within New Zealand primary care. Her assessment was that reform emphasis was placed on the population health gains expected from capitated funding, and less management and policy attention was paid to the development of more integrated primary care services for individual patients [From the beginning, the Localities initiative encompassed a bundle of interventions. patients . Adaptiowhat was happening to drive change. The key recommendations from the evaluation were to:Multi-component complex interventions can vary in their delivery and be vulnerable to one or more components not being implemented as originally intended . Recent Temper the expectation that the creation of four localities would reduce demand for secondary care and be more targeted about which local relationships need to be improved in order to benefit which groups of patients. The experience confirms the challenges of the field of integrated care, which can easily be saddled with ambitious business cases claiming significant effects when the reality is that behavioural changes are much more nuanced .Acknowledge the different contexts for local general practices compared to local care organisations. Local care providers were looking to be affirmed as an advocate and coordinator of care for their clients, while general practices wanted to be confident their time was being spent strengthening the local connections most likely to improve individual case management for their patients. These organisational contexts were more influential than the local contexts in each of the four geographical localities.Strengthen the implementation of the At Risk Individuals programme by supporting the growth of team-based cultures within primary care practices. Further research is planned on how patients are reasoning differently in order to support decisions on who is enrolled in the programme.The strength of this evaluation centres on the application of the realist approach. Recognising that the Localities initiative is a social programme involving human decisions and actions, attention was paid to identifying how change is expected to occur, and then testing the extent to which these theories were borne out. A recent realist evaluation of two integrated care initiatives tried to retrospectively identify the context, mechanism and outcomes in play but struggled to identify the relationships between them . This evThe Localities initiative demonstrated an agility in adapting to the complex web of incentives around primary health care in New Zealand, but the consequence was that attributing what was done to earlier defined metrics of success was difficult. The realist logic of enquiry regards programmes as “theories incarnate” . Surfaci


Renal cell carcinoma, particularly the most common clear cell type, is one of the most aggressive of urological cancers with significant risk of metastatic spread. It also has a propensity for venotropism with a proportion of tumors developing thrombi up to the right atrium. The response with newly adopted targeted therapy has been considered to be in the evolutionary stage with no clear role with respect to debulking or reducing the size of the inferior vena cava (IVC) thrombus. We describe a case of a right-sided metastatic RCC with Level IV thrombus initially managed with Pazopanib followed by Nivolumab and Adalimumab followed by cytoreductive nephrectomy and IVC thrombectomy in the post-targeted therapy setting with complete curative response. Renal cell cancers (RCC) comprise 3.8% of all new cancers in the United States with 90% of renal tumors being RCC and about 80% being clear cell type , 2. The A 57-year-old woman with good performance status was detected to have a large right renal mass with adrenal extension and tumor thrombus extending to the right atrium Figures  and 3. SShe was started on Pazopanib 800 mg orally once daily which was later switched to Nivolumab after she developed upper gastrointestinal bleeding secondary to a duodenal ulcer.Interval imaging 6 months after targeted therapy revealed a decrease in the size of the primary renal mass, although the thrombus extension into the IVC still persisted with development of new hilar lymphadenopathy and segmental pulmonary embolism. Nivolumab was continued and 3-month PET/CT showed further reduction in the size of the renal mass with thrombus extension now to the level of liver. There were new enhancing masses in the liver suspicious for metastases with subcarinal, precarinal, and bilateral hilar mediastinal lymphadenopathy.She was initiated on Cabozantinib in addition to the Nivolumab in view of new lymphadenopathy. She tolerated the new regimen very well and was completely symptom-free with this therapeutic combination . New imaBased on the imaging, it was decided to proceed with posttherapy right cytoreductive nephrectomy with IVC thrombectomy. The anticoagulant was stopped and bridging was done with Heparin prior to the surgery. Intraoperative findings were that of a large renal mass with an infiltrating IVC thrombus in the retrohepatic location (using TEE assistance) with no gross evidence of metastases. Open radical nephrectomy with IVC thrombectomy and caval reconstruction was carried out with complete tumor thrombus resection . The patRadical nephrectomy specimen examination showed a necrotic nonviable carcinoma consistent with an RCC with complete response measuring 7 cm in size with perinephric extension. The tumor was extensively sampled and no viable carcinoma was detected . The necShe was fully back to her activities of daily living with no complaints at the time of her first follow-up visit to the clinic at the postoperative visit at 3 weeks. She will continue to follow up with both the Urological Oncology and Medical Oncology teams. She has not been planned for adjuvant targeted therapy at this stage in view of no evidence of residual disease.The management of metastatic RCC with Level IV IVC thrombus is complex and requires multimodality treatments. Current available literature supports the potential increasing role of targeted therapy in the neoadjuvant setting for the management of metastatic RCC and advanced RCC. The therapy does seem safe and feasible with no significant complications. The priority in this case from our standpoint was to achieve substantial downgrading of the tumor and to ensure control of metastatic disease. When this had been accomplished, the next step was posttherapy cytoreductive nephrectomy with IVC thrombectomy.Pazopanib is a preferred Category 1 option for first line treatment of patients with relapsed or medically unresectable Stage IV clear cell RCC. This is supported by the results of the COMPARZ and the PISCES trial which showed a comparable oncological control with fewer side effects reported –7.The data for first line Nivolumab in combination with Ipilimumab for favorable risk patients has been mixed. The Checkmate 214 trial showed that the combination of Nivolumab and Ipilimumab produced a higher objective response rate  and a higher complete response rate  compared to Sunitinib monotherapy [Patients treated with Cabozantinib as a primary treatment modality showed a significantly increased median progression free survival (PFS) compared to those treated with Sunitinib. They also showed a significantly higher objective response rate (ORR) compared to Sunitinib 46% vs 18%) [% [8].One of the benefits of preoperative systemic treatment is the possible reduction in the size of the primary tumor to make it resectable. This has received variable reporting in literature with wide variation in the treatment protocols and adoption. Despite this, there does seem to be some evidence to achieve downstaging in truly unresectable tumors. Thomas et al. reported a series of 19 patients with unresectable or bilateral tumors who received neoadjuvant Sunitinib. 15 patients were able to undergo radical nephrectomy thereafter with mean reduction in tumor size by 16% and significant reduction in tumor burden .The commonly used RECIST criteria to look for response to standardized treatment may not be effective as antiangiogenic therapy may not affect the size of the tumor but effectively produces intratumoral necrosis which is not assessed at all . FurtherPreoperative therapy to produce a reduction in the level of IVC thrombus has remained ineffective with IVC thrombectomy alone remaining the standard of care. Much of the existing literature on the use of preoperative therapy in the setting of an IVC thrombus comes from single center studies. The study by Cost et al. demonstrated there was minimal clinical effect on RCC thrombi with only one case of thrombus level regression from Level IV to Level II .There have been data in the form of randomized controlled trials to demonstrate that overall survival does not increase with a cytoreductive nephrectomy in intermediate and poor risk patients. However this data is not robust for favorable risk patients . Our patDownstaging the advanced primary tumor, tumor thrombus, and metastases provides an option of radical nephrectomy. Although current literature does not advocate neoadjuvant therapy for downstaging the level of IVC thrombus, we found a significant downstaging in the level of the thrombus from Level IV to Level II. Although the standards for neoadjuvant therapy have still not been established due to paucity of literature, more research is required to shed light on management of such tumors.


