HIV counseling and testing is considered an important component of HIV prevention and treatment. This paper examines the characteristics of young males and females at the time of first reported HIV test, including the influence of recent sexual partnerships, and investigates how HIV testing and the cumulative number of tests are associated with sexual behaviors within six months of testing.The study uses data from a random sample of youth aged 18-24 years living in Kisumu, Kenya, who were interviewed using a 10-year retrospective life history calendar. Cox regression models were used to examine the correlates of the timing of first HIV test. Variance-correction models for unordered repeated events were employed to examine whether having an HIV test in the previous six months and the cumulative number of tests predict unsafe sexual practices in a given month.Sixty-four percent of females and 55% of males reported at least one HIV test in the last 10 years and 40% of females were pregnant the month of first test. Significant correlates of first HIV test included marital aspirations among non-pregnant females, unprotected sex in the previous six months among pregnant females, and concurrency in the previous six months among males. Having a recent HIV test was associated with a decreased likelihood of unprotected sex among ever-pregnant females, an increased likelihood of unprotected sex and "risky" sexual partnerships among never-pregnant females, and an increased likelihood of concurrency among males. Repeated HIV testing was associated with a lower likelihood of concurrency among males and involvement in "risky" sexual partnerships among males and never-pregnant females.The high rate of pregnancy at first test suggests that promotion of HIV testing as part of prevention of mother-to-child transmission is gaining success. Further research is warranted to examine how and why behavior change is influenced by client- versus provider-initiated testing. The influence of different sexual partnership variables for males and females suggests that interventions to assess risk and promote testing should be gender- and relationship-specific. The findings also suggest that encouraging repeat or routine testing could potentially increase the uptake of safer sexual behaviors. HIV counseling and testing is widely considered an important and cost-effective component of HIV prevention and treatment ,2. The eEpidemiological data from the 2007 Kenya AIDS Indicator Survey (KAIS) indicate an HIV prevalence rate of 7.1% among adults aged 15-64 years . GeograpThroughout sub-Saharan Africa, HIV prevalence rates are generally higher among female adolescents and young adults -16. AmonThe exceptionally high rates of HIV infection among youth in Kisumu underscore the need for effective preventive and treatment programs tailored to young people. Efforts to develop such programs are often curtailed by lack of empirical evidence showing linkages between knowledge, perception of risk, adoption of preventive practices, indulgence in unsafe sexual practices, and cost effectiveness of various intervention programs. In particular, despite a substantial number of studies assessing HIV testing and its effects on high-risk behavior in general populations, there is a dearth of studies examining the correlates and impacts of HIV testing among adolescents and young adults . With noExisting research on the correlates of HIV testing among youth--and among adult populations in general--is limited in several respects. First, most studies rely on current characteristics to predict the likelihood of ever having an HIV test ,23. CurrThis paper uses unique life history data collected from a population-based sample of youth aged 18-24 years in Kisumu, Kenya's third largest city, to examine HIV testing behavior in this setting of high HIV prevalence. These data come from a larger study whose overall aim was to assess the quality of sexual behavior data collected using a new survey instrument, the Relationship History Calendar (RHC). The analysis has three main aims. First, we describe the characteristics of young males and females at the time of first reported HIV test to gain greater insight into factors associated with testing. Second, we examine the correlates of the timing of first HIV test, paying particular attention to the influence of sexual partnership characteristics in the six months prior to the test. Finally, we examine how recent HIV testing and the cumulative number of tests influence sexual behavior six months after testing to explore the immediate influence of HIV counseling and testing on sexual behavior, and if testing has a greater impact for those who repeat test.Urban Life among Youth in Kisumu study conducted by a team of researchers from the African Population and Health Research Center (APHRC), Brown University, and McGill University. The RHC was designed to collect detailed, 10-year retrospective information on respondents' schooling, residence, sexual partnerships, and HIV testing histories. These data allow us to explore the correlates of HIV testing at the time of and immediately prior to testing as well as how individuals' HIV testing history affects subsequent sexual behaviors.Data were collected in June to July 2007 under the The study sample was drawn by contacting every other household in 45 randomly selected urban enumeration areas (EAs) out of approximately 400 EAs within Kisumu city limits. Men and women aged 18 to 24 years in the selected households were eligible to be interviewed; if more than one eligible person resided in a household, one was randomly selected. Given the overall aim of the larger study, selected respondents were randomly assigned to receive either the RHC or a standard sexual behavior questionnaire similar to those used in large-scale surveys, including the Demographic and Health Surveys . Both thThe RHC is a 10-year retrospective life history calendar that gathers detailed monthly information on life course domains, including sociodemographic history , sexual and non-sexual partnerships, and the respondent's HIV testing history. Within each relationship, information was recorded on partnership attributes . To enhance recall of the occurrence and timing of each partnership and its characteristics, respondents referenced the dates of personal  and public  landmark events as well as the timing and sequencing of their schooling, residence, and other partnership trajectories on the calendar. A separate module of the questionnaire obtained data on gender, ethnicity, and religion. Several studies -31 have Respondents reported monthly retrospective information, including their HIV testing histories, beginning in 1998 when they were aged 8 to 14, and continuing until the month of the survey in 2007. We do not know if respondents tested for HIV before 1998; however, given that testing facilities were very few in Kenya  and the The monthly calendar data allow us to use person-months as the unit of analysis, and all variables are constructed for each person-month on the calendar. For the descriptive and survival analyses of HIV testing, we constructed a dichotomous variable for each month indicating whether or not a respondent reported an HIV test and received the test results. Respondents did not receive their results in only 1.5% of all reported testing occurrences. For the survival analyses, we designate the exposure period as age 14 and above, so all respondents' histories begin at the same chronological age. Only five respondents reported their first test before age 14, and these tests are left censored in the survival analyses.To assess the impact of having one or more tests on subsequent sexual behavior, we created a dichotomous variable for each month indicating whether or not the respondent had an HIV test in the previous six months as well as a continuous variable indicating the cumulative number of tests since age 14 including that month and used these as our key independent variables.We included individual and sexual partnership history characteristics as independent variables in the analyses. Variables for individual characteristics were constructed as the present value for each month in the calendar (and are therefore time-varying), with the exception of religion and ethnicity, which take on the same value for each month of the calendar. Individual characteristics included respondents' age, current schooling status (in- versus out-of-school), highest completed level of schooling . Religion comprised five categories . We created three categories for ethnicity: Luo, Luhya, which are the two major ethnic groups in Kisumu City, and "Other". The RHC recorded monthly information on occupation and income, which allowed us to create a dichotomous variable indicating whether a respondent earned any income in a particular month or not. We also considered whether a respondent was living in an urban or rural area in each month. We created a pregnancy status (self or partner) variable for each respondent for each calendar month.Historically, marriage in sub-Saharan Africa was a union between families; thus, the family played an important role in the choice of a marital partner . Howeveryes or no variables. Individuals may be more likely to get tested if they perceive that one or more of their partners are at high risk of HIV infection. We therefore constructed a variable for engaging in a "risky" sexual partnership, defined as a partnership with a casual partner, commercial sex worker or client, "one-night stand", or a stranger in the previous six months. Individuals who know or suspect their partners to have other sexual relationships may believe they are at greater risk of infection. Thus, we constructed a variable designating whether the respondent knew or suspected any of their partners to have marital or non-marital partners other than him/herself in the previous six months. Finally, as the decision to test could be driven by unsafe sexual behaviors within recent partnerships, we assessed whether the respondent had unprotected sex in any partnership or concurrent sexual partners in the previous six months. Unprotected sex in a given month was constructed as a dichotomous variable indicating whether or not condoms were always used with all sexual partners. Concurrency was defined as having two or more sexual partners in any particular month.HIV testing may also be driven by the characteristics of one's partners. To test the hypotheses that previous behavior affects the decision to test, we constructed partnership characteristics pertaining to the six-month period prior to each calendar month (and they are therefore time-varying). All the partnership characteristics are dichotomous To test the hypothesis that recent HIV testing history and the cumulative number of tests affect subsequent sexual behavior, we created dichotomous dependent variables that included having a "risky" sexual partner, concurrent partnerships, or unprotected sex in the month.The first part of our analysis presents descriptive statistics with respect to HIV testing. Similar to previous studies of the determinants of ever testing for HIV, we examine differences in individual characteristics between those who report at least one HIV test in the 10-year period from 1998-2007 and those who did not report an HIV test. Taking advantage of the monthly information provided on the calendar, we next examine individual characteristics during the month of respondents' first HIV test and sexual partnership history characteristics pertaining to the six months prior to the first test for males and females.The second part of the analysis uses Cox regression models to examine the correlates of the timing of the first HIV test. As noted above, the exposure period begins at age 14 for all respondents. The time to event in the regression models is defined as time in months from age 14 to the first HIV test. Two hundred and forty-five (245) respondents are right-censored because they report no HIV test by the time of survey. The remaining respondents contribute a total of 356 HIV testing episodes. Data from males and females are analyzed separately to explore differences by gender. About 40% of tested women were pregnant during their first HIV test. Given potential differences in determinants of testing among pregnant versus non-pregnant females, we present results separately for females based on pregnancy status at first test. Hazard ratios indicating the relative likelihood of reporting the first HIV test in a given month based on the independent variables and 95% confidence intervals are reported.The final analyses use Cox regression models that account for repeated unordered events using robust standard errors clustered by respondent  to examiTable Table To evaluate the correlates of the timing of the first HIV test, we employed Cox regression models Table . Among nTo assess the pattern of subsequent behavior change associated with testing, we examined the effect of having had an HIV test in the past six months and the cumulative number of tests since age 14 on the likelihood of reporting concurrent sexual partnerships, unprotected sex, and "risky" sexual partnerships in a given month  at least once and that 79% of all ANC attendees