Spigelian hernia (SH) is rarely seen in pediatric age group and is usually associated with cryptorchidism on the same side; termed as a syndromic association of the defect in the Spigelian fascia and absence of gubernaculum and inguinal canal. The absence of the inguinal canal has surgical implication as to placement of the undescended testis into the scrotum. A 3-month-old baby presented with spigelian hernia and ipsilateral impalpable testis. The spigelian hernia was repaired and undescended testis which was present in abdominal wall layers was brought to scrotum with cord structures anterior to external oblique muscle. SH is rare in children with only 59 pediatric cases reported up until 2012 since its first description in 1935.[1-4] The anatomical basis of SH is weakness in the SH belt arising from a transversus abdominis aponeurosis between the lateral edge of the rectus sheath and the semilunar line that stretches from the ninth rib to the pubic tubercle. Whereas adult SHs are considered to be acquired because of trauma or increased intra-abdominal pressure, pediatric cases are suspected to be congenital. Among male infants with SHs, 75% are associated with cryptorchidism.[6] The association of ipsilateral undescended testis and SH is being debated whether it is a cause or effect relationship. Raveenthiran suggested that a defect in the Spigelian fascia combined with ipsilateral cryptorchidism, may be a part of new syndrome.[7] Rushfeldt and others suggested that the additional lack of a gubernaculum and inguinal canal in similar cases, may be considered as two additional and closely connected elements of this new syndrome.[2] We have managed a 3 months old male child who presented with SH and ipsilateral undescended testis along with all the features of this new syndrome.A 3-month-old male baby was admitted with a swelling on the right side of abdomen and absence of testis on the same side. The swelling increased in size on crying. The swelling occupied right lower quadrant of the abdomen and was non-tender. On genital examination, the left testis was normally descended and right one was impalpable in scrotal pouch and inguinal area . Ultrasonography of the swelling revealed an echogenic tissue consistent with testis in the layers of abdominal wall along with small gut loops echoes. At operation a defect found on the lateral border of rectus abdominis muscle around the arcuate line with a hernial sac containing testis without any inguinal canal and gubernaculum .The sac was opened and the testis was separated from the sac. The defect in the abdominal wall was repaired by absorbable sutures and testis placed in the right sub-dartos pouch by placing the cord structures anterior to the external oblique muscle (subcutaneous route). In the post operative period child remained well and discharged home after 3 days.Cryptorchidism in children presenting with SH is considered to be a congenital condition. There has been considerable speculation and controversy regarding the possible mechanism of cryptorchidism in SH. According to the general viewpoint, SH is the primary defect and the undescended testis takes the path of least resistance to descend and lie in the hernial sac accounting for this association. Raveenthiran speculated an ectopic location of the testis is the primary abnormality, and it leads to formation of SH by dragging a peritoneal sac along with it.[7] Rushfeldt et al believed in failure of development of gubernaculum as an inciting event; [2] thus inguinal canal could not develop and the testis remain in their intra-abdominal position.Ultrasonography helps in assessing the size of the defect and contents of the hernia sac. The management of this anomaly includes repair of the hernia and scrotal placement of the undescended testis. While undertaking surgical repair of SH, one should look for an undescended testis, and expect it to be in the hernia sac. Furthermore, since an inguinal canal may not be found, one should be prepared to perform an orchidopexy either via a subcutaneous route or a new internal ring may be created through the abdominal wall medial to the inferior epigastric vessels and just lateral to the pubic tubercle.[4] However one should be careful in orchidopexy by creating neo internal ring as testicular atrophy has been reported in one patient.[4] The possible reported explanations for such an outcome include vascular damage, tension and compression of the cord and scrotal infection.Source of Support: NilConflict of Interest: None declared


We build a model of cuttlefish chromatophore excitation patterns due to environmental input. Specific inputs generate scripted chromtophore pattern responses on the surface of the skin. More complicated responses are then assembled from these templates as sequences of inputs arrive. We build a simplistic cuttlefish brain using neural architecture modeling tools written in MatLab which allow us to construct the brain model from individual modules using a vector addressing scheme  Figure .Inputs come into the sensory input module and are processed by the cuttlefish brain architecture into signals sent to the output module. The signals activate the individual chromatophores in the usual way giving an essentially binary on/ off pixel response. Different cues in the environment are mapped to known cuttlefish pigmentation overlays on the surface of the skin. Individual simple cues result in coarse patterns of chromotophore activation and upon receiving a sequence of simple cues, more complicated responses are constructed in a hierarchical fashion .The chromatophore visibility is known to be due to a brain signal which when received energizes a ring of muscle which contracts and pushes a dot of ink up to the surface of the skin. Hence, activation signals lead to visible dots and lack of activation signal can be inferred from the loss of the pigment dot. Our model therefore treats each chromatophore as a binary switch which moves from 1 to 0 or vice versa depending on the signal sent to the output module from our cuttlefish brain processing ,4.


The percentage of sports and leisure shoes sold worldwide is gradually increasing. However, consumers have little or no objective information on the mechanical properties of the shoes. A justified selection protocol of sports and leisure shoes based on static and dynamic shoe properties considering the intended use is essential. Today, commonly accepted dynamic test protocols for (sports) shoes do not exist.The development of an artificial parametric foot as part of an innovative robot gait simulator is a tool to objectify shoe properties independently from possible compensations encountered during assessment of test persons. This contribution discusses the development of an artificial foot enabling objective testing of the mechanical and functional properties of sports and leisure shoes.An artificial foot consisting of the shank, the rear foot, the mid foot and the toes was designed based on a measurement protocol for barefoot running using 12 active markers sampled at 400 Hz [Based on measurements the design of this initial foot was optimized with respect to functionality and appropriate shoe fit. The multi segment design of this foot is shown in figure An improved artificial foot design with built-in springs and dampers for objective testing of shoe properties is realized. The design needs further elaboration with respect to geometry, foot axes and functional behaviour. This mechanical foot is a promising tool to help us understand mechanical properties of shoes using strictly standardised testing protocols using mechanical gait simulators.


In October 2011 the Mater Child and Youth Mental Health Inpatient Unit developed and implemented the Mater CYMHS Program for the Management of Eating Disorders (the protocols). The protocols were developed to improve admission and discharge pathways for young people with restrictive eating disorders as well as to improve consistency and efficacy of inpatient treatment which supports various outpatient models of care. Currently there exists little evidence for best practice treatment of restrictive eating disorders in children and adolescents on a psychiatric inpatient unit. This presentation aims to fill in the gaps in the existing literature by presenting outcome data for young people treated under the protocols. These outcomes will then be compared with those patients who received "treatment as usual" prior to the implementation of the protocols. Furthermore, we will present data examining staff perceptions of patient care of those with restrictive eating disorders both before and after the protocols were introduced.Care in Inpatient and Community Settings stream of the 2013 ANZAED Conference.This abstract was presented in the


NaP) and an A type potassium current (IA), in combination with the passive properties [Mesencephalic trigeminal (MesV) cells are sensory neurons involved in the brainstem circuitry that generates and controls orofacial activities . Recentloperties . These cNaP and IA currents), is the waveform of the action potentials of these cells characterized by its high amplitude and short duration, with almost no after hyperpolarization and small interspike intervals. Despite the fact that those subthreshold mechanisms have been thoroughly studied [In an attempt to generate a model of a network of electrically coupled MesV neurons that reproduce these behaviors, as critical as the subthreshold active mechanisms responsible for the frequency selectivity of these contacts  , that wa


There is a growing body of literature examining the utility of behavioral treatment in primary progressive aphasia (PPA). There are, however, no studies exploring treatment approaches to improve speech production in individuals with apraxia of speech (AOS) associated with the nonfluent variant of PPA. The purpose of this study was to examine a novel approach to treatment of AOS in nonfluent PPA. We implemented a treatment method using structured oral reading as a tool for improving production of multisyllabic words in an individual with mild AOS and nonfluent variant PPA. Our participant showed a reduction in speech errors during reading of novel text that was maintained at one year post-treatment. Generalization of improved speech production was observed on repetition of words and sentences and the participant showed stability of speech production over time in connected speech. Results suggest that oral reading treatment may offer an efficient and effective means of addressing multisyllabic word production in AOS associated with nonfluent PPA, with lasting and generalized treatment effects.


Radiation oncology practice is a collaborative effort that involves multiple clinical and technical specialists including physicians, medical physicists, dosimetrists, radiation therapy technologists, and nurses. The safe and efficient delivery of radiation therapy was never a simple matter and is now exceedingly complex.The growing complexity of radiation oncology procedures has been identified as a significant risk factor in potentially causing patient treatment errors. National and international standards have evolved to guide the safe and effective use of ionizing radiation for treatment and have been codified by leading professional organizations into accreditation requirements that necessitate rigorous documentation of performance for each aspect of the process of care. The process of care in radiation oncology refers to a conceptual framework for guaranteeing the appropriateness, quality, and safety of all patients treated with radiation for cancer and certain benign conditions.A primary objective of a Comprehensive Radiation Oncology Quality and Safety Program is the design and clinical implementation of approaches that will minimize the incidence of radiotherapy adverse events that could potentially have negative impacts on the quality of patient care.The papers in this Research Topic address multiple issues that should be considered to ensure managing the process of care with approaches that will ensure the optimal delivery of radiation therapy.