Infectious diseases can be manifested by a spectrum of clinical signs and resultant clinical courses that range from acute to chronic and possible persistence in the victim in a latent form. Until recently, the origins of this kind of biodiversity were poorly understood, but advances in immunology — especially in identifying the constitutional mechanisms of immunity — have contributed to our understanding of the origins of biodiversity in infectious diseases. Infectious diseases affect only focal areas in the affected organisms, and the amounts and distribution of infectious lesions vary from patient to patient. In a population attacked by an infectious agent, individuals can be conveniently divided into three categories: totally resistant organisms which contain no susceptible structures and are not affected; mildly susceptible organisms in which a few foci appear and in which the infection runs a benign course; organisms in which the number of constitutionally susceptible structures is high and the infectious process develops in a severe form. The diversity is determined by the differences in susceptibility of various parts of the organism under consideration.


Shale gas is considered by many to have the potential to provide the UK with greater energy security, economic growth and jobs. However, development of a shale gas industry is highly contentious due to environmental concerns including the risk of groundwater pollution. Evidence suggests that the vertical separation between exploited shale units and aquifers is an important factor in the risk to groundwater from shale gas exploitation. A methodology is presented to assess the vertical separation between different pairs of aquifers and shales that are present across England and Wales. The application of the method is then demonstrated for two of these pairs—the Cretaceous Chalk Group aquifer and the Upper Jurassic Kimmeridge Clay Formation, and the Triassic sandstone aquifer and the Carboniferous Bowland Shale Formation. Challenges in defining what might be considered criteria for ‘safe separation’ between a shale gas formation and an overlying aquifer are discussed, in particular with respect to uncertainties in geological properties, aquifer extents and determination of socially acceptable risk levels. Modelled vertical separations suggest that the risk of aquifer contamination from shale exploration will vary greatly between shale–aquifer pairs and between regions and this will need to be considered carefully as part of the risk assessment and management for any shale gas development.The online version of this article (10.1007/s10040-018-1737-y) contains supplementary material, which is available to authorized users. One such use of the subsurface, the production of natural gas from shales, or shale gas, has received growing attention in the last few years, with recognition of the range of potential threats to groundwater  are shown in Fig.  are showA methodology is presented here for evaluating the vertical separation between shales and aquifers across England and Wales. Its application is demonstrated for two important principal aquifer–shale combinations—the Cretaceous Chalk Group aquifer and the Kimmeridge Clay Formation, and the Triassic sandstone aquifer and the Bowland Shale Formation . The Chalk Group and the Triassic sandstone aquifers are the most important aquifers for water supply in southern and northern England respectively  are established as part of the EU Water Framework Directive and applied to groundwater bodies. The UK Technical Advisory Group (UKTAG) have issued guidance on the definition and delineation of groundwater bodies UKTAG , recommeThe UKTAG recommendation is consistent with the zone of active exploitation of groundwater in England based on the distribution of borehole depths within a given aquifer. Most exploitation of groundwater takes place at depths of a few tens of metres below groundwater level—Fig. S1 of the electronic supplementary material . HoweverThe first extensive review of shale gas prospectivity in the UK  National Geological Model (NGM) of Great Britain  of contaminants migrating between shales and aquifers Myers . NumericImportantly, these numerical models of contamination transport do not consider the likelihood of particular geological conditions existing  out of a possible 25 aquifer–shale combinations identified in the UK have been presented and discussed. In general, the vertical separation for the Chalk Group and Kimmeridge Clay Formation is much smaller than for the Triassic sandstone and Bowland Shale Formation though both pairs show quite large variability, reflecting the complex geological history and basin development of the UK. Safe vertical separation distances are difficult to determine due to large uncertainties in geologic parameters and determination of socially acceptable risk levels and aquifer depth limits. Modelled vertical separations suggest that the risk of aquifer contamination from shale exploration will vary greatly between shale–aquifer pairs and between regions.ESM 1(PDF 1622 kb)


