The recession of gingiva is increasingly becoming a more prominent condition in the oral health of many patients and should be treated at its earliest detection. The multi-factorial etiology, decision modality, and current trends followed in treatment of gingival recession are discussed in this presentation. The correction of class I and II gingival recessions are presented as a means of minimizing surgical trauma and achieving predictable aesthetic results. In this case report, I present an alternative technique in treating gingival recession- the tunnel connective tissue graft. Gingival recession is a common occurrence and its prevalence increases with age. The recePeriodontal marginal tissue recessions have numerous causes, but there is a consensus about the gingival recession etiology.An anatomical condition with a pre-existing or acquired alveolar bone dehiscence combined with localized prominent tooth malposition, inadequaet al., to verify the occurrence of signs of excessive brushing or occlusal disturbances associated with abfractions.[Occlusal disturbances and para-functional habits. Cervical dental abrasions, also called non-carious cervical lesions (NCCL), have long been thought to be caused by excessive brushing. Controversy over this concept and occlusal etiology still exists. A study was conducted by Miller ractions. NCCL co-Traumatic, overzealous tooth brushing techniques  frequently associated with a pre-existing lack of cortical bone, or acquired bone dehiscence.Uncontrolled marginal inflammation with accumulation of dental plaque due to improper brushing techniques.Iatrogenic factors related to periodontal, orthodontic and periNo evident clinical etiology in 17% of gingival recessions cases.If the recession is not progressing and does not provoke tooth sensitivity or poor aesthetics, then tooth-brushing instructions and regular observation through a strict maintenance program would be the optimal treatment. A thorough plaque control is the primary condition for the success of any periodontal surgery. The importance of phase I therapy in the successful treatment of all periodontal surgical procedures includes the ones for root coverage. Phase I therapy for such cases includes both home and in-office care. Maintenance of proper plaque control  by the patient is of utmost concern to the periodontist. The in-office procedures include thorough scaling and polishing, root planning and a proper periodic recall for assessment of progression of periodontal disease, in this case-gingival recession. Progressive gingival recession in the presence of high thermal sensitivity and/or compromised aesthetic appearance should be treated with surgical root coverage in Class I and II defects. Smoking Associated gingival vasoconstriction that often causes necrosis of the soft tissues;Lack of adherence of the fibroblasts andAlteration in immune response.The ideal surgical objective is covering the root up to the cemento-enamel junction with a probing depth of less than two mm without probe-induced bleeding. The principal challenge lies in obtaining an excellent blood supply for the covering tissues to avoid possible necrosis and root coverage failure. It is alMiller prescribes complete disclosure at the initial consultation concerning the root coverage that can realistically be obtained through the selected form of treatment Table 1Table 1.A number of reports published on recession treatment emphasize the size of the pre-surgical defect and its effect on clinical outcomes; in other words, the deeper and narrower the defect, the greater the achieved root coverage. Deeper recessions  had greater attachment level gains than shallow  recessions.–17 The mNordland and Tarnow proposedInter-dental contact point.The facial apical extent of the CEJ.The inter-proximal coronal extent of the CEJ.Four categories were identified:Normal: Inter-dental papilla fills embrasure space to the apical extent of the inter-dental contact point/area.Class I: The tip of the inter-dental papilla lies between the inter-dental contact point and the most coronal extent of the CEJ. (Space present but CEJ not visible).Class II: The tip of the inter-dental papilla lies at/or the apical to the inter-proximal CEJ but coronal to the apical extent of facial CEJ. Class III: The tip of the inter-dental papilla lies level with or apical to the facial CEJ.Numerous procedures and techniques have been designed to provide predictable root coverage in order to solve these problems. Conventional mucogingival surgery includes the following steps:The free gingival graft, known to correct mucogingival problems , is used for root coverage.202120The laterally full pedicle flap will be used if a large and thick strip of keratinized tissue is present on the adjacent teeth.23The split-thickness laterally sliding flap is a modification of the previous procedure.The advanced coronally repositioned flap can be used when the keratinized gingival tissue apical to the recession is greater than or equal to 3 mm.Different modifications have been described including the followingTwo vertical incisions are made extending beyond the mucogingival junction. An extension of the intrasulcular incision, however, can avoid the vertical incision with the interposition of a membrane integrating the guided tissue regeneration  within the root coverage techniques.25The semi-lunar coronally repositioned flap technique requires the oral surgeon to make a semi-lunar incision parallel to the free gingival margin of the facial tissue, a partial dissection, and coronally positioning this tissue over the denuded root.The CTG procedure–29 permiPatient selection criteria for the clinical case discussed in this presentation include:Non-smoker;Patients 18 years and older;Buccal recession defects (2.5 mm or greater) classified as either class I or II defects on the maxillary teeth or premolars;Radiographic evidence of sufficient interdental bone ;Clinical indication and/or patient request for recession coverage;Gingival thickness of at least 0.5 mm at a point located three mm below the free gingival margin;A minimum of two mm of keratinized gingiva; andGood oral hygiene .Table 2The selected teeth were vital, free of restorations, bleed-free upon probing after the initial preparation, and had not been treated surgically for at least two years. After obtaining adequate anesthesia, the exposed root surfaces of patients were scaled and planed utilizing ultrasonic hand instruments. The root surfaces were then reshaped with a smooth diamond bur and polished.A 19-year-old female presented whose chief complaint was root sensitivity and poor aesthetics on her maxillary lateral incisors and canines Figures . The tunThere are four basic techniques for root coverage: (1) pedicle grafts, (2) free gingival grafts, (3) connective tissue grafts, and (4) membrane barrier guided tissue regeneration technique. All of these methods are used frequently today, and the use of each one of them is based on its advantage or disadvantage, as well as on the individual surgeon's preference and experience.The basic rationale of the pedicle graft technique is to cover the exposed avascular root surface with a contiguous (in contrast to free) soft tissue auto-graft from an adjacent site. The best-known technique is the “laterally positioned pedicle graft”, which was introduced by Grupe and Warren in 1956; this repThe free gingival graft procedure involves a keratinized epithelial graft obtained from the palate or an edentulous ridge and its placement in the recession area. Hattler was the first to utilize the keratinized gingiva of the interdental papillae to cover denuded root surfaces. The techThe free connective tissue graft is a bilaminar procedure designed to maximize the supraperiosteal and gingival blood supply to the grafted tissue. The graft is placed over the recession area, while nutrients and revascularization are derived from the recipient bed, interdental papillae, and the overlying flap. The use of free connective tissue for root coverage was introduced by Edel in 1974, but it did not receive wide approval by the profession. Later, t3035In cases of deep recessions, the flap may be coronally positioned to provide greater coverage and better blood supply to the connective tissue graft.38 Anothe39The surgical technique of choice depends on several factors, each having advantages and disadvantages. The clinician should choose from among the different surgical protocols available, selecting the least traumatic to the patient. I found this technique, i.e. the tunnel connective tissue graft technique to be a viable option for root coverage in Miller's class I and II type of gingival recession. However, more studies using greater number of patients should be done to determine its advantages and disadvantages in the long run.


