N = 324), was conducted. The results indicate that TRM use was high with prevalence of over 86%. The study found no statistically significant association between national health insurance status and TRM utilisation (P > 0.05). Paradoxically, major sources of TRM, frequency of TRM use, comedical administration, and disclosure of TRM use to health care professionals differed significantly between the insured and uninsured subgroups (P < 0.001). Whereas effectiveness of TRM predicted its use for both insured  and uninsured , work experience predicted TRM use for the insured [OR = 1.528 ]. Cultural specific variables and health philosophies rather than health insurance status may influence health care-seeking behaviour and TRM use. The enrollment of herbal-based therapies on the national health insurance medicine plan is exigent to ensure monitoring and rational use of TRM towards intercultural health care system in Ghana.This paper examines the relationship between national health insurance status and the pattern of traditional medicine (TRM) use among the general population in Ghana. A retrospective cross-sectional survey of randomly sampled adults, aged ≥18 years ( The growing interest and uptake of traditional medicine (TRM) in both local and global scales have been recognised and documented by various studies in both high-income and low- and middle-income countries –7. PrescHerbal medicines, traditional treatments, and traditional practitioners are the main source of health care and sometimes the only source of care for most people in economically less developed countries. Indeed, TRM plays a crucial part alongside the conventional medical practice in meeting the health needs of the vast majority of populations in low- and middle-income countries , 13. In Overwhelming evidence shows that out-of-pocket payment which remains a major means of health care financing across developing countries potentially plummets health care use notably among the resource constrained and underserved –25. Ruin inter alia, United Kingdom, Japan, Germany, Australia, and the United States, have partial insurance coverage for TRM consumption  and those who perceived TRM to be effective were more than four times more likely to report TRM use [OR = 4.374 ]. For the uninsured, compared to those who perceived TRM to be less effective, those who considered TRM to be more effective were more likely to use TRM [OR = 3.383 ].Stratifying by health insurance status, This is the first current survey investigating the relationship between health insurance status and use of TRM in a Ghanaian rural and urban context. The study found among the general adult population in rural Sekyere South District and Kumasi Metropolis of Ashanti Region a high prevalence of TRM use. TRM utilisation rate of over 86% is comparable to findings of other studies in low- and middle-income countries –47. The The study revealed no statistically significant relationship between TRM use and health insurance position. It is not surprising to find no differences in the utilisation of TRM regardless of the status of health insurance in a society where traditional medical therapies have been in the culture. This relationship defies previous studies that found health insurance status of the study sample to influence TRM usage –30, 32. Moreover, most people perceive certain aspects of TRM with particular reference to the biologically based therapies as natural, less toxic, with little or no side effects as compared to the prescribed drugs . In thisIn a bivariate analysis, the study found statistically significant differences between the insured and uninsured subgroups in relation to sex, marital status, nature of occupation, and household size. Females were more likely to be enrolled in the National Health Insurance Scheme than males (65.1% versus 34.9%). In similar sense, the married had greater propensity to be insured compared with the unmarried (65.1% versus 34.9%). Studies have reported that females have a high demand for health care due to the fragility and relapsing reproductive functions and other health-related challenges of females , 52, 53.The uninsured offer full cost recovery for all medications and consultations with a health care provider , 54. ThiThe major strength of this study is that it remains the first population-based study to offer elucidation as regards the specific association between the health insurance status and the pattern of TRM utilisation in the Ashanti Region of Ghana. However, the study is beset with some limitations. Although rural-urban character vis-à-vis gender dimensions was infused, the survey was limited to only two political and administrative districts of the Ashanti Region. Tackling this pitfall was the fact that a representative sample and randomisation procedures were followed in the generation of the study results. The use of cross-sectional survey in retrospect means that recall bias is virtually inevitable. Again, the cross-sectional design could not proffer argument about whether or not the use of TRM is increasing over time. The selection bias was unavoidable. This is reflected in the oversampling of the insured and female participants. This could result in either underreporting or overreporting of TRM use thereby painting a blurry picture from the reality. It therefore comes with a difficulty to ascribe a vivid causal relationship between the study variables of interest. Replication of this research and follow-up studies in other regions would be useful to confirm the consistency of the findings of the current research.Traditional therapy use continues to grow in the global landscape in general and in the Ashanti Region of Ghana in particular where the study found over 86% of the participants using one form of TRM or another. The study has shown that there is no difference between the insured and the uninsured participants as regards TRM use although major sources of TRM, frequency, and disclosure of TRM use to health care providers differ significantly between the subgroups. TRM use may be influenced by culture, personal philosophies, and belief systems of people . Given t


The recent improvement of the high-throughput sequencing technologies is having a strong impact on the detection of genetic variations associated with cancer. Several institutions worldwide have been sequencing the whole exomes and or genomes of cancer patients in the thousands, thereby providing an invaluable collection of new somatic mutations in different cancer types. These initiatives promoted the development of methods and tools for the analysis of cancer genomes that are aimed at studying the relationship between genotype and phenotype in cancer.In this article we review the online resources and computational tools for the analysis of cancer genome. First, we describe the available repositories of cancer genome data. Next, we provide an overview of the methods for the detection of genetic variation and computational tools for the prioritization of cancer related genes and causative somatic variations. Finally, we discuss the future perspectives in cancer genomics focusing on the impact of computational methods and quantitative approaches for defining personalized strategies to improve the diagnosis and treatment of cancer. The advances in high-throughput sequencing techniques are allowing us to identify a large number of genetic variants in human ,2 and unEven with a perfect sequencing approach the detection of causative variants remains a complex task. Indeed, among somatic variants, a large fraction, defined as "passengers", have no impact on the neoplastic process. But a smaller set of genetic variants, referred to as "drivers", provide a selective growth advantage, estimated to be minute (~0.4%), to the cell . The accThe frequency of observed somatic variants draw a mutational landscape made up of few "mountains" and a large number of "hills" that respectively correspond to frequently and rarely mutated genes across tumor samples . Among tGiven that the cancer is a result of interplay of various types of genetic changes, understanding of the role of somatic mutations in tumorigenesis is a complex problem in which different combinations of somatic variants affect different network of genes and associated pathways. Nevertheless, significant breakthroughs have been made in the development of computational methodologies which allow us to identify new driver mutations and genes by analyzing large sets of patients with different tumors . Current1. Robust pipelines for the detection of genetic variations;2. Creation of a benchmark dataset of cancer driver mutations and genes;3. Accurate methods for prioritizing cancer driver mutations and genes;4. New algorithm for predicting the impact of somatic variants at pathway/ network level;5. Translational approaches that make the results of computational analysis clinically applicable ,12.In this review we focus on the description of computational methods for cancer genome interpretation. First, we describe the basic steps for the detection of genetic variants. We summarize the currently available data sources for implementing and benchmarking new computational tools for cancer genome analysis. Second, we review the available methods for the prioritization of driver mutations and genes. We also include a section describing tools for predicting the impact of genetic variants at network level and methods for estimating the consistence of subclonal populations. Finally, we discuss the future perspective in the field, highlighting the contribution of computational approaches to cancer genomics. In contrast to the recently published cancer genomic reviews ,13,14, wAccurate variant calling is the prerequisite of any cancer genome analysis, but it is hindered by several limitations. The first limitation stems from the inherent noise and errors in the sequencing technology. Errors are also introduced in the procedures of short reads alignment, especially in the low complexity regions of the genome. In addition, a recently published work showed that no single variant calling approach is able to comprehensively capture all genetic variations . Thus, tIn general, the variant calling procedure consist of 3 main steps:1. Short read alignment and mapping to the reference genome.2. Removing PCR duplicates, realignment and recalibration.3. Variant calling, filtering and annotation.This procedure includes the calibration of pre- and post-experimental factors to identify reliable variants from the raw data. Such factors include sequencing coverage, single end or paired end sequencing, short read alignment, PCR duplicates, matched sample sequencing, variant calling