Although social environments may influence alcohol-related behaviours in youth, the relationship between neighbourhood socioeconomic context and effectiveness of school-based prevention against underage drinking has been insufficiently investigated. We study whether the social environment affects the impact of a new school-based prevention programme on alcohol use among European students.During the school year 2004-2005, 7079 students 12-14 years of age from 143 schools in nine European centres participated in this cluster randomised controlled trial. Schools were randomly assigned to either control or a 12-session standardised curriculum based on the comprehensive social influence model. Randomisation was blocked within socioeconomic levels of the school environment. Alcohol use and alcohol-related problem behaviours were investigated through a self-completed anonymous questionnaire at baseline and 18 months thereafter. Data were analysed using multilevel models, separately by socioeconomic level.At baseline, adolescents in schools of low socioeconomic level were more likely to report problem drinking than other students. Participation in the programme was associated in this group with a decreased odds of reporting episodes of drunkenness , intention to get drunk , and marginally alcohol-related problem behaviours . No significant programme's effects emerged for students in schools of medium or high socioeconomic level. Effects on frequency of alcohol consumption were also stronger among students in disadvantaged schools, although the estimates did not attain statistical significance in any subgroup.It is plausible that comprehensive social influence programmes have a more favourable effect on problematic drinking among students in underprivileged social environments.ISRCTN18092805ISRCTN:  Alcohol use is a major cause of mortality and morbidity among young people, being implicated in large proportions of unintentional injuries -4, as weGiven social differences in profiles of alcohol use and the recognized need to reduce the social gap in the burden of risk factors , an evalHowever, this effect has rarely been considered in the evaluation of school-based interventions against alcohol use, for instance comparing intervention's effects between areas with different social level.The purpose of the present study was to analyse whether the social environment at the level of the school area affects the effectiveness of preventive school curricula on alcohol use. The EU-Dap (EUropean Drug Abuse Prevention) study was the first European trial designed to evaluate the effectiveness of a new school-based programme ("Unplugged") for substance use prevention. Participation in the programme was associated with a lower occurrence of episodes of drunkenness and alcohol-related behavioural problems 18 months after baseline, compared to usual curricula, while average alcohol consumption was not impacted ,28.Since the socio economic status of the living environment has been associated with adolescents' educational achievements and health behavior ,30, we hThe EU-DAP trial (ISRCTN-18092805) took place simultaneously in nine centres of seven European countries: Austria, Belgium, Germany, Greece, Italy, Spain and Sweden. The research protocol complied with the ethical requirements foreseen at the respective study centres.The study was a cluster randomised controlled trial among students attending junior high school in the participating regional centres: one urban community from each involved country  and three urban communities from Italy . One-hundred and seventy schools were selected on the basis of inclusion criteria and of willingness to cooperate.Schools were sampled in order to achieve a balanced representation of the underlying average socioeconomic status of the population in the corresponding catchment area. Prior to randomisation schools within each regional centre were ranked by social status indicators and classified, as schools of either high, medium, or low socioeconomic level on the basis of tertiles of the corresponding distribution. This stratification was done independently by each regional centre using the most reliable and recently available data. Different indicators were used Table . IndicatSchools in each centre were randomised to either the intervention or a "usual curriculum" (control) group within the socioeconomic stratum.Students in the intervention group participated in the EU-Dap substance abuse preventive programme consisting of 12 one-hour sessions designed to tackle adolescents' use of alcohol, tobacco and illicit drugs. This new curriculum is based on a Comprehensive Social Influence model , and focIn October 2004, 7079 students aged 12-14 years (3532 in control schools and 3547 in intervention schools) participated in the pre-test survey. Post-test data were collected in May 2006, i.e. at least 18 months after baseline. Data from baseline and follow-up surveys were matched using a self-generated anonymous code , leavinghttp://eib.emcdda.europa.eu/), assessed in 2004. A test-retest evaluation of the survey instrument was conducted during a pilot study [Self-reported substance use, along with relevant cognitive, attitudinal, and psychometric variables, was assessed by an anonymous paper-and-pencil questionnaire, administered in the classrooms without teachers' participation. Students were reassured about the confidentiality of their reports and the anonymous code procedure was explained. Apart from language adaptation, the same questionnaire and assessment procedures were used across all countries and all data collection points. Most questions were retrieved in the "Evaluation Instruments Bank"  to "Very unlikely" (4). In addition, we explored some individual psycho-social characteristics: perceived school performance, exposure to siblings' alcohol use, and perceived parents' tolerance concerning alcohol drinking. The questions used for the assessment of outcomes and predictors have been fully described in previous reports ,35.We dichotomized the frequency of alcohol consumption into "Any current drinking" versus "No current drinking" as well as into an indicator of frequent drinking . Also intentions to drink and to get drunk were dichotomized in "Very likely" or "Likely" versus "Unlikely" or "Very unlikely". Since the baseline prevalence of each alcohol-related behavioural problem and of episodes of drunkenness was very low, we collapsed these responses into two dichotomous outcomes of "No alcohol-related problems" versus "Any problem" in the past 12 months, and "No episodes of drunkenness" versus "Any episode" in the past 30 days respectively. Perceived school performance, based on self-comparison of own grades with those of the classmates, was coded as "Worse" versus "As good or better". Exposure to siblings' alcohol use was dichotomized, and students without siblings were considered unexposed to this influence. Perceived parents' tolerance concerning alcohol drinking was dichotomized into "Would not allow me to drink at all" versus "Others". Assessed socio-demographic characteristics included gender, age, school-grade and the family living situation coded as "Living with both parents" versus "Other living situation".We performed descriptive statistical analyses to summarize the main characteristics of the study sample. We tested the baseline equivalence by experimental condition of outcomes and predictors of interest separately by socioeconomic level using chi-square tests with the appropriate degrees of freedom.Odds Ratios (OR) and their corresponding Confidence Intervals (95% CI) were estimated as measure of association between experimental conditions and behavioural outcomes, separately for each socioeconomic level of the school area. A multilevel logistic regression model was fitted to account for the hierarchical structure of the data with one random effect at the classroom level and one at the regional centre level . We testThe sample consisted of 5541 students, 49.1% of whom were females. Mean age was 13.2 years. At baseline, gender and age distributions differed among social levels (data not shown). Schools in the lowest level had a higher percentage of male and older students. Students in schools of high socioeconomic level were more likely than students in other schools to drink at least monthly  and to have intention to drink  while students in schools of low socioeconomic level were more likely to report recent episodes of drunkenness , intention to get drunk , and alcohol-related problem behaviours . The only difference among social levels with regard to the considered psychosocial variables was that students in schools of low socioeconomic level compared to other adolescents were more likely to perceive their school performance as worse than average .Figure Missing information at baseline was negligible for any of the assessed characteristic .Participation in the programme was associated with a significantly lower prevalence of episodes of drunkenness and of intention to get drunk, compared to usual curricula, among students attending schools in low socioeconomic context Table . For botIn a multi-centre trial among European students we found some evidence that the effectiveness of a comprehensive social influence school-based preventive programme on problematic drinking might differ by socioeconomic environment of the school.The differences indicated a higher preventive impact of the curriculum on episodes of drunkenness and intention to get drunk among students attending schools in a socially deprived context, compared to students in medium or high social context. The effects of the programme on the frequency of alcohol consumption and the intention to drink were weak and not statistically significant in subgroups, in line with results on the whole study sample . HoweverThe absence of statistical significance in most interaction tests is compatible with homogeneity of the effects among social strata. However, given the overall pattern of associations, consistently indicating the most favourable effect in areas with low social index, it is also plausible that an existing difference was not detected due to limitations of the study, in particular the imperfect classification of social status of the living environment and the limited sample sizes. Few studies have examined how socioeconomic characteristics influence the effectiveness of substance use school-based prevention. If only life skills training approaches are considered, the evidence is extremely scant and based on observations limited to low social class contexts. In fact, evaluation studies have reported preventive effects on alcohol use in low socioeconomic contexts for Botvin's "LifeSkills Training" -40 as weTo our knowledge, only one recent study has investigated how neighbourhoods influence the effectiveness of a school curriculum in preventing alcohol use . This stA possible explanation for the indication of an effect modification of