Plant cell walls display a considerable degree of diversity in their compositions and molecular architectures. In some cases the functional significance of a particular cell wall type appears to be easy to discern: secondary cells walls are often reinforced with lignin that provides durability; the thin cell walls of pollen tubes have particular compositions that enable their tip growth; lupin seed cell walls are characteristically thickened with galactan used as a storage polysaccharide. However, more frequently the evolutionary mechanisms and selection pressures that underpin cell wall diversity and evolution are unclear. For diverse green plants (chlorophytes and streptophytes) the rapidly increasing availability of transcriptome and genome data sets, the development of methods for cell wall analyses which require less material for analysis, and expansion of molecular probe sets, are providing new insights into the diversity and occurrence of cell wall polysaccharides and associated biosynthetic genes. Such research is important for refining our understanding of some of the fundamental processes that enabled plants to colonize land and to subsequently radiate so comprehensively. The study of cell wall structural diversity is also an important aspect of the industrial utilization of global polysaccharide bio-resources. The first level consists of primary screens for cell wall polysaccharides based on carbohydrate microarrays probed with mAbs and CBMs  using microarray-based polysaccharide screening and lichenase treatments  and also having diverged prior to the gene duplication events associated with the evolution of flowering plants, cautions us not to generalize this principle excessively. The second reason why the number of GTs cannot be inferred from the number of different linkages is that the biosynthesis of some polysaccharides has turned out to be much more complicated than anticipated from the polysaccharide structure; xylan biosynthesis, reviewed by Box 1. The CAZy database is the most extensive database of GTs and contains GTs from all three kingdoms. By using a global approach including the whole CAZy database in the screen, more remote orthologies can be discovered, exemplified by the discovery of a mannosylglycerate synthase of GT78 in S. moellendorffii  of enzymes that degrade, modify, or create glycosidic bonds  genes as encoding putative extensin arabinosyl transferases. This annotation is not proven but was corroborated by Arabidopsis . A number of EST datasets ? Is this to be a paradigm for non-cellulosic wall polymers for which we currently have one or a limited number of probes such as pectic galactan and xyloglucan? The next few years will see more detailed systematic assessments of molecular architectures. This will be in conjunction with enzymatic and/or chemical pre-treatments that are in some cases required to optimize polysaccharide detection and in the case of polysaccharide masking (in which one polymer class blocks access to another polymer class) indicates important features of cell wall architectures reflecting protein access  the absence of pectic galactan from pit fields, we do not have a good understanding of the cellular distributions of all polymers for most plant cell types. Even for ectic HG  and alsoectic HG  where a renchyma . What isn access .Figure 2? How are these heterogeneities integrated into a functional whole in terms of wall properties and functions? In vitro analyses of composites formed from cellulose, pectins, and xyloglucans have yielded invaluable information about the properties of some wall components (in vitro approach cannot reasonably be applied to investigate the functional properties of the full diversity of extant walls. In vivo methods of investigating wall biomechanics, at the tissue and lower levels, have been developed (in situ analyses are combined with genetic and enzymatic interventions. Integrating this knowledge will be a major challenge and is an exciting frontier for cell wall biology.Clearly we face many challenges in understanding cell wall evolution not least of which include sufficient sampling followed by appropriate synthesis and interpretation of large data sets including diverse information such as gene and protein sequence data as well as sugar linkages and epitope distributions. However, as cell and tissue molecular architectures are documented another major issue that is brought into focus is the function of individual wall components and of the entire cell walls, which can vary enormously with respect to quantitative and qualitative composition. Why do some cell walls have xyloglucan, xylan, and mannan hemicelluloses in distinct spatial distributions as for example in the extensively studied tobacco stem system as shown in mponents . Howevereveloped  facilitaThe 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.


Populus tremulae) at the transcript level we inoculated clones of this species with a foliar rust on the leaves and a necrotroph in the bark. Leaf samples were collected from above the inoculation site to examine the long distance (systemic) defense responses and bark tissue around the site of inoculation examined for the local response as early as day1 post treatments. We performed microarray experiments on the biotrophic and necrotrophic interaction and between healthy controls of two SwAsp clones. Selected candidate genes were also examined in more detail by qRT-PCR and chemical analysis for phenols and tannins was also performed. We found that the two clones respond in a very different in fashion at the transcriptional level to both the biotrophic and necrotrophic pathogen. The more resistant clone responded systemically within 24 hours while little response at the transcriptional level was detected in the more susceptible clone in response to the biotroph, while indications of suppression in response to the necrotroph was found.Trees are exposed to a variety of pathogenic fungi. The defense response toward a biotroph may require a different strategy that toward a necrotroph. To understand the key processes of defense responses toward pathogenic fungi in aspen (


The inference of reaction rate parameters in biochemical network models from time series concentration data is a central task in computational systems biology. Under the assumption of well mixed conditions the network dynamics are typically described by the chemical master equation, the Fokker Planck equation, the linear noise approximation or the macroscopic rate equation. The inverse problem of estimating the parameters of the underlying network model can be approached in deterministic and stochastic ways, and available methods often compare individual or mean concentration traces obtained from experiments with theoretical model predictions when maximizing likelihoods, minimizing regularized least squares functionals, approximating posterior distributions or sequentially processing the data. In this article we assume that the biological reaction network can be observed at least partially and repeatedly over time such that sample moments of species molecule numbers for various time points can be calculated from the data. Based on the chemical master equation we furthermore derive closed systems of parameter dependent nonlinear ordinary differential equations that predict the time evolution of the statistical moments. For inferring the reaction rate parameters we suggest to not only compare the sample mean with the theoretical mean prediction but also to take the residual of higher order moments explicitly into account. Cost functions that involve residuals of higher order moments may form landscapes in the parameter space that have more pronounced curvatures at the minimizer and hence may weaken or even overcome parameter sloppiness and uncertainty. As a consequence both deterministic and stochastic parameter inference algorithms may be improved with respect to accuracy and efficiency. We demonstrate the potential of moment fitting for parameter inference by means of illustrative stochastic biological models from the literature and address topics for future research. The traditional approach to modelling of biological reaction networks is based on deterministic mass action kinetics in which the time course of the species concentrations averaged over the population is described by a set of coupled ordinary differential equations Parameter estimation in differential equation models is a classic nonlinear inverse problem that arises in a variety of scientific, industrial and financial applications and is approached both in deterministic and statistical ways for a multivariate normal distribution or a weighted sum of squared residualsfit higher sample moments derived from time series data, e.g., by computing the distance between the sample variance see In this paper we present a moment fitting approach to parameter inference in stochastic biological models from time series data that to the best of our knowledge has not been studied before. First, we suppose that the state variable vector of molecule numbers can be partially - both with respect to time and state variable components - and repeatedly, say that describe the time evolution of parameter dependent moment approximations We studied the concept of moment fitting for parameter inference in stochastic biological models from time series data by means of three reference examples, see Materials and Methods for all model details, and chose The Kolmogorov differential and implies the ODE systemfor the mean For the purpose of data generation we have simulated the true stochastic process In order to infer the rate parameters for a comparison of the sample mean with the analytic mean expression (2). Choosing the initial parameter guess The problem of non-identifiability is overcome if not only the first moment but also the second central moment is fitted to the available data, e.g., by minimizing the cost functionAgain starting from In a further test, we utilized the likelihood functiondoes not involve the error between which compares as priors for the parameters, the algorithm failed to yield acceptable marginal posterior density distributions due to the ignorance of the sample variance Based on the Fokker Planck the normal moment closure technique yields the nonlinear ODE systemfor the (approximative) mean We first only focused on the sample mean data by means of the MATLAB The linear noise approximation (14) yields a nonlinear ODE system describing the temporal development of the mean approximation with the initial guess Our numerical tests by means of reference models from the literature show that comparing sample moments with theoretical moments may enhance parameter identifiability and the performance of parameter identification algorithms in comparison to mean-only approaches. These observations can be explained by an examination of the cost functions that have been used for the parameter inference. In the linear birth death example the mean expression (2) shows that any parameter combination of of (5) evaluated at For the dimerisation example the level sets of the cost function (7) are shown in Similar conclusions can be drawn from the by differentiation with respect to which corresponds to a reduction of the eigenvalue ratio Based on accepted mathematical descriptions of stochastic reaction networks in well-mixed conditions we have introduced the concept of moment fitting for parameter inference from time series data of repeated measurements. In numerical tests for simple reference examples we observed that if the common comparison of sample mean data with the parameter-dependent mean expression derived from the model is augmented by consideration of higher moments such as covariance, improvements both with respect to parameter estimate accuracy and algorithmic efficiency are achieved.Our approach offers opportunities for extension and further research. In case of larger models and real data, then also affected by external noise, measures against data instability and overfitting become necessary. The regularization theory of nonlinear inverse problems see In our examples we used squared errors to build the distance functions. This not only allowed us to numerically demonstrate the advantages of moment fitting but also to give explanations of the results in terms of Hessian matrices which in the squared error case can be computed in a straightforward manner. Furthermore, the squared error approach enables the straightforward utilization of the adjoint method, see Materials and Methods, for providing gradient information to the optimizer. Still, as moments of different order may be correlated but then poses severe challenges with respect to an efficient computational realization.The moment fitting approach presented in this paper rests upon the availability of sufficient data for the estimation of higher moments as only then more traditional mean-only approaches may be outperformed. This raises the question of selecting the sample size see In well-mixed conditions a network of where the integers Let With where An alternative approximative description of the stochastic process is given by the linear noise approximation into a deterministic part and a stochastic process with the increment Finally, the deterministic modelling approach which corresponds to (15) with the setting Depending on the chosen modelling approach the state variable of a stochastic biochemical reaction network is described as a discrete or a continuous random quantity. In the discrete case associated to the Kolmogorov differential where In general, the and the with In case the state space of the biological system is modelled as a continuous random variable Based on the differential see holds only then. Another example is the time evolution of the The simple example exact differential equations for their time evolution impossible to solve analytically or numerically. The problem may be overcome by the technique of moment closure and implies the dependency of the ordinary differential equation for approximatively describes the time evolution of the true moments in which As an alternative to the moment closure approach, a closed form (21) for the approximative description of the moment time course for Here, A classic and illustrative reaction system widely studied in the literature is the linear birth and death process with the associated stoichiometric matrix In all simulations of the discrete stochastic dynamics of the model we chose the rate parameters With respect to the parameter inference problem we suppose that the state variablecan be only partially observed at the obtained from an  equidistant discretization of the time interval such that the partial state observation can be compactly described as A simple reaction system featuring a nonlinear rate function is the dimerisation process The conservation of the total number allows to formulate the stoichiometric matrix for a one-dimensional state space. In all simulations of the discrete stochastic dynamics of the model we chose the rate parameters For testing the practicability of our approach in case of partial state observations we have chosen a model for the In all simulations of the discrete stochastic dynamics of the model we chose the rate parameters andThe time observation parameters were chosen as All molecular copy numbers used in our tests have been generated by MATLAB A of data matrices. For each discrete time point while the empirical covariance matrix of the observables at time in which of length with sample mean vector If we split the state variable Then, in order to compare the parameter dependent solution component may be utilized where the time discretization operator Examples for where, in general, With respect to parameter inference the difference function (26) can be utilized in various manners. For instance, it can be minimized by deterministic or stochastic optimization routines, it can be incorporated as a cost function in approximate Bayesian methods or used in building Kalman filters or Luenberger type observers. In the context of gradient based optimization, the gradient information can be efficiently provided by means of the so-called adjoint technique whenever Supporting Information S1Moment Equations for Test Models.(PDF)Click here for additional data file.Supporting Information S2Adjoint Method for Gradient based Optimization.(PDF)Click here for additional data file.