algorithm, etc. ,15,16. Ahttp://sourceforge.net/projects/picard/). This step is followed by realignment and recalibration with GATK [A plethora of tools have been developed for variant calling purposes. In cancer studies, a standard workflow for variant calling starts with the alignment against the reference genome using BWA  or Bowtiith GATK . Finallyith GATK  and MuTeith GATK . This stAlthough, theoretically the variant calling pipelines are straightforward, the results from different variant callers agree only on a small subset of variants. In a systematic test of several variant callers, namely GRISP , GATK, Shttp://evs.gs.washington.edu/EVS/). The most recent versions of dbSNP (build 142) contains more than 110 million human SNPs, while the current EVS data release (ESP6500SI-V2) include all the exome variant data from 6503 human samples. Some of the common tools used for filtering variants are SnpSift [http://vcftools.sourceforge.net).After the variant calling file (VCF) has been obtained, a filtering procedure is often necessary for the downstream analysis. This filtering procedure aims to reduce the number of false positives corresponding either to low quality and common variants. In particular the common variants, which are assumed to have no implications in tumor development and progression, are filtered out by comparison with the germline polymorphisms collected in publicly available databases, such as dbSNP  or EVS . The analysis of this data enabled the development of several meta databases and resources for the annotation of cancer genomes. In this section, we describe some of the repositories and databases available that collect somatic variants and driver genes putatively involved in the cancer.Large-scale cancer genomic experiments, funded by several national and international consortiums, are generating an amount of data in the magnitude of PetaBytes (PB). The space needed to host the data only from The Cancer Genome Atlas (TCGA) is ~1.1PB (see https://cghub.ucsc.edu/).The Cancer Genome Atlas (TCGA) consortium, which began in United States in 2006, is a comprehensive and coordinated effort to understand the molecular basis of cancer using several genomic analysis techniques. The data generated by the experiments are made available through the TCGA Data Portal and the Cancer Genomics Hub (CGHub) . After sSince the downloading of all the BAM files remains costly in term of time and storage, it is advisable to get all the pre-processed variant files (VCFs) generated by different institutions within the TCGA consortium. Unfortunately, so far the organization of the data in the TCGA repository is not optimized and available data have to be manually selected. In particular, variant data from different platforms, ranging from SNP arrays to SOLID and Illumina sequencers, are reported in different file formats. Out of these files, the most informative ones are the VCF files, which contains the genetic variants for both normal and tumor samples. Currently, VCF file are provided only for a subset of the tumor types (~67%).https://dcc.icgc.org) show that in total 12,232 cancer genomes have been sequenced. In the samples from these donors, collected from 18 cancer primary sites, more than 9.8 million simple somatic mutations have been identified. A summary of the mutations detected for each cancer type is provided in Table The International Cancer Genome Consortium (ICGC) was launched in 2007 to coordinate the efforts of characterizing more than 50 different cancer types from 25,000 patient genomes -37. The Fraction of Somatic Mutations and the Fraction of Donors corresponding to different subsets of somatic mutations  revealed that a large fraction of them are occurring in a single patient and only ~1.7% are recurring more than once  explains a comparatively large fraction of patients (~40%). However, this data could be biased toward cancer types with higher number of samples and with higher of mutations detected.In addition, we calculated the s Figure . Consides Figure . This peWe performed the recurrence analysis on each cancer type fitting the points calculated at different Mutation Recurrence threshold. The results in Figure In general, it is expected that heterogeneous cancer types show a large variety of recurrent somatic mutations, which is inversely proportional to the rate of decay of the complementary cumulative distribution (CCD). Thus, the analysis of recurrent mutations based on the calculation of the CCD can provide an estimation of the mutational heterogeneity of each cancer type  we built a vector, in which each element represents the number of donors affected by a mutated gene. Only genes harboring the aforementioned recurrent mutations are considered. The gene-based vectors of each cancer type are then used to calculate the cosine similarity , which are held by ~96% of the patients . The last release of COSMIC  contains ~2.1 million unique somatic variants detected in ~1 million tumor samples. An important manually curated resource made available through the COSMIC web page is the Cancer Gene Census list. Currently it contains 547 genes for which mutations have been causally implicated in cancer. Out of 547 cancer genes, 85% of them harbor only somatic mutations, 7% harbor only germline variants and the remaining 8% harbor both types.Beside the Cancer Gene Census there are other lists of putative cancer genes identified using computational or expert-based approaches. One is a list of 125 cancer genes, reported in a publication by Vogelstein and collaborators . The lisOther useful databases for the annotation of cancer genome are NCG  and CancIn the last few years, several web portals have been developed for the visualization and analysis of all kinds of data in cancer genome studies. Among the most used is the cBioPortal maintained by the Memorial Sloan Kettering Cancer Center ,58. The A possible alternative to cBioPortal is the Cancer Genome Browser . The CanOther three interesting resources for the analysis of cancer genome data are the Cancer Gene annotation system for Cancer Genomics (CaGe) , the DriThe URLs of the cancer genome data repositories, the cancer gene lists and resources for cancer genome analysis are summarized in Table The analysis of the cancer genome is a challenging task from both the experimental and computational point of views. A recent review, in addition to providing an exhaustive overview of the available tools for the detection of somatic mutation from sequencing data, also highlighted these challenges . The lacIn general, the insurgence of cancer is accompanied with an accumulation of somatic mutations. However, this does not imply that all mutations are of equal importance in the oncogenesis and cancer progression. Rather, driver somatic mutations exert a selective advantage to cancer cells. In contrast, passenger mutations are abundant but do not confer any selective advantage. Driver variants are present in a small fraction that may vary in different cancer types ,67. ThusThe Mutational Significance in Cancer (MuSiC) uses sequence-based input to establish correlations among mutation sites, affected genes and pathways, and to discriminate abundant passenger mutations from significant mutation events. This method aims to identify significantly mutated genes with respect to a background mutation rate. MuSiC has been tested on a set of 316 ovarian cancer samples and it was able to detect 12 significantly mutated genes . MutSigCAlternative approaches have been implemented in ActiveDriver , OncodriFinally, we also highlight ContrastRank , which iDuring the last decades several methods have been developed to predict the impact of non-synonymous single nucleotide variants (nsSNVs) at structural  and funcAlthough most variant effect predictor reached an adequate level of accuracy, their predictions do not provide information about the possible phenotypic effect. This problem has been partially addressed with the development of a new class of disease-specific predictors trained on a subset of mutations with defined phenotypic effect. In particular, several methods have been developed for discriminating between passenger and cancer driver mutations ,89-93. ABRAF and KRAS (involved in RAS/RAF pathway) in colorectal cancer [APC and CTNNB1 (involved in beta catenin pathway) [EGFR and KRAS in lung adenocarcinomas [TP53 and MDM2 in many different cancer types [The accumulation of somatic mutations during the lifespan is the main cause of cancer. Several identified somatic mutations occur in genes involved in many signaling, regulatory and metabolic pathways. Indeed mutated genes such as TP53 and PI3KCA are hubs in pathways and interaction networks which control cell proliferation, growth and apoptosis ,96. In al cancer , APC andpathway) , EGFR anrcinomas , TP53 aner types .From these observations, it is evident that the analysis of genomic variations across gene pathways and networks is important to understand the combinatorial effect of the mutations and explain the disease mechanism. Pathway and network analysis can be performed using previously annotated gene pathways or testing alternative routes from gene interaction networks. Reference databases collecting information about gene pathways are the Kyoto Encyclopedia of Genes and Genomes Kyoto Encyclopedia of Genes and Genomes (KEGG)  and the Recently, several methods for the analysis of cancer gene pathway have been developed -115. FewAlthough annotation-based methods are able to prioritize important cancer pathways, they present some limitations. The main limitations are the incompleteness of pathway databases and the presence of multiple overlapping gene sets across pathways. Thus, more general methods for detecting significantly mutated gene sets use information from biological interaction networks. The Mutual Exclusivity Modules in Cancer (MEMo) algorithm  integratThe De novo Driver Exclusivity (Dendrix) algorithm  is a tooFinally, PARADIGM estimateAn interesting approach, which applies network analysis to the study of the cancer genome, is the Network-Based Stratification (NBS) method . NBS is Tumor progression is an evolutionary process which starts from a single cell and results in the selection of more aggressive subclones . The preA possible solution to this issue lies in single-cell sequencing for revealing diversities in the pattern of somatic mutations within a tumor ,121. AltABSOLUTE  uses datAlternative methods ,125 use A recent publication  presentsThe methods for the detection of genetic heterogeneity in cancer can be also used to detect subclonal mutation conferring drug resistance. This idea has been investigated using cloneHD , a new sThe URLs of the tools describe