social environment on problematic drinking in our study is that the curriculum was more relevant to schools with average low socioeconomic status of the population. It is also plausible that neighbourhood disadvantage correlates with lack of educational resources and of social and familial support to adolescents. Therefore, the relative "preventive gain" from school prevention would be higher in these under-privileged contexts.Differential teacher's response to training is another possible explanation. Teachers in schools from socially disadvantaged communities may have taken a greater advantage of the training, improving their capability to conduct interactive teaching to a larger extent than teachers in communities of medium or high socioeconomic status. It is also possible that contamination occurred to a larger extent in control schools from medium or high socioeconomic areas, if these schools conducted other health promoting interventions, based on skill-enhancing methods similar to the "Unplugged" curriculum.There are three major weaknesses in this study. First, the sample size was calculated to study the programme effects on the whole sample. Economic and organizational difficulties made it impossible to sample a number of schools sufficient to explore differential effects across sub-groups. Given the need to employ a multi-level analysis, the study had limited statistical power to detect intervention effects for specific subgroups. Despite the lack of power, tendencies in the results were consistent in indicating a higher effectiveness in socially disadvantaged contexts, with significant interaction for one outcome.Secondly, the participating centres classified the socioeconomic status of school areas using the best locally available indicators and sources of information, that were however different among centres and not validated. This may have lead to measurement error and misclassification of social grouping for some schools. However, since schools in the EU-Dap study were randomised within blocks of social level the misclassification would be independent from the experimental arm as well as from the study outcome. The most probable consequence of this unconditional classification error would be to bias the effect estimates towards the value expected under the null hypothesis, i.e. an underestimation of the effect modification.Thirdly, intervention and control arms within each socioeconomic level differed on some potential confounders related to baseline characteristics, despite the random assignment. This was probably due to group allocation of a relatively low number of schools within each socioeconomic block. Therefore, some residual confounding within strata could be present, although all analyses were adjusted for measured baseline factors that could constitute potential confounders.Lack of information on socioeconomic status at the individual level could also be acknowledged as a limitation. However, this was rather the consequence of a deliberated choice, since children's reports of parental occupation or education are generally not reliable .This was one of the few studies designed to consider differential effects of a preventive programme across socioeconomic groups. In fact, the assignment of schools to treatment or control conditions was accomplished through block randomisation that controlled for environmental socioeconomic characteristic, thus achieving a balanced representation of social strata in the study sample. Also, many different behavioural aspects of alcohol use were investigated.The innovative school curriculum evaluated in the EU-DAP study seems to have a beneficial preventive effect on problem drinking, motivating its further dissemination in schools in lower socioeconomic levels.Since higher prevalence rates of unhealthy behaviours among lower socioeconomic groups contribute substantially to socioeconomic inequalities in health , universThe authors declare that they have no competing interests.FF and MRG designed the study. MPC and MRG drafted the paper. FF and RB contributed to revising the paper. MPC performed the statistical analysis. The members of the EU-Dap Study Group carried out the intervention and collected the data. MPC has overall responsibility for the paper. All authors contributed to and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/312/prepub


Gliomatosis peritonei is an exceptional finding, expecially with onset on the contralaterally ovary. The implant of the mature glial cells has a high risk of relapse, as seen in our case, thus close follow-up of the patient is necessary.This study aimed to investigate an unusual case of immature ovarian teratoma with onset of mature glial cells implanted on the contralateral ovary, a challenge in the diagnosis of the second ovarian tumor. We report the case of a 31- yr-old woman, who developed at the age of 16 an immature teratoma in the right ovary that was surgically removed. Six years later mature glial implants were present on the left ovary and six months later at the level of peritoneum that relapsed after other six months. The patient suffered three surgical resections after the initial one. Paraffin sections and immunohistochemical examinations using antibodies against glial and neuronal antigens were performed. In the teratoma, the neuroectodermal tissue expressed Glial fibrillary acidic protein (GFAP), S100 protein, Epithelial membrane antigen (EMA) and Cytokeratin 34 beta E12 (Ck34beta E12), wheares the implants expressed only GFAP and S100 protein. The immature teratoma is the rarest type of ovarian teratomas.  They are considered the most common germ cells neoplasm. Teratomas comprise a number of histologic types of tumors, all of which contain mature or immature tissues of germ cell  origin. The immature teratoma (IT) is the currently preferred term for the malignant ovarian teratoma composed of a mixture of embryonal and adult tissues derived from all three germ layers. Any type of tissue may be represented. The main component is usually neurogenic, but mesodermal elements are also common. According to WHO, IT is defined as a teratoma containing a variable amount of immature embryonal type  neuroectodermal tissue [gliomatosis peritonei (GP), the implant with glial cells.The ovarian teratomas are represented by mature, immature, and monodermal . Only the first tumor, from the right ovary, expressed Epithelial membrane antigen (EMA) and Ck34beta E 12. IT contains different types of cells, including the immature glial cells, while the gliomatosis contains only mature glial cells  diagnosed with a right ovarian tumor. The tumor has been removed because of suspected malignant risk. Pathologic examination showed an immature teratoma with glial cells. . Extragonadal teratomas are rare and arise from midline structures . Very rarely, teratomas are found in other solid  and hollow  organs . TeratomGliomatosis peritonei (GP) can be defined as the metastatic implantation of glial tissue on surfaces of visceral or parietal peritoneum. GP is a rare situation, characterized by the recurrence of peritoneal implants after the surgical treatment of ovarian teratoma. At histologic analysis, the implants of gliomatosis peritonei resemble benign mature glial tissue with delicate fibrillar processes and scattered supporting cells. Malignant transformation is exceedingly rare [. In the case we presented, the patient associated ovarian and peritoneal gliomatosis, diagnosed six years after the initial removal of the immature teratoma. Paradoxically, patients who have immature ovarian teratomas in association with mature glial implants appear to have a much better prognosis [gly rare . Howevergly rare . GFAP isgly rare . The assgly rare . In the rognosis . HoweverThe mechanism of implantation is unknown and two hypotheses to explain the origin of GP have been proposed. The first hypothesis suggests that GP is genetically related to the associated teratoma, and the cells from the primary tumor relocated through a spontaneous or surgical capsular defect or disseminated via angiolymphatic channels . Capsulain vitro[To determine whether glial implants are genetically related to the associated ovarian teratoma or whether they arise independently, it was studied the genetic profile of ovarian teratomas. Approximately 65% of teratomas are derived from a single germ cell after the first meiotic division with subsequent failure of meiosis 2 or endoreduplication of a haploid ovum . Moleculin vitro. GP has in vitro.The treatment of IT and GP is complete surgical resection, also useful for identifying the presence or absence of malignant lesions and for preventing malignancy transformation of the GP residual fragments. Because the lesions are extensive, complete excision is usually very difficult. Potential for recurrence is high, and therefore requires a careful monitoring of residual lesions using scanning imaging such as computed tomography. In our case, the diagnosis of GP was difficult since it started as a contralateral ovarian tumor diagnosed with MRI. The prognosis of IT heavily depends on the FIGO stage . It is iRecent study indicates that Oct4 might serve as a promising biomarker for the diagnosis of highly malignant cases of immature teratoma because Oct4 expression was exclusively detected in immature neuroepithelium of high-grade immature teratomas . ImmaturImmature teratoma is a malignant tumor of the first decades of life. In some cases, the difficult evolution comes from the association with glial implants, as seen in our case at the contralateral ovary, and the peritoneal level. The glial features are reflected by positive GFAP and S100 protein in gliomatosis, as well as in the primary tumor. In patients with immature teratoma and no evidence of disease recurrence, surgery alone is an effective treatment of the primary tumor. In immature teratoma associated with gliomatosis peritonei, combined chemotherapy is recommended. Surgery and chemotherapy can give longer survival even in recurrent disease. MRI may also have a role in monitoring patients for many years as a safe, reproducible and accurate technique for patients who associated GP.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.The authors declare that they have no competing interest.AGG: have made analysis and interpretation of data, analysis and microscopic image processing in final form for publication; have been involved in drafting the manuscript and revising it critically for important intellectual content; have given final approval of the version to be published. DCT: have made paraffin sections and immunohistochemical examinations, pathological diagnosis and photo mycroscop. MC: have made acquisition and analysis of data; have been involved in drafting the manuscript. CP: have made the design of the study, analysis and interpretation of data and revising the study critically for important intellectual content. All authors read and approved the final manuscript.


