Silent Sinus Syndrome (SSS) is known to be a rare clinical condition, characterized by spontaneous and progressive enophthalmos and hypoglobus associated with atelectasis of the maxillary sinus and alteration of the orbital floor. Most of the patients with this syndrome present with ophthalmological complaints without any nasal sinus symptoms, and it typically has a painless course and slow development, ergo the term “silent.” Here we present a case report of a patient with occasional coughing spells as the presenting symptom of Silent Sinus Syndrome, which has not been previously described in the literature. The CT scan findings suggested chronic rhinosinusitis. The radiological findings were suggestive of maxillary sinus hypoplasia, with evidence of maxillary sinus atelectasis. Awareness of this syndrome is important for specialists who work with nasal sinus disease, since its management is different than chronic rhinosinusits. Silent Sinus Syndrome (SSS) is known as a rare clinical condition, characterized by spontaneous and progressive enophthalmos and hypoglobus  associatIt’s very common that these patients first present to ophthalmology  due to tThe computed tomography (CT) scans of the nose and paranasal sinuses typically show opacification of the maxillary sinus and inferior bowing of the orbital floor . The sinTreatment should address the obstruction of the sinus and the resultant ocular consequences. Treatment consists of reaeration of the atelectatic sinus by endoscopic sinus surgery. All authors agree that sinus pathology should be treated endoscopically as the first step of the treatment .Limited antrostomy typically results in a release of negative sinus pressure and re-expansion of the collapsed cavity leading to reduction of enopthalmus . A wide Timing for management of the orbital floor is still under debate. As suggested by some authors, orbital floor reconstruction must be performed simultaneously with sinus treatment . Other aA 66-year-old gentleman, non-smoker, with no known allergies or significant respiratory medical history, presented to the Allergy Medicine service with a chief complaint of cough. He describes that he suffered a respiratory infection approximately three months prior to the visit. After it was treated, the majority of symptoms resolved, but the cough and coughing spells persisted with post-nasal drainage and clearing of the throat. The CT scan revealed an asymmetrically smaller and completely opacified left maxillary sinus with left-sided periosteal thickening as well as lateral bowing/bone remodeling of the uncinate process. The opacified left maxillary sinus had hyperdensities which could represent chronic dense secretions Figure . The lefTwo months later when the patient presented to otorhinolaryngology for follow-up, there had been no clinical changes. The physical exam showed some asymmetry of both eyes with mild hypoglobus of the left eye. His nose had a moderate anterior septal deformity to the left with mucoid drainage. He was unaware of vision changes, but testing demonstrated double vision when looking to the extreme right. The rest of the exam was normal.The new sinus CT scan showed no significant change. The interpretation was a persistent opacified hypoplastic left maxillary sinus with obstructed left ostiomeatal unit with lateralization of the uncinate process. The pattern was consistent with type 2 maxillary sinus hypoplasia. A sinonasal endoscopy confirmed the previous imaging findings.The patient underwent a turbinoplasty and endoscopic sinus surgery (antrostomy) to address the total opacification of his left maxillary sinus. The nasal sinus symptoms and cough resolved after the procedure. Correction of the enopthalmos was not necessary.SSS has two main theorized mechanisms: maxillary sinus atelectasis (MSA)—which could be idiopathic, post-traumatic, or post-surgery—or maxillary sinus hypoplasia (MSH).Chronic rhinosinusitis (CRS) has a prevalence of 13.4% in adults older than 18 years of age, according to a national health survey conducted in 2008 . Causes Maxillary sinus hypoplasia (MSH) is an infrequent congenital anomaly that Bolger et al.  noted inChronic maxillary atelectasis (CMA) is a term that describes a persistent decrease in the sinus volume from inwardly bowing antral walls . In a 19CMA, in reference to the Massachusetts Eye and Ear work, was differentiated in 3 stages based on the anatomical changes: Stage 1 (membranous deformity) where there is a lateralization of the maxillary fontanel, Stage 2 (bone deformity) where there is inward bowing of one or more osseous walls of the maxillary antrum, and Stage 3  where enophthalmus, hypoglobus, and/or midfacial deformity is noted (Table In this series of 22 patients, 19 had some degree of sinus symptoms and five had findings of hypoglobus.Silent sinus syndrome is a very uncommon clinical entity . The patIn this paper, we have reviewed the clinical and radiological presentation of SSS. Patients with SSS most often present to ophthalmology practices due to complaints of facial or ocular asymmetry such as hypoglobus or enophthalmos with little or no nasal sinus symptoms . HoweverOur patient presented to otolaryngology and allergy medicine for evaluation of a chief complaint of chronic cough with occasional coughing spells which have not been described in the literature as a form of presentation of Silent Sinus Syndrome. The CT scan findings suggested CRS. The radiological findings were suggestive of MSH, and there was evidence of MSA.The differentiation of SSS from CRS is important since sinus surgery is the procedure of choice and clear knowledge of this anatomy is very important for the surgeon to avoid entering into the orbit and since medical management alone is unlikely to produce a positive result. In surgery, the use of an image-guidance system can also help to avoid complications.Written informed consent was obtained from the patient for publication of this Case Report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.CMA: Chronic maxillary atelectasis; CRS: Chronic rhinosinusitis; CT: Computed tomography; MIW: Medial infundibular wall; MRI: Magnetic resonance imaging; MSA: Maxillary sinus atelectasis; MSH: Maxillary sinus hypoplasia; OMU: Ostiomeatal unit; SSS: Silent sinus syndrome.Clinical and Molecular Allergy. The authors declare no other conflicts of interest.JG serves on the editorial board for DG: conception and design; acquisition of data; analysis and interpretation of data; drafting the manuscript. PP: acquisition of data; drafting the manuscript. JG: analysis of data; revising the manuscript. All authors read and approved the final manuscript.


The four-striped mouse has a grey to brown coloured coat with four characteristic dark stripes interspersed with three lighter stripes running along its back. The histological differences in the skin of the juvenile and adult mouse were investigated by Haematoxylin and Eosin and Masson Trichrome staining, while melanocytes in the skin were studied through melanin-specific Ferro-ferricyanide staining. The ultrastructure of the juvenile skin, hair follicles, and melanocytes was also explored. In both the juvenile and adult four-striped mouse, pigment-containing cells were observed in the dermis and were homogeneously dispersed throughout this layer. Apart from these cells, the histology of the skin of the adult four-striped mouse was similar to normal mammalian skin. In the juvenile four-striped mouse, abundant hair follicles of varying sizes were observed in the dermis and hypodermis, while hair follicles of similar size were only present in the dermis of adult four-striped mouse. Ultrastructural analysis of juvenile hair follicles revealed that the arrangement and differentiation of cellular layers were typical of a mammal. This study therefore provides unique transition pattern in the four-striped mouse skin morphology different from the textbook description of the normal mammalian skin. The typical mammalian skin consists of an epidermis that is in contact with the free surface and an underlying dermis. Deep to the dermis is a layer of subcutaneous tissue known as the hypodermis. In mammals, skin or coat colour is essentially determined by melanocytes either situated in the epidermis or the hair bulb. These specialised cells synthesize melanin in membrane-bound organelles termed melanosomes, which are transferred through dendritic processes to their final destination , 13, 29.Rhabdomys pumilio, is unique in that it is the only species of its genus [The four-striped mouse, ts genus  and partts genus  despite ts genus . We obseTwo juvenile and two adult four-striped mice were treated and used according to the guidelines of the University of the Witwatersrand Animal Ethics Screening Committee, which parallel those set down by the National Institute of Health (NIH) for use of animals in scientific experiments. The mice originated from the Honeydew Grassland, Gauteng 27° 55′S, 26° 4′E, South Africa. A four-striped mouse with a body weight from 40 g  to 80 g μm using a Leica 1400 sledge microtome (Germany). Prepared slides were placed in an oven at 60°C for 30 minutes to ensure that the sections adhered firmly to the slides. All sections were dewaxed in 2 changes of xylene for 5 minutes each, passed through 2 changes of absolute alcohol for 30 seconds each, then transferred to 95% alcohol for 30 seconds, and rinsed in gently running tap water.Tissues were fixed in 10% buffered formalin  and routSections were stained in a modified Mayer's Haematoxylin  for 5 miSections were stained in Iron Haematoxylin  for 10 mSections were treated with ferrous sulfate  for 1 hoSmall pieces of four-striped mouse skin tissue were fixed in 2.5% glutaraldehyde in phosphate buffer, pH 7.4 followed by a wash in phosphate buffer, pH 7.4 for 2 hours [μm semithin sections was cut on a Reichert-Jung Ultracut ultramicrotome (Germany) and stained with Toluidine Blue-Pyronin Y for 30 seconds, dried, and mounted in Entellan. Semithin sections with the area of the dermis and its hair follicles, the hypodermis from the adult; the dermis and its hair follicles, the hypodermis and its hair follicles from the juvenile were selected. Ultrathin gold sections were cut and placed on copper grids and stained with uranyl acetate for 3 minutes. Drops of lead citrate were placed on strips of dental wax, and once stained, grids were rinsed first in dilute sodium hydroxide, followed by distilled water and then dried.After polymerisation 1 Light microscopy analysis of stained sections was done using a Zeiss Axioskop 2 plus Light microscope (Germany), fitted with a Zeiss Axiocam HRc camera (Germany). Ultrastructural examination and electron micrographs were taken, with a JEOL JEM-100S transmission electron microscope (Japan) at 80 kV, and negatives were scanned with an Epson Expression 1680 scanner (Japan).In histological studies of the adult four-striped mouse Figures , the derNo melanin pigment was present in any of the epidermal layers on Ferro-ferricyanide stained sections Figures . The juvThe underlying dermis of the adult skin Figures  presenteUltrastructurally, these cells had very long, thin cytoplasmic processes extending between collagen fibres . Oval-shUltrastructurally, outer root sheath cells had oval nuclei that became progressively flattened moving laterally from the hair cortex, as the cells flattened in the same direction . The derThe hypodermis Figures  was formThe juvenile hypodermis Figures  presenteThe Ferro-ferricyanide stain was specific for melanin on sections in varying shades of green Figures . CollageIt is evident that the number of hair follicles visible in the section from the juvenile exceeded that in the adult. Below is a description of the hair follicles at five different levels and stages of differentiation.Sections at the level of the hair bulb through the dermal papilla were present throughout the hypodermis only Figures . These hSeparating the dermal papilla from the hair matrix was a basement membrane . FollicuSections of follicles at the suprabulbar level were only present in the hypodermis Figures  and had Melanosomes in the cortex stained green on Ferro-ferricyanide sections . The cutUltrastructurally, the nuclei are starting to lose their morphology as cells are filled with numerous trichohyalin granules Figures . The outNear the dermal-hypodermal interface, the medulla was mostly present in