above for the analysis of the cancer genome are summarized in Table In this review we provide an overview of the challenging topics in the analysis of cancer genome. We mainly focused on the characterization of single nucleotide variant, which is by far the most common type of genetic variation. In particular, we provided a summary of the most important cancer genome data available online and described a selection of the available computational tools for cancer genome interpretation.Although several algorithms have been developed, the problem of cancer genome interpretation is far from being solved. The progress in the field is limited by many factors mainly associated with (a) the intrinsic complexity of the problem (b) technical limitations, and (c) ethical issues.The complexity of the problem mainly comes from the huge number of somatic variations present in the in each tumor sample and our inability to select driver and clinically actionable variants. The technical limitations are also affecting the detection of genetic variations present in a smaller fraction of subclones. The third important issue is the restricted access to the data for protecting the privacy of the individual.It is expected that in the near future most of the limitations will be overcome by the development of more accurate computational tools and experimental approaches which will play an important role in the understanding the relationship between genotype and phenotype in cancer. In particular, brute force sequencing initiatives will result in a better mapping of the functionally important regions in the genome and experimental approaches, such as CRISPR/Cas  will proThe integration of more accurate data will have an impact on the development of more accurate computational tools. Indeed, the limited ability to score the performances of currently available algorithms can be addressed by collecting standardized benchmark sets from high-quality experiments. An important component for speeding up this learning process involves the implementation of more effective policies for data sharing. Although major efforts have been made by the TCGA, ICGC and other cancer consortium, the procedures for releasing sequencing data need to be optimized. Standard protocols for extracting and reporting the data are also required for efficient data analysis. Information about the germline variants present in sequenced patients should be made available for validating hypothesis about the tumor predisposition. Furthermore, it will be extremely important to develop appropriate de-identification procedures  and the The authors declare that they have no competing interests.RT and EC carried out the analysis of ICGC data. RT, MKB and EC wrote the manuscript and approved its final version.Supplementary materials including supplementary tables.Click here for file


The causative agents of a number of emerging zoonotic diseases have been identified as paramyxoviruses originating in bats. We report here the complete genome sequence of two Teviot paramyxoviruses, novel rubulaviruses isolated from urine samples collected from pteropid bats in Australia. The zoonotic potential of Teviot paramyxovirus is undetermined. Chiroptera) are reservoirs of many emerging zoonotic viruses  and 3′ (2 nt) ends were inferred from the Tioman virus genome due to their close genetic relationship. Open reading frames were also extrapolated from those of Tioman virus.As part of a surveillance study, Teviot paramyxovirus (TevPV) was isolated from pooled urine samples collected from ber 2009 . The comber 2009 . In NoveParamyxovirinae (The genome of TevPV is 15,522 nt in length and is a multiple of six, conforming to the rule of six for viruses of the subfamily ovirinae , 17. Phyovirinae . Genome The zoonotic potential of TevPV is undetermined. The availability of complete genome sequences of two isolates of a novel bat rubulavirus, TevPV, improves our understanding of the diversity of viruses circulating in bat populations and provides a target in zoonotic disease surveillance.KP271124 and KP271123, respectively.The complete genomes of the Cedar Grove and Geelong isolates of TevPV have been deposited in GenBank with the accession numbers


Diabetes has been one of the most common chronic diseases all over the world. The purpose of this study was to quantitatively assess the foot loading characteristics of diabetic patients with fifth-toe deformity through a comparative analysis with diabetic patients with healthy and normal feet. Six neuropathic diabetic female subjects with the fifth-toe deformation and six age-matched neuropathic diabetic controls without any feet deformities participated in the walking test. Dynamic barefoot plantar pressure was measured with Novel EMED force plate. Peak pressure and pressure-time integral for all 7 foot regions  were collected. Peak pressure was significantly higher in the patients with toe deformity in rearfoot, central forefoot, and great toe regions compared with the control group. Meanwhile, loading sustaining period extended longer in great toe region of deformed group than in that of the control group, and the center of pressure was nearly in the big toe region during toe offstage. Diabetic patients with fifth-toe deformity could have plantar contact area reduction in the other toes part and increased loading to the great toe part. The result showed that fifth-toe deformity was associated with potential ulceration risk especially in hallux region. Diabetes mellitus has been one of the most common chronic diseases that influenced people's normal daily life. It has been estimated that the number of people with diabetes all over the world will surpass 365 million by 2030 . DiabetiIt was clear that the emergence of the diabetic foot ulceration, to a great extent, was caused by the changes of foot loading characteristics . And diaA total of twelve age-matched diabetic female participants joined in the experiment, six of them with toes lesions and another six with healthy feet. Subjects in the experimental group were elected based on deformity presented in the fifth toe under non-weight-bearing condition , consideThe Novel EMED pressure measuring plate  was used for plantar pressure data measurement. Before the experiment, participants were required to adjust their walking step with right foot landing on the plantar pressure measuring plate, which was fixed in the center of the walkway aisle. During the test, subjects walked along the aisle straightly with their selected and comfortable speed so as to perform their normal gait characteristics. Each participant walked six trials successively to show their normal gait. To accurately and deeply illustrate the plantar loading features, the foot was divided into seven anatomical regions, which are rearfoot part (RF), midfoot part (MF), lateral forefoot part (LFF), central forefoot part (CFF), medial forefoot part (MFF), great toe part (GT), and other toes part (OT). For each region, peak pressure, pressure-time integral, and trajectory of the center of pressure (CoP) were collected and the average of the six walking trials was used for data analysis to minimize error.P = 0.05 was used for all analyses.All statistical tests were performed using SPSS (version 17.0.) and statistical test data of the two groups of subjects, which are indicators mean, standard deviation, and significant statistics. A significance level of The plantar pressure distribution patterns showed significant difference  between As to the peak pressure of the deformed group  comparinTo sum up these characteristics, the peak pressure of the deformed group, central forefoot (CFF), and the great toe (GT) areas was relatively concentrated. It should be noted that, in other toes (OT) area, the peak pressure of the deformed group was also significantly less than the control group; the pressure value of the other toes region only took up one-third the value shown in the control group while the peak pressure value in GT was 32% higher than that appeared in the control group.Comparing the pressure-time integrals, the lateral forefoot (LFF), central forefoot (CFF), medial forefoot (MFF), great toe (GT), and the other toes (OT) parts showed significant difference. But as to the pressure-time integral in the GT and CFF regions, deformed group were significantly larger than those of the control group . The resFor the trajectory of center of pressure (CoP) , the defThe clinical importance of studying the biomechanics of toe deformity in neuropathic diabetic patients has been demonstrated by several prospective population-based studies which showed that this structure abnormality was a significantly independent predictor of plantar ulceration in diabetic patients , 15. TheFrom the plantar pressure point of view, the CoP line of the deformed group transfers to the hallux part during walking. Because the fifth toe has been significantly deformed that was unable to withstand greater pressure, it showed obvious reduction of peak pressure in the lateral forefoot and other toes regions. The contact area in the other toes (OT) region of the deformed group is significantly less that of the control group, which is similar with the previous studies . One impCompared with the control group, the pressure-time integral of toe deformed group showed significant reduction in lateral and medial forefoot and other toes regions, while great toe demonstrated significantly greater one than that of the control group . CombiniOne limitation of this study was that the kinematic analysis of diabetic deformed feet were not taken to investigate the lower extremity motion characters, particularly the ankle movement in the sagittal plane . This should be the next step to further reveal the gait patterns of fifth-toe deformed diabetic patients.This study found that the great toe and central forefoot regions are the foot loads bearing parts in the fifth-toe deformity group and the most sensitive areas to foot ulceration due to long-term collapse impact. The changes of plantar pressure distribution and center of pressure trajectory should be considered while analyzing and treating diabetic-deformation-related plantar ulcers. The quantitative illustration of foot loading characteristics of fifth-toe deformity could be of great beneficial for diabetic patients to understand their foot loading conditions and doctors or rehabilitation therapist to make protocols to prevent or even rehabilitate fifth-toe-deformation-related foot ulceration and other traumas. Some functional footwear is necessary to use so as to reduce the risks of ulceration in relevant regions, normalizing the distribution of diabetic patients with fifth-toe deformity.