Recent studies of the mechanisms underlying plasticity and recovery following neurological injuries have originated innovative lines of research in neurorehabilitation. Additionally, the development of new technologies to facilitate the performance of evaluation and intervention procedures has stimulated research on novel rehabilitation paradigms and more effective rehabilitation strategies. However, translation of novel interventions into clinical practice remains a challenge. Further investigation to evaluate the effectiveness of novel rehabilitation approaches is needed. In this thematic series, six manuscripts summarize the results of current research with focus on evaluation and treatment strategies of relevance in neurorehabilitation. Many relevant areas in the field of neurorehabilitation (NR) have witnessed significant developments over the last two decades. Nevertheless, there are still major challenges that neuroscientists need to address to achieve clinically-relevant results in this field. The manuscripts included in this thematic series deal with two main problems in NR:1) The development of accurate assessment tools for the evaluation of neurological deficits, such as spasticity, sensorimotor impairments, weakness and functional limitations.2) Improvement in therapies aimed at both minimizing chronic deficits and maximizing function after central nervous system (CNS) injury.On one hand, relatively simple techniques that can be easily utilized in the clinic to assess the severity of injuries of the CNS that affect descending motor commands and thus movement control are still lacking. These tools should allow clinicians to accurately diagnose and characterize different deficits and detect changes over time. In addition, the evaluation procedures should be easy to implement and hence applicable in a clinical setting. The outcomes of such evaluation procedures would be used to guide therapies, predict prognosis and monitor changes. On the The 2012 International Conference in Neurorehabilitation (ICNR2012) was recently held in Toledo  and was partially founded by the HYPER project . ICNR2012 aimed to bring together scientists from multiple disciplines with a common interest in Neural Engineering and Rehabilitation. The meeting provided a suitable scientific environment to discuss the latest advances in the field. Assessment and treatment strategies in NR were the focus of many contributions many presentations at the conference. The autThree articles focused on the development of assessment strategies of relevance to the field of NR. Coscia et al. explored how changes in the amount of arm weight support affect muscle activation, kinematics and motor control during arm reaching movements in healthy volunteers. They analyzed the hand, elbow, shoulder and trunk trajectories, and the activation of fourteen muscles of the upper extremity to derive muscle synergies during arm reaching movements in six different conditions or arm weight support. They found that the same eight muscle synergies were consistently observed during the performance of arm reaching movements across different levels of arm weight support. The magnitude of the activation of individual muscles showed a decrease with an increase in the amount of arm weight support. The authors found variability in the kinematic of arm reaching movements across different levels of arm weight support, although no specific trend was associated with the amount of arm weight support.Bravo-Esteban et al. investigated the potential of the electromyographic (EMG) coherence analysis of the tibialis anterior (TA) muscle as a measure of strength, quality of movement during gait and severity of spasticity in subjects with an incomplete spinal cord injury (iSCI). They explored the coherence value within specific frequency bands during isometric, isokinetic and isotonic controlled movements of the ankle. They found that intramuscular 15–30 Hz TA coherence value during isometric contractions generating maximal voluntary torque (MVT) was correlated to residual strength and gait function after iSCI, and that several spastic symptoms were negatively correlated with 10–16 Hz and 40-60Hz TA coherence value during isometric contractions at MVT.Meyer et al. presented results suggesting that pre-trial brain electroencephalographic (EEG) data analysis can be used to predict performance in a reaching task in healthy subjects. In order to measure the learning process, the authors used the normalized time-to-target parameter, defined as the time required to reach the target from the verbal command to begin the movement, divided by the distance from starting to target position. The analysis of EEG data revealed the involvement of brain areas that also play a role in the motor learning process, and that the α/μ frequency band contains the most relevant information to predict intervention outcomes.The remaining three articles are focused on the assessment of different treatment strategies in NR. Marchal-Crespo et al. assessed different robotic training strategies to evaluate the impact of movement error amplification and reduction on motor learning and muscle activation during the performance of a simple task. This study was performed with the robotic system MARCOS, suitable to be used simultaneously with Magnetic Resonance Imaging (MRI). Healthy subjects were asked to train under four control strategies: haptic guidance, no guidance, error amplification and noise disturbance while measuring muscle activation in addition to neuroimaging data. The authors found that strategies adding disturbances and amplifying error enhanced muscle activation and boosted motor learning.Fleerkotte et al. evaluated the effects of an eight-week training program with a prototype of a robotic gait trainer (LOPES) in patients with iSCI, using an impedance control strategy. Improvements in functional outcomes were observed after training, which were retained at an eight-week follow-up. Significant improvements were also observed in the hip joint kinematics. The authors reported that participants showing pre-training lower walking function showed the largest relative improvements.Finally, del-Ama et al. presented a cooperative control strategy for an hybrid exoskeleton (Kinesis) that leveraged robotic actuation and functional electrical stimulation of lower limb muscles. This control approach was tested in healthy subjects showing that the system is able to monitor muscle performance during gait to estimate and manage muscle fatigue while training with the Kinesis system. The authors argue that the system has potential for gait rehabilitation in patients with SCI.Altogether, this thematic series present new approaches to evaluate CNS motor control and innovative treatment strategies in NR. Future research in this field should focus on providing evidence of usability and efficacy in the clinical settings, including a detailed description of the ideal conditions for application of these new NR technologies.