Hepatic and splenic hemangiomas are common benign tumors that mainly affect female patients. Giant splenic hemangiomas are extremely rare, especially when correlated with multiple hepatic hemangiomas. Pathogenetic mechanisms between hemangiomas and oral contraceptives, as well as therapeutic approaches, are analyzed in this case report, in particular for the management of synchronous splenic and hepatic hemangiomas.We report here a 42-year-old woman with a giant splenic hemangioma, multiple hepatic hemangiomas and a history of oral estrogen intake for many years. At first it was difficult to determine the organ from which the giant hemangioma originated. Angiography proved extremely helpful in tracing its origin in the spleen. Hematomas in the giant hemangioma posed a significant threat of rupture and catastrophic hemorrhage. We left the small hepatic hemangiomas in place, and removed the spleen along with the giant splenic hemangioma.Diagnostic pitfalls in the determination of the origin of this giant hemangioma, attribution of its origin to the spleen angiographically, the unusual co-existence of the giant splenic hemangioma with multiple hepatic ones, and the potential threat of rupture of the giant hemangioma are some of the highlights of this case report. Estrogen administration represents a pathogenic factor that has been associated with hemangiomas in solid organs of the abdominal cavity. The therapeutic dilemma between resection and embolization of giant hemangiomas is another point of discussion in this case report. Splenectomy for the giant splenic hemangioma eliminates the risk of rupture and malignant degeneration, whereas observation for the small hepatic ones (<4 cm) was the preferable therapeutic strategy in our patient. Splenic hemangioma is a vascular malformation that represents the most common benign primary neoplasm of the spleen. Its prevalence at autopsy ranges from 0.03% to 14% and it is the hemangioma most commonly seen in adults in the mid-30- to mid-50-year-old range [Most hemangiomas are small asymptomatic lesions that are found incidentally. Previous studies have noted liver and spleen hemangioma augmentation during estrogen administration for endometriosis treatment, revealing a potential association . AdditioA 42-year-old woman presented with a left upper abdominal distention, early satiety and discomfort. There was no family history of hematological or splenic disorders. There was no evidence of thrombocytopenia, hemorrhagic episodes, hepatomegaly or lymphadenopathy. The patient had received estrogen therapy as treatment for endometriosis for 10 years, but she discontinued this medication 12 years prior to her presentation to our unit. The patient had a palpable mass in her left upper abdomen. The mass could be palpated approximately 9 cm below the left costal margin. Her full blood count was in the normal range.Initially a spiral computed tomography (CT) scan with IV contrast showed multiple hypodense lesions with centripetal filling in delayed venous phase compatible with hemangiomas. Two large lesions were located in the right hepatic lobe and multiple smaller ones in the caudate and left lobe. All these hepatic lesions were consistent with the features of hemangiomas.The CT scan also showed a large hemangioma-like formation in the left abdomen. It was difficult to determine whether this originated from the spleen or from the left adrenal gland, and a large cyst of the right ovary, suspicious of endometriosis Figure , was alsSelective arteriography of renal arteries, SMA (superior mesenteric artery), and the celiac trunk, undertaken to clarify the vascularity of the lesion, showed a giant splenic hemangioma with its vascular supply deriving from the splenic artery Figure .We decided to proceed to splenectomy because of the possibility of malignant transformation and of rupture and massive bleeding, complications which have been reported by other authors ,3,4. TheHistology of the spleen showed a large hemangioma with central foci of hematoma Figure . At the The first successful surgery for splenic hemangioma was reported by Hodge in 1895. Hemangiomas constitute the majority of benign hepatic neoplasms and are nine times more frequent in females than in males [Hemangiomas are often asymptomatic and undergo enlargement in fewer than 10% of cases, manifesting as a palpable non-tender mass in the left upper quadrant. Very rarely, splenic hemangiomas may become as large as 25 cm . GeneralCT and MRI failed to achieve appreciable sensitivity and specificity to define the origin of the giant splenic hemangioma we describe. Velkova and Neveda report a combined sensitivity of 61.3% for ultrasound and CT scan in the recognition of liver and spleen hemangiomas, leaving a substantial number of cases requiring further investigative procedures . They alThe presence of central hematomas in the giant hemangioma we describe showed possible rupture. Serious complications of hemangiomas include rupture and malignant transformation. Spontaneous rupture of a giant hepatic hemangioma (diameter >4 cm) with hemoperitoneum occurs very rarely. Willcox et al. report a spontaneous rupture incidence of 25% . MalignaSplenectomy may be efficacious in the correction of coagulation abnormalities in Kassabach-Meritt syndrome associated with ruptured giant splenic hemangiomas ,7. An alTo our knowledge, there is no specific report of giant splenic hemangiomas associated with administration of oral contraceptives. There are numerous reports of intrahepatic and extrahepatic hemangiomas associated with estrogen administration . The exaEstrogen administration represents a predisposing factor associated with the appearance of hemangiomas in solid organs of the abdominal cavity. Giant splenic hemangiomas are extremely rare, and require surgical intervention combined with observation or embolization of possibly synchronous multiple small hepatic hemangiomas. Alternative approaches are preoperative embolization and subsequent surgery, which minimizes the risk of intra-operative bleeding, and partial splenectomy or embolization in case of polar localization of small splenic hemangiomas.CT: computed tomography; OC: oral contraceptives.The authors declare that they have no competing interests.All the authors have been involved in literature search, writing and final reviewing of this manuscript. All authors read and approved the final manuscript.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.


Taenia solium by ingesting its eggs from contaminated food. The most common sites of involvement of cysticerci are soft tissue, eye and central nervous system. Unusual location of the cysts may result in uncommon manifestations. Ocular cysticercosis can involve both the intraocular and extra ocular muscle. Extra ocular muscle cysticercosis is rare. We are reporting the unusual manifestation of ptosis, proptosis, diminution of vision and medial rectus palsy due to cysticercosis. The patient was successfully treated with systemic steroids and albendazole.Cysticercosis is the most common parasitic disease of the nervous system. The disease occurs when humans become the intermediate host in the life cycle of  Cysticercosis is the most common parasitic disease of the nervous system. The disease occurs when humans become the intermediate host in the life cycle of Taenia solium by ingesting its eggs from contaminated food. The cysts of cysticercus cellulosae in man lodge frequently in muscles, central nervous system and in the eye . UnusualOcular cysticercosis involve both the intraocular and extra ocular muscle. Extra ocular muscle cysticercosis is rare. Unusual presentations of extra ocular muscle are mentioned in the literature. We here are reporting a unusual manifestation of ptosis, proptosis, diminution of vision and medial rectus palsy due to cysticercosis.A 40-year-old man, origin of south-east Asian country from India presented to the medicine ward with complaints of drooping of left eyelid and diminution of vision in the same eye from 7 days. The drooping of eyelid was associated with pain. The pain was aggravated by movement of the eyeball. He had a history of intermittent protrusion of left eyeball since one year. There was no history of fever, headache, and vomiting. There was no history of any weakness of limbs, deviation of mouth or slurring of speech. On examination patient was conscious and oriented with vitals stable. Rest of general examination was normal.On central nervous system examination higher function were normal. Ptosis and medial rectus weakness of left eye was present , with reBlood investigations in the form of complete blood count, plasma blood sugar  were normal. X ray chest PA view was within normal limits.Visual evoked potentials study showed prolonged P100 latency with reduced amplitude of P100 in left eye. Right eye recording was within normal limits.Ultrasonography (USG) orbit revealed thickened distal part of the left eye medial rectus with increased vascularity with thickened optic nerve with echogenic retro bulbar fat suggestive of inflammation cause. computed tomography (CT) orbit was advised.Computed tomography of brain showed no obvious abnormality. CT orbits revealed multiple small non enhancing well defined hypodense lesion in medial rectus and superior rectus muscles of left orbit posteriorly and the lesion in superior rectus muscle hyperdense dot in central area may likely to cysticercosis causing thickening of the left medial rectus and superior rectus muscles posteriorly comprising optic canal and compressing, thickening of optic nerve .th day patient turned to the OPD with minimal ptosis and no medial rectus palsy. The movements of both eyeballs were normal in all directions.Accordingly, patient was started on systemic steroids and albendazole in the prescribed doses. On the fourth day of hospital stay patient started responding. Pain subsided, medial rectus palsy and ptosis was partially improved. On 15Taenia solium, in various body tissues. It is the most common parasitic disease of the central nervous system and also affects the eye, skeletal muscle, and subcutaneous tissue.Cysticercosis is caused by haematogenous spread and encystment of the larval form of the swine tapeworm Soemmering reported the first case of ocular cysticercosis in 18304  but someIt has been pointed out by Malik et al  that theCysticercosis cellulose within the optic nerve is rare. Cysticercosis may cause significant visual loss, especially if the cyst is located in the optic nerve or is compressing the optic nerve. As the condition is often mistaken for optic nerve tumors. On neuroimaging the diagnosis is often delayed or missed. The cyst has a highly reflective pinhead lesion within it representing the scolex, which may be detected by ultrasonography or careful examination of CT or magnetic resonance imaging scans with 1 mm sections.Intermittent proptosis in our case could be attributed to the inflammation. The predominant symptoms in patients with extra-ocular muscle involvement are proptosis, pain, diplopia, ptosis, and diminution of vision. The most commonest extra ocular muscle to get involved in cysticercosis in medial rectus. Khwaja et al has reported recurrent headache and unilateral ptosis as a manifestation of cysticercosis . Kundra The association of brain tissue cysticercosis is very rare with eye cysticercosis . The samThe treatment of ocular cysticercosis is conflicting. Where the intraocular cyst responds best by surgery, surgical removal of extraocular cysticercosis is fraught with complications. R Sihota et al evaluated the efficacy of oral albendazole in extraocular cysticercosis in the randomized clinical trial and reported a marked clinical respond in the patients . In our


In preparation for multivariate analysis, an exploratory study has been undertaken to investigate the relative position, separability, homogeneity and shape of three major disease groups, using data from a clinical chemical routine package.The data set consists of 46 hepatology patients, 50 nephrology patients and 46 cardiology patients, and the measured blood levels include 20 common clinical chemical routine assays. Missing value problems were avoided by deleting some of the variables and objects.A univariate analysis was used as the basis ofa rescaling of the data.Bivariate (pairwise) plots of some major assays each show limited separation. The set of three such plots of the three major principal components reveals more distinction between the groups than was offered by univariate analysis. Three-dimensional extensions of these techniques allow better insight than any of the two-dimensional plots, but these three-dimensional versions require more plots for complete interpretation.Non-linear mapping of the data is the best way of retaining the distances and a fairly good separation is achieved in the plot. The plot is less informative about shape and relative position of the classes.Representation of the data as pictures of faces does not offer additional information and visual clustering is worse than in any of the techniques mentioned.During the analysis many assumed properties of the data are confirmed and a good starting pointfor multivariate classification is attained. Easy visual detection of outliers is offered by all techniques. Unfortunately, valuable information is lost in this data set by deleting some incomplete variables.