The Paediatric Rheumatology European Society (PReS) has over many years, developed a portfolio of educational activities to address increasing educational needs of workforce and support young clinicians to acquire skills to develop new knowledge and deliver clinical care in the future. These educational activities aim to facilitate growth of paediatric rheumatology and ultimately improve the clinical care for children and families. This article describes the current portfolio of PReS educational activities and their relevance to the international paediatric rheumatology community. The Paediatric Rheumatology European Society (PReS) has an overarching aim to promote paediatric rheumatology as a sub-specialty across Europe and also further afield through the expanding international membership. PReS aims to improve the lives of children with rheumatic diseases through collaborative networking to raise awareness, facilitate high quality research to create new knowledge, support education and training, promote advocacy and ‘best care ’ based on evidence, consensus and active consumer engagement. The importance of education and training activities to achieve these aims and address unmet need within Europe has been highlighted following the SHARE initiative . This new syllabus ensures that rheumatology training is compliant with the revised European Syllabus structure and format. The educational activities of PReS reflect the roles of the paediatric rheumatology specialist; namely ‘life-long’ scholarly clinician, researcher and teacher. These roles have foundations firmly embedded in the European Syllabus which sets out the minimum requirements for training to cover knowledge , skills  and professional roles . In the context of education and training, the 2016 European syllabus for paediatric rheumatology has the following aims:Harmonise training programmes across European countries.Establish defined standards of knowledge and skills required to practice paediatric rheumatology at the tertiary care level.Foster development of a European network of competent specialist centres to facilitate collaborative research and training opportunities.Improve the clinical care of children with chronic and acute rheumatic disorders within Europe.Enhance European contribution to international scientific progress in the field of paediatric rheumatology.Promote teaching of paediatric rheumatology at undergraduate and postgraduate levels to raise awareness about the importance of early diagnosis, prompt referral to specialist care and facilitate potential recruits to fellowship programmes and the future workforce.The educational activities of PReS are overseen by the PReS Education and Training Committee (ETC), currently led by one of us [TA]. The PReS ETC represents rheumatology within the European Academy of Paediatrics and has contributed to the recent 2016 European Syllabus for Training in Paediatrics  through ‘state of the art’ lectures and presentations. There are active allied health and consumer parallel programmes. The annual scientific meeting has become one of the most important educational events in the paediatric rheumatology international calendar and provides a platform to disseminate knowledge, opportunities to network and foster new collaborations. The annual Young Investigators Meeting (YIM) is held over the two days preceding the annual scientific meeting and is organized with support from PReS to facilitate attendance by young researchers  and trainee doctors. The YIM aspires to nurture the PReS research ethos and aims to promote networking and foster opportunities for international collaboration; young investigators are encouraged to present their work to an international audience with feedback and guidance from PReS & YIM senior faculty. Over recent years the number of young investigators attending the YIM meeting has increased significantly with a substantial number of trainees from non-European countries . Proceedings of future meetings and how to apply for YIM bursaries are available on the PRES website (https://www.pres.eu).The annual scientific meeting of PReS disseminates advances in knowledge and research (http://www.pres.eu). The aim is to have one of either the Basic or Advanced course per year and to reach audiences who may not otherwise have access to education and training. PReS members are encouraged to contact the ETC for further information if they wish to consider organizing a Basic or Advanced course in their country and seek PReS support.The ETC oversees a ‘rolling programme’ of courses which are financially supported by grants from PReS. Details of future courses and how to register for them are available. , Sao Paulo (Brazil 2015), Budapest (Hungary 2015) and Cape Town (South Africa 2017) with future courses planned in the Ukraine and South East Asia. The aim is to promote the specialty, facilitate networking and ultimately improve patient care. The model includes an organising committee led by a local paediatric rheumatologist with faculty drawn from local and national colleagues as well as international faculty who are PReS members. Examples of previous Basic Courses are available from the ETC and it is envisaged that lectures from courses will be archived on the PReS website. The Basic Courses have a similar format  and up to 100 delegates, with interactive lectures and workshops. Case presentations are encouraged from delegates. Workshops focused on joint examination have been included since 2015 with practical demonstrations of pGALS (paediatric Gait Arms Legs and Spine)  website (octors [  Smith ethttps://www.printo.it/pediatric-rheumatology/). The importance of patient and family advocacy and engagement in clinical care, service delivery and research has been highlighted [ [Patient and parent information - Further to the SHARE initiative there has been a complete revision of the freely available information leaflets covering a broad spectrum of conditions and including translations into several languages  and through a bimonthly newsletter highlighting activities and opportunities for members (contact emerge.pres@gmail.com). The PReS EMERGE fellowship programme (https://www.pres.eu/activities/young-investigators/fellowship-programs.html) was launched in 2017 with financial and practical assistance for clinical trainees who are members of PReS and younger than 40 years, to facilitate placements of up to 6-months within a European Paediatric Rheumatology Centre. In addition to gaining clinical knowledge and skills, the trainee is expected to participate in a research project. From 2018, the programme is open to basic science trainees (pre-PhD to five years post-PhD) working in paediatric rheumatology. It is envisaged that the programme will enhance both clinical and basic collaborative research, foster a network of emerging and established paediatric rheumatologists and allow sharing of ideas and practices between different countries to harmonize paediatric rheumatology training.PReS EMERGE (EMErging RheumatoloGists and rEsearchers) encompasses young paediatric rheumatologists and researchers working together to improve clinical and research opportunities for trainees, participating in organisation of PReS educational events  and liaising with other young investigator groups . The group was set up following the 2016 YIM and currently includes trainees mainly from Europe but also from all other continents. Further details are available through an active social media network (The Standards of care for Juvenile Arthritis Management in Less Resourced countries (JAMLess) is a collaborative effort with funding and support from International League Against Rheumatism (ILAR) and PReS to develop consensus based guidelines relevant to challenging health care contexts; these highlight the importance of education and training being integral to the delivery of clinical care. This project was initiated by PReS colleagues from South Africa, Argentina and India and has resulted in a consensus document [  Scott C The activities of the PReS ETC aim to improve access to, and provision of, high quality clinical care delivered by an appropriately trained workforce and ultimately improve outcomes for children and families. The emergence of Basic and Advanced courses, specialist courses, online resources and the EMERGE fellowship programme, supplement the annual scientific meeting of PReS and YIM as a means to facilitate advances in knowledge being implemented into high quality evidence-based clinical care. We recognize that more work is needed to enable and support the expanding paediatric rheumatology community both in Europe and Internationally. The uptake and implementation of the new 2016 European syllabus into training programmes needs to address the accreditation of training centres, a proposed European sub-specialist examination and certification in paediatric rheumatology.There is now an overarching structure to the education and training activities of the PReS ETC to address the expanding needs of the broad paediatric rheumatology community with the content based on the 2016 European Syllabus for training. The format and structure of the PReS educational portfolio, much of which is free and open to all, serves as a template relevant to the wider international paediatric rheumatology. There is clear synergy between the educational and training activities of PReS and other initiatives led by paediatric rheumatology organisations elsewhere in the world . Through working with colleagues around the world, the aim has been to ‘reach out’, raise awareness and facilitate growth of paediatric rheumatology relevant to the local context.


