Starting dialysis at an advanced age is a clinical challenge and an ethical dilemma. The advantages of starting dialysis at “extreme” ages are questionable as high dialysis-related morbidity induces a reflection on the cost- benefit ratio of this demanding and expensive treatment in a person that has a short life expectancy. Where clinical advantages are doubtful, ethical analysis can help us reach decisions and find adapted solutions.Mr. H is a ninety-year-old patient with end-stage kidney disease that is no longer manageable with conservative care, in spite of optimal nutritional management, good blood pressure control and strict clinical and metabolic evaluations; dialysis is the next step, but its morbidity is challenging. The case is analysed according to principlism .In the setting of care, dialysis is available without restriction; therefore the principle of justice only partially applied, in the absence of restraints on health-care expenditure. The final decision on whether or not to start dialysis rested with Mr. H (respect for autonomy). However, his choice depended on the balance between beneficence and non-maleficence. The advantages of dialysis in restoring metabolic equilibrium were clear, and the expected negative effects of dialysis were therefore decisive. Mr. H has a contraindication to peritoneal dialysis (severe arthritis impairing self-performance) and felt performing it with nursing help would be intrusive. Post dialysis fatigue, poor tolerance, hypotension and intrusiveness in daily life of haemodialysis patients are closely linked to the classic thrice-weekly, four-hour schedule. A personalized incremental dialysis approach, starting with one session per week, adapting the timing to the patient’s daily life, can limit side effects and “dialysis shock”.An individualized approach to complex decisions such as dialysis start can alter the delicate benefit/side-effect balance, ultimately affecting the patient’s choice, and points to a narrative, tailor-made approach as an alternative to therapeutic nihilism, in very old and fragile patients. In faSome authors have reported that with integrated clinical management, including nutritional management and optimization of symptomatic treatment, survival rates are comparable to those obtained with dialysis –12. ThisThe contraposition between dialysis care and conservative care may however be less Manichean. Just as the definition of alternative and complementary or allied medicines has shifted from being opposed to one another to being integrated, maximum “conservative care”, in its semeiotic meaning of “preserving the residual kidney function” should probably be offered to all patients, in particular to those with the highest comorbidity –17. SomeIn this report we will analyse a clinical case, referred to as “Mr H”.In addition to the analysis of its clinical issues, looking at a case with an eye to the four principles of principlist ethics, integrated when necessary with an individual “narrative ethics” approach, can help clinicians decide what to do and how to support patients in critical phases of their disease.Therefore, the case of Mr. H will be discussed on the basis of the four principles, to exemplify how the modulation of clinical options can change the beneficence/non-maleficence balance, thus affecting ethical reasoning and the patient’s choice –33. DiffFurthermore, we will discuss how combining principlism with narrative ethics can furnish practical suggestions, in the context of patient-centred, individualized medicine –36.The case we discuss is that of Mr. H, a 90-year-old patient with end-stage kidney disease, diagnosed as nephroangiosclerosis. This clinical diagnosis was based on a long-standing history of hypertension, the presence of diffuse signs of vascular disease, the absence of severe proteinuria, relevant haematuria or systemic symptoms suggesting a different cause of chronic kidney disease (CKD). Furthermore, up to the last CKD phase, the progression trajectory had been relatively slow, after which a relatively rapid increase in creatinine was observed in the course of 1 year .In June 2016 Mr. H was hospitalised for a further reduction in kidney function, probably after an oligo-symptomatic infection . At hospitalisation, serum creatinine had reached 7.5 mg/dl, with severe acidosis (bicarbonate 15 mEq/l) and anaemia (haemoglobin 7.9 g/dl). The possibility of a cholesterol emboli syndrome was also considered, on account of the diffuse vascular disease observed, but no eosinophilia, livedo reticularis or skin lesions were present.At hospitalisation, the patient’s weight was 80.7 kg, for a body mass index of 30.7 Kg/m2 (height 1.62 m), with no clinical signs of malnutrition; severe arthrosis and diffuse leg hyperkeratosis were also part of the clinical picture. During hospitalisation his general metabolic balance improved, but his serum creatinine stabilised between 6.0 and 7.0 mg/dL.At 90 years of age, Mr. H lived alone, with help from the social services for home management; he received a hot meal at noon from a retirement home . The meal served as a basis for lunch and supper, supplemented with bread, potatoes, or cheese. He kept a garden and claimed to grow the best potatoes in the area.While the usual prognostic indexes may not be of great help in patients in advanced old age, his Charlson index was 9 , i.e. a comorbidity mainly linked to age and end-stage kidney disease. Perhaps more importantly, given the close link between nutritional status and survival, his SGA  score was A (well nourished) and his MIS  index was 3 .With this background, the decision on whether or not to start dialysis was discussed, including the options of peritoneal dialysis, haemodialysis and a low-protein diet. Since Mr. H suffered from severe arthrosis, which would have prevented self-performance, and did not receive nursing care, it was decided that peritoneal dialysis should not be undertaken. Haemodialysis was considered as a potential option that could be undertaken if absolutely necessary, and a low-protein diet was chosen as the best initial option. His diet was adapted to make up a 0.6–0.8 g/Kg/day moderately restricted, plant-based, but not fully vegan, low-protein diet that was supplemented with amino and ketoacids (1 Ketosteril pill for each 10 Kg of body weight), to avoid malnutrition. Given the low probability of creating a functioning arteriovenous fistula, the placement of a tunnelled catheter was decided on in case dialysis became necessary.Close follow-up was started, with monthly or twice monthly controls; however, acidosis was very difficult to control and rapid unpredictable weight gain was observed, requiring frequent hospitalisation, in spite of good nutritional compliance, and good blood pressure control.From a theoretical point of view, treatment should maximize survival and improve quality of life while the negative effects produced should be minimal. This was not fully clear in our patient and the medical and nursing staff was concerned about the clinical implications of dialysis start in a patient of Mr. H’s age; therefore there were further extensive discussions of treatment options, presented by the nurses and a psychologist. After this step, Mr. H, who had initially agreed to start dialysis was reported to refuse treatment, considering it incompatible with his daily routine. Subsequent conversations revealed that the underlying problem was missing his mid-day meal: “If I come to dialysis, I won’t be home at noon; and if I’m not home at noon, the people who deliver my meals will not find me, and if they do not deliver my meals, I won’t have anything to eat. I’m 90, I have severe arthrosis, and I’m no longer able to cook my meals myself. And I want to eat.”Identification of the communication problem  led to an empiric “narrative” compromise, with a prescription of 2.30–3.0 h of dialysis, one session per week, combined with a 30-min change in the delivery time of his meals. Mr. H felt that this arrangement was compatible with his needs.At the time of the present report, Mr. H is alive and in good clinical condition. He is still on a once-daily schedule. Some relevant biochemical data are reported in Table The main electrolytes are normal in the predialysis phase, except for mild acidosis (Bicarbonate between 17 and 20 mEq/L); parathyroid hormone is in the 100–300 ng/mL range and brain natriuretic peptide is between 80 and 120 pg/ml, in line with the absence of fluid overload . Haemoglobin has been kept on target (10–11 g/l) with recombinant erythropoietin; blood pressure has been controlled with Lercanidipine 20 mg, Nebivolol 5 mg and Urapidil 120 mg. Serum albumin is well preserved, and the patient’s “dry weight” increased after the start of dialysis. Mr. H is still on a 0.8 g of protein/Kg/day diet, supplemented with Ketosteril (1 each 10 Kg of BW).Meanwhile, he has celebrated his ninety-first birthday. His good clinical and psychological adaptation to dialysis treatment have made the medical and nursing group confident that it will be possible to extend this option to a twice weekly schedule, with limited dialysis time (2.5–3 h) if necessary in the future.In this first part of the discussion we analyse the case of our ninety-year-old patient on the basis of the four principles of justice, autonomy, beneficence and non-maleficence, as an integration to the clinical discussion and as a way to highlight the points in which a flexible clinical approach, in line with personalized medicine, can support a patient’s decisions.There are several ways to consider justice from an ethical point of view in medicine; although they are all legitimate, they differ markedly –44.A “social” reading of justice sees it as the fair distribution of opportunities and resources between individuals, with particular attention to competing situations, in which the choice of care for one patient may mean a lack of availability of care for another –44.Since in the setting of in which Mr. H received care (France) dialysis treatment is available without limitation for all patients needing it, we considered that he had the right to be treated. While the risk of over-treating and of a futile use of resources persists, our patient is not the only nonagenarian on dialysis, nor the oldest one reported in the literature, in which positive results have been recorded, challenging an age-centred policy –48.On a more general basis, our case elicits somewhat contrasting reflections on the complex relationship between physicians’ time, delivery of resources and the cost efficiency of health care services. In this context, justice may have a more pragmatic connotation. In settings of limited resources, in which dialysis treatment is not freely available, or is limited by logistic reasons, a lower number of dialysis sessions per patient makes it possible to treat more individuals, and optimise access to care. In contrast, in high-resource settings, in which dialysis is a well-established right, and often a quite cost-efficient treatment, a flexible approach to dialysis sessions is a departure from a rigid “thrice-weekly” organisation, thus reducing the economic efficiency of the system. A tailor-made dialysis system is, of course, not incompatible with economic efficiency, but as a rule, flexibility and cost-cutting are inversely related, and treatments that differ from a time-honoured routine usually require additional control, which is obviously more demanding.In this regard, personalized medicine, increasingly advocated as the best model of care, emphasizes the ethical issues physicians