Cross-border cholera outbreaks are a major public health problem in Sub-Saharan Africa contributing to the high annual reported cholera cases and deaths. These outbreaks affect all categories of people and are challenging to prevent and control. This article describes lessons learnt during the cross-border cholera outbreak control in Eastern and Southern Africa sub-regions using the case of Uganda-DRC and Malawi-Mozambique borders and makes recommendations for future outbreak prevention and control.We reviewed weekly surveillance data, outbreak response reports and documented experiences on the management of the most recent cross-border cholera outbreaks in Eastern and Southern Africa sub-regions, namely in Uganda and Malawi respectively. Uganda-Democratic Republic of Congo and Malawi-Mozambique borders were selected because the countries sharing these borders reported high cholera disease burden to WHO.A total of 603 cross-border cholera cases with 5 deaths were recorded in Malawi and Uganda in 2015. Uganda recorded 118 cases with 2 deaths and CFR of 1.7%. The under-fives and school going children were the most affected age groups contributing 24.2% and 36.4% of all patients seen along Malawi-Mozambique and Uganda-DRC borders, respectively. These outbreaks lasted for over 3 months and spread to new areas leading to 60 cases with 3 deaths, CRF of 5%, and 102 cases 0 deaths in Malawi and Uganda, respectively. Factors contributing to these outbreaks were: poor sanitation and hygiene, use of contaminated water, floods and rampant cross-border movements. The outbreak control efforts mainly involved unilateral measures implemented by only one of the affected countries.Cross-border cholera outbreaks contribute to the high annual reported cholera burden in Sub-Saharan Africa yet they remain silent, marginalized and poorly identified by cholera actors . The under-fives and the school going children were the most affected age groups. To successfully prevent and control these outbreaks, guidelines and strategies should be reviewed to assign clear roles and responsibilities to cholera actors on collaboration, prevention, detection, monitoring and control of these epidemics. Cholera is preventable and treatable disease however, it remains a major public health problem in many Sub-Saharan African countries causing deaths and retarding development –5. CrossInterventions for cholera prevention and control include provision of good sanitation, safe water, hygiene, health education, surveillance, treatment of the patients, and recently vaccination with the World Health Organization (WHO) recommended vaccines ,8. It shOn the other hand, for a long time, the Asian sub-continent was the home of cholera ,10. HoweMajority of cholera affected countries in Africa subscribe to WHO and use Integrated Disease Surveillance and Response (IDSR) strategy to prevent and control cholera outbreaks . While IDue to several reasons known and unknown, countries in the Great lakes region of Africa are among those with the highest cholera burden . In 2013To reverse the status quo, the current approach has to be reviewed and lessons of the good actions in South America to prevent cholera outbreaks copied. The introduction of the new Oral Cholera Vaccines (OCV) which works synergistically with the other known cholera prevention interventions and are recommended for use by the WHO in cholera prevention in endemic cholera setting for preemptive vaccination for highly at risk communities  is anothHowever, since the production and the stock of these new vaccines is limited, efficient and effective use of the available vaccine stocks is highly recommended by WHO. Therefore, for the Sub-Saharan cholera endemic countries to qualify to use these vaccines, accurate data and documentation on the affected population is a necessity. In the case of the cross-border endemic setting, collaboration of the two neighboring states is very important if successful cholera prevention and control is to be achieved .The objective of this article is to share experiences and challenges for the prevention and control of cross-border cholera epidemics in Sub-Saharan Africa. The country experiences from the two major Africa grouping zones of Eastern and Southern Africa represented respectively by Uganda and Malawi are shared. Most importantly, the authors give recommendations for prevention and control of future and ongoing cross-border cholera outbreaks in Africa and beyond.This article reviewed data from the Ministries of Health epidemiological records of the two countries in Sub-Saharan Africa namely; Uganda and Malawi which were purposively selected to represent East Africa and Southern Africa regions respectively. The countries were selected because they had endemic cholera outbreaks along their international country borders with Democratic Republic of Congo (DRC) and Republic of Mozambique respectively. The study area is shown in Democratic Republic of Congo and Republic of Mozambique are among the countries with the highest cholera burden in WHO African region. The two countries  were both implementing IDSR strategy, thus had similar and comparable data including the use of the same official national language which was English and standard case definition for cholera below .In an area with no cholera epidemic: a suspected case of cholera was defined as a patient aged five (5) years or more presenting with severe dehydration or a death from acute watery diarrhoea.If there is a cholera epidemic in the area: a suspected case is any person age 5 years or more with acute watery diarrhoea, with or without vomiting. In Uganda, this case definition was modified by lowering the age of the affected person to 2 years or more.Vibrio cholerae O1 or O139 has been isolated from the stool sample of the patient.Confirmed cholera case is a suspected case in which For the purpose of this study, a cross-border cholera outbreak was defined as a confirmed cholera epidemic occurring in the community located along or close to the international country boundary with cholera patients originating from both countries sharing the international border.For the two selected countries, records and personal experiences from the most recent cross-border cholera outbreaks were extracted, analyzed and shared. The authors had added advantage because they actively participated in the implementation and coordination of cholera prevention and control interventions in their respective countries.Additional information to support the data from the line lists were obtained from country specific outbreak reports  for the selected outbreaks meeting inclusion criteria. No interviews were conducted, however, information on the risk factors for the outbreaks, interventions implemented and challenges noted were collected from the outbreak investigation reports and weekly epidemiological reports.For an outbreak to be included in the study the following had to be met namely; a cholera outbreak occurring in 2015 in the border districts with the patient data showing location (country) of origin from both neighboring countries. We excluded cholera outbreaks reported in the border districts but data, reports and experiences from only one country and nationality. In this article the country refers to a place of origin of the patient.www.maplibrary.org and from Uganda Bureau of Statistics (UBOS), www.ubos.org/statistical-activities/gis/. The administrative units used to shade the maps were the district level for Malawi-Mozambique and Sub-county level for Uganda-DRC. The difference between the mean ages of the two groups of the reported cross-border cases was tested using unpaired t-test. Ethical consideration was paramount in the conduct of this study. Involvement of the human subjects was limited to the authors describing their personal experiences.Data was collected using a questionnaire on following variables: age, sex, country of origin, date of onset of illness, number of stool samples collected from the cases and tested, stool samples that tested positive by culture, risk factors for outbreaks, interventions implemented to control the outbreaks and challenges noted by the cholera actors in controlling the outbreaks. The data was cross-checked for errors before and after entering it into the spreadsheets. Data storage and analysis was conducted using spreadsheet (excel), powerpoint and graphpad by the authors. The maps were drawn using Arc View geographical referencing software. The shapefiles used to draw the maps were downloaded from The information used in this study was secondary data, collected during the routine surveillance activities by the ministries of health of the two representative countries .Institutional Review Boards (IRBs) of the two representative countries from African sub-regions of Eastern and Southern Africa were consulted and IRBs weavers provided. The authors had access to personal patient information from the cholera line lists (cholera patient registers) namely the patient numbers, names of patients and their villages of origin. However, in this study these personal identifiers were omitted (converted to anonymous) or substituted with the codes known only to the authors or categorization appropriate for the public surveillance information. For instance, the villages were replaced with the sub counties / country as appropriate.One of the authors  interacted with the patients during his work as a healthcare provider to save lives. This allowed him access to more personal patient information. However, in his contribution to this study he strictly observed the professional ethical requirement  and only shared information required for routine surveillance work and free from personal identifiers.The potential benefits of this study to the cross-border cholera affected communities are enormous and include: awareness rising among cholera actors and guidance to the policy-makers to take action to prevent more infections, suffering and deaths.Using the inclusion and exclusion criteria above, out of 5 districts in Malawi and 8 districts in Uganda which reported cholera outbreaks in 2015, 3 and 1 districts respectively were classified as fitting cross-border outbreaks. These districts were: Mwanza, Nsanje and Chikwawa in Malawi and Kasese district in Uganda .Chikwawa district and Karambi sub-county (Kasese district) were the most affected communities in Malawi and Uganda respectively. In both Malawi and Uganda the outbreaks later spread to other parts of the country leading to 60 cases with 3 deaths, CFR of 5% and 102 cases with 0 deaths respectively. The areas where the outbreaks spread were Blantyre and Ntcheu districts in Malawi and Katwe-Kabatoro Town Council (TC) and Kitchwamba Sub-county in Kasese district, Uganda .th calendar week) and ended in May 2015 . The outbreak in Uganda started in March 2015  and ended in July 2015 . In both countries the outbreaks lasted for over 3 months, 14 weeks for Malawi-Mozambique and 17 weeks for Uganda-DRC border  where treatment occurred reported the biggest number of cross-border cholera cases and deaths.Slightly more females were affected in Malawi, Mozambique and DRC than the males. In Uganda, 53.30% (63/118) of the affected were males. The under-fives and school going children combined contributed 24.2% (120/495) and 36.4% (43/118) of all cases seen in the cholera treatment centres in Malawi and Uganda respectively. The distribution of the cross-border cholera cases by age groups in the two regions was as shown in The mean ages of the cholera cases were 24.54 years, Standard Deviation (SD) of ±18.39 years for Malawi-Mozambique and 22.59 years, SD of ±20.17 years for Uganda-DRC cross-border cholera cases respectively. The mean ages of the two groups of patients  were not statistically different .The communities along the borders interacted freely with their counterpart on the other side of the international boundary. In Malawi, this was facilitated by the common market regional grouping called Southern Africa Development Community (SADAC) to which the two neighbors belonged. The reasons for migration across the borders were: visiting relatives, cross-border trade, looking