relatively large follicles Figures . In the In the medulla, the cell nuclei had substantially decreased in size with large intercellular spaces . IndividAt this level, the medulla cortex and its cuticle were fully keratinised . The haiIn human skin, melanocytes are located in the basal layer of the epidermis and the stratum basale –10. FromAccording to Rhodin , melanocR. pumilio [The pigment-containing cells in the dermis of the four-striped mouse were similar in structure to those in the naked mole-rat as reported by Daly and Buffenstein . Another pumilio .In the four-striped mouse, there are obvious colour differences in the hair from the striped areas due to varying pigmentation of coat hair. Juvenile hair follicles obviously outnumbered those in the adult with distinct differences in hair follicle location. Hair follicles were situated in the dermis of the adult four-striped mouse which is consistent with normal mammalian skin. In the juvenile four-striped mouse, hair follicles of different sizes were present not only in the dermis but also in the hypodermis. The location of hair follicles in the epidermis, dermis, and hypodermis in the juvenile four-stripe mouse does not conform to normal mammalian skin where hair follicles are only present in the dermis and occasionally extending into the superficial hypodermis . The juvenile skin provided hair follicles at all levels of differentiation. Identification of tissues becomes easier as the cells differentiate while rising in the follicle . The murThe dermal papillae in the juvenile four-striped mouse did not house a capillary as found in animals with larger hairs . HoweverThe four-striped mouse medulla formed the centre core of the shaft and hardened by keratinisation similar to the inner root sheath (described later). Trichohyalin remains a major protein component of the medulla , 20 and The inner root sheath does not form part of the hair that emerges from the skin surface, as it is released from the shaft before it projects through the skin . InsteadIn the juvenile four-striped mouse hair follicle, a single layer of cells formed the outer root sheath at the hair bulb. It thickened higher in the follicle, consisting of multiple layers of cells as reported , 26. At In general, the layers of the skin from both the adult and juvenile four-striped mice conformed to the structure of normal mammalian skin. The only exception was the pigment-containing cells located in dermis of the four-striped mouse. The morphology of the epidermis as well as dermal pigment-containing cells was the same in both the juvenile and adult four-striped mouse. The epidermis lacked pigmentation, while the melanocytes were homogeneously distributed throughout the dermis. Hair follicles were present in the dermis and the hypodermis of the juvenile but confined to dermis in the adult. The major and unique differences observed between the juvenile and adult four-striped mouse were the size, structure, and location of the hair follicles. Further ultrastructural analysis of juvenile hair follicles established that their structure and differentiation were similar to normal mammalian follicles. Although little is known about the underlying reasons for the structural differences the description provided can form the basis for further investigation especially of the biology of the transition process of the hair follicles.


The Chronic Care Model (CCM) is an evidence-based approach to improving the structure of care for chronically ill patients with multimorbidity. The Assessment of Chronic Illness Care (ACIC), an instrument commonly used in international research, includes all aspects of the CCM, but cannot be easily extended to the German context. A new instrument called the "Questionnaire of Chronic Illness Care in Primary Care" (QCPC) was developed for use in Germany for this reason. Here, we present the results of the psychometric properties and test-retest reliability of QCPC.A total of 109 family doctors from different German states participated in the validation study. Participating physicians completed the QCPC, which includes items concerning the CCM and practice structure, at baseline (T0) and 3 weeks later (T1). Internal consistency reliability and test-retest reliability were evaluated using Cronbach's alpha and Pearson's r, respectively.The QCPC contains five elements of the CCM . All subscales demonstrated moderate internal consistency and moderate test-retest reliability over a three-week interval.The QCPC is an appropriate instrument to assess the structure of chronic illness care. Unlike the ACIC, the QCPC can be used by health care providers without CCM training. The QCPC can detect the actual state of care as well as areas for improvement of care according to the CCM. The number of patients with multiple chronic diseases is growing world-wide . MultimoThe Chronic Care Model (CCM) is an evidence-based approach to improving care for chronically ill patients with multimorbidity . It was The ACIC assesses all six elements of the CCM . To measure how care is provided in German practices, researchers have started to translate-and tried to culturally adapt the ACIC instrument. During this process, we determined that the ACIC is not fully applicable to the German health care system. These limitations are due to a multifaceted understanding of terms, different levels of knowledge of the CCM, and fundamental differences between health care systems . The CCMIn a first step, we collected data on the CCM and factors influencing the care of patients in Germany with multiple chronic conditions based on a literature search and our own hypotheses. The ACIC instrument and questionnaires such as Patient Assessment of Chronic Illness Care (PACIC)  and the Nine general practitioners were asked to evaluate the questionnaire to determine whether each item was understandable, whether the content of an item was important for care of chronically ill patients, and whether any important aspects were missing. Details of this process are published elsewhere .A total of 288 general practitioners throughout Germany, each of which had participated in the European Practice Assessment for health care quality improvement  during thealthcare delivery system cannot be easily extended to the German context due to fundamental differences between health systems [The version of the QCPC used in the validation study contained 42 questions concerning care based on the CCM and 28 questions based on other hypotheses . The questionnaire is shown in the additional file The "decision support" subscale consists of two items rated on a five-point Likert scale . The "delivery system design" subscale consists of eight items, two of which are rated on a five-point Likert scale , and the other six on a different five-point Likert scale (1 = 0% to 5 = more than 75%). The "self-management support" subscale consists of eight items rated on a five-point Likert scale . The "clinical information systems" subscale comprises 15 items answered with a "1 = yes" or "2 = no". The "community linkages" subscale consists of nine items rated on a five-point Likert scale (1 = very satisfied to 5 = very unsatisfied).All analyses were carried out using SPSS 18.0 software . A hierarchical cluster analysis was performed to identify differences and similarities in the hierarchy structure of the different practices. Internal consistency was assessed using Cronbach's alpha, which indicates whether an item of a scale is appropriate for assessing the underlying concept of the scale [r) to determine the stability of the questionnaire. This criterion refers to the likelihood that a test will yield the same description of a phenomenon if the test is repeated and the phenomenon is unchanged [r values larger than 0.50 are considered to be very reliable. However, their reliability also depends on the expected stability of the investigated construct.Test-retest reliability was assessed using the nonparametric Spearman rank order correlation coefficient .Of 288 practices invited to participate in the validation study, the completed questionnaire was returned by 109 (38%) at T0 and by 87 (30%) at T1. The characteristics of our study participants are presented in Table Table Table The results for the "clinical information systems" subscale are presented in Table Table Because one item of the "community linkages" subscale ("satisfaction with the exchange of information with other GP practices") was not stable, it was deleted from the questionnaire.This report describes the results of the psychometric properties and test-retest reliability of the QCPC, which contains elements of the CCM. The results indicate that the QCPC might be the first instrument giving psychometric properties insight into the question of whether and to what degree German practices have already implemented CCM elements into daily care of patients with one or more chronic conditions. The importance of practice structure has been demonstrated in previous research ,20. AlmoFor "delivery system design" the internal consistency was low. One reason for this result might be that especially reasons for referral are very little reflected in daily practice. Stability, as assessed using the Wilcoxon matched paired test, was very good. Because one item of the "community linkages" subscale was not stable, it was deleted from the questionnaire. A low test-retest reliability was observed for the item "disease management programs or guidelines" (r = 0.48). The implementation of guidelines in German primary care practice is basic yet. Decision making is rather a matter of former individual hospital pathways but evidence . TherefoThe QCPC is a questionnaire for assessment of care according to the CCM with psychometric properties and test-retest reliability. The QCPC can be used in a large number of practices without previous teaching in CCM background. However, the construct of the questionnaire especially different measurement scales in one questionnaire does not allow exploring a factor analysis. To conduct an exploratory or confirmatory factor analysis the measurement scales should be consistent . This spAs the QCPC was designed for use by primary care physicians, we were unable to assess different points of view from other practice team members. Another limitation is that the preliminary QCPC results will not be comparable to those of past international studies.The QCPC is a questionnaire for assessment of care according to the CCM in Germany which was tested of their psychometric properties. Unlike the ACIC instrument, the QCPC can be used in a high number of practices as the respondents need no prior training in CCM. The QCPC can gauge the current state of care as well as areas for improvement of care. The ESTHER-cohort was the first study performed in the federal state of Saarland, Germany, in which the QCPC was used to survey whether structured care according to the CCM leads to better care of multimorbid (and frail) patients. The ESTHER-cohort includes almost 700 GPs and about 10,000 patients ,28. OutcThe authors declare that they have no competing interests.All authors made substantive contributions to the study. JS, AM, DO, KGl, IN, JSz, and KG contributed in producing the QCPC. JS drafted the manuscript and analysed together with KG the data. All authors made contributions to the manuscript. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/11/295/prepubThe Questionnaire of Chronic Illness Care in Primary Care (QCPC). English translation of the Questionnaire of Chronic Illness Care in Primary Care (QCPC).Click here for file