Placement of the Avalon Elite bicaval dual lumen cannula for venovenous extracorporeal membrane oxygenation (VV-ECMO) via the internal jugular vein requires precise positioning of the cannula tip in the inferior vena cava with echocardiography or fluoroscopy guidance. Correct guidewire placement is clearly the key first step in assuring proper advancement of the cannula. We report a case of unexpected wire migration into the right ventricle at the time of final cannula advancement, resulting in right ventricular rupture and tamponade. Transesophageal echocardiography is an important monitoring modality for appropriate placement of the VV-ECMO guidewire and Avalon cannula, and in particular, for early identification of potential complications. The Avalon Elite bicaval dual lumen cannula  has been used for venovenous extracorporeal oxygenation (VV-ECMO) ,2. The cA 53 year old female without significant past medical history developed severe viral pneumonia, with rapid, progressive deterioration in her respiratory status. She developed ARDS and mechanical ventilatory management using ARDS protocol were unable to maintain adequate oxygenation. As a result, bedside VV-ECMO was planned. Transesophageal echocardiography (TEE) was performed to visualize proper positioning of the guidewire and cannula. Using the Seldinger technique, the right internal jugular vein was accessed and a guide wire was placed. Placement of the guidewire into the IVC proved difficult due to repeated migration of the guidewire into the right ventricle. After multiple attempts, the guidewire was visualized to course properly from the SVC to the IVC. After a bolus dose of 5000 units of intravenous heparin was given, the right internal jugular venous access site was dilated. Just as the final dilatation was completed and upon dilator exchange with simultaneous advancement of the 23 French Avalon cannula, TEE lost visualization of the guidewire. Multiple premature ventricular beats were noted and immediately, a new, rapidly enlarging pericardial effusion was detected (Figure Correct positioning of Avalon cannula during placement of VV-ECMO is crucial for avoiding complications and to ensure effective oxygenation. The drainage ports of the Avalon cannula should be in the SVC and IVC optimizing removal of deoxygenated blood, with the infusion port in the mid right atrium directed toward the tricuspid valve optimizing delivery of oxygenated blood directly toward the right ventricle and diseased lung. TEE can be an effective modality in confirming proper positioning of cannula. Once the cannula is placed in the correct position, VV-ECMO using Avalon cannula from the right internal jugular access has significant advantage over conventional femoral-femoral or femoral-jugular VV-ECMO. Since Avalon cannula does not require second femoral drainage cannula, the patient is able to sit up, to receive pulmonary toilet and to participate in limited physical therapy, all of which are important in critically ill patients with ARDS.However, placement of the Avalon cannula may be difficult and has the potential to lead into life threatening complications as described in this report. The guide-wire may not easily advance into the IVC and could migrate across the tricuspid valve and into the right ventricle. This may be caused by the presence of a large Eustachian valve in the right atrium, prohibiting the guidewire passing into the IVC. The wire may curl at the Eustachian valve or in the right atrium and prolapse into the right ventricle. Guidewire malposition should be suspected if there are runs of the premature ventricular complex noted, which should prompt the surgeon to withdraw the guidewire. If the guidewire subsequently migrates to the right ventricle undetected, it could lead to right ventricular rupture from the guidewire, the dilators, or the cannula itself. Avalon cannula placement requires either echocardiographic or fluoroscopic guidance. We use bedside TEE for Avalon cannula placement because most patients requiring VV-ECMO are not stable for transportation to a catheterization or interventional radiology laboratory. Fluoroscopic guidance may however provide better confirmation and continued surveillance of proper guidewire and cannula positioning.In our patient, we suspect that during the dilator exchanges, the guidewire may have been accidentally pulled back from its originally confirmed position in the IVC and/or prolapsed into the right ventricle just as the final Avalon cannula was being advanced, which occurred simultaneously with loss of visualization of the guidewire within the IVC. The complication was quickly recognized as a new pericardial effusion was appreciated, at the same time as attempting to revisualize the guidewire and cannula position. Subsequently cardiac tamponade was recognized before patient lost her blood pressure, and emergent preparation for pericardial window was performed at the bedside without delay, saving the patient's life.TEE is an important bedside imaging modality to guide proper placement of the Avalon cannula for VV-ECMO via the internal jugular vein, and can be essential in the early detection of related complications.Written consent was obtained from the patient for publication of the case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief.ARDS: Adult respiratory distress syndrome; ECMO: Extracorporeal membrane oxygenation; IVC: Inferior vena cava; SVC: Superior vena cava; TEE: Transesophageal echocardiography; VV-ECMO: Venovenous extracorporeal membrane oxygenation.The authors declare that they have no competing interests.HH: conception and design, analyses of data, drafting the manuscript and final approval. KY: analyses of data, drafting the manuscript and final approval. GDM: analyses of data, drafting the manuscript and final approval. NC: analyses of data, drafting the manuscript and final approval. All authors read and approved the final manuscripts.


Single Sample Count' (SSC) to estimate prevalence of discriminating or embarrassing behaviour in epidemiologic studies.An advantage of randomised response and non-randomised models investigating sensitive issues arises from the characteristic that individual answers about discriminating behaviour cannot be linked to the individuals. This study proposed a new fuzzy response model coined 'The SSC was tested and compared to the established Forced Response (FR) model estimating Mephedrone use. Estimations from both SSC and FR were then corroborated with qualitative hair screening data. Volunteers  in a rural area in north Wales and a metropolitan area in England completed a questionnaire containing the SSC and FR in alternating order, and four questions canvassing opinions and beliefs regarding Mephedrone. Hair samples were screened for Mephedrone using a qualitative Liquid Chromatography-Mass Spectrometry method.how many without revealing which ones are true. The two probability models yielded similar estimates with the FR being between 2.6% - 15.0%; whereas the new SSC ranged between 0% - 10%. The six positive hair samples indicated that the prevalence rate in the sample was at least 4%. The close proximity of these estimates provides evidence to support the validity of the new SSC model. Using simulations, the recommended sample sizes as the function of the statistical power and expected prevalence rate were calculated.The SSC algorithm improves upon the existing item count techniques by utilizing known population distributions and embeds the sensitive question among four unrelated innocuous questions with binomial distribution. Respondents are only asked to indicate The main advantages of the SSC over other indirect methods are: simple administration, completion and calculation, maximum use of the data and good face validity for all respondents. Owing to the key feature that respondents are not required to answer the sensitive question directly, coupled with the absence of forced response or obvious self-protective response strategy, the SSC has the potential to cut across self-protective barriers more effectively than other estimation models. This elegantly simple, quick and effective method can be successfully employed in public health research investigating compromising behaviours. Outcome based evaluation of interventions, which play a central role in public health prevention, need to show the effect the policy or intervention makes at the public level. Whilst a plethora of literature focuses on evaluating various social marketing campaigns that tackle public health and safety issues such as drug use, health compromising lifestyle choices, unprotected or risky sexual behaviour, or unsafe driving practices, tend to rely on self reports, regardless of whether or not they were conducted in laboratory or field settings -3. The iThe need to obtain the maximum intelligence on health related behaviours stems from the necessity to develop and deploy optimal intervention measures to counteract consistent failures to attain acceptable levels of behaviour across a wide range of health practices. These range from adherence to medication, resistance to addiction, avoidance of exploration of social drug use through to uptake of illegal and health damaging performance enhancement agents. The immense health, financial and social consequences of enhancing these health related behaviours has led to decades of investigation into improved approaches to obtain accurate data on sensitive personal behaviours.Investigating the epidemiology of socially sensitive or transgressive behaviours such as illicit drug use, unhealthy weight management practices, risky behaviour, cheating, doping or non-adherence to prescribed medication or treatment, is hindered by respondents evasively answering questions about sensitive behaviours . A recenApproaches range from techniques such as the Bogus Pipeline  to proviThe concept behind randomised response models (collectively termed RRT) rests on introducing a randomising element to the survey question by using some device  which determines how the respondent should answer . Since tp and 1-p). Thus compared to the observed pattern of 'yes' and 'no' answers Warner was able to determine the proportion of respondents in the sample admitting the sensitive behaviour.The RRT aims to elicit sensitive, embarrassing or compromising information that may portray respondents unfavourably. The common characteristic of the RRT is that sensitive behaviour estimation can only be made at the aggregated population level. The method is based on the principle introduced by Warner  using a Subsequent adaptations of the RRT have covered a wide range of sensitive issues along with numerous attempts to refine the approach . Among tResearch has shown that whilst respondents understand the reason behind the use of the RRT approach in surveys, they generally find it obtrusive and favour simpler approaches . ContrarThe non-randomised model (NRM) has received increased attention lately. A recent review  showed tAlternative approaches have been progressively developed which preclude the need for the randomising device. These include an item count method , later tone of the two statements is true but which one remains hidden. Similarly, the Hidden Sensitivity (HS) model for two sensitive questions with binary outcomes using one quadrant such as season for birthday or geographic location  )The major advantage of the Single Sample Count method over other models such as the Forced Response model is rooted in its simplicity, equal face validity for each respondent, simple calculations and maximum use of the data. This elegantly simple, quick and cost effective method can be successfully employed in public health research aiming to establish the epidemiology of potentially compromising behaviours. Notwithstanding, this approach, akin to other randomised and non-random models, is suitable to establish group level prevalence.The authors declare that they have no competing interests.AP and DPN initiated the project. AP devised the study, contributed to analyzing the data and prepared the first draft of the manuscript. PC, HT and CA collected the data and contributed to the final draft of the manuscript. TN, MS and JS analysed the survey data and provided the additional statistical information. SH, ND, DPN and JB developed the method for and conducted the hair analysis; and prepared the relevant section of the manuscript. All authors have contributed to drafting the paper; read and approved the final version of the manuscript.