for employment and seeking better medical treatment. Informal border crossing was common, with the two international borders acting as an artificial demarcation to the communities.Besides, the investigation reports indicated that the risk factors for the cholera outbreaks were on the either side of the international borders for both Malawi and Uganda since the residents and migrants acquired cholera on any side of the border.Also some migrants acquired cholera on the other side of the border and crossed to receive treatment while some could have crossed incubating the infection and developed the disease after crossing into Malawi or Uganda where they ended up getting medical care. Another possibility was that some migrants acquired infection in Malawi or in Uganda after interacting with the sick residents or cholera contaminated environment.Vibrio cholerae organisms. The two sub-regions had the same Vibrio cholerae serogroup O1 biotype El Tor. The serotype on Uganda-DRC border was Inaba while that on Malawi-Mozambique border was Ogawa. In both settings the pathogens were sensitive to tetracycline antibiotics, a cheaper and more affordable antibiotic. Laboratory results for the tests conducted during the cross-border cholera outbreaks in 2015 in the two sub-regions were as in A total of 146 stool samples were collected and tested for The Ministries of Health, Malawi and Uganda and their respective local teams identified the factors leading to the cholera outbreaks, and implemented activities to prevent and control these outbreaks. In conducting these activities, the country teams experienced some challenges as shown in the Our study showed that cross-border cholera outbreaks are a major public health threat which affects all categories of people along the common country borders in Eastern and Southern Africa with children being the most affected group. These outbreaks cause protracted ill-health and deaths and can easily spread to other areas with devastating consequences as happened in both Malawi and Uganda.Despite these, cross-border cholera outbreaks have received little attention and identification by the cholera actors (governments and non-governments). Few studies have documented the experiences of managing cross-border cholera outbreaks in Sub-Saharan Africa. This article is unique in highlighting the importance of this relatively common but marginalized cholera issue. The current cholera prevention and control strategies/guidelines do not identify cross-border cholera outbreaks as a special threat requiring dedicated attention from all actors.Similarly, though these outbreaks involve both countries this is not conveyed in the national reports submitted to WHO by the countries. Therefore, there is no accurate quantification of the burden of these outbreaks. Also during implementation of the cholera control interventions, the affected countries generally work exclusively within a country rather than in an international manner, and this national approach may lead to protracted outbreaks.It seems likely that these unilateral efforts within these bordering communities provide a fertile ground and probably a reservoir for cholera multiplication allowing the transmission and spread of cholera to other areas as happened in both sub-regions in this study.In the two sub-regions the outbreaks were protracted and peaked at the same time, possibly because they were aggravated by similar weather and environmental factors such as increased rainfall which occurred during the month of April 2015 resulting in floods in some areas. This therefore, presents an opportunity for the sub-regions to collaborate and acquire more reliable and accurate early warning equipments for the benefit of the entire region without duplication of the efforts.According to this study, the most affected age groups in both sub-regions were the children 1–4 years and 5–9 years (school going children). This suggests increased vulnerability of these age groups. In the two study countries of Malawi and Uganda these age groups receive childhood vaccinations (non cholera vaccines) with support from Global Alliance for Vaccine and Immunization (GAVI). These same groups therefore, should be supported to access OCV from the available GAVI stock-piles . To reduFurthermore, in order to comprehensively address the gaps noted in this study, concerted efforts by the two neighboring countries is required. These efforts should be in terms of sharing of the health information, joint planning of response activities, coordination and harmonized implementation of cholera control interventions. In addition, the sources of funding for joint cholera prevention and control activities should be clearly specified in the revised strategies so as to adequately guide the country teams. The 2014–2015 Ebola outbreak in West Africa provided good experience for the countries and international bodies regarding the benefits of collaboration in the prevention and control of the outbreak . These gThough the current cholera outbreak control strategies in Africa such as IDSR / International Health Regulations (2005) ,24 have Given this scenario and faced with the threat of cross-border cholera outbreaks, there is urgent need to review the available cholera prevention and control strategies to clearly deliberate on cross-border cholera outbreaks, outline the mechanism for collaboration between states, provide guidance on information sharing between neighbors and propose source of funding for joint activities. The revised strategies should clarify what will be done in case the two affected countries are at war, conflict or are unable to respond on their own.Most importantly, regional bodies such as the East African Community (EAC), SADAC and international agencies should be empowered to play a more active role in supporting the prevention and control of these outbreaks. In addition, international agencies such as WHO, UNICEF and others should monitor incidences using specific indicators which are able to recognize the trans-boundary (two States) nature of these outbreaks and provided timely support to facilitate the processes . Where applicable, coordinated implementation of joint interventions leading to prompt prevention and control of these outbreaks should be instituted.In order for these strategies to be effective, supportive policies have to be enacted at national and sub-regional levels (EAC and SADAC). The signing of bilateral or regional agreements between the countries to ensure implementation of the appropriate measures is paramount. International bodies such as WHO, UNICEF and others could spearhead such efforts to ensure that policies and agreement are in place and implemented.We could not estimate the attack rates for each affected community (district or country) during these outbreaks because the other part of the population at risk was not known and belonged to the neighboring country of either DRC or Mozambique. In addition, follow up monitoring after vaccination could not fully be accomplished since some of the persons in Malawi returned to Mozambique immediately after floods had receded.vibrio cholerae organisms which is inadequate to fully guide interventions. Therefore, further studies especially genotyping should be done to establish similarity and differences in vibrio cholerae in the two sub-regions.In this study, characterisation of the pathogens stopped on the phenotying of the Our data analysis relied on the accuracy of the epidemiological records, therefore misclassification and misreporting could not be fully detected. Our epidemic curves may not be the true representation of the outbreaks, since half of the cases and deaths could have been on the other side of the border for which we had no access to information. On the other hand, because we reviewed data and documented experiences from Eastern and Southern Africa only, our findings may not be generalized to entire Sub-Saharan Africa. We therefore recommend that further studies be done in Central and West Africa to better understand the additional barriers to cross-border cholera outbreak prevention and control. Furthermore, a comprehensive study should be conducted to estimate the true burden of these outbreaks in entire Sub-Saharan Africa. The design for this study among other things should be able to compare the disease burden of the cross-border cholera outbreaks with the other cholera outbreaks within individual countries.Our study showed that cross-border cholera outbreaks contribute to the high annual reported cholera burden in Sub-Saharan Africa yet they remain silent, marginalized and poorly identified by cholera actors . The under-fives and school going children were the most vulnerable groups to these outbreaks.To successfully prevent and control these outbreaks, guidelines and strategies should be reviewed to provide more focused information, assign clear roles and responsibilities to actors on collaboration, prevention, detection, control, monitoring and financing of joint activities for the cross-border outbreaks.S1 Information(XLS)Click here for additional data file.S2 Information(ZIP)Click here for additional data file.


Complex distal femoral fractures in the young patient often occur as a result of high velocity trauma. Timely recognition and treatment is everything in such a situation, and it needs a robust staged management pathway to optimize the chance of limb preservation. We report a case of a motorcyclist admitted to the department of orthopedics at Chambery hospital, France, with a complex comminuted and open distal femoral fracture of the left leg, associated with a brachial plexus injury to the ipsilateral upper limb. On arrival to the emergency department, damage control stabilization and surgery was commenced, debridement of contaminated non-viable tissue, abundant antiseptic lavage and application of external fixation coupled with the use of antibiotic spacer. Following normalization of inflammatory markers and ensuring no clinical signs of infection, subsequent management consisted of joint reconstruction to achieve a functional knee. The external fixator and femoral spacer was removed and a modular megaprosthesis was implanted with a lateral gastrocnemius flap to cover the exposed knee joint and reinforce the extensor apparatus. Nerve graft to the left brachial plexus injury was performed at University Hospital of Grenoble. Our patient entered an intensive rehabilitation program and at 1 year follow-up achieved good knee function and sensation to the left upper limb. Distal femoral fractures are not uncommon and are often the result of high velocity road traffic collisions. The management of such injuries is challenging. Supra-condylar femoral fractures with bone loss and neuro-vascular involvement in the poly-traumatized patient demand emergency timely decisions, the aim being to preserve the limb, avoiding amputation. Considerations in the management of these injuries are addressing the open fracture, method of skeletal stabilization, soft tissue coverage and timing of soft tissue coverage and strategies for bone grafting . The aimA 46 year old man was admitted to the emergency department at Chambery hospital, France, one hour after a high velocity traffic accident . He was in hemorrhagic shock on arrival. He had sustained a comminuted open distal femoral fracture (Gustilo-Anderson classification 3C, . Neuro-vSerious limb injuries can occur as a result of high velocity trauma, as a result of road traffic accidents or in the workplace. Comminution and open injuries can indicate high velocity trauma. This can also be associated with other bony injury and fatal visceral injury . In the The choice of megaprosthesis was an interesting alternative with the aim to preserve some quality of life for our patient. The modularity of such a device enables good restoration of the limb length at the same time avoiding iatrogenic injuries related to the stretching of major neurovascular structures . A complWe have described our staged management of a complex limb injury. These injuries have a huge socio-economic impact. Timely decision making is fundamental in such situations.