in 2007 received an HIV test . Thus, bMotivations for HIV testing may affect its behavioral impacts and the effectiveness of testing on behavior change may be diminished for those who are tested because it is recommended (as part of PMTCT services) or required . However, our results suggests otherwise. We find that never-pregnant women (whose decision to test was more likely to be driven by their own concerns about their HIV status) were more likely to engage in "risky" sexual partnerships and practice unprotected sex in the six months after testing, while these associations were not observed among ever-pregnant women. Indeed, testing was associated with a decrease in unprotected sex among ever-pregnant women. Further research is needed to determine how and why behavior change is influenced by client- versus provider-initiated testing.Previous studies of the impact of HIV testing on sexual behavior have found mixed results. We found limited evidence that HIV testing resulted in safe behavior six months after the test in terms of concurrency, the use of condoms, and engaging in "risky" partnerships. Indeed, we found that, in addition to increases in unsafe behaviors for never-pregnant females, HIV testing was associated with increased subsequent sexual concurrency for young males. In previous studies that observe a post-HIV test increase in the adoption of protective behavior ,4, HIV cOn a more positive note, we uncover some evidence that repeated testing may increase safe sexual behavior, specifically reducing the likelihood of engaging in "risky" types of partnerships for both males and never-pregnant females and concurrent sexual partnerships for males. These results were only marginally significant for some associations; however, they may indicate the potential benefits of repeated testing and counseling. While we postulate that repeat or routine testing may increase the adoption of safer sexual practices, we are cognizant that individuals who repeatedly get tested may be a select group that is in fact more likely to be HIV negative and less likely to engage in risk behavior. Further research on the characteristics of repeat testers that takes into account their HIV status would be helpful in enhancing our understanding of the drivers and impacts of repeat testing and its importance as an HIV/AIDS program strategy.Our study findings must be interpreted in light of several limitations. First, the data were collected as part of a larger study focusing on the life course transitions and sexual relationship histories of youth. While details on sexual partnerships and changes over time allow us to examine more fully the social context and timing of HIV testing, details of attitudinal or other contextual factors that may affect testing, such as access to testing facilities , perceivOverall, given young people's susceptibility to HIV, we highlight key factors that may be important determinants of HIV testing among this young population in a high HIV prevalence setting in sub-Saharan Africa. Our findings point to the potential success of PMTCT programs in increasing the uptake of HIV testing among pregnant females. In light of this, we suggest that provider-driven or routine testing may be an important alternative to voluntary counseling and testing in increasing HIV testing among youth. Further research on the potential for school- or home-based testing in increasing the number of young people who are aware of their HIV status may be warranted in this respect. Consistent with past research, we find that urban residence is associated with a greater likelihood of testing. As such, there may be need to ensure that rural residents are not marginalized in the provision of HIV information and testing services. Although we find little evidence supporting the impact of HIV testing on unsafe sexual behavior, our results suggest that repeat testing may be associated with the adoption of safer behaviors. Again, encouraging repeat testing (and counseling) as part of routine health care appears to be one avenue to reduce the prevalence of unsafe sexual practices. Finally, our data on partnership characteristics suggests that marital aspirations may be an important driver of HIV testing among females. Given trends showing an increasing emphasis on HIV status as a basis for entering long-term relationships, couples testing may be an important means to increase testing uptake.The authors declare that they have no competing interests.CWK conceptualized the manuscript idea, conducted the data analyses, participated in the literature review, and prepared the first draft of the manuscript. NL was the primary investigator for the larger study from which the paper is drawn, made substantive contribution to the conceptualization of the manuscript, reviewed the literature, informed the data analyses, and assisted with revising the manuscript. COI and EMZ made substantive contributions to the conceptualization of the manuscript. All authors critically reviewed the manuscript. All authors are aware that the manuscript is being submitted to the journal.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/412/prepub


Neuraminidase inhibitors (NI) and social distancing play a major role in plans to mitigate future influenza pandemics.InfluSim, the authors examine to what extent NI-treatment and prophylaxis promote the occurrence and transmission of a NI resistant strain.Using the freely available program 0 = 2.5, a NI resistant strain can only spread if its transmissibility (fitness) is at least 40% of the fitness of the drug-sensitive strain. Although NI drug resistance may emerge in treated patients in such a late state of their disease that passing on the newly developed resistant viruses is unlikely, resistant strains quickly become highly prevalent in the population if their fitness is high. Antiviral prophylaxis further increases the pressure on the drug-sensitive strain and favors the spread of resistant infections. The authors show scenarios where pre-exposure antiviral prophylaxis even increases the number of influenza cases and deaths.Under a basic reproduction number of RIf the fitness of a NI resistant pandemic strain is high, any use of prophylaxis may increase the number of hospitalizations and deaths in the population. The use of neuraminidase inhibitors should be restricted to the treatment of cases whereas prophylaxis should be reduced to an absolute minimum in that case. De novo emergence of a resistant strain does not necessarily cause negative outcomes; it is the transmission fitness of the resistant strain which plays a major role ,,de novo nce than ,21.Surveillance of the appearance of NI resistant infections and, most importantly, of the fitness of resistant strains will be crucial to manage a pandemic wave. Uncontrolled use of NI may do more harm than good. If a NI resistant pandemic strain is reported to spread, the use of NI should mainly be restricted to the treatment of cases whereas prophylaxis must be reduced to an absolute minimum. If the fitness of the NI resistant pandemic strain is high, any use of prophylaxis may increase the number of hospitalizations and deaths in the population. Thus, public health systems should diversify intervention strategies by using prophylaxis in a very restrictive manner, by stockpiling different types of antiviral drugs and by supplementing pharmaceutical interventions with social distancing measures ,23.The authors declare that they have no competing interests.ME was responsible for model design, mathematical formulas and the writing of manuscript. MS designed and programmed the software and provided the simulation results. HPD advised on modeling questions, helped preparing the figures and proofread the manuscript. MW gave epidemiologic advice and co-wrote the manuscript. DK and SOB defined the research questions, made public health decisions and proofread the manuscript. BV coordinated the research project and co-wrote the manuscript. All authors have read the manuscript and have given final approval of the current version to be published.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/9/4/prepubAge-dependent parameters and effective reproduction number.Click here for file


Bifid first metacarpal is a common congenital anomaly. Here, we report an unusual case of bifid first metacarpal in a 13-year-old girl who presented with swan neck deformity of left thumb, a bony prominence on ulnar aspect of left thumb in the first web space and a bifid first metacarpal lacking its own epiphysis. The patient underwent surgery, resulting in complete functional recovery as well as cosmetic improvement of the left thumb. The bifid thumb represents a complete or partial duplication of the thumb . The cause of the bifid thumb is not known.67This report describes a case of bifid first metacarpal with the bifid “metacarpal limb” that lacks its epiphysis, associated with ulnar duplication and swan neck deformity of left thumb, which is, in itself, a unique entity. There was no duplication of soft tissues or any other congenital anomaly. The deformity of left thumb got corrected after excision of ulnar duplication. Roentgenogram of the hand is essential pre-requisite to determine the level of bifurcation. A thorough search of the literature revealed that such a case has not been reported in English language literature till date.A 13-year-old girl presented to the outpatient department in March 2005 with complaint of bony prominence in the first web space on ulnar aspect associated with deformity of the left thumb. There was no family history of polydactyly and any other congenital anomaly. The parents gave a history of partial flexion of interphalangeal joint and nodular bulge on the ulnar aspect of left thumb since birth, which had gradually increased in size.On examination, there was a hard bony prominence on ulnar aspect of the left thumb in the first web space. It was more prominent on dorsal aspect as compared to the palmar aspect. The thenar crease was more prominent and deep on radial aspect of hand. Flexion deformity of interphalangeal joint and hyperextension of metacarpophalangeal joint was noted, which were partially correctable on adduction of thumb and deformity became more prominent on abduction of thumb.Roentgenogram showed incomplete bifid first metacarpal on ulnar aspect with hyper extension at metacarpophalangeal joint and flexion at interphalangeal joint of thumb. Metacarpophalangeal and interphalangeal joints were normal . A cliniThe patient was placed in supine position with the hand kept over the hand rest. Under brachial block and tourniquet, an incision was made along the lateral aspect of first metacarpal and reached to the ulnar component of bifid metacarpal. Adductor pollicis muscle was tight and soft tissue was felt on the ulnar aspect of the bifid metacarpal. Pulling onto this soft tissue worsened the flexion at interphalangeal joint, which suggested it to be flexor pollicis longus. Normally, the flexor pollicis longus passes between the thenar muscles and the adductor muscles. The swan neck deformity of the thumb was seen to be due the action of adductor pollicis muscle on the base of proximal phalanx of thumb (causing thumb adduction), flexor pollicis longus causing flexion of interphalangeal joint secondarily leading to hyperextension of first metacarphalgeal joint due to tightness of extensor pollicis longus muscle. After excision of bony ulnar component of bifid metacarpal at the base of bifurcation, the swan neck deformity of thumb got corrected automatically due to unhindered excursion of flexor pollicis longus and adductor pollicis muscle. After surgery, the balance between the thumb flexors and extensors got restored and the swan neck deformity got corrected.th day of surgery. The patient was then followed up clinically and radio-logically at 6-monthly intervals for 3 years to assess the range of motion at interphalangeal and metacarpophalangeal joints. At the final follow-up of 3 years, the deformity is well corrected with no residual or recurrent bulge in the first web space [Figure Stitches were removed on the 12e Figure –d. The pe Figure . The fine Figure .Duplication of digits, or polydactyly, is a common and conspicuous hand anomaly. It was recorded in biblical literature as long ago as 3000 years and approximately 9000 to 10,000 new cases are recorded every year.The pre-axial polydactyly (bifid thumb) is either complete or partial duplication of the thumb. It is most common duplication in white and oriental population, occurring in 1:3000 births. It is usually unilateral.4In our case, pathophysiology of swan neck deformity is explained by disruption of the balance of flexors and extensor forces acting across the joint. Flexor-overpull on the bifurcated metacarpal also increased the pullover the metacarpophalangeal joint. Constant efforts to extend the thumb against this pull then lead to stretching of the collateral ligament and the volar plate at the interphalangeal joint. Bifurcated first metacarpal was lacking its own epiphysis, which was congenital in origin. With this deformity, the patient was unable to perform the routine activities of the daily living. Hence, surgical intervention was necessary at early age.