Prediction and competition mechanisms are here combined into a neuro-inspired computational model in order to enhance robustness for spatiotemporal tracking and pattern recognition tasks. The research presented in this abstract extends the initial experimental results and mathematical accuracy proof obtained with a single predictor  to a setThe performance and emergent attentional properties of the model were ascertained on a 2D visual tracking application with ambiguous and noisy signals. Results are synthesized in Table While the predictors improve tracking performance when they adequately anticipate the dynamics, their inadequacy simply leads to a fall back on the original CNFT dynamics. This allows the system to perform correctly while learning the predictors, but also to discriminate between trajectories, as the relative level of assimilation of the dynamics is updated in real-time.


Patient diaries have the potential to support food allergy diagnosis. The time relationship between the consumed product and the experienced symptoms is of high value for diagnostics as well as for therapy control. The combination of a barcode reading handheld device and a dedicated electronic patient record is a unique method to support the diagnostic process.A Smartphone based Personal Allergy Assistant (PAA) allows patients to keep an electronic patient diary by scanning the barcode of the consumed food products. A catalogue of predefined symptoms as well as their medically justifiable time window during which a symptom can manifest itself after the ingestion has been defined. An Electronic Patient Record for Allergies (EPRA) stores results from patient investigations with allergy specific medical knowledge, provided by allergy experts . Data on the PAA is regularly synchronised with the electronic patient record and the food database. Diaries are evaluated by emphasising the association between food intake and occurred symptoms in order to calculate the relative risk (RR) of a specific food product or nutrition.The PAA provides patients with an easy to use device to create high quality diaries for food intake and symptoms by scanning the food package's EAN barcode. It sets automatic timestamps to reduce potential data tampering and increase the data quality and allows recording of food intakes from non-packaged food  as well as pharmaceuticals. For diagnostic purpose, the diary is regularly transmitted to the allergist's electronic patient record. Diaries are evaluated automatically providing measurement categories that are commonly used in medicine. To support the individual diet management, the PAA gives a warning before the consumption of allergenic food.During a pilot study with 35 participants the feasibility and patient acceptance has been proven. Information and Communication Technology has the potential to simplify the interdisciplinary exchange of patient information between patients and medical experts.


Randomised control clinical trials of acupuncture have been hampered by the challenges of assessing it as a complex intervention. Controlling for and separating placebo effects whilst identifying its efficacy as a treatment can be difficult . The comThe objective of this pilot trial is to investigate the feasibility of undertaking a novel randomised cohort design study with a nested factorial RCT, investigating acupuncture alone versus manual therapy alone versus a combination of acupuncture and manual therapy versus usual care.The pilot will investigate recruitment rates to allow for planning a full-scale trial, identify any compliance issues and strategies for reducing these in a full-scale trial and assess patient’s acceptance and therapist delivery of combined therapies for the treatment of their LBP.The study will follow a randomised cohort trial design and participants from the cohort will be selected to participate in the pilot trial. The use of this design as a recruitment method for nested trials is relatively new methodology but the cohort design has been suggested as an effective method for the use with chronic conditions  and its The factorial pilot RCT will investigate the treatment of low back pain with Acupuncture vs Manual Therapy vs Acupuncture and manual therapy vs Usual GP care. All interventions will be delivered by a chartered physiotherapist.Recruitment and retention rates will be presented. The acceptability and feasibility of the design for use with complex interventions and in a common musculoskeletal condition will be discussed.


The purpose is to introduce the Lebanese Society for Infectious Diseases and Clinical Microbiology (LSIDCM).The Society was established in 1992.It includes 46 infectious diseases physicians as well as clinical microbiologists. The members are spread across the country. All physicians are involved in managing infection control programs in their respective hospitals. So far the Society has organized twelve national and regional congresses on infectious diseases and clinical microbiology. Over the last 4 years, a yearly course on infection control is offered during each congress and many national and international speakers are involved.The LSIDCM is currently working on developing national guidelines for the management and control of infectious diseases, national antibiotic usage monitoring, monitoring of antibiotic resistance on a national background and the establishment of a national registry of health care associated infections.None declared.


