Telehealth systems benefit from the rapid growth of mobile communication technology for measuring physiological signals. Development and validation of a tablet PC enabled noninvasive body sensor system for rural telehealth application are discussed in this paper. This system includes real time continuous collection of physiological parameters  and fall detection of a patient with the help of a body sensor unit and wireless transmission of the acquired information to a tablet PC handled by the medical staff in a Primary Health Center (PHC). Abnormal conditions are automatically identified and alert messages are given to the medical officer in real time. Clinical validation is performed in a real environment and found to be successful. Bland-Altman analysis is carried out to validate the wrist blood pressure sensor used. The system works well for all measurements. The population of elderly individuals is quickly expanding far and wide. The population of individuals of more than 65 years of age around the world will achieve 761 million by 2025, more than twofold of the 1990 figures –6.Hypertension and accidental falls are the two emerging public health problems and a barrier to active ageing . HyperteFall prevalence in India increases with age and is the highest in women and older adults . All perLatest developments in the field of wireless technology can be utilized for monitoring. Wireless body area sensor network (WBASN) is a developing technology that interconnects tiny nodes with sensing capabilities in, on, or around a human body . Recent Community Health Centers (CHC) and Primary Health Centers (PHC) are managing a heavy patient load with the shortfall of doctors as well as supporting staffs . So the This paper is organized as follows: A wearable wrist sensor worn by the patient is used in this work for real time implementation. An embedded platform is used for acquiring the biological information from the wrist sensor and transmitting to a mobile phone/tablet PC running on android platform which is monitored by a medical staff.The hypertension status of the person under test is immediately sent to the tablet PC and automatic alert facility for hypertensive patients is sent to the medical officer through short message service (SMS) facility. The proposed telehealth system architecture with remote monitoring facility is shown in The block schematic of the body sensor unit developed for this work is shown in The body sensor unit, connected to the patient at the health center, consists of the following sensor units.(a) Blood Pressure/Pulse Rate Sensor. Arterial pressure is defined as the hydrostatic pressure exerted by the blood over the arteries as a result of the heart left ventricle contraction [traction . Blood pA noninvasive blood pressure (NIBP) sensor working on oscillatory principle is connected at the wrist of the subject. Wrist sensor measures systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse rate (PR) of the subject under test. The proper cuff and bladder size used in the assessment of blood pressure is important for accurate measurement. The use of a cuff that is too short and narrow for a given arm results in erroneously high blood pressure measurement. Use of a cuff that is too large results in erroneously low blood pressure measures. Wrist blood pressure sensor used in this work has a cuff with a bladder that is 120 mm wide and 250 mm long.(b) Temperature Sensor. The LM35 series are precision integrated-circuit temperature sensors, whose output voltage is linearly proportional to the Celsius (Centigrade) temperature [perature . The LM3(c) Accelerometer Sensor. A wearable sensor system called Smart Wristlet, providing 24-hour fall detection service, is discussed in [x-, y-, and z-axes are experiencing free fall, 0 g pin (6th pin) will generate a high voltage which can be used to detect person fall. This signal is given to the interrupt pin of microcontroller in order to give highest priority to this event.ussed in . The aboussed in . MMA 736Embedded technology is implemented to perform a specified task. The programming of PIC 16f877A microcontroller is done using embedded C . This isBluetooth wireless communication has the advantage of higher data rate and easy interfacing with personal digital assistant such as a smart phone or a tablet PC. JYMCU HC-05 Bluetooth Module is used in this work which connects to the embedded platform for wireless transmission. Bluetooth module is connected at the software serial port of the microcontroller.Android Studio IDE is used to develop the application for tablets/smart phones with Android Operating System . AndroidA low cost high performance tablet PC (Digiflip XT 811) with Kitkat 4.4 operating system is used in this work for real time implementation. Tablet PC has the advantage of large screen size and better functionality compared to a mobile phone. The android application receives the data transmitted from the body sensor unit via bluetooth communication facility. An android application developed for tablet PC is used for the purpose of real time acquisition of data, comparison with threshold value, storage in SQL database, and alert mechanism generation using SMS facility.The android application initiates GPS services provided by the mobile phone network. While executing the subroutine for fall alert the developed android application collects location information via services given by the network provider or GPS provider. Information such as latitude, longitude, and exact address are collected by proper subroutines. This information is sent along with the text of fall alert message.The examinations have been carried out in Rural Primary Health Center in Andoorkonam, Trivandrum district of Kerala, India. The measurements were authorized by the Office of the District Medical Officer. Patients having Blood pressure variations or under medication for hypertension were directed by the medical officer for measurement. Overall 291 patients including healthy staffs in the PHC have been included.The aim of the validation of the device is to understand the reliability of the data obtained using the wrist sensor. The study also aims to get the feedback of the patients under test about the wrist sensor for blood pressure measurement. The study was conducted at a rural Primary Health Center in Trivandrum and the procedures in this study were approved by the District Medical Officer (DMO) and the medical officer, Andoorkkonam. The study was conducted in accordance with guidelines provided by the medical officer and under the supervision of two trained staff nurses. All subjects were informed and got consent for this study.291 subjects suspected to have hypertension/under medication for hypertension were suggested for BP measurement by the medical officer. 113 male subjects and 178 female subjects were first measured by the sphygmomanometric method and then by the digital wrist sensor based on oscillometric method. Hardware setup  is shown in Age frequency plot of males and females in different age groups under study are shown in The same subject was asked to take measurements using the wrist sensor also. The sensor was suitably positioned at the heart level in order to eliminate errors caused by position artifacts. The pair of data were used for validation of the wrist sensor. The statistical analysis was done for systolic blood pressure and diastolic blood pressure using Bland-Altman method.The system was tested in a practical environment and found to be most successful. The information was transmitted successfully to the tablet PC and stored in the SQL database by the developed android application. Patients with hypertension  were correctly identified and automatic alert messages were generated and sent to the medical officer by the developed android application. Low blood pressure conditions (SBP below 90 mm of Hg and DBP mm of Hg below 60) were also identified. Normal and high body temperature were identified and transmitted to the tablet PC via bluetooth module.Screen shots of outputs obtained are shown in The validations were carried out largely according to the recommendations of the Association for the Advancement of Medical Instrumentation (AAMI). AAMI recommends the inclusion of a larger patient number and a greater number of subjects in an older age group in order to test the monitors' performances over a wider range of patient characteristics. The criteria require device to observe discrepancy within 5 ± (8 s.d.) mm of Hg for mean difference and standard deviation.Bland-Altman analysis was carried out to show the agreement between the two tests. The scatter plot of difference and average of SBP and DBP taken by wrist sensor method and sphygmomanometric method of female population and male population are shown in The accuracy of wrist sensor is calculated by identifying true positives, false positives, true negatives, and false negatives. The obtained accuracy is shown in The aim of this comparison was the analysis for clinical suitability of the wrist blood pressure sensor for family and community health care application. A comparison was done with sphygmomanometric method, which served as a reference device because of its wide distribution and acceptance. The parameters under investigation were the systolic and diastolic blood pressure.The trials showed satisfactory acceptance from the patient side because of the low discomfort caused by the wrist blood pressure sensor. Bland-Altman analysis shows very good agreement between the two methods of measurement.Wrist blood pressure sensor is more suitable in subjects with obesity having large arm sizes. Wrist blood pressure sensor does not require patients to remove clothing while taking measurements and it provides less discomfort compared to arm cuff monitors during inflation.The measurement taken at any time is successfully transmitted to the tablet PC and is stored in the SQL database of the android phone/tablet by the developed application without any manual intervention. This enables the medical officer to ascertain whether a drug is effective or not. The developed system is less expensive and causes less inconvenience for the patients.The validation conducted for the oscillometric wrist technique yields good results which shows good correlation between the BP readings taken with a sphygmomanometer and oscillometric wrist sensor. Patient's opinion about wrist sensor was promising. The device passed the AAMI criteria for SBP and DBP measurement except for male systole data. This study suggests that wrist devices can produce reliable and accurate results. The principal easiness of wrist blood pressure sensor based on oscillometric methods offers the opportunity for wide spread use. This may ultimately lead to an improvement in common efforts to prevent hypertension.A modern approach of health monitoring and management is put into practice by the experiment conducted using the developed system. The ever-increasing workload of physicians can be significantly reduced by the use of such systems.