Intensive care units (ICUs) play an important role in MRSA epidemiology. Although successful interventions are usually multimodal, the relative efficacy of single measures remains unknown. We developed a mathematical model to explore the transmission dynamic of MRSA and assess several control strategies.A discrete time individual-based stochastic model was built and calibrated on the number of crosstransmissions obtained through prospective surveillance. Most of the input parameters were derived from locally-acquired data. After model fitting and sensitivity analysis, several screening and isolation policies were tested by simulating the number of crosstransmissions and isolation-days under various scenarios.The three unknown values were fitted to the model. Under the used assumptions, the environment played a negligible role. The number of crosstransmissions increased by almost 40% if only alert patients are screened and isolated, by about 50% if isolation is put in place only after the results of the admission screening become available, and over 60% in the absence of admission screening and isolation. The method used (culture or PCR) for admission screening had no impact on the number of crosstransmissions. Systematic regular screening during ICU stay provided no added-value.Aggressive admission screening and isolation are effective to reduce the number of crosstransmission. Colonized HCW may play an important role in MRSA transmission and HCW screening should be reinforced.None declared.


Constant technological advances have allowed scientists in biology to migrate from conventional single-omics to multi-omics experimental approaches, challenging bioinformatics to bridge this multi-tiered information. Ongoing research in renal biology is no exception. The results of large-scale and/or high throughput experiments, presenting a wealth of information on kidney disease are scattered across the web. To tackle this problem, we recently presented the KUPKB, a multi-omics data repository for renal diseases.In this article, we describe KUPNetViz, a biological graph exploration tool allowing the exploration of KUPKB data through the visualization of biomolecule interactions. KUPNetViz enables the integration of multi-layered experimental data over different species, renal locations and renal diseases to protein-protein interaction networks and allows association with biological functions, biochemical pathways and other functional elements such as miRNAs. KUPNetViz focuses on the simplicity of its usage and the clarity of resulting networks by reducing and/or automating advanced functionalities present in other biological network visualization packages. In addition, it allows the extrapolation of biomolecule interactions across different species, leading to the formulations of new plausible hypotheses, adequate experiment design and to the suggestion of novel biological mechanisms. We demonstrate the value of KUPNetViz by two usage examples: the integration of calreticulin as a key player in a larger interaction network in renal graft rejection and the novel observation of the strong association of interleukin-6 with polycystic kidney disease.The KUPNetViz is an interactive and flexible biological network visualization and exploration tool. It provides renal biologists with biological network snapshots of the complex integrated data of the KUPKB allowing the formulation of new hypotheses in a user friendly manner. During the past decade major advances in biological research, mainly in the field of high throughput analysis (e.g. –omics), has led to an exponential increase in available experimental data, produced through a variety of techniques including DNA, miRNA and antihttp://www.kupkb.org.The renal biology field is facing similar problems. Although kidney diseases have been extensively studied in different species , this wealth of information remains hidden across several layers of public data and/or literature repositories. Although considerable effort has been devoted in aggregating data from several resources-7, the rThe iKUP comprises a powerful tool in terms of speed, selectivity and descriptive power. Nevertheless, its nature restricts the user to viewing the query results in tabular format, only skimming the surface of the rich interconnected data otherwise available in the KUPKB. In addition, although it succeeds in displaying findings hidden in scattered repositories, such as the expression of a set of genes under a very specific combination of kidney tissue, cellular type and disease, it remains unable to map this information to interaction networks available as background information and in a multiple species manner.The value of biological network representations has been extensively analyzed in bioinformatics and systems biology literature,11. SomeIn this article, we describe KUPNetViz, an interactive biological network querying and visualization application. Its main purpose is to assist renal scientists to extend their research by providing an alternative KUPKB data image depicting interactions among the queried molecules and their neighbors, coupled with functional and biochemical pathway annotation in both a species dependent and independent manner. The main tasks supported and promoted by KUPNetViz are: i) the display, exploration and manipulation of general protein-protein interaction as well as functional and biochemical pathway association networks for a number of widely studied mammalian species, ii) the transformation of these general networks to kidney specific networks through their association with related gene/protein/miRNA expression datasets, iii) the mining of possibly hidden relationships among co-regulated and/or directly interacting (“neighboring”) entities under several combinations of kidney anatomies and/or disease models and iv) the extrapolation of both expression data and network interactions across different diseases, anatomies but also different species facilitating the quick formulation and screening of biological hypotheses and the design of new experiments.The molecule and interaction visual representations in KUPNetViz have been inspired by previous work in the field with sevhttp://www.jquery.org) coupled with static HTML for the client side. The backend of the application is a MySQL database hosting the background knowledge used to build the mappings among entities, the network interactions, annotation data and properly parsed experimental data that make up the most important part of the KUPKB. The backend database can be very easily updated and maintained as it can be rebuilt in an automated fashion with a single one-line command, through a series of Perl scripts that download, parse and import KUPKB data and the background knowledge resources into the schema, using a wrapper script and a simple YAML (http://www.yaml.org) configuration file. The resulting interaction networks from user queries along with experimental data mappings  are rendered, visualized and controlled using the Cytoscape Web graph visualization library)The reasoning behind the construction of a MySQL backend database to support the application instead of using the KUPKB semantic web repository includes three main arguments: firstly, during the development we sought to maintain software modularity and re-usability even though in its current version, the visualization application is adjusted to kidney. Thus, we considered that an RDB model  can be adjusted easier to other similar experimental data sources (e.g. a different organ) or data sources of different structure (e.g. multi-omics data from different types of cancer), requiring minor modifications only in the user interface part. Secondly, not all the background knowledge data sources that are used by the KUPNetViz were initially incorporated in the semantic web model (e.g. the protein-protein interactions or the reference pathways). This does not suggest a KUPKB model design problem but rather highlights the different initial purpose of the model which was not network visualization, but the detailed knowledge representation of kidney anatomies and disease models and the experimental data mapping and annotation to this knowledge representation model. Finally, during the design process, we realized that not all of the knowledge stored in the semantic web repository  was required for the minimalistic approach promoted by KUPNetViz. Thus, we used an RDB model to reduce query complexities and running speeds. In addition to the latter, the backend database building time, including the download and parsing of the background knowledge files and the re-parsing of the experimental data requires less than three hours while the rebuild of the semantic web repository requires over a day (the times were measured on the same computer). This allows the easier maintenance of the KUPNetViz and the more frequent synchronization of the backend database with the latest releases of the incorporated background knowledge sources.KUPNetViz is a user-friendly biological network visualization tool dedicated to renal research. This tool uses data gathered from multiple resources on several renal pathological states and background knowledge elements regarding biomolecular interactions as well as functional and biochemical pathway associations and creates biological network snapshots that can shed light on mechanisms involved in renal disease. It provides renal biologists with an alternative network data representation, complementary to the functionality of the iKUP exploration tool with a small cost regarding the display complexity. Moreover, maybe