Fracture healing is a biological process in continuum from fracture to healed stage. It involves a sequence of dynamic events which ultimately restores the integrity of the bone and its biomechanical properties.The severity of damage to the physical environment at the fracture site as a result of injury affects the biological potential for healing. The magnitude of injury decides the insult occurring at the fracture site. The disruption of soft tissues and network of vascular channels makes the bone ends devoid of circulation to a variable length. The more is the force of impact and disruption to the tissues the more is the devascularization. The repair process starts with demineralization of devitalised bone ends and subsequent revascularization. The pleuripotent cells get converted into cartilage cells and later osteoblasts to make a new bone on the scaffold of the devitalised bone and thus finally a woven bone is laid down which in due course gets trabeculated. The fracture ends first get temporarily stabilized by organized fracture hematoma, cuff of fibrocartilage followed by woven bone. The woven bone is seen as fracture callus which continues to remodel for many years. This in short is described as secondary  fracture healing which occurs in the majority of fractures. The primary bone healing occurs where there is a rigid internal fixation. This consists of cutting cones traversing through the devitalised bones which progress across the fracture site directly in a similar way to normal bone remodeling.The process of healing is a very slow process occurring at cellular levels hence the need to provide a temporary stability by plaster cast for a certain length of time which allows the cascade of events of fracture healing to take place unabated. The normal cascade of events is modified by open injuries, surgical intervention and instability at the fracture site. The length of immobility by plaster cast adds the effects of immobility such as stiffness of joints, secondary to fibrosis in the injured muscles and ligaments hence an exercise regimen is indicated till such time normal joint motions are regained. The stability at the fracture site is of paramount importance. The motion at fracture site within a permissible range (micromotion) stimulates the fracture healing potential while beyond a certain level retards the healing process. The rigid immobilization of fracture is considered unphysiological and micromotion occurring secondary to functional activities encourages osteogenesisThe objective of fracture care is to allow the biological process of healing to occur at a normal pace with minimal hindrance and damage to the injured limb. Since some of the fractures are not aligned by closed manipulation they are treated by open reduction and internal fixation by implants. The surgery has its impact on the natural cascade of fracture healing. The fractures ends are exposed surgically, manipulated and aligned anatomically and internally fixed (stabilized) by intramedullary or extramedullary implants. All this require exposure of bone to certain length and disrupts normal soft tissue with results and disruption of already damaged blood supply. The biological efforts needed for fracture healing are going to be more extensive than healing in a closed fracture. The healing process becomes further complicated when internal fixation fails to achieve relative stability at the fracture site or wide exposure leads to lifting of periosteum and consequent damage to its cambium layer or the fracture fragments are stabilized at the fracture site with a gap of 2 mm or more.The ideal objective of surgical treatment should be to achieve a better outcome than nonoperative treatment. The outcome of surgical treatment are going to be worse if surgery is not executed perfectly as prescribed by the surgical principles of fracture fixation technique. The open reduction and internal fixation (ORIF) in a closed fracture increases the risk of infection and consequent retardation of fracture healing. A good outcome following ORIF of fractures can only be achieved when the fracture is anatomically reduced, stably fixed, and there is no risk of infection, to allow early postoperative mobilization. When an implant is inserted a race starts between fracture healing and implant failure. In a successful osteosynthesis the fracture unites first before implant fails. The implant has to survive till the biological process of healing is over. The concept of minimal access or least invasive skeletal stabilization is being suggested to minimize the surgical insult to the fracture milieu during internal fixation.The bad results of ORIF are worse than the worst results of closed reduction. Multiple variables influencing sound osteosynthesis by surgical means include the nutritional state of patient (soil), severity of trauma, complexity of fracture configuration, choice of treatment method, ORIF or closed reduction and internal fixation, quality of instrumentations and implants available, quality of operating room and level of surgical training. If everything is good one can choose any method of treatment. However, if anything is wanting than the surgical treatment of fractures gives bad results than those of conservative treatment.On a review of the literature we encounter variable conclusions on a clinical problems from different studies and thus a controversy is created. The possible reason for the controversy is dissimilar variables considered for sound and successful fracture outcome. The clinical results are comparable and predictable if identical outcomes are reported by various studies. The evidence based guidelines are relevant when the conclusions drawn from a particular setup are implemented in identical clinical settings. This becomes particularly more relevant when conclusions drawn in a developed country are considered in a primary health centre of a developing country disregarding infrastructure, quality of instrumentation and implants and level of surgical training available at that centre, hence the outcomes of fracture management are different. By the time these differences in infrastructure are understood lots of complications are produced and reported. More nonunions and infected nonunions are being reported because various fractures are operated for relative indications in suboptimal theatre conditions with poor quality instrumentations and implants and surgical principles are not adhered to. Hence it is imperative to talk about rational treatment. It is justified to treat a simple closed fracture tibial by interlocked nailing on the pretext of early weight bearing when it is guaranteed that it would not produce any risk of infection. Even if there is a 1% risk of infection (100% for that poor patient) then closed reduction and functional treatment outweigh the surgical treatment. We should read and use the published literature keeping all variables in mind. The rational treatment of fractures is selection of a particular modality of treatment keeping in mind all variables to achieve a predictable and consistent outcome of fracture treatment. Grahm Apley once wrote “the indication for fixation are not immutable; this if the surgical skills or backup facilities  are of low order; internal fixation is indicated only when the alternatives are unacceptable . With average skills and facilities, fixation is indicated when alternative methods are possible but are very difficult or unwise (eg. multiple injuries) and with the highest levels of skills and facilities, fixation is reasonable if it saves time, money or bed”.4We at Indian Journal of Orthopaedics attempt to appraise the readership with the best available evidence on controversies of fracture management. We provide guidelines5


The study team were advised by the independent oversight committees to stop recruitment to the trial and the delivery of the trial therapy due to a difference in the number of reported hospitalisations between the treatment and control group.There was a lack of guidance on how to proceed with implementation of the changes in a trial of this type and little precedent for cessation of trial treatment in a psychotherapy trial following a safety alert. Furthermore, there were concerns over the potential for distress and disruption to participants and clinical teams as a result of the trial changes and the potential risks of discontinuing treatment prematurely.A collaborative approach to the development of the process and supporting documents was adopted, with attention given to the impact on participants and clinical teams. The changes were implemented as an urgent safety measure.The following were developed:• Written process for implementation.• Written information for participants, potential participants and clinical teams.• Guidance documents for sites.• Arrangements for local and national telephone helplines.• Media response.The following key features were intended to reduce the impact on participants and clinical teams:• Prompt, but careful action.• Staged, allowing adequate time to inform and support participants and clinical teams, and ensuring feedback received could inform further development.• Clinically appropriate, with reference to national guidelines and accepted good practice.• Honest, concise and consistent information given to all concerned and follow-up support offered as appropriate.• Regular review and reflection.


New advances in medicine often raise challenges, and none more so than those involving the manipulation of human oocytes and embryos. Issues around clinical need and ethical considerations must be taken into account, as well as the safety of the proposed technique. The discussion around the proposed mitochondrial replacement techniques to prevent the transmission of mitochondrial DNA disease has perhaps raised more challenges than most Mitochondrial DNA diseases are both common and, in their severest forms, devastating In the United Kingdom, the Human Fertilisation and Embryology Authority (HFEA) recently considered the safety issues after extensive expert and public consultation The authors raise an interesting evolutionary argument that the human mitochondrial genome co-evolves with the nuclear genome in females, raising the possibility of a conflict with the paternal nuclear genome. They suggest Leber's hereditary optic neuropathy (LHON) and male infertility could be potential examples of this in humans The studies in macaques are also highly relevant to the risks proposed in humans associated with mitochondrial replacement. There are now multiple reports of the health status of the offspring born after mitochondrial replacement, and all have shown no difference between these offspring and controls Some studies in laboratory mice have proposed a nuclear DNA–mitochondrial DNA interaction, but there are others that have reported no defect despite the use of very divergent genomes Whilst we accept that any new technique is associated with risk, we think the lack of any reliable evidence of mitochondrial-nuclear interaction as a cause of disease in human outbred populations provides the necessary reassurance to proceed. The recent studies in macaques after mitochondrial replacement are also supportive that the possible harmful interactions are unlikely to occur in man


