To eliminate blinding trachoma, the World Health Organization emphasizes implementing the SAFE strategy, which includes annual mass drug administration (MDA) with azithromycin to the whole population of endemic districts. Prevalence surveys to assess impact at the district level are recommended after at least 3 years of intervention. The decision to stop MDA is based on a prevalence of trachomatous inflammation follicular (TF) among children aged 1–9 years below 5% at the sub-district level, as determined by an additional round of surveys limited within districts where TF prevalence is below 10%. We conducted impact surveys powered to estimate prevalence simultaneously at the sub-district and district in two zones of Amhara, Ethiopia to determine whether MDA could be stopped.Seventy-two separate population-based, sub-district surveys were conducted in 25 districts. In each survey all residents from 10 randomly selected clusters were screened for clinical signs of trachoma. Data were weighted according to selection probabilities and adjusted for correlation due to clustering.Overall, 89,735 residents were registered from 21,327 households of whom 72,452 people (80.7%) were examined. The prevalence of TF in children aged 1–9 years was below 5% in six sub-districts and two districts. Sub-district level prevalence of TF in children aged 1–9 years ranged from 0.9–76.9% and district-level from 0.9–67.0%. In only one district was the prevalence of trichiasis below 0.1%.The experience from these zones in Ethiopia demonstrates that impact assessments designed to give a prevalence estimate of TF at sub-district level are possible, although the scale of the work was challenging. Given the assessed district-level prevalence of TF, sub-district-level surveys would have been warranted in only five districts. Interpretation was not as simple as stopping MDA in sub-districts below 5% given programmatic challenges of exempting sub-districts from a highly regarded program and the proximity of hyper-endemic sub-districts. Trachoma, the leading cause of preventable blindness, is targeted for “elimination as a public health problem” by the year 2020. National programs are implementing the recommended strategy of surgery, antibiotics, facial cleanliness, and environmental improvements (SAFE) to meet this target. Many programs are currently facing the decision of when to scale down interventions, particularly mass drug administration (MDA) of azithromycin. We implemented large population-based surveys in two different zones of the Amhara National Regional State of Ethiopia. Rather than conducting an impact assessment first at the district level, followed by additional sub-district-level surveys, we took a novel approach to measure the prevalence of trachoma at sub-district level to be able to make an immediate decision of whether to stop MDA. Over 72,000 people in 714 communities in 72 sub-districts were examined for clinical signs of trachoma. We identified only six sub-districts that met criteria for being able to stop MDA. Our work demonstrates that determining the prevalence of trachoma at sub-district level is feasible but requires significant resources. In this hyper-endemic setting, sub-district-level surveys were not needed in the majority of districts. Overall, the clinical data suggest some decline in trachoma within these areas since the SAFE strategy was implemented. The new guidelines suggest using the district as the evaluation unit (EU) on which to estimate trachoma prevalence, followed by a decision to continue SAFE or estimate trachoma prevalence through additional surveys at the sub-district level to determine whether MDA could be stopped. The new guidelines also suggest that “outcome surveys can be used to pronounce achievement of UIG for TF, if the sample size is powered to calculate estimates at the sub-district level” Realizing that estimating trachoma prevalence in every community in sub-Saharan Africa places a heavy burden on resource-constrained programs, the 3rd GSM in two different programmatic settings in the Amhara region of Ethiopia by conducting trachoma outcome surveys at the sub-district level to determine where MDA might be stopped. A secondary aim of the study was to compare current estimates to baseline prevalence in order to monitor impact of interventions.The purpose of this study was to apply this latter statement from the 3The study protocols for surveys in both South Wollo and South Gondar were reviewed and approved by the ethical review committee of the Amhara Regional State Health Bureau. Additionally, the study activities were approved by Emory University Institutional Review Board under protocol 079-2006. Due to the high rate of illiteracy, verbal informed consent was obtained and recorded prior to data collection rather than written information and a signed statement. Consent for trachoma examination and household interview was obtained from heads of households, individuals, and parents of minors according to the principles of the declaration of Helsinki.Widespread implementation of the full SAFE strategy to all endemic areas in Amhara was initiated in 2007, which included outreach camps to provide surgery in addition to the existing static service; annual MDA with antibiotics; promotion of facial cleanliness and hygiene in schools and communities by health extension workers; community-level promotion of latrine construction and use through the health extension workers and environmental health officers. Provision of improved water sources was simultaneously supported by the development sector.woredas (districts) which had received a third consecutive round of MDA in April 2010. The remaining eight woredas in South Wollo had not yet received three rounds. In South Gondar, training and field collection activities were conducted in the rainy season from late June to early August 2011 covering all 12 woredas in the zone. All woredas in South Gondar had received at least five rounds of MDA, the last round of which took place in November 2010.Previous data indicate that 6–12 months since the last round of MDA is the ideal time to