face: is their primary responsibility to guarantee the individual patient’s rights, or to ensure the economic efficiency of the health care system?On an organizational basis, we need to take into account that personalization requires medical time, as does discussion; while the temptation to dismiss this issue by arguing that “time constraints make it impossible to follow all patients in this way” is evident, personalized medicine offers a precious tool not only for defending the autonomy of physicians’ choices, but also for ensuring that time is available for attaining this qualitative goal.A “legal” interpretation of the sense of justice sees it as synonymous with laws. In this context, Mr. H’s right to treatment is guaranteed by French law, as is his decision not to undertake dialysis treatment if he does not wish to .In addition, justice can be seen as a moral/ethical right, taking religious beliefs into account. In this regard, Mr. H’s religious beliefs may have influenced his decision on whether or not to undertake a potentially complex treatment, but once more, the decision was his, and offering dialysis to an elderly, independent and competent person does not challenge current ethical or moral norms –53.In western countries, respect for the patient’s autonomy is usually considered to be the most important of the four principles, which is of particular importance when different principles are in conflict or are not syntonic, as in the case of Mr. H, in which the balance between beneficence and non-maleficence is particularly delicate , 55.In fact, in the absence of an a priori decision in favour or against starting dialysis, the choice Mr. H. made depended on how he saw the balance between beneficence and non-maleficence, the latter consisting in the risks and side effects involved in dialysis.A discussion of the impossibility of offering patients wholly unbiased information, as it is inevitable that physicians’ or nurses’ convictions will influence how they explain options to patients, and of the role of the “way we say” things, whose importance sometimes overrides the meaning of the content, is beyond the scope of this paper –58.Information depends upon the model of care: paternalistic approaches “manoeuvre” patients towards the physician’s opinions, and can be considered intrusive, while a purely informative model often lacks empathy and participation –65. PersBy definition, empathy cannot exist without pathos, nor can counselling without convictions.In the case of Mr. H, we chose the dynamic interaction of therapeutic alliance: in this model, the physician not only offers a choice of all the feasible options , but discusses with the patient how to adapt the options to their needs and preferences. When using this model, the strategy chosen may be a compromise between the “best”, or most validated option, and a reasonable, but more feasible one.In the case of incremental dialysis, there is wide variability between specific modalities: while some authors hold that dialysis should be started with “soft” once-weekly sessions, others prefer a longer session, or define twice-weekly dialysis as incremental. In the absence of a validated, uniform way to perform this schedule, we adapted the initial policy to the patient’s needs and concerns . While in his case the initial policy proved to be successful and the original schedule was followed for 1 year, the same dynamic approach could have been followed if additional adaptations or changes had been needed.A further issue, that here is mentioned only in passing, on account of its extreme complexity, is the feasibility of a non-experiential choice in the exquisitely subjective field of “tolerance”, in which an individual’s response is nearly impossible to foresee a priori.In this regard, a shared decision process also supports starting dialysis on a “trial basis”, to test tolerance, and clinical advantages; no approach is without cost, but since the patient  further supported this approach –89.No less importantly, as previously mentioned, an incremental dialysis start allowed us to perform a “dialysis test” for tolerance, and reach an experience-based decision on whether dialysis treatment should be continued, intensified or discontinued.In our case we believe that the “treatment test” was the best way to overcome a potentially endless discussion on the advantages versus the drawbacks of the incremental dialysis policy that we had a priori identified as a clinically reasonable choice, in keeping with Mr. H’s everyday routine and quality of life.In fact, a single 3-h dialysis session per week might not correct fluid overload or acidosis; instead a moderately protein-restricted diet  could induce malnutrition. Furthermore the presence of a vascular access, or the development of intradialytic or post-dialysis hypotension could have had a negative effect on quality of life and morbidity.The biological variability of the “old-old” is well known, and, although several experiences of incremental dialysis have been published, the data are still too scant to supply exhaustive indications .The good results obtained in our patient, apparently thanks to the combined benefits of diet and dialysis, cannot of course be taken as an a posteriori demonstration of the efficacy of this policy; conversely, they do suggest that being flexible and adapting to the patient’s needs means that an approach can be evaluated and adjusted as treatment progresses.While principlist ethics offer a simple framework for analysing the clinical problem, a narrative approach enables us to identify solutions in individual cases, taking into account the patient’s history, family support, fears and concerns, as well as daily life routine –35.By definition, a narrativist tries to capture the stories that patients and their families tell or hide, and that, with silences as well as words, characterize decision-making . NarratiThe history of our patient reflects the need for a flexible approach adapted to his needs that takes into consideration the importance different individuals attribute to the constraints of daily life. A problem with the home delivery of hot meals may seem trivial in comparison to living or dying, but can appear as unsolvable to an elderly individual, becoming the focus of their fears and concerns. In this regard, finding pragmatic solutions is not only a way to come to grips with a specific inconvenience, but also shows the patient that problems can be solved and dialysis can be adapted to their needs and wishes, and need not be “a prison”.In terms of a principlist analysis, it seemed likely that Mr. H would benefit from a flexible approach to dialysis, which would serve to overcome his health problems . Attention to minimizing side effects  led to the choice of an incremental dialysis approach, in a setting in which the principle of justice was respected, at least for treatment availability . While the physicians were mainly concerned with finding the best compromise between beneficence and non-maleficence, the patient was worried about the disruption of his daily routine . While he was not a priori against dialysis , he subsequently refused treatment because “If I’m not home… I won’t have anything to eat”.A rigid interpretation of autonomy would probably have led to his not starting dialysis ; inquiring in detail about what had made him change his mind, and asking about his habits and quality of life, identified a problem  and found pragmatic solutions that did not impact on clinical aspects, but modulated the individual’s choice (autonomy). Narrativism allowed us to get a detailed picture of the patient and mitigated the rigidity of the four principles; while many of the considerations regarding dialysis start could apply to other elderly patients with end-stage kidney disease, the patient’s choice was unique to Mr. H, as the solution also was.In this regard, we suggest that principlism allows us to arrive at an initial analysis of difficult cases, identifying the specific aspects of the problems involved, while narration serves to put problems in perspective and possibly solve them.The case discussed illustrates the limits of a Manichean contraposition between dialysis and palliative care.In this extreme balance, dialysis is intended as “renal replacement therapy” (RRT), a treatment that has to deliver, regardless of the residual renal function, full artificial depuration. While the definition of “adequate” and “optimal” dialysis is not clear, a strict “RRT approach” ignores residual renal function, in spite of the fact that its presence is one of the most important survival markers , 87–89.Palliative-conservative care is defined as a comprehensive treatment which allows for reasonable survival, with a good quality of life, without dialysis –14. HoweIndeed, this sharp opposition between palliative-conservative care and dialysis, which is often thought to be unavoidable, has begun to be seen as less of a contrast, and what is now being proposed is the integration of the two in what is called kidney supportive care, aimed at improving the quality of life, whenever possible together with therapies intended to prolong life, such as dialysis. Furthermore, the term palliative dialysis is also occasionally used to indicate a form of patient-centered dialysis that focuses on quality of life.In our case, the decision to start dialysis was postponed until the time when “conservative care” could no longer ensure well-being. The once-weekly session was started to correct acidosis, reduce overload, and allow some degree of correction of uremic intoxication. The interventions were graduated to clinical context and life expectancy, and their purpose was to correct the derangements associated with short-term clinical problems (acidosis and overload).The contraposition between RRT and palliative-conservative care points to what is now called “transition” to dialysis –14. StudThe choice of starting a “full schedule” of dialysis is often the only one possible in patients with minimal or no predialysis follow-up that start dialysis when admitted to the emergency room. However, in patients who have been consistently followed, the best choice may be to progressively increase their scheduled visits, from every 3 months to once a month to weekly, to a once-weekly dialysis sessions.The case of Mr. H, in which the availability of a “soft” dialysis start smoothed the terms of a tough ethical dilemma, without forcing us to sacrifice quality to quantity of life, is a story with a happy ending, at least for the time being: our patient is doing well on dialysis, enjoys his role as our “oldest patient”, gets home by the time his meal is delivered, and tolerates dialysis sessions well.Concerned about his daily routine, Mr. H would not have accepted more intrusive treatment which, as his story shows, was not really needed; his positive experience with dialysis will modulate his further choices, including intensifying dialysis, if need be.In conclusion, this case encourages us to reflect on the reasons why laypeople and many physicians have a negative view of dialysis. Is dialysis in itself a killer, or is the way we use this treatment the cause of “dialysis shock”?Unlike standardized medicine, based on identifying the best solution, in an ethical discussion there is no best solution, but instead a personalized choice adapted to the context and to the individual. As in chemotherapy, in which protocols are increasingly being adapted to patients, there is room and a need for well-grounded “personalized medicine” in renal replacement therapy.


Recently, important discoveries regarding the archaeon that functioned as the “host” in the merger with a bacterium that led to the eukaryotes, its “complex” nature, and its phylogenetic relationship to eukaryotes, have been reported. Based on these new insights proposals have been put forward to get rid of the three-domain Model of life, and replace it with a two-domain model.We present arguments  to resist such proposals. The three-domain Model represents an accurate description of the differences at the most fundamental level of living organisms, as the eukaryotic lineage that arose from this unique merging event is distinct from both Archaea and Bacteria in a myriad of crucial ways.not be revised when considering the recent discoveries, however exciting they may be.We maintain that “a natural system of organisms”, as proposed when the three-domain Model of life was introduced, should  Escherichia coli or Bacillus subtilis constitutes one of the most important biological discoveries of the twentieth century. These revolutionary insights regarding the nature of prokaryotes resulted from the analysis of ribosomal (r) RNA sequences by Carl Woese, unambiguously demonstrating that they consist of two entirely distinct cells: Bacteria and Archaea [regio (English: domain) as a higher taxonomic level than regnum: introducing the three domains of cellular life, Archaea, Bacteria and Eucarya. This paradigm was proposed by Woese, Kandler and Wheelis in PNAS in 1990 [The discovery that methanogenic microbes differ fundamentally from Bacteria such as  Archaea . rRNA an in 1990 . AcceptaRecently, evidence has been accumulating , and especially the process of endosymbiosis thus poses major problems, requiring important decisions on how to classify organisms in which fusing branches play a (major) role. Initially, this issue was largely ignored with regard to eukaryotic origins because of the following view: that they started out as pre-endosymbiotic (presumably anaerobic), phagocytosing, cells. The picture of such an “anaerobic amoeba” feeding on Bacteria, sits well with the tendency towards linear phylogenetic branching. However, such a picture is deeply flawed (see the next sections). The “host-endosymbiont view” suggests that eukaryotic cells are merely modified forms of the cell that acquired the bacterial component, which blinds us to the bacterial contributions to the Eucarya. We will come back to this, but first focus on why basal taxonomy is important.do agree), but because the eukaryotic cell is not an archaeon with a bacterium inside, and because we are convinced that at the most fundamental level there are three cell types, archaeal, bacterial and eukaryotic, and that the primary biological distinction should reflect this reality. At this point we also want to stress the fact that these taxonomic considerations are not “just about semantics”. Taxonomy  should not only reflect our scientific findings as accurately as possible, but will shape their interpretation in turn. To quote Woese: "A biological classification is...an overarching evolutionary theory that guides our thinking and experimentation, and it must be structured...to reflect evolutionary reality" [and Bacteria) more important, and thus argued for a two-domain (“Empire”) model [Here, we concisely try to defend the three-domain model, not because we do not agree with the concept that the eukaryotes came about as the result of a merger of an archaeon and a bacterium  model . One mighuge amount of eukaryotic genes with a bacterial origin. As Koonin observes: “Notably, altogether, the number of eukaryotic protein-coding genes of bacterial origin exceeds the number of ‘archaeal’ proteins about threefold” [If we are to succeed in our aim of distinguishing three fundamental cell types, we first have to get rid of a most harmful preconception. The picture which is generally present (though as a tacit assumption) when discussing eukaryogenesis, is that of a large, “pre-eukaryote” or “pre-eukaryotic archaeon” which takes up a small, alphaproteobacterial cell, which is subsequently reduced to an organelle. With this picture in mind, it is only natural to state: “Collectively, the results from the A/E and A/B analyses support a two-domain topology for the tree of life, with eukaryotes as a sister lineage to the whole TACK superphylum”. An important first issue ignored here, is the reefold” .larger kind of ribosomes present in the cytosol should not be seen as “the eukaryotic ribosomes”, contrasted with the “bacterial” ribosomes in the mitochondrion. Both the ribosomes in the cytosol and the ones in the mitochondrion are eukaryotic. The cytosolic ribosome is different from prokaryotic ribosomes in many respects. Eukaryotic cytosolic ribosomes are much larger and more complex, incorporating more rRNA  and extra ribosomal proteins or protein extensions. This goes along with some fundamentally different activities and regulations  of life’s evolution a truly new type of cell emerged (see next paragraph). Of note, the fact that many of the “genes of bacterial origin” Koonin referred to, were already present in the archaeon before the merger . Howevesee e.g.  and refesee e.g. ) at the as a result of mutual adaptations of two prokaryotes. Whether one agrees with the specifics of the proposal is less important than this conceptual framework. More and more new findings demonstrate that this general scheme is basically correct;  is used in many tRNA anticodon first-positions, in the Archaea inosine is not used at all, and in Bacteria inosine is only used in the anticodon first position in one codon box (CGN). This use determines domain-characteristic codon usage patterns.We again introduce a “milestone paper”: in 2012 Novoa et al. described a major role for tRNA modifications in codon usage in the different domains of life . In this5U by tRNA-dependent uridine methyltransferases, which also leaves its “fingerprint” on bacterial codon usage. How do these fingerprints come about? The evolution of tRNA repertoires and codon use can be understood in light of the fact that modifications of the wobble position increase the decoding capacity of tRNAs, and thus, crucially, translation efficiency. Modifiable tRNAs are then positively selected (and tRNA gene content distribution/codon usage with it). As the modification enzymes differ between the three domains we find a characteristic codon usage bias for each [signature eukaryotic codon usage pattern could still evolve (due to the substrate repertoire expansion of a tRNA-dependent adenosine deaminase). We quote: “One functional theme that has emerged is that the addition of a partner protein may allow for an expansion of the substrate repertoire for a given enzyme, as for the eukaryotic Tad2-Tad3 enzyme, which modifies an additional 6 tRNA species (in S. cerevisiae) in contrast to its homodimeric bacterial TadA counterpart, which appears to only modify tRNAArg(ACG)” [Of note, eukaryotes generally have (at least) a double tRNA set as the mitochondrial genome  encodes a second set of tRNAs. The domain-characteristic codon usage pattern of eukaryotes referred to above is linked to the cytosolic tRNAs. Considering domain-specific codon usage and tRNA gene content characteristics, a further factor is the specific bacterial modification of U into xofor each . We are rg(ACG)” .not an archaeal cell), in the event leading up to green algae, a eukaryote took in a cyanobacterial cell, while remaining eukaryotic.Thus, not only in cell structure, membrane composition and general level of complexity, do we find three kinds of cell. Also in tRNA set (as defined above) and codon usage  the living world is divided three ways. This basic three way partition should be reflected in the primary taxonomic division, and after starting with that, phylogeny can step in to provide the details per domain. Of note, chloroplasts do not complicate this picture. They come from a cyanobacterium entering at a later stage ). The endosymbiosis leading to green algae is a major event, but not comparable in impact with that of eukaryogenesis. Another way of describing the difference: in the event leading up to LECA, an archaeon combined with an alphaproteobacterial cell to give rise to a eukaryote  interprets to be a negatively defined concept (“not being a eukaryote”), developed prior to the insight regarding the chasm between Archaea and Bacteria . It mighsee e.g. ). We useretain the three-domain model, with the understanding that the primary taxonomic division among cellular organisms ought to reflect that 3 basic cell types exist. First, an archaeal cell type, with isoprenoid units attached to glycerol-1-phosphate by ether linkages forming their membranes and a codon usage not shaped by inosine. Then, another prokaryote, the bacterial cell type with ester-linked lipids (fatty acids linked to glycerol-3-phosphate by ester linkages) and a codon usage mainly moulded by a bacterial tRNA dependent uridine methyltransferase. Finally, the complex cell type resulting from eukaryogenesis, the type representing the “Eucarya” of Woese, Kandler and Wheelis. Here codon usage reflects the massive use of inosine in anticodons, membranes are of the bacterial type, two types of ribosomes -both different from prokaryotic ones- are present, and a completely reconfigured metabolism resulting from the interactions between both prokaryotes involved, can be found. Later on, some eukaryotes even acquired further ribosomes (e.g. in chloroplasts). In conclusion, our proposal does not challenge the primacy of the phylogenetic approach, and allows the first taxonomic division to be a functional division, reflecting biological reality. Three phylogenetic trees can now be build, separately, for each of the domains. We have to start with a tiny Darwinian forest before we can tend to its massive trees.Because of the considerations brought forward here, we propose to


Most, if not all, academic librarians are by now familiar with the term “predatory publishing.” Beall in 2012 defined predatory publishers as “those that unprofessionally exploit the gold open-access model for their own profit,” often taking advantage of junior faculty and graduate students  as of 20On an almost daily basis, many academics now receive invitations to publish in journals that Beall correctly identifies as suspect and very probably corrupt. Beall’s open access and alphabetized list makes it extraordinarily easy to investigate and evaluate journals involved in such practices , 3. Of cAnother rather obvious warning sign is often the clumsy, poor, or just plain incorrect English grammar that is used in such communications. The following are two examples that the author recently received:“Being impressed by your quality work, we are contacting you to know if you can associate with us by submitting your upcoming research.”“Our reputed journal, aspire to deliver high quality research work in the field of health care as Open Access to the globe.”Based on reflection on the issues of predatory publishing and mindful of current events globally and nationally, it is in relation to this final point that I felt an ethical obligation to write this cautionary piece. Surely there is something wrong when poor English grammar in an email evokes such immediate suspicion.Before continuing, it is important to note that in 2016 Dictionary.com announced that its word of the year was “xenophobia”:At Dictionary.com we aim to pick a Word of the Year that embodies a major theme resonating deeply in the cultural consciousness over the prior 12 months. This year, some of the most prominent news stories have centered around fear of the “other.” Fear is an adaptive part of human evolutionary history and often influences behaviors and perceptions on a subconscious level. However, this particular year saw fear rise to the surface of cultural discourse. Because our users’ interest in this overarching theme emerges so starkly for one specific word in our trending lookup data, xenophobia is Dictionary.com’s 2016 Word of the Year. [It is important, therefore, to ensure that concerns over predatory publishing, which may be evoked by something as incidental as poor English, do not develop into a more widespread emotion-heated xenophobia. As White recently noted in response to populist election outcomes globally: “Facts are irrelevant. Emotion and prejudice rule” .Beall’s pioneering work in developing awareness of predatory publishing and in continuing to devote time and energy to this subject is to be admired. However, it is important that whole populations are not indiscriminately written off. Beall’s Scholarly Open Access website contains the following statements in a blog post, titled “Hyderabad, India — City of Corruption,” which are perhaps a cause for concern:Hyderabad, India is one of the most corrupt cities on earth, I think. It is home to countless predatory open-access publishers and conference organizers, and new, open-access publishing companies and brands are being created there every day. All institutions of higher education, all funders, governments, and researchers should be especially wary of any business based in Hyderabad.The tacit rule of thumb of Hyderabad-based businesses is: Use the internet to generate revenue any way you can.There are numerous internet-based businesses in this over-crowded city, many located in a special enterprise zone called HITEC City, which some refer to as “Cyberabad.” American Journal of So-and-So”).Evidence of this potentially prejudiced appraisal of foreign publications can ironically now be seen in more recent strategies adopted by predatory publishers, including using a “fake” US mailing address and assuming a title falsely indicating that it is a US journal  [The Guardian notes, “The relationship between big pharma and publishers is perilous” [However, we must, of course, acknowledge that high-quality non-English-language health and medical journal publications do exist and make a valuable addition to the health sciences. Our ethical duty is to keep an open mind and resist succumbing to ethnocentric prejudice and racism. It is important to remember that it is not only in industrializing nations that publishers have been noted to engage in dubious practices. Even high-status established and reputable academic publishers in the West have been found to be in breach of expected academic norms. Perhaps one of the best examples was the decision by Elsevier Australia to publish six “academic journals” sponsored by the pharmaceutical company Merck  . As Ben erilous” , clearlyElsevier Australia went the whole hog, giving Merck an entire publication which resembled an academic journal, although in fact it only contained reprinted articles, or summaries, of other articles. In issue 2, for example, nine of the 29 articles concerned Vioxx, and a dozen of the remainder were about another Merck drug, Fosamax. All of these articles presented positive conclusions. Some were bizarre: such as a review article containing just two references. Bad Pharma: How Drug Companies Mislead Doctors and Harm Patients [Elsevier has condemned this practice , but thePatients .Predatory publishing undoubtedly represents a clear and present danger to the integrity of academic publishing. To date, little has been done to curb the excesses in this field, although some recent action by the US government has been noted . It is i


At present, the standardisation of electrical equipment communications is on the rise. In particular, manufacturers are releasing equipment for the smart grid endowed with communication protocols such as DNP3, IEC 61850, and MODBUS. However, there are legacy equipment operating in the electricity distribution network that cannot communicate using any of these protocols. Thus, we propose an infrastructure to allow the integration of legacy electrical equipment to smart grids by using wireless sensor networks (WSNs). In this infrastructure, each legacy electrical device is connected to a sensor node, and the sink node runs a middleware that enables the integration of this device into a smart grid based on suitable communication protocols. This middleware performs tasks such as the translation of messages between the power substation control centre (PSCC) and electrical equipment in the smart grid. Moreover, the infrastructure satisfies certain requirements for communication between the electrical equipment and the PSCC, such as enhanced security, short response time, and automatic configuration. The paper’s contributions include a solution that enables electrical companies to integrate their legacy equipment into smart-grid networks relying on any of the above mentioned communication protocols. This integration will reduce the costs related to the modernisation of power substations. Electricity generation, transmission, and distribution are essential for the development of modern society. Their underlying monitoring and control activities are performed by a variety of electrical system components. Current trends aims towards the automated operation of these components, particularly devices that are known as intelligent electronic devices (IEDs). The interconnection, communication, and control of these devices are embodied by the concept of smart grid, which is explained in ,2,3,4,5.In addition, another trend aims to monitor electrical equipment that is installed outside the power substation, at electricity distribution or transmission lines, or even at the point of consumption. However, the distance from the substation makes these monitoring tasks difficult and costly, provided that the communication between electrical equipment and the power substation relies on wired networks . Hence, the best option is to use wireless communication. In fact, the low cost and energy consumption of radio-frequency (RF) communication is more convenient, thus making wireless sensor networks (WSNs) an excellent solution for monitoring tasks over wide areas. To this end, electrical equipment can be connected to a sensor node and communicate with the power substation control centre (PSCC) through WSNs.A typical PSCC requires information from different systems and controls several IEDs installed in the electricity distribution network. The wide variety of protocols, interfaces, and proprietary systems to manage the required communication and automation infrastructure represents the major barrier to the effective deployment of smart grids. To overcome standardisation issues in this area, various protocols were developed, such as the distributed network protocol 3 (DNP3) , IEC 618The correct operation of electrical systems is critical, because faults might cause power outages affecting neighbourhoods or even entire cities, with the consequences impacting society as a whole. Thus, systems supporting and operating smart grids should meet certain important requirements, such as short response time and communications security. Hence, the same requirements should be met by communication protocols, for WSNs enabling the smart grid to comply with suitable response time and communications security, and to improve the operation of every system composing the smart grid.To successfully integrate legacy electrical equipment into a smart grid that uses standard communication protocols , we propose a suitable infrastructure. The infrastructure consists of a ZigBee-based WSN that operates under the IEEE 802.15.4 standard, where the sensor nodes are connected to the legacy equipment, which then communicates with the PSCC through the sink node. The sink node, which has a wired connection  to the central controller, runs a middleware that uses the Internet Protocol (IP) for communication between the sensor nodes and a terminal installed in the PSCC. In particular, the middleware mainly translates messages communicated between the PSCC and the electrical equipment in the smart grid. Furthermore, the proposed infrastructure allows guaranteeing the above mentioned requirements for smart-grid applications, including short response time, communications security, and even automatic configuration capabilities. To test the infrastructure, we setup an scenario to perform electrical measurements, where we evaluated the features and requirements of a power metering application.This solution enables electrical companies to integrate their legacy equipment into smart-grid distribution networks using the following smart-grid protocols: IEC 61850, DNP3, and Modbus.The infrastructure proposed in this study provides the facilities to guarantee the important requirements for smart-grid applications, such as short response time, communications security, and even automatic configuration capabilities.The infrastructure presented in this paper allows both the interoperability of electrical equipment from different manufacturers and the reduction of costs related to the modernisation of power substations.The main difference between the middleware-based infrastructure proposed in this study and other available middleware-based solutions is the possibility of integration using the following smart-grid protocols: IEC 61850, DNP3, and Modbus. Many solutions do not use standard communication protocols for smart grids, and other systems and architectures communicate using only the IEC 61850 protocol, such as approaches presented in The rest of the paper is organised as follows. Related work is presented in WSNs have been used to improve different aspects related to smart-grid operation, such as bidirectional communication and delivery, real-time seamless monitoring, energy quality and efficiency, and reliable and low-cost solutions for control management ,10,11. HA novel technological paradigm has been proposed in . AccordiIn , SchrodeIn , Lloret Salvadori et al.  describeDespite the abundant research, to the best of our knowledge, this is the first middleware-based infrastructure that aims to integrate legacy equipment into a smart grid. Moreover, many solutions do not use standard communication protocols for smart grids. For instance, middlewares presented in ,33,34,35In this section, we present the proposed infrastructure with its components and strategies. These components consist of software applications that we implemented to run at both power substation equipment and WSN nodes. An important component of the infrastructure is the middleware that we implemented to run on the WSN sink node. This node is located in the power substation, and it has an Ethernet wired connection with the PSCC. Thus, the proposed middleware can communicate, via wired connection, with the supervisory software  that runs on the central controller (PSCC computer). In this proposal, the WSN sensor node is wire-connected to the electrical equipment that is installed outside the power substation . For instance, the supervisory software performs requests to the middleware, which communicates with sensor nodes to receive electrical measurements from electrical equipment that is located outside the power substation. We also proposed strategies to satisfy important requirements for smart-grid applications, such as high security and suitable response time. These strategies are transparent to the user, provided that they are embedded in software applications. These components and strategies are addressed in the sequel.The proposed infrastructure includes software applications and strategies that we implemented to run at the components of the power substation and at WSNs. In addition, the PSCC and WSN sink node are located in the power substation, as shown in The PSCC, among other activities, monitors events and measurements of the electrical system and executes commands on the substation equipment. In addition, the control centre has a terminal executing SCADA to handle information from productive processes or physical installations. This terminal has a wired interfaced  with the WSN sink node.We installed the proposed middleware in the sink node, which we considered to be a Raspberry PI model B , with thWe implemented the sensor node, which can have a wired interface (using either the RS-485 or RS-232 standards) with electrical equipment, in the EK-TM4C123GXL ARM board  . The wirThe RF communication between the sink and sensor nodes is based on the ZigBee specification, and sensors can be organised according to mesh or hierarchical topologies. ZigBee is a reliable, low power, low cost and efficient technology, and it is widely used in home area network (HAN). However, due to these characteristics, it is also used in smart-grid applications, as shown by the authors in ,45,46,47The focus of this study is the smart metering concept, and leading smart-meter manufacturers, such as Lands+Gyr and Itron, use ZigBee technology or IEEE 802.15.4 standard for wireless communication of their smart meters ,51.There are real applications using ZigBee technology for smart metering infrastructures. For instance, the gridstream smart metering solution from Landis+Gyr for Helen Electricity Network uses ZigBee technology . SoutherMany devices for energy metering and management use ZigBee technology, such as universal controller ENOCEAN ZigBee  , smart pThere are smart metering technical specifications that suggested ZigBee technology as standard for HAN applications. For instance, the smart metering implementation programme (Department of Energy and Climate Change—UK Government) presented the smart metering equipment technical specifications—Version 2 (SMETS 2), which suggested the ZigBee technology as the standard for the HAN application layer .Power utilities in most regions of Brazil do not offer infrastructure  for PLC-based communication in their power grid. They do not authorize the use or installation of any equipment in their power network. Thus, no PLC-based communication test is possible.ZigBee technology has lower cost than other technologies such as LoRaWAN and Sigfox. These technologies require base stations or access points (APs) to operate, which must be installed on RF transmission towers. In many cases, RF transmission towers must be built, which increase the financial cost. DLMS is considered a standard protocol for smart metering, and there is no study or related work that evaluates whether the LoRa or Sigfox technology has sufficient bandwidth to satisfy the amount of information exchanged in a DLMS communication.The following reasons motivated us to use ZigBee technology in this study:As mentioned above, a wide variety of protocols, interfaces, and proprietary systems from different manufacturers are installed in electrical systems. Hence, the standardisation of these components is required. Furthermore, there are some communications requirements between electrical equipment and the PSCC, such as high security and suitable response time. These requirements, which enable operation and monitoring applications running in smart grids, are addressed in the next subsection.Standardisation: Power substations are currently using standardised equipment for operation, monitoring, and communications. This facilitates the integration and interoperability among electrical devices, improving the power system maintenance and operation. In particular, communication protocols such as DNP3, IEC 61850, and Modbus are widely used in smart grids. Thus, a WSN-based integration of legacy electrical equipment and sensors into a smart grid requires the use of such standardised protocols. Moreover, a middleware must support the WSN sink node to enable the communication between different equipment and either the PSCC or another smart-grid system.Response Time: Smart-grid applications must comply with a suitable response time. In fact, the IEC 61850 protocol specifies a time constrain for message exchange. For instance, this protocol limits the transmission time of type 3 messages (i.e. low-speed messages) to 500 ms [Security: Security is a major concern in smart-grid applications. For instance, in a power metering application, the information of customer power consumption retrieved by the electricity utility must be treated with safety and reliability. Otherwise, a WSN transmitting information between the electricity utility and smart meters might be corrupted by a spy node, which could alter the consumption readings in the benefit of the customer. To avoid this type of problem, we propose the use of an encrypted channel with keys generated at the sink and sensor nodes to secure their communications. The keys are modified at runtime to hamper the inclusion of corrupted data, and we verified the effectivity of this encryption method, as shown in the corresponding results of The proposed middleware shows a novel and different approach for the concentrator core which was developed in previous research . HoweverMaster.py: This module commands the others and contains a Python class called “Management”, which has a method for initialising modules “protocol.py”, “smartgrid.py”, and “interface.py”. Other methods include “scannodes”, “pingnodes”, and “announce”. Method “scannodes” sends a broadcast message at different instants to discover new nodes in its coverage area; “pingnodes” sends a message to each node in the routing and control table for checking the node status on the network, and it removes from the table the non-responding nodes; and, finally, “announce”, which is called after “scannodes”, searches for new nodes and tries to initialise node data, and it creates a new alias for the network interface, thus assigning a unique virtual IP address to a discovered sensor node. The IP address, ID, and basic information of the node are stored in the routing and control table. These methods correspond to the automatic configuration which allows a sensor to be seamlessly included in the network. Moreover, this automatic configuration might simplify scalability, which is out of the scope of this study. In addition, module “Master.py” contains a method called “request” which starts any request on the WSN and aims to guarantee the security requirements for WSN communication, as detailed in Interface.py: This is another essential module in the middleware and contains a class called “nodes” with methods “request_lock”, “request_release”, “del_NODE”, and “add_NODE”. Methods “request_lock” and “request_release” operate as locks and prioritise the requests from the SCADA application to send data through the sensor network. Thus, these methods block any command sent from Web application, provided that the SCADA application is transmitting. In fact, for a smart-grid application, SCADA commands and requests must have top priority because it performs real-time and autonomous monitoring from the power substation. Still, the proposed middleware also allows requests to sensor nodes from a Web application, without the use of standard protocols for smart grids. Method “add_NODE” is invoked by the above-mentioned method “announce”, whereas method “del_NODE” performs the reverse operation of “add_NODE”, i.e., it removes the sensor node information from the routing and control table.Protocol.py: This module basically specifies the WSN communication protocol. It contains the following classes: “crypt”, “data”, and “comm”. Class “crypt” performs data encryption and comprises methods “encrypt”, “decrypt”, “crypt”, “setHASH”, “getHASH”, and “getNEXThash”. Clearly, these methods allow encrypting and decrypting the data transmitted through the WSN, and create, configure, and modify the encryption keys. Hence, these methods are part of the security strategy for the sensor network communications. Then, class “data” basically consists of methods “encode” and “decode”, which convert the message format in the middleware to the request packet structure used by the WSN. Specifically, method “encode” uses method “pack” to construct the WSN request packet, and “decode” uses method “unpack” to extract information from the WSN responses. Finally, class “comm” is responsible for the communication between the Raspberry PI and the radio transceiver. It contains methods “_init_”, “close”, “cleanSerial”, “send”, and “receive”, which set the transceiver parameters, close the serial connection, clean the serial buffer, send data, and receive data, respectively.Smartgrid.py: This module creates a link between either the SCADA application or DTM and the sensor nodes, and contains a class called “smartpoll” that comprises methods “waitRequest”, “sendResponse”, and commInterface”. Method “waitRequest” waits for requests and receives them from the converter layer. Then, method “commInterface” sends the request to module “Interface.py”. In addition, module “smartgrid.py” has a poll (buffer) to store the data (responses) received from the sensor nodes. These data can be used as responses for the SCADA application or DTM. Method “sendResponse” sends responses stored in the poll to the converter layer.ConverterLayer: The middleware is intended to receive requests from the supervisory control and data acquisition (SCADA) software and respond them with the values that are stored in the buffer area created by the servers of smart grid protocols. These servers represent the converter modules in the middleware converter layer. Thus, input signals can be represented by reading commands sent by the SCADA software, and output signals are the values returned as responses to these requests.To receive requests from the TCP/IP layer, the modules in the converter layer create new servers on the ports related to protocols DNP3, IEC 61850, and Modbus. For instance, if the SCADA application performs a request using the Modbus protocol, the module for “Modbus frame/sink frame conversion” creates a new server at port 502 to receive the corresponding commands. Hence, the TCP port that receives the request determines the corresponding server for communication.Module “DNP3conv.py” (DNP3 frame/sink frame converter) contains class “DNP3Server” with four methods: “startServer”, “linkLayer”, “transportLayer”, and “AppLayer”. Method “startServer” instantiates the server and receives the request parameters from the SCADA application using the DNP3 protocol; “linkLayer” extracts the fields from the DNP3 frame header and then reassembles the frame information to compose fragments; “transportLayer” gathers and formats the fragments to compose the corresponding message. Method “AppLayer” maps both the static data and point indices of the request into the electrical parameters recognised by the middleware and the sensor node IDs, respectively.Likewise, module “MODBUSconv.py’ (Modbus frame/sink frame converter) contains five methods: “init”, “setValues”, “StartTcpServer”, “getALLdata”, and “getSINGLEdata”. These methods perform several tasks, e.g., instantiate the server and receive the request parameters, extract the fields from the header of the Modbus application protocol, convert slave addresses into sensor node IDs, convert function code into request parameters, and construct the corresponding Modbus TCP messages.Finally, module “IECconv.py” (manufacturing message specification (MMS) frame/sink frame converter) contains some classes, with the most important being “IedServer”, which has methods “IedServer_create”, “IedServer_start”, “IedServer_stop”, and “IedServer_destroy”, among others. These methods allow creating an IEC 61850 server application and manage both the MMS protocol stack and IEC 61850 data model. Moreover, they initialise the protocol stack, listen for client connections, provide process values to the MMS server, react to client events, stop the MMS server, and free all the resources allocated by the IedServer instance. The methods from class “IedServer” to provide process values  include “IedServer_lockDataModel”, “IedServer_updateAttributeValue”, and ’IedServer_unlockDataModel”.Given that the converter layer of the proposed middleware must receive messages that comply with standard protocols for smart grids and translate them into a format recognised by the WSN, we proposed a memory mapping to facilitate this translation in previous research . This maAlthough ZigBee specifies security management for communication, the security measures we propose can be used for communications in radio technologies that are not endowed with intrinsic security. In Thus, an encryption key is generated per sink-node request and per sensor-node response, as shown in As shown in To meet the response time requirements for smart-grid applications, we use strategies to reduce the communication time in WSNs. We consider two phases of the polling technique. In the first phase, which is illustrated at the left side of This strategy has allowed to meet one of the time requirements of the IEC 61850 protocol for critical operations in intra-substation environments. Other requirements such as those related with quality of service demand a high-speed message communication below 1 s . As showWe used two strategies to include new sensor nodes in the network without requiring manual configuration. The first strategy, which we proposed in , consistIn this strategy, the inclusion process begins when a new sensor node is installed in the electrical system. The sensor node listens for messages from nearby CHs, and, for each received message, the node stores the radio signal strength, given by the received signal strength indicator. Then, it compares the signal strengths and selects the strongest CH. Finally, the node sends a message to the selected CH to inform the presence of a new sensor node, and the CH acknowledges this message by returning an ID to the sensor node. The ID is based on the corresponding table, which is stored in each CH. The CH also notifies the new sensor-node ID to the sink node in response to a request from method “The second strategy is based on module “We performed experiments using a scenario with power meters connected to sensor nodes to allow remote readings of customer energy consumption. These experiments aimed to perform these readings using either a SCADA application or DTM. In the sequel, we describe the environmental setup.We validated the proposed integration infrastructure in a laboratory environment. The test scenario consisted of a WSN with three sensor nodes and one sink node. As mentioned above, each sensor node, which is connected to a Cronos 7023 power meter, was implemented in a EK-TM4C123GXL ARM board equipped with a MRF24J40MC transceiver module. The sink node was implemented in a Raspberry PI model B and had an Ethernet connection with a computer, which was running the Windows 7 operating system, and the open-source licenses of ScadaBR and DTM.After preparing the experimental setup, we performed a test to validate the middleware converter layer, i.e., to determine whether the requests made by the ScadaBR or DTM  using anIn addition, we developed a Python program to present the voltage readings performed by the sink node directly on the sensor nodes. For each voltage-reading request from ScadaBR arriving at the sink node, the program records the corresponding response in an XML file, before the middleware sends the response to ScadaBR. The objective of this program was to compare the values received by ScadaBR with those obtained by the sink node from the sensor nodes. This comparison, which is illustrated in The 3D graph in f” is the type description attribute, which is floating-point ; “variable-name attribute for the phase voltage magnitude; “named variable object, which is related to the voltage value of the power meter connected to sensor node 1 ; “functional restriction attribute which is related to measurement activities; and “In The abovementioned results verify the applicability of the proposed middleware for communication between the WSN and a supervisory software running on a server which uses one of the three presented communication protocols for smart grids. Therefore, an electrical device connected to a sensor node can be integrated into a smart grid that supports the DNP3, IEC 61850, or Modbus protocols.Next, we performed another test to evaluate the response time. The computer running DTM and the pcap application performed a series of requests to sensor node 1  for retrieving the electrical voltage from the power meter. We configured DTM to use the IEC 61850 protocol, which presents tight constraints regarding response time. We used the pcap application to capture the transmitted and received data packets in the computer. Consequently, we could determine the time intervals between the requests and responses. The screenshot shows a sequence of packets, which contain the sequence number, event time, destination and source nodes, protocol type, and packet information. The two red marks in sequences 16 and 21 indicate the beginning of a request and its corresponding response. The instants when these events occurred were recorded: request began at 0.053 s, and its response reached at 0.976 s. Thus, we determined the response time to a request given by the difference between these instants. We performed 100 requests to sensor node 1 to evaluate the response time, which was determined from the difference between the instants of the request triggering and the response arrival. Then, we setup a scenario to validate the automatic configuration of sensor nodes in the WSN. Initially, only one sensor node was installed and located near the sink node, which was running an application to perform requests on the nodes located within its coverage area. In this scenario, only one sensor node answered to each request. A similar procedure was performed using ScadaBR, but only named nodes were allowed to perform requests. We observed the same event, and verified that the unique sensor node answered to the request. Then, we installed and activated another sensor node, which was located near the sink node. We performed the same procedure, and requests were sent to the sensor nodes by both the sink-node application and ScadaBR. To verify the proposed security strategy, we setup another scenario considering the WSN communication. The purpose of this experiment was to investigate the presence of any data pattern that can be recognised by the analysis of the captured dataset. In From the analysis of the sample distribution and two estimation techniques by both points and intervals, we are not able to find any data pattern. Hence, even if a spy node captures the data communicated through the network, it would be difficult to decipher the values stored in the message fields.We propose a middleware that runs on the sink node of a ZigBee-based WSN to integrate legacy electrical equipment into a smart grid that uses standard communication protocols, such as DNP3, IEC 61850, or Modbus. This middleware allows, as its main feature, the translation of messages communicated between the PSCC and electrical equipment in the smart grid.After surveying different infrastructures, middleware programs, and converters to integrate the smart-grid components using WSNs, we found that this is the first work that proposes an infrastructure to integrate a WSN into a smart grid operating with three different protocols and to satisfy some requirements for smart-grid applications.In fact, we used several strategies to meet these requirements. As a result, one of the proposed strategy was able to meet the response time requirement of the IEC61850 protocol for real-time monitoring. Moreover, we implemented strategies to improve the security in the WSN communication and to automatically configure and include new sensor nodes to the network. The results from various experiments verified that these strategies are effective in a WSN composed of a few sensor nodes.In future work, we will evaluate WSN characteristics such as scalability, response time, and reliability from simulations using the Castalia software to improve the proposed infrastructure. Moreover, we will make an agreement with a power utility to install a neighbourhood area network (NAN) with several electronic power meters to evaluate the response time, reliability in communication, and scalability in a real deployment. Analytical tests will be carried out in a smart metering real scenario to evaluate mainly the response time and reliability characteristics in WSN communication based on the number of sensor nodes, their distributions and distances.


Stressful early life experiences cause immune dysregulation across the lifespan. Despite the fact that studies have identified childhood sexual abuse (CSA) survivors as a particularly vulnerable group, only a few attempts have been made to study their lived-experience of the physical health consequences of CSA. The aim of this study was to explore a female CSA survivor’s lived-experience of the physical health consequences of CSA and how she experienced the reactions of healthcare providers. Seven interviews were conducted with this 40-year-old woman, Anne, using a phenomenological research approach. Anne was still a young child (two to three years old) when her father started to rape her. Since her childhood, she has experienced complex and widespread physical health consequences such as repeated vaginal and abdominal infections, widespread and chronic pain, sleeping problems, digestive problems, chronic back problems, fibromyalgia, musculoskeletal problems, repeated urinary tract infections, cervical dysplasia, inflammation of the Fallopian tubes, menorrhagia, endometrial hyperplasia, chlamydia, ovarian cysts, ectopic pregnancies, uterus problems, severe adhesions, and ovarian cancer. Anne disclosed her CSA experience to several healthcare providers but they were silent and failed to provide trauma-informed care. Anne’s situation, albeit unique, might reflect similar problems in other female CSA survivors. There is no real distinction between mind and body because of the communications between the brain, the nervous system, endocrine system, and immune system . PsycholAs The emotional and psychological part of the body suffers in traumas and CSA survivors often deal with complex mental problems that greatly affect their well-being and health ,33,34. ADespite the fact that studies have identified CSA survivors as a particularly vulnerable group, only a few attempts have been made to study their lived-experience of the physical health consequences of CSA. No study was found where a CSA survivor’s life story is examined for a holistic view of the physical health consequences. Since there are indications of gender differences in the CSA experience, men reacting with extroversion and women with introversion, which seems to lead to more health problems for female CSA survivors , we deciThe research method was a phenomenological case study using the Vancouver School of doing phenomenology, a unique blend of phenomenology, hermeneutics, and constructivism . It is oStep 1 in a Vancouver-School phenomenological case study is selecting the dialogue partner. Eligibility for participation in the current study was having experienced CSA and a willingness to talk about it. The volunteer research participant came from a group of 12 female CSA survivors who took part in The Wellness Program , a ten-wStep 2 is silence. Because the study is a process, this reflective silence was re-entered repeatedly throughout the study . In the Step 3 of the Vancouver School involves in-depth interviews. Data collection was conducted through individual interviews. The first author, as the primary researcher, conducted all the interviews. Each interview took 30 to 60 min. Data collection stopped when no new information was obtained as judged by the primary researcher. During the interviews, the primary researcher used an interview guide but strived to ask open questions and encourage Anne to express herself freely, also seeking confirmation of emerging themes and probing further into individual topics arising during the interviews. Interview questions were for example: Can you tell me about your experience of violence? How has your health been affected by the violence? What is your experience of communicating with healthcare providers regarding CSA? Did you experience support from them as a CSA survivor? The primary researcher interviewed Anne seven times. The interviews were aimed at exploring Anne’s life story concerning the physical health consequences of CSA and how healthcare providers reacted to her as a CSA survivor. Steps 4–6. The interviews were recorded, transcribed, and analyzed for main themes and subthemes through thematic analysis. Codes were extracted from the transcripts (deconstruction). Those were then arranged into themes (reconstruction). The findings were constructed into an analytic framework, in accordance with Steps 4 through 6. The primary researcher repeated this procedure after each interview until a holistic understanding of Anne’s life and physical health was constructed. Step 7. To ensure that her words were understood correctly, Anne verified her story after each of the interviews. This verification process is one of the main strengths of the Vancouver-School because the participant is able to verify or correct the researcher’s interpretation about the participant’s lived-experience.Step 8. After the primary researcher’s initial work, both researchers were involved in the data analysis, synthesis, and interpretation of the data. The primary researcher discussed the preliminary findings with the second author. All possible variations were explored independently and together, and after much deliberation, the essential structure of the lived-experience of the physical consequences of CSA and the reaction of healthcare providers to her as a CSA survivor were constructed. Step 9. The primary researcher then ensured that this interpretation of Anne’s story was based on the actual data by rereading all the transcripts and comparing them with the findings. Step 10 is about constructing the over-arching theme of the study. Just as the research question was twofold, so is the overarching theme as constructed by both authors, “Screaming body and silent healthcare providers”, which was deemed the essence of the physical health consequences of CSA, as well as the reactions of healthcare providers—from the perspective of Anne as a CSA survivor. Step 11. Anne then verified the results and the conclusions in a face-to-face meeting. Step 12. In writing up the findings, Anne was quoted directly to increase the trustworthiness of the findings and conclusions. At every step, the researchers went through the research process of the Vancouver school: silence, reflection, identification, selection, interpretation, construction, and verification see .Before the first interview commenced, Anne was given an introductory letter in which all the main ethical aspects of the study were addressed. The first author described the study before the interviews started and Anne signed a document providing her informed consent. The letter of introduction provided her with names of a psychologist and an emergency nurse who had consented to be available for her if difficult emotional reactions emerged during or after the interviews. The time between the interviews was about two to six weeks, which gave Anne an opportunity to reflect on the experience of the former interviews. Because the study involved a vulnerable woman, every effort was made to protect her ethically. In order to protect her personal identity, tape recordings were deleted as soon as interviews had been transcribed; and all information that could identify her was removed from the transcripts. Ethical permission was obtained from the National Bioethics Committee (VSNb2011080004/03.7) and the study was reported to the Data Protection Authority (S7663/2016/TS/). Each interview was analyzed thoroughly, emphasizing critical assessment of the quality of data collection, data analysis, and presentation of findings. The research process of the Vancouver School has some in-built strategies designed to enhance validity, particularly “member checking” in steps 7 and 11 see . The “reSimilar to the research question, the overarching theme of the study was twofold, “Screaming body and silent healthcare providers”. On one hand, it denotes the multitude of physical complications, need for medical treatment and chronic pain, and discomfort and ailments Anne has been dealing with all her life (screaming body). On the other hand, it answers the question of how she experienced healthcare providers’ reactions . It thus answers the research question about the lived-experience of the physical health consequences of CSA, as well as the reactions of healthcare providers, who were silent and did not provide her in any way with trauma-informed care. In presenting the findings, we first give an overview of Anne’s story to provide the context of her lived-experience. Then we present her experience of the burden of CSA on her body and the reactions of healthcare providers to her as a CSA survivor. When Anne was eight months old, her mother remembers something suspicious about her father regarding Anne. Anne was still a young child (two to three years old) when her father began to rape her and he did that until she was nine years old when he had the chance. She later brought charges against her father. He pleaded guilty but the charges were dropped because they were considered too old for prosecution. Anne was also raped by her uncle, her stepfather, her friend’s father, and by more than one relative. An overview of Anne’s life is found in Anne has had symptoms of anxiety since childhood, suffered from depression and social anxiety since she was a teenager, and has suffered from severe postpartum depression. She has suffered from flashbacks, nightmares, numbness and dissociation, a broken self-image, problems with personal boundaries, and repeated re-traumatization. She tried to forget her painful childhood experiences but began having flashbacks when she was 15 years old. She experienced violent nightmares, which intensified when she became sexually active. Anne claims that she was able to endure the abuse by disconnecting herself. She exited her body through dissociation.“I clearly remember when I was younger, maybe not right when the abuse was happening, but just afterwards—I would lie somewhere and escape to that feeling… I would always exit on the left side, I just left there, it wasn’t a conscious decision. It felt like I was asleep, but I was not sleeping. It didn’t matter what was happening, I just disconnected completely”.Anne disconnected from herself and her environment, trying to be invisible. She asserts that sexual abuse at such a young age from such a close relative has had a horrendous effect on her and that she has difficulty defining her own and others’ boundaries. From early on in her childhood, her understanding is that her own personal boundaries became blurred, which made her vulnerable to repeated abuse. She was 20 years old when she gave birth to her first child and, shortly after, a relative raped her. She became severely depressed and lost the will to live. Subsequently, she lost the custody of her child. Anne has been in six cohabitations, three marriages, is newly divorced, and has entered a new cohabitation. She has three children with three different men. Anne has suffered much in her body as long as she can remember. She has suffered from numerous physical health problems such as repeated vaginal and abdominal infections, widespread and chronic pain, sleeping problems, digestive problems, chronic back problems, fibromyalgia, musculoskeletal problems, repeated urinary tract infections, cervical dysplasia, inflammation of the Fallopian tubes, menorrhagia, endometrial hyperplasia, chlamydia, ovarian cysts, ectopic pregnancies, uterus problems, severe adhesions, and ovarian cancer. All of these problems are unknown in her family, except for her 19-year-old daughter who has been diagnosed with fibromyalgia. Anne’s family members are healthy and live a long life. Her grandmother died last year at the age of 90.Anne’s physical symptoms began after her parents divorced and she was sent to her abusive father during weekends. She became very sick during those visits and was sent back home to her mother, where she quickly got better. From early on in her childhood, she was a regular patient in hospitals because of pain, muscle aches, and uterine problems. As a child, she often had stomachaches. During her teens, Anne’s poor health got even worse. She recounts, “When I was about 12–13 years old, the winter that my mother became pregnant with my sister and my stepfather began making sexual advances to me, I lost nearly all my sight and hearing for a while. My eardrums were perforated and I had a constant ear infection, just from stress”.During adolescence, she suffered from gastrointestinal problems, an eating disorder, musculoskeletal health problems, genital/urinary problems, and musculoskeletal health problems, as well as severe and chronic uterine pain.Gastrointestinal problems. As a child, Anne regularly had stomachaches. At age 13, she had an operation due to suspected appendicitis, which turned out to be gastritis: “It was all because of the stress, you see, all these years and you could never talk about it”. She also began to have colon spasms when she was in adolescence. Eating disorder. Anne has been overweight since her teens: “I was quite thin as a child but I gained a lot of weight at 16 due to the abuse and my broken self-esteem. I just started eating to numb myself, I didn’t think about what I ate, and I’ve been overweight since then.” She was able to lose 15–16 kg in rehabilitation, but regained the weight after yet another setback. Her weight gain has continued.Musculoskeletal health problems. Anne has had back problems for as long as she can remember. At sixteen, she had severe myositis (muscle pain) in all her muscles. Genital/urinary problems. From an early age, Anne has had repeated urinary tract infections and chronic ovarian cysts since she first became sexually active. “When I was 16–17, I started getting ovarian cysts, it was chronic… if things got bad, emotionally or stress in my personal life I got ovarian cysts and adhesions. It started as soon as I started having sex at around 16”.She has also had severe and chronic uterine pain after she became sexually active: “I was 17 with the father of my first child and all of a sudden I just fell down the day after we had sex, I felt excruciating pain in my uterus. I was sent to hospital by ambulance. There was always pain on the right side of my uterus”.Sexually transmitted diseases. Anne was first diagnosed with chlamydia at 17, and was diagnosed again so many times after that she was constantly getting antibiotics.Anne’s adult physical health consequences have included numerous genital/urinary problems, gastrointestinal problems, musculoskeletal problems, insomnia and fibromyalgia, as well as endocrine problems. She has had numerous surgeries in her adult years.Genital/urinary problems. At the age of 27, after the birth of her second child, the repeated urinary tract infections returned after sex: “It’s a really intense pain in the stomach that goes up the back and down into the groin area. It’s unbearable”. Once she was sent to hospital with abdominal pain and a serious urinary tract infection and inflamed Fallopian tubes: “I got a horrendous bladder infection. I called the hospital and then I started having heavy menstrual bleeding for ten days, very painful menstruations. I knew that something wasn’t right”. At the age of 34, she had serious problems with her ovaries due to ruptured cysts. She had a hysterectomy when she was 37 years old because of nodules, heavy bleeding (menorrhagia), pain, and endometrial hyperplasia. Anne has had two ectopic pregnancies, when she was 24 and 32. The latter ectopic pregnancy was very difficult for her and she became very depressed. By the age of 32, she had given birth to three children. Anne was about 30 when first diagnosed with cervical dysplasia and went through cervical conization. She had bleeding problems after that. She connects her physical condition partly to the fear, which she kept inside: “I am pretty sure that such intense fear of a person I was so close to has played a part in this”. Negative birth experiences. When Anne gave birth to her first child at 20, she experienced no understanding or support from healthcare professionals and for her it was a terrible experience. This happened again when she was 27 and gave birth to her second child. At that time, she had a chlamydia infection, which was passed on to the child, who became very sick. Anne also suffered from repeated abdominal infections as a result.“I nearly lost everything here on my right side: my ovary and Fallopian tube, it (the infection) was spreading everywhere. I was very sick that whole year. There was always something wrong somewhere (in the body)–(even) infection in my kidneys. The whole system had broken down”.Gastrointestinal problems. She also suffered from colon spasms. The gastroscopies and X-rays taken of her colon revealed that she had gastric reflux and esophagitis. Anne saw many urologists and family doctors because of her gastrointestinal problems. Musculoskeletal problems. Anne has not been able to work since her early thirties because of the pain in her back, lumbar and sacral region, shoulders, and head. “I have had back pain for as long as I can think back, from the lower back to the head”. The pain was so intense that she had difficulty walking and holding onto objects.Insomnia and fibromyalgia. Anne began suffering from insomnia due to chronic body aches and was diagnosed with fibromyalgia at the age of 33. She states that these symptoms, starting in her teens, included widespread pain, muscle aches, fatigue, and depression, and had become worse in the last few years. Other physical health problems. Since Anne turned 35 years old, she has also had symptoms of arrhythmia. She consulted a cardiologist, received a Holter, and had all kinds of tests, but everything seemed to be normal. There was seemingly no explanation for her symptoms. At 39 years of age, an ultra-sound of her neck revealed she had a growth on her parathyroid gland and she was diagnosed with para-thyroid adenoma. Surgeries. Anne has had many surgeries. She has had an appendectomy, cervical conization, and three operations to remove adhesions—twice when she was 27 and then again at 28. Her right ovary was operated on, but it was not removed entirely. The pain went away for a while after the operations. At 36, she had surgery to empty an ovarian cyst. She also had laparoscopic surgery because of another ovarian cyst on her right ovary. When the decision was made to remove her uterus (hysterectomy), she specifically asked that her right ovary be taken as well due to the discomfort it had caused her since her early teens. She wanted to get rid of it. The doctor agreed to do so after much deliberation, and Anne had curettage.“When I regained consciousness, he told me that my uterus was full of nodules (…) I tell him to take them, and when you have opened me up, remove the right ovary. He said ‘no’, I said ‘yes’! ‘I have been in pain in my right ovary since… my girl was born. You open me up and you take it out’, and fortunately he did it… I could feel that something was wrong there”.After the removal and biopsy of the right ovary and the Fallopian tube, it turned out they were malignant. At that point, the left ovary and Fallopian tube were also removed in another operation shortly after. “The doctor told me after the operation that it looked good enough, nothing wrong with it. He said that if I hadn’t been so insistent, he wouldn’t have removed it… but seven days later I’m called in to the hospital because they had found first stage cancer in it… The doctor told me, ‘thank you for insisting and pushing me to do it, because within two years you would have been gone, it wouldn’t have been detected during that time’.”.The cancer was limited to the ovaries, so Anne did not require chemotherapy, but she goes for a check-up every six months.“But it’s always such a huge pain to go in for these check-ups. Today I need to go and be checked for cancer… It is always just as painful. As time goes by, I’ve learned not to be there while it’s happening, I just ‘go out’, but this is just one of the many factors that may push women not to get checked, which increases the risk of cancer—it brings all kinds of bad feelings to the surface”.Anne went through a major operation at 40, a para-thyroidectomy. Many tests were done and she was sent to an endocrinologist who diagnosed her with abnormal growth of the parathyroid gland.Anne has looked to the healthcare system for solutions to her physical health problems but believed that she was not offered treatment solutions appropriate for CSA survivors. As a child, she went with her mother between healthcare providers, crying in pain. As an adult, she visited several healthcare providers and persisted in sharing her thoughts about how her physical problems were related to CSA but their reaction was silence. They failed to provide any consideration, or even validation, of her traumas. Health providers’ solution for her problems was mostly medication: “I’ve been using a lot of pain medication, but I’m now trying not to take them unless strictly necessary”. Anne received many antibiotics for her infections, and a lot of medication for insomnia, pain, and inflammation. She had many demoralizing encounters with healthcare providers offering her psychiatric drugs. Even though she tried to talk about the CSA as a possible source of her many health problems, she was not heard, and there was only silence. Once when Anne met with a gynecologist she told him she was convinced that the sexual violence she suffered in her childhood caused the terrible effects she had to deal with today. She recounted: “Once I told my gynecologist that I was always in such pain because of my womb, especially after sex, and I told him that it must have been because I was damaged back then when I was so small and sensitive down there, but I never got an answer”.No one asked her about trauma or CSA and even if she brought it up, she was met with silence. “When I was diagnosed with fibromyalgia, I… said that it was probably the result of stress in my teens. The doctor asked why I thought it was acquired, and I answered that I had been sexually abused as a child… and there was just silence, and we didn’t discuss it any further”.Anne has constantly been looking for pathways for healing. She has tried writing, singing, painting, praying, and going to self-help meetings and various religious congregations. She has also tried going to rehabilitation programs, e.g., programs for obesity and pain, as well as all kinds of non-traditional therapies. When Anne participated in the Wellness-program , a 10-we“I had to learn to set boundaries. I needed to do exercises on my own in setting boundaries. I had to look at other people and notice for example how people acted in a crowd. I realized that personal space was something I did not know and had to create. Of course, I still make mistakes. I set boundaries regarding individuals who do not understand them, which I do not even understand myself. Sometimes I push people too far away from me or hurry to close myself, but I have been practicing”.Anne frequently visited gynecologists due to pain in the uterine region. She regularly had to go to hospital because of the pain. She said that in all her encounters with healthcare providers, she was never asked about sexual violence and she sees that as the main problem: “I think it’s important to ask, to say the bare minimum… you should be able to just put an x somewhere on a form to say that you’ve suffered abuse or violence. That’s always the first step”. Anne stated that although people may not self-identify as CSA survivors at first or even the second time, some eventually would. She believes it is critical that healthcare providers who work with her know her story: “When you go to the doctor for example, a gynecologist, a therapist, a psychologist, they need to know your story. It’s a whole other story to get a doctor who doesn’t know your story… a totally different understanding and interaction”. Anne asserts that the most important aspect of them all is to be able to talk to healthcare providers, and that they in turn believe what you tell them. “The most wonderful thing was finding people who believed me. It’s all connected, it’s all about telling people your story and expressing yourself, being believed; what you say is heard. Somehow, it makes you feel complete. It’s not about pity (…), just being believed and like I said, to feel relieved. When someone recognizes that it’s not your fault. When you don’t tell your story, you are taking responsibility for what happened. ‘This was my entire fault so I won’t say a word’. When you tell your story, it’s no longer your fault; it’s someone else who should be ashamed”.In this case study, we explored the physical consequences of CSA by describing the lifetime physical health problems experienced by one woman. The unique findings clearly depict the burden of childhood sexual abuse on the body. The study also demonstrates how healthcare providers failed to recognize and validate her lived-experience as a CSA survivor, as well as the connection these experiences have had on her physical health. The silence she experienced at the hands of healthcare providers is unacceptable. However, it points to a systematic organizational problem in healthcare providers’ education and socialization about the body and mind being separate and subsequently treating only symptoms with medication, not the underlying problem. It also points to an epistemological dualism that implies a primacy of medical knowledge so that if there is not obvious objective evidence known to the healthcare provider justifying the patient’s suffering, the problem is classified as psychogenic. Regrettably, this does not lead to a solution of the problem, and these healthcare users often have to add to the burden of their pain the weight of the delegitimization of their suffering .Anne has been suffering from widespread and complex health problems since her childhood, sometimes without any medical explanation. She repressed her memories from the sexual violence, felt frozen and numb, and began having flashbacks and violent nightmares when she got older. When she became sexually active, she disconnected herself from her body and her feelings because of the pain inside. As other studies show, dissociation is a factor that people use when experiencing trauma, a defense mechanism that protects people from suffering ,54, a loAnne has suffered much in her body as long as she can remember. She has had widespread and chronic pain since her childhood, symptoms similar to the physical illness burden presented in other studies ,6,17,19.Research results indicate that women with a history of CSA have problems in three domains of the pelvic floor: micturition, defecation, and sexual function . Anne haAnne has constantly searched for ways to live with the physical consequences of CSA. From a young age, she looked to the healthcare system for solutions without receiving adequate help, support, or understanding. Anne feels she not only did not get the support she needed within the healthcare system, but her lived-experience was neither recognized nor validated. Research results by McClure et al.  and PutnThe blurred lines of the boundaries that Anne experienced because of her CSA-experience need to be examined further, especially in terms of how we can shift the boundaries of CSA survivors to safeguard them against future predators. In Anne’s case, there seems to have been a lack of knowledge in how to assess for CSA and support her as a female CSA survivor within the healthcare system. This seeming lack of knowledge needs to be studied further. Moreover, it needs to be studied further how additional sexual assaults affect CSA survivors. Finally, the lifetime sequelae of CSA need to be studied among a larger sample of survivors. The participant in this study is only one woman and we cannot say that she is the most typical of female CSA survivors. Therefore, we cannot generalize from this study to all women who are CSA survivors, but it provides an increased knowledge and deeper understanding of the physical health consequences of CSA and the reactions of healthcare providers to her as a CSA survivor. By using the Vancouver School with its case-study characteristics, we were able to portray the detailed history of Anne’s CSA experiences and the consequences for her body. The results of the study confirm that CSA can have serious and widespread physical health consequences and illustrates the complexity of CSA and its lasting effects. According to Anne, it is important to ask CSA survivors about CSA, provide information about possible consequences, have an understanding, be supportive, and listen with attention. In her encounters with healthcare providers, Anne often felt silenced, marginalized, and re-victimized in a healthcare system that seemed to refuse to validate her lived-experience of CSA and how this is tied to her chronic health problems. This seems to reflect a need for trauma-informed education and training within healthcare educational institutions.