Clostridium difficile infection (CDI) and development of national prescribing indicators to support reduction of CDI.The Scottish Antimicrobial Prescribing Group (SAPG) was established by the Scottish Government in 2008 to lead the first national initiative to actively address antimicrobial stewardship. Healthcare associated infection (HAI) is a priority in Scotland and the work of SAPG contributes to the national HAI Delivery Plan. SAPG's early work has focused on restricting the use of antibiotics associated with a high risk of Scottish Antimicrobial Prescribing Group has developed prescribing indicators for hospital and primary care, which are measured and reported in all 14 NHS board areas. Improvement in compliance with the indicators has been demonstrated with resultant reductions in CDI rates and no adverse effect on mortality or antimicrobial resistance patterns.The establishment of a Scottish national antimicrobial stewardship programme has made a significant contribution to the HAI agenda, particularly in relation to CDI. The programme is supported by local antimicrobial teams, a national framework for education, surveillance of antimicrobial use and resistance and sharing of data for improvement. Antimicrobial stewardship has been integrated with other national programmes on patient safety and quality improvement. The Scottish Antimicrobial Prescribing Group (SAPG)  was formSAPG was established to lead the first national initiative to actively address antimicrobial stewardship. Collaboration with key stakeholders at national level and development of local (NHS board level) leadership through Antimicrobial Management Teams has been essential to develop national consensus and implement key stewardship interventions. This has been combined with the development of national and local systems and a framework for collecting and disseminating data on antibiotic prescribing and resistance surveillance and a framework for educational material to support the healthcare professionals in the workplace.Clostridium difficile infection (CDI) is a key objective for NHS Scotland and in 2009 a target was set for all NHS boards to reduce their rate by 30% (later increased to 50%) in patients over 65 years. Much of the focus of SAPG's early work has therefore been to reduce the use of antibiotics associated with a high risk of CDI across hospital and primary care settings. SAPG developed national prescribing indicators based on compliance with local antibiotic policies to support reduction of CDI:Healthcare associated infection (HAI) is a priority for the Scottish Government and the work of SAPG contributes to the national HAI Delivery Plan. Reduction of Indication for treatment recorded in the patient medical record and antibiotic choice is compliant with the local Antimicrobial Prescribing Policy - target ≥ 95%Seasonal variation in quinolone use, consumption of quinolones in winter months is ≤ 5% greater than consumption in summer months.National surveillance data confirm that there has been a progressive reduction in CDI throughout Scotland and that all NHS boards have exceeded the original target of 30% reduction. The national rate has fallen from 1.5 to 0.32 cases per 1000 acute occupied bed days [National results for the hospital and primary care CDI prescribing indicators are shown in Additional file There is a temporal association between this reduction and the introduction of restrictive antimicrobial policies in line with SAPG guidance. The true impact of this intervention is being evaluated using a time series analysis and results from one region (NHS Tayside) show a reduction in total CDI post-intervention of 54% in Medicine and 50% in Surgery [E. coli. Aminoglycoside-related toxicity is also being prospectively evaluated.National surveillance of antimicrobial resistance shows no significant increases in resistance to key Gram-negative organisms and reduced resistance to third generation cephalosporins in Crude 30-day all-cause mortality (from admission) was analysed for both NHS Tayside cohorts. No change was observed following the introduction of the restricted antibiotic policy. Subgroup analysis by age and Charlson Co-morbidity Index score showed no changes in mortality following the introduction of the policy. Further analysis using adjusted 30-day mortality in patients who have had blood cultures taken as an outcome indicator for sepsis management and antibiotic stewardship interventions is also being undertaken.The establishment of a Scottish National Antimicrobial Stewardship Programme has made a significant contribution to the HAI agenda, particularly in relation to CDI . ProvidiThe authors declare that they have no competing interests.All authors are members of the Scottish Antimicrobial Prescribing Group (SAPG). DN has been chair of SAPG since 2008 and JS has been Project Lead for SAPG since 2008. DN and JS have made substantial contributions to the conception and design of the SAPG work programme including development of the prescribing indicators to support reduction of CDI. AP is responsible for developing and maintaining the data management system for measuring and reporting the hospital prescribing indicators and for performing the analysis of data from NHS Tayside to confirm the impact of changes in antimicrobial use on CDI and mortality. WM made a significant contribution to development of the primary care prescribing indicator and is responsible for evaluation and reporting of the data for this indicator. All authors have read and approved the final manuscript.DN is Chair of SAPG and is a Consultant Physician in Infectious Diseases and Honorary Professor of Infection, Ninewells Hospital and Medical School, Dundee, UKJS is Project Lead for SAPG and has a hospital pharmacy background with a PhD in medicinal chemistry and an MSc in Clinical Pharmacy.AP is an Information Analyst with an MSc in Applied Statistics.WM is Pharmaceutical Adviser at Health Protection Scotland and has a background in pharmaceutical public health and primary care pharmacy.Table S1 Compliance with empirical prescribing in Medical Admission Units April - June 2011. Summary of data for national prescribing indicator for empirical prescribing in hospital.Click here for fileFigure S1 Primary care seasonal variation of quinolone use by NHS board 2008-2011. Annual data for national prescribing indicator for primary care.Click here for file


It has long been known that myeloid derived suppressor cells (MDSCs) inhibit the anti-tumor immune response. And recently a relationship between MDSC levels and patient outcomes to cancer immunotherapy was discovered. Studies conducted at the Memorial Sloan Kettering Cancer Center in New York showed that patients with reduced levels of circulating MDSCs were more likely to respond favorably to Ipilimumab, an immunotherapy approved for the treatment of melanoma. This raises the exciting prospect that baseline levels of MDSCs may help drug developers and physicians identify or select those patients who are most likely to benefit from immune-based cancer treatments. However the development of a robust and commercially available MDSC biomarker assay presents many challenges, from sample handling and logistics to an objective and reproducible definition of this elusive cell type. Here we present data from our MDSC assay development program and discuss the merits of applying this assay to biomarker studies as part of the clinical development of novel cancer therapies.


The thesis examined three different research questions to help build a knowledge base for future intervention strategies by better understanding the reasons behind smoking among pregnant women in Nunavut. The first study focused more at the individual level and investigates clinical and socio-economic factors and their relationship to the readiness to quit smoking. The second article moved beyond the individual level to the broader social and structural environment to identify a broader range of barriers and facilitators to smoking and smoking cessation among Inuit women. This second article draws upon in-depth interviews focusing on perceptions of smoking, and perceived barriers and facilitators of smoking behaviours. Finally, the third article investigated the perspectives of health care providers regarding the barriers and facilitators of smoking cessation for pregnant women in the Baffin Region of Nunavut and describes perceptions of smoking cessation resources available to health care providers in the this Region. It is hoped that the findings from this thesis will help generate a knowledge base that can more appropriately address the smoking cessation needs of Inuit pregnant women.


The Wirral Assistive Technology Programme (WAT) has operated across the whole population of the Borough for 3 years. It includes the installation of telecare technologies such as falls alerts and movement sensors to prolong users’ independence and reduce use of secondary care. Qualitative evaluation of user and carer perspectives indicated a reduction in admissions as a result of the technology and we sought to demonstrate this at a population level.Secondary care episodes for A&E, admissions and outpatients were temporally analysed to identify changed trend in secondary care usage as a result of installation for 400 users. Primary diagnoses at point of secondary care engagement were categorised to discern those that might have been mediated by WAT  from those likely to be incidental (e.g. infection). The nature of the WAT service made the identification of a control group challenging and it was necessary to try and establish the counterfactual of secondary care usage in an equivalent group of patients not engaged with WAT. We used Patients at Risk of Re-Hospitalisation (PARR) scores which are routinely assigned to every patient discharge in Wirral to identify an equivalent group of patients not engaged with WAT and compared trends of secondary care usage as above. Controls were selected on the basis of an equivalent PARR score to an AT user on the same date as that user’s final discharge before installation of AT.A&E and inpatient episodes showed regression to the mean around the point of AT installation, both for AT-related and unrelated diagnoses . Outpatient episodes showed a stable trend. We found no evidence that AT installation reduced the average number of secondary care episodes per patient, reduced the average PARR score or reduced the average length of hospital stay in comparison to controls.Although conceptually and qualitatively WAT should be impacting secondary care episodes, we could find no evidence of this. This has important implications for the way the programme is currently integrated with other local re-ablement schemes, how it is monitored and what incentives there are in the discharge system to promote its use. This paper will outline actions taken to embed the programme since the evaluation was completed (September 2011).


For the interventionalist, intracoronary thrombus remains an important marker for the presence of an acute coronary syndrome as well as a harbinger of potential complications during the percutaneous procedure. Acute complications include myocardial infarction either new and/or recurrent related to coronary embolization, slow coronary flow or acute closure and long term complications include sub acute and late stent thrombosis and possibly restenosis. Over the years, there have been several advances in the development of new and more potent antithrombotic and anticoagulant therapies as well as new interventional and pharmacologic approaches for dealing with intracoronary thrombus before, during and immediately after percutaneous intervention.The purpose of this symposium is at least three fold: 1. Define the pathophysiology of intracoronary thrombus and its relationship to acute and long term complications. 2. Describe the best antithrombotic and anticoagulant approaches in STEMI and NSTEMI. 3. Review the mechanical and pharmacological approaches available to the interventionalist for thrombus removal or/dissolution and/or treating its complications. All of these approaches and particularly for the antithrombotic and anticoagulant therapies must be balanced by the potential for side effects especially the possibility of increasing bleeding complications. I hope this symposium will provide you with important information as well as stimulate further investigation in this area.


The second stage is currently being designed but will take the form of a RCT of probiotic vs. placebo administered alongside the antibiotic. These two studies are governed by separate laws and regulations in relation to mental capacity. PAAD stage 1 is covered by the Mental Capacity Act and, for those service users who lack capacity, personal consultees are able to give agreement to the service user’s participation. PAAD stage 2 is covered by the Medicines for Human Use  Regulations and consent is given by a personal legal representative or a professional legal representative of the participant. The PAAD study also presents novel challenges in relation to advanced consent. We propose to explore some of the ethical and practical challenges of conducting these studies (and others like it) within the care home setting using qualitative methods. Our purpose is to optimise the informed consent process in a vulnerable population in preparation for stage two of PAAD.The PAAD Study (Probiotics for Antibiotic Associated Diarrhoea in care homes) involves 2 stages. The first stage is a prospective 12 month observational study to collect data on the amount and type of antibiotic prescribed episodes of Antibiotic Associated Diarrhoea and Cc.difficile circulating within the care home.We are conducting focus groups with staff within the 9 care homes who are participating in PAAD stage 1. We are also conducting face-to-face interviews with service users who have capacity, with relatives of service users, and with GPs who provide primary care to the care homes. Focus group and interview schedules focus on issues such as: the merits and problems associated with a number of models of consent for both stage one and stage two of PAAD, views about the feasibility and acceptability of taking advance consent/assent for research trial procedures, and views about potentially raising concerns about the possibility of Data collection is in early stages, and we will have data analysed by Autumn 2011.We anticipate that our data will not only optimise the design of our informed consent process for stage 2 of PAAD, but will also provide generalisable insights to guide other studies which plan to conduct clinical trials amongst vulnerable populations within care home settings.