The mice were then given promoting treatment with croton oil for 28 weeks.A tumour initiating dose of ethyl carbamate was administered to mice by subcutaneous injection together with a dose of one of the homologous esters or an ethyl N-alkyl derivative. The homologues used were the methyl, Neither the homologous esters nor the N-substituted derivatives of ethyl carbamate had any influence on the yield of tumours in the skin, lung, or liver. However, increasing the dose of ethyl carbamate increased the yields of tumours.


Establishing the relationship between an organism's genome sequence and its phenotype is a fundamental challenge that remains largely unsolved. Accurately predicting microbial phenotypes solely based on genomic features will allow us to infer relevant phenotypic characteristics when the availability of a genome sequence precedes experimental characterization, a scenario that is favored by the advent of novel high-throughput and single cell sequencing techniques.We present a novel approach to predict the phenotype of prokaryotes directly from their protein domain frequencies. Our discriminative machine learning approach provides high prediction accuracy of relevant phenotypes such as motility, oxygen requirement or spore formation. Moreover, the set of discriminative domains provides biological insight into the underlying phenotype-genotype relationship and enables deriving hypotheses on the possible functions of uncharacterized domains.Fast and accurate prediction of microbial phenotypes based on genomic protein domain content is feasible and has the potential to provide novel biological insights. First results of a systematic check for annotation errors indicate that our approach may also be applied to semi-automatic correction and completion of the existing phenotype annotation. Despite initial expectations that the elucidation of the complete genome of an organism would enable understanding its biology, the establishment of specific links between genotype and phenotype remains one of the major challenges that biology faces today. In particular, this applies to complex phenotypes that depend on the effect of many genes. The identification of phenotype-specific genes or other genomic features opens the way to (1) formulate testable hypotheses on how the action of these genes may explain the occurrence of that phenotype and (2) predict the occurrence of that phenotype from the analysis of genomic sequences. Especially, the inference of microbial phenotypes on the basis of genomic features is highly relevant within the context of a growing number of (meta)genomic projects. Despite the progress that has been achieved for the investigation of phenotype-specific groups of genes, no practical solution exists for the genome-based prediction of phenotypical properties of prokaryotes.phylogenetic profiles - presence/absence patterns of a given gene in a set of genomes - have been used to identify the function of uncharacterized proteins based on their co-occurrence with known proteins . On thens , which achieves the speed of RPS-BLAST . The abovementioned error function can now be minimized bywhere B is a matrix that contains the inverse elements of the vector b as diagonal elements. In case of multi-class learning problems with M classes, the label vector y has to be replaced by a matrix Y = , i, j z∈ {0, 1}, where zi is a class-specific vector with non-zero values for examples belonging to class i. The minimization then yields a matrix W =  of M class-specific discriminative weight vectors.where λ, we randomly divided the data set into 20 partitions with 70% training and 30% validation examples, respectively. Using these partitions, we computed the average area under curve with respect to the precision-recall characteristics  To evaluate the influence of the regularization parameter cs  over alN organism-specific weights. For fast prediction of phenotypes, the discriminant in the original feature space of Pfam protein domain profiles can be calculated by a linear combination of the learned organism-specific weights and the domain profiles in X. The phenotype prediction for a newly sequenced organism then only requires the construction of the organism's Pfam domain profile and the computation of the dot product of the feature space discriminant and the domain profile.The kernel-based RLSC model associated with a phenotype classification problem is represented by a vector of The feature space discriminant also allows to inspect the learned discriminative features in terms of phenotype-specific Pfam domain families. For each phenotype prediction problem, we assemble two ranked lists of domain families that are associated with the 50 largest positive and negative weights in the profile space discriminant, respectively. This allows to identify indicative and counter-indicative domain families directly.® function 'dendrogram' to the domain phylogenetic profiles using average linkage (UPGMA) and the profile correlation as a distance measure. Dendrogram branch colors are calculated by the 'dendrogram' function using the default color threshold at 70% linkage branch length.For further interpretation of the abovementioned lists and for identification of functional modules, we also calculate clustering dendrograms for the 50 most discriminative domain families based on their phylogenetic profile, i.e. the absence/presence pattern of a particular domain across all organisms. To calculate the dendrograms, we apply the MatlabFor comparison to a method that can in principle be used for microbial phenotype prediction, we evaluate our approach using the dataset presented in . BecauseFor direct comparison of the results, we measure the prediction performance in terms of the area under ROC curve  and the TL carried out experiments and wrote the manuscript. SM carried out experiments and performed annotation check. TG performed biological interpretation of the results and wrote the manuscript. CN contributed conceptually and wrote the manuscript. PM designed the experiments, collected the data and wrote the manuscript. All authors read and approved the final manuscript.List of organisms for validation and test. The file "organisms.pdf" contains the names of all 1032 (443) organisms that have been used for validation (test) of the classification methods. The table also shows the sequencing status and the phenotype annotation associated with the organisms.Click here for fileLists of phenotype-specific discriminative domain families. The archive "discDomains.zip" contains lists of the 50 most discriminative (indicative and counterindicative) Pfam domain families associated with the four phenotype categories "Endospores","Gram stain", "Motility" and "Oxygen Requirement" in HTML format.Click here for fileClustering dendrograms of discriminative domain families. The file "Dendrograms.pdf" contains the phenotype-specific phylogenetic clustering dendrograms for the 50 most discriminative domain families. For the phenotype categories "Gram stain" and "Oxygen Requirement" dendrograms for positive and negative discriminative domains are shown, for the "Endospores" and "Motility" phenotype categories only the dendrogram associated with positive discriminative domains is shown.Click here for fileComparison of predicted phenotypes to NCBI annotation. The file "DeviationNCBI.pdf" contains the prediction results of the domain-based approach for the set of 443 test organisms separated according to NCBI phenotype categories for the four phenotypes used in this study. The lists contain the predicted labels as well as the original label according to the NCBI annotation; label differences are highlighted using a red cell background. Furthermore, organisms that have been identified as possibly containing a wrong NCBI phenoype annotation in section "Quality of annotation" are highlighted using a bold face type.Click here for fileProtein domain profile data. The file "EvaluationData.zip" consists of two comma separated value (CSV) files containing the data matrices with UFO counts associated with all organisms of the validation and test set, respectively. Here, each column corresponds to one organism and each row corresponds to one of the 10797 Pfam-A (version 23.0) families PF00001,..., PF10797. In addition, two CSV files contain the list of organism names and the associated NCBI phenotype annotation for the categories used in this study.Click here for fileHistograms of phenotype-specific phylogenetic distribution of example organisms. The file "histoGroups.pdf" contains phylum-level histogram plots of the phenotype-specific number of positive and negative examples.Click here for file