Duplication of the alimentary tract is a rare congenital malformation that occurs most often in the abdominal region, whereas esophageal duplication cyst develops typically in the thoracic region but occasionally in the neck and abdominal regions. Esophageal duplication cyst is usually diagnosed in early childhood because of symptoms related to bleeding, infection, and displacement of tissue surrounding the lesion. We recently encountered a rare adult case of esophageal duplication cyst in the abdominal esophagus. A 50-year-old man underwent gastroscopy, endoscopic ultrasonography, computed tomography, and magnetic resonance imaging to investigate epigastric pain and dysphagia that started 3 months earlier. Imaging findings suggested esophageal duplication cyst, and the patient underwent laparoscopic resection followed by intraoperative esophagoscopy to reconstruct the esophagus safely and effectively. Histopathological examination of the resected specimen revealed two layers of smooth muscle in the cystic wall, confirming the diagnosis of esophageal duplication cyst. As reported by Ladd and Gross, duplication of the alimentary tract is a rare congenital malformation that develops potentially anywhere in the gastrointestinal tract, from the root of the tongue to the anus . SeveralA 50-year-old man had a history of an operation for lumbar herniated disc at the age of 37 and hypertension since the age of 42 that was controlled with medication. He visited a nearby clinic because of epigastric pain and dysphagia that started 3 months earlier. He was referred to our hospital because of gastroscopic findings of extrinsic compression.The initial physical examination revealed normal heart and lung sounds, a flat and soft abdomen, and no tenderness on palpation. No superficial lymph nodes were palpable. Hematological and biochemical findings were normal. Gastroscopy performed at our hospital revealed a submucosal tumor with a smooth surface at the 9 o'clock position in the lower esophagus . Barium Intraoperatively, the mass was soft and elastic and had a smooth surface in the lesser curvature of the stomach near the cardiac region and along the esophagus when approached from the mediastinum by partially dissecting the crus of the diaphragm. The mass was carefully resected along the esophagus in the abdominal cavity toward the mediastinum. At the resection site, normal mucosa was left in some areas, but in other areas resection extended through all layers. Using a 3-0 synthetic absorbable suture, the surgical site was closed under intraoperative esophagoscopic observation to ensure proper closure and prevent esophageal stricture due to suturing. Cystic fluid in the resected specimen was mucous and reddish brown, with no cellular components . HistopaDuplication of the alimentary tract is rare malformation observed in 1 of 25,000 deliveries . In 1940n = 15) accounted for 79% of the patients with intra-abdominal EDC even though many duplication cysts of the alimentary tract are diagnosed before 2 years of age. This may be because no structures in the vicinity of the lower esophagus restrict the growth of tumor. EDC size ranged from 1 to 15 cm and no significant differences in patient background factors were observed between symptomatic patients and patients whose diagnosis was incidental. In general, the preoperative diagnosis of EDC is made based on CT and endoscopic ultrasonography findings. As in the present study, the definitive diagnosis of EDC is relatively easy for lesions with homogeneous signal intensity and smooth margins. However, it is sometimes difficult to definitively diagnose mediastinal cystic masses because of diverse components, such as hemorrhage, sebum or sebaceous fluid, and proteinaceous fluid. Surgical resection is recommended as the primary treatment for EDC because of reports of malignant transformation of cysts even though the frequency is unknown [The present case is extremely rare because intra-abdominal EDC was discovered because of the onset of epigastric pain and dysphagia at the age of 50 years. A literature search extracted only 18 published case reports of intra-abdominal EDC –23, maki unknown . Althoug unknown  and beca unknown . In our In summary, we reported an extremely rare adult case of intra-abdominal EDC and reviewed the 18 previously published case reports.


The aim of this study was to design and trial an Adherence Scale to measure fidelity of Motivational Care Planning (MCP) within a clinical trial. This culturally adapted therapy MCP uses a client centered holistic approach that emphasises family and culture to motivate healthy life style changes.The Motivational Care Planning-Adherence Scale (MCP-AS) was developed through consultation with Aboriginal and Islander Mental Health Initiative (AIMhi) Indigenous and non-Indigenous trainers, and review of MCP training resources. The resultant ten-item scale incorporates a 9-Point Likert Scale with a supporting protocol manual and uses objective, behaviourally anchored criteria for each scale point. A fidelity assessor piloted the tool through analysis of four audio-recordings of MCP . File audits of the remote therapy sessions were utilised as an additional source of information. A Gold Standard Motivational Care Planning training video was also assessed using the MCP-AS.The Motivational Care Planning-Adherence Scale contains items measuring both process and content of therapy sessions. This scale was used successfully to assess therapy through observation of audio or video-recorded sessions and review of clinical notes. Treatment fidelity measured by the MCP-AS within the pilot study indicated high fidelity ratings. Ratings were high across the three domains of rapport, motivation, and self-management with especially high ratings for positive feedback and engagement, review of stressors and goal setting.The Motivational Care Planning-Adherence Scale has the potential to provide a measure of quality of delivery of Motivation Care Planning. The pilot findings suggest that despite challenges within the remote Indigenous community setting, Indigenous therapists delivered therapy that was of high fidelity. While developed as a research tool, the scale has the potential to support fidelity of delivery of Motivation Care Planning in clinical, supervision and training settings. Larger studies are needed to establish inter-rater reliability and internal and external validity. Specifically, the strategy identified the need for enhanced health research, a broadening of funding programs, and promotion of understanding within the workforce[The orkforce–4. Dawsoorkforce and Clayorkforce have higorkforce, 7 and tIn the Northern Territory, researchers have sought to address these barriers to engagement of Indigenous Australians within the health system–11. Two Northern Territory Aboriginal and Islander Mental health initiative (AIMhi) aims to promote access of Indigenous Australians to mental health services through development of culturally adapted resources and training tools[The ng tools. These tng tools.A number of joint studies have suggested there are benefits to the adoption of this model for Indigenous mental health clients, 14, 15.The past decade has seen a marked increase in psychotherapy research evaluating fidelity and adherence instruments that assess treatment efficacy. One such instrument is the treatment manual. In the 1990s the effectiveness, appropriateness and capacity to incorporate treatment manuals into similar training programs were explored. It is wResearch into the use of fidelity tools  is gaining increased importance in the area of clinical trials–34. InclResearchers, 41 haveThis paper reports on the development and implementation of the Motivational Care Planning-Adherence Scale (MCP-AS). This fidelity measure supported examination of the consistency and quality of the delivery of MCP within a clinical trial based in a remote Indigenous community setting.This study developed and tested an adherence scale for application within a clinical trial to measure fidelity of the experimental treatment  and to document deviations from the intended treatment model. The clinical trial aimed to test the effectiveness of Motivational Care Planning for clients at risk of depression or depression comorbid with substance misuse. The adhThe clinical trial was conducted in two remote Northern Territory communities. It initially used a wait list design over two periods of six months, and followed participants for a further six months. The research team aimed to deliver ‘early treatment’ at baseline while local Indigenous workers would deliver ‘late treatment’ at six months under researcher supervision. Treatment involved two 30 minute ‘Motivational Care Planning’ sessions with client and carer. The project received approval from the Human Research Ethics Committee of the Northern Territory Department of Health and Families and the Menzies School of Health Research.The team included a non-Indigenous psychiatrist, project manager and three Aboriginal and Torres Strait Islander research officers who conducted consultation, recruitment, assessment and delivered therapy in the remote communities. The Aboriginal and Torres Strait Islander research officers  had between one to five year experiences in MCP delivery. One was an experienced mental health worker, whilst the remaining two had no formal mental health training. The team was chosen to allow the treatment to be delivered by a primary therapist of the same gender as the client. This was recommended through consultation. For male clients the male research officer led the treatment, and for female clients one of the female research officers led treatment. An independent program assessor was utilised to develop a fidelity measure to monitor the treatment delivery through the review of 10% of audio recordings of treatment sessions.Individual treatment sessions of approximately thirty minutes were conducted with the client (supported by carers) by two research officers, one of whom delivered the therapy and the other took written notes. Therapy was preceded by completion of outcome measures. Therapy sessions included identification of strengths, stressors, family and support networks, observation of a motivational video narrated by a Larrakeah traditional owner, provision of information, and establishment of goals to effect meaningful change. The story of this traditional owner engaging in key steps of the therapy was shown on an iPad, which was also used to audio record the treatment session following completion of baseline outcome measures.The clinical trial recruited participants from within targeted communities and the local health centres. Inclusion criteria required participants to be over the age of 12 years and screened at risk of depression and/or substance misuse. Persons identified with other mental health conditions, deemed not at risk of depression, or unable to give informed consent were excluded.The PHQ 2+, a brief version of the PHQ-9, was used as a screening tool. If screRecruitment challenges in both communities led to revision of the trial design to a detailed descriptive study. Only 39 participants were successfully recruited for screening. Of the 39 people screened only 16 met the criteria for inclusion. Of these 16 participants, nine were randomised to the treatment condition. Four of these treatment sessions were recorded for the purposes of measuring treatment fidelity .Review of established specific MCP model protocols and treatment processes. These had been tested within a clinical trial setting with positive treatment outcomes and subsequently delivered through 60 training workshops;Analysis of feedback from the founders of MCP and review of existing literature including MCP publications;Consultation with MCP trainers and incorporation of their views of the essential elements of MCP therapy into the MCP-AS.The following three steps helped shape, identify and specify the fidelity criteria:Structure provides the framework for service delivery, and process determines the manner in which services are delivered[The fidelity criteria of the MCP-Adherence Scale sought telivered. The fidnot observed, "1"= slight evidence "5"= minimal acceptable evidence and "9"=fully implemented.The MCP-AS is a semi-structured observational measurement tool to measure therapist fidelity in delivery of MCP. The scale items represent the core therapeutic goals of the treatment model and each