Negative pressure wound therapy (NPWT) is widely applied, although the evidence base is weak. Previous reviews on medical interventions have shown that conclusions based on published data alone may no longer hold after consideration of unpublished data. The main objective of this study was to identify unpublished randomised controlled trials (RCTs) on NPWT within the framework of a systematic review.RCTs comparing NPWT with conventional wound therapy were identified using MEDLINE, EMBASE, CINAHL and The Cochrane Library. Every database was searched from inception to May 2005. The search was updated in December 2006. Reference lists of original articles and systematic reviews, as well as congress proceedings and online trial registers, were screened for clues to unpublished RCTs. Manufacturers of NPWT devices and authors of conference abstracts were contacted and asked to provide study information. Trials were considered nonrandomised if concealment of allocation to treatment groups was classified as "inadequate". The study status was classified as "completed", "discontinued", "ongoing" or "unclear". The publication status of completed or discontinued RCTs was classified as "published" if a full-text paper on final study results  or interim results  was available, and "unpublished" if this was not the case. The type of sponsorship was also noted for all trials.A total of 28 RCTs referring to at least 2755 planned or analysed patients met the inclusion criteria: 13 RCTs had been completed, 6 had been discontinued, 6 were ongoing, and the status of 3 RCTs was unclear. Full-text papers were available on 30% of patients in the 19 completed or discontinued RCTs . Most information about conference abstracts and unpublished study information referring to trials that were unpublished at the time these documents were generated was obtained from the manufacturer Kinetic Concepts Inc. (KCI) (19 RCTs), followed by The Cochrane Library (18) and a systematic review (15). We were able to obtain some information on the methods of unpublished RCTs, but results data were either not available or requests for results data were not answered; the results of unpublished RCTs could therefore not be considered in the review. One manufacturer, KCI, sponsored the majority of RCTs . The sponsorship of the remaining trials was unclear.Multi-source comprehensive searches identify unpublished RCTs. However, lack of access to unpublished study results data raises doubts about the completeness of the evidence base on NPWT. Conservative estimates report that about 1% of the population in Western countries is affected by chronic wounds . Besides®) device.Negative pressure wound therapy (NPWT) consists of an open-cell foam dressing covered with an adhesive drape. The dressing is connected to a vacuum pump that creates and maintains a subatmospheric pressure . The mosGemeinsame Bundesausschuss), the decision-making body of the self-administration of the German health care service, commissioned the Institute for Quality and Efficiency in Health Care  to conduct a systematic review on the efficacy and safety of NPWT versus conventional wound therapy in patients with acute or chronic wounds. The full review was published in German in March 2006, and an English-language article has recently been published [The Federal Joint Committee  were available; these were, moreover, of poor quality . PreviouPrevious reviews on medical interventions have shown that conclusions on efficacy and safety based on published data alone may no longer hold after consideration of unpublished data, which may reverse favourable risk-benefit profiles and attenuate treatment effects of an apparently superior intervention -13. WithThe literature search comprised a total of 7 steps. Table We searched 4 bibliographic databases  for RCTs on NPWT versus conventional wound therapy in patients with acute or chronic wounds. All databases were searched from inception to May 2005. The search was updated in December 2006 within the framework of the preparation of the rapid report on NPWT . The seaWe then screened online trial registers Table  and the ® device, and BlueSky Medical Group Inc.  markets the Versatile 1 Wound Vacuum System®. Both were asked to provide information on the study status and publication status of sponsored trials, as well as on methods and results. Finally, we contacted the authors of conference abstracts by e-mail and by post. All contact details of the relevant institutions were checked beforehand on the corresponding websites. Manufacturers and authors were informed that IQWiG does not accept "commercial in confidence" data and publishes all data contributing to a systematic review [Two manufacturers of NPWT devices were identified: Kinetic Concepts Inc.  markets the V.A.C.c review .® Therapy System was used.All languages were included, as long as a title was available in English. If the title indicated a potential relevance of the study, the corresponding article was obtained and translated. Only RCTs comparing NPWT versus conventional therapy were eligible. Trials were considered nonrandomised if concealment of allocation to treatment groups was classified as "inadequate" . The intResults of trials that were not available as full-text publications were only considered in the review if detailed data were available . Results data from conference abstracts were not considered.All steps of the literature screening were performed by two reviewers independently of one another. Any disagreements were resolved by discussion. The titles and abstracts of the retrieved documents were screened to exclude citations that were clearly irrelevant. The full texts of the remaining potentially relevant articles were then screened to identify RCTs that fulfilled the inclusion criteria stated above.With the help of the information obtained, the study status of the RCTs identified was classified as "completed", "discontinued", "ongoing" or "unclear". The terminology used in the literature to classify unpublished data or so-called "grey literature" is inconsistent . We clasOnly a summary of results on the quality assessment and outcomes of the RCTs included in the IQWiG systematic review and rapid report is presented here, as the main focus of this paper was to identify unpublished RCTs.An overview of the search results is presented in Table Of 2675 potentially relevant publications, 317 full-text papers were obtained for further assessment. Of these, 289 were excluded as not relevant  had been completed -29, 6 RCFull-text publications were available on 30% of the 1649 patients in the 19 completed or discontinued RCTs . Of the 14 conference abstracts on these 19 trials, 6 abstracts (43%) were later published as full-text articles.A total of 17 authors and 2 manufacturers were contacted, of whom 10 (59%) and 2 (100%) responded respectively. KCI readily provided information on study and publication status and on methodological issues. BSM did not sponsor relevant RCTs and provided information only on case reports.The Lancet [One author provided information on an RCT that had been classified as "ongoing", and stated that this trial had recently been completed and the manuscript submitted to e Lancet . As thisThe sources of the conference abstracts and unpublished study information referring to 28 RCTs on NPWT are shown in Tables The sources of all 11 published full-text articles  are shown in Tables The overall methodological quality of the 12 published RCTs included in the IQWiG systematic review and rapid report was poor. Methodological flaws included the lack of blinding, the lack of intention-to-treat analyses, inadequate allocation concealment, the unclear definition of primary outcomes, and high drop-out rates. Significant differences in favour of NPWT for wound healing parameters, such as time to wound closure or the incidence of wound closure, were shown in 3 of 7 RCTs analysing these outcomes. Data on other patient-relevant outcomes, such as reoperation rates or pain scores, were scarce or not interpretable.Because of insufficient available information on the 9 completed or discontinued unpublished RCTs, an assessment of their quality could not be conducted. Regarding the 5 discontinued industry-sponsored trials, as stated, the reasons for discontinuation were provided by KCI, which also reported the number of enrolled patients for one trial . HoweverThe manufacturer KCI sponsored the majority (19/28) of RCTs . The sponsorship of the remaining trials was unclear.The main objective of this paper was to identify unpublished RCTs on NPWT within the framework of a systematic review. An RCT was classified as "unpublished" if no full-text paper on final study results  or interim results  was available.An extensive search strategy was employed that included handsearching of retrievals, as well as contacting manufacturers and authors of publications. The sensitivity of bibliographic database searching for RCTs is reported to be unsatisfactory , and mulA total of 28 RCTs referring to at least 2755 patients were identified. The publications on completed or discontinued RCTs reported data on less than a third of patients planned or analysed. Less than half of the conference abstracts on these trials were later published as full-text publications; similar results were found in a review by Scherer et al, who found a full-text publication rate for abstracts describing RCTs or controlled clinical trials of about 60% .On the basis of results of published data alone, the IQWiG review and rapid report concluded that although there was some indication that NPWT may improve wound healing, the body of evidence available was insufficient to clearly prove an additional clinical benefit of NPWT. This finding is in line with findings from previous reviews.Regarding the discontinued unpublished trials, according to the manufacturer the main reason for discontinuation was insufficient patient numbers. No results data for these trials were available. Regarding the completed unpublished trials, the authors of conference abstracts did not respond to IQWiG's request for information. Therefore, unpublished results data could not be considered in the IQWiG review and consequently the impact of unpublished data on the conclusions of reviews based on published data could not be assessed.Previous research has shown that inclusion of unpublished data in systematic reviews may affect the review's prior conclusions ,13. The Klassen 2002 assessed the proportion of RCTs presented at a major paediatric meeting that were subsequently published as full publications; about 60% of abstracts were subsequently published, and RCTs were more likely to be published if they favoured the new therapy. The author concluded that "publication bias is a serious threat to assessing the effectiveness of interventions in child health" and called for a registry of RCTs in children so that the totality of evidence could be assessed .As unpublished results data on NPWT were not available, no statement can be made on the impact of unpublished data on the validity of published evidence. However, if one assumes a "worst case scenario" , the current conclusion would no longer hold that there is some indication of a potential advantage of NPWT over conventional therapy.Besides possible problems of statistical evaluation due to insufficient sample sizes, the reasons for the existence of unpublished RCTs on NPWT remain unclear and one can only speculate. For example, it may be possible that some of these RCTs remained unpublished because they were of poor quality or produced negative results. Previous research has shown that studies with statistically significant or positive results are more likely to be published than those with non-significant or negative results, and are also published earlier -54. ThesThe inclusion of unpublished data in systematic reviews is controversial. Although less than a third of meta-analyses include unpublished data, nearly 80% of meta-analysts and methodologists believe that unpublished data should definitely or probably be included in systematic reviews; in contrast, less than half of journal editors agree . The ideIn general, the quality of reporting of systematic reviews on both drug and non-drug interventions is inconsistent . MoreoveApproximately two thirds of the RCTs on NPWT were sponsored by one manufacturer (KCI). Industrial sponsorship of clinical trials is common. The percentage of industry-sponsored clinical trials has increased to over 60% in recent years and the number of industry employees named as co-authors of clinical trial publications is rising . HoweverFive systematic reviews on NPWT (including the IQWiG review) published in December 2004 or later showed considerable differences in the selection of primary studies published between 1994 and 2004 ,67,68. TMulti-source comprehensive searches identify unpublished clinical trial data. However, lack of access to unpublished study results data raises doubts about the completeness of the evidence base on NPWT. The implementation of regulations such as prospective mandatory trial registration and the obligation to publish all results is needed to ensure that independent researchers have access to all outcomes of completed or discontinued clinical trials.The author(s) declare that they have no competing interests.StL initiated the study. FP coordinated the study and conducted the literature search. StL, FP, and StS screened and analysed the retrievals. NM and FP drafted the manuscript. All authors interpreted the data and made an intellectual contribution to the manuscript. All authors reviewed and approved the final version.The pre-publication history for this paper can be accessed here:


Despite recent achievement in economic progress in India, the fruit of development has failed to secure a better nutritional status among all children of the country. Growing evidence suggest there exists a socio-economic gradient of childhood malnutrition in India. The present paper is an attempt to measure the extent of socio-economic inequality in chronic childhood malnutrition across major states of India and to realize the role of household socio-economic status (SES) as the contextual determinant of nutritional status of children.Using National Family Health Survey-3 data, an attempt is made to estimate socio-economic inequality in childhood stunting at the state level through Concentration Index (CI). Multi-level models; random-coefficient and random-slope are employed to study the impact of SES on long-term nutritional status among children, keeping in view the hierarchical nature of data.Across the states, a disproportionate burden of stunting is observed among the children from poor SES, more so in urban areas. The state having lower prevalence of chronic childhood malnutrition shows much higher burden among the poor. Though a negative correlation  is established between Net State Domestic Product (NSDP) and CI values for stunting; the development indicator is not always linearly correlated with intra-state inequality in malnutrition prevalence. Results from multi-level models however show children from highest SES quintile posses 50 percent better nutritional status than those from the poorest quintile.In spite of the declining trend of chronic childhood malnutrition in India, the concerns remain for its disproportionate burden on the poor. The socio-economic gradient of long-term nutritional status among children needs special focus, more so in the states where chronic malnutrition among children apparently demonstrates a lower prevalence. The paper calls for state specific policies which are designed and implemented on a priority basis, keeping in view the nature of inequality in childhood malnutrition in the country and its differential characteristics across the states. Despite recent achievement in economic progress in India , the fruExhibiting a sluggish declining trend over the past decade and a half, the recent estimate from the National Family Health Survey -3 (NFHS-3)- the unique source for tracking the status of child malnutrition in India - indicatSocio-economic differences in morbidity and mortality rates across the world have received its due attention in the recent years -17. SuchIn this backdrop, the paper attempts to shed lights on two specific objectives: 1) to find out the extent of socio-economic inequality in chronic childhood malnutrition, across the major states of India, separated for urban and rural locations, and 2) to understand the conditional impact of household socio-economic condition on nutritional status of children per se, controlling for various other important covariates. The conceptual framework  3rd round data (2005-06) for study and analysis. Similar to NFHS-1 and NFHS-2, NFHS-3 was designed to provide estimates of important maternal and child health indicators including nutritional status for young children (under five years for NFHS-3), following standard anthropometric components. The survey was conducted following stratified sampling technique, details on the sampling procedure can be found at IIPS, 2007 . Of the We have also used secondary data from Handbook of Indian Economy 2004-05 , for theThe study uses two analytical methods for studying the objectives. The first objective is catered through the measurement of concentration index and understanding its linkage with the state level indicator of economic development. While for studying the second objective, multi-level regression model have been employed. Further details on methodology are presented below.equal treatment for equal needs  [The widely used standard tool that examines the magnitude of socio-economic inequality in any health outcome, i.e. Concentration Index (CI)  is emplobe 2000) . CI valuDue to the stratified nature of data in NFHS , the chiResearchers have adopted fixed effects models to estimate nutrition models and control for unobservable variables at the cluster level, which leads to the difficulty that if the fixed effect is differenced away, then the effect of those variables that do not vary in a cluster will be lost in the estimation process . AllowinBroadly, we test the two types of multilevel models following the practice in contemporary literature; the variance components (or random intercept) models and the random coefficients (or random slopes) models. As in above, STATA routines for hierarchical linear models using maximum likelihood estimators for linear mixed models were used for both model forms.The variance-components model correct for the problem of correlated observations in a cluster, by introducing a random effect at each cluster. In other words, subjects within the same cluster are allowed to have a shared random intercept. We consider two clusters, i.e., community and household, since in most of the cases NFHS provides information on children of one mother chosen from a particular household. Thus, we have,zij is the HAZ score for the child(ren) from the jth household in the ith community. β is a vector of regression coefficients corresponding to the effects of fixed covariates xij, which are the observed characteristics of the child, the household and the community. Where, 'i' is a random community effect denoting the deviation of community i's mean z-score from the grand mean, 'j' is a random household effect that represents deviation of household ij's mean z-score from the ith community mean. The error terms δi and μij are assumed to be normally distributed with zero mean and variances σ2c and σ2,h respectively. As per our arguments above, these terms are non-zero and estimated by variance components models. To the extent that the greater homogeneity of within-cluster observations is not explained by the observed covariates, σ2c, and σ2,h will be larger [where e larger .xij. A significantly different ICC from zero suggests appropriateness of random effect models [To evaluate the appropriateness of the multilevel models, we test whether the variances of the random part are different from zero over households and communities. The resulting estimates from the models can be used to assess the Intra Class Correlation (ICC) i.e., the extent to which child undernutrition is correlated within households and communities, before and after we have accounted for the observed effects of covariates t models . The ICCFollowing this, the total variability in the individual HAZ scores can be divided into its two components; variance in children's nutritional status among households within communities, and variance among communities. By including covariates at each level, the variance components models allow to examine the extent to which observed differences in the anthropometric scores are attributable to factors operating at each level. Thus, the variance components model described above introduces a random intercept at each level or cluster assuming a constant effect of each of the covariates (on the outcome) across the clusters.If additionally, we consider the effect of certain covariates to vary across the clusters , we need to introduce a random effect for the slopes as well, leading to a random coefficients model. Under these assumptions, the covariance of the disturbances, and therefore the total variance at each level depend on the values of the predictors .As mentioned earlier, a subset of 24,896 children have been considered for the analysis from the hierarchically clustered NFHS-3 dataset. Hence, our multilevel models are based on observations on 24,896 children from 18,078 households distributed in 2,440 communities/clusters (PSUs). Inclusion of separate levels for children and mothers were considered not necessary since these were almost unitary to the number of households.The analysis is presented in the form of five models, apart from the conventional OLS model without considering the cluster random effects, primarily as a comparison: Model_Null is the null model, where the HAZ z scores is the dependant variable with no covariates included; while in the later models along with poorest and richest household asset quintile, other covariates are introduced in a phased manner. Such as, Model_Kids introduces child specific predictors ; Model_Moms introduces the mother-specific covariates. Model_Full is the full model with all the model covariates at respective levels. These models are three-level random intercept models with the two clusters: community, and households. In Model_Random_Slope, we introduce a random coefficient for socio-economic status at the household level. We settled for the random coefficient in the form of wealth quintile dummies. The covariates included as controls in our analytical models, with the primary aim of isolating the effect of income or socioeconomic status (SES) on chronic child undernutrition are described below. In the multilevel framework most of these variables can be classified as individual-specific, household-specific or community-specific covariates.As mentioned earlier, the paper uses height for age (stunting) as the key outcome variable, which is an indicator of chronic nutritional status capable of reflecting long-term deprivation of food  followinFollowing the standard approach of assessing economic status of the household , the papApart from the above mentioned asset index, other determinants of childhood malnutrition are chosen based on approaches in literature and presented in the conceptual framework Figure  of the sThe controls on mother's characteristics includes; years of in terms of education, body mass index (BMI), mothers status of anemia, autonomy for seeking medical help for self ,59 and pAs mentioned earlier, the successive waves of NFHS in India indicates a declining trend in the prevalence of child malnutrition among children aged below three years Figure .Except for wasting, across the two different established anthropometric measures of malnutrition; stunting and underweight, a consistent decline is evident during 1992-2005 period  across all the major states, where the rural-urban differential is virtually nonexistent. Whereas the opposite side of the spectrum, more than half the children below five years were stunted in Uttar Pradesh (57 percent), Bihar (56 percent), Gujarat (52 percent) and Madhya Pradesh (50 percent) Table . The rurOverall, all the three indicators of malnourishment are found highly correlated with each other and hence it was worthwhile to explore their association with the incidence of poverty in the states, following the established line of argument. It can be said that the optimal growth of the children (having standard height for their age and weight for their height) have been strongly associated with economic status of the population.The CI values for chronic malnutrition in respect to fifteen major states and at the country level consistently return negative values, reflecting a heavy burden of malnutrition among the poor in India Table .The above table Table  confirmsIt is also seen in a similar vein that aggregate economic status of a population is associated with child nutritional status. CI values for stunting and Net State Domestic Product  share an inverse association Figure , common Overall, the negative correlation established between CI values for stunting and NSDP per capita stands at r = -0.603 (p < .001). The scatter plot of NSDP per capita and CI values for stunted children across the states . It shows Table  nearly 5The variance component models  and the random slope model Table  also supThe calculated ICC coefficient values presented in Table The lower panel of the Table σ2c and σ2h indicates that the homogeneity within cluster observations is not explained by the observed covariates specified in the model. The intra-household correlation remains as large as 0.242 