Myometrial smooth myocytes contract as a result of electrical signalling via a process called excitation-contraction coupling. This process is understood in great detail at the cellular level but the generation and coordination of electrical signals throughout the myometrium are incompletely understood. Recent evidence concerning the vital role of interstitial cells of Cajal in tissue-level signalling in gastrointestinal tract, and the presence of similar cells in urinary tract smooth muscle may be relevant for future research into myometrial contractility but there remains a lack of evidence regarding these cells in the myometrium.Single stain immunohistochemical and double stain immunofluorescence techniques visualised antibodies directed against total connexin 43, unphosphorylated connexin 43, KIT, alpha-SMA and prolyl 4-hydroxylase in myometrial biopsies from 26 women representing all stages of reproductive life.Myometrial smooth myocytes from term uterine biopsies expressed connexin 43 in a punctate pattern typical of gap junctions. However, on the boundaries of the smooth muscle bundles, cells were present with a more uniform staining pattern. These cells continued to possess the same staining characteristics in non-pregnant biopsies whereas the smooth myocytes no longer expressed connexin 43. Immunohistochemistry using an antibody directed against connexin 43 unphosphorylated at serine 368 showed that it is this isoform that is expressed continually by these cells. Double-stain immunofluorescence for unphosphorylated connexin 43 and KIT, an established marker for interstitial cells, revealed a complete match indicating these cells are myometrial interstitial cells (MICs). MICs had elongated cell processes and were located mainly on the surface of the smooth muscle bundles and within the fibromuscular septum. No particular arrangement of cells as plexuses was observed. Antibody to prolyl 4-hydroxylase identified fibroblasts as separate from MICs.MICs are identified consistently on the boundaries of smooth muscle bundles in both the pregnant and non-pregnant uterus and are distinct from fibroblasts. The uniform distribution of connexin 43 on the cell membrane of MICs, rather than localisation in gap junction plaques, may represent the presence of connexin hemichannels. This antibody specificity may aid future study of this potentially important cell type. Although the cellular processes governing the contractility of individual myocytes are understood in great detail, the mechanism for the coordination of uterine activity is less well understood ,2. It isIn the gastrointestinal tract, interstitial cells of Cajal have been shown to be vital in coordinating pacemaking and signal transduction , whilst This paper describes the topographical distribution of MICs by using single stain immunohistochemistry and double stain indirect immunofluorescence techniques with a combination of five antibodies; unphosphorylated connexin 43 (binds only when the serine at residue 368 is unphosphorylated), total connexin 43 (independent of phosphorylation status), KIT  , alpha sMyometrial biopsies were obtained from a total of 26 women. Six of the women were not pregnant, three premenopausal and three postmenopausal, all of whom were undergoing hysterectomy for benign disease. For continuity the site of biopsy was close to the right cornu. The remaining twenty samples from pregnant women were removed from the upper border of the lower segment incision at the time of caesarean section. Nine of these were obtained at the time of elective (pre-labour) caesarean at term and ten were obtained at the time of emergency caesarean section during active labour. The one other specimen was taken from the upper segment of a woman delivered at 27 weeks by classical caesarean section due to placental abruption. All women consented to the procedure and the Ethical Committee of the University Hospitals Leuven approved the clinical protocol.All biopsies were snap frozen immediately in isopentane cooled with liquid nitrogen and underwent single stain immunohistochemistry. Sections measuring 5 μm in thickness were cut with an HM 560 Cryo-star Cryostat  and air-dried overnight before fixing for ten minutes in acetone. Monoclonal mouse anti-human antibody to unphosphorylated connexin 43  was added for 30 minutes and rinsed with phosphate buffered saline (PBS) before adding polyclonal rabbit anti-mouse biotinylated immunoglobulin . The slide was rinsed once again before adding Avidine-Biotinylated horseradish peroxidase complex for 30 minutes . The complex was stained with aminoethylcarbazole for ten minutes and the slide counterstained with Maeyers haematoxylin for 1 minute. A similar procedure was employed for all biopsies using a polyclonal antibody to total connexin 43 , KIT , and prolyl 4-hydroxylase . All slides were compared with controls in which the primary antibody had been omitted. Microscopy was performed with an Axioplan 2 upright microscope with image capture by Axiovision software .Double-stain indirect immunofluorescence was performed on four myometrial biopsies, one from each of the above groups . Cryostat sections of a thickness of 10 μm (HM 560 Cryo-star) were dried overnight and fixed in acetone for ten minutes. Slides were labelled in sequence with monoclonal mouse anti-human antibody to unphosphorylated connexin 43 , FITC-labelled rabbit anti-mouse antibody , mouse anti-human antibody to alpha smooth muscle actin  and TRITc-labelled rabbit anti-mouse antibody . The duration of staining for each antibody was 1 hour and the slide was rinsed between each step with PBS. Finally the slide was mounted with glycerol buffer with the anti-fading agent PPD (p-Phenylenediamine DakoCytomation) before being sealed with nail polish.A similar double staining procedure was performed on slides from the same biopsies using antibodies to unphosphorylated connexin 43 and KIT (Dilution 1/20). Again, controls consisted of the same steps with omission of one or both of the primary antibodies.The slides were examined with a confocal laser-scanning microscope  using either a ×40 or ×100 objective and electronic zoom. For each slide either a single section or a stack of five optical sections at one-micrometer intervals were digitally recorded for red and green fluorescence and stored on separate channels. Where multiple sections were recorded, these were superimposed using the extended depth of focus function. The coloured images were then overlaid to produce the final image.Single stain immunohistochemistry for total connexin 43 in all biopsies from labouring women was positive for smooth muscle cells within the muscle bundles with peripheral punctate staining of the cytoplasm typical of gap junctions Figure . In addiIn contrast to total connexin 43, unphosphorylated connexin 43 was confined to the cells described above, located mainly on the boundary of the smooth muscle bundles and in the fibromuscular septum in all of the biopsies examined Figure . In all Immunofluorescence provides crisp clear images for a more precise localisation of bound antigens and was used to confirm the homogenous pattern of binding of unphosphorylated connexin 43 found with the HRP method. Examination of the double-stained immunofluorescence slides stained for α-SMA and unphosphorylated connexin 43 confirmed the appearances of the standard single stain immunohistochemistry slides Figure . Smooth Double stain immunohistochemistry using anti-KIT antibody , and unphosphorylated connexin 43 antibody was performed. Superimposing the immunofluorescence patterns obtained with both antibodies showed a perfect match indicating co-expression of these two proteins in these cells Figure . KIT wasStaining for prolyl 4-hydroxylase showed the presence of fibroblasts in fewer numbers and with a more even distribution throughout the myometrium when compared with MICs showing that these are two distinct populations of cells Figure .The appearance, number and location of the cells that we identified by staining for unphosphorylated connexin 43 and c-kit correspond most probably with MICs. Previously, MICs containing numerous mitochondria have been identified in the uterus and account for approximately 10% of the total number of cells in the myometrium . In addiIt is important to note that with the exception of one upper segment biopsy, all the samples in our study obtained from pregnant women were from the lower uterine segment. In other species such as rodents, the uterus is a tubular structure and effective labour requires peristalsis that starts at the corn of the uterus for the expulsion of the fetuses. In theory, the study of a pacemaking mechanism in such a system may be more informative if it were to use myometrium obtained from the corn of the uterus. In humans, however, the uterus is more globular in form. Given this shape, it has been argued that pressure generation is more important than peristalsis for the expulsion of uterine contents . In addiConcerning the coordination of myometrial smooth muscle contractility, it is thought that the smooth myocytes become coupled electrically at the time of labour by connexin 43 gap junctions to form a functional syncytium , of non-Our findings with antibody directed against total connexin 43 are consistent with the increased expression of connexin 43 in the myometrium around the time of labour although it can also be seen that connexin 43 is also present at times other than labour. Using the specific antibody directed against unphosphorylated connexin 43, we have shown that it is MICs and not smooth myocytes that continually express this connexin 43, and that this connexin 43 is distributed evenly throughout the MIC cell membrane in its unphosphorylated form. The antibody used has had its specificity for unphosphorylated connexin 43 tested extensively in the field of brain and cardiac research -17. The In summary, the finding of MICs on the boundaries of uterine smooth muscle bundles in myometrial biopsies taken throughout reproductive life may have important implications. Interstitial cells in both the gut and the bladder are believed to be critical to the processes for contractile signal initiation and coordination. MICs have the potential to perform a similar role in the myometrium and further study of these cells may improve our future understanding of uterine contractility.The authors declare that they have no competing interests.GH, TG, JD and DDR conceived the study and participated in its design. JD took the myometrial biopsies. GH and TR imaged and interpreted the immunohistochemistry and GH and AVL imaged and interpreted the immunofluorescence. GH drafted the manuscript and BN revised the manuscript critically. All authors read and approved the final manuscript.