Background: Pharmacy has utilised the changes in legislation since 2000 to increase the range and supply function of services such as travel health to travellers. With the number of travellers leaving the UK and trying new destinations there is an increasing need for more travel health provision. Working models: The models of supply of a travel health service vary according to the size of the corporate body. The large multiples can offer assessment via a specialist nurse or doctor service and then supply through the pharmacy. Others will undertake an onsite risk assessment and supply through the pharmacist. The sole Internet suppliers of medication have been reviewed and the assessment standards questioned following survey and inspection. Education: There is no dedicated pharmacist-training programme in advanced level travel health. As a consequence one academic institution allows pharmacists to train on a multidisciplinary course to obtain an academic membership. With training for travel health not being mandatory for any travel health supply function the concern is raised with standards of care. Future: There is a consultation paper on the removal of travel vaccines from NHS supply due to be decided in the future. If these vaccines are removed then they will provide a greater demand on pharmacy services. Discussion: The starting of a travel health service can be made without any additional training and remains unregulated, giving cause for concern to the supply made to the traveller. Conclusions: Pharmacies in the UK offer a range of options for supplying travel health services; however these need to be with improved mandatory training and supply. This is a review of the development of the practice of pharmacy in the UK developing from the legal changes that occurred in the 2000s to include modern working models and specialist eduction that is available to pharmacists.In the UK, prior to 2000 the role of the pharmacist was that of the traditional supply function against the supply of a prescription and the sale of over the counter products (OTC). Within the UK the legislation is defined in 3 legal categories of medicines, prescription only (POM)—only supplied against a doctors or dentists prescription ); pharmacy only medicines (PM)—only supplied from a licensed pharmacy in the presence of a pharmacist and OTC products. At this time there was no legislation that allowed pharmacists to provide routine or travel vaccinations or to supply POMs without a relevant prescription.With changes to both the legal supply of POMs and the increasing requirement to use pharmacist’s clinical skills then evolvement of influenza vaccination was introduced. This led onto the consideration of travel health health services from a pharmacy, by a pharmacist, to become established.The changes to a nationally funded travel health service remain under scrutiny and with increasing numbers of patients travelling abroad annually (+5%) and +27% intending to to travel a country they have never visited before  the NHS In 1998 the NHS reviewed the medicines that where be allowed to be supplied on a prescription. This review included the removal of chloroquine for malaria prophylaxis and the change to PM status allowing it to be purchased from pharmacies, . The NHSIn 2000 following lobbying from the Royal College of Nurses (RCN) for group protocols to supply national immunisation services, the law was changed to allow the supply of medication by healthcare professionals using Patient Group Directions [At the same time-work was underway to allow a new category of prescribers to be formed. This became known as supplementary prescribing, which was originally given to practice and district nurses working alongside a doctor to reduce the workload . A supplWith the increase in clinical knowledge and skills being taught and applied to other healthcare professions the role of independent prescriber was created in 2006, which included pharmacists . This roA major change in the law occurred in 2012 with the introduction of the Human Medicines Regulations . This alWith the UK Government reviewing the impact of annual influenza absences and the pressure for new roles to be allowed to pharmacy the first pharmacy flu vaccination services were introduced in 2007 as a private service utilising PGDs. This continued until 2015 when it was extended and included as a pharmacy NHS funded service.Alongside the provision of seasonal influenza vaccinations other vaccination services supplied by PGDs and Pharmacist Independent Prescriber (PIPs) evolved such as travel vaccinations and the supply of antimalarials for prophylaxis. With the austerity measures imposed on public spending private clinical services were considered as a part solution to maintaining financial solvency.In late 2017 the PHE was tasked with a consultation between professionals to consider if the total withdrawal of all vaccines for pre-travel should be removed from the NHS [The significance of the changes to practice working at a faster rate than legislative changes has led to the introduction of support networks for pharmacists providing travel health service using telemedicine or at distance triage services completed by a nurse or doctor .Within the pharmacy population in the UK, 49.2% of pharmacies are owned by groups and termed large multiples. Examples of these include Boots, Lloyds, Well, Rowlands and the supermarket groups of Asda, Morrisons and Tesco. Other smaller independents provide 12.4% and the remainder is made up small chains (<3 outlets) and independents 38.4% of the market [Access to travel health or medicine services is varied and one type of model includes a risk assessment being completed externally by a doctor, nurse or pharmacist and then the vaccination or anti-malarial supply being authorised by either a private prescription or directed to a pharmacist through a Patient Specific Direction (PSD). .Other pharmacies, allow an online booking service to be made with one of its selected stores  for a risk assessment lasting up to 40 min. The clinical support and backup is provided by a nurse led service to which the pharmacist can refer. The pharmacist can administer the vaccinations and supply the medication at the appointment.The UK legislation differs at this point regarding the regulation of the standards of practice between solely organised pharmacist clinics and those by other healthcare professions. The regulating body in England, the Care Quality Commission (CQC)  regulateA small independent survey study in 2018 concluded that a pharmacy travel health service was well accepted by patients and met their needs, providing a value for money service .With the supply of POM medication made by pharmacists either under a PGD or as an Independent Prescriber the professional expectation is that the standard of training to use these preparations should be of the a similar standard at an advanced level. Within the UK there is no legal requirement to have received any formal advanced level training before using a PGD and whilst an Independent Prescriber qualifies in a defined area of competence, they are legally allowed to prescribe any medicinal product outside of their competence, including controlled drugs.To ensure that basic immunisation is practiced correctly the GPhC in alliance with the Royal College of Nursing and Public Health England have published a document that lists the national minimum standards and core curriculum for immunisation training for registered healthcare practitioners .For those pharmacists who do elect to undertake extended training there are ranges of courses in travel health that are shared with other professions allowing an equality between practitioners. Examples of this can be found at the centres of excellence of in London, Liverpool and Glasgow. Details of the courses available to pharmacists are seen in Additionally an external representative body, the British Global Travel Health Association (BGTHA) has produced its own e-learning programme that is currently awaiting accreditation.The Association of British Travel Agents travel trends report  indicateWithin the UK the changes in national legislation have provided wider and more extensive powers for pharmacists to supply POM medication. The term travel health is undefined and yet to be recognised by the General Medical Council as a medical speciality. The consequence is that a pharmacist can initiate a travel health service and the levels of service being offered can vary from the supply of antimalarial medication to specialists who have completed an extensive level of training. To become competent in travel health, pharmacist practitioners should consider the need to complete an independent prescribers course, a recognised formal qualification in travel health and membership to a medical Royal College. This has been accomplished by a small number of pharmacist practitioners, however the practice of travel health without all of the additional skill sets, relies on the pharmacist to understand the limits of their competency when assessing and providing a clinical service.As highlighted before, the supply function of POMs can be made using a PGD, however no mandatory training on the use is required to use these. The other supply function is using an independent prescriber that trains in a specific area of competency but are legally allowed to prescribe any POM. A consequence of this is that pharmacist independent prescribers can supply travel health medication without being specifically trained in the specialist clinical area.The professional guidelines advise that independent prescribers should only practice within their competency and that PGDs are only used following specific training. Due to the complex nature of travel health a review is required of the supply provision and training and that should include arrangements for referral of complex patient cases to specialist pharmacists. The need of specialist, mandatory training is supported by the Faculty of Travel Medicine who have published a statement indicating that there is no licensing or checks on the level of care and that travellers are at risk .By comparison in Alberta, Canada pharmacist provided travel health services are supplied by suitably trained pharmacists with basic life support skills and prescribing skills. The additional requirement is the completion of a formally recognised qualification in travel health, such as the Certificate of Knowledge of the International Society of Travel Medicine .Travel health provision through UK community pharmacies is well advanced due to changes in national legislation. The supply of POM medications using PGD and independent prescriber services allows any pharmacist to privately supply travel health medication; however the minimum skill base to provide these services remains undefined and not legally required. To ensure the ongoing safety of travellers then the UK licensing authorities need to consider working with the specialist education providers to define minimum standards of competence for pharmacists. The formal training of advanced level services available to pharmacists is supplied through a single awarding institution, with other institutions selectively offering to medical practitioners and nurses only. To match the demand of pharmacist level travel health services more formally certified post-graduate courses in travel medicine would need to be made available. The future would indicate that with more people travelling there would be an increased demand on travel health services in the UK.