suggesting that the height outcomes of two children belonging to the same family are more homogenous than those of two children chosen at random, even after adjusting for other observed covariates (Model_Full).Estimation of household random effects Table  indicateσ2h ; i.e., variance at household level denotes existence of higher homogeneity at the household level. These results further imply that choice of one-level model with the similar data set might yield underestimation of parameters.Overall, the higher value of Successive waves of NFHS brings to the fore widespread under nutrition among the Indian children, however it shows a declining trend during the inter survey period. Though, the latest estimates as provided by the NFHS 3, highlights the continuance of high overall levels of child malnutrition in India. As we find here, prevalence of child malnutrition in India is widely varied across the states and also across rural and urban areas. It needs special mention that chronic malnutrition among children is more concentrated among urban poor compared to their counterpart living in rural areas Table  where inThe intra-state inequality in child malnutrition is stark as we find through the divergent values of the Concentration Index highlighting the disproportionate burden among the poor. The variance component models clearly show clustering of observation at community and household levels. In other words, for the fifteen major states in India, children in the households that shared similar communities do posses similar nutritional status. Intra-household correlation is the most substantial, comparing intra-PSU correlation. In other words, children from a cluster or community do not seem to share stronger correlation in terms of their nutritional status. But, at the household level the observations are not independent. It implies the fact that children belonging to a particular household do share certain common characteristics while growing up. The children who belong to households from the poorest SES quintile have higher prevalence of worse nutritional status. While, on the contrary the children hailing from richest asset quintile households are associated with better nutritional status. The finding is supportive of many earlier observations made based on NFHS data . Such asHowever, at the more macro level it is seen that absolute levels of malnutrition prevalence across the states is not necessarily linearly correlated with the intra-state inequality in malnutrition prevalence. In other words, states that records higher prevalence of childhood malnutrition are not always reflective of the disproportionate burden shared by the poorest households. Mazumdar (forthcoming) , while eIn states like Punjab and Kerala with better development, a typical scenario emerges. Here, higher inequality in malnutrition prevalence can be observed at the lower levels of percentage of stunted children. On the other hand, states like Madhya Pradesh, Bihar, Gujarat and Rajasthan the states with less economic development or at par with the national average, though have considerably high prevalence of malnutrition exhibited lower values of the concentration index suggesting lower levels of inequality. It is particularly since a higher average implies prevalence of malnutrition irrespective of SES with fewer differentials. Hence a clear gradient of malnutrition inequality, biased against the poor is more pronounced in states where absolute levels of malnutrition are low. This is largely due to the overall inequality in household asset ,62 amongforthcoming) [On the other hand, the states with higher levels of child malnutrition, generally tend to have a uniform distribution of malnourished children across the socio-economic distribution (Mazumdar hcoming) , and theThe situation in Orissa is however the worst and does not confirm to any of the pattern discussed above. Here, with much lower per-capita NSDP as compared to the national average, the state exhibits a noticeably higher burden of chronic malnourishment among the poor. Hence, perhaps economic development cannot be considered as the straightforward indicator for removing overall disparity in various input and outcome indicators among different income bracket, especially in a country like India. It is argued that reduction in child malnutrition does not seem to depend so much on economic growth of a state per se or even on the efforts at reducing income poverty at the state level . AchieviNevertheless, this issue of malnutrition and poverty deserves special treatment incorporating other parameters reflecting the possible predictors of overall socioeconomic inequality and its bearing on malnutrition inequality among the states, as future research in this area. Attempts can be worthwhile to know the reasons why the states with better economic development coupled with noticeable success in arresting the overall level of chronic child malnutrition, have failed to remove its disproportionate prevalence across the socio-economic classes. It can be said that prevalence of worse nutritional status among children in India cannot be addressed with utmost success unless, inequality in prevalence across socio-economic classes are taken care of. A more state specific policy should be designed on a priority basis, to arrest such unequal prevalence.Regional heterogeneity in malnutrition across the major states and rural-urban locations are observed to be widespread during NFHS-3. The concerns amplify with the disproportionate burden of malnutrition among poor, more so in the states where the absolute level of malnutrition is seen to be at the lower level, but where they are experiencing better status of economic development. Multilevel analyses with introduction of controls on various covariates continue to indicate the household SES-undernutrition gradient. Hence, an appropriate policy guideline that focuses on altering the nutritional intake among the poor children, especially in the states with apparent lower prevalence of childhood malnutrition is need of the hour. In the high prevalence states much stronger programme are awaited to reduce the overall level. More focused programme attention targeted at the poor to enhance the level of nutrition and behavioral changes, through interventions like the positive deviance approach in a state like Orissa should be further expanded in the near future.The authors declare that they have no competing interests.BK conceptualized, developed the theoretical ideas and oversaw the project. PGM performed analysis and wrote the manuscript. MM contributed to the analysis and helped to draft the manuscript. MHR contributed in theoretical ideas and presentation of the manuscript. All authors read and approved the final manuscript.


Darmkrebs-nie?" and "Self-Care" in the German, French and Italian regions of Switzerland.Health campaigns are frequently covered by printed media, but coverage is not homogeneous across different types of newspapers. Switzerland as a multilinguistic country with many newspapers offers a good field for study. A better understanding of how printed media report on national campaigns against colon cancer in the three main linguistic regions may help to improve future public health interventions. Therefore, we analyzed articles published between 2005 and 2007 during the campaigns "Some 65% of articles reporting on colon cancer were in German, 23% and 12% were in French and Italian respectively. During the campaign, topics linked to colon cancer were increasingly covered by the media. Regional newspapers (66%) reported significantly more about colon cancer and produced the most detailed articles.Both gain- and loss-framed messages have been used by journalists, whereas the campaigns used merely gain-framed messages. Latin  newspapers mixed gain- and loss-framed messages in the same articles, while German articles mainly used a single frame throughout.Swiss-German papers reported more about the topic and the reporting was quantitatively and qualitatively more prominent in regional papers. The press followed the campaigns closely only during the period of campaigning, with high coverage. We propose to consider the regional press as an important vehicle of health information. Moreover, slight differences in framing can be observed between German and Latin articles. Health is one of the main concerns in modern societies and messages regarding health occupy sizeable sections in the media. Health campaigns are a means of spreading such messages to the general public and mainly focus on preventive or protective measures. Despite their important coverage in the Swiss printed media, the effects of health campaigns have not been extensively studied in this context . This isThe effect of health campaigns on behavioral changes in the population depends in part on the framing of the campaign message and the way it is relayed by journalists . Health We focused on colon cancer campaigns since this medical condition represents a main public health concern in Switzerland with 4000 incident cases and 1600 deaths from colon cancer per year ,11. OverDarmkrebs-nie?" [Self-Care" [st September 2005 to 31 August 2007. The "5 a day" campaign (on-going during our inquiry) served as a baseline.We investigated how printed media responded to "bs-nie?"  and "Sellf-Care"  colon caWe used the ZMS/PMA Medienbeobachtung online archive of Swiss printed media to search for articles on colon cancer that mention the campaigns and 754 articles (corresponding to our research criteria) were kept for evaluation. The total numbers of articles of each speaking area were normalized to the relevant populations .We analyzed both the contents and the quality of the journal articles mentioning each campaign. First a coding exercise  was done with three independent coders; then the coding consistency among them was tested followed by a second coding run. In addition, a content analysis was used as a formal approach to quantify and analyze the presence, meanings and relationships of the articles for media evaluation .The texts were examined for the occurrence of the 11 most frequent items used by journalists in relation with the main topics of colon cancer prevention, diagnosis and treatment. The items were chosen for their pertinence to colon cancer and related health attitudes . The Among the eligible articles, 666 were written in German (143.5 articles per million German-speakers), while 75 were written in French (50.3/Mio French-speakers) and 13 in Italian . This analysis (Table 5 a day" (12.5%), "Swiss cancer league" (11.4%), and "Screening" (11.3%). Other items such as "Early symptoms", "Overweight", "Genetics", "Involvement of a pharmacy", "Physical activity" and "Advertising" were mentioned less than 10%.We then analyzed the themes preferentially covered by the media. The "Colon cancer" item was quoted in the 21% of the selected media , early signs/symptoms and screening 25%) and cancer treatment , in depth (4-7 items) and extensive reporting (8-11 items). The regional press contained the bulk of publications in all groups and was significantly more represented in the 8-11 items group than any other type of printed media , which is not due to an overrepresentation of printed media in the region. There may be a cultural gap between the German and Latin parts of the country in receiving the same health message. The Swiss media are segmented in at least three distribution areas and thus Swiss citizens tend to address the same problems differently %, which ,18.Second, the distribution of types of newspapers is interesting as two thirds of all selected articles were from regional newspapers. We discovered that most of them were local papers whose distribution was limited to small regions within Switzerland. Given the high local impact of this regional press, we offer for interpretation that these newspapers may be an efficient vehicle for public health information .Third, we observed that the media response to both colon cancer campaigns was restricted to the duration of the campaign. Colon cancer is not adequately treated during 10 months per year. Such short term effects of campaigns have already been described ,20.5 a day" campaign had the same background level of reporting during the whole observation period. The efficiency of "5 a day" may be explained by its strong identity (an easy-to-remember slogan and a good logo).The "Fourth, both loss- and gain-frames were used by the journalists, whereas the campaign itself was merely using gain-frames. According to prospect theory, even if the information within the messages is equivalent, the willingness to incur risk in order to obtain a desirable outcome or avoid an undesirable outcome changes depending on the message framing . SeveralDramkrebs-nie" and "5 a day" campaigns through their preventive attitude induce more behavior shift than "Self-care" which