Providing basic surgical and emergency care in rural settings is essential, particularly in Tanzania, where the mortality burden addressable by emergency and surgical interventions has been estimated at 40%. However, the shortages of teaching faculty and insufficient learning resources have hampered the traditionally intensive surgical training apprenticeships. The Muhimbili University of Health and Allied Sciences consequently has experienced suboptimal preparation for graduates practising surgery in the field and a drop in medical graduates willing to become surgeons. To address the decline in circumstances, the first step was to enhance technical skills in general surgery and emergency procedures for senior medical students by designing and implementing a surgical skills practicum using locally developed simulation models.A two-day training course in nine different emergency procedures and surgical skills based on the Canadian Network for International Surgery curriculum was developed. Simulation models for the surgical skills were created with locally available materials. The curriculum was pilot-tested with a cohort of 60 senior medical students who had completed their surgery rotation at Muhimbili University. Two measures were used to evaluate surgical skill performance: Objective Structured Clinical Examinations and surveys of self-perceived performance administered pre- and post-training.Thirty-six students participated in the study. Prior to the training, no student was able to correctly perform a surgical hand tie, only one student was able to correctly perform adult intubation and three students were able to correctly scrub, gown and glove. Performance improved after training, demonstrated by Objective Structured Clinical Examination scores that rose from 6/30 to 15/30. Students perceived great benefit from practical skills training. The cost of the training using low-tech simulation was four United States dollars per student.Simulation is valued to gain experience in practising surgical skills prior to working with patients. In the context of resource-limited settings, an additional benefit is that of learning skills not otherwise obtainable. Further testing of this approach will determine its applicability to other resource-limited settings seeking to develop skill-based surgical and emergency procedure apprenticeships. Additionally, skill sustainability and readiness for actual surgical and emergency experiences need to be assessed. Injury is a growing epidemic in East Africa and large numbers of injured people are at risk of death and lifelong disability . SurgeryDisease control priorities in developing countries (DCP2) has brought attention to the role of surgery as a public health strategy [The second edition of strategy . The DCPstrategy .One of the primary obstacles to expanding surgical services is the relatively few trained surgeons to care for more than 200 million people in the eight-country region of East Africa. The limited numbers of medical graduates in Tanzania are preferentially posted to District Medical Officer (DMO) positions in rural areas, where they are expected to perform essential surgical and emergency obstetric care. Improving the quality of their training is therefore a means of improving patient outcomes.The Muhimbili University of Health and Allied Sciences (MUHAS) trains the greatest number of medical students in Tanzania. Several challenges have constrained MUHAS' ability to properly train medical students to serve these roles.The medical school has experienced an explosion in the number of students enrolled in the past five years, without a proportional increase in teaching resources or faculty. In surgery, the faculty-to-student ratio has decreased from 1:2 to 1:10, with less individual teaching time – an essential part of surgical skills apprenticeship . The teaLimited space and decreases in surgical case-load due to major hospital rehabilitation work has resulted in students' being able to attend only a handful of surgeries during their eight-week surgical clerkship. Lack of preparation at the medical student level extends into internship, when interns believe they are ill-equipped to perform the skills necessary for surgical specialization, which affects their career choices .One way to improve surgical skills training has been to transfer parts of the surgical apprenticeship to laboratory settings, by means of simulation models. Such surgical training, for example, in tying, suturing and instrument handling, has been shown to reduce the failure rate after formal training . Such skAlthough there is an increasing amount of literature on simulated surgical training, we found no published reports on surgical skills training for medical students in Africa. The Canadian Network for International Surgery (CNIS) has had the greatest amount of experience in surgical training with simulation in Africa, with 5000 primary care physicians in Ethiopia, Malawi, Mozambique, Tanzania, and Uganda having benefited from training through the essential surgical skills programme .In order to address the gaps in surgical training of medical students at MUHAS, we created, implemented and evaluated a low-cost surgical skills curriculum using limited technology for senior medical students carrying out their surgery clerkship. The goal of the training was to teach medical students the fundamental skills and knowledge required to assist with surgical procedures and feel comfortable in the operating room in a context with limited resources. The purpose of this article is to describe the creation and evaluation of a surgical skills training course for senior medical students developed and implemented by the MUHAS Department of Surgery.To guide the development of the curriculum, we conducted a needs assessment of surgical faculty to determine the gaps in surgical and emergency procedures training for the surgery clerkship between what is offered and what is needed. Seven members of the surgical teaching faculty in the MUHAS Departments of Surgery, Orthopaedics, Obstetrics and Anaesthesiology were interviewed individually to get their feedback on the skills actually taught and those they believed students were missing. The Canadian Network for International Surgery (CNIS) surgical training curriculum used to train interns, registrars and primary care consultants at the Muhimbili National Hospital was also reviewed as part of the needs assessment. Based on these findings, the CNIS curriculum was adapted with the overall goal of improving essential surgical and emergency skills. The two-day curriculum covered nine skills in the fundamentals of assisting in the operation room (OR), general surgical skills, anaesthesia skills and emergency obstetrical skills Table .The planned curriculum included five one-hour training sessions over a two-day period held in the MUHAS Department of Anatomy Laboratory. Thirty-six of the 60 eligible students (60%) agreed to participate. They were divided into two groups of 18 for convenience purposes and completed the two-day training course after completing their mandatory eight-week surgery rotation Figure . Thus weTo teach students operating room etiquette with proper scrubbing, gowning, gloving and maintaining a sterile field, we worked with two operating-theatre nurse teachers. For the knot-tying and suturing instruction, we used the Ethicon Knot Tying Manual . For theModels used for the training course are listed in Table For the tying and suturing stations, we used coloured ropes and several types of sutures . Ethicon boards were used to practise knot tying; handcrafted procedures boards were used to practice suturing Figure .The venous cutdown model consisted of a firm plastic tube placed on an arm stabilizer covered with foam and opaque vinyl. Students were to identify the anatomical location of the long saphenous vein on themselves, then perform a venesection and insert the intravenous cannula into the vein of the model and secure the cannula in place.The intubation station was carried out using adult intubation mannequins  and adult laryngoscopes. The chest model used to teach chest tube insertion consisted of a teaching-skeleton rib cage draped with layers of foam and opaque vinyl that were sewn shut Figure . StudentFor the laparotomy station, an abdominal frame consisting of a square wood frame covered with three layers of foam, clear vinyl and colored vinyl, respectively, was used Figure . StudentFor the small-bowel repair station, we used inner tubes from bicycle tires to mimic small bowel Figure . StudentFor the vacuum-assisted vaginal delivery, we used an obstetrical mannequin on which students practised appropriate placement of the vacuum on the fetal head and developed proper delivery traction with the vacuum.The total budget for these materials was USD 555, outlined in Table Development and execution of the training required a total of 290 work-hours  – before and after participating in the two-day surgical skills training course. The surgical performance evaluation was used only to measure effectiveness of the training, and was not incorporated into students' final grades for their surgery clerkship. This study was performed with the approval of the Muhimbili Ethics Committee and the UCSF Institutional Review Board.Students completed pre- and post-training questionnaires to measure self-perceived confidence in performing select surgical procedures. After training, they also provided their overall satisfaction with the training. Quantitative data gathered also included demographic data, information on previous surgical experience, and whether students envisaged surgery to be part of their future clinical practice and career. The surveys rated student confidence in each of the skills listed in Table The OSCEs that measured baseline surgical skills performance and acquisition of skills as a result of the training focused on four of nine skills taught during the course that were identified as most relevant and measurable Table . BecauseTo minimize biased ascertainment of the outcome, faculty members were instructed to adhere to the same grading system. Four to six critical steps were identified for each skill observed, and were evaluated as performed correctly or incorrectly by the observing faculty, for a total of 30 possible points over the five rated skills. For example, for the scrubbing, gowning and gloving station, five steps were scored: washing in the fingers to elbow fashion; drip drying with hands-up technique; drying hands correctly, making sure not to repeat same site; donning gloves without touching fingerstalls; and doing up the gown properly without breaking the sterile field.We calculated descriptive statistics for the items on the survey including percentages, means and standard deviations. We used matched paired t-tests to compare performance pre- to post for those students participating in the surgical skills study. We also calculated effect sizes to identify the magnitude of the effect of the intervention independent of sample size. Effect sizes exceeding 0.8 are considered large .While completing the post-test survey, students were also asked to respond to two open-ended questions: "How has this training changed your perceptions about practising surgery?" and "How would you improve this training?" These written, qualitative responses were entered into an Excel database and reviewed independently by two researchers to identify general themes. The qualitative