The stress response is a natural reaction by the body, against potentially harmful stimuli to enhance the chance for survival. Persistent activation of the stress response can cause changes to homeostatic mechanisms. The study of stress neurophysiology, in the evaluation of the manifestation of disease in the body, suggests that these chronic changes have detrimental effects on sub cortical structures. Furthermore, there is much scientific support for the notion that chronic activation of supraspinal systems will lead to maladaptation of homeostatic mechanisms, causing the impairment of processes within the body, and ultimately leading to visceral disorders. The chiropractic profession for many years has alluded to chronic change of neurophysiological pathways as a potential explanation of visceral disorders, but the profession has typically described these in terms of somatovisceral or viscerosomatic reflex activity. Change in supraspinal neurophysiological efferent activity is increasingly being used to explain "stress" related disease. The chiropractic profession should consider investigating such stress responses by conducting spinal manipulative therapy trials that evaluate supraspinal effects of manipulation. Such research may help elucidate key mechanisms associated with the change of visceral disorders noted by some chiropractors following manipulative therapy. Walter Canon offered the first model of homeostasis as the "coordinated physiological processes which maintain most of the steady states in the organism" -3, and fIt is in times of sustained or repeated activation that the stress response may alter . Due to As stress becomes more prominent in society, trying to understand mechanisms with which it manifests in the body, and potential treatment for these manifestations is imperative to the development of effective chiropractic treatment strategies. This commentary attempts to address the development of disease within in the body due to chronic stress activation. It discusses the anatomy, physiology and the relationship of adverse chronic stress activation on systems within the body. This is followed by discussion of how these variables integrate and are potentially affected by the application of manipulative therapy.This section will outline the neuroanatomy of the stress response, focusing on input and output pathways. As there are multiple brain structures concerned in the organization of the stress response, these systems are intricately related. A schematic representation of the stress system is presented in Figure Nearly all stress-related information projected to the hypothalamus is congregated to the lateral hypothalamus, where combinations of numerous ascending and descending fibres are integrated from areas including the limbic system, medial hypothalamus, and the autonomic nervous system containing with thousands of interneurons .viscerosensory signals arise from glossopharyngeal (IX) and vagal (X) cranial nerves in the spinal cord and from the lower brain stem, which project to the nucleus of the solitary tract (NTS), and terminate via multisynaptic pathways at the hypothalamus [Somatosensory signals reach the hypothalamus directly via the spinohypothalamic tract [Numerous thalamus . The NTSthalamus . The NTSthalamus . Somatosic tract , by axonic tract , or throic tract .Ascending medullary viscero- and somato-sensory neurons have been associated as carriers of autonomic signals to the hypothalamus. Signals may directly project to the hypothalamus, or indirectly through secondary autonomic centres, such as the parabrachial nuclei .The output system involves the recognition of the stress response, and engages both the neuroendocrine and neuronal pathways . The higThe hypothalamus is able to exert effects via neurohumoral pathways through the pituitary, autonomic effects via neuronal pathways to preganglionic neurons, and able to exert both parasympathetic and sympathetic effects through the medulla oblongata and spinal cord .vulgaris-leucoagglutinin in intact brain stem operated rats. Paraventricular fibres descend by the length of the brainstem and spinal cord via two descending tracts: one from the lateral hypothalamus, along the lateral lemniscus and from the pons, moving ventrolaterally and running into the ventrolateral medulla. Some of these fibres loop dorsomedially in the caudal ventrolateral medulla to innervate the NTS, and dorsal motor nucleus of the vagus nerve (X). Secondary fibres run periventicularly and join the above tract at the pontine level [The four predominant nuclei containing descending hypothalamic-autonomic fibres include the paraventricular, arcuate, perifornical and dorso-lateral hypothalamic nuclei. The hypothalamic paraventricular nucleus (PVN) is a central site in the complex of interacting systems controlling the stress response . It is tne level . Toth etne level  found dene level , A1/C1 cne level , pre-symne level . The PVNne level .With arrangements of ascending and descending fibres from various areas including the limbic system, medial hypothalamus, and the autonomic nervous system, the hypothalamic system is able to exert effects on the neuro-endocrine and neuronal pathways, as well as indirect influences to the periphery, playing an extremely important role in mediation of the stress response.The limbic system is located in the boundary between the telecephalon and the diencephalon. Environmental stimuli, posing as external stressors, are recognized by specific sensory receptors systems, which transmit information via the nucleus of the solitary tract to respective sensory areas of the thalamus from spinal or cranial sensory neurons. These inputs include mechanoreceptors. Sensory information is transmitted to the amygdala through direct thalamo-amygdala connections, or indirectly though thalamo-cortico-amygdala connections . The latThe hippocampus does not receive information involving individual sensory stimuli, but more general contextual cues . ContextIndividual stimuli presenting as external stressors, or emotional evaluation of internal stressors are fundamentally analyzed by the amygdala . TherefoThe hippocampus also regulates the neuroendocrine stress response by inhibition of the HPA axis through glucocorticoid negative feedback . NetworkThus, the limbic system is actively involved in the body's stress response and this stress response is affected by memory and emotion. It is important these interactions are considered in terms of the known associations of chronic pain and psychosocial variables -45. It iMechanisms used by the body to respond to stressful stimuli are illustrated below. The intricate biology of the stress response is depicted via numerous pathways working together to function at a systemic level. These systems are activated under different mechanisms, controlling areas of the body as means of survival. The principal physiological responses to stress are mediated by the sympathoadrenal system, and the hypothalamo-pituitary-adrenal axis .The autonomic nervous system is a rapidly responding mechanism, controlling numerous systems including cardiovascular, gastrointestinal, respiratory, renal and endocrine which are under control of the sympathetic, parasympathetic or both nervous systems . ActivatDuring an antecedent event, activation of the SAS system (locus coerulus/norepinephrine/sympathetic nervous system) evokes the release of noradrenaline and neuropeptide-Y from postganglionic nerve terminals, while preganglionic innervation of the adrenal medulla results in an increased secretion of adrenaline and dihydroxyphenylaline (DOPA) . ActivatThe hypothalamo-pituitary-adrenocortical (HPA) axis plays a fundamental role in adaptation of the organism to homeostatic challenge, and should be thought of as the body's energy regulator, as it is ultimately responsible for controlling virtually all of the hormones, nervous system activity, and mineral homeostasis . ActivatThe HPA axis is readily activated by stressful stimuli . SensoryCatecholamines are involved in these pathways as chemical messengers. Brainstem catecholaminergic and non-catecholaminergic neurons, through collateral branching inputs may provide coordinated signaling of visceral input to rostral forebrain sites. This may lead to a synchronized response of the CNA and PVN for the maintenance of homeostasis . Thus, eThe magnoceullular neurons of the supraoptic (SON) and PVN, along with scattered clusters of cells between the two nuclei, comprise the hypothalamo-hypophyseal system. These cells send oxytocin and vasopressin containing fibres to the posterior pituitary where these substances are released into the peripheral circulation. Vasopressin is an antidiuretic hormone (ADH) and is released in response to changes in osmotic pressure of circulating blood or extra-cellular space. ADH controls water balance, in particular retention of water regulated in the distal tubules of the kidneys.Everyday interactions with the environment inevitably expose the body to a wide range of stressful stimuli. The stress response has evolved for efficient functioning of the neuro-endocrine and neuronal pathways to play a vital role in adaptation of the body to homeostatic challenges brought to bear on it. It is during times of repeated, chronic activation that dysregulation of the stress response may lead to manifestation of disease of the body. Chronic stress may lead to physiological systems within the brain and body fluctuating to meet internal or external demands, causing deterioration, and leading to maladaption . PhysiolGlucocorticoids, adrenal hormones secreted during stress, are seen as key hormones, which are able to permit, stimulate or suppress the stress response . The priUno et al.  providedExcess glucocorticoids, as the end effect of chronic stimulation of the HPA axis, may constitute a base for pathophysiological consequences in the periphery of the body. This includes potentiation of sympathetic nervous system-mediated vasoconstriction, proteolysis and lipolysis , energy Systems activated by stress can influence reproduction at the hypothalamus, pituitary gland or gonads. There are close relations with the sustained activity of the end-product of the HPA axis and suppressed steroid sex and growth hormones . The firThe female reproductive system is regulated by the hypothalamic-pituitary-ovarian axis. The principal regulator of the hypothalamic-pituitary-ovarian axis is GnRH . GnRH stStress is understood to contribute to the pathogenesis of disease, and under chronic conditions contributes to disease by impairing the body's ability to correctly control normal responses of the body. Increased glucocorticoid secretion causes resistance of growth hormone from osteoblastic cells of bones, inhibiting osteoblastic activity that renders them osteoporotic . ChronicA, interferon (IFN)-Y and interleukin-12 (IL-12), and to stimulate the production of anti-inflammatory cytokines such as IL-10, IL-4 and transforming growth factor (TGF)-B [Glucocorticoids have been clinically used to control autoimmune disease, and inflammation, as well as organ donation rejection for many decades . The rol (TGF)-B . During  (TGF)-B . Chronic (TGF)-B . The rol (TGF)-B .Predictable disorders such as low back pain, tension headache and even rheumatoid arthritis may be a result of repeated activation of postural musculature during chronic flight-or-flight responses . JacobsoChiropractors treat conditions of a neuromusculoskeletal and non-neuromusculoskeletal nature . The majThe literature supports the existence of somatovisceral and viscerosomatic reflexes -100, butTraumatic stress of a physical nature is known to manifest in changes to limbic, memory and other relevant stress centres in the brain including the hypothalamus and pituitary . Whilst Despite prolonged debate, very little consideration has been given to other potential mechanisms (and solutions) for the presence (and resolution) of the "type O" condition. A recent review has detailed that the somatovisceral reflex is a short term effect (millisecond to seconds in duration) when compared to supraspinal influences on the spinal cord which can be weeks to months in duration . The revChronic pain is associated with stress . It is aAs with all homeostatic function, individual functions often have an optimum range of function outside of which function is decreased or becomes pathological. Thus, it is plausible that too little or too much of a particular function may be detrimental to the optimal function of the organism. Chronic stress is associated with abnormal organ function and the presence of disease ,117. RemIt seems reasonable to examine physiological systems involved in the processing of symptoms such as pain in the many conditions reported to be managed by chiropractic intervention strategies. Whilst the somatoviseral reflex has been used as an example of a possible mechanism for the cause and management of these conditions, the scope of conditions that cannot be addressed by this mechanism is still large. We contend that a higher centre system impacting on the spinal cord could better explain the diversity of conditions.In doing so, a consideration should be given to the role of psychosocial variables resulting from the stress of various events including trauma . FindingChiropractic management strategies have been used to manage or co-manage a number of non-musculoskleletal, non-malignant conditions. The pubmed database was searched in June of 2006 with the terms "chiropractic" and "case" and returned more than 589 hits. Of these, more than 40 related to non-musculoskeletal care. Some examples included: Ehlers-Danlos syndrome , gastroeBy contrast, 416 hits were returned from the same search string on the Index to Chiropractic Literature database (ICL). There appeared to be fewer reports of negative outcomes, and the scope of the reports appeared just as broad as that presented on the Pubmed databases. Some examples include: otitis media , post poIt appears that the two databases present very different perspectives based on the content of their contributing journals, one (Pubmed) largely a medical database and the other largely chiropractic (ICL). This differential may explain and or reflect the different perspectives that chiropractors hold with regard to the management of non-musculoskeletal conditions when compared with their medical counterparts.As mentioned previously, chiropractic often postulates the somatovisceral reflex as being the vehicle for the changes noted in the above conditions . HoweverA review by Siegrist and Marmot discusses psychosocial variables as causative, aggravating, and perpetuating factors for the stress response, as well as stress implicating elevated psychosocial variables . The strFuture studies could utilize a randomized controlled trial design and measure variables such as: self reported levels of pain, disability, anxiety, depression, as well as objective blood and urine based measures of stress including: proinflammatory cytokines  ,164,165 Sufficient evidence exists to consider stress and its mechanism, in the generation of diseases often seen by chiropractors. To date little investigation of this potential mechanism of disease and treatment has been conducted by the chiropractic profession. In a time when peak chiropractic organizations are calling for a mind-body approach to the management of chronic musculoskeletal and non – musculoskeletal disease , due conThe author(s) declare that they have no competing interests.KH participated in its design, constructed the literature review, and helped to draft and edit the manuscriptHP conceived of the study, participated in its design, constructed the literature review, and helped to draft and edit the manuscript. All authors read and approved the manuscript.


The site, The Biomass Basics topic from the toolbar offers a collection of fact sheets, journal articles, weblinks, presentations, and reports that provide general insight into the biofuel production industry. One of the fact sheets, “The Bioenergy Cycle: A Vision of the Future,” details how the bioenergy cycle works in a best-case scenario. The Economics selection in the tool bar has much more information in this vein, with a number of presentations on the topic that have been developed and presented by collaborating members. One presentation discusses how bioenergy crop production might impact the U.S. agricultural sector, including effects on crop prices and changes in land area allotted for crops.Impacts of bioenergy production on air, biodiversity, soil, water, and other areas are subtopics within the Environment section of the network website. Among the items in the Environment section page is a document titled “Energy Crops and the Environment,” which looks at how growing crops for energy purposes can positively impact the environment by improving water quality and decreasing erosion and runoff. Other reports in the Water subsection of the Environment section address environmental benefits of cellulosic energy crops (such as switchgrass) and soil and water quality aspects of herbaceous and woody crop production.An Analysis of the Environmental Impacts of Energy Crops in the USA, which explores the tipping point at which biomass crop cultivation would begin to negatively affect the environment. Other reports examine research priorities for energy crop production and ways of ensuring the sustainability of feedstock production.Within the Biomass Resources section of the website are several other reports, databases, weblinks, presentations, and fact sheets that address environmental issues. One is a National Audubon Society report, The Supply System portion of the site offers information on the various stages of biofuel production, including harvesting, preprocessing, storage, systems integration, and transportation. Finally, the Glossary section lists not only terms used in the bioenergy industry, but also a seven-section assortment of Frequently Asked Questions on topics ranging from the basic to the more technical.


Solitary fibrous tumour (SFT) is an uncommon mesenchymal neoplasm that most frequently affects the pleura, although it has been reported with increasing frequency in various other sites such as in the peritoneum, pericardium and in non-serosal sites such as lung parenchyma, upper respiratory tract, orbit, thyroid, parotid gland, or thymus. Liver parenchyma is rarely affected. Clinically, SFTs cause symptoms after having reached a certain size or when vital structures are involved. In recent years, SFTs are more often identified and distinguished from other tumours with a similar appearance due to the availability of characteristic immunohistochemical markers.In this manuscript we report the case of a large tumour of the liver, which was histologically diagnosed as a SFT, and showed involvement of a single hepatic segment. Because of the patient's presentation and clinical course, it may represent a radiation-induced lesion.When a SFT has been diagnosed, surgery is the treatment of choice. The small number of patients with a SFT of the liver and its unknown natural behaviour creates the need to a careful registration and follow-up of all identified cases Solitary fibrous tumour (SFT) is an uncommon mesenchymal neoplasm that most frequently affects the pleura ,2, althoIn this manuscript we report the case of a large tumour of the liver, which was histologically diagnosed as a SFT, and showed involvement of a single hepatic segment. Because of the patient's presentation and clinical course, it may represent a radiation-induced lesion.A 74-year-old man was referred to our department with complains of gastric fullness, frequent episodes of post-prandial nausea, and weight loss over the previous 3 months. Medical history revealed a high-grade mucosa-associated lymphoid tissue (MALT) lymphoma of the stomach in 1996. The lymphoma was staged as IE according to the Ann Arbor staging system, and showed complete response after chemotherapy followed by radiation therapy (60 Gy) of the local nodal regions. On physical examination, a large mass was palpated in the epigastrium that filled the entire right upper quadrant of the abdomen. Routine laboratory investigations, including blood glucose levels, and serum levels of tumour markers  were within normal limits. Computed tomography (CT) of the abdomen demonstrated a large, heterogeneous mass in the left hepatic lobe, measuring 24 cm in largest diameter, with necrosis and calcification  declare that they have no competing interests.CV and JHW carried out the surgical procedure and contributed to the design of the study. TT and CV gathered the data from the literature search and made the first draft of the manuscript. MK performed the histological analysis of the surgical specimen and provided histological sections as figures for the manuscript. ANG, AMME and JHW revised and finally approved the manuscript for been published. All authors approved the final manuscript.


Hair follicles are the focus of this primer on mammalian skin development. The largest organ in the body, the skin provides protection against environmental insults and dehydration, and is an important gateway for sensory input. In addition to forming an environmental barrier, the skin has evolved to produce an amazing variety of appendages, including scales, feathers, hair follicles, sweat glands, and mammary glands . These oMammalian skin contains three major cell types: epithelial cells that form a stratified epidermis containing specialized intermediate filament proteins called keratins; mesenchymal cells that form the underlying dermis and, together with epithelial cells, contribute to hair follicles and other appendages; and melanocytes that provide the skin and hair follicles with pigmentation. In addition, the skin is highly innervated, and contains populations of specialized cells including dentritic Langerhans cells (a type of antigen presenting cell), Merkel mechanoreceptor cells (which form complexes with sensory axons), and mast cells (which produce histamine). These different cell types have diverse origins, and undergo extensive interactions, migration, proliferation, and differentiation during embryonic development.Morphogenesis is controlled by a relatively small number of key intercellular signaling pathways that occur sequentially and in specific combinatorial fashions. Activation of these pathways is directed by secreted ligands, including members of the WNT, fibroblast growth factor, tumor necrosis factor, and Hedgehog families, and bone morphogenetic protein (BMP) and other transforming growth factor superfamily members, which act over relatively short distances and bind to specific receptor proteins on neighboring cells to regulate cell shape, size, adhesion, polarity, movements, proliferation, and transcriptional activity. The molecular events underlying skin development in mammals have been studied using a variety of systems and techniques. These include analysis of human genetic syndromes and spontaneously occurring and induced mouse mutants, production of transgenic and gene-targeted mouse models, in vitro culture of rodent and human skin cells, and grafting of human or rodent skin to immune-deficient mice.The epidermis originates from the outer layer of the embryo, the surface ectoderm. BMPs activate the epidermal differentiation program and induce the expression of keratin proteins via several known transcription factors ,2. The sThe dermis of the skin consists of loosely packed fibroblasts and has a remarkable variety of embryonic origins. Fate mapping of mammalian dermis, which traces the developmental path of dermal cells, has been achieved by introducing artificial genes into mice. Specifically, the bacterial Cre recombinase enzyme is introduced under the control of a promoter that is active in a particular embryonic region, in this case either lateral plate mesoderm or neural crest. This transgene is combined with a Cre-activatable lacZ reporter gene, resulting in lacZ expression in Cre-expressing embryonic cells and all of their descendants. This allows tracking of the fates of these descendants by X-gal staining to detect activity of the β-galactosidase enzyme encoded by lacZ. These experiments showed that the lateral plate mesoderm gives rise to ventral trunk dermis, while head dermis arises, at least in part, from neural crest, a transient population of migratory cells derived from the neural plate . While fPigmentation of the epidermis and hair follicles is supplied by melanocytes that manufacture melanin (black pigment) or phaeomelanin (yellow/orange pigment) and deposit it into melanosomes that are transferred to hair shaft or epidermal cells. Melanocytes differentiate from melanoblasts that arise from the neural crest. After undergoing an initial period of proliferation, melanoblasts migrate between the dermatome and overlying ectoderm, and from E10.5 of mouse embryogenesis migrate through the developing dermis. Starting at approximately E12.5, melanoblasts move from the dermis to the epidermis, and by E15.5 they begin to migrate into the developing hair follicles  Figure . By two While epidermal cells, dermal fibroblasts, and melanocytes have differing embryonic origins and migration pathways , these cSurgical removal of the DP and the contiguous lower dermal sheath prevents hair growth, indicating the importance of the DP as a key signaling center for the follicle . DPs or Not surprisingly, these extensive epithelial–mesenchymal interactions require the activities of secreted ligands that allow communication between different cell types. WNT signals play key roles at the initiation of embryonic hair follicle development . FibroblThe hair follicle undergoes cycles of growth and regression throughout life. At the onset of a new cycle of hair growth (anagen), signals from the DP are thought to stimulate the transient proliferation of epithelial SCs in the permanent bulge region of the follicle . Bulge SSeveral recent reports have identified cell populations in the skin that appear to be capable of differentiating into cell types other than hair follicle epithelium and epidermis, raising the exciting possibility that skin SCs could be used to regenerate organs beside the skin and hair follicles. For example, neural crest derivatives  and cellRelatively few cells reside in specialized niches such as the hair follicle DP and bulge, making molecular analyses of pure populations of these cells difficult. Recently, however, hair follicle bulge epithelial SCs have been isolated by utilizing a specific promoter to target GFP to adult bulge epithelium , or by tPLoS Biology, Rendl et al. [In the current issue of l et al.  take simImportantly, the results of this study support and extend previous observations that the DP expresses genes originally associated with neural SCs . HoweverThe approach employed by Rendl et al. has produced a remarkably comprehensive picture of gene expression in different components of the skin and hair follicles in the early postnatal period. These data will likely form the basis for a multitude of further investigations into the molecular nature of mesenchymal–epithelial interactions in the hair follicle, and the functions of hair-follicle-expressed genes in both normal development and disease. Similar approaches could be employed to begin to address outstanding questions in skin and appendage biology. Profiling of different follicular compartments during the hair growth cycle may identify putative inductive signals produced by the DP, and could provide clues as to how cycling activity of epithelial and melanocyte SCs is coordinated. Profiling of different cell compartments in various developing appendages might begin to reveal the molecular mechanisms by which apparently similar sets of signaling pathways direct the formation of diverse organs. As the basic mechanisms of hair follicle development and hair growth are conserved between mice and humans , these s


Given the public-private mix of the Greek health system, the purpose of this study was to assess whether variations in the utilisation of health services, both primary and inpatient care, were associated with underlying health care needs and/or various socio-economic factors.Data was obtained from a representative sample (N = 1426) residing in the broader Athens area (response rate 70.6%). Perceived health-related quality of life (HRQOL), as measured by the physical and mental summary component scores of the SF-36 Health Survey, was used as a proxy of health care need. Health care utilization was measured by a) last-month visits to public sector physicians, b) last-month visits to private sector physicians, c) last-year visits to hospital emergency departments and d) last-year hospital admissions. Statistical analysis involved the implementation of logistic regression models.Health care need was the factor most strongly associated with all measures of health care utilization, except for visits to public physicians. Women, elderly, less wealthy and individuals of lower physical health status visited physicians contracted to their insurance fund (public sector). Women, well educated and those once again of lower physical health status were more likely to visit private providers. Visits to hospital emergency departments and hospital admissions were related to need and no socio-economic factor was related to the use of those types of care.This study has demonstrated a positive relationship between health care need and utilisation of health services within a mixed public-private health care system. Concurrently, interesting differences are evident in the utilization of various types of services. The results have potential implications in health policy-making and particularly in the proper allocation of scarce health resources. Several studies have identified perceived health status or health-related quality of life (HRQOL) as a very important predictor of health service utilization -7. FurthOther studies have focused on the extent to which socio-economic differences affect the use of health services. Individuals with a lower level of education make fewer visits to specialists ,12. ContMany studies have examined the influence, on service utilization, of factors such as race/ethnicity or community area , with the latter differentiating access in favour of urban area residents . In the The purpose of this study was to examine if demographic, socio-economic and need characteristics of individuals influenced their use of the following health services: visits to public sector physicians, visits to private sector physicians, visits to hospital emergency outpatient departments and admissions to hospitals. In addition we attempted to identify factors that differentiate the use of public and private services. Based on previous research it was hypothesized that need factors ranked as the most important determinant of health care use. Concerning the different use of public and private services, it was assumed that socio-economic factors played an important role. This study contributes to the available literature as it investigates variations in health care service utilization in Greece, by using SF-36 Summary Scores, instead of the usual eight subscales, as proxies of health care needs. The results have potential health policy and planning implications and could support administrators in their difficult task of properly allocating health resources.the SF-36 Health Survey, a generic instrument constructed to be a brief alternative in health policy evaluations, general population surveys, clinical research and practice. It is the most widely used measure of self-perceived health with the aim of assessing concepts representing basic human values relevant to health status and well-being. The SF-36 has proven useful in comparing general and specific populations and for assessing the impact of disease and treatments on patients' perceived health state and quality of life [Self-assessed health status was measured with  of life . The SF- of life .Physical Component Summary (PCS) and Mental Component Summary (MCS) scores was also established [Factor analytic studies have shown that the physical and mental summary factors account for 80%–85% of the reliable variance in the eight scales, leading eventually to the construction of two summary scores for physical and mental HRQOL. The use of summary scores provides the advantage of requiring fewer statistical comparisons in order to analyze SF-36 results, while not forfeiting the discrimination potential between physical and mental health status and outcomes. The two summary scores are usually normalized to a mean value of 50 and a standard deviation of 10 ,21. In aablished .The National Health System (ESY) in Greece was established in 1983 with an axiomatic aim to provide coverage for the entire population. It has evolved during the 1980s, and this is reflected by a substantial increase in public resources  . MeanwhiThe Greek health care system provides full coverage to the entire population, but at the same time has observed an increased use of the private sector. Access to all public services is free and there are no fees at the point of use, whereas the private sector requires out of pocket payments. Differences, between more and less prosperous insurance funds, concerning the extent and quality of services provided are evident. Health care services in Greece are basically provided by: a) the National Health System  b) health units of Health Insurance Funds  and c) the private sector .Health insurance funds are public schemes financed by employees, employers and the public budget. In Greece it is mandatory for the entire workforce (including their families) to be insured according to professional status, via one of 32 different health insurance funds . It is wThe study involved a stratified sample of residents of the broader Athens area, where approximately 35% of the Greek population lives. Institutionalized people were excluded. Participants were chosen proportionally to the population size, according to a three-staged sampling methodology. Specifically, in the first stage a random sample of 84 blocks of residences were selected according to information from the 1991 national census. In the second stage, households were selected from every block by systematic sampling. In the third stage, a participant (> 18 years) was chosen from every household by simple random sampling. Totally, 1007 out of 1426 candidates (response rate 70.6%) agreed to participate, constituting a representative sample of the population living in this particular area.Participants were interviewed and the survey included the SF-36 and various health service utilization and socio-demographic questions. The necessary approval for carrying out this study has been provided by the Review Board of the Hellenic Open University. Physical and mental health summary scores, calculated and presented in previous work, were used as a proxy of health need. Principal Component Analysis was conducted to extract two components, which were subsequently rotated to an orthogonal simple structure using the Varimax method in order to facilitate comparisons with published results and simplify interpretation .Health service utilization was measured by the visits: a) to public sector physicians within the last month b) to private sector physicians within the last month, c) to hospital emergency outpatient departments within the last year and by d) admissions to hospitals within the last year. Dependent variables were dichotomised to 0,1 values (0 → non use and 1 → use). Independent variables were grouped into three clusters, specifically i) demographic: age (continuous), gender , marital status , ii) socio-economic: education level , net monthly family income (continuous) and self-owned or rented residence (dummy variable with reference category residence freely provided) and iii) a proxy measure of need variable: SF-36 PCS and MCS scores. Only the variables demonstrating statistical significance (P < 0.05) were included.it makes considerable difference whether we are studying initial contact during a given period or whether we are studying the number of services received in a given period of time". There is no clear perception on how frequent and non-frequent users should be distinguished, as they are defined arbitrarily and there is a lack of consensus in the literature [Multivariate logistic regression models were implemented, one for each type of service, in order to determine predictors of health service utilization. Initially, access to health services was assessed and particularly the characteristics of those using the services compared to those not, and secondly the frequency of health service use, i.e. characteristics of those having used the services once compared to those using them more frequently. As Andersen and Newman , underliterature .Subsequently, we explored different predicting factors for the use of public, compared to private, services. Separate regression models were employed for primary and secondary services. The independent variables remained the same as in the analysis previously mentioned. The dependent variables were binary variables with 0, 1 values (0 → use of private services and 1 → use of public services). All statistical analyses were undertaken using SPSS v13.0.Out of 1007 participants, 53.4% were women and the entire sample, with a mean age of 45 years, is classified into six age groups. Detailed socio-economic characteristics are provided in table Upon initial investigation of the socio-economic characteristics of users and non-users table , we obseGiven the four types of health service utilization designated in this study, we used regression models combining both public and private sector users, in order to determine the best predictors of utilization. Utilization of primary health services table  appears Table Table In the previous analysis, regression models were implemented to distinguish between users and non-users in an attempt to examine possible socioeconomic barriers to initial care seeking. Another basic element, in this study, is the frequency of use for those making at least one visit, and the identification of predictors of the number of subsequent visits . In the The logistic regression model in table In this study we investigated the impact of demographic, socio-economic and need factors on the utilization of health services. The data showed that self-perceived health status -as a proxy measure of need- is the most important contributor to the utilization variance for three of the designated services , a finding which is consistent with many previous studies -7. DemogThe results of the study seem to suggest the existence of equity in the use of primary health care services. Demographic and, to a lesser degree, need factors affected utilisation and no socio-economic gradient was apparent. Things were slightly different when the public and primary sectors were analysed separately, but once again inequity is not implied. Use of primary health services, provided by health insurance funds, was made according to demographic, socioeconomic and health care need variables. Women, elderly, less wealthy individuals and people with a lower physical health status visited their insurance fund physicians more. Demographic variables were the most important contributors and this may be explained by the fact that women reported higher consumption due to their increased awareness of health problems and symptoms when assessing their health status . FurtherUtilisation of private services was also affected by socio-demographic and need factors. Women, well educated and those once again of lower physical health status were more likely to visit private providers. It was expected that economic factors like income would affect utilisation of private physicians, which involves out of pocket payments. However, this was not confirmed by our study as opposed to an earlier study in Italy , where aAnother noteworthy fact is that the independent variables in the regression model table  explain Visits to hospital emergency departments and hospital admissions were related to health care needs, and no socio-economic factor characterized the use of those types of care. As reported in an earlier study, hospital utilization and the volume of inpatient services were significantly influenced by medical needs  or as AnUpon examining the number of visits, no socio-economic influence was revealed. The poorer and those with worse mental health visited more frequently physicians linked to their health insurance fund. Other studies ,4 have sPatients' preferences, awareness of their medical profile, availability of services and their expectations are important factors in seeking referred health care, mainly from specialists, in many European countries. Higher educated or wealthier individuals have different attitudes about the potential benefits, so they are more motivated to request specialist care . In the After studying the different use of public/private services table , a pro-rLow-income individuals have greater health care needs expressed by lower physical and mental summary scores, and further supported by research in western European countries showing that morbidity and mortality risks are higher in lower socioeconomic groups . AlthougAnother possible explanation is the structural problems of the system. The large number of health insurance funds and the different range of health services they cover is the most typical characteristic in this case. More specifically, wealthier funds cover a large range of services, provide a better set of inpatient services or, in many instances, offer reimbursement when individuals purchase from private providers. Often, people insured by the most prosperous health insurance funds (approximately 10% of the insured population) are covered, to a large extent, for hospitalization in prestigious private hospitals, for all illnesses, specialized operations and examinations . This unIn spite of social insurance coverage of Greek citizens, the use of private services is extensive throughout the country. This could be attributed also to the absence of the "family doctor" in Greece, and the inability to select the desired physician in primary and secondary health care. The absence of the family doctor affects the delivery of care, access and the referrals to the health system. This results in patients accessing secondary care based on their own initiative. The adoption of a gate keeping system could result in a link between primary and secondary care, and an effective patient transfer. Moreover it could give emphasis to issues such as prevention and over-consumption , which pose a great burden on the health system . On the Finally, two limitations should be briefly underlined. First, this study concerned the broader Athens area, the capital of Greece, where medical personnel is more experienced and better equipped technologically, and consequently more specialised health services are available. The heterogeneous dispersion of resources in relation to the population throughout the country reflects an unequal availability of health services, which is expected to be more intense in rural areas. So the first restriction reflects lack of data on the pattern of use of the rural population. Another limitation, reported also in a study by Morris , was theThis study has demonstrated a positive relationship between health need and the utilisation of health services under a mixed public-private funded health care system. Health need, defined by self-perceived health status, was the most important determinant for visiting public or private sector physicians, emergency departments and admissions to the hospitals. Moreover, health need and low income were the main factors influencing subsequent visits to public sector physicians. Concerning the use of public vs private services, we observed that socio-economic characteristics of individuals were the main determinants. People with higher education and income levels used more private sector services, although they were not the exclusive users, since low-income groups used private services as well. In Greece, it seems that access into the health system is relatively easy. However the aim is to access a complete, uniform and satisfying public health system with respect to the quality and the extent of provided services. Despite 25 years of Greek NHS reform, this target has not yet been achieved.The author(s) declare that they have no competing interests.EP has participated in the design of the study, the statistical analysis, the interpretation of the results and drafted the manuscript. DN conceived the study, interpreted the results and made refinements of the manuscript. Both authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Yet only three donor human milk banks existed in the United States in 1998. Having observed better outcomes in human milk-fed neonatal intensive care patients, two neonatologists in Austin, Texas, founded The Mothers Milk Bank at Austin (MMBA). Since opening in 1999, the MMBA has expanded rapidly as the result of careful planning, innovative procedures, fiscal stability, and widespread community support. The non-profit organizational structure, diversity and progressive vision of the board of directors and staff, and creative on-going public relations efforts have contributed to the success of the project. The MMBA demonstrates a model for 21 The nutritional superiority and immunological benefits provided by human milk are widely accepted ,2. CertaRecently, Schanler and colleagues questioned the benefit of banked human donor milk . HoweverWhile un-pasteurized, own mothers' milk remains the gold standard, many mothers, particularly those who have given birth to preterm babies, have difficulty producing adequate volumes of milk ,11-13. Ist century milk banking.Dr. Sharpe recalls, "I became enamored of the prospect of not having to treat NEC, one of the worst complications of the growing premature. A milk bank seemed an essential thing to do for our babies." Dr. Rivera agrees. "We started the milk bank to ensure that feedings for preterm infants would be safe and healthy, resulting in fewer complications." In 1998, doctors Rivera and Sharpe joined forces to found what would become the fourth US human donor milk bank, the first such facility to open since 1992. The ambitious scope of the project makes it a model for 21Rivera and Sharpe held a series of exploratory meetings to investigate available resources and solicit community support. Their reputations were crucial to selling the idea of a new milk bank. Two local lactation consultants, a NICU nurse, several La Leche League leaders, a hospital chaplain, the mother of a preterm infant, and two additional neonatologists formed a core group. The group adopted an egalitarian working style, set family-friendly policies, pledged to support breastfeeding, and developed ethical guidelines for the project. Further, they agreed to embrace new technologies and to include a research component to the project in order to advance the science of human donor milk banking.After touring existing milk banks and engaging in helpful dialog with the Human Milk Bank Association of North America (HMBANA), the group decided to organize the Austin milk bank as a community-based, free-standing facility. This crucial decision resulted from concerns that over-identification with any single institution would prevent acceptance from competing hospitals and limit widespread community support. Because historical review suggested that milk banks within existing institutions are vulnerable to funding cuts during budget crises, an autonomous milk bank with a supervising board of directors was deemed the most stable model for success. Additionally, the founders committed to the principle of non-profit milk banking in order to protect their ability to provide donor milk by prescription without regard for recipients' ability to pay. Once these organizational and philosophical decisions were made, the group constituted itself as a Board of Directors (BOD). In 1998, with pro bono assistance from a generous attorney, the BOD applied for and was granted status by the US Internal Revenue Service (IRS) as a 501(c)(3) nonprofit organization.The Mothers Milk Bank at Austin (MMBA) owes much of its success to the camaraderie and diverse composition of the BOD, its exceptional staff, and to careful fiscal management. The project is funded by grants, donations, and, increasingly, by milk processing fees paid by hospitals that order supplies of milk for their preterm nurseries. The healthy financial status of the MMBA allows for expansion of services and continual up grading of equipment and methodologies.The founding neonatologists currently serve as President and Vice President of the BOD. A vital liaison with the Austin Blood and Tissue Center was established when their president consented to serve as the MMBA's treasurer. The 21 member BOD meets eight times yearly to review operations, set policy, and continually reevaluate program goals. Initially, BOD members performed operational tasks. Staff now assumes total responsible for the day-to-day running of the milk bank. Consequently, such frequent board meetings are not essential. However, the creative input of the diverse fellowship comprised by the BOD is felt to be one of the cohesive elements guaranteeing the continuing success of the project.Permanent board seats are designated for a representative from La Leche League, an IBCLC, and a public member (either a donor or a mother whose child had been a milk recipient). Another seat is designated for an ethics advisor. An Episcopal priest, a rabbi, and a Catholic nun have served in this capacity. The remaining board seats include representatives from the insurance, business, high tech, advertising, legal, arts and entertainment communities. The diversity of the BOD connects the milk bank project with funding and publicity resources that might otherwise not have been available, and provides a flexible mechanism for accessing valuable consulting expertise at no cost.An early task of the MMBA was the creation of an informational website . In 1999In the spring of 1999, the BOD and the project's first Executive Director, Andrea Morgan, produced a Policies and Procedures manual, and adopted the milk banking standards and guidelines of HMBANA. The first milk donors were screened and approved following the HMBANA guidelines, (available on the HMBANA website) .Staphylococcus aureus, methicillin- resistant S. aureus, and any of the bacillus species are discarded owing to the fact that endotoxins of these organisms are heat-resistant. Pasteurization may not render them harmless [The MMBA adopted protocols for bacteriological screening, milk pasteurization, and nutritional labeling that met or exceeded HMBANA guidelines. Pre-pasteurization milk samples are drawn and plated for identification and counting of bacterial colonies. Milk testing positive for harmless . AsepticMilk samples are drawn and re-tested following pasteurization. No bacterial growth is tolerated in post-pasteurization milk. Pasteurized milk is held in freezers until results of post-pasteurization bacteriological testing are received. The milk is approved once pasteurized milk samples show no growth on 48-hour cultures plated and read by an independent microbiology laboratory. MMBA staff maintains careful records for each batch of processed milk, including statistics on what percentage of milk is discarded owing to contamination. All bottles and batches are labeled and numbered to permit tracking.Pediatrix, a national organization of pediatricians and neonatologists, donated a Foss Milkoscan to the milk bank in 2000, allowing for nutritional analysis of pre- and post-pasteurization human donor milk  of milk and was dispensing milk to three hospitals and one infant in the community. By 2000, the staff grew to include a program director and a program assistant, who supervised all aspects of the donor milk program, including pasteurization. The addition of staff enabled increased enrollment of donors and increased pasteurization capacity. By the end of 2000, the MMBA had 148 donor mothers, and was serving six hospitals and nine outpatients clients from all over Texas. Over 51,000 ounces (1508 litres) of milk were pasteurized.Human donor milk obtained from non-profit milk banks is not sold. A processing fee is charged to partially recover the expense of producing the milk. Production costs include donor screening and blood testing, microbiological testing of milk, pasteurization costs, storage costs, equipment and shipping expenses, staff salaries, and the expenses of operating the physical plant. Because actual production costs exceed the processing fees charged, human donor milk from the MMBA is partially subsidized by charitable donations and grants. The current processing fee charged for one ounce (28 ml) is US$3.25.In January 2006, 14 non-hospitalized children were receiving milk from the MMBA. These recipients included infants who were discharged from the preterm nursery unable to tolerate infant formula. Others included older babies with nutritional handicaps. Approximately one half of these recipients are termed "charity patients". This means they pay a token fee or nothing for the milk. The MMBA absorbs these costs and raises donations from the community to defray them.Approximately 90 per cent of MMBA milk recipients are hospitalized preterm infants. Generally, the cost of the milk provided to hospitals is recovered in the form of processing fees. Some milk is paid for by private insurance, and some families pay for all or part of their infant's supply. In Texas, some of the milk processing fees are paid for by Medicaid.Medicaid is a US government-sponsored program that releases money to the states to help meet the medical needs of specialized groups of citizens, including low income families and children in foster care. A special provision of Medicaid allows preterm infants to be temporarily enrolled as recipients, providing help to families who would otherwise be overwhelmed by their medical costs. Rep. Glen Maxey, state representative from the MMBA's congressional district, successfully sponsored legislation in 2001 to obtain Medicaid funding to pay for human donor milk. The inclusion of Medicaid coverage for donor human milk made it possible to routinely secure donor milk for a wider variety of clients including hospitalized preterm infants without private insurance, outpatient babies with special nutritional needs, and infants in the Texas foster care system.The BOD conducts annual strategic planning sessions to chart the course for each up-coming year. This encourages continual evaluation of the goals of the project. The BOD made an early decision to expand collection centers outside of the Austin area in order to keep pace with increasing demands for milk. A milk collection depot was opened in Houston in 2000, the first of nine collection sites around the state. Some hospitals in various US cities that were using MMBA donor milk began exploring the idea of starting their own milk banks. Since the founding of the MMBA, one milk bank has re-opened in Delaware, and four additional US human donor milk banks have been established in Ohio, Indiana, Iowa, and Ft. Worth, Texas, each with mentoring assistance from the MMBA.In 2004, Dr. Rivera presented research on nutritional data collected at the MMBA to the American Association of Pediatrics conference in San Francisco. Several on-going research studies describing growth outcomes of infants receiving human donor milk await completion and publication.Starting a Donor Human Milk Bank: A Practical Guide [Staff members of the MMBA have written a manual entitled al Guide . The guiIn January 2006, the MMBA consisted of a staff of eight, and a well-organized cadre of volunteers. In addition to the BOD, an advisory panel of medical doctors and researchers has been formed, providing an additional expert consulting body. Year-end figures for 2005 report that the MMBA dispensed 186,777 ounces (5524 litres) of milk, routinely supplying milk to 26 hospitals nationally.The MMBA is outgrowing its current facility, which houses the staff, three pasteurizers, nine freezers (equipped with sensors and emergency back-up power sources), a commercial dishwasher, an ice-maker, and a small research laboratory. The BOD plans to launch a campaign to acquire funds for a new space. Ideally this will include a loading dock to better handle deliveries and shipments, expanded research facilities, and space for new, advanced pasteurization technologies.Inquiries and requests for mentoring assistance from Australia, Israel, Korea, and numerous American cities suggest a resurgence of interest in human donor milk banking. Based on a very successful first six years, the MMBA believes that the model of a non-profit, community-based milk bank is viable and sustainable. As new research and improved technologies provide better mechanisms for quality control, less loss of milk nutrients, and permit specific nutritional labeling, an expanded role in the use of human donor milk to provide a safety net for infants seems assured.Barbara Wilson-Clay is a co-founder and serves as an unpaid volunteer on the Board of Directors of The Mothers Milk Bank at Austin. Neither she, nor any member of the Board of Directors of the MMBA receives any income from any aspect of donor human milk banking.


Using a quantitative cytochemical technique for measuring beta-glucuronidase activity in the peripheral nerves of mice, we have investigated the effectiveness of four potential adjuncts for reducing the dose limiting neurotoxicity of misonidazole (MISO) in the clinic. Under the conditions used, the most effective adjunct was the steroid anti-inflammatory agent dexamethasone. When given over the week previous to MISO treatment, this agent almost completely eliminated the MISO neurotoxicity as determined at week 4 after commencement of MISO dosing. The second most effective adjunct was phenytoin, the third flurbiprofen and the last adjunct, phenobarbitone, was ineffective. Dexamethasone, phenytoin and phenobarbitone all reduced the clearance half-life of MISO and hence the drug exposure dose calculated as the area under the curve of MISO tissue concentration against time. However, no correlation was evident with these parameters and MISO neurotoxicity in the mouse. Dexamethasone, whilst affording protection against MISO toxicity, did not alter the radiosensitivity of the anaplastic MT tumour.


The association between poverty and mental health has been widely investigated. There is, however, limited evidence of mental health implications of working poverty, despite its representing a rapidly expanding segment of impoverished populations in many developed nations. In this study, we examined whether working poverty in Switzerland, a country with substantial recent growth among the working poor, was correlated with two dependent variables of interest: psychological health and unmet mental health need.This cross-sectional study used data drawn from the first 3 waves (1999–2001) of the Swiss Household Panel, a nationally representative sample of the permanent resident population of Switzerland. The study sample comprised 5453 subjects aged 20–59 years. We used Generalized Estimating Equation models to investigate the association between working poverty and psychological well-being; we applied logistic regression models to analyze the link between working poverty and unmet mental health need. Working poverty was represented by dummy variables indicating financial deficiency, restricted standard of living, or both conditions.After controlling other factors, restricted standard of living was significantly (p < .001) negatively correlated with psychological well-being; it was also associated with approximately 50% increased risk of unmet mental health need .The findings of this study contribute to our understanding of the potential psychological impact of material deprivation on working Swiss citizens. Such knowledge may aid in the design of community intervention programs to help reduce the individual and societal burdens of poverty in Switzerland. Recent statistics have indicated that working individuals represent a growing proportion of Swiss residents living in poverty ,2, with The association between poverty and health has been the focus of vast research , and incworking poverty has been the subject of less directed research, although numerous inquiries have examined occupational and social correlates of income inequality among employed individuals, building on the concept of relative deprivation first identified in the economics literature [The potential health impact of terature ,15 and eterature ,17. Suchterature -21. Therterature ,23 of a A number of other gaps remain in the literature. First, the majority of Swiss studies of the working poor are descriptive in nature and based on civil administrative data, which typically include only demographic information. They are thus largely ineffectual for research involving outcomes related to well-being. Second, no study attempting to associate working poverty with psychological health of which we are aware has been carried out in Switzerland, notwithstanding the emergence of this important class of Switzerland's poor. And finally, many studies have conventionally defined poverty based solely on income thresholds, which exclude the notion of deprivation, and thus do not fully capture the multifaceted nature of economic insecurity.Regarding this last point, it is worth noting that the way in which we characterize poverty in this study is obviously dependent on the country under study–or perhaps more importantly, its level of economic development. Poverty is relevant only in context, with substantial definitional variation across nations according to economic circumstances . Thus, aThe objective of this research is to investigate the association between working poverty and two mental health measures among prime-age (20–59 years) workers in Switzerland. Using individual-level data from the 1999, 2000, and 2001 Swiss Household Panel, and a measure of poverty that takes account of both income deficiency and restricted standard of living ,25, we aWe put forward two main hypotheses for this research:Hypothesis 1: First, we propose that working poverty will be correlated with poorer psychological health and higher likelihood of unmet need, after accounting for socio-demographic and occupational characteristics, which may confound the relationship between poverty and mental health.Hypothesis 1a: Working poverty, when defined by both income deficiency and restricted standard of living, will have a more salient effect on our outcomes than will working poverty, as defined independently by income deficiency or restricted standard of living.Hypothesis 2: Second, we hypothesize that the effect of working poverty on psychological well-being will vary across demographic and occupational characteristics, where differential effects will be detectable by civil status, employment status, and sex. In particular, we purport that working poverty will have a more significant impact on psychological well-being among: unmarried individuals than those who are married or partnered, because of the lack of buffering provided by the social and financial support of a spouse; full-time employees than part-time workers, due to differences in labor force attachment; and women than men, because of the various interrelated burdens attached to the labor market and family .This is a cross-sectional study that uses data from the first 3 waves (1999–2001) of the Living in Switzerland survey of the Swiss Household Panel, a longitudinal survey designed to investigate trends in social dynamics among the Swiss population. The SHP is a nationally representative random sample of the permanent resident population, drawn on the basis of the largest national telecommunication provider's electronic telephone directory, which covers over 95% of all private households. Data are collected annually by telephone, and are obtained at both the individual and household level. All interviews are carried out in one of three  of Switzerland's four national languages. At the 1999 SHP baseline, the sample comprised 7799 participants, who were aged 14 years and older, from 5074 households. The Swiss Household Panel is a collective effort of the Swiss National Science Foundation, the Swiss Federal Statistical Office, and the University of Neuchatel. A detailed description of the SHP is provided elsewhere . As the 99 = 4560; n00 = 4236; n01 = 3909). Eliminating observations with missing data in one or more study variables resulted in a final study sample of 5453 unique respondents, who contributed of 11869 person-wave data records. As nearly 20% of household income data were missing, we used a multiple imputation process [Our eligible study sample comprised prime-age individuals who reported working at either the 1999, 2000, or 2001 surveys  . This vapsychological well-being scores = 3 (top 25% of the distribution), and reported that they had not received mental health counselling in the year prior to the survey. Determination of mental health counselling was based on responses to the following survey question, During the last 12 months, have you been treated for psychological problems?Unmet mental health need: This binary  dependent variable was coded as 1 if individuals jointly offered rd (private) pillar of pension system, and home computer. Two additional items  were excluded from consideration because of their potential endogenous determination by the outcomes. That is, psychological well-being might predict whether a respondent participates in such activities.The measure of working poverty, adapted from the designation of poverty developed by Budowski and colleagues for the SHP data , is defiFour, mutually exclusive dichotomous dummy variables represent our working poverty categories Figure . The firAdjustment variables and potential confounders were selected from a number of domains for use in multivariable cross-sectional models of the relationship between working poverty and our outcomes. These variables Table  includedTo test our first hypotheses, we fit a multivariable model of working poverty to our outcomes  with the 3 mutually exclusive dummy variables defining our poverty categories (working non-poor omitted as referent category), and compared the relative magnitude and statistical significance of the estimated coefficients on the working poor dummies. To test our second hypothesis, i.e. that the association between working poverty and our outcomes may vary within sub-populations, we added to the initial model a number of additional terms which multiplicatively interact the working poverty variables with relevant covariates, and assessed the statistical significance of the interaction terms. While effect modification was hypothesized for civil status, sex, and employment status, and these variables were thus the primary focus of such analyses, other covariates were also assessed for differential impact. As none of those variables was judged to be a significant effect modifier, the results of these supplementary analyses are not reported.We used repeated measures Generalized Estimating Equations (GEE) -31 to inThe analysis of unmet mental health was carried out with logistic regression, in which both bivariate and multivariable models were estimated. Once again, as a major component of this variable  was assessed just once, at the baseline survey, only the 1999 sub-sample of participants is used in this analysis.For both outcomes, models were independently fit on 4 data sets, each of which contained one of the imputed household income values. We then averaged estimated coefficients and standard errors on explanatory variables for the 4 models, using the approach developed by Schafer and Olsen , to arriSample members average 39 years of age, with 60% percent reporting married civil status Table . ConsistComparing sample characteristics across poverty categories, we find a number of striking differences. Swiss workers with restricted standard of living are more often divorced, female, and French speaking than the non-poor. The occupational profile of the deprived also differs from that of the non-poor, with a higher proportion of workers in manual and lower-skilled occupations, and a lower proportion of workers in managerial and professional positions. Workers classified by low income also contrast markedly with the non-poor in several attributes. Income deficient sample members are more apt to be married (and less likely to be single), be self-employed, and once again, to work in lower-skill occupations than the working non-poor.The results of multivariable estimation of the effect of working poverty on psychological well-being are presented in Table p < .001) negatively associated with psychological well-being relative to the working non-poor, confirming Hypothesis 1, whereas financial deficiency is not. The combined effect of the two variables, just marginally non-significant (p < .10), is smaller in magnitude than the independent effect of deprivation, reflecting the statistical averaging of the two effects, contrary to Hypothesis 1a. Among covariates, female sex and higher perceived risk of unemployment are also negatively related to psychological well-being. Significant protective factors include being married, better educated, German or French speaking, and full-time employed, and rating health as very well or well.Our findings suggest that, after other factors are controlled, restricted standard of living is significantly (p < .05) in the association between restricted standard of living and psychological ill-health, with women demonstrating a more potent effect than men. Neither of the other hypothesized effect modifiers  was significant. Hypothesis 2 is therefore partially confirmed. The results of the sex-stratified analyses illustrate what cannot be demonstrated by the interaction model: namely, that the psychological well-being of both sexes is significantly influenced by the experience of working poverty.Considering the model testing effect modification, our results indicate sex differences  well-being scores were in the top quartile of the distribution, which we assumed to reflect a necessity for psychological services. The results further indicate sex differences in the effect of economic deprivation on overall psychological well-being. Thus, while the data confirm that the psychological health of both Swiss men and women is adversely influenced by living without certain common household items, or partaking in fairly customary activities, women appear to be affected more intensely than men.The analysis did not suggest that relative income deficiency had any measurable bearing on psychological health or unmet counseling need. Furthermore, the intersection of restricted standard of living and income deficiency, assumed to be the worst possible state of working poverty, was only not significantly related to psychological ill-health, owing to the dilution of effect caused by combining a strongly significant factor (deprivation) with a non-significant one (low income). In any case, the reader should be reminded that, given the cross-sectional design of the study, all reported associations merely imply correlation, and should not be interpreted as causal.Our findings from this research are generally supportive of those of earlier studies linking material deprivation to negative psychological outcomes, and strongly consistent with evidence from the Poverty and Social Exclusion (PSE) Survey of Britain , with onIn contrast, our data revealed that among Swiss workers with a restricted standard of living (deprived), men and women reliably designated the same 2 items from the potential list of 10: the inability to save 100 Swiss Francs monthly, and to contribute to the 3rd pillar superannuation fund. Consequently, the sex difference in the magnitude of effect of material deprivation in Switzerland seems rather produced by sex-specific perception and processing of the deprivation than by variation in the goods or activities. The environment in which the deprivation occurs may also play a role in the observed sex differences. Single parenthood, more likely among women than men in the sample of working poor, is associated with multiple burdens  and less time for recreational activities, which could limit the opportunity for emotionally supportive social relationships. Recent research  has suggSex differences aside, the notion that Swiss workers with a restricted standard of living are so defined by items of a somewhat non-material nature is intriguing from a sociological perspective, and may imply a uniquely Swiss economic outlook. Both of the items commonly identified by deprived individuals  acknowledge the importance of current financial behavior to future consumption. Further considering that low income, when combined with deprivation, had no additional effect on psychological health in our analyses, one could infer that the association between working poverty and poor mental health is based more on the inability to accumulate wealth, at least part of which may not be expended until retirement, than on any deficiency in current consumption goods or services, or the ability to purchase them. Such farsighted underpinnings differ markedly from the current items identified by British PSE study subjects with elevated mental health scores. It would be imprudent, however, to wholly attribute the cross-national difference to cultural divergence in perception, as deprived PSE participants included both working and unemployed individuals.It would be similarly unwise to ignore the fact that the mechanism between poverty and health is a complex one, and that large secondary data sets such as the SHP, no matter their depth or sophistication, can never fully capture the process of mediation from a socioeconomic status to an adverse health status or event, if that is, in fact, the direction of the relationship. Our findings should be interpreted in the context of this limitation. Seemingly simpler matters, moreover, remain unresolved. For example, much debate has focused on the question of how best to operationalize poverty for the purpose of investigating its correlates. Studies have used a range of measures, including relative income levels, earnings thresholds for receipt of public assistance, and varied measures of socio-economic stratification and labor market exclusion. However, no real consensus exists on the optimal measure of poverty. In this study, which exclusively considered employed individuals, we both separated and combined variables measuring low income and deprivation to broaden the possibilities of potential associations. Having found an association in just one of the two variables, and a weakening of this effect when uniting the two measures, appears to justify our decision.Two other matters also merit mention. First, our primary outcome variable has not been validated against clinical assessment of mental ill-health, as the establishment of psychological illness prevalence and incidence is not a goal of the SHP. Further, the outcome variable captures neither intensity nor severity. Rather, this variable is a subjective pseudo-frequency of negative psychological states that summarizes individuals' perception of their psychological well-being. The robust statistical results nonetheless suggest that our measure is sensitive to the experience of deprivation. And second, as our design is cross-sectional, we are unable to assess whether the association between restricted standard of living and poorer psychological well-being is a causal one, and must be left for future research.This research may have important implications. From our findings, social planners and policy makers can be made aware that financial deprivation among working Swiss may have mental health consequences. Mental ill-health, with its myriad associated costs, has the potential to place a great burden on the economic and social structure of Switzerland. Being able to identify a population that is at risk for mental illness can provide a base for further research. Future investigations should focus more closely on the specific needs, attitudes, and expectations of the economically deprived residents of Switzerland. A more specific knowledge regarding the mental health consequences of financial deprivation can help in designing intervention programs in the community, and thus help to reduce the individual and societal burden of poverty in Switzerland.The author(s) declare that they have no competing interests.SV participated in the design of the study, helped draft the manuscript, and oversaw all work on the project. JE performed the data management, participated in the statistical analysis, and helped draft the manuscript. IS participated in the design of the study and helped draft the manuscript. HT led the statistical analysis, interpreted the findings, and helped draft the manuscript. WR participated in the design of the study and provided critical revisions to the manuscript. WTG conceived the study, participated in its design, oversaw the statistical analysis, and drafted the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Teratomas are manifested with a great variety of clinical and radiological features, while sometimes they simply represent incidental findings.A rare case of benign teratoma of the dermoid cyst type, in an adult 40-year-old female patient, is reported. The patient had presented recurrent pulmonary infections for the previous 2 months, persistent cough, and progressively aggravating dyspnea. A chest X-ray showed total atelectasis of the left lung, and the thoracic CT-scan revealed a huge mass, containing multiple elements of heterogeneous density, probably originating from the mediastinum, occupying the whole left hemithorax. The mass compressed the vital structures of the mediastinum, great vessels and airways, and a chest MRI was performed to accurately detect the anatomical relations. The patient underwent left thoracotomy and the tumor was totally resected. The size of the tumor was extremely large although no invasion to the vessels or to the airway had occurred. Adherence to the adjacent left pulmonary artery and left main bronchus was present, but without erosion or fistulization. The postoperative course was uneventful, while the histological examination confirmed a teratoma.A teratoma is a non-homogeneous pathological entity, clinically, radiologically or histologically. It is predominantly diagnosed between the second and fourth decade and the incidence is equal for both sexes. Symptoms are absent in one half of the patients. The case reported is noteworthy as the tumor appeared with total atelectasis of the left lung, and symptoms started 2 months prior to diagnosis. Total removal of the tumor is adequate treatment for this type of teratoma and the prognosis is excellent. Mature teratomas are the most common histological type of germ cell tumors, followed by seminomas . Germ ceA 40-year-old female with negative smoking and medical history was admitted with productive cough, progressively aggravating dyspnea on exertion, and recurrent pulmonary infections for the previous 2 months. The chest X-ray showed total atelectasis of the left lung Figure , and thend postoperative day. Preoperative atelectasis of the left lung was totally resolved  have no signs or symptoms when the mass is initially diagnosed. Symptoms commonly present are chest, back or shoulder pain, dyspnea, cough, fever, pleural effusion, and bulging of the chest wall . In the In spite of the pressure on the mediastinal vessels or the airway, invasion of these anatomical elements does not usually occur. However, erosion of the tumor to the bronchus, as well as to the pleural space, to the skin, and to the aorta has been reported.Diagnostic assessment is performed with classical X-rays, followed-up by CT. Typically, a well-circumscribed anterior mediastinal mass extending to one side of the midline and protruding into one lung field is revealed. CT accurately estimates the density of all included tissues, such as soft tissue , fluid (88%), fat (76%), calcification (53%), and teeth and such imaging findings are considered specific . MRI is Macroscopically the tumors are spherical, lobulated, with a well-defined capsule, and contain a variety of material, lipid-rich fluid, cheese-like substances, teeth, hair, and cartilage. Histologically, benign teratomas comprise at least 2 of the 3 primordial layers: ectoderm (skin and hair), mesoderm , and endoderm .Surgical resection is the treatment of choice and radical extirpation secures a long survival out of recurrence. Median sternotomy is usually preferred for tumor removal, but access via either posterolateral or anteroposterior thoracotomy depends on the size, location, and expansion of the tumor. Difficulty in surgical maneuvers may be a result of the vital structures involved. In a large series of 95 patients with benign mature teratoma, in addition to tumor resection, 3 patients required lobectomy, 5 patients additional partial resection of the lung, and 7 patients pericardectomy. VATS techniques have been introduced in teratoma resection with promising results . The appIn the case reported, left posterolateral access was chosen, as the tumor was almost entirely located into the left hemithorax, reaching and adherent to the left hemidiaphragm. Such a location precludes median sternotomy, otherwise the preferred approach, as surgical manipulations are impossible on the lower lobe of the left lung and on the left hemidiaphragm. MRI was performed after the CT-scan in order to more precisely reveal the relations with the mediastinum vital anatomical structures  because it was critical to clarify whether there was an invasion or simply compression. The examination pointed to the latter and loose tumor adhesions with the great vessels were confirmed on surgery and gently submitted to blunt dissection. The left lateral decubitus position of the patient did not influence ventilation during operation, as ventilation conditions with a double lumen tracheal tube were similar to the preoperative values affected by the left lung atelectacis. Furthermore, left lung operation secured the right lung against potential contamination from infected content of the chronically collapsed left lung.• Such a huge teratoma extending to the whole hemithorax and resulting in total atelectasis of the left lung has been only sparsely reported previously ,15.• Even a huge mass causes simple compression and deviation without invasion of the vascular and airway structures.• Complete resection is adequate treatment for the patient with favorable long-term prognosis.The author(s) declare that they have no competing interests.CZ was the main surgeon of the patient, who reviewed the literature and had the central responsibilityin the management ofthe patient and the writing of this report,DR was the pathologist, who examined and diagnosed histologically the resected specimen,GS was the interventional bronchoscopist and pulmonologist, who performed bronchoscopy, functional respiratory tests and assessed the patient as candidate of major surgical procedure,KV and KS were assistants in this operation and helped in preparation of the manuscript,MA offered his valuable experience in the management of the patient and the writing of this report,IB coordinated writing of the manuscript.All authors read and approved the final manuscript.


Allergic rhinitis and asthma are conditions of airway inflammation that often coexist.In susceptible individuals, exposure of the nose and lungs to allergen elicits early phase and late phase responses. Contact with antigen by mast cells results in their degranulation, the release of selected mediators, and the subsequent recruitment of other inflammatory cell phenotypes. Additional proinflammatory mediators are released, including histamine, prostaglandins, cysteinyl leukotrienes, proteases, and a variety of cytokines, chemokines, and growth factors. Nasal biopsies in allergic rhinitis demonstrate accumulations of mast cells, eosinophils, and basophils in the epithelium and accumulations of eosinophils in the deeper subepithelium . Examination of bronchial tissue, even in mild asthma, shows lymphocytic inflammation enriched by eosinophils. In severe asthma, the predominant pattern of inflammation changes, with increases in the numbers of neutrophils and, in many, an extension of the changes to involve smaller airways . Structural alterations  of bronchi in mild asthma include epithelial fragility and thickening of its reticular basement membrane. With increasing severity of asthma there may be increases in airway smooth muscle mass, vascularity, interstitial collagen, and mucus-secreting glands. Remodeling in the nose is less extensive than that of the lower airways, but the epithelial reticular basement membrane may be slightly but significantly thickened.Inflammation is a key feature of both allergic rhinitis and asthma. There are therefore potential benefits for application of anti-inflammatory strategies that target both these anatomic sites. Asthma is a chronic, inflammatory condition of the lower airways characterized by largely reversible airflow obstruction, airway hyperresponsiveness, and episodic respiratory symptoms, including wheezing, productive cough, and the sensations of breathlessness and chest tightness . AllergiIn the present article, we summarize the patterns of inflammation of the upper and lower airways; we emphasize the need to consider treating the inflammation that is common to both. We introduce briefly techniques currently used to describe characteristic cells and mediators of inflammation common to both asthma and AR. Of course, patients with asthma, as well as AR, can demonstrate a spectrum of symptoms clinically and, likewise, of inflammatory changes. As more data emerge it is likely that distinct phenotypes of both AR and asthma will become accepted. Despite this, there are some obvious similarities in the patterns of inflammation yet differences in the extent of remodeling.With the exception of the anterior nares and a good proportion of the nasopharynx and larynx , the microscopic anatomy of normal nasal and bronchial mucosa is similar: a pseudostratified epithelium resting on a reticular basement membrane with underlying subepithelium . The epithelium is composed of columnar ciliated cells interspersed by goblet cells , and benThere are several techniques for evaluating inflammation in lower or upper airways in both clinical and research settings. The lower airways can be investigated by rigid or flexible fiberoptic rhinoscopy and bronchoscopy -10. BronBronchoscopy has its limitations. It samples only a small portion of the entire lung and in its airways, only the superficial portion of the bronchial wall is sampled. While possible, examination of the smaller (2–3 mm) airways is difficult in practice and there are greater safety and ethical issues. Moreover, bronchoscopy may not be practical in severely compromised adults or pediatric patients  although2, cysteinyl leukotrienes, and neutral proteases [The inflammatory cascade in the nose begins with allergen deposition on the nasal mucosa and consists of early phase responses and, in many cases, late phase responses in susceptible individuals. Upon activation by antigen via cross-linking of IgE receptors, sensitized mast cells immediately degranulate, releasing a variety of inflammatory mediators, including histamine, prostaglandin Droteases . These mroteases ,27.Nasal biopsies of patients with active AR show accumulations of mast cells, eosinophils, and basophils in the epithelium and an accumulation of eosinophils in the deeper lamina propria . In timeBoth inflammation and structural changes (referred to as remodeling) occur in the tracheobronchial tree of patients with asthma. It has been generally considered that chronic eosinophilic inflammation is a prerequisite for the development of remodeling, and there is some animal experimental evidence to support this . InvestiAirway inflammation can be present even in patients with normal lung function but with symptoms indicative of asthma ; hence, Chronic inflammation plus remodeling contribute to airway wall thickening, which encroaches upon the airway lumen and increases resistance to airflow Figure . Airway Lymphocytic inflammation enriched by eosinophils is characteristic of the bronchi in mild asthma in both adults and school children, and also of the bronchi and luminal secretions in fatal asthma Figures  and 4. Iper se. As occurs in the nose, the sequence of reactions in the lungs may include both early phase and late phase responses. There is presentation of antigen to mast cells, cross-linking of cell surface IgE, degranulation of mast cells, release of mediators such as histamine and leukotrienes that markedly increase vascular permeability, followed by recruitment of more inflammatory cells, and further release of proinflammatory mediators.In allergic asthma, inhaled allergens that penetrate the mucociliary lining layer enter the airway epithelium either via the tight junctions that surround the apical zone of bronchial epithelial cells or by direct uptake by the cells In asthma, the predominant orchestrator of the chronic inflammation is the CD4 or T-helper lymphocyte, producing key regulatory cytokines such as IL-5 and IL-4 . Eosinop1) receptor) present on the eosinophil, but not exclusively so. In support of this, challenge with leukotriene E4 results in greatly increased numbers of eosinophils in the bronchial wall [in situ hybridization and immunohistochemistry to localize cells that express either the mRNA or the protein for the cysLT1 receptor, respectively [1 receptor are increased – in comparison with normal healthy nonsmokers – in nonsmoking patients with mild, stable asthma and that there is a further increase among patients experiencing a severe exacerbation of asthma leading to hospitalization  recepRemodeling in asthma has been defined as a change in structure that is inappropriate to the maintenance of normal airway function . RemodelThickening of the reticular basement membrane occurs early in asthma Figure , even beAirway smooth muscle surrounds the airways as two opposing helices; namely, in a geodesic pattern. As the muscle shortens, therefore, it not only constricts but tends to shorten the airway against an elastic load. Leukotrienes are very powerful constrictors of airway smooth muscle, being 1000-fold or 2000-fold more active than histamine. There are at least three possible mechanisms of smooth muscle mass enlargement in asthma: myocyte hypertrophy, myocyte hyperplasia due to cell division and proliferation, or myocyte de-differentiation and migration across the mucosa in the form of myofibroblasts or fibromyocytes. It is speculated that these may then re-differentiate to form new blocks of smooth muscle that come to lie just below  the epithelium .per se. No doubt there will be many more studies to test this hypothesis.Greater numbers of mast cells have recently been found located within the bronchial smooth muscle of patients with asthma than in those with eosinophilic bronchitis – the latter is also a condition of airway eosinophilia and remodeling but without the functional abnormalities characteristic of asthma. The difference in smooth muscle mast cell number that discriminates between these conditions has led to the hypothesis that the infiltration of airway smooth muscle by mast cells is responsible for the disordered airway function characteristic of asthma, and thus that asthma is the result of a mast cell myositis . These aAllergic asthma and AR are often considered clinical manifestations of the same condition, the chronic allergic respiratory syndrome ,39. The Possible mechanisms for the influence of AR on lower airways include disturbance of the beneficial role of nasal mucosa in conditioning the air entering the respiratory tree; neural interaction between upper and lower airways; irritant effects of nasal secretions directly entering the lower airways; and systemic propagation of nasal inflammation to the bronchial mucosa (or vice versa) via effects of mediators and inflammatory cells on bone marrow – 'systemic cross-talk' ,40,44.Nasal corticosteroids, antihistamines, and the leukotriene receptor antagonist (LTRA) montelukast have each been shown to have anti-inflammatory effects on different aspects of inflammation in AR, and these effects have been recently reviewed .in vitro evidence from isolates and cultures of human airway smooth muscle that leukotrienes enhance myocyte proliferation and migration, processes that can be attenuated by LTRAs [In patients with asthma, inhalation of corticosteroids (ICS) produces reductions in bronchial inflammation by days or weeks, whereas reductions in reticular basement membrane thickening are achieved over longer periods, after about 1 year . Treatmeby LTRAs -51.The clinical benefits of early treatment with anti-inflammatory therapy for asthma were shown in studies in the early 1990s ,53. In 12-agonist [Several recent studies have shown that there is still room for improvement in anti-inflammatory treatment of patients with asthma. There are several arguments that favor the combined use of ICS and an LTRA in asthma. First, cysteinyl leukotriene levels in induced sputum remain increased in patients with asthma receiving ICS, suggesting that corticosteroids do not suppress leukotriene production . Also, t-agonist . Among t-agonist .For patients with comorbid AR and asthma, effective management of their rhinitis may also improve the coexisting asthma . As discFinally, the World Allergy Organization, in conjunction with the World Health Organization, has recently published Guidelines for the Prevention of Allergy and Allergic Asthma that include primary, secondary, and tertiary prevention strategies ,63. The 2-agonist as needed. In moderate to severe asthma, regular long-acting β2-agonists are used if anti-inflammatory therapy fails to control the disease, as indicated by increasing daily requirement for short-acting β2-agonist. The combination of ICS and oral LTRA anti-inflammatory therapy is one alternative approach to treatment and provides the option of treating airway inflammation as a whole. Given the similarity that exists between the patterns of inflammation seen in AR and asthma, patients may best benefit from an approach that considers treating the entire airway rather than only a part, as well as the skin as necessary.As inflammation and its relationship to remodeling in AR and asthma are becoming better understood, the importance of anti-inflammatory treatment is increasingly accepted. For patients with symptoms of asthma, it is important to detect inflammation (and remodeling) early and to control inflammation in all its stages and severities. Initial therapies comprise anti-inflammatory medication, usually ICS or LTRA in mild asthma or ICS in more severe asthma. This is usually supplemented with rapidly acting β1 = cysteinyl leukotriene type 1; ICS = inhalation of corticosteroids; IL = interleukin; LTRA = leukotriene receptor antagonist; RANTES = regulated upon activation, normal T-lymphocyte expressed.AR = allergic rhinitis; cysLTPKJ has received funds to support independently initiated research and lecture fees from Merck & Co, USA. TH has received speaker's fees from Merck & Co.