Health insurance schemes have been widely introduced during this last decade in many African countries, which have strived for improvements in health service provision and the promotion of health care utilization. Client satisfaction with health service provision during the implementation of health insurance schemes has often been neglected since numerous activities take place concurrently. The satisfaction of enrollees and its influencing factors have been providing evidence which have assisted in policy and decision making. Our objective is to determine the enrollee's satisfaction with health service provision under a health insurance scheme and the factors which influence the satisfaction.This retrospective, cross-sectional survey took place between May and September 2008. Two hundred and eighty (280) enrollees insured for more than one year in Zaria-Nigeria were recruited using two stage sampling. Enrollee's satisfaction was categorized into more satisfied and less satisfied based on positive responses obtained. Satisfaction, general knowledge and awareness of contribution were each aggregated and assessed as composite measure. Logistic regression analysis was used to analyze factors that influenced the satisfaction of enrollees.A high satisfaction rate with the health insurance scheme was observed (42.1%). Marital status (p < .05), general knowledge (p < .001) and awareness of contributions (p < .05) positively influenced clients' satisfaction. Length of employment, salary income, hospital visits and duration of enrolment slightly influenced satisfaction.This study highlighted the potential effects of general health insurance knowledge and awareness of contributions by end-users (beneficiaries) of such new program on client satisfaction which have significant importance. The findings provided evidence which have assisted the amendment and re-prioritization of the medium term strategic plan of operations for the scheme. Future planning efforts could consider the client satisfaction and the factors which influenced it regularly. Health insurance as a complementary or alternative source of health care financing has become important in the developing world . It has Already there has been insufficient knowledge and awareness of the health insurance activities by those enrolled in the scheme. Complaints have arisen where providers denied enrollees their full entitlements and some providers have charged additional fees on the pretext of non-inclusion of the service in the benefit package . Again, Certainly, problems associated with health service provision needed to be understood and rapidly resolved at all times. This would have helped immensely in the future implementation strategies of the scheme by identifying what has happened, and how to progress to make it better for all. It would aid to have improved the monitoring of health care providers' activities within the scheme. Like any other country, the national health insurance scheme (NHIS) in Nigeria aimed to provide health insurance so that insured persons and their dependants are able to have access to good quality and cost-effective healthcare services . But, thIt is essential to consider how policy interventions such as the NHIS have influenced the barriers to health care utilization, which not only included geographical access, but also perceived quality of care and access to information . MeasureThe focus on client satisfaction with the health insurance scheme's service provision after more than four years of active implementation highlights the importance of monitoring and evaluation. It provides information regarding the activities of the health care providers participating in the health insurance scheme. Client satisfaction of any health system or health insurance scheme has been, in most cases, associated with certain individual characteristics and factors, which encompass socio-economic, demographic and cultural factors. However, enrollee's knowledge and awareness of the health insurance system are often not taking into consideration. Policy and decision makers have to understand the potential factors influencing enrollee's satisfaction in order to viably implement such health insurance schemes. Here, we focussed on client satisfaction with health service provision and factors that could have influenced the enrollee's satisfaction. This study was carried out to monitor the progress of implementation of the health insurance scheme in terms of health service provision.Our hypothesis was that an insured person (household head) would either be more satisfied or less satisfied with the scheme based on certain individual factors and encounter with health care providers (HCPs). We assumed that the aged, females, and low salary income earners were expected to be more satisfied. Enrollees with longer years of service, poorer health condition, frequent hospital visits and longer duration of enrolment in the health insurance scheme were also expected to be more satisfied. We have also explored religion and native language differences. Individuals with a higher educational level, high occupational status, polygamous status, more than four children and residence outside the city were expected to be less satisfied. The most important hypothesized factors were that enrollees with better general knowledge of the health insurance scheme and awareness of monetary contributions were expected to be more satisfied. This hypothesis in respect to the assumptions was supported by the theoretical framework of various satisfaction reviews and adaptations -16.A cross-sectional survey was conducted in Zaria at Ahmadu Bello University located on the high plains of Northern Nigeria, 270 Km northwest of Abuja, the country's capital. Zaria is semi-urban and it has both public and private health facilities. The health facilities are spread around the metropolis and its environs. The University has two campuses, 14 faculties and 82 academic departments . The stuTwo-stage sampling method was used to select the study subjects. We employed simple random sample selection at each stage to eliminate selection bias. The first stage involved selecting seven out of fourteen faculties. These seven faculties included 36 departments. The second stage involved the selection of staff from each of the 36 departments using proportionate method based on the size of the departments. Only insured persons enrolled for more than one year in the health insurance scheme are included in the study. Verification of enrolment was carried out in collaboration with the NHIS desk officers in Zaria-Nigeria. The participants had to have met the inclusion criteria at both stages to be eligible for the study.power of 90% at a (2-sided) significance level of 5% based on an assumed proportion of (.5) and a null hypothesis value of (.4) with detectable difference of 10. The detectable difference was taken into consideration which dealt with the assumed knowledge gap that could have existed in the population. The sample size was calculated using the "single proportion formula for sample size determination" method [A minimum sample size of 250 for this study was estimated. We calculated the sample size using a " method . To alloA pre-tested interviewer-administered questionnaire was used. It was addressed to insured-persons who had been enrolled in the health insurance scheme for at least one year. The questionnaire included five sections with questions related to the socio-economic and demographic characteristics of the respondents, general knowledge of the health insurance scheme, awareness of monetary contributions, utilization of health services, and clients' satisfaction. Three hundred questionnaires were distributed.Clients' satisfaction was divided into two categories. Firstly, enrollees who had positive responses on any four or more of the six criteria, which formed the composite index measure, were defined as more satisfied. Secondly, those with zero to three positive responses were defined as less satisfied. The composite index measure comprised of criteria which concerned (i) the receipt of courteous attention at the hospital, (ii) decreased waiting times, (iii) the availability of a doctor or nurse throughout the hospital visits, (iv) the receipt of better health care, (v) the frequency of hospital visits when sick, and (vi) the preference for health insurance in participants' own neighbourhoods. The framework for these dimensions was derived from satisfaction reviews and adaptation of previous measures ,13,14.General knowledge as a composite was based on whether the respondents felt that the health insurance was a good way to have helped them in solving their health expenditure problems. It also included knowledge of the basic benefits package of the health insurance scheme.Awareness of monetary contribution as a composite focussed on whether the respondents were knowledgeable of both the employees' and the employer's monetary contributions to the health insurance programme.To analyze client satisfaction, enrollees were categorized into the above mentioned two groups i.e. more satisfied and less satisfied individuals. The explanatory variables selected were based on the study hypotheses. We assessed bivariate associations between all variables and client satisfaction. Differences between the associated explanatory variables subsequently were analyzed by comparing means using t-tests and chi-square tests.P-value of (.05) was used as the threshold for statistical significance. The SPSS program  was used for all analyses.After testing for collinearity, we eliminated only one variable with a correlation above (.75) and created our final model. The eliminated variable was health condition (people who were sick or not). It was strongly correlated with hospital visits (people who had consulted a doctor or not). We kept the utilization variable because of its relevance to the study since health insurance aimed to improve and promote utilization of health services. Logistic regression was used to model the potential factors associated with clients' satisfaction. A The response rate was 93.33% (i.e 280 insured-persons responded). The socio-demographic characteristics of the sample are presented in table The insurance and health related responses of the sample are presented in table Less than half of the respondents reported being satisfied (42.1%). All the aforementioned variables were included using logistic regression Table . MaritalThe study revealed that clients satisfaction rate with the health insurance scheme was somewhat low. Enrollee's satisfaction of service provision served as an important aid to monitor the progress of implementation activities of the scheme. However, certain factors such as general knowledge of the health insurance scheme and awareness of monetary contributions greatly influenced enrollee's satisfaction of health care delivery. Ways of creating better knowledge of health insurance activities among the population were given top priority by both the policy and decision makers, which previously were insufficient until this stage (middle) of implementation. These formed a major part of considerations in the amended medium term strategic plan of operations of the NHIS.Older clients were more satisfied with service provision than the younger clients. There is direct relationship between enrollee's satisfaction and age which has been similar with related studies ,19. StudInsured persons' knowledge of the health insurance scheme was a vital determinant of perceived satisfaction of health care services. Enrollees knowledge of the health insurance was aggregated to their understanding of insurance to be a good way of helping clients' to relieve their health expenditure problems and also their knowledge of the basic benefits package of the health insurance scheme. Poor knowledge of the benefit package has affected utilization rates of health facilities in developing countries ,23. EffeInsured persons are more satisfied if they have been aware of the contributions made by both the employees and employer. The less awareness of enrollees with health insurance activities, the less satisfied they become of its offerings in terms of service provision. Better awareness of the enrollees might enhance interactions between patients and health care providers due to better satisfaction of services. There are tendencies that, those who do not have full knowledge of insurance services offered would likely evaluate schemes poorly .The enrollee's satisfaction with service provision was somewhat low. Monitoring of health service provision could assist to provide important information when health insurance satisfaction declines. Regulatory agencies should check the situation regularly so as to avert problems before they become crises. Policymakers and monitors needed to realise that, individual patients recognize an effective health system or health insurance scheme as one that provides timely access to the full array of necessary services, efficacious and safe care leading to improvement in health, continuity of care, and respect ,26-28.General knowledge of the health insurance package, awareness of monetary contributions, frequent hospital visits due to illnesses, length of