data were then coded and organized within these themes, based on their frequency.Thirty-eight of 60 eligible fifth-year medical students who had completed their eight-week surgery clerkship consented to participate in the study. We could match pre- and post data for 36 of the participants. Twenty-four of the participants were male and 12 were female. Their average age was 26 years (range 22 to 34). All participants anticipated practising general surgery after completing medical school. Seventy seven percent of participants reported they were likely or very likely to practise general surgery, while 33% stated they were somewhat likely to practise surgery.Students reported a low number of times scrubbing into the OR, suturing or knot-tying prior to the training course. Among participating students, the average number of times entering the operating theatre was seven, with 84% of the students estimating they had observed a surgical procedure 10 times or less; 70% of the students reported scrubbing and gowning for a procedure one to five times. Twenty-one percent of the students had no prior opportunity to practice suturing (an average of 1.4 times/student), while 46% had not performed surgical knot-tying (an average of 2.4 times/student) during their surgery rotation Table .Students scored an average of 6.3 out of 30 points (SD 3.2) on the pre-training OSCE. No student was able to correctly carry out the steps for a surgical hand tie or an instrument tie. Only one student was able to perform the correct steps for adult intubation; three out of 36 students were able to correctly scrub, gown and glove Table .Performance on the post-training OSCE demonstrated a fourfold improvement in skill. Scores increased by 19.4 points (SD 4.0). Improvements were most significant for knot-tying skills, with a 3.39-point mean increase in skill for the instrument ties and a 4.86-point mean increase for the hand ties  and the individual attention each student received to learn the skills. However, the two days of training did not significantly change self-perceived confidence levels of surgical skills or participants' likelihood to practise general surgery after medical school.Although the acquisition and mastery of basic surgical procedures, trauma management and emergency obstetrical skills are essential for medical graduates, the quality of surgical training at Muhimbili University has declined in recent years. This study highlights how surgical training has been affected at the medical student level. The decline in surgical training is reflected in the low mastery of practical skills in the pre-training OSCE. While students may have the opportunity to enter the operating theatre, there is little opportunity to practise surgical skills in the current training context.Reasons why students have limited opportunity to assist in surgeries are most likely related to the expanding number of students needing to be accommodated during surgery clerkships. Thus, even though five students are allowed to scrub into an operation at any given time, it is impractical for all of them to assist on the case. The introduction of simulation in teaching surgical skills is a feasible solution to redressing surgical performance in this group. The need to emphasize surgical skills mastery at the medical student level is important for the purpose of improving quality of patient care, but also to increase the odds of students' pursuing surgical practice or surgery as a career.The use of low-fidelity and low-cost simulation has been demonstrated to be an effective alternative to high-fidelity computer simulation -18. ThisAlthough we believe the increase in performance was a result of increased skill performance, there are other potential explanations for this increase independent of actual performance. One possibility is that performance improvement was a result of rater bias or expectations from the non-blinded faculty raters. We believe that the OSCE rating system we developed focusing on the grading of discrete skills mitigates the likelihood of rater bias.Other explanations for performance improvement not related to the two-day course include short-term Hawthorne effects , the effect of repeated observation and the effect of repeated testing. We believe that the magnitude of the improvement, as indicated by the large effect sizes, combined with the complexity of skills being taught, cannot be a result solely of these factors. However, it is possible that all these factors influence the magnitude of the increase in performance seen in our cohort of participants.The confidence levels reported by students were not significantly changed by the exposure. One reason for this may be that the duration of the training was not long enough for students to boost their self-confidence in performance.This study capitalized on existing expertise in teaching surgical skills at MUHAS, a result of CNIS annual training-of-trainers workshops in surgical skills since 2003. Eight of the 19 teaching faculty members in the MUHAS Department of Surgery trained in this way took part in the study. Beyond the monetary resources to build such a centre, the presence and availability of teaching faculty versed in pedagogical methods for surgical skills are essential to the effectiveness of the training.We used low-technology models with locally available supplies to carry out the surgical skills training. Except for the Ethicon boards, the adult intubation models and obstetric mannequins, all models were locally produced at minimal cost. As there was an outbreak of West Nile virus at the time we performed the training, animal models were replaced by man-made models of wood, foam, rubber and vinyl. This eliminated many of the procurement, storage and disposal complexities associated with prior training courses conducted at MUHAS. One of the unintended consequences of this event was a considerably reduced materials cost of USD 15 per student Table . AlthougIrrespective of whether medical graduates choose surgery as a final career path, having proficiency in essential surgical and emergency obstetrical skills is necessary for Tanzanian physicians. This is due to the structure of medical training in Tanzania, where medical graduates are expected to practise in rural settings for one to three years after completing internship.MUHAS has a strong culture of public service, and there is an underlying expectation that medical graduates will adopt rural postings upon completing medical school. This expectation is reflected in our study, where participants reported a high likelihood that they would be required to perform surgery in the future on both the pre- and post-training surveys. Thus, students were able to gain a basic level of mastery and begin entertaining the possibility of practising surgery as a career choice.In addition to the implications for quality of patient care, surgical training has implications for the future production of surgeons in Tanzania. Although no data exist to determine what proportion of MUHAS medical graduates actually end up staffing district hospitals and working in rural areas, a study in 2003 to determine employment patterns of MUHAS graduates found that 76% of medical graduates eventually took advantage of opportunities for additional training . In viewFeelings of inadequacy ultimately affect career choices: students who are plagued with preoccupations of incompetence about their skill levels do not end up in a field they feel they cannot master. Several students described surgery as something unattainable for them because the skills were too difficult to acquire. When the surgical process was demystified, students were able to gain a basic level of mastery and begin entertaining the possibility of practising surgery as a career choice.The use of simulation in teaching surgical skills fills an essential gap for which there is no substitute. Surgical skills learning facilities provide an educational environment in which protected time can be devoted to the development of a wide range of skills. Although these facilities are not intended to replace the learning derived from real clinical experience, they do enable the learners to establish a foundation in a range of skills that can subsequently be honed and made more substantial through experiential learning in surgical practice.One limitation of this study is the lack of longitudinal data to demonstrate whether these skills were retained over time. Further study is required to measure the longer-term impact of such training with regard to skill retention and performance.In order to redress the decline in surgical apprenticeship highlighted by this study, MUHAS, in association with CNIS and UCSF, will build a surgical skills laboratory on the main campus. Teaching of essential surgical procedures will therefore be integrated into the MUHAS curriculum in the near future so that students may learn skills that are otherwise not attainable. Plans to measure skill sustainability and readiness for actual surgical and emergency experiences will be imbedded into this programme.CNIS: Canadian Network for International Surgery; DALY: disability-adjusted life year; DCP: disease control priorities; DMO: District Medical Officer; MUHAS: Muhimbili University of Health and Allied Sciences; OR: operation room (or OT: operating theatre); OSCE: Observed Structured Clinical Examination; UCSF: University of California San Francisco.The authors declare that they have no competing interests.NB and ST contributed equally to the development of this manuscript and share first co-authorship. Additionally, NB participated in the needs assessment and curriculum design and coordinated the entire study; ST contributed to the study design and data collection; NM carried out data analysis and assisted with logistics and procurement of equipment and drafting of the manuscript; FT contributed to the study design and manuscript writing; CM provided writing assistance; PO assisted with data analysis and manuscript writing. All authors read and approved the final manuscript.


Plasmodium falciparum malaria. While efficacy remains high in many areas of the world, prolonged parasite clearance times following treatment with some ACTs and seven-day artemisinin therapy have been observed on the Thai/Cambodian border [Artemisinin-based combination therapies (ACTs) are the recommended first-line treatment for n border .Despite increasing investment in control, we still do not know the extent to which artemisinin resistant falciparum malaria has spread. Such knowledge is vital to plan an effective public health response to either eliminate or control the disease within the region, and to guard against spread to Africa where 85% of global deaths from malaria are recorded. The potentially catastrophic consequence of failing to contain these genetically altered, resistant parasites is clear .The WorldWide Antimalarial Resistance Network (WWARN) has built a web-based informatics platform enabling the malaria community to collate, analyse and share information on different aspects of antimalarial efficacy. WWARN has also provided a platform for researchers to share information on artemisinin resistance with the goal of identifying molecular markers of artemisinin resistance.Dr Sibley will review the current understanding of the epidemiology of artemisinin resistance, identify the organizational gaps in that information, and discuss how scientists can contribute to the project.