invites people to perform detection screening. The contents of the articles promote both behaviors, suggesting a prevention package linking a daily consumption of 5 portions of vegetables and fruit with regular physical activity and early detection by screening.Moreover, the influence of framing depends on the type of behavior which is promoted, which can be prevention or detection behavior. Among these two behaviors, a different degree of proximal risk is perceived, and prevention behaviors are usually considered less risky that detection ones . For theChanging health behaviors requires more than media communication and increasing health literacy. It largely depends on different enabling factors. First, self-motivation and personal skills are necessary to carry out successfully all of the tasks involved in changing behaviour. Second, human and structural health care resources are required to increase array of health information and health-related support services and extend the reach of health communication. Third community and environmental condition should be supportive of that change -26.The next step would be to determine the impact of these messages on the population and ultimately their behavioral change. A pre- and post-campaign questionnaire study could be a first means of testing the uptake of the message as the campaign runs every September. However, the objective of this study was to analyze the quantitative and qualitative aspects of the reporting of the two campaigns; a further study should investigate the effects on awareness in the target population.We have shown that measurable differences exist between the German and the Latin part of Switzerland in reporting on colon cancer in the printed media, with the German press reporting most often.Among the printed media, the regional press in Switzerland plays an important role in reporting health campaigns and this should be more exploited. The future of the local press is still under debate ,28, but The authors declare that they have no competing interests.CFWB collected the data and prepared them for publication. ML helped in writing and designing the article. BB conceived the study, created the contacts and led the study. All authors subsequently collaborated on finalizing the article.Supplemental Methods S1. Eleven items coded (by two independent observers): "Colon cancer", "Swiss Cancer League", "Involvement of a pharmacy", "5 a day", "Genetics", "Screening", "Early symptoms", "Physical activities", "Fruits and vegetables", "Overweight" and "Advertising". These items have been chosen as they represent important key terms of the campaigns. For each article, several items could be registered.Click here for file


The blocking of some active centers inmelanin molecules by metal ions, which potentially exist in living systems, may change the clinicaltherapeutic efficiency of the analyzed local anaesthetic drugs.The affinity of melanin biopolymers for metal ions, drugs and other organic compounds is an importantfactor in the etiology of toxic retinopathy, hiperpigmentation, otic lesions and irreversible extrapyramidaldisorders. The aim of the presented work was to examine the interaction of local anaesthetic drugs used inophthalmology with model DOPA-melanin in the presence of metal ions. It has been demonstrated that theanalyzed drugs form complexes with melanin biopolymer. Based on the .values of association constants,, thefollowing order of drugs affinity to melanin was found: tetracaine > procaine >> bupivacaine > lidocaine. Ithas also been shown that Cu


Sir,Central venous pressure (CVP) monitoring is a simple, relatively inexpensive method of assessing a patient’s circulating blood volume, cardiac status and vasomotor tone. It is essential to be aware of the inherent fallacies and inadequacies of the information derived. Inaccurate measurements are often obtained by the aberrant lodgement of the central venous catheter (CVC) tip.In continuation of the previously published letter to editor concerning misdirected CVC, we describe an unusual case of CVC coiling in the superior vena cava (SVC) leading to falsely high CVP measurement. A 55 year old male patient was brought to the emergency room (ER) with head injury, blunt trauma abdomen with haemodynamic instability. He was further posted for an emergency laparotomy. In view of the clinical condition of the patient and the need to know intravascular volume status, a 7 French triple lumen CVC was inserted in the right internal jugular vein (IJV) in the operating room (OR). All the three ports were checked for free flow of blood and the CVC was fixed at 11cm at skin level. On connecting the transducer to the monitor, ideal waveform was absent. Intra operatively CVP tracing was suboptimal despite the change of transducer, the cable, flushing the unit and repeated zeroing. Post operatively the patient was shifted to intensive care unit on ventilator support for further management. Chest radiograph revealed coiled CVC in the SVC . Hence iThe correct placement of the CVC tip is an important factor in obtaining accurate CVP measurements. Malposition of a CVC may occur at the time of insertion or later as a result of spontaneous migration due to anatomic positioning or pressure changes within the thoracic cavity. There haIn conclusion, inaccurate CVP measurements or inability to obtain an ideal wave from tracing are suggestive of an undesirable location of the catheter tip. Awareness of this possibility and careful review of the CVC tip position on X-ray pictures in suspicious cases are important. Inaccurate CVP readings lead to improper assessment of the intravascular status of the patient. Careful clinical co-relation under such circumstances is essential. Roentgenograms after insertion of CVC are essential to eliminate this problem, which is often encountered in clinical practice.


Laparoscopic radiofrequency ablation (RFA) is an accepted approach to treat unresectable liver tumours distinguishing itself from other techniques by combining minimal invasiveness and the advantages of a surgical approach. The major task of laparoscopic RFA is the accurate needle placement to achieve complete tumour ablation. The use of an ultrasound-based, laparoscopic online-navigation system could increase the safety and accuracy of punctures. To connect such a system with the laparoscopic ultrasound (LUS) transducer or the RFA needle especially designed adapters are needed. In this article we present our first experiences and prototypes for different sterilizable adapters for an electromagnetic navigation system for laparoscopic RFA.All adapters were constructed with the help of a standard 3D CAD software. The adapters were built from medical stainless steel alloys and polyetherketone (PEEK). Prototypes were built in aluminium and polyoxymethilen (POM). We have designed and developed several adapters for the connection of electromagnetical tracking systems with different RFA needles and a laparoscopic ultrasound transducers.Based on earlier experiences of the initial version of the adapter, sterilisable adapters have been developed using biocompatible materials only. After short introduction, the adapters could be mounted to the laparoscopic ultrasound probe and the RFA needle under sterile conditions without any difficulties. Laboratory tests showed no disturbance of laparoscopic navigation system by the adapters. Anatomic landmarks in the liver could be safely reached. The adapters showed good feasibility, ergonomics, sterilizability and stability.The development of usable adapters is the prerequisite for accurate tracking of a RFA needle for laparoscopic navigation purposes as well as 3D navigated ultrasound data acquisition. We designed, tested and used different adapters for the use of a laparoscopic navigation system for the improvement of laparoscopic RFA. Laparoscopic Radiofrequency-ablation is a save and effective method for local tumour destruction and offers a combination of minimal invasive surgery and the advantages of laparotomy. However in contrary to the transcutaneously free-hand puncture application of the laparoscopic free-hand puncture is restricted because of the capnoperitoneum and the consecutive fixation of the needle on 2 different points. The use of a laparoscopic ultrasound probe with a canal for puncture can solve this problem and improve the precision of puncture. However, a stiff needle limits the necessary angulation that is needed to reach right-lateral and cranial liver metastases .An ultrasound-based, laparoscopic online-navigation system, which allows guided out-of-plane needle placement, could significantly increase the accuracy of puncture. The system is aligned to help the surgeon to perform laparoscopic radiofrequency ablations using preoperative planning data and tracked laparoscopic ultrasound (LUS) as well as a tracked RFA needle . The tra®, Tirat Hacarmel, Israel), which is a six-degree-of-freedom electromagnetic tracking system for percutaneous interventions, was connected to the LUS transducer  by using adhesive tape. The nearer the adapter could be placed to the tip of the instrument, the higher is the accuracy of the system. The tracking of the LUS was feasible but too inaccurate  or internally cooled RFA needles  the electromagnetic tracker was mounted to the basis of the RFA needle Fig. . We haveAll newly developed adapters were constructed using standard 3D CAD software . The adapters were build from medical stainless steel alloys (1.4301 or 1.405) and Polyetherketone (PEEK). Prototypes were built in aluminium and polyoxymethilen (POM).® and Ascension, Type 3D-Guidance®) with smaller electromagnetic trackers were used.Furthermore, new electromagnetic tracking systems , that can be placed directly on the flexible part of the probe. The sensor is placed inside the inner PEEK part and is fixed with the outer steel part. It was evaluated in combination with the image-guided navigation system. The experimental setup consists of a perfused tumor-mimic-model of the porcine liver Fig. . The senThe newly designed RFA needle adapter can be mounted on the needle itself Fig. . Due to The first experiences with the development of adapters for electromagnetic trackers revealed the feasibility of the combination of an electromagnetic navigation system with a RFA needle and LUS -4,6. HowThe adapters for the LUS can be used to acquire navigated three-dimensional ultrasound even from segments that are difficult to reach , because the electromagnetic tracker was attached to the tip of the LUS probe, which allows free angulation of the ultrasound transducer without interference of the navigation system. Initial material testing for the ring adapter showed no detectable interferences of the navigation system . New labThe new developed adapter for the RFA probe showed neither influence on the NDI Aurora nor on the Ascension 3D-Guidance tracking system. Anatomic landmarks in the perfused porcine liver could be safely reached ,8. AccurOverall, the newly developed adapter for the LUS and the RFA needle showed good feasibility, ergonomics, sterilizability and stability.The laparoscopic approach for radiofrequency ablation, originally described by Siperstein et al. in 1997, offers a minimally invasive procedure in combination with the advantages of an open procedure ,11. EvenOur evaluation shows the difficulties in designing adapters that combine all required qualifications. Ongoing development is needed to solve existing problems, guarantee steady progress and achieve acceptable results for clinical use. This study presents the feasibility and usability of special designed adapters for electromagnetic trackers to combine an electromagnetic navigation system with the LUS and laparoscopic RFA needle. This is the prerequisite for navigated laparoscopic RFA to improve the accuracy and results of laparoscopic liver interventions.In the next steps we are planning to perform animal studies with the presented adapters. Furthermore, we are working on further miniaturization of the laparoscopic adapters to reduce the used trocar size. Besides that, adapters for hybrid tracking  of LUS and different RFA needles are already under evaluation, but can not be presented today for patent reasons.The design and development of adapters for electromagnetic trackers is the prerequisite for an accurate tracking of the RFA needle for laparoscopic navigation purposes as well as 3D navigated ultrasound data acquisition. We designed, built, tested and used different adapters for the use of a laparoscopic navigation system for the improvement of laparoscopic RFA.The author(s) declare that they have no competing interests.All named authors have made substantial contributions to conception, design and carrying out of the study by participating in the design and development as well as the experimental testing of the electromagnetic adapters.