item is allocated a score. Items are scored on a 9-point Likert –Type Scale with the following anchors: "0"= The adherence scale rated each desired element across three domains; execution, frequency of inclusion and competency. The protocol provides a detailed description to support adherence and competence assessments for the individual therapeutic components.One experienced Clinical Psychologist (first author) completing her PhD studies (here in after referred to as the Assessor) was employed to design the adherence scale and code the audio recordings of the MCP sessions.The Assessor listened to each audio-recorded session in its entirety. Session duration ranged from 20 to 35 minutes. The next step involved hearing the audio recording again using pause, rewind and play to confirm a rating of the session. This second step was repeated twice. All three ratings were recorded prior to a mean consensus being obtained. The Assessor documented descriptive commentary of each individual recording to assist in completion of global competence items. Global competence items were scored at the completion of the recordings.A de-identified research file of individual participants was maintained to record the details of the baseline outcome measures and intervention delivery. The research files were audited using the MCP-AS and reviewed three times by the Assessor to promote consistency and completeness. Four items  on the MCP-AS could not be completed through file audit as these items required direct observation of therapist behaviour. The quantitative data was analysed using the SPSS Statistical Programming.Audio recordings of the four therapy sessions with Indigenous clients  were analysed. The ten item MCP-AS and accompanying protocol was completed with fidelity criteria across three domains: rapport (items 1 – 4), motivation (items 5–7) and self-management (items 8–10).Overall, researchers demonstrated high levels of treatment fidelity for the majority of MCP-AS items, especially when scores were adapted following review of file notes.The Gold Standard video demonstration of MCP achieved maximum scores on each item when assessed using the MCP-AS.Table This study reports on the development of the MCP-AS and reveals its potential suitability as a measure of treatment fidelity. The scale was used to measure both video and audio recording of therapy sessions and findings were strengthened by the additional source of information contributed by the file audits.These pilot study findings suggest that the tool measures fidelity and that the Indigenous therapists achieved a high standard of fidelity in challenging circumstances. The Gold Standard training video was assessed as having consistent maximum scores using the adherence scale. This finding strengthens confidence in the potential validity of the MCP-AS. It suggests that the scale is measuring what it was originally intended to measure. In addition, the application of the scale to two different sources of information (audio-recording and file notes) with similar rating results, provides further evidence that the scale is measuring fidelity of the therapy.Ratings were high across the three domains of rapport, motivation and self-management, with especially high ratings for positive feedback and engagement, review of stressors, and goal setting items. The relatively low ratings for Item 2 (information sharing) is likely to be due to the positioning of the therapeutic session after initial baseline outcome measures were completed. The introduction of the therapist to the client will have taken place at commencement of the interview, whereas the recording only commenced once the interview shifted to delivery of therapy. Similarly, the discrepancies between file audit and audio recording ratings for Items 4 and 5 may be explained by those items being covered in the initial introduction to the interview (prior to commencement of therapy). As a result, they were recorded in the file while not heard during the audio recording. The relatively low ratings for Items 9 and 10 (early warning signs discussion and crisis planning) is likely to relate to its position at the end of the therapy session. If time constraints and other commitments interrupted the session, these are the items most likely to remain incomplete. These scores were skewed by their lack of completion within the therapy session of Client B.In the fields of mental health and service research, adherence scales can be used to aid implementation, dissemination, quality assurance of program/therapy, mentoring/supervision, evaluations of programs and process research. WithoutCircumstances changed the direction of the original clinical trial. Given low numbers of recruited participants it was converted in design to a detailed descriptive study. It is acknowledged the research study we report is thus incomplete and for a number of reasons did not achieve its original aims. On the other hand, the development and pilot testing of the fidelity scale was successfully completed and we thus report a preliminary investigation which delivers lessons from the field.The small sample size and lack of validation and inter-rater reliability analyses limits the conclusions which can be drawn from these pilot study results. Accordingly, we recommend testing the MCP-AS with a larger population to confirm criterion validity and inter-rater reliability of the scale. On the other hand, the use of audio recording, employment of an independent assessor, inclusion of file audits, and use of two therapists in each session, strengthened the methods and provided multiple sources of information and rich qualitative data for assessment. Comparison with a Gold Standard video provided additional confidence in the validity of the new scale, although a limitation of this comparison was the assessor of the gold standard video was not blind to the status of the video. Whilst the assessor was not the developer of the tool, there was probable bias introduced to this assessment given the developer put this video forward as an example of best practice in the therapy. Video recording the treatment sessions could have provided greater detail about the content of sessions, however this inclusion was considered likely to inhibit engagement. A comparison of therapists and participants’ perception of the achieved treatment quality would have provided valuable information to complement this treatment fidelity research.The MCP-AS potentially provides a useful measure of adherence to treatment fidelity, and support for clinicians and researchers to deliver MCP in urban, rural, and remote locations. It can be used to support self-assessment of trainee competence levels and ongoing mentoring of clinicians. One future direction for fidelity research is to recognise the likely benefit of simplifying and translating resource-intensive research tools to clinical, training and supervision settings through adaptation of adherence scales such as the MCP-AS.


Cataract surgery is the most common surgery performed on beneficiaries of Medicare, accounting for more than $3.4 billion in annual expenditures. The purpose of this study is to examine racial and geographic variations in cataract surgery rates and determine the association between the racial composition of the community population and the racial disparity in the likelihood of receiving necessary cataract surgery.Using the national prevalence rates from the National Institute of Eye Health and the 2010 Healthcare Cost and Utilization Project—Florida State Ambulatory Surgery Database, we determined the estimated cases of cataract and the actual number of cataract procedures performed, on four race/gender determined groups aged 65 and over in the state of Florida in 2010. The utilization rates and disparity ratios were also calculated for each Florida county. The counties were segmented into groups based on their racial composition. The association between racial composition and disparity ratios in receiving necessary cataract surgery was examined. The Geographic Information System was used to display county-level geospatial relationships.African-Americans have a lower gender-specific cataract prevalence , but they are also less likely than whites to receive necessary cataract surgery . The statistical results show no overall differences between the disparity ratios and the racial composition of the communities. However, our geospatial analyses revealed a concentration of high racial disparity/high white population counties largely along the West Coast and South Central portion of the state.There are racial differences in the likelihood of receiving necessary cataract surgery. However, there is no significant statewide association between the racial composition of the community population and the racial disparity in the likelihood of receiving necessary cataract surgery. Geospatial techniques did, however, identify subpopulations of interest which were not otherwise identifiable with typical statistical approaches, nor consistent with their conclusions. Cataracts are the leading cause of blindness worldwide and the number one cause of poor vision in the U.S. . CataracTreatment of cataract involves removal of the clouded natural lens. The opacified lens is usually replaced with an artificial intraocular lens called an Intraocular Lens Implant (IOL) . The surReducing racial disparities in healthcare utilization and outcome has been consistently highlighted as a national priority . For theGeographic variations in healthcare also frequently correlate with race and poverty  and geosFurthermore, previous studies have addressed the existence of significant residential clustering by race among different regions of the U.S. . AfricanThe purposes of the present study are: 1) to determine the statewide cataract surgery rates among non-Hispanic African-American and White older adults, 2) to examine the county-level racial and geographic variations in receiving the necessary cataract surgery among these populations, 3) to assess whether the racial composition of the community population influences the racial disparity in the likelihood of receiving cataract surgery, and 4) to apply geospatial techniques along with traditional statistical methods in the field of health disparity.Using the Agency for Healthcare Research and Quality's (AHRQ) Healthcare Cost and Utilization Project (HCUP)- State Ambulatory Surgery Database (SASD), we analyzed data from Florida 2010, which capture 100 percent of ambulatory procedures performed on the same day in which patients are admitted and released . The SASCurrent Procedural Terminology (CPT) codes, we restricted our cohort to patients who underwent an Extra Capsular Cataract Removal with Insertion of Intraocular Lens Prosthesis (CPT codes 66882–66984).For our primary analysis, we restricted our study population to non-Hispanic persons 65 years or older because of the low prevalence of cataract among younger people. We excluded Miami-Dade because of its disproportionately large population of Hispanics and concerns about threats to the validity of ethnic assignment . FurtherUsing data from the 2010 Florida Atlas, we identified all Non-Hispanic African-American and White, aged 65 and older in the state of Florida. Using the national prevalence rates from the National Institute of Eye Health, we estimated the expected number of persons affected by cataract in the state of Florida in 2010 and for population aged ≥ 65 by multiplying the national prevalence rates of each race/gender group into their total number of older adults. We used 2010 HCUP—SASD in order to identify the actual number of cataract procedures which were performed on four race/gender determined groups  for the state overall and each of 66 counties.The utilization rate also was calculated for each of the 66 Florida counties and also for each age/gender group by dividing the total number of cataract surgeries performed in our study population by the estimated number of cataracts cases. We then calculated the racial disparity ratio of cataract surgery use. The numerator for our rate calculation was cataract surgery utilization rate of white population. The denominator represented cataract surgery utilization rate for African-American patients. A disparity ratio of greater than one indicates a higher white utilization rate; a ratio of less than one indicates a higher African-American cataract surgery utilization.Next, we divided the 66 counties into groups based on the fraction of their African-American population:Group1: < 5% African-American ;Group2: 5-<10% ;Group3: 10<15% ;Group4: 15-<20% ; andGroup5: ≥ 20% .In the next step we examined the cataract surgery utilization rates and disparity ratios in these categories.One-way ANOVA analyses were used to compare mean differences in disparity ratios across racial composition categories.P ≤ 0.05 was considered statistically significant.STATA 12  was used for all statistical analyses. Using the Geographic Information System tool we displayed racial differences in the likelihood of receiving necessary cataract surgery. We also displayed the categories of the racial composition on a map in order to produce a visual presentation of the level of spatial segregation by race across the state. In the next step, we added the racial disparity ratios to GIS layers of racial composition groups in order to create a county-level choropleth map of racial disparity in receiving cataract surgery across the racial composition groups.GIS Mapping ArcView 9.1  was used to perform GIS functions.The cataract surgeries performed among population aged ≥ 65 accounted for 146,118 of the 3,014,809 total ambulatory surgical procedures in 2010 Florida HCUP-SASD. Furthermore, from the F = 1.51, P-value = 0.2103).In the stratified analysis by racial composition , we founOur geospatial results also support the existence of racial differences in the likelihood of receiving necessary cataract surgery  . ExaminiCataract is the leading cause of visual impairment among the elderly in the U.S. and cataract surgery is the most effective and successful treatment and should be offered to all who can benefit from it. Most previous research show an increased cataract rate among Whites, and also among women as well as a lower utilization of cataract surgical services among African-Americans – 24.Our results are consistent with previous population studies in showing the existence of racial disparities in utilization of cataract surgery. Consistent with previous studies, our study found that non-Hispanic African-Americans have lower cataract prevalence but they are also less likely than whites to receive necessary cataract surgery. Our results revealed high cataract prevalence/ low cataract surgery rate among females compared to males. We also found no overall association between the racial composition of the community population and the racial disparity in the likelihood of receiving necessary cataract surgery, which is inconsistent with previous studies that have generally suggested that an increase in the proportion of African-American or Hispanic population in an area is associated with a decrease in the use of surgical services .As health disparities are often geographically specific, it is particularly important to consider residential segregation with respect to race to understand and address their causal factors. Our findings highlight the advantages of application of geospatial techniques in medical and health services research. The geospatial techniques enabled us to explore an unusual pattern for racial disparity in receiving cataract surgery in an area of the state which was not identifiable in the statistical analyses. We visualized the racial residential segregation of cataract surgery and identified a band of high racial disparity/high white population counties largely along the West Coast and South Central portion of the state. Our Further analyses revealed that the identified band of counties mostly includes small populations and low household income counties with an older population but with a small percentage of African-Americans. Furthermore, because Florida is the fourth most populous U.S. state and has a high level of racial/ethnic diversity, it is a good source of data for studying racial/ethnic variations in the U.S. population.Despite the strengths of this study, it relied on national race and gender specific data to model prevalence estimates. No statewide assessment of cataract development among the population is available. In addition, our administrative data does not allow a measure of cataract development and severity. It is also worth noting that our study population, people 65 and over, is universally insured under Medicare and thus the influence of income on utilization is likely somewhat mitigated.Over the coming decades, the total number of Americans ages 65 and older will increase sharply . As a reRacial and geographic variation in utilization of cataract surgery persists. The geospatial technology is helpful in exploring regional racial disparity patterns which may not be identifiable in traditional statistical analyses. Assessing currently available resources within the geographic areas with higher racial disparity seems necessary to unravel the complexities of racial/ethnic disparities, and begin to identify the target for vulnerable subpopulations interventions.


The first descriptions of blood transfusion in neonates date back to the nineteenth century. Time is past but uncertainties still remain considerable on optimal red blood cell (RBC) transfusion use in an era of evidence-based medicine. The need for RBC transfusion in critically ill neonates is differently judged among clinicians due to a lack of an agreement on measures of the need for transfusion. However some studies have shown an association between preterm infant morbidities, such as necrotizing enterocolitis and significant intracranial hemorrhage, with transfusions. The erythropoietin (EPO) use might prove clinically important. Physiologically in all newborns there is a progressive fall in hemoglobin concentrations to the nadir at about 8–12 weeks of life. The nadir is even lower and sooner in preterm neonates. This anemia of prematurity is the consequence of multiple factors, some are physiological processes as vulnerability of red cells to oxidative damage, reduced red cell lifespan when compared to the adult, lower erythropoietin (EPO) response to anemia than in older ages, increased requirements due to the postnatal growth; some are non-physiological processes as iatrogenic blood sampling, inter-current illnesses and sepsis. All these factors are responsible for low plasma EPO concentration in preterm newborns. This provides a rationale for the use of EPO in prophylaxis or treatment of the anemia. EPO has been used clinically for more than 20 years and many randomized clinical trials demonstrated that EPO successfully stimulate erythropoiesis and decrease the need of transfusion in anemic adults and children with end-stage renal disease or cancer. Differently in preterm newborns, the EPO treatment has demonstrated varied success in decreasing the total number and volume of transfusions. There are not clear evidences from high quality trials to define the absolute requirement and benefit for neonatal RBC transfusion. A recent Cochrane metanalysis performed by Ohlsson A. and Aher S.M. (1) to assess the effectiveness and safety of early initiation of EPO or darbepoetin in reducing RBC transfusions in preterm and/or low birth weight infants, concludes that the small reductions in RBC transfusion observed after EPO treatment are of limited clinical importance. In contrast the possibly increased risk of ROP, does not recommend the administration of EPO. Darbepoetin requires further study for definitive conclusions.


The objectives were to assess the diagnostic value of hysterosalpingography (HSG) with laparoscopy as gold standard in the evaluation of tubal patency and pelvic adhesions in women suffering from infertility.We conducted a comparative cross sectional study on 208 medical files of infertile women followed up at the Yaoundé General Hospital during a period of five years (December 2007 to December 2012). Tubal patency, hydrosalpinx and pelvic adhesions detected at HSG were compared with laparoscopic findings as the gold standard. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of HSG were calculated with 95% confidence interval (CI).Mean age of the patients was 31.4± 6.45 years. Secondary infertility was the most frequent type of infertility (66.82%). HSG had a moderate sensitivity , high specificity , high PPV  and a moderate NPV  in the diagnosis of bilateral proximal tubal occlusion. Concerning, distal tubal patency, HSG had a high sensitivity , low specificity , moderate PPV  and a moderate NPV  in the diagnosis of bilateral or unilateral distal tubal occlusion. However, HSG had a low diagnostic value  in the pelvic adhesions.HSG is of limited diagnostic value in tubal factor infertility and is of low diagnostic value for pelvic adhesions. One of the most common and underappreciated reproductive health problems in developing countries is the high rate of infertility and childlessness , 2. The This was a comparative cross-sectional study based on medical records of 208 women followed up for infertility at the Obstetrics and gynecology unit of the Yaoundé General Hospital (YGH) in Cameroon from December 2007 to December 2012.We included medical records of infertile women investigated by HSG and laparoscopy during the study period for assessment of tubal patency and pelvic adhesions. We had beforehand obtained approval from the medical committee of the YGH to conduct this study. All HSGs were performed at the radiology unit on an outpatient basis between the 7th to the 10th day of menstrual cycle. A water soluble contrast medium was used. X-Ray Photographs were taken at the instant. Images were taken at the instant when the uterine cavity and tubes were filled with opaque material and when an overflow was seen at both sides of the tubes or when maximal filling of the tubes was observed without any overflow. After 30 minutes, a late film was made to assess the contrast material diffusion. HSG findings were classified as having no tubal occlusions, one-sided or bilateral proximal or distal tubal occlusion. The presence of hydrosalpinx or pelvic adhesions were also noted. Additional abnormalities of the uterine cavity were recorded as well. A diagnostic and/or operative laparoscopy was performed in the operating theatre under general anesthesia, during the follicular phase of the menstrual cycle before the ovulatory period. During the laparoscopy, inspection of the pelvis  and the liver was performed, followed by testing for tube patency using methylene blue injected through the cervix via a Novak cannula. The presence of adhesions, structural abnormalities of the uterus, endometriosis and fallopian tube patency were sought for. Tubal patency assessed during laparoscopy was classified as no tubal occlusion, one-sided or two-sided proximal or distal tubal occlusion. When it was necessary, operative laparoscopy was performed. Data were entered and analyzed using IBM-SPSS Version 20 . Proximal and distal tubal occlusions, hydrosalpinx and pelvic adhesions diagnosed at HSG were compared with tubal occlusions, hydrosalpinx and pelvic adhesions detected at laparoscopy as gold standard. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and performance accuracy of HSG were calculated with 95% confidence interval.Two hundred and eight women with a history of infertility who performed HSG and laparoscopy in their work up were included in this study. Exploration of the female genital tract is one of the essential elements of infertility assessment. Laparoscopy provides both a panoramic view of the pelvic reproductive anatomy and a magnified view of pelvic organs and peritoneal surfaces. It is generally accepted that, diagnostic laparoscopy is the gold standard in diagnosing tubal pathology and other intra-abdominal causes of infertility –13. HystThis study showed that HSG has a moderate sensitivity  and a high specificity  in the diagnosis of proximal tubal occlusion. Both false negative and positive results can be seen with HSG in the diagnosis of proximal tubal occlusion . The falThe distal tubal occlusion is accessible to surgical therapeutic procedures and can lead to the practice of operative laparoscopy to improve fertility and prevent in vitro fertilization for some patients . In the The results of this study reveal that Hysterosalpingography is of limited diagnostic value in tubal factor infertility and of low diagnostic value for pelvic adhesions. Therefore, we believe that laparoscopy should be performed in cases of abnormal hysterosalpingograms and even in cases of normal hysterosalpingograms in the context of unexplained infertility.