Early and effective chest compressions have a well known pivot role in cardiopulmunary resuscitation (CPR) and 2010 International Consensus on Cardiopulmonary Resuscitation have strongly reinforced its importance.The efficacy of chest compressions depends on hands position and on compression technique.Medical education can improve chest compression technique, while the choice of thoracic landmark is always blind even if 2010 consensus indicated that it is reasonable to place the hands in the lower half of the sternum.Critical care ultrasound (CCUS) has changed the approach of critical ill patient and can identify potential reversible causes of cardiac arrest during CPR.Our challenge is to use CCUS to locate the most appropriate site for chest compressions.We planned a pilot study (in progress) to evaluate the capability of CCUS to improve the quality of chest compressions while CPR is taking place.We describe data of a small case series from 6 non traumatic cardiac arrests who was treated both in-hospital and in pre-hospital settings.In 3 out of 6 patients compressions were correctly performed while in the other 3 cases partials left ventricle compression or the narrowing of the base of the heart and aorta was observed. Ultrasound guided changes in hands position improved passive left ventricle contractility in the 3 incorrect CPR.Our study doesn’t permit to estimate if the changes made in hands position would have affected the outcome of CPR.Anyway we think that the possibility to focus the power of the hands over the real position of left ventricle certainly improves the quality of our chest compressions.


A 66-years old man suffering from coronary artery disease appeared without symptoms for routine follow-up in our clinic.The echocardiogram revealed a tumorous mass of the right atrium and right ventricle. In the past, coronary revascularization with venous grafts of the right coronary artery and circumflex artery as well as internal mammaria graft to the left anterior descending artery was performed 20 years before. The general clinicians presented the case to the surgeons and it was decided to perform cardiac MRI as a preoperative diagnostic modality.Following cardiac magnetic resonance imaging (MRI) showed a mass in the pericardium in the right atrioventricular groove with thrombotic material. Due to the MRI the patient underwent coronary angiography to confirm an aneurysm.The learning points from this case are that cardiac MRI is a very useful tool for further evaluation of suspected cardiac masses and should be performed for further characterization. Spontaneous bypass aneurysm is a rare complication of coronary bypass revascularization (Hiraoka et al. The learning points from this case are that cardiac MRI is a very useful tool for further evaluation of suspected cardiac masses and should be performed for further characterization and planning of therapeutical options, particularly after previous cardiac interventions (Hiraoka et al. Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.


Manual analysis of abundant behavioral data produced by automated systems for long-time monitoring of a group of animals is extremely inefficient and error prone. Some systems (like IntelliCage™) are shipped with software enough for basic analysis of the data, however lacking flexibility for more advanced analyses."let the computer do the work"), therefore reducing number of possible human errors. The other advantage of such approach is that modern computers are both faster and more precise than humans when dealing with numbers.To facilitate research reproducibility, same analysis of same data should always yield same results. One (possibly the best) way to achieve such robustness is to have the process automated  and a data abstraction layer - therefore shifting ones focus from the form the data is provided to the data itself. A simple analysis can be performed in just a few lines of readable source code (see Figure


The mechanisms that allow biological networks to recognize temporal patterns of spikes that encode sensory inputs are unclear. Here we extend our previous work , using aGReaNs implements a genetic algorithm to obtain the topology of the networks (and the weights of the synaptic connections), starting from a population of networks of neurons connected randomly. The encoding of the neural networks in the genome is inspired by the encoding of genetic networks in biological genomes; neurons in GReaNs are modeled as either leaky integrate and fire neurons with a fixed threshold (LIF) or adaptive-exponential integrate and fire neurons . The numIn the computational task we consider, the network has several input neurons and one output neuron. A spike or burst received by an input neuron corresponds to a certain symbol . The output neuron should be active only after the network receives a certain sequence of symbols .Our preliminary results with LIF networks with a fixed threshold networks suggest that the presence of recurrent connections in the network allows the interneurons to reach plateau subthreshold states that provide a memory of what symbols have been received thus far. Here we will investigate the robustness of this solution to noise in the network, and then discuss the possibility to extend the paradigm to evolve spiking networks to accept regular languages.


Hearing loss—ranging from mild to severe—afflicts large numbers of individuals of all ages. It is estimated that 40–50% of adults over the age of 65 years have some degree of significant hearing loss, with this figure rising to 83% of those over the age of 70  model in which they stress the importance of working memory for online spoken language processing, especially under poor listening conditions  to assess white matter integrity (Rachakonda et al., Together, these collected articles reflect a valuable sample of current approaches to our understanding of the effects of hearing loss on neural and perceptual processing. A theme that emerges from both the human and animal studies in this collection is that of an adaptive plasticity in the sensory, perceptual and cognitive systems that regulates performance in the face of often seriously degraded input. Challenges for future research include better understanding the link between neural consequences of hearing loss and other modifications of acoustic input (Van Engen and Peelle, 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.


We review some recent cognitive models based on generative networks, and we point out promising research directions to investigate neuropsychological disorders within this approach. Though further efforts are required in order to fill the gap between structured Bayesian models and more realistic, biophysical models of neuronal dynamics, we argue that generative neural networks have the potential to bridge these levels of analysis, thereby improving our understanding of the neural bases of cognition and of pathologies caused by brain damage.Connectionist models can be characterized within the more general framework of probabilistic graphical models, which allow to efficiently describe complex statistical distributions involving a large number of interacting variables. This integration allows building more realistic computational models of cognitive functions, which more faithfully reflect the underlying neural mechanisms at the same time providing a useful bridge to higher-level descriptions in terms of Bayesian computations. Here we discuss a powerful class of graphical models that can be implemented as stochastic, generative neural networks. These models overcome many limitations associated with classic connectionist models, for example by exploiting unsupervised learning in hierarchical architectures  Despite the enormous progress in the prevention and treatment of neuropsychological disorders, traumatic brain injury and stroke are still among the major causes of adult disability and death  models  investigated through this approach, many PDP models suffer from serious limitations. In particular, connectionist models are often trained in a supervised fashion using error backpropagation, but the assumption that learning is largely discriminative and that an external teaching signal is available at each learning event is implausible from a cognitive perspective  through feedback connections and Hebbian-like learning mechanisms ? How do learning regularizers  compare with respect to organizational principles of biological neuronal networks?Can we improve lesioning studies in PDP models by taking into account structural and functional properties of the network? Could deep learning systems exhibit the same universal resilience patterns observed in other types of complex networks (Gao et al., AT and MZ equally contributed to the conception and writing of the manuscript. AT and MZ are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.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.


Brain-computer interfaces (BCIs) can provide a means of communication for people with severe motor impairments . For peoThis abstract describes multimodal  P300 BCI communication attempts performed with a 42-year-old male who had an intracranial hemorrhage of the cerebellum and brainstem one year prior to the measurements. The participant is paralyzed except for residual eye blinking and movement as well as some movement of the left hand. This residual muscular control is used for communication .Many pitfalls were encountered when attempting to establish communication. The main aspect is that when we performed the same task at different time points the results varied considerably (see Figure Albeit the fact that the attempts with the brain-computer interface was not successful in establishing free communication, the classified responses were clearly above chance. This illustrates that the user understood the instructions and has the physiological capacities to generate the responses required to operate the system. The fluctuations of vigilance experienced by patients with disorders of consciousness must be taken into account when developing new generations of BCI systems.


There is an error in the fourth sentence of the first paragraph of the Conclusions section. The correct sentence is: This pattern may be observed in other large lakes with spatial and temporal variation in vertical mixing patterns. There are few large lakes where time series of in situ observations encompass a wide enough range of locations to estimate spatial variation in warming rates.