Humans are influencing the global carbon (C) cycle due to the combustion of fossil fuels and due to changes in land use management. These activities are fostering the manmade greenhouse effect and thus global climate change. Negative effects for life on earth are accounted for.Among others the international climate debate focused attention on forests and forestry, knowing about their considerable influence on global climate change. Whilst the global C budget is described fairly well, there is a lack of regional data describing the C reservoirs and flows in detail. This has to be constituted especially for forests in developing countries.This paper presents an investigation at regional scale of the C reservoirs in a South American forest ecosystem. The investigation puts emphasis on the area and stand volume estimation and the development of expansion and reduction factors. Vegetation types are classified and stratified, determining the corresponding areas and estimating the stand volume. Converting factors are developed to calculate C in branches and roots as a percentage of standing wood measured by inventories.


Voice-activated digital assistants  are an emerging technology that have great potential to provide support for adults aging with a long-term mobility disability. Digital assistant technologies allow the user to perform a variety of everyday tasks and activities through voice interactions. Such tasks may include environmental control ; supporting self-health management ; and fostering opportunities for social engagement . This presentation will focus on the perceived facilitators and barriers to digital assistant use in the home among adults aging with mobility disabilities. The findings provide design guidelines and insight for intervention implementation for the use of these technologies for the target population.


Despite being discovered over 50 years ago, and its close association with the development of several important human cancers being well-documented, Epstein Barr Virus (EBV) continues to be a source of important information on how viruses can contribute toward the development of human cancer. EBV is known to be an important carcinogen, but because of its large genome (around 172 kb), much still remains to be discovered about its normal viral life cycle and how it drives malignancy at different anatomical sites.In a recent study in PLoS Pathogens (Lyu et al., Studies such as this are exciting because they begin to define how these viral miRNAs can both contribute toward malignant development and provide favorable environments for viral replication. It will now be very interesting to determine whether blocking the function of these miRNAs has any potential therapeutic applications.In contrast to EBV, two viruses that have only more recently gained notoriety are Dengue and Zika, which belong to the family of Flaviviruses. These viruses are mosquito-borne and represent major and growing health problems in many parts of the world. Whilst a great deal of attention has been placed on understanding the immunology underlying clearance of infection with these viruses, much less is known about the underlying mechanisms by which the viral gene products interact with components of the host cell.In a proteomic tour de force published in the recent issue of Cell (Shah et al., Since Shah et al. provide data on both the mosquito and human viral interactomes, this opens the way for studies to specifically characterize the functions of different viral proteins in the two different hosts and may offer leads for the development of novel therapies or preventative measures.The author confirms being the sole contributor of this work and has approved it for publication.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.


Colijn et al.). Quantifying patient similarity is an important challenge that is critical in predicting patients' disease trajectories  patient similarity concept has been introduced as a paradigm shift in optimizing personalisation of patient care.Appropriate mathematical tools and methodologies are critical for ensuring robust and reliable computational model predictions based on medical and healthcare data in the era of the digital health revolution  of statistical learning in the model space for Attention-Deficit Hyperactivity Disorder medication response prediction at individual patient level. Mental health is intimately related to neurological diseases and brain modeling for neurological disease treatments .Applications of mathematics in healthcare are achieving unprecedented growth at vertiginous speed in a vast number of areas. Mental health presents a formidable challenge in our modern society and computational psychiatry has recently emerged  as well as type 1 diabetes . Chronic diseases are often extremely complex leading to computational models formulated in high-dimensional space, which poses a challenge for characterizing the pathways of disease progression or patient-specific disease progression trajectories as discussed in Colijn et al. Computational cardiology encompasses mathematical modeling and computer simulation of dynamical processes in the heart and the cardiovascular system in health and disease . Computational cardiology applications could help in improving clinical decision support systems in cardiac ablation therapy for example . Moreover, the use of collections of patient-specific models could provide a tool for pre-clinical and clinical assessment of disease pathology such as atherosclerosis and associated calcification .Non-negligible effort is currently being devoted to capturing disease progression, a real challenge in this field. Disease progression modeling involves simulations of disease evolution based on available biomarkers or other time-dependent measures of disease status. This is particularly important in the case of chronic (non-communicable) diseases as demonstrated in this special issue in the case of hypertension  presents a network-based statistical methodology for cancer biomarker selection. Computational and mathematical pharmacology is becoming increasingly relevant for drug development. Mechanistic models has become more and more widely used and our understanding of the models' qualitative and quantitative behavior has improved  as well as the estimation of drug absorption profiles in-vivo .Computational oncology broadly refers to computational modeling and simulations of biological process underlying tumors' development and progression as well as cancer therapy including cancer biomarkers and drug effects . This special issue presents several examples of such methodological developments in the case of quantifying: the biomechanical properties of human gallbladder ; the forces involved in abrasion damage to skin ; and intracellular calcium signals .Robust quantitative methods for identifying biologically/physiologically relevant computational model parameters from experimental data are critical for the successful applications of computational medicine in precision healthcare  that are necessary for implementation of precision healthcare  as well as to inform public policies related to vaccination, for example see .Infectious disease modeling including the underlying mechanisms is becoming increasingly important in the face of the anti-microbial resistance and its associated clinical and public health burden (de Kraker et al., By no means the topics included in this special issue are exhaustive. They are rather indicative of a wider range of problems specific to computational medicine that not only can be tackled by available mathematical approaches but also inspire the development of novel tools and techniques. Examples of methods that have not been included are machine learning and artificial intelligence for electronic health records analysis and usage (Callahan and Shah, KT-A and VD-Z conceived and wrote the editorial.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.