employment and length of enrolment in the health insurance programme confirmed our hypotheses because they positively influenced satisfaction. Conversely, more satisfaction in the polygamous enrollees was contrary to the supposition as previous mentioned. Positive linkages with satisfaction were associated with enrollees who had more knowledge of the health insurance, frequently visited the hospital, had longer length of enrolment, and also had some awareness of monetary contributions. These findings suggest that enrollee's satisfaction with health services provision in the scheme could be influenced by several factors. The factors which lead to less satisfaction could be addressed properly to improve on the health insurance activities. Health care provider's politeness toward clients, decreased hospital waiting times, and increased availability of hospital personnel at all times served as composite measure of satisfaction and will help in improving client satisfaction with service provision in the health insurance scheme.Despite the population consisted of heterogeneous individuals with different socio-economic and cultural backgrounds, which prevailed across Nigeria. However, a study limitation was whether the findings from this survey could be fully generalized to the various facets of the country. Further similar studies are needed in other settings for comparison due to knowledge gap because the studied population was from an academic setting. The dynamic nature of certain regions of Nigeria might exhibit some socio-demographic differences due to cultural, educational, religious and economic status which needed careful consideration.Enrollee's satisfaction with service provision of health insurance can be influenced by several factors especially the poor knowledge of health insurance and lack of awareness of contribution by the insured persons. Periodic identification of related influencing factors on client satisfaction could assist in guiding policy and decision making to detect promising pathways to improve any nascent program like health insurance schemes. Improved knowledge and better awareness of the scheme's activities by the enrollees could be augmented through the provision of requisite available information to the insured persons at all times.The authors declare that they have no competing interests.SM, HD and MNS conceptualized and designed the study protocols. SM and MNS carried out the field study work. SM and HD analysed and interpreted the data. SM and HD drafted the manuscript. HD critically reviewed the findings. All authors read and approved the final manuscript.This study protocol was approved by the University Research Ethics Committee ABU-Nigeria (VC/P. 18890) and also the Ethics Commission of Heidelberg University, Germany.


The field of diagnostic and therapeutic endoscopic ultrasound (EUS) is growing rapidly. Although EUS has enhanced our ability to diagnose and treat a wide variety of GI conditions, there are many controversial issues regarding the appropriate application of EUS techniques. In this review we discuss five controversial topics in EUS: the utility of EUS in staging of esophageal and gastric cancer; selection of appropriate needle gauge for fine needle aspiration (FNA); use of the stylet in FNA; and the emerging role of contrast agents in endoscopic ultrasound. Endoscopic ultrasound (EUS) was first introduced into clinical practice in the 1980s and has rapidly evolved into a reliable technique for diagnosis of lesions of the digestive tract. In its infancy in the 1980s, radial echoendoscopes were used only to image lesions of the GI tract . With thAlthough EUS has enhanced our ability to diagnosis and treat a wide variety of GI conditions, there are many controversial issues regarding the appropriate application of EUS techniques. The purpose of this review article is to describe some of the more common controversies and the current literature surrounding these controversies to help the clinician performing EUS to better understand these issues and optimize his or her practice. We will discuss each issue under a separate heading.According to the National Cancer Institute, the number of estimated new cases of esophageal cancer in the United States alone in 2012 is 17 460 , represeet al. also performed a retrospective analysis on patients at the Academic Medical Center in the Netherlands with superficial esophageal cancer, who had an EUS preceding an EMR. Of 131 patients, EUS found possible submucosal invasion (T1b staging) in 26 (20%) . In. In56]. Perhaps one of the most challenging diagnostic clinical scenarios is differentiating between benign and malignant disease in ‘mass-forming’ acute, chronic and autoimmune pancreatitis (AIP) . Mass-foCEH-EUS may also aid in the diagnosis of pancreatic cystic lesions . Minute et al. conducted a study in 76 consecutive patients who underwent EUS-FNA and CEH-EUS for subepithelial lesions [Finally, an additional potential application for CEH-EUS is in determining the malignant potential of gastrointestinal stromal tumors. 10–30% of GIST lesions are malignant: however preoperative tools to determine malignant potential are not optimal . Obtaini lesions . Twenty-The field of diagnostic and therapeutic EUS is rapidly evolving. Recently published work is already helping to clarify some of the important controversies involving the role of EUS in cancer staging and diagnosis, as described in this review. We expect that many of the questions to be debated and clarified in the near future of EUS will pertain to a variety of therapeutic applications of this technique. Of particular interest is the emerging role of EUS-guided biliary access techniques (vs standard percutaneous approaches) for scenarios in which ERCP is not feasible. EUS-guided intra-tumoral therapy  and EUS-guided management of variceal bleeding are additional topics of great interest, for which the appropriate role of EUS will need to be thoughtfully investigated.Along with this growth come controversial issues. In this review we discussed five controversial topics in endoscopic ultrasound. Although the outcomes of endoscopic ultrasound are highly user-dependent and have their limitations, we have shown literature to support its beneficial use in esophageal and gastric cancer staging. In addition, since its first use in the 1980s, we are still learning which techniques are optimal for fine needle aspiration in aiding diagnosis. Two of the common issues regarding needle size and stylet use were presented in this review. More data is probably needed until we have characterized the correct needle size for fine needle aspiration. Factors related to choosing the correct needle correspond to the type and location of the lesion. We briefly discussed the role of the stylet and whether it has a role in fine needle aspiration. Current data suggests that the stylet may not be an essential component of fine needle aspiration. Finally new techniques in EUS are emerging and will likely have a niche in aiding diagnosis of difficult-to-characterize lesions. In this review we have discussed the role of contrast-enhanced harmonic EUS. This technique is evolving and will likely play a key role in diagnostic EUS in the future.Conflict of interest: none declared.


Osteomyelitis of the jaws following dental treatment is a rare condition which usually occurs in immuno-compromised patients both locally and generally. A case is presented with the alveolar bone necrosis resulting from leakage of an arsenical devitalizing paste into the periodontium. The treatment procedures and the outcomes are discussed in this article. Histopathologic examinations can be consistent with the diagnosis and the microbiologic tests can be helpful.12 Osteomyelitis of the mandible following routine dental treatment has rarely been reported in the literature.11 This article reports a case of a healthy patient who developed osteomyelitis of the lower jaw following root canal therapy.Osteomyelitis has a range of clinical manifestations depending on the virulence of the infecting organisms, host resistance, and the reaction of the periosteum to inflammation.A 24-year-old male patient without any systemic disorders was referred to the Department of Oral and Maxillofacial Surgery, Tabriz University of Medical Sciences, Tabriz, Iran, in December 2008 because of the left mandibular pain and swelling. The patient had no relevant history except for smoking for 5 years. The left mandibular first molar had been extracted 5 weeks before the examination. Three days before extraction, the tooth had undergone pulpotomy using an arsenic-based pulp devitalizer. This material is commonly used to accelerate pulpal necrosis and consequent pain relief by some non-academic practitioners. Four days after extraction the patient had experienced severe pain in the left mandibular region, which had progressively increased.Clinical examinations revealed spontaneous mandibular pain, tenderness, and a poorly healed socket with alveolar bone exposure. No fistThe hematologic profile showed an increase in white blood cell count; however, the red blood cell count was normal. The Erythrocyte Sedimentation Rate (ESR) had risen (40 mm first hour).With the clinical diagnosis of osteomyelitis, the patient was given intravenous penicillin 3,000,000 units every 3 hours and was scheduled to the operating room for sequestrectomy and exploration. The exposed bone was removed and complementary curettage and irrigation was performed. The necrotic bone was sent for histopathologic examination. The postoperative period was uneventful and the patient was discharged from the hospital with oral penicillin 500 mg 4 times a day for the next two weeks. The histopathologic view showed necrotic bone with acute inflammatory cells. The pat3Osteomyelitis of the jaws is a rare condition, which has been associated with multiple systemic diseases including diabetes, autoimmune states, malignancies, malnutrition, and acquired immunodeficiency syndrome. The medications linked to osteomyelitis are steroids, chemotherapeutic agents, and bisphosphonates.9 Some of them are used traditionally in old dentistry. One of the examples is arsenic-based compounds. These materials are popular among practitioners who are not familiar with new anesthesia techniques of contemporary dentistry. In the past, local anesthesia was less reliable and the use of devitalizing pastes was an established practice. Arsenic reduces pulp sensitivity by necrotizing the nerve endings of dental pulp. However, arsenic and its compounds are extremely toxic and potentially carcinogenic when placed in contact with the hard and soft tissues of the body. Caution should be exercised during cavity preparation not to perforate the floor of pulp chamber, which could provide an easy and direct route for leakage of the material. To avoid the risk of arsenical necrosis, the manufacturer strongly recommends that no pressure should be exerted on the pellet or during sealing the cavity hermetically with temporary cement.There are many therapeutic materials affecting bone metabolism.5The osteomyelitis seen in this case occurred after condensation of arsenic trioxide into the pulp chamber and the canals of the tooth. It is probable that the material passed beyond the apex of the tooth following heavy condensation or probably the material penetrated into the peridental tissues because of loose or inappropriate temporary filling. Treatment of osteomyelitis of the jaws includes elimination of the cause, incision and drainage, sequestrectomy, saucerization, decortication, resection of the jaw, antibiotics and hyperbaric oxygen.3 Antibiotic therapy should be instituted at the earliest moment and can be changed according to the results of antibiogram.13 In the present case treatment plan included removal of the localized necrotic bone and sequestrum. Antibiotic therapy was instituted prior to the surgery with intravenous penicillin and continued postoperatively to prevent post-surgical infection. Post-treatment evaluations showed complete healing.The main treatment of localized osteomyelitis in a patient without any systemic conditions is to remove the etiology of the disease as well as antibiotic therapy to prevent post-surgical infection.Arsenic compounds have no place in contemporary dental practice and dentists should be warned against their potential hazards and adverse effects.