The K13 gene mutations have been found to be associated with artemisin resistance in Cambodia, although the relevance of these mutations on artemisinin resistance in other endemic areas have to be better documented. We present here new data on K13 mutations and on the artemisinin resistance outside Cambodia. We propose to open the discussion about how these new findings have to be interpreted regarding the emergence and spread of artemisinin resistance and their usefulness to identify and prevent the spread of resistant strains in order to reach the malaria control and elimination global program goal.


Recombinant human growth hormone (GH) has been used as an effective treatment for short stature since the late 1980’s. Although clinical trials were crucial in developing GH treatment strategies, database analyses have the potential to provide additional information with regard to treatment efficacy and safety. The OZGROW database was established in 1989 as an initiative of the Australasian Paediatric Endocrine Group (APEG) to allow monitoring of children receiving GH under the national Pharmaceutical Benefits Scheme (PBS). There are currently (June 2014) 1948 children receiving subsidised GH treatment in Australia and the OZGROW database contains records from 6959 individuals. This unique resource has allowed a number of clinically relevant questions to be addressed.Defining short stature and therefore eligibility for GH treatment relies on the use of appropriate growth standards. There has been debate as to whether the World Health Organisation (WHO) or the Center for Disease Control (CDC) growth charts best describe the heights of contemporary Australian children. There appears to have been a positive secular trend for height in Australian children such that both charts under-estimate the number of children eligible for growth hormone treatment.Ascertainment bias has been proposed as an explanation for the fact that more boys than girls receive GH treatment. Analysis of the OZGROW database demonstrated that ascertainment bias did not appear to be a major factor explaining the gender discrepancy. It is possible that biological factors influencing the tempo of growth and development may contribute to the greater number of boys receiving growth hormone.Another issue that has complicated comparisons of international studies of growth hormone response has been the different dosing schedules used. A simple method for converting weight and surface area based doses was therefore developed. Further analysis suggested that the surface area based protocol used in Australia may disadvantage older children, given that the dose per kilogram reduces over time even if the dose per meter squared remains constant.The importance of commencing GH treatment early and maximising height gain during the first year of treatment was also highlighted by analysing GH responsiveness in a number of conditions including Turner syndrome, Prader-Willi syndrome and idiopathic short stature. Ensuring that referring physicians are able to diagnose these conditions in a timely fashion therefore remains a priority.Although the OZGROW database has allowed clinically relevant questions to be studied there remain a number of challenges, particularly with regard to long term follow up.


Community Care Centres (CCCs) represent an innovative response to the containment of infection and the care of those infected in the context of an an Ebola Virus Disease (EVD) outbreak of unprecedented scale. This paper describes the implementation of this response in the Port Loko district of Sierra Leone in the last quarter of 2014. CCCs were effective in encouraging EVD patients to come forward, thus removing risk of transmission to their families and communities however there is significant scope for improvement in care for patients in the centres if the model is applied in future outbreaks of infectious disease. Changes in lay out of the centres, in staff training and support, in logistics and patient education are recommended. Sierra Leone has borne a significant burden of the ongoing EVD outbreak in West Africa. As of 25th February, 2015 the country had reported a cumulative total of 11,301 cases and 3,461 deaths (CFR 31%) making it the worst affected country in the history of the disease [A CCC is a community-based Ebola isolation unit where suspected and probable cases of EVD are isolated and provided with basic health care as they await their confirmatory test results. They also serve as places where confirmed cases can commence early treatment as they await transfer to bigger ETCs. They are small, low technology, mainly staffed by nurses and community health workers and can accommodate 8 to 10 maximum 15) patients. They focus on supportive management of patients; invasive procedures (except for collection of blood samples for EVD confirmatory test) are discouraged to reduce the risk of health facility acquired infection. The objectives of CCCs are to among others complement conventional ETCs by early isolation of EVD cases as close as possible to their communities and to improve access to Ebola care among the general populations especially for those in rural areas. The basic package of care offered at CCCs include presumptive treatment for malaria, supportive therapy such as management of fevers, body pains etc., provision of Oral Rehydration Solution (ORS), food, water and psychosocial care among others [ patientsCCCs were of two forms; frequently they were improvised around existing permanent structures, for instance the CCC in Lunsar was established within a hospital. In other circumstances CCCs consisted entirely of temporary shelters (tents) constructed on a new site. The centres were clearly identifiable at a distance as CCCs, were peripheral to or outside of a village, they required access to a water source for cleaning and washing, and were well demarcated from the surrounding community by a perimeter fence usually made of plastic sheeting. The CCCs had separate access points for staff arriving for work and for patients presenting for assessment. The centres had triage areas constructed with at least one metre separation between patient and staff areas. The triage area opened into a patient area (red zone). Movement to and from the triage zone to the red zone was variably controlled and frequently allowed movement in both directions. The red zone consisted of two or more separate spaces, either rooms within existing permanent structures or tents which were intended as cohort areas for two different categories of patients, those most infectious and those likely to be less infectious. There was generally no effective barrier to movement between these cohort areas within the red zone. The red-zone included patient latrines and shower facilities. In some cases communal traditional thatched shelters were provided in each cohort area for patient comfort. The red-zone included soak pits for effluent from showers. There were three exits from the red-zone, one to a mortuary area, one for those discharged from the CCC to the community and one through a PPE doffing area for staff leaving the red zone. The staff entrance to the CCC opened into the “green zone” where there were staff facilities including latrines and changing area. These facilities were in existing buildings or temporary tents. The green zone also included storage areas and staff rest areas. There is an entrance, typically gated, from the green zone into the red zone. Typically close to the exit from the red zone there was a pit for disposal of used PPE and other waste.Patients presented to a triage area either on foot or by ambulance. Staffs were expected to assess patients presenting by application of a triage algorithm. Those assessed as requiring admission then entered the patient area (red zone). Patients were confined to the red zone until such time that a blood test for detection of Ebola virus was available. The interval from admission to receipt of a laboratory report varied from approximately three to seven days. Patients who were well enough could move freely within their cohort area, sometimes between different cohort areas within the red zone and sometimes between the red zone and the triage area. Typically staff entered the red zone 3 times per day  for periods of 30 to 60 minutes on each occasion. During the visits the condition of patients was observed, ORS, water and food was provided and cleaning performed. When patients’ test reports were received those who tested positive were transferred to EVD treatment centres as soon as possible and those with reports of EVD not detected were given a certificate and allowed to leave or provided with transport home.The CCC model was implemented rapidly in response to unprecedented pressures with a view to controlling ongoing community spread of EVD. Despite concerns raised by several partners about conducting EVD case management in such low technology setting, recent scientific evidence and field experience showed that the strategy has considerable potential for EVD outbreak prevention and control. Kucharski et al. in their recently published article demonstrated that CCCs could reduce EVD transmission in the community if well managed and all things are equal . Logan eThe concept was however not without its challenges. The small size of the units meant that they could only admit limited number of patients whilst the use of cadres of health workers with lower levels of qualification such as community health workers meant that more intensive training, support supervision and monitoring of the infection prevention and control practices was required. Although training was provided on site before opening of CCCs, ongoing training and close supervision of their operation was limited by the relatively remote locations and by the limited number of available IPC specialists. There were also significant supply chain issues resulting in intermittent shortages of drinking water, oral rehydration solution and items of personal protective equipment. Observation of practice within the CCCs suggests that messages to health care workers regarding self-protection at work were well received but balancing this requirement with the need to provide an appropriate level of patient care was less satisfactory. Our observations indicated that even in full PPE many staff would still avoid even minimal physical contact with patients who were too weak to stand or walk and too weak to drink ORS. The force of the message regarding self-protection may also have contributed to the long periods during which no health care workers were present in the red zone leaving debilitated patients to care for themselves or dependent on informal care from other patients. In practice our observations showed that half or more than half of patients admitted to CCCs may not have had EVD at the time of admission. Thus an unintended consequence of the CCC model was that many patients who did not have EVD were potentially exposed to the risk of acquiring EVD in the CCCs for extended periods of up to seven days or more, however this was also the same in the conventional holding centres. The provision of staff supervision in patient areas (which in many cases included minors) and of delivery of an appropriate level of care for critically ill patients with the CCC model was problematic because of the limited time during which staff were present in the red zone and the over whelming emphasis on self-protection in training. Our observations are based on implementation of the CCCs in rural and semi-urban settings; its applicability to urban settings where the community structures are different and transmission (and patient load) are likely to be higher may be tricky due to two main reasons. Firstly since the strategy is based on the principles of community ownership and participation and given that such structures are not well defined in urban centres, community participation in the process may be limited. Secondly, the limited number of beds in the CCC may not be able to cope with the patient load in a high transmission outbreak in an urban area.In conclusion, there is some evidence that the use of CCCs to isolate EVD patients in defined areas may have contributed to control of transmission in Port Loko, however there were unintended consequences associated with its roll out. Furthermore, a recent rapid assessment of the CCC concept which was conducted in six districts of Sierra Leone also highlighted key benefits of the concept . The use