We have developed Oligopaints  along with a suite of scripts and documentation that will assist researchers with probe set design and allow our technology to be extended to any organism whose genome has been sequenced. Oligopaints robustly label chromosomes both in tissue culture cells and whole-mount tissue preparations and can be generated using standard molecular biology techniques and equipment at a price well below the cost of commercial FISH probes. The flexibility offered by our bioinformatic design platform has allowed us to perform complicated hybridizations, such as the simultaneous targeting of RNA and the genomic DNA flanking its site of transcription. Thus, we anticipate that Oligopaints will be a valuable tool for the study of nuclear architecture and the relationship between chromosome positioning and gene expression.Fluorescence gopaints , a PCR-b


The dynamics of synaptic plasticity and the encoding of spatial information have been extensively studied in the hippocampus. Yet few attempts have been made to investigate how the two combine to produce the most striking emergent function of this system, the cognitive map Toleman, .Here, Bush et al. present a neural network model describing how a cognitive map based on empirical findings from hippocampal electrophysiology could function in order to encode space and enable sequence learning. The model demonstrates how both functions could be accommodated within the same network architecture and using the same learning rule (Bush et al., The network employed by the authors is based on the recurrently connected CA3 region of the hippocampus, where individual “place cells” fire maximally at specific locations within one, two, and three-dimensional space (O'Keefe and Dostrovsky, When the network experiences neural activity corresponding to a series of shuttle runs across a square arena, heteroassociative connections between activated place cells become potentiated, cells with overlapping place fields develop strong bidirectional connections and asymmetric connections between cells against the direction of motion become depressed. The elevated connectivity of the activated ensemble resembles the broad development of a “cognitive map” with bidirectional connections providing detailed information about the relative proximity of individual place fields. The firing patterns of cells with overlapping place fields satisfy the STDP rule and enable connections between such cells to become potentiated, as demonstrated in slices (Isaac et al., During simulated random exploration of an arena, a similar pattern of bidirectional connectivity develops between place cells encoding proximal place fields, with local asymmetric connections reflecting fragments of recent trajectories. Repeated traversals of a one dimensional route in a single direction through such a learned environment does not alter the gross structure of the map, but profoundly alters the connections of place cells that lie on the route. As before, connections following the direction of travel are significantly potentiated but those against it are depressed, suggesting information concerning recent trajectories can be embedded in the cognitive map.in vivo and in vitro data demonstrating the role of synaptic plasticity within the of development of the cognitive map and the encoding of episodic memory; it also prompts a number of predictions as to when and where plasticity may be induced during these processes (Sadowski et al., The model goes some way to supporting in vivo hippocampal recordings, where sequences of place cell activity are recapitulated during sleep or rest following behavior (Skaggs and McNaughton, One unexplored aspect of the paper relates to the “offline” dynamics of a network when such patterns of connectivity have been established. The phenomenon of place cell replay has been observed during in vivo and in vitro approach is necessary to test such predictions; recording from place cells during behavior and investigating the consequences of such activity on connectivity. In addition, robust empirical data regarding the influence of neuromodulators on STDP must be acquired in order to improve the physiological relevance of this promising model of plasticity and the cognitive map.Overall, the paper demonstrates how computational modeling can elegantly combine parallel strands of hippocampal electrophysiology and make defined predictions about how behavior might shape connectivity and therefore the function of neural networks. An integrated


I read with interest the study performed by Eizadi Mood et al. recently published in Critical Care Research and Practice . The autCan they provide more details on the types of the complications they meant and their correlation to the GCS and its components? Also, may they provide the rate of intubation in these two groups (with or without complications)? In other words, did they only intubate the complicated patients or was there any uncomplicated patient who was intubated from the beginning and developed complications afterwards ? Thanks


In September 2010, 9 months after empowerment of caring for patients with severe sepsis and septic shock and implementation of a cooperative sepsis management protocol between community hospitals and tertiary referral hospital in Phitsanulok, the Phitsanulok Co-operative Sepsis Management (PCSM) team announced the Saving 500 Lives Campaign. This campaign aimed to encourage the unity and importance of caring for patients with severe sepsis and septic shock.From October 2010 to September 2011, eight community hospitals and one tertiary referral hospital in Phitsanulok established and promoted a set of achievable goals and interventions for patients with severe sepsis and septic shock . The group of patients from community hospitals that can be admitted directly to the ICU from the emergency department using a sepsis fast-track protocol had the lowest mortality rate (19%).Setting a numeric goal using the 500 Lives Campaign was another way to support and empower the cooperation of sepsis care in Phitsanulok, Thailand.


The poster is based on the in silico identification and analysis of the variation in the gene network related to the pancreatic cancer. Pancreatic cancer has been a major cause of death in Asia and European countries. This cancer is not easily detectable in its initial stages and at the later stages it becomes very hard to cure this disease. So the in-depth understanding of the variation in the genetic pathway of this disease is very important. We selected 5 candidate genes from various published journals which are involved in the pancreatic cancer pathway  in generating their interaction network using Agilent literature search plugin in cytoscape. The organic layout of interaction revealed the cross interaction between these genes and the other neighbour genes. Merging the expression profile data of the pancreatic cancer to the parent network helped us in understanding the variation of the network in the diseased state. Using the merged profile network we found out the importance of the KRAS & CDKN2A gene interaction with other 21 neighbour genes among which PIK3CA and TP53 interactions were showing major variation on their expression pattern. This study reveals the importance of change in expression level of candidate genes in causing pancreatic cancer. The results obtained in our study will be very much useful in detecting the disease in its initial stages and in finding the cure.


Scotland has one of the highest liver cirrhosis mortality rates in Western Europe. The Scottish government has invested in a range of policies to address this and the wider harms from alcohol, including a national programme on alcohol brief interventions (ABIs). The initial focus of this work was primary care, accident and emergency care, and antenatal care but it was expanded in 2012 to include ABIs delivered in wider settings and with populations such as social work service users and young people. This process evaluation aims to explore the feasibility and acceptability of ABIs delivered to young people and in social work settings. The study involves two phases: one that maps existing projects providing ABIs in these areas and examines barriers and facilitators to their delivery, and a second that explores case study projects in depth and develops proposals for a potential future outcome evaluation. Phase 1 of the study involved conducting 24 semi-structured interviews with 28 professionals from 12 projects providing ABIs in the wider settings of social work and young people's services between December 2012 and April 2013. Two field visit observations were also completed and documentation/data gathered from all projects, including numbers of clients and ABIs delivered where possible. A framework approach was used for coding and analysis of data. In addition to a detailed thematic analysis, 10 project case summaries were produced to retain the specificity of information about the diversity and similarities across the cases studied. Results from Phase 1 of the study will be presented and implications for policy and practice will be discussed.


To study frequency and associated factors for care giving among elderly patients visiting a teaching hospital in Karachi, Pakistan.A cross sectional questionnaire-based study was conducted at the Community Health Centre (CHC), Aga Khan University Hospital (AKUH) Karachi, Pakistan from September to November 2009. All individuals, visiting the CHC and aged 65 years or above were interviewed after taking written informed consent.A total of 400 elderly completed the interview. Majority were females, 65–69 years age, More than half of the individuals ie: 227 (85%) had received Care Giver experience for assistance and among these 195(72%) had care provided by an immediate family member. A large proportion of them stated that their Care Givers managed to provide less than four hours in a day for care giving. Around 37% showed substantial improvement in their relationship with the care givers. About 70% of the respondents stated that the care provided by the Care Giver improved their quality of life.Elderly care is provided by majority of the family members resulting in increased satisfaction level, however small number still not satisfied due to unfulfilled need of these older people. This demands that efforts should be made to strengthen the family support by increasing awareness regarding elderly care and arranging support system by the government. Elderly population particularly aged 65 years and more contributes to 380 million people globally and by the year 2020, this population is projected to increase to more than 690 million This older population is vulnerable to various disabilities as a consequence of stroke, dementia, heart diseases and trauma According to Center for Disease Control (CDC), about 80% of older Americans are living with at least one chronic condition, and 50% with two Care Givers can either be formal (paid volunteers associated with a service system) or informal which includes family, friends, neighbors or trust members who provides unpaid care out of love, respect, obligation or friendship to a disabled person In accordance with accepted social and cultural norms in Pakistan, people prefer to live in an extended family system as it is cost effective and has many other advantages including availability of support for the elderly by the family members There is serious scarcity of formal Care Givers and also non availability of Trusts and social projects to provide care to the elderly people in Pakistan, we designed this study to assess the problems faced by the people requiring support from Care Givers and the barriers faced by the care givers in providing support., so that proper intervention techniques could be devised to raise the quality of life of the elderly and to reduce the negative outcomes of care giving practices.This was a cross sectional survey conducted at the Community Health Centre (CHC), Aga Khan University Hospital (AKUH) located at Karachi from September 2009 to November 2010. AKUH is a tertiary level teaching facility in the private sector and caters to the medical needs of a large majority of patients coming from all over Karachi as well as from other parts of Pakistan. CHCalong with family medicine clinics also provides specialist services to a number of patients thus enabling a diverse assortment of patients from all backgrounds to be encountered.A total of 423 people who were 65 years or older presenting to CHC for consultation were approached out of which 400 agreed to participate in the study through non probability convenient sampling.Sample size was calculated through WHO sample size calculator by using following assumptions: since we do not have any prevalence data for the Frequency and associated factors for care giving among elderly patients visiting a teaching Hospital in Karachi, Pakistanhence a prevalence of 50% was assumed to observe a difference, with bound of error of 5% and level of significance of 5%, the estimated sample size was 385.After addition of 10% for non-response the final sample size was approximately 423 study participants.The initial questionnaire was designedbased on the prior experience of investigators, input fromcolleagues, peers as well as patients.The proforma was then pre-tested on 25 respondents and no changes were deemednecessary to be made in the questionnaire based on this pretesting.The questionnaire was initially prepared in English; then translated into Urdu, the national language of Pakistan, for the convenience of the respondents. The questionnaire was also back-translated into English by two non-medical personnel to check for any paraphrasing errors.The questionnaire was divided into four sections and included questions related to Socio demographic factors, needs of elderly people and their choices for Care Givers, perception of elderly people regarding their Care Givers and the impact of Care Giving on their life. And lastly characteristics of care giving among respondents based on gender.p-value of <0.05 was considered significant.Data was entered using Epi-data version 3.1 and analyzed through SPSS version 15. Frequencies were calculated for categorical variables (Gender), Mean and standard deviation for age. Cross tabulation was done and chi-square test was applied to compare different factors related to care giving on the basis of gender and Written informed consent was obtained from the subjects after explaining the study objectives. The subjects were free to withdraw at any time without giving any reason.Strict confidentiality was maintained throughout the process of data collection, entry and analysis. All efforts were made in this study to fulfill the ethical considerations in accordance with the ‘Ethical principles for medical research involving human subjects’ of Helsinki Declaration A total of 423 people were approached out of which 400 agreed to participate in the survey.The overall response rate was found to be 91%.Among these respondents, 165(41%) were male and 235 (59%) female with a mean age of 69±5.95 years.On enquiring about the relationship of the care givers with the participants around three fourth of the care givers (72%) were their immediate family members whereas only (15%) were house Maids and (9%) their relatives. Relationship of the elderly with the care givers have improved in only (37%) cases while (59%) did not felt any change at all. Impact of care giving to respondents showed improvement as mentioned by majority of the respondents and .on specifying improvements areas majority responded for medical problem (37%) followed by improvement in financial (10%), social (12%) and emotional well being (16%).Problems in providing service was faced by (43%) of the care providers as mentioned by care recipients. Most common reasons responsible for slow down of taking care of elderly people/relatives included financial difficulty (30%) lack of time(30%) followed by job responsibility(22%),home responsibilities(10%) and, health reasons(6%)respectively.It is important to note that 290 (73%) respondents reported they provided care in their past life and among these 66% of them acted as a Care Giver for their family members. Regarding duration of care giving 54% of the participants recalled that they provided care for more than 3 years. About 68% of them accepted that they faced difficulty in providing care with majority having financial difficulty and lack of time as the main barrier.This study assessed frequency and associated factors of care giving among elderly population visiting a teaching hospital in Karachi. Numerous studies have been conducted worldwide but to the best of author's knowledge very limited data exist regarding trends of care giving in Pakistan.In this study majority of the participants were females probably females required more assistance of care givers in comparison to males and they have higher life expectancy as compared to males these results are consistent with studies in other parts of the world It was seen that majority of the elderly needed care givers for medical and physical reasons as large number of population in this age group suffers from multiple Co-morbidities Similarly financial needs were also reported by only small number of respondents probably because they belonged to educated and financially better placed group of individuals. It also is explained on the basis of support being available to those living in extended family model.Social needs were stated by small number of respondents because of their limited mobility as a consequence of multiple co-morbidities and physical limitations. A need exists to promote Senior Citizen Clubs and societies that may provide opportunities for socializing among elderly population and social interactions and exchanges.A majority of respondents reported immediate family members specially females as care providers similar to another study done in Thailand This will lead to a serious issue in future with the substitute of traditional extended family system with nuclear family system. On the other hand it was interesting to note that small numbers of respondents were using House Maid as care givers.Time provided by the care givers by half of the elderly population was less than four hours per day and only a small number were able to give up to eight hours of care giving which is required for minimum needs. Another aspect was that there were more than one Care Giver for a given patient and the added supported may be able to satisfy most of the patient requirements this is consistent with a study done in Spain which showed care givers spent around 14 hrs/day with more than one care givers It is also notified that a significant respondents required assistance from Care Giver for more than three years similar results of study done in Pakistan on care giving of cancer patients Relationship between patient and care provider has an important role to play in care giving as evident by a prior studies It was heartening to see that around one third of the respondents reported improvement after care giving. Major areas of Improvements were medical, physical, social and financial well being On further questioning one third of the respondents reported unfulfilled needs despite provision of care giving. Financial need was the most commonly reported unfulfilled need. These results are in contrary to findings of a study done in Japan on females with or without dementia and showed majority of the females without dementia were satisfied with their daily life and economic status Nearly two third of the respondents reported that their needs were fulfilled by care giving. Majority of the people had an impression that the care provided by the care giver improved their quality of life Majority of the respondents reported they provided care in their past life and more than half of them acted as a Care Giver for their family members. This shows that Care Giving is an accepted practice in Pakistani society. Half of these individuals recalled that they provided care for more than 3 years, again emphasizing long term and ongoing nature of care giving in the elderly.On further enquiring about difficulties which they faced while providing care more than half of the respondents faced difficulty in providing care with a majority having financial difficulty and lack of time as the main barriers these results are similar to a study done in Canada and Spain This study highlights the issues and problems encountered by elderly people and their care givers and also clearly demonstrate the level of satisfaction regarding their care. Elderly care is provided by majority of the family members resulting in increased satisfaction level, however small number still not satisfied due to unfulfilled need of these older people as a consequence of hindrance faced by the family members in the form of financial, mental and psychosocial issues. Lack of awareness among family members for elderly care is also an important area of concern. Pakistan lack social services or study respite centers or any support system for the elderly. This situation demands efforts to strengthen the family support by increasing awareness regarding elderly care and arranging support system by the government for these older population.This study was done on a selected population of elderly in a tertiary hospital which caters mostly educated people with good financial background so it cannot be generalized. However Community Health Centre caters people from all socioeconomic groups this fact helped us in offsetting this particular limitation of study.


Studies have widely documented the socioeconomic inequalities in maternal and child health related outcomes in developing countries including India. However, there is limited research on the inequalities in advice provided by public health workers on maternal and child health during antenatal visits. This paper investigates the inequalities in advice provided by public health workers to women during antenatal visits in rural India.The District Level Household Survey (2007–08) was used to compute rich-poor ratios and concentration indices. Binary logistic regressions were used to investigate inequalities in advice provided by public health workers. The dependent variables comprised the advice provided on seven essential components of maternal and child health care. A significant proportion of pregnant women who attended at least four ANC sessions were not advised on these components during their antenatal sessions. Only 51%–72% of the pregnant women were advised on at least one of the components. Moreover, socioeconomic inequalities in providing advice were significant and the provision of advice concentrated disproportionately among the rich. Inequalities were highest in the case of advice on family planning methods. Advice on breastfeeding was least unequal. Public health workers working in lower level health facilities were significantly less likely than their counterparts in the higher level health facilities to provide specific advice.A significant proportion of women were not advised on recommended components of maternal and child health in rural India. Moreover, there were enormous socioeconomic inequalities. The findings of this study raise questions about the capacity of the public health care system in providing equitable services in India. The Government of India must focus on training and capacity building of the public health workers in communication skills so that they can deliver appropriate and recommended advice to all clients, irrespective of their socioeconomic status. Janani Suraksha Yojana (JSY) – under the National Rural Health Mission to promote births in the public health care system in the country. Further, maternal and child health services are provided free of charge in the public health care system. Another important step taken by the Government of India to improve accessibility of health services is to make certain primary health centres in the rural areas functional 24 hours a day.Prenatal care, skilled birth attendance and postnatal care strategies have been recommended for several years Despite all these efforts, the utilisation of care during pregnancy, at childbirth and during the postpartum period has been limited in India. Recent data from the National Family Health Survey 2005–06 suggests that only 37% of pregnant women made 4+ antenatal visits for their most recent pregnancy, 39% delivered their recent babies in a health facility, and only 42% of women reported receiving postnatal check-up after their most recent birth Advice and counselling are important components of the antenatal care package and key to improving health behaviour and care seeking during pregnancy, labour and delivery and in the post-partum period There are only a few studies that have examined inequalities in advice provided during the antenatal sessions. Recent studies in rural Tanzania reported that most recommended topics critical to improving maternal and newborn survival were rarely covered during the antenatal sessions The Government of India guidelines recommend that every pregnant woman have at least three antenatal visits and that the first visit is preferably in the first trimester. During the antenatal visits, pregnant women must undergo physical examination , interventions (such as iron folic acid supplementation and tetanus toxoid vaccinations), laboratory investigations, counselling , etc Our study is, therefore, an attempt to investigate the inequalities in advice provided by the public health workers to women during antenatal sessions in rural India using a recent and representative large-scale dataset that was particularly designed to monitor the performance of the Reproductive and Child Health (RCH) program in India. In particular, this paper examines the inequalities in advice according to the wealth status of the clients. The paper investigates the inequalities in advice separately for higher level and lower level health facilities. We restrict our analysis to rural areas as the rural population depends heavily on public health facilities for maternal and child health care services.The study is based on a secondary data set with no identifiable information on the survey participants. This dataset is available in the public domain for research use and hence no formal approval from the institutional review board is required. So, no ethics statement is required for this work.We used data from the ‘District Level Household Survey’ round three (DLHS-3) conducted in 2007–08 in 601 districts from 34 states and union territories of India. The DLHS-3 was designed to provide estimates on maternal and child health, family planning and other reproductive health indicators at the district level Dependent variables used in the analysis are the advice provided on seven essential components of maternal and child health care during antenatal sessions. These components include 1) breastfeeding, 2) keeping the baby warm, 3) spacing methods of family planning, 4) limiting methods of family planning, 5) nutrition, 6) institutional delivery, and 7) visiting a health facility in case of pregnancy complications. Advice and counselling during antenatal sessions play a critical role in preventing morbidity and mortality among the mothers and the newborn by enabling women and their family members to adopt health promoting behaviour and to identify and act on medical emergencies that may arise during pregnancy, delivery and post-partum periods The main explanatory variable of interest in the analysis is a measure of wealth – computed in order to investigate inequalities in access by poverty status. In the absence of direct data on income or expenditure in many surveys, a wealth index based on the ownership of household assets is widely used as a proxy for assessing the economic status of the households Wald test was used in the binary logistic regression models to examine whether or not wealth status was a predictor of receiving advice during the antenatal sessions.To assess the extent of inequalities in access to advice, we estimated rich-poor ratios , as well as concentration indices (CI). The CI measures the relationship between the accumulated proportions of individuals ranked by their socioeconomic status against the cumulative proportion of utilisation of healthcare The advice given to pregnant women on the seven components during antenatal sessions in India was far from universal and varied considerably across the type of advice . The advThe provision of advice on the seven components also varied by the level of public health facility; the chances of providing such advice being higher in higher level facilities compared to lower level facilities. For example, 75% of pregnant women who availed themselves of antenatal care in the higher level facilities were advised on breastfeeding compared to only 70% among those who availed of antenatal care in the lower level facilities. Likewise, 65% of women availing of antenatal care in the higher level facilities were given advice on keeping the baby warm compared to only 59% among those who availed themselves of antenatal care in the lower level facilities.The rich-poor ratios suggest enormous socioeconomic inequalities in the provision of the aforementioned advices. The rich-poor ratios were consistently above one, thus indicating that the rich were more likely than the poor to receive advice . MoreoveWald test was significant in all the models indicating that wealth status was indeed a predictor of receiving the seven sets of advice. Findings further suggest that women availing of antenatal care in the higher level facilities were significantly more likely to receive advice on breastfeeding, keeping the baby warm, spacing and limiting methods of family planning, and nutrition than women availing of antenatal care in the lower level facilities.The binary logistic regression results for providing advice on the seven components during antenatal sessions are shown in Wald test results suggest that wealth status was a predictor of receiving advice in only five out of seven components . In contrast, among those women who availed themselves of antenatal care facilities, the rich were 1.3 to 1.5 times more likely than the poor to receive advice on all the seven components in the lower level facilities  which also showed significant socioeconomic inequalities in the utilisation of postnatal care among facility births The World Health Report 2005 has particularly emphasized on the critical issues of exclusion and equity A few studies from the developed and developing world have shown that inequity is built in the health systems This study has some limitations. The information in DLHS-3 on advice during antenatal sessions was obtained from women and thus might be affected by recall bias. However, the chances of such bias are limited because we restricted our analysis to only those women who had four or more antenatal visits. By doing this, we included only those women in our analysis who were motivated enough to utilise the antenatal care services and thus recall the information provided to them. The analysis was also restricted only to the most recent birth that took place in the three years preceding DLHS-3. The survey format has been regularly used in the various rounds of DLHS and the findings are widely used to monitor the performance of policies and programs in India. Survey teams receive formal training and quality control measures are in place. Moreover, a study conducted in Indonesia, India and China has shown that while systematic reporting heterogeneity was significant, it was relatively small in magnitude and did not have a substantial effect on measured socio-economic inequality in health Our findings have important policy implications. The Government of India has taken a number of steps for improving maternal and child health in India. Promoting antenatal care, delivery care and postnatal care are some of the interventions. Studies have shown that there is a preference among the health workers for medical procedures during antenatal visits and advice and counselling are limited In addition, the Government of India is taking a number of initiatives to improve public health care infrastructure to provide quality care to the rural and socioeconomically deprived population under its most ambitious program, the National Rural Health Mission (NRHM) 2005–2012. The Government of India has also formulated Indian Public Health Standards (IPHS) and is trying to bring health care infrastructure especially in rural areas up to IPHS. A number of other architectural corrections have also been proposed to deliver quality care to the rural population. The Government of India is planning to launch the second phase of NRHM. So, it is high time that the Government of India focused more on training and capacity building of the health personnel so that they can deliver appropriate and recommended care to the clients. Special sessions must be organised to sensitize health workers towards the special needs of the socially and deprived classes of the population, who need more care and attention. The health workers must also be informed about the rising inequalities in maternal and child health and its negative consequences. These strategies are particularly needed for public health workers deputed to the lower level health facilities, as our findings clearly reveal higher inequalities in advice among women who availed of antenatal care from lower level health facilities compared to those who availed of antenatal care from higher level health facilities. Policy-makers and program managers should think seriously about improving the managerial skills of the health workers, so that they treat their clients equally irrespective of their socioeconomic status. If immediate attention is not given to these findings, there is every chance that the public health care system will improve in terms of infrastructure, but will fail in delivering the required services to those who need them the most.


In less than 40 years of the first human gene being isolated, which involves putting isolated and manipulated DNA (genes) back into individuals for treatments of genetic diseases. Gene therapy is now more widely accepted to encompass all forms of therapeutic intervention in which DNA is used to alter the overall pattern of gene expression within an organ. Potential applications of gene therapy are widespread and implications for the management of various human diseases are becoming available. Approaches are being developed to overcome difficulties and identify a number of potential applications . The manIt is now relatively well accepted that much of human disease can and should be treated at the level of underlying genetic manipulation. Much of the theoretical basis of gene therapy are going to be worked out step by step . What weSeveral approaches have also been made to modify cell phenotype including inhibition of gene function associated with cell proliferation and to arrest the progress of atherosclerosis and restenosis, and the local production of growth factors to promote angiogenesis  to elicit regionally specific effects i.e., directed for to regions of hypoxia or other stress. Approaches most likely to succeed in gene therapy remain a subject for speculation and based on experimental findings. We should also take caution and not only overestimate the importance of gene therapy at this early, but promising stage. These are exciting times but it takes additional and substantial effort before gene therapy makes real impact in humans. What appears certain is that cardiovascular diseases will be a major of therapeutic applications.


Case finding by using screening on frailty and physical activity among elderly and coaching them on lifestyle and to find appropriate activities in order to increase physical activity and well-being of elderly.Several stakeholders in community health services and social services, can detect signs of frailty and poverty of physical activity in their contacts with elderly clients. It is also known that adequate physical activity will positively affect the different area’s of frailty like physical and mental abilities as well as social well-being.Therefore valid screening on frailty and physical activity and subsequent interventions are important to (positively) affect the negative spiral of becoming more and more frail and dependent on health and social services.In each municipality a local network of health care professionals and social workers came together in order to make agreements on the process of early screening and lifestyle coaching focused on physical activity and on the stakeholders which should be involved. For each municipality 20–40 elderly can be included in the process of lifestyle coaching with the following inclusion criteria:in the age of 55 years or olderliving independent frailty score of 4 or more or physical ability-score of 2 or morepoor physical activity and motivation to improve physical activity.Questionnaire among stakeholders in community health services and social services (for early screening) and among the lifestyle coaches. Structured interviews among elderly who are participating in this field project. Measurements using the GFI-scale for frailty and a scale for physical activity.During the period September 2011 until June 2012 the early screening will be performed using the validated Groninger Frailty index and the lifestyle coaches will select and reach them in order to start a coaching process.Starting up early screening by several stakeholders demands a good preparation; involvement in making the local appointments about the process of screening and lifestyle coaching is important. Having a coordinator with an important responsibility for communication is crucial. New connections are realized between social workers and health care professionals. To get other professionals involved for early screening is not easy. Focus on frailty in early screening is altered to physical activity. Success for including elderly differs among the municipalities.Results from structured evaluation are not available yet. In March 2012 some preliminary results will be presented.