The cells were then inoculated under standard conditions into mice, and the growth of ascites tumour was determined.Ehrlich ascites cells or another strain derived from a spontaneous mouse mammary carcinoma (DiVita's ascites cells) were incubated vitro at pH 7.4 for 30 minutes. This retardation of tumour growth was not dependent on the presence of glucose in the incubation medium and could be observed in the presence of about 5% ascitic fluid. However, the retardation appeared to be considerably less marked (though readily detectable) when the incubation with Synkavit was performed anaerobically.On this basis, Synkavit has been shown to retard the growth of ascites tumour provided that the cells were incubated in The retardation of tumour growth by Synkavit was abolished completely by simultaneous incubation with excess ATP or partially by equimolar ATP. Simultaneous incubation with excess ADP also abolished the retardation by Synkavit of the growth of tumour. Moreover, ATP addition to the medium at a later period appeared to be partially successful in abolishing the Synkavit effect on tumour growth.The mechanism by which ATP reduced the growth-inhibitory effect of Synkavit has been partially clarified by investigating the effect of ATP on the incorporation of a tritiated derivative of Synkavit, TRK 219. The results show that in Ehrlich ascites cells, simultaneous incubation in Spinner-medium with excess, or equimolar, ATP reduced the incorporation of labelled metabolites of Synkavit by 78% or 14% respectively. On the other hand, in a continuous cell line of human epithelial cells (HEp/2), excess ATP reduced the incorporation of metabolites of labelled Synkavit very slightly.These results have been discussed in the light of other evidence to consider the mechanism whereby ATP reduced the growth-inhibitory effects of Synkavit.


Lamiophlomis rotata-based herbal Pain Relieving Plaster (PRP) on healing closed soft tissue injury (CSTI) has been reported. The herbs contained in Plaster are also referred as 'blood-activating and stasis-dispelling' in herbal medicine. The formula of the plaster contains four China's Tibetan medical herbs, including Lamiophlomis rotata, Oxytropis falcate Bunge, Curcuma longa Linn, and Myricaria bracteata. Two of these herbs  are commonly used in different formulae of Chinese medicine. The objective of this study is to use an interdisciplinary approach to test the hypothesis that the formula and its components influence the process of CSTI.Soft tissue injury imposes major public health burdens worldwide. The positive effect of China's Tibetan medicine and the In vivo models have been established in 30 rabbit ear pinnae and studied for: (1) blood flow velocity (BFV) which was affected by pressure of 21.2 kg/cm2 for 30 second over the local rabbit ear tissue; (2) edema formation of the closed soft tissue injury; (3) in vivo local temperature change.The results of in vivo studies indicated that CSTI significantly increased the velocity of blood flow and increased edema formation within the control group. The PRP extracts for 5 hours significantly slowed down the BFV of CSTI in rabbit ears, markedly decreased the elevated edema level from the 3rd to the 5th day.The ingredients contained in the formula have positive effects in healing CSTI and further study is worth exploring. The overwhelming majority of injuries caused by a variety of activities as well as high-velocity accidents typically involve moderate to severe trauma to the musculoskeletal soft tissues. Clinical and investigational experience has shown that primary traumatic muscle injury induces a plethora of pathological alterations known to converge in secondary structural and functional deterioration . This seWhile the primary insult cannot be influenced therapeutically, the secondary lesion growth after CSTI is amenable to certain interventions, including temporary immobilization, administration of analgesic anti-inflammatory drugs, and some traditional herbs such as China's Tibetan Medicine -6. The WLamiophlomis rotata, Oxytropis falcate Bunge, Curcuma longa Linn, and Myricaria bracteata.Many traditional remedies are based on systematic observations and methodologies and have been time-tested, however many of them are still lacking scientific evidence. There are only a few prospective randomized, controlled trials that have proved the clinical efficacy of these traditional healing agents for soft tissue injury. Pain Relieving Plaster (PRP) composed of herbs only from China Tibetan Plateau, most of which have been used clinically for hundreds of years in China to remove stasis and relieve pain ,10. The Lamiophlomis rotata,Curcuma longa Linn, Oxytropis falcate Bunge and Myricaria bracteata are the main composition. PRP is produced by the Tibet Linzhi Cheezheng Tibetan Medicine Factory. The composition of PRP is listed in Table Lamiophlomis rotata, Curcuma longa Linn, Oxytropis falcate Bunge and Myricaria bracteata . Animals were kept for one week to be acclimatized prior to the investigation. During this time they were given standard diet and water. All animals were housed, fed and treated in accordance with the in-house guidelines for animal protection. The study complied with the Declaration of Helsinki, and the study protocol was approved by the institutional ethics committee.Twenty four hours before the beginning of the modeling, the dorsal skin of the rabbit ears were shaved and the deep hair were removed by barium sulfide suspension. In the next day and under phenobarbital sodium anesthesia (1 ml/kg), a 6 mm × 6 mm injury was created by applying a soft tissue clamp with pressure of 21.2 kg/cm2 controlled by mechanical sensor for 30 seconds over the rabbit ear tissue.After the CSTI to the rabbits, ears were randomly subjected to surface application for 30 minutes with herbal extracts (PRP) or 0.9% NaCl  (n = 10 per group). Rabbits remained anesthetized for 5 hours during which determination of intravital microscopy, edema formation and temperature change were conducted. Uninjured rabbits subjected to the same procedures served as shams (n = 10), considering the effects that different steps may bring.Quantification of CSTI microcirculation and microvascular parameters was performed by the same investigator, who was blinded to the status of the rabbits. The ear was focused with the objective lens of the microscope on some spot just beneath the injury being examined. The image of the examined capillaries and the red cells inside them can be viewed with the eyepiece of the microscope and a digital video camera  simultaneously. The images of the venules and capillaries and the red cells were projected on the charge coupled device  connected to an video recorder  and they can be recorded on videotape for analysis at a later time with image processing techniques  via computer . VideotaThe soft tissue edema formation is part of the injury effect. A caliper for measuring soft materials  was used to evaluate successive change of edema formation. The edema thickness gain was assessed by measuring the difference that remains after the basic thickness was subtracted from the posterior one. This differs from the wet-to-dry weight ratio previously described by others ,15. In oResults are expressed as mean ± SD. The groups were compared using repeated – measures ANOVA. The results from different time points were analyzed by group t-test to test differences from groups. Differences were considered significant at p < 0.05.The results of in vivo studies indicated CSTI increased the BFV significantly. The PRP extracts at the 5th hour significantly slowed down the velocity compared with the controls, and the extracts could speed up the BFV of normal tissue Figure . No inteThe caliper for soft materials can easily measure the edema formation induced by CSTI in temporal sequence, as well as the reducing edema due to PRP treatment. No significant difference between the edema gain of the control group and the PRP group was observed within 5 hours. However the PRP application for half hours caused a significant decrease in edema gain after two days Figure . There iThere is no significant difference between the temperature of control group and PRP group Table , though In this study, we found that PRP extracts could significantly prevent the deterioration of CSTI and decrease the edema formation in rabbit ears. The results suggested that PRP has active medical ingredients for activating the blood and removing stasis. We also found that the application of PRP extracts could decrease redness in rabbit ears which is one of the signs of inflammation.Significant increase in BFV in short time after injury suggests that decreased tissue oxygenation is essential to support and maintain cellular viability and impairment known to compromise structural and functional cellular integrity ,17. BothThe temperature result suggested that CSTI-induced ear flushing and unchanged temperature could be mediated by peripheral activation of some other receptors and affected by the environment factors ,20. A grLamiophlomis rotata may improve blood circulation and remove stasis through inhibition of thrombin and activation of plasminogen [Lamiophlomis Rotata orally administered in rats can increase the contents of fibrinogen and shorten thrombin time. 10 Among these effects, the significant geographic structure of Lamiophlomis rotata may be one of the reasons affecting the process of CSTI [Oxytropis falcate Bunge with the anti-inflammation effect may decrease edema formation for many soft tissues [Curcuma longa Linn and Myricaria bracteata have the effects of activating the blood and removing stasis, and relieve pain as well [Curcuma longa Linn demonstrated anti-inflammatory activity. It may exert its anti-inflammatory activity by inhibition of a number of different molecules that play a role in inflammation [PRP is a combined herbal medicine of four herbs from the Tibetan Plateau in China. Individual herbs play roles in promoting the microcirculation, decreasing edema and relieving pain. sminogen . In addi tissues -25. Curc as well -28. Furtammation . Reportsammation ,5.Prescriptions for Chinese medicine usually combine several herbs or other ingredients to gain the maximal therapeutic effect. According to data from the present study, PRP extracts possesses blood-activating and stasis-dispelling properties that are consistent with studies of each individual herb . PRP extThis study showed that PRP extracts could prevent the deterioration of CSTI and speed up BFV of normal tissue in rabbit ears. PRP is a crudely combined herbal medicine that contains many chemical compounds and unknown ingredients. Isolating and identifying the main active components of PRP and their mechanisms of action exceeds the settings of the present investigation and merits further study.The authors declare that they have no competing interests.FHD, HGZ participated in the design of the study and WNZ, DLW and CYG performed the statistical analysis. XW collected and interpreted the data. YZW, WNZ and HGZ carried out the studies and drafted the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Overall survival rates for out-of-hospital cardiac arrest rarely exceed 5%. While bystander cardiopulmonary resuscitation (CPR) can increase survival for cardiac arrest victims by up to four times, bystander CPR rates remain low in Canada (15%). Most cardiac arrest victims are men in their sixties, they usually collapse in their own home (85%) and the event is witnessed 50% of the time. These statistics would appear to support a strategy of targeted CPR training for an older population that is most likely to witness a cardiac arrest event. However, interest in CPR training appears to decrease with advancing age. Behaviour surrounding CPR training and performance has never been studied using well validated behavioural theories.The overall goal of this study is to conduct a survey to better understand the behavioural factors influencing CPR training and performance in men and women 55 years of age and older. The study will proceed in three phases. In phase one, semi-structured qualitative interviews will be conducted and recorded to identify common categories and themes regarding seeking CPR training and providing CPR to a cardiac arrest victim. The themes identified in the first phase will be used in phase two to develop, pilot-test, and refine a survey instrument based upon the Theory of Planned Behaviour. In the third phase of the project, the final survey will be administered to a sample of the study population over the telephone. Analyses