Health professionals need to be integrated more effectively in clinical research initiatives to ensure that research addresses key clinical needs and provides practical, implementable solutions at the coal face of care. The recent McKeon review of Health and Medical Research in Australia suggested that the best way to achieve practical and implementable solutions in healthcare is to involve the health-delivery workforce in research to ensure that research addresses key clinical needs . Through


Dear Sir:We thank Rebaudet and others for independently confirming the value of cholera DNA preservation on filter paper and its suitability for molecular analysis. These two studies highlight the benefits of being able to store samples at room temperature for extended periods without risk of specimen compromise, as well as the ability to transfer and ship samples without a cold-chain requirement or risk of biohazard. This reduces the need for advanced laboratory capacity in cholera-prone areas while eliminating transportation issues. Moreover, the methodology can be combined with the use of the cholera rapid dipstick test  to provide immediate results confirmed by subsequent detailed (but delayed) molecular confirmation. We are also exploring the use of the filter paper with fecal sample directly, and agree this further simplifies the process under field conditions.


We observed that only 20% of the recorded neurons accounted for 80% of the total information flow in these networks (see Figure rich nodes. The rich nodes were characterized by a higher firing rate, and graph theoretic analysis revealed their participation in a number of highly non-random network features. The networks were highly clustered with small average path lengths and thus exhibited small world attributes and the sub-network formed by the rich nodes was more efficient than the rest of the network. The networks also exhibited a central core of rich nodes which persisted even when the rest of the nodes in the network were peeled away. The rich nodes were also connected to each other more strongly than expected by chance giving rise to the rich club effect, observed for the first time in effective connectivity networks of individual neurons (see Figure Elegans [Structural and functional connectivity of macroscopic brain regions has been very widely researched  in the l Elegans .Our find


Oxytocin is a key molecule in social behavior. A recent study reported lateralized oxytocin signaling specifically in left auditory cortex during pup-retrieval behavior of female mice.Brain asymmetry shows great advantage in evolutionary adaption to the environment  significantly facilitated the process 1 day). In single housed virgin female mice, oxytocin signaling was sufficient to induce the maternal behavior. Given the important roles of pup calls in triggering the maternal behavior, Marlin et al. examined the expression of oxytocin receptor (OXTR) in the auditory cortex. They then identified large population of OXTR expressing interneurons, suggesting for a potential role of oxytocin in disinhibiting the auditory cortex  is dominated in the right brain (Ross et al., Knowing that oxytocin signaling lateralization is important for maternal behavior raises a new set of questions. What determines the asymmetrical distribution of oxytocin receptor expression between left and right cortical areas? Which cortical area is crucial for each types of maternal behavior and how does oxytocin facilitate the learning process? What other signaling molecules or neural circuits might the brain use for maternal behavior in parallel? How are these maternal cues encoded in infant's brain? The answers to these questions will lead to the further understanding of the most generous love—mother love.TY and GH designed the study and wrote the paper together.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.


SUI is a common and distressing condition affecting 3 million women in the UK. As part of the multicentre NIHR HTA funded SIMS study  we are evaluating the acceptability and correlation of two patient tests of SUI -the objective 24hr pad test (PT) and the subjective home continence stress test (HCST).Participants (n=197) were given sufficient standardised, pre-weighted incontinence pads to wear for 24hrs (changing when necessary) and two large tissue sheets. Used pads were returned to the study team in sealed plastic bags on the day of surgery for weighing and disposal. The tissue sheets were used as part of the HCST conducted before and after the pad test. Participant feedback on both tests is being collected.Results will be presented reporting response rates to both tests and comparisons between responses to the PT and the HSCT.The acceptability to participants and the advantages and disadvantages of each test from a trial management perspective will be discussed. Data collection challenges will be considered including; issuing of pads to sites and participants, the receipt (including the handling and delivery) of used pads and the decision process around which data to use in analysis when responses are available to both tests. Cost implications of both tests will also be presented.


Current available in vitro tests including the lymphocyte toxicity assay (LTA) and the lymphocyte transformation test (LTT) are cumbersome and expensive, and their predictive values are undefined. We have recently developed a novel in vitro diagnostic test for DHRs, the in vitro platelet toxicity assay (iPTA) to test patient susceptibility to DHS. The aim of this study was to evaluate the predictive value of the iPTA in diagnosis of DHRs to sulfonamide antibiotics.Drug hypersensitivity reactions (DHRs) are rare but potentially fatal types of adverse drug reactions (ADRs) that develop in susceptible patients following exposure to certain drugs including sulfonamides. The diagnosis of this type of ADRs is challenging and currently depends on clinical expertise. A safe and reliable We have recruited 66 individuals  to participate in the study. The DHR cases were referred and diagnosed based on rigorous internationally accepted criteria. Blood samples were obtained and both LTA and iPTA were performed independently. Results were then analyzed to determine the degree of agreement between the likelihood of the occurrence of the reaction as determined clinically and the performance of the two diagnostic approaches.in vitro toxicity (p<0.05).There was concentration-dependent toxicity in the cells of patients when incubated with the reactive hydroxylamine metabolite of sulfamethoxazole for both the LTA and iPTA (p<0.05) and toxicity was significantly greater for the cells of patients versus controls (p<0.05). The tests had a high degree of agreement (correlation coefficient: R2 = 0.97). The iPTA was significantly more sensitive than the conventional LTA test in detecting the susceptibility of patient cells to The novel iPTA has considerable potential as an investigative tool for DHS as it is cheaper to perform and requires no special reagents that make it an excellent candidate for wider use. The iPTA has also a greater sensitivity in detecting patients with predisposition to develop DHRs to sulfonamides and other drugs and thus can be used to screen for susceptible patients prior to drug prescribing and during drug development process.


Biologic therapy has not made the breakthrough in the treatment of patients with systemic lupus erythematosus (SLE) that it has managed in patients with rheumatoid arthritis and psoriatic arthritis. However, there are distinct signs that this form of treatment is going to find a place in the pantheon of SLE therapy. Based on a better knowledge of the ethiopathogenesis of lupus drugs, which interfere with B cell activation notably, Benlysta and Atacicept have been reported in major clinical trials to be successful in terms of controlling disease activity and preventing flares respectively. In addition, although the formal clinical trials did not meet their primary endpoints  the use of B cell depletion in the form of rituximab is widely accepted and appears to be helpful and highly beneficial in aspects of lupus ranging from skin disease to severe proliferative glomerulonephritis.My colleagues and I have treated 120 lupus patients with rituximab and have reported that 90% of patients are in partial or complete remission at six months , though some questions remained unanswered. For example, why is it in some patients B cells return within two months and in other cases it may be many years? In addition, once the B cells have returned there is a highly variable length of time before the clinical features return. In spite of disappointing results with major clinical trials, at least two new clinical trials using rituximab, are about to start recruiting, the RING trial for patients with lupus nephritis who failed conventional therapy at six months and RITUXILUP which aims to treat lupus patients at the time of diagnosis with two infusions of rituximab followed by a low dose of mycophenolate the state of aim avoiding the use of oral steroids. In an open label study of 50 lupus nephritis patients given rituximab at the time of diagnosis followed by low dose mycophenolate, Condon et al (Ann Rheum Dis 2013. In press) have reported that just two out of 50 patients after two years have required oral steroids.None declared.


The mammalian nervous system can adapt to the challenges of life through neural plasticity. The brain will undergo extensive reorganization following sensory deprivation or damage to afferent pathways Kaas, . This plAge at implantation plays a substantial role in performance with a CI. Research has shown the existence of an early critical period for brain development and demonstrated how deprivation-driven functional changes in the cortex are affected by age. Cats that were implanted after the fifth month of age had smaller activation areas of the auditory cortex, compared with cats implanted earlier, even when they had longer experience with implant (Kral et al., In humans, the latency and morphology of the P1 component of auditory-evoked potentials can serve as a biomarker for the development of the central auditory pathways (Sharma et al., Despite the dominant role of age at implantation, experience with a CI also induces functional changes in the auditory system—at both peripheral and central level—stressing the importance of a post-implantation rehabilitation period (Sandmann et al., Returning to the parallel between visual and auditory deprivation, studies on critical period and visual implantation are still not possible as retinal implants are currently only available to adults. However, several questions arise, for instance, can we observe a similar benefit when implanting during the sensitive period for retinal implants? As hearing aid use correlates with positive CI outcomes (Lazard et al., In sum, both the time spent in a deprived state and acquiring sensory experiences matter for the brain to cope with the challenges of change. Stimulating the impaired sense as much as possible and restoring it as soon as possible within the cut-off period shall maximize the benefits from implantation.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.


Recent review of Bidulescu and colleagues’ article on the association between vitamin D and adiponectin and its relationship with body mass index in African-Americans, as compared to Whites, reinforced the value of conducting stratified analyses using more resolute subpopulation/subgroup data . AlthougThe 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.


Authors Wagner et al. in your journal demonstrated effectiveness of mechanical chest compressions in the coronary catheterization laboratory to facilitate coronary intervention and survival in patients requiring prolonged resuscitation efforts. We dare to comment on this article and advocate to use mechanical chest compressions only as a bridge to extracorporeal membrane oxygenation to completely substitute failed circulation and enable percutaneous coronary intervention or other procedures to treat the cause of cardiac arrest. In line with an increasing interest in rescuing patients from refractory cardiac arrest by means of routine implementation of mechanical devices, we have read with a great interest an article by Wagner et al.  in your


Patient and public involvement (PPI) in research involves the active contribution of members of the public in research studies and within research organisations. PPI is important in ensuring the relevance and quality of general health care research. Funders often now request evidence of prior and future planned PPI in health research.The impact of PPI on various aspects of study development and delivery has been described, from study design through to the dissemination and implementation of study findings. Research, however suggests that PPI is inconsistent in terms of levels of engagement, quality and reporting. Within clinical trials variations in intentions and plans for PPI and the experience and impact of such involvement have been identified. Additionally resources to support PPI in clinical trials are often not used in practice. The University of Liverpool Clinical Trials Research Centre PPI working group decided to design a web based toolkit designed to support the PPI activities in clinical trials. The toolkit will signpost chief investigators and trial teams to a range of tools. The tools are designed to facilitate meaningful and effective PPI at all stages of a clinical trial.The development of the toolkit involves:• Describing the PPI pathway through a clinical trial• Identifying existing internal and external resources to support PPI• Identifying additional required resources• Evaluating the use the resources• Disseminating information about the use and impact of the resources and making improvements and modifications to them based on our experience.The results of developing this toolkit will be presented.


In this study we propose to investigate the effect of the neovascularisation and blood flow to the sternum and surrounding tissues in diabetic & non-diabetic patients by using a laser Doppler imager. The reasons for the delayed healing are not entirely clear, but are thought to include both mechanical factors such as poor wiring of the breastbone during surgery, and biological factors related to the interruption to the blood supply to the sternum and surrounding tissues associated with the procedure.To assess the role of neovascularisation in diabetic & non-diabetic following coronary artery bypass graft (CABG) surgery using Laser Doppler Imager.Patients were divided into two groups as diabetic & non-diabetic had undergone CABG (30 patients). Sternal microcirculation measurements were taken by using a Moor LDI laser Doppler imaging system, at ten time points (pre-induction to 96 hours after bypass). The regional blood flow was estimated by measuring the Doppler shift of laser light caused by blood cells passing within the laser light field. Blood samples were taken for the analysis of number of factors.Results: The neovascularisation and wound healing were comparatively faster in non-diabetic surgical patients than diabetic group. New vessel formation from the right internal thoracic and intercostal arteries to the left side confirmed that the vascular supply of the sternum on the left side following CABG surgery was not entirely depended upon the left internal thoracic arteries. This is due to secondary changes in diabetic patients on vascular system.There was a formation of new vessels from right side of the sternum following the mobilization of left internal thoracic artery in CABG surgical patients. The healing process was faster in non-diabetic CABG surgical patients.


Careful attention to clinical phenotypes can identify new diseases which are now amenable to molecular genetic elucidation. In the late 1980's I met a family labelled as having Huntington's disease but with absence of dementia. Scanning revealed unusual cavitation of the basal ganglia. The pedigree was extended my connection to a second family using birth records. We mapped the gene to chromosome 19 and went on to identify an unusual mutation in the E helix of light chain ferritin. Staining for iron revealed huge accumulation of iron/ferritin complexes in the brain leading to neurodegeneration. We named the condition neuroferritinopathy and tested desferrioxamine without success. We have shown that accumulation of iron commences in childhood and are now preparing to test deferiprone as an iron chelator which crosses the blood brain barrier.


Action Plan for the Prevention, Care, and Treatment of Viral Hepatitis  in the United States. Although care and treatment can be life-saving, many of the 3 million persons estimated to be living with hepatitis C virus (HCV) infection are unaware of their infection and are not receiving preventive services and medical management. In addition, an emerging epidemic of HCV infection among a new demographic of persons who inject drugs is unfolding in several areas throughout the nation. Guided by the goals of the 2014 U.S. Department of Health and Human Services 9 in the The first report shows that trends in new cases of HCV infection are highly correlated with trends in substance abuse treatment admissions for opioid dependency and opioid injection in four states in the central Appalachian Region. The second report describes strategies for integrating HCV testing into primary care settings. These reports demonstrate how data can be used to identify patterns of risk for HCV transmission among persons who inject drugs and how programs can be successfully implemented to identify persons disproportionately affected by HCV infection and ensure they receive appropriate medical care and treatment.


Research on human brain development has seen an upturn in the past few years due to increasing use of noninvasive neuroimaging tools for studying the anatomy and function of the developing brain. Here we gathered innovative studies of human brain function and development using magnetic resonance imaging (MRI), near infrared spectroscopy (NIRS) and magnetoencephalography (MEG) with experimental paradigms suitable for pediatric research. These modalities are without significant risk to the developing brain, generally require minimal patient preparation, and are well tolerated by children when performed by experienced teams. A review of recent studies of human brain development using these advanced neuroimaging tools is quite timely, since we are witnessing advances not only in the instrumentation optimized for the pediatric population, but also in research focused on the human fetuses in utero, neonates, and older children. MRI methods such volumetric T1 imaging and Diffusion Tensor Imaging (DTI) are being used more frequently in children to determine the gross anatomy and structural connectivity of the developing brain. Functional MRI and NIRS are being used to assess the hemodynamics of neurovascular responses and functional localization in development (Govindan et al., 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.


Monitoring of services in the National Health Service in England is framed around clinical outcomes, safety and patient experience.A system of dashboards is being developed to provide monthly information about specialised services. The initial pilot has included a set of key information about services to patients with haemophilia and cystic fibrosis, for example the proportion of patients on home treatment (haemophilia) or the proportion admitted to a ward with specialist staff (cystic fibrosis). Data items were agreed by clinicians as relevant and important. The information is available from every provider.In the highly specialised services for very rare disease  the dashboard runs annually, not monthly, and is based on long experience [Quality of life measures are used in some services such as epidermolysis bullosa and neurofibromatosis type 2 [Safety incidents such as ‘never’ events are rare; they are reported and investigated immediately.Patient experience is monitored through surveys and close contact with patient organisations.A key mechanism for monitoring quality in the highly specialised services is an annual meeting. Attendance by all providers of the service is mandatory. Clinical outcome data is presented on all patients treated, and interesting or informative cases are discussed by the clinical teams. The meeting provides an excellent forum for peer review, exchange of clinical experience and learning.


From 1978 National Health System (NHS) primary care pediatricians (PdF) in Italy take care of infants and adolescents from birth until 14 (in selected cases 16) years of age . HoweverAnother objective of primary care pediatricians will be to structure shared programs with general practitioners (MMG) to favour the shift of care from the primary care pediatrician to the family doctor. It should be necessary to always support a well planned care transition between Pdf and MMG . This will enable the MMG to receive the complete information on the health of the patient as well as on social and relational aspects.


From February 2012 until January 2014 an acute medical ward at a 600 bed tertiary hospital in Western Australia conducted an internal audit of youth and adult inpatient separations for patients admitted with complications of severe eating disorders. This cohort exhibited levels of severe malnutrition on par with or more severe than those managed in a specialist service in another state of comparable size,  and may reflect the fact that Western Australia is one of only two states / territories in Australia that does not have a publicly funded specialist adult inpatient eating disorders program.Proposals for development of a state wide comprehensive specialist eating disorders service for youths and adults in Western Australia must take into account a potential legacy of decades of under investment in this area of health care, and potential barriers to optimising nutritional recovery within the confines of an activity based funding framework.Service Initiatives stream of the 2014 ANZAED Conference.This abstract was presented in the


This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It discusses the role of the clinical nurse specialist in the head and neck cancer patient journey and provides recommendations on the clinical nurse specialist led assessments and interventions for this group of patients receiving cancer care.• All cancer patients should meet a clinical nurse specialist at the point of diagnosis. (R)• Clinical nurse specialists must act as gate keeper to the patients' cancer pathway to provide a seamless journey. (R)• Holistic needs assessment should be completed at different stages of the patient's pathway to reflect the changes of the patients' needs. (R)• Clinical nurse specialists to be part of local and national initiatives for health promotion and raising awareness in the public domain. (G)• Clinical nurse specialists should lead in redesigning of services and policies to ensure they are responsive to patient's needs for the future. (G)• Treatment summaries should become part of practice to provide good communication between primary and secondary care to enable continuity of care for the patient. (G) A diagnosis of cancer leaves patients frightened and vulnerable, often unable to understand the full implication of the treatment they are being offered.Carers of patients with head and neck cancer are under considerable stress during and after treatment as a result of disruption to daily life, the financial and emotional strain of long-term treatment and in many cases, role reversal within the family unit. Patients and carers look to healthcare professionals to provide information to help manage the psychological and social elements of head and neck cancer.–It is the function of the clinical nurse specialist (CNS) to give the patient and carer the wherewithal to cope with the diagnosis, treatment and long-term consequences through the use of empathy and experience.The National Institute for Health and Care Excellence Improving Outcomes Guidance•Specialist technical knowledge of the cancer process and treatment options•Acting as the patient’s key worker for a specific part of the process and linking in with the MDT•Utilising advanced communication skills to support the patient and carer psychologically through the disease process•Lead on redesigning services to make them responsive to the patient's needs•Health education and promotion to reduce the risk of recurrence and promote a healthy lifestyle•Assisting in local and national initiatives to promote awareness and prevention.The CNS workload can be complex and varied dependent on the patient's needs, it can be categorised into themes:The CNS acts as the key accessible professional to the patient within this multiprofessional setting, and allows the CNS to influence the patient's pathway. They are well placed to support the patient at each stage of their pathway and promote integration within the team. The CNS should be recognised as the patient's advocate within the MDT meetings where they deliver patient-centred care tailored to the individual patient's needs. In acting as the patients' advocate, the CNS also plays a key role in ensuring that the multidisciplinary care is responsive to the patients' needs and preferences.Clinical nurse specialists increasingly take the lead role in shaping patient care pathways and refining systems to make a difference to the patient experience and their safety. By acting as the key worker,Patients and carers have always been at the centre of cancer services, but have not always been encouraged or empowered to help influence and shape them.The Cancer Planvs risks of treatment.Patients and carers now have a realisation that they have considerable influence in gaining access to treatments and medicines, can participate in the designing of clinical trials and influence the amount of money spent by central government on research.A diagnosis of cancer has far reaching effects beyond the patient to their loved ones. This life-changing experience means that relationships and roles and responsibilities can often be changed. Treatments for head and neck cancer can have devastating effects on the lives of patients, including disfiguration, speech and swallowing impairment.•Holistic needs assessment•Treatment summary•Cancer care review•Education and support events.‘The Recovery Package’It also compliments stratified care plans, which enable individualised follow-up care and self-support. It facilitates urgent access back to the specialist team if needed or on-going support from healthcare professionals.•All cancer patients should meet a cinical nurse specialist at the point of diagnosis (R)•Clinical nurse specialists must act as gate keeper to the patient's cancer pathway to provide a seamless journey (R)•Holistic needs assessment (HNA) should be completed at different stages of the patient's pathway to reflect the changes of the patients' needs (R)•Clinical nurse specialists to be part of local and national initiatives for health promotion and raising awareness in the public domain (G)•Clinical nurse specialists should lead in redesigning of services and policies to ensure they are responsive to patient's needs for the future (G)•Treatment summaries should become part of practice to provide good communication between primary and secondary care to enable continuity of care for the patient (G)An HNA ensures that the patients' and carers' physical, emotional and social needs are met in a timely and appropriate way, and that advice and support is available from the right source at the right time.Different assessment tools are used, i.e. distress thermometer, concerns checklist and more recently the patient concerns inventory. The tools can be used at different stages along the patient trajectory, but with an emphasis being on assessing and eliciting patients' and carers' concerns and expectations. This leads to a discussion and care planning of the patients' needs and helps to manage expectations.Pre-treatment clinics provide an opportunity for patients and carers to meet the CNS and other allied health professionals prior to surgical or oncological treatment. It allows HNA assessment to take place, but also facilitates discussion of acute treatment and rehabilitation with the key professionals involved prior to commencement of such.A care plan is based on the diagnosis and holistic assessment of the patient.A key component to effective patient care is good communication between the primary and secondary care sectors. Making sure that general practitioners are fully informed about their patients’ cancer journeys can ease the transition between acute and long-term care. For this to be effective, treatment summaries are provided at the end of any acute treatment by the MDT for the general practitioner and patient. The treatment summary describes the treatment that that person has received, including any adverse reactions, the side effects and signs and symptoms of recurrence. This treatment summary provides confidence to the patient that their care is continuing albeit in the community setting. Patients report feelings of abandonment and vulnerability once initial treatment is complete but with a treatment summary and care plan these feelings can be minimised. Patients' on-going self-management can be well supported through peer support groups and health and wellbeing events. The CNS is obliged to inform patients of what is available in the local area that may be accessed by the patient and carer.•meet every patient at the point of diagnosis to assist in a smooth transition along the cancer pathway•ensure effective communication within the MDT, with patient and carer and within the community setting•be at the centre of the patient's pathway and make effective use of resources•act as the patient advocate, utilising support groups to act as patient voices in the changing healthcare environment to make them patient-centred•perform holistic needs assessment for all patients at diagnosis and specific points along their journey to ensure patient-focused care is being provided•offer treatment summaries to all people involved in the patient's recovery to ensure effective communication•offer individualised care plans to help patients take control of the recovery phase.Clinical nurse specialists should:


The past decades have witnessed tremendous growth in the use of biostimulants in agriculture and it is estimated that biostimulants will grow to $2 billion in sales by 2018  for biocontrol applications. The application of salicylic acid (SA) has been shown to have negative effects on plant productivity either as a result of direct toxicity or changes in allocation of assimilates to plant defense responses. This response was also observed by Ghazijahani et al. (Vergnes et al.  used foli et al.  who noteMany biostimulants contain simple and complex carbohydrates that when applied to plant may alter metabolism by directly acting as a source of energy for endophytic and non-endophytic microbial populations or acting as signaling molecules. The complexity of the roles of carbohydrates in plant immunity was reviewed by Trouvelot et al. , who sugThe great diversity of plant response to biostimulants highlights the challenges faced by researchers. Many plant responses to biostimulants cannot be explained by our current understanding of plant processes and while this represents a challenge, it also presents a great opportunity.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.