The Journal retracts the 20 September 2016 article cited above. Following publication, the authors discovered through further analysis that the species of bacteria discovered in this study was resolved in error.This retraction was approved by the Field Chief Editor of Frontiers in Microbiology.


An error was found in the first and second sentence of the original article's abstract.It had originally been published as:Hereditary inclusion body myopathy (HIBM) is a rare autosomal recessive adult onset muscle disease which affects one to three individuals per million worldwide. This disease is autosomal dominant and occurs in adulthood.The corrected sentences should read:Hereditary Inclusion Body Myopathy (HIBM) is a rare autosomal dominant or recessive adult onset muscle disease which affects one to three individuals per million worldwide. This disease is autosomal dominant or recessive and occurs in adulthood.The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way.The original article has been updated.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 paper is a commentary on the training of Chinese Primary Health Care Doctors to reduce chronic illness and its burden. First, we will consider the policy position of the Chinese government concerning the development of a competent and enlarged primary physician workforce to deliver the proposed primary health care system reforms. We then turn to a review of the drivers of the high burden of chronic illnesses especially in older people in China. We argue that the curriculum for the training of primary health care medical practitioners should match the demonstrated high prevalence chronic illnesses and their risk factors and that there needs to specific competencies in prevention and mitigation of the diseases and their risk factors. The various policy statements from the Chinese State Council  and the China has also recognized the need for expansion of its primary care physician workforce and has set ambitious targets for the growth in this workforce . Its phyIn designing training systems for the Chinese primary care physician workforce it is necessary to understand the health needs of the people that the workforce is intended to service . The popThe United Nation's Sustainable Development Goals for 2030  include The China Joint Study Partnership comprising the World Bank Group, the World Health Organization, the China Ministry of Finance, the National Health and Family Planning Commission, the Ministry of Human Resources and Social Security  recentlyHowever, the Deepening Reform report  differs Shaping a tiered health care delivery system in accordance with People-Centered Integrated Care modelsImproving quality of care in support to People-Centered Integrated CareEngaging citizens in support of People-Centered Integrated CareReforming public hospitals and improving their performanceRealigning incentives in purchasing and provider paymentStrengthening health work force for People-Centered Integrated CareStrengthening private sector engagement in production and delivery of health servicesModernizing health service planning to guide investment.https://www.cochranelibrary.com/ which at the time of writing had 162 systematic reviews of patient centered care with almost universally successful results). A further key feature of the Deepening Reform report is its evidence-based philosophy. The report focusses on what can be done to improve the efforts in the delivery of services that address the demonstrated health needs of the Chinese people.The central inclusion of the concept of People-Centered Integrated Care reflects best global health care practice . This isWhile all the identified “levers” are certainly worthy of attention, our focus as educators of primary health care physicians in this commentary is on delivering the required numbers of appropriately trained doctors to participate in the new reformed Chinese system. This raises the question of what should be included in an appropriate Chinese primary care physician curriculum?We have made substantial progress in the development of the Shenzhen standards for primary care physicians. We have critically analyzed the major Western General Practice clinical standards. The new Shenzhen standard was developed using rigorous modified Delphi procedures with a large expert panel building on a detailed analysis of relevant international standards. Embedded in the standards are assumptions about what doctors will and should do in their everyday practice. We have separately reported the Shenzhen standards development in another publicationThe major illnesses associated with China's disease burden have been studied in detail by many government bodies and academic researchers. The same lists emerge from these analyses. The Deepening Reform Study  and the Stroke (35.9 million DALYs)Malignant neoplasms (30 million DALYs);Ischaemic heart disease (22.6 million DALYs);Respiratory diseases (16 million DALYs);Diabetes mellitus (5.6 million DALYs);Mental health conditions such as depression, suicide and dementia (5.3 million DALYs);Hypertensive heart diseases (3.6 million DALYs); andFalls (3 million DALYs).Thus, it is evident that primary health care physicians require a substantive knowledge of these conditions and their prevention and management. This is how many medical curriculums are organized with a list of key conditions to be covered.However, we consider that the second key focus is the need for primary care physicians to identify and to mitigate and control the risk factors that exacerbate the main diseases. To mitigate these risk factors requires a quite specific skill set. The same analyses have identified risk behaviors amongst the Chinese population that exacerbate the above list of diseases. For example, smoking is a key health risk for most of the above list of diseases/ conditions. But there are others that the WHO analysis  has idenDietary risksHigh blood pressureSmokingHigh fasting glucose levelsExposure to air pollution andPhysical inactivityWhile our focus for this paper is behavioral risk factors that can be mitigated in the primary health care setting, in order to address behavioral risk factor mitigation in China we recognize that multi-level approaches are needed including a systematic approach to chronic illness management within the health system, public health interventions, as well as primary health care physician training in behavior change approaches. In China, as discussed previously, the Deepening Health Reform in China monograph , developIn the United Kingdom and Australia, chronic illness management systems have been strongly influenced by the Wagner Chronic Care Model  and a foIn Australia, General Practitioners (GPs) are funded by the national health insurance system and government to provide longer consultations and care planning for patients with chronic illnesses . A recenMedication management in primary care in people with chronic illnesses has been a particular focus in Australia and world-wide. Polypharmacy, the prescription of potentially inappropriate conflicting medications has been recognized a potential risk to patients with chronic illness and the typical pattern of multimorbidity. However, the effectiveness of polypharmacy reduction programs –22 and tChronic illness management also needs to address mental health co-morbidities. Since 2006 the Chinese Government policy has promoted the detection and treatment of mental illness in primary care settings through integrated mental services . Yet traPublic health approaches are also an important part of addressing behavioral risk factors at the population level. Smoking is an example of the need for combined regulatory, public health and primary care approaches. For example, to reduce smoking rates, strategies such as increasing excise on tobacco, regulating smoking advertising, banning smoking in public places, public health education and health promotion programs and plain paper packaging have been used in Australia and other western countries to reduce smoking levels . In ChinAddressing physical inactivity is another important risk factor for poor health and chronic illness prevention and management that requires primary care and public health interventions as well as legislative approaches. In a review of national policies to increase Health Enhancing Physical Activity (HEPA) in seven European countries, Bull et al.  reportedThe Chinese National Fitness Plan (2016-2020) aims to increase physical activity and population health . The plaThere has been significant Chinese work in clinical trials and systematic reviews of this issue. For example, we examined the therapeutic effects of motivational interviewing on blood pressure control by conducting a meta-analysis of randomized controlled trials . The revThere is widespread agreement about the need to appropriately train general practitioner physicians so that they may deliver high quality and effective care to their patients. There is also strong evidence that there is a global shortage of skilled practitioners and China has particular needs to develop the talent pool to support its ambitious primary care reform agenda. We have argued that primary care physician training needs to be informed by rigorous analysis of the causes and underlying risk factors for high burden of disease conditions. These conditions and their treatments have been well-researched and there is a strong evidence base. We propose that to effectively prevent and mitigate the many chronic conditions and diseases that are caused and exacerbated by lifestyle factors requires high level behavior change skills, mental health detection and management skills and other patient management skills that need to be included in the Chinese primary care physician curriculum.http://datatopics.worldbank.org/world-development-indicators/Publicly available datasets were analyzed in this study. This data can be found here: All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Based on rapidly increasing numbers of older adults and growing populations of culturally diverse citizens, we developed and provided an interprofessional education program for graduate nursing and social work students that focused on the delivery of care to older adults and veterans with multiple chronic conditions. The students participated in multiple activities together over a year long period. Activities included an introductory IPE day with all students together and simulated patient cases that had required roles for the students’ specialties. Knowledge and skills of interprofessional collaborative practice were measured with the Interprofessional Self Assessment Competencies (IPEC) and Assessment of Interprofessional Team Collaboration Scale (AITCS). We also measured attitudes toward cultural differences using the Cultural Awareness Scale (CAS). The entire project was repeated a second year with a second cohort of students. Overall, our students were better able to understand and work collaboratively with other health care professionals after participating in this program. Regarding cultural awareness, both NP and SW students were more aware of and comfortable with cultural differences after participating in the program. After one year of experience, we wanted to know more about our students’ skills and attitudes. Focus groups were added to the design to dive deeper into the students’ perceptions about which activities were most impactful and recommendations for future IPE activities. This paper will describe these data and implications for future planning of more effective interprofessional and cultural programming for students caring for older adults and veterans.