High rates of mental disorders have been found in detained juvenile offenders, whereas the role of psychopathology in non-detained offenders is less clear. Therefore, the present study compared psychopathology in male non-detained delinquent juveniles and two matched samples from the community and an adolescent psychiatric clinic.125 male adolescents aged 11 to 19 years  from an outpatient adolescent forensic clinic were compared to a community sample from the Zurich Adolescent Psychology and Psychopathology Study (ZAPPS) and a referred sample from a psychiatric clinic matched for age and nationality. All subjects responded to questionnaires measuring internalizing and externalizing problems, depressive symptoms and self-esteem.The sample of non-detained juvenile offenders showed similar rates of self-reported internalizing and externalizing problems when compared to the community sample, whereas the clinic sample displayed an increased rate of various disturbances. Similar results were found also for self-esteem. In agreement with these findings, non-detained juvenile offenders less frequently had a psychiatric diagnosis after full clinical assessment when compared to the clinical sample. However, a diagnosis of conduct disorders and a lower IQ range was found more frequently in non-detained juvenile offenders. Offenders with serious delinquent acts and involving weapons showed higher depression scores than the rest of the offenders.In non-detained assessment situations before court examination, juvenile offenders present rather normal behaviour. Their lack of awareness of potential behavioural problems should be considered during assessment and treatment of this group of offenders. There is clear evidence that incarcerated juveniles show high rates of psychiatric disorders and comorbidity -6. In paAmong various mental disorders, depression and affective disorders play a particular role in juvenile offenders. Ritakallio et al.  found a Among various personality features, self-esteem plays a major role due to its close association with various kinds of psychopathologies and delinquencies. There are contradictory findings on the association of self-esteem and delinquency with some studies finding no relation between these two variables ,18,19, aIn addition to focusing on psychopathology and personality features in both incarcerated and non-detained juvenile delinquents there is also a need to more clearly specify the type of offenders to whom the observed abnormal features most strongly apply. This more recent approach has made a distinction between sexual and non-sexual offenders. In their recent review, Van Wijk, Vermeiren, Loeber, ‘t Hart-Kerkhoffs, Doreleijers & Bullens  suggesteThe first aim of the present study was the comparison of internalizing and externalizing problems, depressive symptoms and self-esteem among male non-detained juvenile offenders, a male community group, and a clinical group of male adolescents attending a mental health service. More specifically, we assumed that based on self-reports the delinquent sample would show (a) higher levels of internalizing and externalizing problems and depressive symptoms and a lower self-esteem than the community sample and (b) similar scores in these measures when compared to the clinical sample. The second aim of the study was to compare the frequencies of psychiatric diagnoses after full clinical assessment. It was expected that the frequencies of diagnoses would be similar in the forensic and the clinical sample. Finally, the third aim of the present study was to analyze the association of specific offense characteristics such as sexual offenses vs. non-sexual offenses as well as the severity of crimes on internalizing and externalizing problems, depressive symptoms and self-esteem.The present study is based on three male samples, namely a forensic sample with 125 delinquent juveniles and two matched samples from a mental health service  and a community survey matched for age and nationality. In each sample, there were N = 12 participants who were aged 11–14 years, N = 83 aged 15–17 years and N = 30 aged 18–19 years. In each sample, the age was 16.2 (SD = 1.5) years and N = 87 participants were of Swiss origin whereas N = 38 were migrants living in Switzerland.Originally, the forensic sample included all offenders who had been assessed on judicial order at the Forensic Child and Adolescent Outpatient Division, Department of Child and Adolescent Psychiatry, University of Zurich, Switzerland during the years from 2005 to 2008. Of the initial 199 adolescents, 43 were excluded due to missing values (>20%) in one or more questionnaire (see below). An additional 31 individuals were excluded because of either female gender or incarceration. Thus, the final sample included 125 young male delinquents. A total of 67 (53.6%) adolescents in the forensic sample were repeated offenders at the time of the assessment. In terms of the type of delinquency, 43 (34.4%) had been involved in violent offenses, 50 (40%) in property crimes, 54 (43.2%) in one or more current sex offenses and 41 (32.8%) in another type of delinquency. There were 67 (62.6%) multiple offenders.The community sample was based on the original sample of the Zurich Epidemiological Study of Child and Adolescent Psychopathology (ZESCAP) in 1994 with 1964 pupils aged 6 to 17 years, living in the canton of Zurich, Switzerland . From thThe clinic sample consisted of patients attending the Child and Adolescent Psychiatric Service (CAPS) of the Canton of Zurich, Switzerland, during the years 1994 to 2010. Participants included both outpatients and inpatients. From this cohort of 2428 patients, another matched sample of 125 individuals was randomly drawn.The assessment of the forensic sample took place under the order of the referring legal prosecutors and included informed consent from the adolescents. The community sample was collected in the nineties of the last century prior to the existence of an ethical committee in the region of the study. The patient sample came from a large child and adolescent service where parents and adolescents provided informed consent for assessment and treatment.The ZAPPS community study was approved by the local school authorities of the government of the Canton Zurich, Switzerland, at a time when there was not yet existing an official ethical commitee for scientific studies. In addition, the study was based on informed consent of all participating adolescents and their parents. In agreement with the guidelines of the local ethical committee of the Canton Zurich, Switzerland, data from the clinical and forensic samples was collected as a part of the clinical assessment and did not need a special approval by the local ethical committee. When attending the local services, all juveniles and their parents of the clinical and forensic samples provided written consent that their data can be used in an anonymised form for research purposes.The study used the Swiss version  of the YThe Swiss adaptation  of the GThe translated version of the 10-item scale for the measurement of self-esteem by Rosenberg  was usedConsensus diagnoses were obtained for each participant of both the forensic sample and the clinic sample by standardized quality procedures involving the approval of junior clinicians’ diagnoses by senior expert clinicians. Diagnoses were based on the International Classification of Diseases  criteriaEach client attending our unit receives a standardized documentation of data including socio-demographic data, developmental and crime history, psychiatric diagnoses, and offense characteristics. To study the impact of the various offenses, the latter were defined by the following variables: sexual vs. non-sexual offending, history of other previous crimes, reoffending with the same type of delinquency, group delinquency vs. individual delinquency, use of weapon, severity of delinquent act , and use of drugs or alcohol at the time of the offense.2 statistics were used to compare the frequencies of diagnoses in the clinic and the forensic sample. Analyses of offense characteristics within the forensic sample were based on independent t-tests comparing the means of various subgroups.In a first step, multivariate General Linear Models  were used to compare means of self-reported internalizing and externalizing problems, depression, and self-esteem in the forensic, the community, and the clinical sample. The multivariate approach was used to avoid type 1 error. The models were followed by post hoc comparisons of the means by Scheffè tests. Furthermore, ChiAs can be seen in Table The distribution of psychiatric diagnoses in two samples is shown in Table Findings based on various subgroups of specific offense characteristics within the forensic sample are presented in Tables In the present study, the comparison of self-reports showed no differences in internalizing and externalizing problems in non-detained juvenile offenders and the community sample. However, the forensic sample had significantly more depression symptoms and the clinic sample was significantly more disturbed than the other two samples including lower scores in self-reported self-esteem.The analysis of clinical diagnoses revealed that half of the forensic sample had no diagnosis, whereas the clinical patients significantly more often had at least one diagnosis. However, co-morbidity rates were not significantly different in the two samples. When comparing clinical diagnoses in the clinic and the forensic sample, the clinic sample displayed more psychopathology in various domains, whereas the forensic sample showed more conduct disorder diagnoses and borderline intelligence.In the forensic sample, there were more internalizing problems in non-sexual offenders than in offenders with sexual delinquency only. Group delinquency as opposed to individual delinquency, use of weapons, and severe delinquent acts were all associated with higher depression scores. Finally, self-esteem was lower in juvenile offenders with severe delinquent acts.Against our expectations and in contrast to previous findings ,7,8, juvPrevious studies of predominantly detained juvenile offenders found higher rates of psychopathology. Detained juvenile offenders may differ from non-detained juvenile offenders by the higher severity of the crimes they have committed and the presence of psychosocial risk factors for subsequent reoffending . Studies based on incarcerated juveniles found that psychopathology was associated with serious and persistent offending as well as with criminal recidivism ,36. In aWe found that juvenile offenders showed higher rates of depressive symptoms than community controls. These findings are in agreement with previous studies on depression in detained and non-detained juvenile offenders ,11,14,15The discrepancy between the low rate of self-reported externalizing problems and expert-ratings of conduct disorders in adolescent non-detained offenders is noteworthy. The most plausible explanation for this finding may be selective perception of problems in the non-detained offenders. Confronted with their actual judicial problems including legal consequences, these youngsters may be repressing and denying their behavioural problems in the time frame of the past six months as defined by the YSR. Furthermore, the evaluation took place before they had to appear in court, thus potentially leading to a reduced interest in disclosing any existing behavioural and, in particular, externalizing problems. In addition, the higher rate of borderline intelligence in this sample may have contributed to less self-awareness so that the rate of behavioural problems may have been underreported. Similar conclusions may also