Europe is characterised by several high mountain systems dominating major parts of its area, and these structures have strongly influenced the evolution of taxa. For species now restricted to these high mountain systems, characteristic biogeographical patterns of differentiation exist. (i) Many local endemics are found in most of the European high mountain systems especially in the Alps and the more geographically peripheral regions of Europe. Populations isolated in these peripheral mountain ranges often have strongly differentiated endemic genetic lineages, which survived and evolved in the vicinity of these mountain areas over long time periods. (ii) Populations of taxa with wide distributions in the Alps often have two or more genetic lineages, which in some cases even have the status of cryptic species. In many cases, these lineages are the results of several centres of glacial survival in the perialpine areas. Similar patterns also apply to the other geographically extended European high mountain systems, especially the Pyrenees and Carpathians. (iii) Populations from adjoining high mountain systems often show similar genetic lineages, a phenomenon best explained by postglacial retreat to these mountains from one single differentiation centre between them. (iv) The populations of a number of species show gradients of genetic diversity from a genetically richer East to a poorer West. This might indicate better glacial survival conditions for this biogeographical group of species in the more eastern parts of Europe. The evolution within species and sibling species complexes in Europe is closely connected to the range shifts caused by the cyclic changes between relatively short and warm, mostly humid and longer cold and predominantly dry periods ,2. TheseThe Mediterranean species survived the cold stages of the Pleistocene in the Mediterranean Basin and expanded northwards during the postglacial ,8. TheseThe group of alpine and arctic-alpine species is most strongly shaped in their biogeographical and evolutionary history by the geographic location and complexity of the different European high mountain systems because (i) these species are now restricted to these mountain ranges and (in some cases) the arctic and (ii) most of their actual distribution areas were covered by extensive ice-shields during the glacial periods ,20. In gHowever, the distribution histories and evolutionary processes underlying these different distributional types in mountain species are still poorly understood. Therefore, I summarise the known examples and extract the repetitive pattern. Examples are preferably taken from the butterflies because this group is well studied and suitable for biogeographical analyses e.g. -29], but, but29]](1) Which repetitive biogeographical and evolutionary patterns are characteristic for European mountain species?(2) What is the influence of the climatic cycles on their differentiation?Most of the larger European high mountain systems possess endemic species (or at least subspecies) confined to just one of them. As the Alps are by far the most extensive and highest mountain system of Europe, it is not surprising that the highest number and amount of endemics of typical high mountain species is found in this mountain range, as for example demonstrated by lepidopterans and especially in the little mobile group of the micro-moths . Some ofTwo types of hotspots for local endemics of the Alps can be distinguished:Erebia species, Lycaenids etc.; for details see Varga & Schmitt . Th. ThErebiibutions .Erebia nivalis) ; the; the38]] eunomia ,40 and tr Figure  41]..ProclossNebria rufescens and the butterfly Erebia pandrose, two arctic-alpine species, were found here . melas) , but theErebia gorgone, three Sattleria species) , Er, ErErebipandrose  and Erebr animal ,43 and pr animal .The summer-arid high mountain areas of the extreme south of Europe  and the Maghreb (here in particular the Atlas Mts.) do not have the typical alpine zonation , but shoThe large high mountain systems of the southern part of Europe  have in many cases been colonised after the postglacial deglaciation by several genetic lineages, which have survived at least the last glacial period in several allopatric refugial areas often adjoining these high mountain systems.Oreina elongata ..Pieris bPritzelago alpina ..PritzelaNevertheless, many examples also revealed long-lasting separations between the populations from the Alps and the Carpathians ,60,65,70Coenonympha gardetta, Erebia ottomana, E. stirius, E. oeme spodia, E. epiphron aetheria and E. styx trentae , an, anDrusu. thore)  underlincillatum . In Pulsthe Alps . These pDrusus discolor showing the same mtDNA lineage in the COI gene in middle high mountain systems (Figure Rhyacophila aquitanica with very similar populations in the French Massif Central, the Vosges, the Black Forest and the Swiss canton of Fribourg (Figure Close biogeographical connections were also revealed among these middle high mountain systems. One striking example is the caddisfly s Figure  41]. A . A Drusug Figure  90]. Th. ThDrusuThe topology of the European mountain systems had a strong influence on the biogeography and evolution of mountain and high latitude species. Due to the dynamic changes of these biota over time, a large variety of different evolutionary processes are responsible for the development of numerous biogeographical patterns. The most simple of these is the evolution of one genetic lineage or species endemic to one single mountain system due to vicariance with subsequent long processes of geographic isolation and evolution, as observed in almost all European high mountain systems. Especially in the Alps, but also in smaller high mountain systems, different genetic lineages exist beside each other as a result of evolution in geographically isolated areas, with often secondary contacts in these mountain systems. Where such centres of evolution and differentiation of lineages were located between two mountain systems, retraction during the postglacial into both of them is commonly resulting in one genetic lineage being found in two different mountain systems.The author declares that he has no competing interests.


In low income countries, the task of providing primary health care is often the responsibility of community health workers. In Pakistan, community workers called Lady Health Workers (LHW) deliver basic health care at the doorstep in the rural areas and urban slums. Evaluations show that it is a successful programme but point out inconsistencies in the quality of service provided. In order achieve this, it would be important to obtain the workers' viewpoint on their job-description, the problems they face and the levels of stress they encounter.We conducted a multi-method study to investigate the aforementioned issues. All LHWs from one typical rural sub-district in Rawalpindi were surveyed. Focus group discussions with a sub-set of these workers were also conducted.About a quarter of the LHWs were found to have significant occupational stress. Factors associated with stress included having low socio-economic status and having to travel long distances for work. Inconsistent medical supplies, inadequate stipends, lack of career structure and not being equipped to communicate effectively with families were the main factors for job dissatisfaction among these workers.Improvement in remuneration, better administration of supplies and a structured career path should be ensured for better performance of community health workers. In addition, communication skills learning should be an essential part of their training programme. Health workers deployed from within their own communities to deliver basic health care have various titles but "Community Health Worker (CHW)" is the term most commonly used to describe this cadre. According to the WHO: "Community Health Workers should be members of the communities where they work, should be selected by the communities, should be answerable to the communities for their activities, should be supported by the health system but not necessarily a part of its organization, and have shorter training than professional workers." These workers play a crucial role in improving access and broadening coverage of health services in far flung areas and can contribute to improved health outcomes .The "Lady Health Worker" (LHW) of the National Programme for Family Planning and Primary Health Care in Pakistan broadly fits into the definition of community health worker, and is a crucial component of the health care delivery system of the country. The Lady Health Workers Programme (LHWP) is a federally funded development programme working at the grass root level since 1994. About 96,000 workers and their supervisors have been trained and deployed in all the 135 districts of Pakistan. They currently cover about 65% of the target population , and full coverage is planned in the next few years . PakistaThe job description of the LHW has evolved over time. Initially it included health education and basic preventive services for family planning; maternal and child health; improving nutrition; basic hygiene and sanitation; and child immunization. Today it also includes mass immunization for polio eradication; newborn care; maternal immunization with tetanus toxoid (TT); referral of eligible cases to health facilities and regular record-keeping for updating the management information system (MIS) of the programme; community management of tuberculosis; and health education on HIV-AIDS and Hepatitis . Lady HeSince the commencement of LHWP in Pakistan, a number of programme evaluations have been carried out. Most extensive among these was the national-level, external evaluation conducted during 2000–2001 . It concWe assessed the perceived level of job stress, personal efficiency and quality of service delivery by LHW. An attempt was made to understand factors which might be responsible for below optimal performance of LHWs.The study was conducted in Tehsil Kahuta, one of the six Tehsils (sub-districts) of District Rawalpindi, located 60 Km southeast of the capital city of Islamabad. Kahuta has an area of 1096 Sq. Kms, a population of 313,200, and consists of 20 union councils . The Tehsil is a typical rural area of Pakistan, and is similar to most of the under-developed rural areas in South Asia. The average household consists of 6.2 members. Most families depend on subsistence farming, supplemented by earnings of one or more of the adult male members serving in the public sector, the armed forces or the private sector. Male and female literacy rates are 80% and 50% respectively. The infant mortality rate is 84 per 1000 live births. There are 20 basic health units and two rural health centres, employing 28 doctors, 12 midwives, 15 vaccinators, and about 200 LHWs, providing basic primary health care.Multi-stage, stratified, random sampling was done. 15 out of 20 union councils of the sub-district Kahuta were randomly selected. Union councils not covered by LHW were excluded. The sample comprised all LHWs from the selected union councils who were physically healthy (without any diagnosed or known chronic illness), aged 18–50 years, based at their respective villages, married or un-married, had education of grade 8 and above, willing to participate in the study and having at least one year of work experience as LHW.The study design was cross sectional. It consisted of three sub-components (i) survey type investigation aimed at describing accurately the characteristics of the LHW specific beliefs, attitude and opinion related variables including socio-demographic profile (ii) comparison of naturally occurring variables of work-related stress (iii) qualitative analysis of LHWs work-related problems and their suggestions to improve their role as primary agent for primary health care. The study used three techniques for the process of data collection including questionnaire, interview and focus group discussion.'socio-demographic profile of the LHW' a form was designed by adopting multiple methods including key informant interviews, and consultations with professional researchers/experts in the field. It was pre-tested and finalized before the actual data collection process. 'Assessment of mental distress and work-related stress' was done by using the Self-Reporting Questionnaire, briefly known as SRQ-20 [Two experienced Research Assistants (RAs) interviewed the LHWs individually at their homes. To collect data for the development of s SRQ-20 . The SRQs SRQ-20 ,16.Further, to supplement the SRQ-20, two additional scales, namely sources of 'job pressure' and 'job satisfaction' were used. The questionnaire was provided and the LHW was asked to mark her responses on a scale of 1 to 5 with reference to her sources of job pressure and job satisfaction. These two scales were translated, culturally adapted and pre-tested using a standard procedure . OriginaPerceived job description & identification of LHWs problems' a form containing two open-ended questions was used. The responses to these questions were recorded on a proforma for further content analysis. In order to conduct a Qualitative analysis of LHWs problems & suggestions focus group discussions (FGDs) were organized within the field area. A sub-sample of LHWs participated in the FGDs.To document 'A total of 150 LHWs were randomly selected according to inclusion criteria and asked to fill out the questionnaires. Interviews were also conducted with all these LHWs. Six Focus Group Discussions (FGDs) were organized using a sub-sample (48/150) of these LHWs. The RAs obtained lists of all working LHWs in the selected union councils from the concerned authorities. The RAs collected data from the LHWs after getting their informed consent. All the data including socio-demographic variables, SRQ, LHWs perceptions about their job description and problems, and sources of job pressure and job satisfaction scales was collected in a single visit.Six focus groups were organized with subgroups of LHWs for the assessment of their work-related problems and practical suggestions to improve their job related efficiency/quality. The collected data were coded and entered in a computerized database by an expert data controller/statistician. A trained statistician performed the data analysis and generated outputs under the supervision of the principal investigator.inferential' t-test and descriptive statistical methods as appropriate. Inductive content analysis method was used to analyze the qualitative data of the focus group discussions to generate relevant result categories.The quantitative data was analyzed using the Statistical Package for Social Sciences (SPSS 10.0), applying 'The study was completed between15 April 2003 and 31 January 2004. Ethics approval was obtained from the Human Development Research Foundation (HDRF), Pakistan.All 150 interviews were successfully completed. Table Comparison was made with respect to different socio-economic variables given in Table Factors leading to increased job pressure were also explored. Overall, the absence of career advancement was a source of moderate to very high pressure in 53% of the respondents  was used as a measure of job satisfaction among the respondents and the mean OSI for the group was 33.96 Table . On a scThe researchers also asked an open-ended question about the main problem the LHW faced while performing her job. Problems that were reported with high frequency (20% or more) have been shown in Figure To our knowledge, this is the first study from Pakistan that focused on the LHW's work related stress and various factors contributing to it. It has clearly shown that over a quarter (26%) of the LHWs of the National Programme are mentally distressed. In addition to the administrative issues like inadequate amount and irregular disbursement of salary, and inadequate and irregular supply of medicine and other supplies, the rest of the 'causes for concern' are related to communication and interpersonal skills. The study has also established that a large proportion of health workers of this important public health program are not satisfied with their job because of the perceived absence of professional development and lack of career path.A motivated workforce has been described as central to any health system. The improvement of human resource management in the health sector has been recommended in order to achieve millennium development goals (MDGs) . The thiThe potential role of CHWs in improving community health has been acknowledged especially in resource poor countries. Haines et al  have desOther studies have also reported areas for improvement in the structure and performance of CHW programs including the LHWP of Pakistan. The low salary and lack of career path was highlighted by Afsar et al  as a reaDouthwaite & Ward  found thMultifaceted interventions (e.g. training plus supervision) which address multiple determinants of performance have been recommended  to improThe authors declare that they have no competing interests.ZH carried out analysis of data, conceptualized this paper and drafted the manuscript while ZI and AR helped in the design and supervision of the study and reviewed drafts. All authors read and approved the final manuscript.