In addition to the broad panel of aging related biomarkers available in HRS, we will describe measurement of novel aging biomarkers such as telomere length and mitochondrial DNA copy number in 4000 HRS participants. Both these biomarkers were measured in DNA obtained from whole unsorted blood using quantitative real time polymerase chain reaction (PCR) and were adjusted for individual cell composition measured from flow cytometry. We will describe the relationship between these two biomarkers and other measures of biological age available in HRS. Differences in these two novel aging biomarker by socioeconomic status, race/ethnicity, and exposure to early life hardships will be presented to clarify the value of the data to further unravel how social factors get under the skin to affect the process of aging.


In order to provide effective mental health care to older adults with major neurocognitive disorders  within outpatient mental health clinics, mental health practitioners must possess a basic understanding of these disorders, the needs of and challenges faced by people living with dementia and their families, and effective treatment approaches for this population. The Mental Health Gero-Champions Program was established in 2015 at a large Veterans Affairs medical center with the aim of providing clinical support and opportunities for training to multidisciplinary mental health providers to enhance skills in assessing and treating older adults with neurocognitive disorders. This presentation will provide an overview of the Mental Health Gero-Champions Program, describe the development and implementation of this program, and discuss challenges and successes in sustaining this transformative initiative over time.


Chlamydomonas to the addition of acetate during day/night cycles”  icl mutant, a null mutant of the isocitrate lyase gene, and its control are summarized and the FPKM values are listed. The data were analysed using surprisal analysis and the genes contributing the strongest to the mutant and wild type phenotype are listed. The raw data are accessible at BioProject PRJNA437393 with SRA accession number SRP136101 (experiments SRX3824204–SRX3824249). The raw data set and expression values used for surprisal analysis are made public to enable critical or extended analyses.The data presented in this article are associated to the research article “Surprisal analysis of the transcriptomic response of the green microalga  Data shared concerns the reads information for each biological replicate (The dataset of this article provides information on raw RNA-seq reads obtained from the eplicate , the FPKeplicate , the numeplicate , the liseplicate .List of shared data is found in the 2Chlamydomonas to the addition of acetate during day/night cycles’ by Willamme et al. The experimental design has been described in the accompanying research paper (‘Surprisal analysis of the transcriptomic response of the green microalga


We consider the human genetic targets of many proven and hypothesized pharmacologic interventions meant to promote healthy-aging and explored not only how polymorphic these targets are in the human population, but also whether these polymorphisms have been shown to impact longevity and age-related phenotypes in general. We also determined if polymorphism in the genes or proteins modulated by healthy-aging interventions have been shown to also modulate the expression levels of those genes and proteins  and whether they have been subjected to mediation analyses testing their potential causal relationships to aging and longevity phenotypes. We compare our results to studies of other classes of drugs used to treat specific conditions, such as hypertension.


A radiographer has the unique advantage of directly seeing the patient and presenting injury at the time of imaging. Extending this skill set to further evaluate the image acquired and document the findings may be helpful in reducing diagnostic errors in emergency department. Since the invention of X‐rays, medical imaging has played a prodigious role in the field of medicine, with it being an important and at times the only diagnostic tool amongst an array of investigative methods available to a healthcare practitioner. Emergency departments (ED) form the frontline defence for a healthcare system, and with increasing activity seen throughout Australian departments,Due to the constant rotation of junior doctors in and out of the ED, coupled with the spectrum of skills that junior doctors are required to develop, the consultant group in my ED are always considering new processes/initiatives that assist in mitigating error. One such initiative is radiographer preliminary image evaluation (PIE). The introduction of a PIE system in 2016 into my ED has seen an extra layer of safety implemented for patients whose radiographic images are interpreted by referring healthcare practitioners such as medical doctors, nurse practitioners and physiotherapists. Healthcare practitioners are advised to initially review the radiographic images and make an assessment before checking their assessment against the radiographer PIE. This workflow assists referrers in developing their image interpretation skills by having an immediate second opinion.A radiographer has the unique advantage of directly seeing the patient (and presenting injury) at the time of imaging. This scenario along with their knowledge and expertise of radiography promotes the acquisition of high‐quality X‐ray imaging. This also provides the radiographer with an extra edge at interpreting the radiographic images when compared to the referring practitioner and the reporting radiologist. Radiographers in a public healthcare system may form a stable workforce when compared to junior doctors who tend to rotate between multiple specialities, and training a radiographer would be more cost‐effective and may result in consistent image interpretation.In reference to the study by Brown et al.Following review of the findings of this audit, an additional process was employed to reduce errors that may have occurred from the radiographer's incorrect PIE. This process involves the reporting radiologist flagging examinations where a discrepancy exists between the radiographer's PIE and the radiologist's report. These discrepancies are reviewed by a senior radiographer who compares the radiologist report to the ED diagnosis. If a true discrepancy exists, the senior radiographer notifies an ED consultant and requests the case to be reviewed. I believe this additional process improves the overall diagnostic accuracy of our service, thus reducing error.Some ED radiographs such as obvious dislocations or fractures, or injuries of fingers and toes may not require formal reporting by a radiologist. The adoption of a selective reporting policy may reduce the reporting workload of the radiology department without compromising patient careRadiographer PIE is likely to benefit both the patients and ED in reducing missed injuries and reducing recall rates. For any ED who is planning on implementing such a system, it is important to clearly advertise and communicate the process prior to implementation with regular reminders of the availability of such a process. Regular audits on efficiency and a robust verification platform are crucial to the effective functioning of PIE by radiographers. Further research into comparing the accuracy of ED referrer interpretation and radiographer evaluation of radiographic images and also the combined accuracy of the ED referrer and radiographer versus radiologist's interpretation will give better understanding of the future direction of the radiographer image interpretation role to improve patient outcomes in ever‐demanding ED.The author declares no conflict of interest.