its most important feature is the biomolecular interaction extrapolation across species which allows the researcher to quickly formulate and screen several hypotheses in a simple manner. We have demonstrated the value of KUPNetViz in two case studies, further investigating the role of calreticulin as a key player in a gene network mostly up-regulated in renal graft rejection and newly investigating the potential involvement of IL6 and the IL6 receptor in the progression of polycystic kidney disease.The value of the KUPNetViz in kidney research will be increased in parallel with the number of related public multi-omics datasets which will be also available in the KUPKB. The expertise of the KUPNetViz hosting group in renal biology guarantees its constant curation and addition of related datasets, as these are getting published. This will potentially lead to increased confidence in the observed networks as additional biological evidence will eventually pile up from those constantly added datasets. The addition of datasets is easy and straightforward, since data are entered in ready-to-fill Excel sheets by biologists and incorporated by a single command line. We are aiming to the inclusion of the latest omics data sets in the KUPKB at least once a year from which the KUPNetViz will directly benefit from. Future extensions include the incorporation of additional biomolecule annotation and interaction resources (KEGG compounds) and the addition of a module that will identify highly enriched and over-represented biological functions and biochemical pathways using the StRAnGER algorithm.Home page: Accessible through the website of KUPKB and the iKUP browser  athttp://www.kupkb.org or directly athttp://www.kupkb.org/vis/index.php.Operating system: KUPNetViz is a web-based application thus it is platform independent.Requirements: KUPNetViz is best used and viewed under Internet Explorer 8 or higher, Mozilla Firefox, Google Chrome, Apple Safari and Opera. The use of Internet Explorer 7 and lower is not recommended.License: KUPNetViz is free for academic use but requires a license from the authors for any commercial purposes. The software is available without user registration.Further information: An analytical user’s guide coupled with usage examples is available at the application’s homepage and as supplementary material online (Additional fileKUP: Kidney and urinary pathways; KUPKB: Kidney and urinary knowledge base; KUPNetViz: Kidney and urinary pathway network visualizer; GO: Gene ontology; KEGG: Kyoto encyclopedia of genes and genomes; PKD: Polycystic kidney disease; CKD: Chronic kidney disease; IL6: Interleukin 6; IL6R: Interleukin 6 receptor; RDB: Relational database.The authors do not declare any conflicts of interest.PM conceived, designed and implemented the software as a whole, tested the software and drafted the manuscript. JK and JPS tested the software, suggested interface modifications, performed the case studies and contributed in drafting the manuscript. SJ and RS contributed to the database design and the integration of KUPNetViz to the iKUP browser. JB contributed in drafting the manuscript and data management. All authors have read, revised and approved the manuscript.An example of KUPNetVis multispecies view. Three snapshots of a simple KUPNetViz network presenting the multispecies view, either with ‘supergenes’ encompassing orthologs among the supported species, or with collapsed ‘supergenes’ for simplified view.Click here for fileThe KUPNetVis user guide. An extensive user guide presenting all the features of the application with additional examples.Click here for file


A statistically significant improvement in birth weight of the newborn was observed in the intervention group, where expectant mothers were made aware about desired nutrition during pregnancy. A reduced incidence of complications associated with pregnancy was also observed in the intervention group. Providing awareness about nutritional requirements during pregnancy and suggesting the pragmatic ways to meet them was shown to be one possible effective measure to deal with pregnancy-related undernutrition. We show the efficacy of the intervention for underprivileged regions of India marked by inadequate health care delivery and lower socio-economical standards. We discuss our findings in the context of available evidence-based guidelines.Poor maternal nutritional status and substandard antenatal care, which result in increased women's risk, low birth weight and stillbirth, afflict many countries with weak or emerging economies even today. Studies that address the effect of extending nutrition awareness among pregnant women to the net outcome of pregnancy remain scarce. We aimed to compare and contrast the effect of a pragmatic nutrition awareness program for expectant mothers (NAPEM) on birth weight of the newborn with a control group who received no such nutrition awareness activity. The effect of variables of mode of newborn delivery, associated complications at birth, and APGAR score of the newborn were also assessed. A pragmatic intervention trial of an antenatal care (ANC) program that consisted in nutrition awareness was conducted involving 53 pregnant women. Awareness was given through one-to-one interview and through informational literature provided to the participants in the local language. A hospital registry for deliveries undertaken during the study period was screened for identification of variables. A control group of matched pregnant women ( Improving the health of pregnant women is critical to their prospects of surviving pregnancy and childbirth and to their long-term health. It is also pivotal to improving the survival and health of children . It follIn developing countries, maternal undernutrition is a significant cause of pregnancy-related poor outcomes including maternal mortality, low birth weight and stillbirth . India, Iron and folate distribution to expectant mothers through primary healthcare centers is the usual method of nutrition interventions during pregnancy in India. However, this distribution is limited to those women who are availing an antenatal care (ANC) at a health care facility. In India, a regular ANC at a healthcare facility is poorly delivered and largely unsuccessful, particularly in rural areas where the healthcare delivery system is scarce making the situation gloomier. The National family health survey (NFHS)-3 of India indicates that only 77% pregnant women have at least one ANC at a healthcare facility during their pregnancy. In certain States in India, where gross inequality of healthcare exists, this percentage can drop as low as 34%. A poor distribution of iron and folic acid among those receiving ANC (only 65% receive such a supplementation) and an additional poor compliance to supplements (only 23% take the supplementation for recommended 90 days) further contributes to poor nutrition during pregnancy in India [Taken together, these findings suggested an alternative approach to deal with pregnancy-related undernutrition. Specifically, the purpose of our study was to test whether or not an effort to increase awareness about nutrition requirements during pregnancy could help significantly in improving the nutrition status among pregnant women in terms of birth weight of the infant. It was hypothesized that extending awareness about actual nutrition requirements during pregnancy and suggesting their pragmatic solutions would eventually lead to a better self-care among pregnant women . We outlIn support of our hypothesis, a Cochrane systematic review had identified five studies upon 1134 pregnant women provided with advice for an improved protein and energy intake as the only intervention during pregnancy. The effects were analyzed in terms of nutritional status and net pregnancy outcomes. Overall, the reported evidence-based findings showed significant positive changes in the mothers' nutritional status, but inconsistent outcomes with respect to net pregnancy outcomes [In a translational mode, we crafted a novel intervention program based on these evidence-based results, which provided greater awareness about practical, economical and locally customized approaches to meet the nutrition requirement during pregnancy. We pilot-tested this pragmatic Nutrition Awareness Program for Expectant Mothers (NAPEM) in the pragmatic clinical trial reported here. We evaluated the outcome of NAPEM by contrasting birth weight of the newborn among the expectant mothers in the intervention group, comparing them with a group of matched control infants born of mothers at the same healthcare facility, who did not undergo NAPEM. We discuss our findings in the context of recent systematic reviews, which, taken together, provide compelling grounds for newly revised evidence-based clinical practice guidelines.A pragmatic trial was designed to explore the effects of an indigenized NAPEM. The NAPEM program contained two key elements. First, it provided awareness regarding actual nutrition requirements during pregnancy. Second, it proposed a practical and an economical approach that was specific and appropriate to the indigenous culture, site and locale, and that aimed specifically to meet the nutritional requirements during pregnancy. This component of NAPEM also contained specific inputs to assure optimal availability of the desired nutrients during pregnancy through appropriate food combinations, cooking and intake methods.To ensure proper delivery of the NAPEM intervention, an active program was devised that included extending one-to-one interaction with all the expectant mothers receiving ANC at a healthcare facility. The participants were provided with a supplementary take-home brochure containing the key messages designed in their local language. These dietary instructions were supplementary to conventional ANC recommendations at the healthcare facility, which included the medications recommended for the ANC.Following launch of NAPEM, initial intervention was provided to every pregnant woman who had attended the outdoor care at the healthcare facility. Actual outcome was measured by observing the hospital registry for maternity services after 3 months of launch of the NAPEM program and continued for 3 months thereafter.Birth weight of the newborn was used as the key outcome variable for evaluating impact of the program, however the mode of delivery be, associated complications during pregnancy or at the time of delivery; the APGAR scores of the newborns were also recorded.n = 53) were evaluated, and compared with control pregnant women (n = 53). The control group was identified through the hospital registry for a corresponding period in the preceding year when no such nutrition awareness activity was observed in the hospital. In order to match the women in the intervention and the control groups, subjects were assigned to the control group as they were receiving the similar ANC from same hospital but were devoid of the gains of any additional nutrition awareness program. The program was designed in adherence to ethical standards, and an approval of ethics research committee was obtained. Informed written consent from patients participating in active intervention was obtained prior to their participation in the study.Expectant mothers fulfilling the inclusion criteria  accredited level 2 maternity healthcare facility at Lucknow, India. NAPEM was launched on February 1, 2009. The hospital registry for deliveries conducted from May 1, 2009 to July 30, 2009 was screened for study. Age of the mother, mode of delivery, associated medical illness, complication occurred during delivery, APGAR score of the newborn 1 min after birth, and birth weight of the newborn were extracted from the hospital registry. Similar data were collected through screening of the hospital registry for deliveries conducted in corresponding period of the preceding year for the control subjects.Subjects for the intervention and the control groups were selected by screening the hospital registry for deliveries undertaken during a prescribed period. Only term deliveries with records of regular ANC from the same hospital were included. Subjects fulfilling these criteria were included irrespective of age, parity or outcome of the preceding delivery.Attending pediatrician's note for determination of term or preterm babies was used to differentiate term from preterm deliveries. Subjects who were receiving ANC from the hospital were identified by their registration cards.t-test. The level of significance was taken at alpha = 5%.Mode of delivery was expressed as a categorical variable, and analyzed by chi-square analysis (Fisher Exact test for 2 × 2 design). Descriptive statistics (mean ± standard deviation (SD)) were obtained for birth weight. Assumptions for parametric statistics were tested and met, and the means compared by unpaired, equal sample size Descriptive statistics  were obtained for other outcome variables, including complications during pregnancy and delivery and APGAR score.n = 53), presented with the customary ANC but not including the NAPEM intervention under test here, and otherwise fulfilling the eligibility criteria, were taken up from the hospital records of the corresponding period in the preceding year.A screening of hospital registry from May 2009 to July 2009 found 53 deliveries fulfilling the inclusion criteria as determined for study. These subjects, exposed to the NAPEM intervention, were recorded for age of mother, mode of delivery and birth weight of the newborn through the hospital records. Correspondingly, control expectant mothers  and lower segment Cesarean section (LSCS) in both the groups . P <  .05) in birth weight of the newborn, when compared with the control group. The mean birth weight of newborn in the NAPEM intervention groups (mean weight in kg ± SD: 3.067 ± 0.46) was significantly higher than that of the control group (2.860 ± 0.45) (∼207 g (7.24%) higher in the NAPEM intervention group, when compared with the birth weight of infants in the control group. The NAPEM intervention did reveal a significant difference ( ± 0.45) . The birThe data also suggested a trend toward a reduced incidence of complications associated with pregnancy or delivery in the NAPEM intervention group .NAPEM, a first of its kind in terms of both, the fact that it is grounded on evidence-based outcomes and that it addresses culture-specific adoption and intake processes, which are complementary to those ANC traditionally utilized in Western medicine, demonstrated a clear and statistically significant improvement in birth weight of the newborn, when compared with the infant birth weight from expectant mothers who had undergone the traditional ANC, devoid of NAPEM. It is noteworthy, moreover, that the mean birth weight of infants born to mothers in the intervention group (ANC supplemented with NAPEM) 3.067 ± 0.46) was greater than the Indian normal mean birth weight (2.700–2.800 kg) [7 ± 0.46 That no difference was uncovered in terms of modes of delivery  between the groups suggests that a maternal nutrition has little effect upon the mode of delivery performed at a healthcare facility. A reduced incidence of complications during pregnancy in the intervention group further suggests a better positioning of mothers for events of delivery if they are better nourished.The outcomes of the pilot pragmatic trial study presented here suggest a significant value to the nutrition awareness campaign as a mode to intervene in pregnancy-related undernutrition, specifically in terms of improving infant birth weight. Nevertheless, a potential bias from the study may lie in the form of improper selection of the subjects. The two groups of subjects under the study were not evaluated for their corresponding weight gains during the pregnancy period, which could have been taken as a direct measure to observe the impact of nutrition awareness upon the recipients. Furthermore, a nutritional status of the expectant mother at the time of their registration was also not accounted in the study. These threats to the internal validity of our reported observations are compounded by the fact that our sample was obtained from one healthcare facility in India, which limits the external validity of the findings.Parity of the mother is also found to play a significant role in pregnancy-related care among expectant mothers. A better ANC compliance is reported among women with a higher parity . It was Nonetheless, the results of this pilot pragmatic trial strongly suggest that a well-crafted NAPEM intervention can substantially improve perinatal outcome, specifically in terms of infant birth weight. A larger sample size will be needed to establish the statistical significance of other related compelling trends in the data.Despite the limitations of this pilot trial, the study is critical and timely, and provides a significant inference about potential use of extending nutrition awareness as a prospective tool to intervene in pregnancy-related undernutrition. An improved birth weight of the newborn is one of the strongest determinants, which signifies the future prospects of the infant in terms of their survival . A recenConsidering the unabated and unequivocal importance of nutrition during pregnancy and considering the inadequate access to nutritional requirements among Indian women, primarily because of unavailability and secondarily because of lack of awareness, it is important and urgent to establish the foundations of a nutrition program designed to educate women for the possible ways to meet out their requirements through simple modifications of conventional food and also through simple knowledge of certain conventional foods more apt for pregnancy. Incidentally, the knowledge of immuno-modulating effects of food and also the therapeutic values of certain foods, which can also be useful for various pregnancy associated ailments, further underscores the importance of food-related interventions during pregnancy , 17. As In this study, we have proposed NAPEM as a simple nutrition awareness program among pregnant women in a North Indian urban setting. In this paradigm, expectant mothers were made aware of their nutritional requirements during pregnancy, and also of simple domestic measures that could be considered to overcome these nutritional gaps. The NAPEM intervention was evaluated for its clinical outcomes in terms of birth weight, and led to a clear and statistically significant improvement in birth weight of the newborn.Improving the birth weight of newborn and consequently reducing the incidence of low birth weight lowers infant mortality rates and has multiple additional benefits. A recent study estimates the economic gains of reducing the incidence of low birth weight in low-income countries through lower mortality rates and medical costs and through increased learning and subsequent productivity. The estimated economic benefits, under plausible assumptions, are presumed to be fairly substantial. Interventions aiming to improve the birth weight are also warranted for developing countries on the grounds of resource saving and increasing productivity .The State of Asia Pacific Children (SOAPC) 2008 report of UNICEF clearly identifies Indian role in global attainment of the health-related millennium development goals. India's achievements in improving health, nutrition, water and sanitation, education and child protection, gender equality and women's empowerment in the coming years are considered crucial to balance the global health markers [Translational evidence-based medicine must draw novel clinical trial interventions from the best available evidence derived from systematic reviews, as we have done in this study. But, it must as well rejoin, with the findings it obtains, the current state of research synthesis in order to contribute to the formulation and testing of revised and recommended clinical practice guidelines. In this light, it is informative to place our findings, obtained in a hospital setting in India, in the context of evidence-based policies being currently formulated. For example, and based on the best available evidence, it is the opinion of the American Dietetic Association that women of child-bearing ages and pregnant women should maintain good nutritional status through a lifestyle to optimize maternal health and to reduce the risk of birth defects, suboptimal fetal growth and development, low birth weight and chronic health problems in their children . Case inThe findings of the pilot pragmatic trial we report here are particularly important because a cross-national perspective of evidence-based medicine on prenatal care indicates that ANC, while widely used in low- and middle-income countries because it provides a natural facility-based contact through which to provide or educate about many of the interventions, generally yields no or little clear evidence of benefit from a programmatic perspective. Therefore, the vast majority of global stillbirths still occur in countries with weak or emerging economies, because poor nutritional status, lack of ANC and a number of behaviors increase women's risk of low birth weight and stillbirth in many resource-poor settings. Evidence-based recommendations for interventions to reduce these risks have been proposed with the goal to reduce the resulting burden of low birth weight and stillbirths . The eviReferring to the proposal of optimal ANC particular to India, this would be contextual to find a good nutrition-based ANC description in Ayurvedic classics. In recognition to temporal changes in growing fetus and changing nutrition requirement to fetus and subsequently to mother, Ayurveda proposes a monthly dietary regimen to ensure an optimal growth of fetus besides preparing mothers for the upcoming event of child birth. This is important to observe here that these regimen, as recommended during pregnancy, are essentially composed of various food combinations in addition to herbs having feto-protective and promotive actions. Many of these recommendations of Ayurveda providing traditional care to expectant mother are still in vogue as folklore , 26.


Techniques for hepatic surgery have evolved over the past few decades and have broadened indications for liver resection (LR) for liver tumors. New strategies including downsizing chemotherapy, two-stage LR with or without portal vein embolization, and resection combined with ablative methods allow tailoring the treatment to each patient depending on condition of the liver and tumor burden. In the recent years, the new dissector devices have been developed and together with the use of intraoperative ultrasound allow a new approach to the anatomical ultrasound-guided liver resection, even for large tumors located in challenging positions.Improvements in imaging evaluation with high-resolution CT scan or MRI allow new methods for the study of the future remnant liver and play an important role in the planning of the resection strategy reducing the risk of major complications and liver failure, especially in patients who undergo major resection. In addition, development of new technology in local ablative therapies for liver tumors is posing a competition to LR.The incidence of hepatocellular carcinoma (HCC) is climbing rapidly and in a current climate of organ shortage has led to the re-evaluation of locoregional therapies and resectional surgery to manage the case load. The introduction of biological therapies has had a new dimension to care, adding to the complexities of multidisciplinary team working in the management of HCC. S. E. Khorsandi and N. Heaton give a very comprehensive overview of the present day management strategies and decision making for patients with HCC.Simultaneous resection of primary colorectal carcinoma (CRC) and synchronous liver metastases (SLM) is subject of debate with respect to morbidity in comparison to staged resection. In contrast to the extensive literature on staged laparoscopic colorectal and laparoscopic liver surgery, there are only a few reports on combined laparoscopic colorectal and liver resection.L. T. Hoekstra and colleagues report their initial experience of simultaneous laparoscopic resection of primary CRC and SLM. According to the modern literature, the authors conclude that patient selection and expertise are essential for this complex type of surgery and the multidisciplinary team should decide on optimal timing within multimodality schedules.I. Popescu and S. T. Alexandrescu challenge recent evidence in the different surgical options for initially unresectable colorectal liver metastases. The authors illustrate the available oncosurgical modalities including liver resection following portal vein ligation/embolization, “two-stage” liver resection, one-stage ultrasonically guided liver resection, hepatectomy following conversion chemotherapy, and liver resection combined with thermal ablation. The authors discuss the role of liver transplantation (LT) as a future opportunity in the treatment of unresectable CRLM in selected patients, taking into account the related ethical considerations especially in case of LT from living donor or LT with marginal grafts. Although the available data do not support liver transplantation as a routine procedure in patients with CRLM, this paper could promote the debate on this issue.Partial liver transplantation, including split-liver and living donor liver transplantation, represents another important application of these advantages applied in the field of organ transplantation. N. Akamatsu and Y. Sugawara provide a review article on the current trends and controversies in living donor liver transplantation (LDLT) for patients with HCV in relation to the perspectives from deceased donor.They focused their attention on the recent advances in antiviral treatment for the recurrent hepatitis C after LT reporting the different strategies from the Japanese LDLT centers.Minimally invasive approach in the field of HPB surgery is gaining popularity due to the availability of new laparoscopic instruments for liver transection. Laparoscopic LR has evolved significantly over the past decade moving from an experimental procedure to a standard part of the hepatic surgeon's armamentarium. Most recently, robotic-assisted technology offers solutions to overcome the limitations of conventional laparoscopic resection.“Laparoscopy in liver transplantation: The future has arrived,” Q. Lai and colleagues shed further light on the role of the laparoscopy in this field of surgery. Intent of the review is to underline the current role of diagnostic and therapeutic laparoscopy in patients waiting for LT, in the living donor LT and in LT recipients.With the review paper titled G. Dapri and colleagues report their initial experience with single-incision transumbilical laparoscopic liver resection (SITLLR) with a detailed technical paper and discuss the future of this approach in terms of indications, potential benefits, and limitations in comparison with multiport laparoscopic technique.Single incision transumbilical laparoscopy represents the latest advance of the laparoscopic approach; however, its use in LR still remains limited to small reported series, and further evaluation is required to assess the potential advantages and the improvement in the patients outcome. As reported by the authors, at this point of the experience, several questions on SITLLR remain to be addressed, concerning the feasibility and mostly the reproducibility of this technique, the indications, selection criteria, limitations, effect on postoperative outcomes, and long-term results.F. Romano et al. provide a summarizing paper illustrating methods to prevent bleeding in hepatic surgery. This is of particular interest, as bleeding in HPB surgery represents one of the most common features associated with poor outcome. The paper is based on the literature information and author's experience, and the aim of the study is to investigate the principal solutions to the problem of high blood loss in LR focusing on technological approach to the parenchyma transection.The aim of this special issue is to update and promote interchange of the current knowledge and recent progress focusing on innovative strategies and recent advances in liver surgery. These manuscripts represent an exciting and insightful snapshot of the recent advances in liver surgery. State-of-the-art, existing challenges, and emerging future topics are highlighted in this special issue, which may inspire the reader and help advance in this field of surgery. We would like to thank all the authors and reviewers for making this special issue in HPB surgery possible.Andrea LauterioAndrea LauterioIrinel PopescuIrinel PopescuJuan Carlos García-ValdecasasJuan Carlos García-ValdecasasLuciano De CarlisLuciano De Carlis