To systematically review the medical literature to assess the effect of geriatric educational games on the satisfaction, knowledge, beliefs, attitudes and behaviors of health care professionals.We conducted a systematic review following the Cochrane Collaboration methodology including an electronic search of 10 electronic databases. We included randomized controlled trials (RCT) and controlled clinical trials (CCT) and excluded single arm studies. Population of interests included members (practitioners or students) of the health care professions. Outcomes of interests were participants' satisfaction, knowledge, beliefs, attitude, and behaviors.We included 8 studies evaluating 5 geriatric role playing games, all conducted in United States. All studies suffered from one or more methodological limitations but the overall quality of evidence was acceptable. None of the studies assessed the effects of the games on beliefs or behaviors. None of the 8 studies reported a statistically significant difference between the 2 groups in terms of change in attitude. One study assessed the impact on knowledge and found non-statistically significant difference between the 2 groups. Two studies found levels of satisfaction among participants to be high. We did not conduct a planned meta-analysis because the included studies either reported no statistical data or reported different summary statistics.The available evidence does not support the use of role playing interventions in geriatric medical education with the aim of improving the attitudes towards the elderly. Educating health care students and professionals in geriatric medicine is important for providing optimal healthcare to the growing elderly population . In factThere have been efforts to define competencies required to care for elderly patients. The Association of American Medical Colleges (AAMC) hosted in 2007 a Geriatrics Consensus Conference that devised the Geriatric Competencies for Medical Students . SimilarEducational game represents a type of experiential learning where the learner "engages in some activity, looks back at the activity critically, abstracts some useful insight from the analysis and puts the results to work" . Gaming In board games, the learning process happens indirectly through providing new information, correcting old thoughts or implementing common ideas. Simulation games allow participants to temporarily experience the aging-related changes including memory, senses and functional status as well as some of the stereotypes that older patients encounter. A debriefing session usually follows the game and helps in summarizing the results and in building a more solid knowledge and exposure for future experiences.Some types of educational games, such as role playing, have been commonly used and studied in the field of geriatric education. Pacala et al reported on their review of 10 years experience of conducting the Aging Game at the University of Minnesota Medical School . They coThe objective of this study was to systematically review the medical literature to assess the effect of geriatric educational games on the satisfaction, knowledge, beliefs, attitudes and behaviors of health care professionals.We used the following eligibility criteria:• Study design: randomized controlled trials (RCT) and controlled parallel-arm clinical trials (CCT). We excluded single arm studies because of the inability to draw inferences about a causal link between any change in the intervention group and the intervention itself in the absence of a control group.• Participants: members (practitioners or students) of the health care professions.• Interventions: educational games intended to improve health care of the geriatric population. We defined educational games as "instructional methods requiring the learner to participate in a competitive activity with preset rules" . We excl• Control: Interventions in the control group could have been: a) no intervention; b) standard educational activity; c) untargeted activity. • Outcomes: participants' satisfaction, knowledge, beliefs, attitude, and behaviors.The main search strategy consisted of an electronic search in January 2007 of the following databases starting with the dates of their inception: the EPOC Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 onwards), EMBASE (1980 onwards), PsycINFO (1967 onwards), CINAHL (1982 onwards), AMED (1985 onwards), ERIC (1966 onwards), and Dissertation Abstracts Online (1980 onwards). The electronic search strategies used no language restrictions and combined the methodological component of the search strategy of Cochrane Effective Practice and Organization of Care Group (EPOC) with selected MeSH and free text terms relating to educational games , the intervention, the control, the participants, the outcomes, the methodological quality and the results. We collected similar information for studies excluded because of their single arm design. In addition, and irrespective of whether a study was eligible or not, we created a database of educational games used in geriatric medicine education.We calculated the agreement between the two reviewers for the assessment of eligibility using kappa (κ) statistic. The primary summary statistic we considered in interpreting the effectiveness of the intervention was the difference between the 2 study groups in change of the score from pre to post intervention. We did not conduct a planned meta-analysis because the included studies either reported no statistical data or reported different summary statistics.Figure Additional file In terms of intervention, all eight studies evaluated role playing games: four evaluated the "Into Aging" game -16 whileIn terms of outcomes, none of the studies assessed beliefs or behaviors. Two studies assessed learners' satisfaction ,17. One Of the 8 included studies, 5 were RCTs and 3 were CCTs ,11,17. Anone of the 4 studies evaluating Into Aging -16 or ofin the study of Wright's simulation activity, there was no statistically significant or important difference between the 2 groups for knowledge.both studies evaluating this outcome found high levels of satisfaction among participants.The systematic review included 8 studies evaluating 5 geriatric role playing games for healthcare professionals. No study evaluating a social and cooperative game was eligible. The included studies suffered from one or more methodological limitations but the overall quality of evidence was acceptable. None of the studies assessed the effects of the games on beliefs or behaviors. None of the 8 studies found a statistically significant difference between the 2 groups in terms of change in attitude. One study assessed the impact on knowledge but found no statistically significant difference between the 2 groups. Two studies found levels of satisfaction among participants to be high.The major strength of this systematic review is the use of rigorous systematic review methodology including a comprehensive search strategy and duplicate and independent processes for screening, assessing methodological quality of included studies, and abstracting data. Also, we are not aware of any attempt to systematically review the medical literature about the use of educational games in geriatric medicine education.The findings of this systematic review point to limitations in the literature. All included studies were conducted in the United States, limiting the generalizability of our results to settings with different cultures or other languages. The methodological limitations of the included studies limit the confidence in our conclusions. Our inability to perform a meta-analysis prevented us from uncovering any potential effectiveness of the interventions that individual studies could have been underpowered to detect.The results of our study suggest that role playing games are not effective interventions for geriatric education. These results are not consistent with the positive conclusions of the review by Pacala et al  and of oWhile the findings of RCTs and CCTs included in this study were consistent, those of single arm studies evaluating role play were not , assessThe authors declare that they have no competing interests.Conception and design: EAA, HJS; screening: ZA, EAA, data abstraction: ZA, EAA, data interpretation: ZA, EAA, HJS; manuscript drafting: ZA, EAA. All authors critically reviewed the content of the report and approved its final version.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2318/10/19/prepubSearch strategies of electronic databases. Search strategies of electronic databases.Click here for fileCharacteristics of single arm trials excluded from the systematic review.Click here for fileDetailed description and list of publications related to game identified through this review.Click here for fileCharacteristics of randomized controlled trials included in the systematic review. Characteristics of randomized controlled trials included in the systematic review.Click here for fileValidated tools for assessing attitude outcome. Validated tools for assessing attitude outcome.Click here for file


Two-dimensional polyacrylamide gel electrophoresis combined with a non-enzymatic sample preparation technique is useful for analysing clinical tumour material. Using these techniques, we analysed the relationship between the histopathological findings in primary lung malignancies and the expression of a number of unidentified polypeptides that were detected in the molecular weight region 20-35 kDa. In this study 45 cases of primary lung cancer (PLC)  were examined. For reference, a human diploid fibroblast cell line (W138) and normal peripheral lymphocytes were used. Sixteen polypeptides were judged to be associated with histopathological features. These polypeptides seem to be valuable as differentiation markers. The simultaneous evaluation of these polypeptides and some other proliferation markers  seems to clarify the characteristics of each case of PLC. Furthermore, it is possible to classify PLC based on the two-dimensional electrophoresis findings, and this classification of PLC is suggested to reflect the biological features of the tumour more precisely than that based only on morphology.