will include measures of sampling bias, reliability of the measures, construct validity, as well as multiple regression analyses to identify constructs and beliefs most salient to seniors' decisions about whether to attend CPR classes or perform CPR on a cardiac arrest victim.The results of this survey will provide valuable insight into factors influencing the interest in CPR training and performance among a targeted group of individuals most susceptible to witnessing a victim in cardiac arrest. The findings can then be applied to the design of trials of various interventions designed to promote attendance at CPR classes and improve CPR performance.ClinicalTrials.gov NCT00665288 Cardiac arrest refers to the sudden cessation of cardiac mechanical activity as confirmed by the absence of signs of circulation . The vicCardiac arrest remains the leading cause of mortality in North America. The incidence of out-of-hospital cardiac arrest in Canada is estimated to be 55 per 100,000 of population , resultiThe American Heart Association "Chain of Survival" illustrates important concepts in the community response to out-of-hospital cardiac arrest . The chaData from Seattle indicates that a survival rate of 30% can be achieved for witnessed VF cardiac arrest victims receiving bystander CPR . Other cVarious attempts have been made to improve bystander CPR rates in the past. Two very popular and contrasting approaches are mass CPR training events and targeted CPR training of family members of patients suffering from cardiovascular disease. The objective of the mass CPR training is to teach as many CPR providers as possible from the general population in a group setting. Although mass CPR training events can reach groups of a few hundred to thousands of participants at a time -14, thesThe second approach, targeted CPR training, involves spouses and other family members of cardiac arrest victims, the people most likely to witness the event -20. ManyIrrespective of the teaching method, retention of CPR knowledge and skills is poor -48. The Authors have asked many people why they were not interested in taking a CPR class. A common response from lay persons is that it simply never occurred to them that CPR training was something they should be doing. Interest in CPR training appears to decrease with advancing age -73. WhenIt is also important to address the fear of contracting an infectious disease. Historically, tuberculosis and polio were major concerns on the minds of potential rescuers . In our Besides fear of disease transmission, there exist other deterrents to bystander CPR. Mouth-to-mouth ventilation is an intimate act that may influence the decision of potential rescuers to perform CPR ,88. WillCPR certification is associated with increased confidence in one's ability to provide care, which in turn is associated with an increased helping behaviour ,98-101. While it remains unclear from previous research if situation-specific factors such as the ones mentioned previously affect the likelihood of CPR-related behaviours, it may also be that general constructs known to affect other health-related behaviours are also relevant. Examination of CPR training and performance behaviours have never been studied in the context of these more general theories, despite their utility in explaining a wide variety of health behaviours -118. ForCPR is a crucial yet weak link of the Chain of Survival for out-of-hospital cardiac arrest. We sought to understand what is known about the determinants of bystander CPR and factors associated with successful CPR training by conducting a systematic review of the available literature . Eleven A total of 252 articles were included out of 2,409 located. Differences in their study design precluded a meta-analysis. Twenty-two recommendations were classified. Recommendations with the highest scores  were: 1) Dispatch-assisted CPR instructions; 2) Teaching CPR to family members of cardiac patients; 3) Braslow's self-training video; 4) Maximizing time spent using manikins; and 5) Teaching concepts of ambiguity and diffusion of responsibility. Other examples include: Mass training events , pulse taking by laymen , and CPR using chest compressions alone .This exercise resulted in the evaluation and classification of the potential impact of interventions designed to improve bystander CPR rates. These results will help identify common barriers and facilitators to CPR training and CPR performance for the purpose of the current project, more specifically for the purpose of including theoretical constructs represented in the literature.The overall goal of this study is to design and conduct a survey to better understand the behavioural factors associated with successful CPR knowledge transfer in independent-living older Canadians (aged 55 or older).Specific objectives are:1) To conduct semi-structured qualitative interviews to identify factors influencing CPR training and performance behaviours;2) To develop a survey instrument about factors influencing CPR training and performance behaviours based on a systematic review of the literature , the res3) To conduct a telephone survey among an independent-living population aged 55 or more using the survey instrument, and to identify factors and strategies that might be targeted by knowledge translation interventions.A multi-phase approach will be taken to develop, pilot-test, and administer a telephone survey examining the determinants of CPR training and performance among a population aged 55 or older. In the first phase, data will be used from a recently completed systematic review of the literature  to inforThe purpose of this phase of the research is to identify and describe barriers and facilitators about CPR training and CPR performance among our target population, and examine this group's perceptions of the factors influencing their behaviour. This will be accomplished by conducting semi-structured interviews on a convenience sample of people from the target population. Data from this preliminary work will be used to describe all relevant barriers/facilitators to these two target behaviours in this high impact population, and inform the content of the larger scale telephone survey.An interview guide will be developed using the results of the systematic review . A reseaApproximately 20 individuals  from the urban and sub-urban Ottawa region will be interviewed. While 6–8 participants are often enough for a homogeneous sample, 12–20 are commonly needed when looking for disconfirming evidence or trying to achieve maximum variation -132.The interviews will yield a large quantity of data. To monitor the progress of the interviews and permit follow-up of issues that may emerge from the data, interviewing, transcription, and analysis will proceed concurrently. The audio-tapes will be transcribed verbatim and verified by the interviewer prior to analysis. Data will be imported into a qualitative software package (Nu Dist NVivo™) to facilitate thematic coding, evaluation and analysis . The anaThe purpose of this phase is to use the data generated from the interviews to develop and pilot test a psychometrically sound telephone survey instrument examining issues around our two target behaviours in the context of a well-validated theoretical framework.Based on now-standard methodologies for developing context-specific measures of the general constructs proposed in the Theory of Planned Behaviour ,136-138,An initial draft of the survey will be circulated around the extended project team to ensure face and content validity. We will pilot the survey with 10 participants twice over a two week period for clarity, acceptability, and test-retest reliability. Data from the pilot survey will be analysed for temporal stability and internal consistency using standard techniques and revised if necessary .The purpose of this phase of the research is to survey our target population using the survey instrument developed in the survey development phase.We intend to recruit a representative sample of people over the age of 55 in the Canadian population. Our respondents will be stratified by province (excluding the territories), and urban  versus rural communities.The survey will be administered using random digit dialling. The administration protocol will include a pre-test of 10 interviews, a minimum of 12 calls/attempts to each random telephone number to obtain a call outcome, and one attempt to convert all first refusals. Ten percent of all interviewers' work will be monitored for quality assurance purposes. We anticipate a response rate of at least 60%.The primary hypotheses of the third phase of the project (Survey Phase) will involve examining whether constructs comprising the Theory of Planned Behaviour are significantly related to our two primary outcomes. Specifically:Hypothesis 1: Attitudes, subjective norms, and perceived behavioural control will be significant predictors of intention to engage in CPR training, andHypothesis 2: Attitudes, subjective norms, and perceived behavioural control will be significant predictors of intention to engage in intention to perform CPR in appropriate circumstances.Analysis of the survey data will first involve descriptive statistics describing the most commonly cited barriers/facilitators to our two target behaviors. Analysis of Hypothesis 1 and 2 will be carried out by multiple regression. For each of the two target behaviours , a blocked multiple regression will test the strength of relationship of these outcomes with the constructs predicted by the Theory of Planned Behaviour; i.e. the constructs of attitude, subjective norms, and behavioural control will be added into the model as a block, and any additional constructs suggested by the Interview Phase added to the model to see if it contributes to the model over and above the factors discussed in the Theory of Planned Behaviour.In addition to standard regression modelling, we will also produce a structural equation model of our data. Structural equation modelling (SEM) allows the researcher to model not only direct relationships between constructs and outcomes , but also indirect relationships through intervening constructs . Because the constructs in the structural model are determined theoretically rather than statistically, this technique is useful for testing the validity of whole theories within a single analysis. Furthermore, SEM does not assume perfect measurement of the constructs, as does regression, but rather explicitly measures and excludes error in the measurement variables from the definition of the constructs.Power calculations for multiple regression analysis depend on the number of cases per predictor variable. A minimum sample size of 50 + 8 m, where m is the number of predictor variables, is recommended for testing the multiple correlation, and 100 + 8 m for testing individual predictors ,141. TheThis study has been approved by the Research Ethics Board of the Ottawa Hospital (protocol # 2007751-01H).The proposed survey will address important knowledge gaps in our understanding of the barriers and facilitators of CPR training and CPR performance. Several attempts have been made to elucidate these behaviours in the past. For the most part, these consisted in poorly developed and constructed surveys, with no follow-up intervention based on their findings.Guidelines for Resuscitation in 2010, and offer scientific evidence to support a paradigm shift in the approach to CPR training in the community. Ultimately, the most reliable measure of impact from all proposed interventions will be an unequivocal increase in bystander and survival rates for out-of-hospital cardiac arrest victims.The results of the proposed survey, based on scientifically developed theoretical constructs, will provide invaluable insight into factors influencing the interest in CPR training and performance among a targeted group of individuals most susceptible to witnessing a victim in cardiac arrest. We plan to apply our findings and evaluate their impact during randomized controlled trials of various interventions designed to promote attendance at CPR classes., and CPR performance. The results of this survey should contribute to the development of the updated version of the The authors declare that they have no competing interests.CV conceived of the study and drafted the manuscript. JG, JB and IS assisted with the methodology and revised it critically for important intellectual content. GW assisted with the statistical design and methodology. MC helped draft and edit the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here: