Health care in post-war situations, where the system's human and fixed capital are depleted, is challenging. The addition of a frozen conflict situation, where international recognition of boundaries and authorities are lacking, introduces further complexities.Nagorno Karabagh (NK) is an ethnically Armenian territory locked within post-Soviet Azerbaijan and one such frozen conflict situation. This article highlights the use of evidence-based practice and community engagement to determine priority areas for health care training in NK. Drawing on the precepts of APEXPH  and MAPP (Mobilizing for Action through Planning and Partnerships), this first-of-its-kind assessment in NK relied on in-depth interviews and focus group discussions supplemented with expert assessments and field observations. Training options were evaluated against a series of ethical and pragmatic principles.A unique factor among the ethical and pragmatic considerations when prioritizing among alternatives was NK's ambiguous political status and consequent sponsor constraints. Training priorities differed across the region and by type of provider, but consensus prioritization emerged for first aid, clinical Integrated Management of Childhood Illnesses, and Adult Disease Management. These priorities were then incorporated into the training programs funded by the sponsor.Programming responsive to both the evidence-base and stakeholder priorities is always desirable and provides a foundation for long-term planning and response. In frozen conflict, low resource settings, such an approach is critical to balancing the community's immediate humanitarian needs with sponsor concerns and constraints. Evidence-based approaches in public health practice provide a systematic, objective framework that can inform policy and decision-making by establishing priorities that make maximal use of limited resources. Within the realm of humanitarian assistance, the evidence on how to respond to disasters has evolved: Public health specialists and Non-governmental Organizations (NGOs) have developed protocols for preparing for and managing responses to earthquakes, cyclones, natural disasters, and, sadly, endemic wars -4 and evNagorno Karabagh is a fertile, mountainous region located in the northeastern part of the Armenian highlands  See map. Part ofde facto government faces many challenges to meeting the population's health and human services needs [The absence of international recognition presents a serious impediment to NK's recovery, as it hinders international communications, trade and foreign assistance that countries emerging from war situations typically receive . Thus, Nes needs .The economic and political climate in NK has created difficulties for health care delivery ,15. HealInternational non-governmental organizations and the Armenian Diaspora have addressed some of NK's most urgent health challenges. However, the NK population now simultaneously suffers transition health problems such as infectious and parasitic diseases (including tuberculosis outbreaks) and conditions more typical for post-transition populations: heart diseases, cancers, and diabetes , often rResponding to the need for an integrated humanitarian support program, the United States Agency for International Development (USAID) in 2003 contracted the Fund for Armenian Relief (FAR) and the American University of Armenia's (AUA) Center for Health Services Research and Development (CHSR) to carry out the Humanitarian Assistance Project in Nagorno Karabagh (HAP-NK). The AUA CHSR implemented the health component of the program, which envisioned a combined approach of infrastructure rehabilitation paired with targeted workforce development activities. The first phase of the project (2004) consisted of parallel detailed health facility and health worker training needs assessments.The healthcare workforce is vital to protecting and advancing health. Developing competent healthcare providers is central to achieving national and global health goals . GovernmThis article summarizes the health workforce assessment conducted by the American University of Armenia's (AUA) Center for Health Services Research and Development (CHSR). This effort was the first of its kind ever conducted in NK and the largest-scale health sector assessment conducted in NK to date.At the time of the health workforce assessment, the NK health system contained 200 health facilities including four hospitals, four dispensaries, and three ambulatories in the capital (Stepanakert), five central regional hospitals, five village district hospitals, 16 village ambulatories, 145 obstetrical centers, and nine sanitary-epidemiological stations. The system employed 274 physicians (6 years of training) and 837 nurses (2 years of training) and feldshers The NK health system retains most of its Soviet structure. Under the Soviet Union's Semashko model of health services ,21, ruraThe current state of NK's health system is attributed to the "inherited" deficiencies from the Soviet health care system ,21 furthTo the extent practicable, the health workforce assessment followed the community engagement principles of APEXPH   and MAPPGiven the limited existing data, the NK health workforce training needs assessment primarily relied on qualitative methods, which included in-depth interviews (IDI) and focus group discussions (FG) with a cross-section of system planners, health care administrators, and health workers from all service levels in NK. Healthcare administrators were recruited via snowball sampling drawing upon contacts provided by international organizations having worked previously in NK. These healthcare administrators, in turn, helped to identify a pool of healthcare workers who could participate in the interviews and focus groups.Ten focus groups totaling 41 participants  were conducted with NK physicians, nurses, and feldshers. A total of 11 IDIs were conducted with health system administrators, including representatives from the Ministry of Health, the NK Feldsher Academy, and health facilities. Experienced moderators supported by trained note-takers/recorders facilitated all FGs and IDIs. The interview and focus group sessions were conducted in Armenian and Russian according to the participants' preference. In keeping with the IRB approval of the American University of Armenia, audio recordings to supplement the written session notes were made only after obtaining agreement from the participants.Both the FG and IDI guides were developed in English, translated into Armenian, and then pre-tested and revised. The semi-structured guides sought to elicit information addressing gaps in situational knowledge pertinent to the training needs assessment. Both semi-structured guides contained about 25 items, with the FG guides more oriented toward the population's practices and providers' perceived training needs and the IDIs focused more on administrators' perspective on staffing needs, training capacity, and other workforce issues. While similar, the specific prompts varied by provider type and scope of practice. So as not to deplete the limited pool of administrators, the IDI guide was pre-tested on several administrators who worked with health-related non-governmental organizations in NK. The FG guides were pre-tested using a pool of staff from a nearby health facility not targeted for inclusion in the pool of FG participants. Minor revisions were made to better elicit the desired information. The FGs lasted approximately 60 - 90 minutes. The interviews lasted approximately 60 minutesThe facilitator and note-taker prepared a detailed report of each FG and IDI (in English). Their expanded notes accompanied the report from each session and the session transcript . The report reflected a consensus translation of quotes and specific phrasing where necessary. The facilitators then prepared a preliminary analysis that identified major themes and delineated the structure of the findings. These qualitative findings were then triangulated with data from the concurrent facility assessment .The perspectives of providers and administrators about their training needs and priorities were then synthesized with the expert opinion of the project staff, who relied on the limited existing data, their observations, and their knowledge of similar efforts conducted in similar settings. The training options were then weighed against pragmatic concerns such as resource availability and concordance with sponsor priorities and constraints. After summarizing the data in a tabular form Table , a finalDiscussions with the various stakeholders across the service and organizational levels of the NK health system yielded rich data on the current situation, perceived challenges and needs, and priorities for intervention. Across the region, levels of healthcare facilities and training varied and perceived needs were naturally more focused on and relevant to a given person's training and role within the larger system. However, key themes and considerations emphasizing the primary care delivery system emerged and the main ideas are summarized in Table Table According to system administrators, NK requires physicians to possess a medical degree and have completed a one-year internship in order to practice medicine as a therapeut . Specialists require an additional clinical residency that typically lasts several years. In 1998 a licensure system for physicians, nurses, and feldshers was implemented, paralleling the system adopted in Armenia . As in ABased on the size of the population being served, staffing and service levels are below expectations. Furthermore, a significant proportion of providers, especially those serving remote areas, are nearing retirement age, with little hope of replacement in the short term.Since the cease-fire, the quality of medical education available in NK has suffered, and only a few training programs have been conducted, most by international organizations as part of their targeted humanitarian efforts. The major organizations working in NK during this period included Family Care Foundation, International Committee of the Red Cross , and Medecins Sans Frontieres. Their training programs had primarily focused on reproductive health, Integrated Management of Childhood Illnesses (IMCI), Adult Disease Management (ADM), and TB control.Participants perceived the trainings as helpful and of high quality, stimulating demand for further training. The trainees appreciated that the trainings were free of charge and encouraged by their employers. System administrators, however, noted several shortcomings, including the lack of adaptation to local needs, protocols, and expectations; the lack of "hands-on" training components; and the provision of training without ensuring the corresponding support  needed to implement the training. Both trainees and administrators noted that these trainings had mostly targeted primary health care workers, but felt that providers at secondary and tertiary facilities also would benefit from these trainings. Furthermore, none of these sponsor-driven programs had covered the entire system, leading to imbalances in the quality of care and scope of practice, both perceived and actual, across the system. Thus, some regions within NK had received several trainings and others none, leaving a patchwork of knowledge, skill, and resources, with some providers feeling overlooked.While emphasizing the needs in rural areas, providers stressed that all population groups would benefit from having well-trained doctors, citing the centrality of physicians in the organization and delivery of healthcare services. The head of the Republican San-Epi Station stressed the need for his staff to receive training in epidemiology, hygiene, pediatrics, and general therapy. He felt that training topics should emphasize knowledge and skills for both infectious disease surveillance and immunization system management. At the regional san-epi stations, staff felt they would benefit from trainings on general hygiene, epidemiology, parasitology, and bacteriology. System administrators noted the lack of up-to-date knowledge and skills among the entire health workforce, the lack of functional equipment, and poor conditions in general. System administrators also emphasized that the government's newly adopted decentralized management structure created a need for health financing, personnel management, planning, and leadership training for facility managers. System planners suggested coronary heart disease, hypertension, diabetes, family planning/contraception use, smoking/substance abuse, adult psychological health, nutrition, and STI/AIDS as the focal points for future training programs. They stressed, however that, although the primary care sector was important, the secondary and tertiary levels had been neglected and therefore had more training deficits. Furthermore, the planners noted that many patients now wait until their condition is severe and enter the system directly at a tertiary care site.Physicians and administrators from rural primary care facilities stressed the need for expanding the scope of practice of primary care physicians and the cross-training of other mid-level staff, who often were forced to address more complex cases due to patient difficulty in accessing a secondary or tertiary care center. Physicians tended to focus on the need for more specialized trainings rather than on primary and preventive services. Despite the lack of basic equipment, supplies, and laboratory reagents, most physicians believed that they were able to provide appropriate and adequate care to patients using their current skills, intuition, and experience. Most physicians believed that nurses and feldshers, however, would most benefit from primary care and preventive services training.Many of the rural nurses and feldshers had received one or more of the recent trainings from international organizations. Nurses expressed the need for trainings related to providing and supporting primary and preventive services, but emphasized the need for suitable work conditions and stable drug supplies that would enable them to apply their new knowledge and skills in practice. Several nurses stated that they were not confident in their ability to provide adequate care when a physician is not present: only in critical situations would they rely on their own knowledge and experience.A technical assessment of health care facilities conducted in parallel with this assessment  corroborFacility administrators from regional hospitals stated that their staff needed training in many specialty areas. This view was shared by the physicians, who added that nurses needed further specialized training as well as cross-training as nurses in secondary facilities were expected to cover multiple departments . Nurses and feldshers from regional-level facilities identified the need for training to provide and support primary and preventive services. The parallel facility assessment  identifiHealth care administrators and physicians from referral-level facilities prioritized the need for specialty training. While the training topics aligned with the major sources of morbidity and mortality, special emphasis was placed on mental health as an important concern for this post-war/frozen conflict situation.Virtually all respondents preferred trainings that emphasized active learning strategies such as interactive workshops, on-the-job training, and other practice-based trainings. Physicians preferred trainings that would last from several weeks to one to two months and combine theoretical information with practical experience in health care facilities. Several respondents suggested that international experts or specialists from Armenia could train NK specialists to become trainers for the rest of the health workforce. Physicians identified the NK capital city of Stepanakert or Yerevan (Armenia) to be the optimal setting for training.Nurses and feldshers felt they would benefit most from trainings lasting from several days to 1-2 weeks, with regional healthcare facilities as the most suitable place for conducting their training sessions. Such an arrangement would minimize disruption of care in their communities where only a few providers operated. They believed that international specialists, as well as local specialists trained by international or Armenian experts, were best suited to deliver their training. Several nurses stressed that seasonal factors should be taken into account when planning the appropriate timing for trainings, as many health care workers from rural and regional facilities are involved in subsistence agriculture and that winter often makes travel difficult.Based on the above information, priority training areas were identified. The determination of priorities involved consideration of several elements, including: health providers' and health system staff's assessment, the expert opinion of the project staff, the objectives and scope of the sponsor-funded project , and the availability of resources to conduct the trainings. Due consideration was given to the administrators' insistence that the training program needed to be locally relevant and hands-on. Further consideration was given to the likelihood of support from the professional and lay communities.Effectively managing human resources first requires that the profile and professional needs of the local health care workforce be captured and considered . The ada• In sum, five key principles for planning training strategies were applied Trainings needed to be consistent with existing protocols and use locally attainable and sustainable supplies.• Trainings needed to be coordinated with on-going facility renovations and refurbishments to ensure that the requisite basic primary care equipment was in place so that providers could practice the skills as taught to them.• Trainings needed to develop a cadre of master trainers who could institutionalize the training within existing structures and not be reliant upon continued outside support.• Where diagnostic and other laboratory equipment was provided, training on its use and maintenance also needed to be provided.• Furthermore, trainings needed to ensure equity in access to health care services across all of NK.These principles should be broadly applicable to other frozen conflict situations.Based on a synthesis of these assessment factors, potential training topics, training strategies, and their targeted recipients were then ranked as first priority, second priority, or excluded from further consideration. The group of excluded topics contained mostly efforts that would improve tertiary care, reform basic professional training curricula, or, while important, were outside the scope of the project. Thus, the topics that emerged as first priority items are a collection of related training projects that built upon past efforts and predominantly address the critical needs of village-level health workers. Second priority items generally relied upon the foundation established by those first priority efforts to be fully effective. These priorities are summarized in Table Included among the non-training recommendations was the suggestion to distribute provider resources and patient health education handouts focused on the pressing health problems. The AUA CHSR had developed for the Armenia Social Transition Program sixteen evidence-based patient education modules in Armenian and English that were relevant to IMCI and ADM related conditions . These mDeliberations with the sponsor, in light of these findings and changing programmatic constraints, led to the implementation of a 5-part training program closely aligned with these priorities over the subsequent three years. Primary care providers received first aid training that resulted in internationally recognized Red Cross certification. Primary care providers not previously trained in ADM or ICMI received an updated version of those training programs. Primary care providers were trained in basic patient counseling and health promotion skills. They were given sets of provider and patient level educational handouts and the means to make additional copies as needed . Over 500 volunteers from 40 pilot communities (8 from each NK region) were trained in community-level IMCI.The training programs utilized a train-the-trainers approach whereby international experts worked alongside a cadre of local trainers to deliver the training programs in the local languages and to assure the competence of a critical mass of local trainers to sustain the training after the completion of the project. In a clinical review of educating the medical professional, Kaufman  enumeratHealth care in post-war situations where the system's human and fixed capital are depleted is challenging enough. The addition of a frozen conflict situation, where international recognition of boundaries and authorities are lacking, introduces further complexities with healthcare planning, international aide, and funding. Despite these challenges, the precepts of evidence-based public health practice and community engagement, can contribute to meaningful assessments and determinations of priorities that balance objective needs, consensus needs, and disparate stakeholder priorities and concerns against an ambiguous political status and consequent sponsor constraints in cases such as Nagorno Karabagh.This comprehensive workforce training needs assessment was the first of its kind in NK. The information obtained from both qualitative interviews and the facility assessment confirmed that NK health personnel, at all levels of care, were in dire need of training. Health administrators at the system and regional levels needed management and leadership training to cope with a newly decentralized and underfunded system. Hospital-based physicians desired continuing medical education in their specialty. Primary care physicians working at rural and regional level facilities desired cross-training to cope with the diverse patient population they now encountered. Nurses and feldshers reported needing broader training in primary care and preventive services and the skills to more effectively practice quasi-independently. Natural differences in priorities emerged between specialist, primary care providers, and system planners, reflective of their training, experience, and their perspective of what would be best for the health system in general versus their specific and immediate needs. Overall, the training topics mapped with the dominant current and emergent health issues facing the NK population and the desire to improve basic practice skills.The methodology used to collect information and the criteria used to evaluate training priorities drew upon the principles and precepts of evidence-based practice  and commThe project focused on primary health care training of the existing workforce. Therefore, some information obtained during the assessment ultimately was beyond the scope of activities that could be implemented within this grant program. Still, the data should be of value to others contemplating programmatic efforts in NK. Not fully addressed by this analysis is the need for specialty training for secondary and tertiary level providers and the refurbishment of their facilities, the need for a comprehensive curriculum review of the Feldsher Academy programs, and the longer-term need for a workforce development plan that ensures a sufficient number of qualified providers are available to sustain the health system. Hopefully, such information will not be ignored, and can serve as a basis for efforts by others.Frozen conflict, low resource settings are characterized by virtually collapsed health systems, disruptions to most economic sectors, and diversion of resources and personnel to defense, and weakened government capacity ,8. ProgrThe authors declare that they have no competing interests.MET wrote the initial proposal, planned the conceptual approach to implementing the study, oversaw its implementation and led the analysis and interpretation.AHD contributed to the design, planning, and implementation of the needs assessments, provided expert opinion, and contributed to the analysis.TLH contributed to the planning of the study, conducted focus groups and interviews, and otherwise managed data collection and translation, and contributed to the analysis.All authors contributed to the preparation of the manuscript.At the time of this study, MET and TLH were with the American University of Armenia Center for Health Services Research and Development (CHSR): MET was CHSR Director and TLH was Senior Program Manager/Monitoring & Evaluation Specialist.


The increasing number of antibiotic resistant bacteria motivates prospective research toward discovery of new antimicrobial active substances. There are, however, controversies concerning the cost-effectiveness of such research with regards to the description of new substances with novel cellular interactions, or description of new uses of existing substances to overcome resistance. Although examination of bacteria isolated from remote locations with limited exposure to humans has revealed an absence of antibiotic resistance genes, it is accepted that these genes were both abundant and diverse in ancient living organisms, as detected in DNA recovered from Pleistocene deposits . Indeed, even before the first clinical use of antibiotics more than 60 years ago, resistant organisms had been isolated. Bacteria can exhibit different strategies for resistance against antibiotics. New genetic information may lead to the modification of protein structure affecting the antibiotic carriage into the cell, enzymatic inactivation of drugs, or even modification of cellular structure interfering in the drug-bacteria interaction. There are still plenty of new genes out there in the environment that can be appropriated by putative pathogenic bacteria to resist antimicrobial agents. On the other hand, there are several natural compounds with antibiotic activity that may be used to oppose them. Antimicrobial peptides (AMPs) are molecules which are wide-spread in all forms of life, from multi-cellular organisms to bacterial cells used to interfere with microbial growth. Several AMPs have been shown to be effective against multi-drug resistant bacteria and have low propensity to resistance development, probably due to their unique mode of action, different from well-known antimicrobial drugs. These substances may interact in different ways with bacterial cell membrane, protein synthesis, protein modulation, and protein folding. The analysis of bacterial transcriptome may contribute to the understanding of microbial strategies under different environmental stresses and allows the understanding of their interaction with novel AMPs. According to our recent history, human activity has markedly enhanced the evolution and distribution of resistant bacteria worldwide both in hospitals, human, and animal communities, and in the open environment, although this human activity is not necessarily the only, or even the proximate, cause for antimicrobial resistance phenomenon   is a class of molecules that may be used to overcome the bacterial resistance challenge. Their occurrence is a wide-spread phenomenon in all forms of life, from multi-cellular organisms to bacterial cells. In higher organisms, AMPs contribute to innate immunity and are part of the first defense line against harmful micro-organisms. In bacteria, production of AMPs provides a competitive advantage for the producer in certain ecological niches because the peptide mediates the killing of other bacteria  bacteria and possess low propensity for developing resistance probably due to their distinguished mode of action , change of antimicrobial peptide target , and removal of antimicrobial peptides from their site of action  . Several enzymes, encoded by pagP, pagO, pmrC, pmrG, lpxO, pmrHFIJKLM, modify LPS, mostly by adding or modifying palmitate, phosphoethanolamine or 4-aminoarabinose to mask negative charges that allow interaction with cationic AMPs  and plant.Some bacteria such as Antimicrobial peptides (AMPs), particularly the so-called bacteriocins produced by bacteria, may be an important contributor in this context as they often have a relatively narrow killing spectrum which comprises mostly bacteria closely related to the producers  resulting in repulsion of CAMPs. Other mechanisms have also been reported such as expelling CAMPs through energy-dependent pumps, altering membrane fluidity and CAMPs cleavage with proteases  and observed MIC50 increased in both mutant strains. They also observed a reduction in the lag phase after subsequent growth in pexiganan presence. The contribution of these resistance mechanisms in bacterial pathogenesis may be confirmed by studies with mutants. It is accepted that such prospective investigations are of extreme relevance, since these potential AMPs are thought to be an alternative to well established antibiotics used in chemotherapy against multiresistant bacteria  transporters encoded by the cdr genes (CDR1 and CDR2) and major facilitators encoded by the mdr genes.With regards to the antifungal drug resistance mechanisms, the genetic markers codifying for multidrug efflux pumps and their upregulation have been highlighted .Salmonella infection four steps were observed and none of the genes was directly involved in bacterial infection, but associated with inflammatory response . The information provided can be linked to the data on the hydrophobic moment calculated by the web-program HydroMcalc  is one of the main databases of antimicrobial peptides, allowing users to search for families of peptides, post translational modified peptides, among other options , hemolytic activity of the peptide and links to external databases such as SwissProt, PDB, PubMed and the NCBI Taxonomy  the peptide belongs. Peptides are promiscuous molecules  available at  Franco,  and are  Franco, . All of comparative modeling, threading (folding) modeling and ab initio (de novo). Experimental methods of peptide prediction and modeling have typical difficulties. The lack of structural conformation of plant bactericidal peptides prevents more detailed classification of AMPs , X-ray diffraction and crystallography, and theoretically, by computational modeling methods, which involve Comparative homology modeling is a method based on the structures similarity, i.e., similar amino acid sequences tend to have a very similar secondary structure. Thus, it is possible to use as a template structures solved by experimental means, in order to predict the 3D conformation of peptides and proteins using computational algorithms. In comparative modeling, the alignment of the sequence to be predicted and the template must present an identity of at least 30%  identification of structures and selection of templates, (2) alignment of the target sequence with the chosen model structure, (3) generation of models for the target structure, using information about the structure of the template; (4) validation of the models generated for the target .The LOMENTS is a meta-server which includes nine major servers threading , allowing the selection of models through research for 30 models for each of the individual servers, excluding short alignments, and defining models of greater structural similarity  makes use of the energy minimized functions and research of spatial conformations that the target can take, and this is important for the use of force fields and methods of molecular dynamics and Monte Carlo simulations  experimentally solved homology molecules, and even if the target presents high similarity with templates, it does not mean they will present the same structural profile.This method of predicting three-dimensional structures ignores in principle the use of reference structures solved experimentally. Prediction ab initio Software such as ROSETTA and I-Tasser, cited above, have been used as de novo prediction programs , which does not make use of structures or reference sequences, initiating the construction of the target from the extended chain as a result. The simulation performed by the software promotes the disruption of conformations of three randomly chosen residues, and evaluates the energy, using Monte Carlo procedure to validate the favorable conformation predicted , a tool that builds models from small fragments (residues 1–20) using Monte Carlo simulations –such as those used in the treatment of chronic diseases such as cancer or sexual dysfunction, for example—rather than the development of antimicrobial drugs used for short term treatment of acute infectious diseases   Act, which states: (i) warranty for new approved drugs protection from competition in the marketplace by limiting FDA approval of similar drugs during the a certain exclusivity period; (ii) review and fast-rack approval priority for qualified antimicrobial drugs, antibiotic applications will be eligible for both priority review and fast-track approval through the FDA new drug application process; and (iii) study of incentives for Qualified Infectious Diseases Biological Products, to encourage research, development, and marketing for qualified infectious disease biological products Forsyth, . BesidesIn this regard, considering the evolution of bacterial pathogens associated with infectious diseases today, the need to develop new agents to control multiresistant bacteria is presumed, or to prospect new ways of using the inefficient well-established antimicrobial arsenal, aiming to overlap the existing limitation in antibacterial chemotherapy .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Complementary and alternative medicine (CAM) has frequently been used to treat tinnitus, and acupuncture is a particularly popular option. The objective of this review was to assess the evidence concerning the effectiveness of acupuncture as a treatment for tinnitus.Fourteen databases were searched from the dates of their creation to July 4th, 2012. Randomized clinical trials (RCTs) were included if acupuncture was used as the sole treatment. The Cochrane risk of bias tool was used to assess the risk of bias.A total of 9 RCTs met all the inclusion criteria. Their methodological quality was mostly poor. Five RCTs compared the effectiveness of acupuncture or electroacupuncture with sham acupuncture for treating tinnitus. The results failed to show statistically significant improvements. Two RCTs compared a short one-time scalp acupuncture treatment with the use of penetrating sham acupuncture at non-acupoints in achieving subjective symptom relief on a visual analog scale; these RCTs demonstrated significant positive effects with scalp acupuncture. Two RCTs compared acupuncture with conventional drug treatments. One of these RCTs demonstrated that acupuncture had statistically significant effects on the response rate in patients with nervous tinnitus, but the other RCT did not demonstrate significant effects in patients with senile tinnitus.The number, size and quality of the RCTs on the effectiveness of acupuncture for the treatment of tinnitus are not sufficient for drawing definitive conclusions. Further rigorous RCTs that overcome the many limitations of the current evidence are warranted. Tinnitus is a common yet poorly understood disorder . It is dComplementary and alternative medicine (CAM) has frequently been used to treat tinnitus, and acupuncture is a particularly popular option. Acupuncture is a therapeutic technique involving the insertion and manipulation of needles in the body. The use of acupuncture for treating the symptoms of tinnitus is similar to its use for pain relief because both conditions produce disagreeable sensory and emotional experiences . The ratDobie  summarizThe aim of this systematic review was to critically evaluate the current evidence from RCTs on the use of acupuncture as a symptomatic treatment for patients with tinnitus.The following databases were searched from their dates of creation through July 4th, 2012: MEDLINE, AMED, EMBASE, CINAHL, five Korean medical databases , four Chinese medical databases  and the Cochrane Library . Two sets of search terms were used. The first set included terms for acupuncture, and the second set included terms for tinnitus , superficial insertion at an acupuncture point or non-penetrating acupuncture at an acupuncture point or a non-acupoint) and relevant conventional drug therapies for tinnitus. Trials with designs that did not allow for the evaluation of the efficacy of the acupuncture  were excluded.Studies were required to include either the symptom severity or the relief of symptoms in tinnitus as outcome measures. Other clinically important outcomes included the quality of life, the response rate  and adverse events.Hard copies of all articles that appeared promising based on their abstract were obtained and read in full. All articles were read by three independent reviewers , and data from the articles were validated and extracted according to pre-defined criteria Table .The risk of bias was assessed using the Cochrane classification of seven criteria: random sequence generation, allocation concealment, patient blinding, assessor blinding, incomplete outcome data, selective outcome reporting and other risks of bias . BecauseThe literature searches revealed 382 articles, of which 373 studies were excluded Figure . Of thesFive studies employed mixed interventions that included acupuncture in the active treatment group, including electroacupuncture plus herbal medicine injection , acupuncNine RCTs met our inclusion criteria, and their key data are listed in Table Four RCTs employed adequate methods of random sequence generation ,15,20,23Seven RCTs tested the effectiveness of several types of acupuncture on symptoms of tinnitus comparing with penetrating or non-penetrating acupunctures -18,20,21Among them, five RCTs compared manual acupuncture or electroacupuncture on the symptoms of tinnitus to penetrating or non-penetrating acupuncture on acupoints -18,20,21Two RCTs compared the effectiveness of a short one-time scalp acupuncture treatment to penetrating sham acupuncture at non-acupoints in achieving subjective symptom relief on a visual analog scale and in reducing the amplitude of otoacoustic emissions (OAE) ,15. One Two RCTs compared acupuncture with conventional drug treatments, including Bandazol and Flunarizine hydrochloride ,23. One Few sham-controlled RCTs have tested the effectiveness of acupuncture on tinnitus. Collectively, the results of the existing studies have failed to demonstrate specific effects of acupuncture. Only two of the 7 sham-controlled RCTs suggested positive effects. These two RCTs demonstrated beneficial effects of acupuncture for tinnitus when acupuncture was compared with drug therapy. However, the studies were too small to generate reliable findings. Both of the trials had small sample sizes [n < 40 for each group] and were thus prone to a type II error or an exaggeration of the treatment effect ,40. OverWe identified 6 new RCTs that had not been examined in previous reviews ,15,20-23Although most of the RCTs included in the present review employed sham-control groups, none was flawless. Five RCTs included fewer than 10 sessions -17,21,22Several sham acupuncture methods have been proposed for acupuncture trials. These methods include the penetrating insertion of needles at non-acupoints ,15,16, sTwo RCTs from China compared acupuncture with conventional drug treatment and demonstrated positive effects on at least one outcome. However, the current evidence for the effectiveness of these drug therapies for treating tinnitus is not clear, and some drug therapies have been shown to be less effective than other forms of therapy. Additionally, the risk of bias in these RCTs was high, and the findings may be overestimated. Consequently, the evidence comparing acupuncture with drug therapies for the treatment of tinnitus is not clear.Two RCTs compared the efficacy of scalp acupuncture with sham acupuncture for treating tinnitus,15. Althde-qi) in the patient is considered to be important for achieving maximal effects. This needle sensation was considered in the six RCTs included [The rationale for the acupuncture point selection was stated in all of the included RCTs. The authors in eight of the included RCTs quoted traditional Chinese theory as the justification for their point selection and used acupoints from the previous study in one RCT . Needle included -18,20-22Most of the included RCTs adopted questionnaires or self-reported inventories concerning the symptoms related to tinnitus. However, it is important to use only validated questionnaires. Unless the reliability and validity of the outcome measures used have been established, the data derived from the measures are subject to bias, and comparisons between the results of different studies are difficult.In the included studies, several types of active acupuncture treatment were used: five RCTs used traditional manual body acupuncture ,20,22,23The experience and the number of the acupuncture practitioners used can influence the results of acupuncture clinical trials. Of the included trials, one trial  reportedReports of adverse events from acupuncture are scarce, and those that have been reported are mild ,48. AdveOur review has a number of important limitations. Although substantial efforts were made to retrieve all RCTs on the subject, we cannot be certain that our search was exhaustive. Moreover, selective publishing and reporting are major causes of bias that should be considered -51. It iIn conclusion, the evidence from sham-controlled RCTs testing the effectiveness of acupuncture for the treatment of tinnitus is not yet convincing. The number, size and quality of the RCTs are not sufficient for drawing definitive conclusions. Further rigorous RCTs that overcome the many limitations of the current evidence are warranted. However, in clinical practice, acupuncture treatment by experienced and licensed practitioners might be an option for tinnitus patients, especially when the patients refuse psychological behavioral therapy, which is the only treatment with clinical evidence demonstrating improved quality of life in tinnitus patients. Additionally, because acupuncture is a safe procedure and because there is no current treatment for which clinical efficacy has been demonstrated for specific tinnitus symptoms, acupuncture is an option for the treatment of tinnitus symptoms in patients who request this procedure in the clinic.The authors declare that they have no competing interest.JIK, JYC, TYC and MSL designed the review, performed searches, appraised and selected trials, extracted data, contacted authors for additional data, carried out analyses and interpretations of the data, and drafted this report. DHL and EE reviewed and critiqued this review and report and assisted with interpretation of the data. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6882/12/97/prepubSupplement 1. The search strategies.Click here for file


Sometimes some members of multicellular organisms need to sacrifice for the good of the whole. Perhaps with the exception of immunomodulatory processes , 2, it iThus, do mitochondria have the mechanisms to trigger host cell death or is the host directing the mitochondria depending on physiological needs? To what extent are mitochondria autonomous in their function and death? Recent reports about mitochondrial suicide (mitoptosis) and relocation of mitochondria to the nuclear periphery (thread-grain transition) may provide substantial answers to these basic questions. Two very interesting reviews  by Vladimir P. Skulachev elaborate the fundamental understanding of mitochondrial suicide and the phenomenon of apoptosis and coined the term mitoptosis , 18. MitDuring “outer mitochondrial membrane mitoptosis”, mitochondria undergo condensation, followed by swelling and fragmentation of cristae. Finally, the outer mitochondrial membrane bursts, and the vesicular remnants of cristae float into the cytoplasm. Mitochondrial swelling can be detected even at the fluorescence microscopy level. At high resolution, mitochondria appear round and swollen, before they disintegrate, rather than typically elongated and bean-shaped. During “inner mitochondrial membrane mitoptosis”, the outer mitochondrial membrane remains intact and the cristae deteriorate. The inner membrane begins to coalesce, followed by rarefaction (loss of density) of the matrix, and finally degradation of cristae. We have often observed a third mixed form of mitoptosis in which mitochondria undergo condensation, followed by swelling and vesicular fragmentation of cristae, similar to “outer mitochondrial membrane mitoptosis”, but instead of disruption of the outer mitochondrial membrane, the mitochondria become engulfed in autophagosomes. Thus, the fate of mitochondria inside stressed cells varies, and the study of mitoptosis in different model systems and the subcellular mechanisms underlying these processes still await conclusions. Mitoptosis occurs primarily due to the loss of membrane potential either because of the apoptotic signal or disruption in the respiratory chain, the inherent inability to synthesize major constituents, and failure to take up the nuclear-coded mitochondrial matrix proteins due to the loss of own membrane potential . Thus, i


Randomized, double-blind, placebo-controlled trials constitute the gold standard in clinical research when testing the efficacy of new psychopharmacological interventions in the treatment of major depression. However, the blinded use of placebo has been found to influence clinical trial outcomes and may bias patient selection.To improve clinical trial design in major depression so as to reflect clinical practice more closely we propose to present patients with a balanced view of the benefits of study participation irrespective of their assignment to placebo or active treatment. In addition every participant should be given the option to finally receive the active medication. A research agenda is outlined to evaluate the impact of the proposed changes on the efficacy of the drug to be evaluated and on the demographic and clinical characteristics of the enrollment fraction with regard to its representativeness of the eligible population.We propose a list of measures to be taken to improve the external validity of double-blind, placebo-controlled trials in major depression. The recommended changes to clinical trial design may also be relevant for other psychiatric as well as medical disorders in which expectations regarding treatment outcome may affect the outcome itself. The treatment of patients with major depression remains one of the major challenges in psychiatry in the 21st century . There iIn the era of evidence-based medicine, randomized, double-blind, placebo-controlled, trials constitute the gold standard for testing the efficacy of new pharmacological interventions for major depression ,7. TheirDuring the last few years however it has become increasingly evident that the very strength of this type of trial, that is, the blinded use of placebo, may itself influence antidepressant and placebo response and remission rates ,10 and cWhile clinical trials in major depression focus on the antidepressant efficacy of medications, clinical care has a wider remit and is concerned with the overall treatment of individual patients suffering from this disorder. In the context of clinical care the medication offered is already approved and the choice of the specific antidepressant does not happen in a randomized fashion but through a process of shared decision making between the treating physician  and the patient -21. DuriThe introduction of the core features outlined above will be achieved in a number of steps:1) Active medication for all study participants: At the end of late phase III clinical trials study participants could be offered the option of receiving the active medication or to remain on the study medication if it had been efficacious and well tolerated. The duration of this non-randomized phase could vary according to clinical need and patient preference.2) Detailed explanation of potential benefits: Placebo is often referred to as an 'inert and deceptive intervention intended to please or placate the patient but without any potential to produce meaningful therapeutic results' . While nThe combination of these features mirrors clinical practice and redresses patients' fears of a negative outcome following study participation . An appr'The goal of this trial is to find out whether patients receiving drug 'X' will have an additional benefit compared to those receiving a placebo. A placebo or inactive medicine looks like real medicine, but contrary to a real medicine, it does not contain any substance believed to influence brain mechanisms relevant to depression. However, patients receiving placebo in clinical trials for depression often report significant improvements in their symptoms. There may be several reasons for this. Firstly, depressive symptoms are known to improve even without treatment as part of the natural course of the illness. Second, having frequent and regular discussion about your feelings and progress with the study clinicians may be therapeutic in itself. Third, being positive about getting better during the clinical trial may actually contribute to improving your symptoms ,30. TherIn order to test the impact of shared decision making and of study drug availability to all participants we propose to start with a number of Phase IV trials. In this agenda we will refer to a study design incorporating these proposed changes as an 'enhanced randomized controlled trial (RCT)'. This agenda should focus on comparing the antidepressant efficacy of study drug 'X' when evaluated using a traditional double-blind RCT versus the proposed enhanced RCT design. The evaluation will consist of comparisons of the effect size of placebo-active treatment arms differences on depressive symptoms and on outcome-relevant demographic and clinical characteristics of enrolled patients. This would then allow an estimation of the representativeness of the enrolled patients compared to all patients in the eligible target patient population.The set of trials we propose to conduct consists of two steps:In the first step potentially eligible patients suffering from a major depressive episode in the context of a major depressive disorder will be asked about their willingness, in general, to participate in clinical trials to evaluate different study designs on antidepressant efficacy. They will be given a first informed consent form (ICF#1) which will outline the general purpose of the trial but will not include details regarding study design. If patients are interested they will be asked to sign ICF#1. By doing so they give permission to study clinicians to access and analyze outcome relevant demographic and illness-related variables and check their eligibility for inclusion in clinical trials. This may also involve drawing blood for laboratory tests. Those signing ICF#1, and who fulfill eligibility criteria, will then be randomized to one of the following two treatment trial set ups (not treatment arms):1) traditional double-blind, randomized, placebo-controlled eight-week trial, including a traditional informed consent form, no option for extension period; or2) enhanced double-blind, randomized, placebo-controlled eight-week trial, including the novel informed consent form outlined above, option for extension period.The two treatment trials will be conducted by independent research teams who will be unaware that the two trial designs will be compared. Each clinical trial team will approach patients randomized to their study design  and will ask them for their consent to participate. The wording of the ICF#2 will differ between the two trial designs. Patients approached to participate in the traditional trial will be presented with the traditional version of the ICF#2 while patients approached to participate in the enhanced trial will be given the new proposed ICF#2 outlined above.At study completion the traditional and enhanced designs will be compared in terms of:1) Efficacy, by comparing the outcomes of the two trial designs based on the effect size symptom score improvement, number of responders, number of patients in remission, number of patients withdrawing, and Number Needed to Treat;2) Tolerability, by comparing the outcomes of the two trial designs based on number and type of reported adverse events; and3) Representativeness of study participants, by comparing outcome-relevant demographic and clinical characteristics of enrolled patients in each design (enrollment fraction) to the respective eligible target clinical population.Comparisons between the two study designs can be straightforward and performed using ordinary linear models with treatment success being explained by study arm, study design and their interaction. As the goal is to assess study designs rather than specific drugs, the active medication to begin with, in both the traditional and enhanced clinical trials outlined, will be sertraline which has already been approved for the treatment of depressive disorder and is thought to have a balanced profile of efficacy and tolerability ,32. For In the era of evidence-based medicine it is paramount that we produce clinically relevant scientific evidence for the pharmacological treatment of patients with major depression. We therefore propose to enhance double-blind, placebo-controlled trials in such a way as to reflect clinical practice more closely. This could be achieved by adding extensions, thus offering every patient the possibility of receiving active treatment and formally integrating the process of shared decision making while obtaining informed consent. The proposed changes in the process of informed consent focus on a balanced presentation of evidence regarding the benefit of study participation irrespective of whether patients are assigned to active or placebo treatment. In order to evaluate the impact of the study designs on the efficacy and enrollment fraction of an intervention we further outlined a research agenda involving direct comparison of traditional and enhanced trial designs. While we feel that our approach represents an important step towards a more comprehensive assessment of the efficacy and external validity of the treatment options available, further research is needed in this area to improve the clinical care of patients suffering from this complex and often severely debilitating psychiatric illness . FinallyICF: informed consent form; RCT: randomized controlled trial.Emanuel Severus has been on the speakership bureaus of AstraZeneca, Eli Lilly and Company and Lundbeck. Florian Seemüller received grants and research support from Lilly, Astra Zeneca and Glaxo-Smith Kline. He received honoraria from Lundbeck, Bristol-Meyers Squibb, Lilly and Astra Zeneca, Bial, BMS, Cephalon, Eli Lilly, Glaxo-Smith Kline, Janssen-Cilag, Organon, Pfizer Inc, Sanofi -Aventis, Servier, UBC and UCB Belgium. Andrea Pfennig received a stipend/research support from GlaxoSmithKline and research support from AstraZeneca. She has received speaker honoraria from AstraZeneca and Eli Lilly and Company. Michael Riedel has received research grants/support or has served as a consultant for AstraZeneca, Pfizer, Otsuka Pharma, and Janssen-Cilag. In the context of investigator-initiated trials, M. Riedel has received support from AstraZeneca and Pfizer.Sophia Frangou has served as a consultant on advisory boards for Janssen Cilag and Bristol-Myers Squibb/Otsuka. Hans-Jürgen Möller has received grants or is a consultant for and on the speakership bureaus of AstraZeneca, Bristol-Myers Squibb, Eisai, Eli Lilly, GlaxoSmithKline, Janssen Cilag, Lundbeck, Merck, Novartis, Organon, Pfizer, Sanofi-Aventis, Schering-Plough, Schwabe, Sepracor, Servier and Wyeth. Michael Bauer has received Grant/Research Support from The Stanley Medical Research Institute, NARSAD and the European Commission (FP7). He was/is a consultant for AstraZeneca, Lilly, Servier, Lundbeck, Bristol-Myers Squibb and Otsuka. Michael Bauer has received Speaker Honoraria from AstraZeneca, Lilly, GlaxoSmithKline, Lundbeck, Bristol-Myers Squibb and Otsuka. Michael Berger, Sandra Dittmann and Michael Obermeier have no conflicts of interest to declare.All authors have made substantive intellectual contributions to the paper. ES conceived of the paper and drafted the manuscript. FS assisted in conceiving of the paper and helped to draft the manuscript. MBerger, SD, MO, MR, SF, HJM and MBauer all helped to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1741-7015/10/67/prepub


Calfhood diseases have a major impact on the economic viability of cattle operations. A three part review series has been developed focusing on calf health from birth to weaning. In this paper, the last of the three part series, we review disease prevention and management with particular reference to pneumonia, focusing primarily on the pre-weaned calf. Pneumonia in recently weaned suckler calves is also considered, where the key risk factors are related to the time of weaning. Weaning of the suckler calf is often combined with additional stressors including a change in nutrition, environmental change, transport and painful husbandry procedures . The reduction of the cumulative effects of these multiple stressors around the time of weaning together with vaccination programmes (preconditioning) can reduce subsequent morbidity and mortality in the feedlot. In most studies, calves housed individually and calves housed outdoors with shelter, are associated with decreased risk of disease. Even though it poses greater management challenges, successful group housing of calves is possible. Special emphasis should be given to equal age groups and to keeping groups stable once they are formed. The management of pneumonia in calves is reliant on a sound understanding of aetiology, relevant risk factors, and of effective approaches to diagnosis and treatment. Early signs of pneumonia include increased respiratory rate and fever, followed by depression. The single most important factor determining the success of therapy in calves with pneumonia is early onset of treatment, and subsequent adequate duration of treatment. The efficacy and economical viability of vaccination against respiratory disease in calves remains unclear. Calfhood diseases have a major impact on the economic viability of cattle operations, due to the direct costs of calf losses and treatment and the long-term effects on performance . FurtherThis paper is the last in a three part review series, which collectively focuses on calf health from birth to weaning. The first and second parts focus on general aspects of disease prevention  and the Calves are born with functional thermoregulatory mechanisms. Therefore, healthy calves are readily able to deal with outdoor temperatures as long as they receive adequate amounts of energy and are provided with a dry, well-bedded and draft-free shelter . The lowIndividual housing of dairy calves, either indoors or outside, is generally linked with improved calf health. There is long-term recognition of the benefit to dairy calf health of outdoor housing in hutches, especially for the prevention of diarrhoea and respiratory disease . HutchesThere have been mixed reports on the impact of group housing of calves, both indoors and outside, on calf health. A number of authors have reported higher morbidity -19 and mIn summary, there are a high number of experimental studies and surveys dealing in various ways with aspects of individual and group housing, as well as outdoor and indoor rearing, with sometimes contradicting results. Overall, outdoor individual hutches appear superior to indoor housing, and individual housing/small group housing appears superior to large group housing with regards to calf health.Inadequate ventilation of calf barns increases the risk of disease due to a build up of high levels of humidity, noxious gases, dust and bacterial content . Ammonia3 up to 6 weeks and 10 m3 up to 12 weeks of age [To prevent adverse conditions, at least 4 air changes per hour are needed in winter and up to 40 in summer . NaturalProblems can arise in naturally ventilated calf barns in cold and damp wintry conditions, when it can be impossible to keep relative humidity below an acceptable level of 85% . AdditioIn suckler herds, calves generally remain with cows at pasture until they are weaned, usually between 5 and 9 months of age. In addition to removal from the cow, the weaning procedure may be compounded by other stressors occurring around the same time, e.g. change of diet (grass and milk to conserved feed with or without concentrates), change of environment (outdoors to indoors). Non-integrated systems often combine weaning with additional stressors such as transportation and marketing, prior to entry into feedlots . AlteratDelaying housing of calves post-weaning reduces the magnitude of the stress response . Also, cThere are aspects of cattle production such as castration, disbudding and dehorning which cause pain and stress for the animal. Dehorning or disbudding of horned cattle is a mandatory requirement in many countries to reduce the risk of injuries to humans or other animals ,56. CortPharmacological methods  are available that are highly beneficial in alleviating the acute pain caused by castration, dehorning or disbudding ,63. NatiMycoplasma bovis, Pasteurella multocida, Mannheimia haemolytica, Histophilus somni), as well as calf-related and environmental risk factors. Bovine viral diarrhoea virus (BVDV) appears to play an important role, both in terms of immunosuppression and synergistic effects with other pathogens and also as a primary pneumopathogen [Pneumonia in pre-weaned calves is a multi-factorial disease involving a well known group of viruses  and bacteria  in reducing morbidity rates associated with pneumonia in feedlots is variable . A recenThe use of antimicrobials for prevention (prophylaxis or metaphylaxis) of calf pneumonia has to be seen in the context of increasing pressure on the veterinary profession to promote prudent use of antibiotics, noting that indiscriminate use of antibiotics promotes the selection and subsequent proliferation of antibiotic-resistant strains of bacteria . The EurNon-steroidal anti-inflammatory drugs (NSAIDs) have shown to reduce pyrexia -91, clinIt has been suggested that pneumonic animals should be isolated in appropriate facilities . HoweverThe efficacy and economical viability of vaccination against respiratory disease in calves remains uncertain. Although substantial relevant literature is available, a consensus, underpinned by robust scientific findings, has not yet been achieved. The evaluation of vaccine efficacy, and the interpretation of trial results, is complicated by the nature of bovine respiratory disease, and in particular the multitude of pathogens and environmental stressors that contribute to disease development. Additionally, the disease pattern of pneumonia in calves can vary under a variety of husbandry systems, as a consequence of differing challenges at different points in the rearing period.Modified live vaccines, inactivated vaccines, or subunit vaccines are available for most of the major pathogens. For the most part, relevant research has focused on the ability of these vaccines to trigger an immune response or to decrease clinical disease and pathogen shedding in challenge trials. Although field trials are needed to provide conclusive evidence of vaccine efficacy under field conditions , few of Substantial data are available on pneumonia in feedlot cattle, predominantly from the USA. These data provide useful insights, albeit for different husbandry systems, of the impact of multiple stressors on recently weaned suckler calves. The feedlot studies clearly indicate that vaccination provides best results when carried out in healthy animals and prior to the exposure to defined stressful events, such as weaning, marketing, transportation and associated changes in environment. Vaccination together with further management measures (preconditioning) in suckler calves before weaning has been shown to be beneficial on the performance of these animals after arrival in feedlots. However, in these studies the benefit of vaccination and management procedures cannot be assessed independently . Perino Bovine Respiratory Syncytial Virus vaccines demonstrated enhancement in disease severity after subsequent infection [Early studies with formalin-inactivated experimental nfection . Meanwhinfection -100 but nfection  trials. nfection  tested aYoung calves do not produce specific antibodies after vaccination in the presence of maternally derived immunity. For this reason, it is commonly believed that maternal antibodies can interfere with the efficacy of vaccination . To overBovine Herpes Virus 1 infection can cause clinical pictures from severe classical Infectious Bovine Rhinotracheitis (IBR) to no clinical signs at all. Regardless, infection will lead to latency in the host. In relation to calf pneumonia, it is important to consider the immunosuppressive effect of BoHV1 infection as well as BoHV1 reactivation [-) modified live virus and inactivated marker vaccines, to distinguish vaccination from field virus infection, have been developed and are commercially available [Depending on virus virulence and host resistance, tivation . Conventtivation . Howevertivation . Gene-devailable . Vaccinavailable . Intranavailable . Howevervailable ,113. In vailable .Pasteurella multocida, Mannheimia haemolytica, Histophilus somni) can decrease clinical signs in challenge models but are rarely tested in monovalent form in field trials [Mannheimia haemolytica and Pasteurella multocida vaccine.Vaccines against the major bacterial pathogens involved in bovine respiratory disease  and Volac Ireland (LG); these companies played no role in the design, development or journal submission of this review series.IL, BE, JG, IH and EK drafted the manuscript and compiled the literature. All authors made substantial inputs to the review, critically discussed the progressing manuscript and approved the final manuscript.


Venomous snakes are among the most serious health hazards for rural people in tropical regions of the world. Herein we compare the monthly activity patterns of eight venomous snake species (Elapidae and Viperidae) with those of rural people in the Niger Delta area of southern Nigeria, in order to identify the periods of highest potential risk for persons, and the human group actually at greater risk of snakebite.We documented that above-ground activity of all venomous snakes peaked in the wet season, and that high snake activity and high human activity were most highly correlated between April and August. In addition, we documented that women and teenagers were at relatively higher risk of encountering a venomous snake than adult males, despite they are less often in the field than men.Our results suggest that future programs devoted to mitigate the social and health effects of snakebites in the Niger Delta region should involve especially women and teenagers, with ad-hoc education projects if appropriate. We urge that international organizations working on social and health problems in the developing world, such as IRD, DFID, UNDP, should provide advice through specific programs targeted at especially these categories which have been highlighted in comparatively potential higher threat from snakebites than adult men. Venomous snakes certainly are among the main health hazards for rural people in tropical regions of the world, while it is calculated that many thousands of people die yearly on account of snakebite, especially in India, but also in Africa and South America ,2.Bitis arietans) is more inclined to bite than a Gaboon viper (Bitis gabonica); thus, despite similar ecologies (but not habitat selection) and venom compositions and potency, the former is more likely to kill people than the latter [Several independent factors may increase the probability of being bitten and eventually killed by a snake in a tropical area. Firstly, the antipredatory behavior of a snake species certainly influences the likelihood of a bite: for instance, the puff adder , which otherwise tends to inhabit the savannah, to the detriment of the once dominant cobra species (the forest cobra Naja melanoleuca), typically adapted to life in the rainforest [In the present paper, by taking advantage of the most prolonged longitudinal field study 16 years) on the ecology of tropical snake communities available in the world ,5, we aninforest ,6-11. years onAs to Nigeria, the only detailed data on the epidemiology and occurrence of venomous snakebites came from the savannah region in the north of the country ,13. ThesAvicennia spp., Rhizophora racemosa) are the dominant vegetation types in the areas of the fluvial systems influenced by salty or brackish water. The climate of the study region is tropical sub-Saharan, with well delineated dry and wet seasons and relatively small monthly fluctuations between maximum and minimum temperatures [The study was conducted during field surveys between September 1996 and June 2011, in the plantation-bushland-secondary-forest mosaic region of the Niger Delta, in southern Nigeria. We conducted our surveys in eight states of the Federal Republic of Nigeria, from West to East: Delta, Bayelsa, Anambra, Imo, Rivers, Abia, Akwa-Ibom, and Cross-River. Thus, we surveyed an irregular surface of approximately 400 × 250 km. The study area, which is heavily populated with hundreds of villages interspersed by patches of forests and cultivated lands, is especially important for the economy of Nigeria because of its large-scale oil extraction and liquefied natural gas transmission installations . The foreratures . The monAnnual snake activity patterns were assessed by visual-encounter surveys (VES) and by counting death-on-road (DOR) specimens, assuming that there should be a linear relationship between intensity of above-ground activity in snakes and their probability of being observed during VES surveys and risk of being squashed along a road ,15-17. TSurvey time was typically from 7h00 to 11h00 and from 16h00 to 19h00, whereas searches were generally suspended during midday because of reduced snake activity at that time. Nocturnal surveys were generally avoided due to safety reasons.To compare the monthly patterns of activity between snakes and rural persons, we constructed an empirical index of the frequency of encountering of people in the field by month, during the snake surveys. The following human activities were considered: walking, farming, fishing, hunting, canoe-carving, logging, and palm-oil production. This index was calculated during the year 2011, and was assumed to be relatively constant over the years.To evaluate whether each of the species (and the whole of the species at once) was observed at a similar frequency of occurrence throughout the various months, the various records were grouped into monthly intervals (from the first to the last day of each month). Then we determined the relative sampling per monthly interval by dividing the number of days spent in the field in each month by the total number of days in the field during the entire research period Table . Using aAlthough not an entirely rigorous comparison between the activity patterns of snake and rural people, we constructed a frequency index showing the overlap between the empirical index (mean number of people/hectare), as an annual percentage (%) for men, women and teenagers; and the % index  of the number of snake observations according to species. In this graphical comparison, it should be emphasized that the human index is related to a surface (hectare), contrary to the ophidian index.Naja nigricollis, the forest cobra Naja melanoleuca, the tree cobra Pseudohaje goldii and Jameson’s green mamba Dendroaspis jamesoni) and four from Viperidae . Other venomous snakes found in the Niger Delta include: Toxicodryas blandingii, Toxicodryas pulverulenta, Thelotornis kirtlandii, Dispholidus typus, Crotaphopeltis hotamboeia and Atractaspis spp. [Toxicodryas spp. and Crotaphopeltis hotamboeia), or they are very rare (Dispholidus typus), or they are back-fanged and hence unlikely to pose a real threat to people (Thelotornis kirtlandii), or because they are subterranean, hence being difficult to analyze reliably as to their monthly activity patterns (Atractaspis spp).This study focuses on eight venomous ophidian species, four from Elapidae  and the Viperidae  had significantly uneven activity patterns, with above-ground activity peaking during the wet season  typically in a 3:2 ratio, representing 10-15% of each community. Hunting is performed during the day, at night and overnight. Trapping is also practiced using wire snares with a drift fence, subterranean trap or snap trap, while each trapper maintains an average of 1.5 km of traps with 50–70 wire snares which he inspects daily or at intervals of two or three days. Venomous snakes usually encountered during hunting are Gaboon and nose-horned vipers, green mambas and forest cobras.Logging is an exclusively male occupation . BecauseDendroaspis jamesoni, Atheris squamiger, Naja nigricollis, Pseudohaje goldii, Thelothornis kirktlandi, and Dispholidus typus), which may be very abundant in local palm oil plantations [Palm oil production is another of the main business activities of the study area. The palm fruit ripens between the late rainy season and dry season. Harvesting is carried out exclusively by men and youth, who climb up to the palm fruit (8–20 meters high) to cut down three to five bunches. Occasionally they encounter venomous snakes  by month in the study areas, and assumed a linear relationship between the quantities of farmers and those involved in the other abovementioned activities.The general trend in the empirical index of humans in the bush throughout the year for this economic activity is outlined in Figure A comparison of the relative frequency of occurrence of venomous snakes in distinct habitats of the Niger Delta area Table  suggestsFirst of all, it is necessary to emphasize that our data are cumulative from several places in the plantation-bushland-secondary forest mosaic, whereas it is well known that the specific composition of snake assemblages may change considerably at the local level, probably due to local environmental conditions and adaptability of each species ,16,22-25Interestingly, our study showed that, in the Niger Delta, the highest degree of correlation between the monthly activity patterns of the eight most abundant dangerous venomous snakes and that of rural people was in April-August (wet season), and that women and teenagers were at relatively greater risk than men of encountering a venomous snake during their usual daily practices, although, as expected, the absolute numbers of males at work was higher than that of females or teenagers.Echis ocellatus, a Viperidae species which does not occur in the rainforest region of southern Nigeria [Our first finding was clearly consistent with previous studies: indeed, the seasonal incidence of bites to humans was higher in the rainy season in the Asian agricultural landscapes and in the African savannah, with this pattern being observed in Bangladesh, Mali, Burkina Faso, Nigeria, Ivory Coast, Cameroon, Ghana, and Benin, and even presented a direct relationship with monthly rainfall in Benin, Ivory Coast and Nigeria ,26. The  Nigeria ,16,18.Our finding of an expected higher risk of bites for women and teenagers seems to be clinically compelling, as it would be interesting to analyze the hospital records to verify whether our predicted pattern really occurs. Unfortunately, the authors are still in the process of collecting the epidemiological dataset, and thus these noteworthy results could not be corroborated by clinical records. Indeed, according to our present results, it is highly possible that some gender-specific or age-specific human behavior may also reduce the risk of being bitten in the theoretically more exposed groups (women and teenagers). For instance, if women exercise greater cautiousness when entering large plantations than men or teenagers, it would greatly reduce their risk of being bitten. However, given that the body weight of a snakebite victim tends to be positively correlated with the survival rate, it is likely that the mortality incidence should be proportionally higher in women and in teenagers than in adult males . This liEthics committee approval was not required according to the Federal Republic of Nigeria laws and our institution rules given the type of protocol used to perform this study.The authors declare no conflicts of interests.LL provided the idea; GCA, NE, EAE, EP, DF and LL collected and assembled the data; LL and DF analyzed the data; LL and FP drafted the manuscript, and all authors read and approved the final manuscript.


In many developing countries, the majority of births are attended by traditional birth attendants, who lack formal training in neonatal resuscitation and other essential care required by the newly born infant. In these countries, the major causes of neonatal mortality are birth asphyxia, infection, and low-birth-weight/prematurity. Death from these causes is potentially modifiable using low-cost interventions, including neonatal resuscitation training. The purpose of this study was to evaluate the effect on perinatal mortality of training birth attendants in a rural area of the Democratic Republic of Congo (DRC) using two established programs.This study, a secondary analysis of DRC-specific data collected during a multi-country study, was conducted in two phases. The effect of training using the WHO Essential Newborn Care (ENC) program was evaluated using an active baseline design, followed by a cluster randomized trial of training using an adaptation of a neonatal resuscitation program (NRP). The perinatal mortality rates before ENC, after ENC training, and after randomization to additional NRP training or continued care were compared. In addition, the influence of time following resuscitation training was investigated by examining change in perinatal mortality during sequential three-month increments following ENC training.More than two-thirds of deliveries were attended by traditional birth attendants and occurred in homes; these proportions decreased after ENC training. There was no apparent decline in perinatal mortality when the outcome of all deliveries prior to ENC training was compared to those after ENC but before NRP training. However, there was a gradual but significant decline in perinatal mortality during the year following ENC training , which was independently associated with time following training. The decline was attributable to a decline in early neonatal mortality. NRP training had no demonstrable effect on early neonatal mortality.Training DRC birth attendants using the ENC program reduces perinatal mortality. However, a period of utilization and re-enforcement of training may be necessary before a decline in mortality occurs. ENC training has the potential to be a low cost, high impact intervention in developing countries.http://www.clinicaltrials.gov (identifier NCT00136708).This trial has been registered at  More than 98% of the estimated 3.7 million neonatal deaths and 3.2 million stillbirths per year occur in developing countries. In manyThe major causes of neonatal mortality are birth asphyxia, infection, and low-birth-weight/prematurity ,5, and dFeatures of the perinatal care systems that might have influenced birth outcomes, for example, type of birth attendant, location of births and support systems, varied among sites in the FIRST BREATH Trial. Our objective was to evaluate outcomes following training of birth attendants in the unique context of the environment in the DRC by evaluating the effect of training on rates of stillbirth, early neonatal (seven days or less of age) and perinatal mortality in fetuses/infants weighing ≥1,500 grams at birth.This study is a secondary analysis of data collected during the FIRST BREATH Trial, a multi-country study conducted by the Eunice Kennedy Shriver National Institute of Child Health and Human Development Global Network for Women's and Children's Health Research. That stThe study was conducted in the rural Equateur Province, where the economy is based on subsistence farming. Women are active participants in family farms; few work in other occupations. More than one-third of the population is in the lowest economic quintile of the country. Communities were selected to be representative of this province. Each had at least 300 births per year and was geographically distinct, such that the birth attendants in one community did not attend deliveries in another community. Most communities had poor health systems with a high rate of home births assisted by TBAs. The study in the DRC was approved by the institutional review boards at the Kinshasa School of Public Health and the University of North Carolina. Informed consent was obtained from the mothers.The study included all births in 12 communities, including deliveries in hospitals, health clinics and homes. Pregnant women were enrolled at their first antenatal visit or at the onset of labor for those who had not received antenatal care. Data describing maternal, pregnancy, delivery, and neonatal variables and exposures, and seven-day outcomes were collected. Data analyses were limited to fetuses/neonates with birth weights ≥1,500 grams .A train-the-trainer educational program was developed using a variety of teaching methods, including clinical practice sessions and demonstrations. Supervisory personnel of the FIRST BREATH Trial trained two DRC Country Trainers. The supervisory personnel had extensive global health and educational experience, and specifically in instruction in both the ENC program and NRP. Country Trainers were general medical doctors with experience in rural health practice but no previous training in the ENC program or NRP. In a five-day workshop, the Country Trainers subsequently trained one Community Coordinator (CC), a professionally trained nurse, from each study community and the four physicians who staffed the district hospitals. In addition to instruction in the program content, these trainees were taught adult education methodologies. Thereafter, in a series of three-day workshops , the CCs and local physicians trained the practicing birth attendants within each community. Birth attendants included 152 TBAs and 18 nurses and nurse midwives. Nurses in the DRC typically complete four years of nursing education following ten years of primary and secondary education. Nurse midwives receive an additional three years of maternal and child health education. TBAs receive variable training, which is usually limited to an apprenticeship with an experienced TBA. They do not have formal education and are usually illiterate. Separate workshops were conducted for TBAs and for nurses and midwives. All workshops for each phase of the study were completed within one calendar month.The study began with training in data collection and other basic study procedures, including evaluation of newborns, particularly the identification of vital signs to ensure the proper differentiation between stillbirths and live born infants. Scales for weighing newborns  and disposable delivery kits  were distributed at this time. Thereafter, a period of baseline data collection began.After the period of baseline data collection, the train-the-trainer model was used to train all personnel in the ENC program. The ENCAfter an additional period of data collection, birth attendants in six randomly selected communities received more extensive resuscitation training using an adaptation of the NRP. This training also utilized a train-the-trainer model, and material that was adapted for the environment. This intensive basic resuscitation course included the initial steps of resuscitation and bag and mask ventilation, but excluded the use of oxygen, intubation, chest compression and the administration of drugs. In contrast to the resuscitation training in the ENC program, NRP training included a systematic approach to resuscitation that included repeated observations throughout the first few minutes following delivery and standardized responses to these observations. A refresher course was conducted six months after initial training.Reinforcement of training occurred throughout the study at monthly meetings attended by CCs and birth attendants in each community. The CCs  reviewed the ENC program in all communities. In addition, they reviewed the NRP in the intervention communities. The content of the meetings was left to the discretion of the CC, but in general was based on observations made during the supervision of the birth attendants' activities, including deliveries when possible. Deficiencies in care or gaps in knowledge were the focus of discussions at these meetings. Additional training was usually practical rather than theoretical and involved repetition of hands-on skills, for example, mannequins and bags and masks were used to practice resuscitation skills. Although we did not systematically record attendance, we estimate that more than 95% of birth attendants participated in these meetings.CCs or birth attendants obtained consent (at the time of enrollment) and collected all data on standardized data forms. Community Health Workers assisted illiterate TBAs in the completion of these forms. Data forms were reviewed for accuracy by the CCs. Data edits, including inter- and intra-form consistency checks, were performed upon data entry locally and by the data coordinating center .The number of communities selected from the DRC was determined by the sample size calculation for the FIRST BREATH Trial, and the number of deliveries observed was a function of the timing of the study periods for that trial.The primary outcome for the analyses in this manuscript was perinatal mortality (stillbirth or death during the first seven days after birth). We used this combined outcome, in lieu of using early neonatal mortality, to eliminate the possibility that early neonatal deaths incorrectly classified as stillbirths would confound the results. Pre-specified secondary outcomes included stillbirth and early neonatal mortality rates, mortality rates stratified by sex, birth weight, birth location and birth attendant, and one and five minute Apgar scores and the use of bag/mask ventilation.Generalized estimating equation (GEE) extensions of logistic regression models that adjust for correlation of outcomes within communities were used to determine differences in maternal and neonatal characteristics between the pre- and post-ENC data and between the NRP intervention and control data. Adjusted relative risks (RR) and 95% confidence intervals (CI) using GEE extensions of multivariate log-binomial models are reported for the post- versus the pre- comparison of the effect of training in ENC, in the comparison of the NRP intervention versus control (no NRP) groups, and in the comparison of post-NRP versus pre-ENC. The data were analyzed using SAS version 9.2 . To examine the possibility that benefits of ENC training were time dependent, we analyzed perinatal mortality as a function of time, modeled continuously, using a robust piecewise Poisson GEE model that included two covariates, location of birth and birth attendant.The study was conducted in 12 communities. Baseline data were collected from June of 2005 until November 2005 in all but two communities; in these communities, the study did not begin until July of 2006, and there was no period of baseline data collection. Therefore, only post-NRP data from these communities (one control and one intervention community) were used in analyses. During pre-ENC period, there were 1,867 births, and following ENC training but before NRP training, a period of approximately 13 months, there were 5,528 births , and the relative risk of perinatal mortality for babies born one year after ENC training compared to those born at the start of ENC training was 0.73 (CI: 0.56-0.96). For the piece following the hinge point (one year after training) until the end of the study, there was not a significant correlation between time and mortality.We explored the possibility that time following ENC training or other variables  might explain the reduction in perinatal mortality over the entire study period. We began by plotting mortality rates as a function of three-month increments of time Figure . During The FIRST BREATH Trial, a large multi-national study, investigated the effects of training birth attendants using the WHO ENC program and an adaptation of the AAP NRP. Across There was no apparent decline in rates of early neonatal and perinatal mortality or stillbirth when rates among all births during a baseline period of data collection prior to ENC training were compared to rates among births after ENC training but before NRP training, suggesting that ENC training was ineffective at reducing mortality. However, three observations caused us to examine the relationship between ENC training and mortality in an alternate way. First, perinatal mortality declined significantly over the entire study period. Second, mortality rates increased during the period of baseline data collection. The cause of this increase is not certain. However, a possible explanation is that some deaths were unreported at the outset of the study, and reporting became more reliable with time as a result of study oversight. Therefore, combining all births during the baseline period did not reflect the true baseline mortality rates; a more accurate estimate was more likely to be the rate during the latter portion of the baseline period. Finally, there was a gradual but significant decline in perinatal mortality during the first year following ENC training. Therefore, we examined change in mortality following ENC training as a function of time, after adjusting for known factors that might have confounded mortality rates (that is type of birth attendant and location of birth). After adjustment for these factors, a significant decline in perinatal mortality was associated independently with time during the first year following ENC training.We are not aware of changes in any factors, such as birth rate or maternal mortality rate, other than type of birth attendant or location of birth that might have influenced perinatal outcomes during the conduct of the study. Therefore, we presume that the decline over time resulted from ENC training. One possible explanation for the time-dependency of benefit of ENC training is that repeated experience using the techniques included in the ENC program and/or re-enforcement of the education is necessary before implementation and improvement occurs. However, it is also possible that the decline in mortality resulted from changes in medical care not attributable directly to ENC training that were not recorded during the study, and therefore not accounted for in our analyses. These changes might include the availability of healthcare services, such as medications, diagnostic capabilities or transportation to healthcare facilities,As was observed in the across-country analysis in the FIRST BREATH Trial, NRP training in the DRC had no demonstrable effect on neonatal or perinatal mortality. The lack of benefit of NRP training is most likely attributable to the fact that the strategies for resuscitation recommended in the ENC program reach the limits imposed by the environment of most deliveries in rural DRC. Although the NRP includes a more regimented approach to resuscitation, benefit beyond that achieved by ENC training may depend upon the availability of more extensive resources at the site of delivery.The effect of ENC training has been evaluated in other studies in low resource countries. Two studies evaluated the benefits of incorporation of ENC training of professional birth attendants in Sri Lanka,13. UsinOur study has a number of strengths. It was population based, and used pregnancy and birth registries to capture all births during the study period, although we cannot be certain all births were included because the registries may have been of variable quality. Birth attendants received intense instruction in the differentiation between stillbirths and live born infants. Therefore, we believe that we have accurately assessed the contribution of stillbirth to perinatal mortality. Follow up rates to seven days approached 100%. To our knowledge, this is the largest population-base study conducted in rural areas of the DRC. Because the demography and medical resources in the area in which the study was conducted are similar to other rural areas of the DRC, we assume that the results are generalizable to those areas, and perhaps other low resource countries with similar environments.An important limitation in this study was the use of pre-post data as a reference for determining the effect of the ENC program. To minimize the impact of this aspect of study design, all training, except ENC and NRP training, was conducted before the initiation of any data collection. This active baseline study design ensured, to the extent possible, that observed changes in mortality resulted from changes in practice rather than changes in the quality of data. In addiWe conclude that training birth attendants using the ENC program may reduce perinatal mortality by reducing neonatal deaths during the first seven days after birth. However, this benefit may not be achieved immediately after training. A period of utilization and re-enforcement of training may be necessary before a decline in mortality occurs. Reduced mortality following training can be expected among births attended by both professionals and non-professionals, including TBAs. As in the DRC, ENC training has the potential to be a low cost, high impact intervention in many other low resource countries, where deliveries are commonly attended by TBAs. A train-the-trainer model appears to be effective; the use of this strategy may minimize the impact of the isolation of many rural communities and their distance from sites of traditional medical education. Our findings suggest that implementation should include a strategy for re-enforcement following the initial training.CC: Community Coordinator; CI: confidence interval; DRC: Democratic Republic of Congo; ENC: Essential Newborn Care program; GEE: generalized estimating equation; NRP: Neonatal Resuscitation Program; RR: risk ratio; TBA: traditional birth attendant; WHO: World Health Organization.The authors declare that they have no competing interests.RM, the principal and corresponding author, drafted the paper, and provided technical assistance  and management of the field staff in charge of the study data collection. CE provided expert technical assistance to the country study team and revised the manuscript. JD collaborated closely with RM on technical and managerial aspects of the study; he revised the manuscript. JG managed the data collection on a daily basis, providing direct oversight to birth attendants in the field. He also provided input on data analysis. AT, the Senior Foreign Investigator of the First Breath Study in the DRC, revised the manuscript. RK, worked in-country at the outset of the study, and helped develope the infrastructure of study team. She also assisted with training and study oversight. EM helped with data organization and analysis, and revised the manuscript. JM performed data analysis and revised the manuscript. DW developed the time-dependent statistical models and assisted with other aspects of data analysis. WC, Principal Investigator of the international First Breath Trial, revised the manuscript. LW provided technical and managerial support on behalf of the NIH and the Global Network for Women's and Children's Health Research. She also revised the manuscript. CB, Principal Investigator of the First Breath Study for the DRC, supervised the conduct of the study and revised the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1741-7015/9/93/prepub