be drawn from the study by Vreugdenhil et al.  in a samAlthough non-detained juveniles had lower rates of clinically diagnosed affective disorders than the clinic sample, the self-reported rates of depressive symptoms in the former group was higher. In terms of severity, these feelings of depression may have been sub-threshold symptoms without fulfilling criteria of a clinical diagnosis. Higher depression scores were observed in some offenders, in particular in group delinquency rather than in individual delinquent acts, in the group of young offenders using weapons, and in the group with more severe delinquent acts. Similar relations of depression and the seriousness of delinquency have also been found by Howard . It has In contrast to the review by Van Wijk et al. , the preThe present study confirms and expands previous findings on the psychopathology in juvenile offenders by focusing on a non-detained sample including to some extent also juvenile offenders with less severe offenses. All these juvenile offenders received forensic assessment on judicial order. Confronted with the information that the expert report of the psychiatric assessment would be given to the court and in the expectation of a juridical decision, these juvenile offenders may have denied their mental problems. Hence, the present findings may differ from those obtained in studies of juvenile offenders in other setting providing strict confidentially of the findings. The present findings may be typical for forensic practice in general and may also be important for clinical decision making in forensic expert reports.Some limitations of the present study have to be noted. The forensic sample was selective by court decision because not all of the court cases were referred for forensic evaluation. Most frequently, cases with severe delinquency or developmental problems or poor living situations were referred to the forensic unit for further examination or treatment. Furthermore, it has to be acknowledged that self-reports rather than structured clinical interviews were used and that clinical diagnoses were based on expert evaluation using all available information but without formal testing of reliability.However, the present study also has several strengths. The design used the opportunity to compare a forensic sample with a representative community sample as well as with a clinical sample. The findings support the view that only a subgroup of juvenile delinquents suffer from mental problems and disorders which is in contrast to studies based on incarcerated juveniles with higher rates of psychopathology. Clinicians should be aware of a potential denial of mental symptoms in self-reports of juvenile offenders. The clinical implications for this population include the need of accurate clinical assessment so that the non-detained juvenile offender may also become more aware of his behavioural problems associated with his delinquent acts. Juvenile offenders may benefit from offence-oriented therapy even if psychiatric treatment is not indicated .None of the authors has any competing financial interests relating to the content of this article.DI and HCS designed the present study. HCS was the principal investigator and CWM the research associate of the original Zurich Epidemiological Study of Child and Adolescent Psychopathology (ZESCAP). CB was responsible for the design of the forensic psychiatric documentation system including the offense data system. DI and MA performed the statistical analyses. DI drafted the manuscript and MA, CB, and HCS made substantial contributions to the final manuscript. All authors read and approved the final manuscript.


The relationship between smoking and pulmonary fibrosis is under debate and intense investigation. The aim of this paper is to review the existing literature and identify further areas of research interest. Recently the negative influence of cigarette smoking on IPF outcome was highlighted, as non-smokers exhibit a better survival than ex-smokers and combined current- and ex-smokers. In patients with non-specific interstitial pneumonia (NSIP), a high prevalence of emphysema was recently demonstrated, providing an indirect support for a smoking pathogenetic hypothesis in NSIP. The coexistence of pulmonary fibrosis and emphysema has been extensively described in a syndrome termed combined pulmonary fibrosis and emphysema (CPFE). Connective tissue disorders (CTDs) are a group of autoimmune diseases which affect the lung, as one of the most common and severe manifestations. However, the relationship between smoking and autoimmune disorders is still conflicting. Rheumatoid arthritis results from the interaction between genetic and environmental factors, while the best established environmental factor is tobacco smoking. Smoking has also a negative impact on the response of the RA patients to treatment. The aforementioned smoking-related implications give rise to further research questions and certainly provide one more important reason for physicians to advocate smoking cessation and smoke-free environment. Smoking is one of the most prevalent and addictive habits, affecting billions of people and influencing their behaviour. The health risks and effects of tobacco smoking are well known, and their span affects multiple systems of the human body. The direct pathogenetic relationship between cigarette smoking and certain respiratory diseases such as emphysema, chronic obstructive pulmonary disease (COPD), and lung cancer is well documented . Regardiα resulted in major changes in the lungs of the animals, including both fibrosis and emphysematous-like airspace dilatations, thus resembling a possible experimental model of CPFE [Recently Katzenstein et al. reported the presence of frequent and often severe fibrosis in cigarette smokers undergoing lobectomy surgery for lung cancer with no clinical evidence of interstitial lung disease . This ty of CPFE . Although cigarette smoking is believed to be a risk factor for the development of IPF and the disease is known to occur more frequently in smokers , 8, therγ-) inducible protein of 10 kDa (IP-10), in lung fibroblasts from patients with IPF, via histone H3 hypermethylation [Another possible effect of smoking in IPF development, outcome, and response to treatment could be related with the regulation of inflammatory genes. Posttranslational modifications of histone proteins in chromatin structure play a central role in the epigenetic regulation of gene transcription. Histone acetylation and methylation are the two most common and best characterized modifications that function as specific transcription regulators. In interstitial lung disease, the high level of oxidative stress may impair histone deacetylase-(HDAC-) 2 activity, and we know that cigarette smoke induces acetylation of histone H4 and decreases HDAC2 activity and expression . Recentlhylation . More imTobacco smoking has serious effects on both the innate and the adaptive immunity. It is associated with multiple proinflammatory effects favouring allergic and autoimmune reactions and also immune-suppressive effects predisposing to a lower activity of the immune system against infections. The relationship between smoking and autoimmune disorders is conflicting. Environmental factors and exposures including infections, vaccines, drugs, and smoking have been involved in the complex pathogenesis and clinical development of autoimmune disorders . ConnectIn a very recent study the effect of smoking regarding the respiratory outcome has been evaluated in a cohort of smokers  and non smokers with systemic sclerosis (SSc) . The autIn the past ten years the role of cigarette smoking in the pathogenesis, progression and outcome of interstitial lung disorders, both idiopathic, and secondary, has been elucidated. A number of smoking-related pathogenetic implications are now being established giving rise to further research questions. The interaction of smoking and genetic susceptibility in the pathogenesis of lung fibrosis is multiple and complex. The issue of smoking affecting the patients' response to treatment has to be addressed, in order to provide therapies tailored to different patient groups needs. Furthermore smoking could be associated independently with serum or BAL biomarkers providing insight in the outcome of fibrotic lung diseases. It is important to remember, however, that, apart from investigating smoking-related pathogenetic pathways and other harmful consequences, all physicians have to advocate smoking cessation and a smoke-free environment.


Babesia. The disease is endemic primarily in the Northeast and upper Midwestern United States. The genus Babesia comprises multiple species of apicomplexan parasites that infect red cells of many vertebrate hosts. Babesia divide and replicate in the hosts' red blood cells and are called piroplasms due to their pear-shaped appearance within the RBCs  Babesia from donor blood Babesia (TTB) Babesia in Giemsa smears had detectable amounts of B. microti DNA in their blood for three months B. microti may become resistant to azithromycin-atovaquone in highly immunocompromised patients B. microti is known to survive and remain viable under blood storage conditions (4°C) for up to 35 days in RBCs and indefinitely in cryopreserved RBCs In the United States, almost 5 million recipients undergo blood transfusions annually. These transfusion recipients are at potential risk of exposure to transmissible pathogens like Babesia has resulted in the current complete dependence on a donor response questionnaire to safeguard the nation's blood supply.The current strategy of blood screening, nationwide, to prevent transfusion-transmitted babesiosis (TTB) relies on a donor questionnaire to identify potential deferrals B. microti exploit the gene encoding 18s rRNA as the template Babesia detection.The major barrier to preventing parasite transmission is the absence of a licensed assay to detect the parasite in blood donors. At the diagnostic level, there are both antibody and DNA detection tests available that are not suitable for blood donor screening for a number of reasons. The qPCR detection assays for Babesia is an intra-erythrocytic parasite, PI technologies would have to target the red cell component of the blood. No pathogen reduction technology for RBC units is commercially available at the present time, although there are two major platforms that are poised to change this status. The first is a technology  based on the use of S-303, an intercalator group that inserts into the helical region of the nucleic acid, an effector group that allows covalent modification of nucleic acid, and a central frangible bond that allows degradation of the compound Babesia species Pathogen reduction and inactivation technologies represent a different approach from testing donors for recognized pathogens. If sufficiently broad-spectrum and robust, they may prevent transmission of many emerging blood-borne infectious agents in the future, if they do not harm the recipient or blood component. Multiple pathogen inactivation (PI) technologies for the treatment of platelet or plasma components have been developed and are in routine use, based on methylene blue, psoralen, and riboflavin technologies. As In summary, TTB has become one of the most commonly reported transfusion-transmitted infections in the United States. Thus, there is an urgent need to develop sensitive and specific methods for screening for this pathogen or alternative methods for eliminating it from the blood supply. Uncovering the basic biology of the parasite, including the identification of immuno-dominant antigens that could be used in designing more sensitive screens, may represent the path forward.


Objective. We report a rare and unusual case of bronchial carcinoma presenting with symptoms of complications of sinonasal disease. Case Report. A 66-year-old lady was referred with a 1-week history of progressive ocular pain, chemosis, and visual disturbance. Computed tomography of the paranasal sinuses revealed frontal and ethmoidal sinus opacification with orbital involvement consistent with a diagnosis of orbital cellulitis secondary to sinusitis. Surgical exploration revealed that the sinuses and right orbit were filled with soft tissue and subsequent histopathological examination of the biopsies indicating metastases from an adenosquamous bronchial carcinoma. Further imaging revealed a large, asymptomatic, bronchial primary with deposits in the brain and liver. The advanced presentation of the disease limited treatment to best supportive care. Conclusion. Orbital cellulitis and sinonasal malignancies have a similar pattern of clinical presentation, posing a potential diagnostic pitfall. There are only two previously reported cases of metastatic lung carcinoma in the frontal sinus with 15 cases of sinonasal tract involvement reported overall. There are no reported cases of adenosquamous carcinoma in the sinonasal tract. We describe a case of a frontal and ethmoidal sinonasal carcinoma secondary to metastatic primary bronchogenic carcinoma, presenting as a referral for orbital cellulitis. There are two reported cases of metastatic lung carcinoma in the frontal sinus , 2, withA 66-year-old lady was referred to the Ear, Nose and Throat emergency clinic by ophthalmology with a diagnosis of right-sided orbital cellulitis secondary to sinusitis. The patient gave a one-week history of gradually worsening right ocular pain and periorbital swelling with deterioration in vision. She denied any history of nasal obstruction or discharge. She was a smoker of 20 cigarettes per day and consumed in excess of forty units of alcohol per week. Examination of the eye and orbit revealed significant proptosis with peri-orbital erythema and oedema, chemosis, and diplopia. Colour vision was intact but visual acuity was reduced to 6/12. Nasal examination did not reveal any abnormalities.A CT scan of the paranasal sinuses revealed an area of low attenuation within the right frontal and ethmoidal sinuses with soft tissue inflammation medial to the medial rectus muscle within the orbit. Meningeal enhancement was present along the frontal lobe suspicious of an empyema. In addition, there was a ring-enhancing lesion in the right temporal lobe, again suspicious of infection, but metastatic disease could not be excluded. .The patient underwent an endoscopic examination of the paranasal sinuses under general anaesthesia. Exploration of the ethmoid bulla and frontal recess revealed a soft tissue mass but no evidence of pus. This tissue also extended into the orbit where it was biopsied via a Lynch-Howarth incision. With the suspicion of sinonasal malignancy being the underlying diagnosis, a staging CT scan was performed with an MRI of the head.Radiology confirmed the presence of a large right upper lobe lung tumour with hilar lymphadenopathy along with metastases to the brain and liver. Histopathology from the paranasal sinuses and orbit confirmed poorly differentiated adenosquamous carcinoma, suggestive of a bronchial primary. The advanced nature of the disease led to the conclusion that best supportive care would be the mainstay of treatment.This is rare case of nonsmall cell lung cancer (NSCLC) presenting with late ethmoidal and frontal sinus and orbital metastatic disease. It is an uncommon lung malignancy presenting in an unusual fashion by involving a part of the sinonasal tract that is usually spared with metastatic disease.Sinonasal malignancies (SNM) account for less than 1 percent of all neoplasms and only 3 per cent of all head and neck cancers . SNMs moAdenosquamous cell carcinoma of the lung is a rare form of nonsmall cell lung cancer (NSCLC) responsible for approximately 3 per cent of all lung cancers . It exhiNSCLC often presents with symptoms related to local disease such as dyspnoea, cough and haemoptysis but can present with signs of distant metastases, most commonly weight loss, pathological fractures, and neurological symptoms associated with central nervous system involvement.The patient in discussion had no respiratory complaints nor was there a history of previous sinonasal symptoms. The presenting complaints of facial pain and periorbital oedema alongside signs of visual change, chemosis, and proptosis are certainly features of orbital cellulitis; however, the insidious onset is highly suspicious of a malignant cause. The risk factors of heavy smoking and excessive alcohol consumption are further red flag indicators of malignancy.The findings on any imaging requested must always be interpreted with a close correlation to the clinical picture, and it is, therefore, imperative that the request form is completed with all the relevant history. A ring-enhancing lesion on CT can represent abscess formation; however, it is also a feature of primary tumour or metastatic tumour with central necrosis . Metastases from primary lung carcinomas to the paranasal sinuses and orbit are extremely rare with deposits favouring the liver, bone, and brain.Renal cell carcinoma is the most common primary malignancy to metastasise to the paranasal sinuses.The frontal sinus is the least likely paranasal sinus to be involved in metastatic disease, with the maxillary sinus being the most common.Adenosquamous carcinoma is an uncommon type of nonsmall cell lung carcinoma.Visual disturbance and ocular pain with objective evidence of orbital compromise should be treated with a high index of suspicion.It is imperative to provide radiologists with a clear clinical history to facilitate accurate reporting of requests images.Clinicians should be aware of the pitfalls of diagnosis with regards to orbital cellulitis and paranasal sinusitis.


As urban and rural land development become widespread features of the global landscape so an understanding of the landscape requirements of displaced and isolated wildlife species becomes increasingly important for conservation planning. In the Cape Peninsula, South Africa, rapid human population growth, and the associated urban and rural land transformation, threatens the sustainability of the local chacma baboon population. Here we analyse spatial data collected from nine of the 12 extant troops to determine their population-level landscape requirements. We use hurdle models to ascertain the key landscape features influencing baboon occurrence and abundance patterns on two hierarchical spatial scales.Both spatial scales produced similar results that were ecologically reliable and interpretable. The models indicated that baboons were more likely to occur, and be more abundant, at low altitudes, on steep slopes and in human-modified habitats. The combination of these landscape variables provides baboons with access to the best quality natural and anthropogenic food sources in close proximity to one another and suitable sleeping sites. Surface water did not emerge as an influential landscape feature presumably as the area is not water stressed.The model results indicate that land development in the Cape Peninsula has pushed baboons into increasingly marginal natural habitat while simultaneously providing them with predictable and easily accessible food sources in human-modified habitats. The resultant spatial competition between humans and baboons explains the high levels of human-baboon conflict and further erosion of the remaining land fragments is predicted to exacerbate competition. This study demonstrates how the quantification of animal landscape requirements can provide a mechanism for identifying priority conservation areas at the human-wildlife interface. The primary goal of ecologists is to understand the ecological factors that determine species distribution and abundance patterns . FurtherHabitat domination by humans , and thePapio) are among the genera exhibiting the greatest degree of spatial overlap with humans . Secondly, baboons gain access to high protein food resources along the coastline by consuming a variety of marine intertidal organisms. Not all local troops have access to the latter food source but troops that spend the majority of their time in the protein-poor indigenous vegetation  routinelPinus plantations, ostrich feed in livestock farms), humans in the Cape Peninsula have introduced many species of invasive alien plants  which hus spp., . Human-mus spp., ,42. ThatBaboons were less likely to occur in urban than in natural habitat despite the abundance of high quality food sources available in both houses and gardens. This is almost certainly a consequence of conflict with humans, with baboons suffering from harassment, injury and mortality when foraging in urban habitat . HoweverHowever, an additional explanation for these results may lie in the statistical procedure of the modelling process. In both the Scale 1 and Scale 2 models the proportion of urban habitat used was much lower than what was available. When the amount of available urban habitat was decreased relative to the habitat use values  the negative effect of urban habitat on baboon occurrence was reduced. This suggests a sensitivity of the occurrence models to large discrepancies between use and availability values. With these discrepancies controlled, as they were in the abundance models, urban habitat was found to be favourable to natural habitat at both spatial scales.A similar pattern was found for agricultural habitat where the occurrence models determined that baboons preferred this habitat to natural habitat, but the abundance models found the preferences for the habitats to be similar. There are two possible - perhaps interacting - explanations for this pattern. First, some crops  have a distinctly seasonal growth cycle and are consequently not used consistently by baboons on an annual basis . Second,Both the occurrence and abundance models revealed that baboons found invasive alien vegetation to be significantly preferential to natural habitat. This result is unsurprising given the 3-10 fold increase in above-ground biomass associated with invasive alien vegetation  and the While food resources play a crucial role in determining primate spatial distributions, their availability to the animals is constrained by their proximity to other critical resources. In affording baboons safety from predators  and provThe baboons' use of trees as sleeping-sites provides an additional explanation for the preference shown for invasive alien vegetation and agricultural habitat over natural habitat. Natural habitat in the Cape Peninsula is characterised by shrublands, grasslands and low trees . By contThe importance of cliff sleeping-sites was also detected by the models. Both models indicated that baboons are more likely to occur, and be more abundant, on steep slopes - the inaccessibility of which provides them with a safe night-time refuge. The coincident preference for steep slopes and low altitudes once again represents the importance of proximity of sleeping-sites to favoured foraging areas. In the Cape Peninsula, slope steadily increases from the 100 m contour line Figure . Becausesensu  where mCurrently, the most widely used method of baboon management is the employment of baboon monitors who attempt to reduce levels of human-baboon conflict by preventing troops from crossing the urban edge . BecauseThe implications of extensive land development for the future of baboon management and conservation are equally concerning. Currently, minimal amounts of the land considered to be ecologically suitable for baboons (probability of occurrence > 0.5) remain undeveloped. This is most pronounced in the northern half of the Cape Peninsula , the Cape Peninsula  observation at the start of the study. Four troops were managed by baboon monitors - people employed by the local management authorities to minimise human-baboon conflict by preventing troops from entering urban areas . We used the same DEM to determine the slope of each cell, and calculated distances to permanent surface water sources using a shapefile  that details drainage systems in the region. We used GIS maps containing landscape information specific to the Cape Peninsula (details below) to categorise habitat for each grid cell. In addition, we used observer records of location-specific habitats, and information gleaned from digitisation of the Cape Peninsula using Google Earth imagery to confirm and identify habitat in areas where the extent and or the detail of the GIS layers was insufficient or inaccurate in its descriptions. The percentage cover of each habitat within every cell was calculated using the Intersect Function of the Geoprocessing Wizard in ArcView 3.3. We converted the percentage values to categorical variables, and assigned habitat categories based on the dominant habitat (> 50% of cover) within each cell. We categorised habitat as natural, urban, agricultural and invasive alien vegetation. Natural habitat, categorised using a shapefile from , includeEcological variables are frequently correlated with each other (multicollinear), and Pearson r values as low as 0.28 have the potential to bias analyses . We usedThe study areas differed in their overall composition of habitats but were similar in their topographic profiles Table . We usedFor all datasets we used hurdle models  to analyCount data is typically modelled using the Poisson distribution, which assumes equality between means and variances . HoweverWe ran occurrence and abundance models for the Scale 1 and Scale 2 study areas. For the occurrence models we used a binomial distribution with logit link, and for the abundance models we used a negative binomial distribution with log link to ensure that the predicted values were always positive . We condb) and spread , where a perfectly calibrated model has b = 0 and m = 1 . These Finally, using the Scale 1 model results, we calculated the absolute and cumulative areas of natural habitat remaining in the Cape Peninsula for each level of probability and each category of predicted abundance.The authors declare that they have no competing interests.TH and JO conceived of, designed and coordinated the study and drafted the manuscript. TH collected the data and performed the statistical analysis. Both authors read and approved the final manuscript.


Due to the increase of cardiovascular diseases acetylsalicylic acid (ASA) has become one of the most frequently prescribed drugs these days. Despite the rising number of patients with ASA medication presenting for elective general and abdominal surgery and the potentially increased risk of hemorrhage in these patients, there are no clear, evidence-based guidelines for the perioperative use of antiplatelet agents. The present randomised controlled trial was designed to evaluate the safety and optimize the use of ASA in the perioperative management of patients undergoing general and abdominal surgery.This is a two-arm, monocenter randomised controlled trial. Patients scheduled for elective surgical treatment  with ASA as a permanent medication are randomised equally to perioperative continuation or discontinuation of ASA. Patients who are randomised in the discontinuation group stop the administration of ASA five days prior to surgical treatment and start intake of ASA on postoperative day 5. Fifty-two patients will be enrolled in this trial. The primary outcome is the incidence of postoperative bleeding and cardiovascular events at 30 days after surgery. In addition a set of general as well as surgical variables are analysed.This is a randomised controlled two-group parallel trial designed to assess the safety and optimize the use of ASA in the perioperative management of patients undergoing general and abdominal surgery. The results of this pilot study build the basis for a confirmative randomised controlled trial that may help to clarify the use and potential risk/benefits of perioperative ASA medication in patients undergoing elective surgery.ISRCTN45810007.The trial is registered with Current Controlled Trials  The individual risk for perioperative bleeding in abdominal and general surgery is influenced by multiple factors. Such factors include extent and type of surgery as well as patient-related features such as age, co-morbidities and perioperative medication. Considering the current demographic development surgeons are being confronted with older patients presenting with multiple co-morbidities and medications. Antiplatelet agents and in particular acetylsalicylic acid (ASA) were shown to be beneficial in a variety of atherothrombotic diseases -4 and arRandomised controlled trials (RCT) that allow evidence-based recommendations regarding the perioperative use and risk of ASA in general and visceral surgery are still lacking. Therefore, the decision to balance possible thromboembolic risks after withdrawal of ASA versus bleeding risks after continuation of ASA during the perioperative period is rather based on the individual experience and personal opinion of the treating physician and/or surgeon.Apart from severe bleeding episodes complicating the clinical course after an operation, thromboembolic events also account for serious consequences for the individual patient. Presumably, the routinely performed discontinuation of the regular ASA medication in the perioperative setting entails to an increased incidence of thromboembolic events. Retrospective analyses have shown that acute cardiovascular events occur in 2-10% of patients after perioperative discontinuation of ASA, mostly within the first eight days after stopping the long-term anticoagulation regimen.This is a randomised controlled two-group parallel trial designed to assess the safety and optimize the use of ASA in the perioperative management of patients undergoing general and abdominal surgery. The results of this trial will be used to perform a valid power calculation and to design a confirmative RCT with a higher number of enrolled patients. This may help to clarify the use and potential risk/benefits of perioperative ASA medication in patients undergoing elective surgery.This study has been designed as a prospective randomised controlled, single centre trial with two study arms.After the study has been approved by the ethics committee of the University of Heidelberg and registration of the protocol at an international registry (ISRCTN45810007) patients on continuous medication with ASA undergoing elective general or abdominal surgery at the Department of General, Visceral and Transplant Surgery, University of Heidelberg, Germany are being screened for participation in this study. Randomisation is conducted using opaque, serially numbered envelopes. The envelopes are being supplied by the Clinical Trial Centre of the Department of Surgery, University of Heidelberg, Germany.This study includes patients over 18 years of age who require long-term ASA therapy and are scheduled for the following procedures:Inguinal Hernia Repair 1.) Cholecystectomy (open and laparoscopic approach)2.) Elective Colorectal Surgery 3.) Written informed consent is obtained prior to inclusion into the trial.Patients with ASA medication who were advised to continue antiplatelet therapy throughout the perioperaive period due to medical indication  or who were cardiologically evaluated as being a high-risk patient were excluded from this trial. Moreover, emergency procedures, simultaneous participation in another clinical trial, withdrawn or missing written consent and/or a mental condition rendering the subject incapable of understanding the nature, scope, and consequences of the trial lead to exclusion from this study. The eligibility criteria are:- Age equal or greater than 18 years-Patient has given written informed consent-Patient is scheduled for elective surgery based on an indication for either inguinal hernia repair, cholecystectomy or colorectal surgery procedures-Patient treated with ASA on a long-term-medication basis-Low- or intermediate-risk patient according to cardiological evaluation-High-risk patient according to cardiological evaluation -Emergency procedure-Withdrawn or missing written consent-Simultaneous participation in another clinical trial with interference of intervention and outcome-Severe psychiatric or neurologic diseases or a mental condition rendering the patient incapable of understanding the nature, scope, and consequences of the trial.-Concomitant treatment with coumarin-type-anticoagulation or clopidogrelPatients are randomized into one the following two study arms:Arm 1: Continuation of ASA during the perioperative periodArm 2: Discontinuation of ASA five days prior to surgery and resumption of ASA intake on postoperative day 5.The primary objective of the present randomised controlled trial is to evaluate the safety of continuous use of ASA during the perioperative period of patients undergoing elective general and abdomina surgery with the ultimate aim to generate high-quality data for the development of evidence-based guidelines on the perioperative use of ASA.The primary outcome is the incidence of perioperative bleeding episodes and clinically apparent thromboembolic events within 30 days after surgery. Secondary endpoints are the duration of the surgical intervention, intraoperative blood loss, transfusion requirements, length of hospital stay (d), medical and surgical morbidity, and the necessity of readmission.Owing to the lack of data that would allow a valid sample size calculation, the present trial was designed as a randomised controlled pilot trial. A total of fifty-two consecutive patients with continous low-dose medication of ASA, who are scheduled for elective general and abdominal surgery, are enrolled in the present study and randomly allocated to either study arm. This pilot trial generates data for the power calculation of a subsequent RCT with a confirmative design. For the pilot phase of this trial the number of patients to be enrolled was arbitrary defined by the investigators.The statistical analysis will be performed on the basis of baseline data such as age, gender, type of surgery, complications/adverse effects and duration of hospital stay. There will be a report of the mean and standard deviation for variables with continuous measures, whereas we will report numbers and percent for categorical data. Statistical computations will be performed with JMP  and SPSS .http://www.controlled-trials.com ISRCTN45810007).The ethics committee of the University of Heidelberg approved this clinical study (Reference number S003-2008). The trial is registered at an international study registry The authors declare that they have no competing interests with this study.DA, CR, AR and MK designed the study and wrote the original protocol, PC and NNR help in enrolling patients in this study and MWB and JW are scientifically responsible for the study. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/11/7/prepub