Rehabilitation care is fundamental to health and human dignity and a human right enshrined in the United Nations Convention on the Rights of Persons with Disabilities. The provision of rehabilitation is important for reducing the need for formal support and enabling persons with disabilities to lead an independent life. Increasingly scholars and advocacy groups voice concerns over the significant barriers facing people with disabilities in accessing appropriate and quality rehabilitation. A growing body of research highlights a “respond-need” gap in the provision of rehabilitation and assistive technologies and underscore the lack of indicators for assessing performance of rehabilitation systems and monitoring States compliance with human rights standards in rehabilitation service planning and programming. While research on human rights and health monitoring has increased exponentially over the last decade far too little attention has been paid to rehabilitation services. The proposed research aims to reduce this knowledge gap by developing a human rights based monitoring framework with indicators to support human rights accountability and performance assessment in rehabilitation.Concept mapping, a stakeholder-driven approach will be used as the core method to identify rights based indicators and develop the rehabilitation services monitoring framework. Concept mapping requires participants from various stakeholders groups to generate a list of the potential indicators through on line brainstorming, sort the indicators for conceptual similarity into clusters and rate them against predefined criteria. Multidimensional scaling and hierarchical cluster data analysis will be performed to develop the monitoring framework while bridging analysis will provide useful insights about patterns of agreement or disagreement among participants views on indicators.This study has the potential to influence future practices on data collection and measurement of compliance with human rights standards in rehabilitation service delivery and organization. The development of a valid and universally applicable set of indicators will have a profound impact on the design and implementation of evidence informed disability policies and programs as it can support countries in strengthening performance measurement through documentation of comparative information on rehabilitation care systems. Most importantly, the resulting indicators can be used by disabled people’s organizations as well as national and international institutions to define a minimal standard for monitoring and reporting progress on the implementation of the Convention on the Rights of Persons with Disabilities in the area of rehabilitation. Disability is a major issue facing global health policy. It is estimated that one billion people around the world experience some significant degree of disability with 80 % of those living in low and middle income countries . FiguresRehabilitation – defined by the World Health Organization (WHO) as “a set of measures that assist individuals who experience or are likely to experience disability to achieve and maintain optimal functioning in interaction with their environment”  p.96] – –6]. AltDemographic and epidemiological trends suggest that the number of people who could benefit from interventions aiming to reduce dependency, optimize functions and promote social participation is set to increase due to, among other factors, population growth and ageing , thus puex-novo to drive the collection of data in consistency with the legal requirements set by the CRPD in areas where data are not available. Data collection on disability (and rehabilitation) is a key obligation of States stipulated in Article 31(1) of the CRPD, under which “States Parties undertake to collect appropriate information, including statistical and research data, to enable them to formulate and implement policies to give effect to the present Convention.” [Health systems performance measurement and human rights monitoring require meaningful, objective and reliable indicators to quantify progress achieved. While it is true that the use of indicators depends critically on the availability and quality of data, in disability rights monitoring some indicators must be constructed ention.” . At presention.” –17. The ention.”  which maDriven by this absence of a unified framework for estimating disability prevalence and measuring environmental barriers to social participation, WHO is undertaking research to harmonize and advance data collection practices. This research, which is mostly guided by the WHO Disability Action Plan 2014–2021 “Better health for all people with disabilities”  aims at These aspects are sidelined in international initiatives to strengthen disability data and left out of States’ monitoring priorities. The narrowed approach to disability data collection that dictates current technocratic agendas  is inappThus far, international efforts to strengthen data collection practices have limited their focus on survey based data and screening for disability through interview questions in population surveys ignoring other types of data from population based disease registries, hospital discharge records, and facility based reviews, all of which are essential for both evidence-based service planning and human rights reporting , 29. ThiGlobal health leaders, agencies and independent expert groups have increasingly been calling upon States to intensify their efforts to collect appropriate data suitable to monitor the human rights status and situation of vulnerable groups and enhance their collaboration with specialized agencies to build the technical capacity required for health monitoring and human rights assessment. These calls have led WHO and the World Bank recently to propose a global framework for monitoring universal health coverage across the entire spectrum of essential health services . The pilCurrently we lack a validated international set of indicators, especially process indicators , that coWhich indicators are appropriate for monitoring the implementation of the rehabilitation aspects of the CRPD?Which indicators are relatively more important and feasible and how the views of researchers, rehabilitation professionals and people with disabilities differ on the subject?What does a human rights monitoring framework for rehabilitation consists of, and how can it be put in practice?Seeking to cover this knowledge gap, this paper proposes a study to develop a monitoring framework with indicators to support countries to assess progress in the implementation of the CRPD in the area of rehabilitation. Specifically the study aims to provide answers to the following research questions:The general approach to answering these questions and the methodological details of this study are explained in the Methods section. But before describing the research process, it is essential to define what a human rights based indicator is and understand some of the challenges associated with their development.In general terms indicators can be defined as numerical or textual values that provide information about a phenomenon. Indicators are essential elements of monitoring and evaluation systems that allow for assessment of progress towards the achievement of goals, enabling comparisons of different units or comparisons of the same unit at different time intervals. Unlike development and performance indicators, which follow programming principles, human rights indicators are explicitly anchored in human rights values and standards . “Such iMethodologically, the development of human rights indicators is a challenging undertaking. In academic research, scholars have proposed and used many ways to accomplish the difficult task of indicators development, ranging from traditional research methods to more sophisticated approaches . CurrentRegardless of the method being used to develop human rights indicators, one of the major challenges lies in the conceptualization of the treaty provisions (what to measure) and the operationalization of qualitative or textual information into measurable entities (how to measure). A thorough legal analysis is therefore essential to delineate the attributes of the right under examination and identify the key obligations of signatories to a specific treaty. These obligations must be then mapped onto indicators for which data are available and reliable. But as Fukuda Par notes, the criterion of measurability cannot dictate the selection of indicators since not all aspects relevant to human rights can be quantifiable or captured with measurement tools such as, people’s participation in the conduct of health affairs , 48. ThuFor developing the rehabilitation monitoring framework and identifying appropriate human rights-based indicators we propose to carry out a Group Concept Mapping study (GCM) that is underpinned by the methodological principles of structured conceptualization . GCM is Conceptually, the study will be guided by key international legal instruments pertaining to disability and rehabilitation, specifically the CRPD and particularly Article 25 , Article 26 (Rehabilitation) and Article 31 (Data collection and Statistics). An analysis of the obligations of States under the CRPD with respect to rehabilitation and its resulting framework will serve as a conceptual platform for identifying potential indicators in key human rights commitment areas . This pln = 150 participants through purposive and self-selection from the following stakeholder groups: (i) n = 50 rehabilitation professionals and service managers, (ii) n = 50 researchers with expertise in various disciplines such as global health law, health services research and rehabilitation medicine, and (iii) n = 50 people with disabilities and representatives of disabled people’s organizations. This will result in n = 27 participants sorting and rating the indicators which is above the minimum number recommended for ensuring the validity and reliability of the study results (n = 15) [There is no limit on the number of people who can participate in GCM. Based on a pooled analysis of 69 concept mapping studies Kane et al. found a range of 20–649 participants with an average of 75 participants completing the rating phase . AssuminFor recruiting experts in the study the investigators will contact international professional organizations and societies, disabled people’s organizations and individual academics and peers asking them to participate in the study and nominate additional experts for participation. A pool of participants who fulfil the criteria for participation  will then be stratified by stakeholder group. A random sample will be drawn from the experts pool for each stakeholder group and sent an email invitation to participate in the survey. Invitees who decline the invitation are replaced by other randomly drawn experts from the same expert pool.In GCM data can be collected either in paper form during pre-scheduled workshops or remotely through dedicated web based platforms. In this study data collection will be facilitated by the Concept Systems Global MAX™, a web based software specifically designed to facilitate concept mapping activities . Data peBased on the principles of GCM  a sequen“An appropriate indicator for monitoring the implementation of the CRPD in the area of rehabilitation is…” Using this question, participants will brainstorm a wide array of measures which will result in a long unfiltered list of potential indicators. After the conclusion of the brainstorming session, the research investigators will review and content analyze the brainstormed indicators to remove duplicate or other irrelevant statements and agree with stakeholder representatives on a final set of measures for further elaboration.At this stage, a focus prompt – an incomplete sentence designed to invite people to complete it – will be used to elicit participants’ best ideas and expertise on the topic. The focus prompt is: In the first data collection activity of this phase all participants will be invited by email to organize the indicators into categories in a way that makes sense to them and thus identify the conceptual building blocks for the rehabilitation monitoring framework. Participants will also rate the indicators for importance and feasibility, thus allowing patterns of agreement and/disagreement among different stakeholder groups to be identified.Data analysis will be performed using special functions of the Concept Systems Global MAX™ software . MultidiThese analyses will finally lead to a general discussion of the reasonability of the resulting monitoring framework and its implications for human rights compliance and rehabilitation systems performance assessment. Specifically, in the final phase of the GCM, stakeholder groups' representatives and experts in public health monitoring will be invited to review the clusters of indicators and the underlying relationships between them and to collectively interpret the results in a way that can drive evidence based action.Ethics review and clearance has been obtained for this project by the Ethics Commission for Northwest and Central Switzerland.This study aims to reduce the information gap in the assessment of performance of rehabilitation services and programmes for people with disabilities. It also has the potential to influence future practices on data collection and measurement of compliance with human rights standards in the delivery and organization of rehabilitation care. The development of a valid and universally applicable set of indicators will have a profound impact on decision making and implementation of evidence informed policies for rehabilitation at national and global level. Furthermore, the resulting monitoring framework can support the documentation of comparative information on national rehabilitation care systems and could be used as a minimal standard for monitoring and reporting progress on the implementation of the CRPD in the area of rehabilitation.A unique feature and major strength of the GCM is that it employs a truly participatory process for developing the indicators. Unlike other research methods the approach to data collection and elaboration is highly structured and under the control of the participants. Specifically and significantly, GCM allows stakeholders to contribute their expert knowledge by identify relevant metrics, participate in the interpretation of their perceptions and elaborate on their potential use of the resulting evaluation framework. An additional strength lies in the use of advanced statistical techniques to provide useful insights about the relationships of the ideas of different stakeholder groups, which provides rigor and enhances the credibility of information obtained during qualitative research processes. This results in visual representations of the indicators in the form of maps that are relatively easy to understand and interpret in the subsequent phases of the research process.Alternative approaches that have been used for the development or selection of indicators in health research either lack scientific credibility  or adoptAs with conducting on line surveys, GCM presents a number of challenges for the investigators to address when collecting, organizing and interpreting the data. Remote data collection in concept mapping may allow researchers to access large and geographically distributed samples of participants, but they carry with them specific limitations when compared to the traditional paper based collection of data. These include the risk of a low response rate and a resource intensive process for collecting and analyzing the data . In ordeThe results of this study are relevant to key stakeholders at both the national and international level in a variety of ways. First, the resulting indicators set will equip national public health and statistical authorities and human rights institutions with a valuable tool to monitor States’ compliance with international human rights law standards in the organization and delivery of rehabilitation services. In so doing, competent authorities may choose to either adjust their own data collection and monitoring systems to include human rights based indicators or use the new metrics separately on an ad hoc basis during periodic country performance reviews. Second, the results will be relevant to researchers, policy analysts, advocates and global health stakeholders, providing them with an evaluation framework and menu of newly created, evidence based measures that can be used to standardize the assessment of rehabilitation services and programs and facilitate comparative evaluation research.In addition to satisfying the need for human rights monitoring and performance assessment, the rehabilitation indicators will be extremely valuable for UN agencies, Member States and other international stakeholders. The metrics proposed by this study will augment existing quantitative and qualitative measures thus offering a more comprehensive evaluation toolbox that WHO and other organizations can use in their programmatic activities, as for example to assess progress in the implementation of the WHO Global Disability Action Plan. Finally, the indicators set will be based on the legal requirements of the CRPD that represents a nearly universal consensus as it has been ratified by nearly 160 countries in the world. This makes the set of indicators applicable in all contexts and thus might be an appropriate start for the development of specific human rights monitoring guidelines for Article 25 and 26 by the UN committee responsible for the oversight of the CRPD.Lastly, from a consumer’s perspective, the long standing misapprehensions surrounding the goals of rehabilitation and the contested role of health professionals in disability management make the results of this research even more important. Since people with disabilities have been traditionally excluded from decision making in rehabilitation care planning and programming, rights based indicators will prompt rehabilitation professionals and service designers to reconsider oppressing attitudes and approaches in their everyday clinical practice and pay more attention to human rights issues in patients care . More imThe results of this study will provide the global health and disability community with a preliminary set of cross-cutting indicators for assessing performance of and monitoring compliance with human rights standards in rehabilitation service planning and delivery. It will help identify gaps in quantitative data and other qualitative information that are essential for the comparative evaluation of national rehabilitation care systems. This will stimulate action toward the expansion of information gathering on rehabilitation services and further research on the development, testing and validation of indicators for various tracer conditions. The study described in this paper is a major step toward advancing the current practice of rehabilitation systems performance comparison and promoting evidence-based human rights monitoring and reporting.


Sir, The response by The very interesting question is the reason for the more severe disease expressivity and complete penetrance in the patients reported (TTN (We attempted to find evidence for a modifier effect for kinase variants by screening a HMERF population of 33 patients, but our findings did not support this hypothesis (


Maternal mental disorders are associated with adverse psychological outcomes in children in countries of low and middle income , 2. AlthWomen with mental disorders sometimes perform self-interruption of medications during pregnancy, and then the self-interruption of medications sometimes deteriorates their state of mental disorders. They seemed to misunderstand that the medication leads to the adverse outcomes of pregnancy. In addition, the pregnant women impoverished economically may be liable to be as follows: 1) they have often received low education leading to their misunderstanding about the influence of medications on their pregnancies because their parents had been also poor; 2) there may be large time and/or economic burdens in their visiting of psychiatric and obstetrics; and 3) the stress of pregnancy may be easy to hunt down their psychological status because there is no room in their life. These may become negative chains in their lives and these may lead to the poverty and adverse psychological outcomes of their children. The Japanese HAP system aids their delivery costs only. Therefore, in Japan the proper education and sufficient financial support are needed for pregnant women who are impoverished economically to prevent the deterioration of their mental status during pregnancy.


Resonance in the membrane potential enables a neuron to discriminate its inputs on the basis of their frequency content, so that oscillatory inputs near the resonant frequency produce the largest responses . RecentlThese results contribute to the understanding of the complex interactions between active and passive properties in MNs and how these interactions can produce membrane potential resonance and affect action potential generation. The relation we found between subthreshold resonance and the minimum firing rate merits further studies to better understand how firing rate may be affected by membrane resonances.