Parkinson's disease (PD) is a neurodegenerative disease caused by a reduction in dopaminergic neurons in the substantia nigra  or rate of perceived exertion (RPE). Prescribing intensity using heart rate responses should not be recommended, as many individuals with PD exhibit autonomic nervous system (ANS) dysfunction  and are prescribed medications that can interfere with heart rate responses and heart rate variability  within the National Institutes of Health (NIH) has called for research scientists to consider sex when designing study protocols to allow for both men and women to receive the full benefit of medical research (National Institutes of Health, All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Early definitions of ageism as prejudice, attitudes and discrimination tend to stress the cognitive aspects of the processes where groups of people are being marginalized and/or excluded because of their age. This differ from recurrent studies which emphazise social categorization such as age and gender as a dynamic social positioning practice and as a complex form of doing age as marginalization and exclusion. Based on qualitative interviews with eleven men between the ages of 56 and 74, who work with manual labour at a steel company in Sweden, this paper discusses the processes where age normality and ageism are constructed in parallel. Departing from the concept age coding; distinctive practices associating a context or a phenomenon with demarcated ages, it shows the disciplining dimension of ageism. The paper concludes with a reflection on the central position which ageism can have in neo-liberal governance by creating social insecurity among older workers.


This paper examines the effect that a man’s retirement has on his wife’s mental and physical health. I exploit the large increase in the probability of retirement at the legal retirement age for urban male wage earners in China as a natural experiment, using data from the China Health and Retirement Longitudinal Survey (CHARLS). I have implemented a fuzzy regression discontinuity design to compare the health outcomes of women whose husbands recently retired with those whose husbands are close to retire. My findings indicate that the retirement of her spouse improves physical and mental well-being of the woman, most likely by increasing the frequency of her social interactions and exercising. Although income and marital quality are less likely to be the main channels through which this positive spillover effect operates, decreased marital satisfaction or severe income constraints can be binding.


This is not surprising since PCMO often resolves spontaneously and can be compatible in mild to moderate cases with good vision. Further, there is no standard means to diagnose PCMO and thus definitions and incidence vary widely among published studies. We agree with the authors' suggestion that confusion surrounding the use of NSAIDs may have arisen from the lack of an accepted diagnostic criteria for PCMO.The article by Donnenfeld et al has also been included as evidence that PCMO was lower in groups where NSAIDs were commenced between 1 and 3 days preoperatively.The review article does allude to the challenges faced in providing advice on prophylaxis of PCMO when citing the report by the American Academy of Ophthalmology. A subsequently published editorial by the same author however questioned how prescribing NSAIDs for routine cataract surgery had become popularized without compelling evidence of visual benefit to patients.The authors have provided a significant review of a complex topic. However, the statement that topical NSAIDs remain the mainstay in the prophylaxis and treatment of PCMO is not supported by the literature reviewed. We hope that this letter may raise awareness of these issues to the readership.None declared.


To the Editor: We read with interest the article by Olesen and Grad  by antimicrobial-resistant bacteria. The New Zealand study found that dispensing rates of topical antimicrobial agents (predominantly fusidic acid) for Pacific and Maori children were approximately twice those for children of other ethnicities and suggested that these high dispensing rates might have contributed to the higher proportion of staphylococcal infections caused by methicillin-resistant (and fusidic acid–resistant)


Following in the footsteps of the first JND special issue in 2018, highlighting the work of the Eunice Kennedy Shriver Intellectual and Developmental Disabilities Research Centers (IDDRCs), this year again showcases the work of the IDDRCs and honors the distinguished career of Dr. Jean de Vellis, world-renowned scientist in the study of white matter pathophysiology and long-standing director of the UCLA IDDRC. As eloquently described in the dedication [Much of the promise in studying white matter comes from the potential this neural structure has for developing new treatments. In a review of both mouse models and clinical work , the novIn addition to investigations of white matter morphology, a key aspect of thinking about novel treatments has come from thinking about inflammation and the negative impact this may have on neurodevelopment. Investigators at the Children’s Hospital of Philadelphia IDDRC present exciting work demonstrating that inflammation caused by Th2 cytokines during early brain development can be rescued with the application of IL-4 antibody treatment in the newborn rat . This woAs may be evident by work focusing on these neurodevelopmental disorders, a key benefit of approaching treatment stems from an ability to change developmental trajectories by acting early through specific interventions. In a comprehensive study examining motor neurons in a Down syndrome mouse model (Ts65Dn), the investigators demonstrated clear changes in the spinal white matter composition across the lifespan . This woThe articles included in this special issue highlight the advances made in understanding white matter in neurodevelopmental disorders that investigators across the IDDRCs strive to tackle daily. By approaching these questions from both clinical (human) and basic neuroscience perspectives, both sides gain knowledge and move forward to the goal of better interventions. We hope that the work showcased in this special issue underscores the promise for developing targeted treatments in neurodevelopmental disorders that comes from these investigations. Many of the IDDRCs contain researchers influenced and inspired by the groundbreaking work Jean de Vellis began. We hope that this special issue also serves to honor his legacy to the field.