conduct impact surveys to assess trachoma woreda being the district-level equivalent. From the 3rd GSM report, a sub-district is defined as three or more villages with combined total population of at least 30,000 people health clusters in groups to create a sub-district EU of approximately 50,000 cumulative population. Gotts are the smallest administrative unit for which there is population data available, which we used as our primary sampling unit or cluster. For each EU surveyed, gotts were selected from a line list arranged according to geographical distribution using a standard methodology Gotts are broken down into smaller administrative units called development teams (DT), which made ideal segments on which to base a modified segmentation design for equal probability sampling gott and all persons present or absent residing in all households within the selected DT were registered and those present examined. Absent households were registered as non-consenting and were not replaced. Heads of household (or their adult representative) were interviewed in consenting households. Physical characteristics were recorded from direct observation.The administrative levels of this area of Ethiopia and the respective population at each tier are presented in To detect whether the prevalence of TF was 3% with 2% precision, we calculated a sample size of 558 children aged 1–9 years per sub-district EU. This was based on a 5% level of significance, design effect of 2, five persons per household with children aged 1–9 years composing 30% of the total population. To obtain the target sample size, population-based, cluster random sampling was utilized for both surveys. We surveyed 10 clusters per sub-district, including 40 households per cluster, which, based on our assumptions, would allow for an 8% non-response rate in children.Prior to the survey data collection, teams participated in a 7-day, applied training and skills examination. Trachoma graders were responsible for diagnosing the clinical signs of trachoma using the simplified trachoma grading system Training for data recorders consisted of classroom instruction and field practice, which included testing and refining the data collection tools, applying the sampling strategy in the field, and taking geographical coordinates of survey households. Persons trained to serve as data recorders were also evaluated to assess their ability to follow protocol, perform the interview, and record responses correctly. The top performers were selected to work with selected graders to form the final survey teams. A total of 21 teams were deployed in South Wollo and 13 teams in South Gondar.gotts of South Gondar, DNA specimens of the tarsal conjunctivae of one randomly selected child aged 1–5 years per household were collected using ocular swabs for detection of infection with Chlamydia trachomatis by polymerase chain reaction (PCR) . The surveys also included non-trachoma indicators to measure outcomes of integrated program interventions for malaria in South Wollo and intestinal parasites in South Gondar. These data have been presented elsewhere Each head of household was interviewed to assess demographics of the households and uptake of the SAFE strategy. All household residents were examined for the presence or absence of all five clinical signs of the simplified trachoma grading system in both eyes using a 2.5× binocular loupe and adequate light gott. Data in South Gondar were collected electronically using Swift Insights, an Android (Google Inc.) application, operated on tablet computers Data were collected by recorders on paper survey forms in South Wollo zone. Forms were reviewed for completion by a team leader prior to leaving the gott, DT, and household levels by identifying the complex survey design and generating a robust estimate of variance 2) statistic accounting for the survey designs.Paper-based survey data were double-entered in Microsoft Access by separate entry clerks, compared for discordance, and corrected with the original hard-copy. Electronic data were downloaded at the end of the survey separately for each team and converted from html to csv format. Data were analyzed using STATA version 13 . The inverse of the selection probabilities was calculated and used to weight the data in the analysis. Additionally, the analysis accounted for clustering at the woredas in the two zones. The six gotts not surveyed were all in South Gondar and inaccessible during the rainy season. gotts refused to participate in the survey. A higher proportion of residents were not available for examination (absent from the house) in South Gondar than in South Wollo . The proportion of enumerated residents examined was lowest among the adult male population (data not shown). Among the target population, children aged 1–9 years, 95.8% and 94.9% of the enumerated children in South Wollo and South Gondar were examined, respectively. The proportion of these children with a clean face was 75.5%  72.8–78.0%; range by woreda 54.0–95.9%). The mean number of children in the 1–9 year age group sampled in each EU was 269.7 (standard deviation (SD) 50.6). The mean number of people examined of all ages in each EU in South Wollo was 938.9 (SD 192.0). The prevalence estimates at the EU were based on a mean sample size of 487.0 (SD 45.8) children 1–9 years of age and 1,073.7 (SD 106.8) total individuals examined per EU.Teams successfully surveyed 714 of 720 communities from 72 EUs across the 25 woreda-level prevalence of TF1–9, classified as <5%, 5–9%, and ≥10% is shown for both zones in 1–9 was below 5% in six EUs and between 5% and 9% in an additional three EUs in South Wollo  where TF1–9 prevalence was between 5% and 9%. For 20 of 25 woredas across the two zones, WHO guidelines suggest there was no need for sub-district level assessment and MDA with azithromycin should continue for at least an additional 3 years.The sub-district-level and th Wollo . Accordindar see . Targete1–9 in the target age group for the combined area in South Wollo zone was 26.4%  . Among all residents, the prevalence of TT was 1.3% . In South Gondar . Prevalence of TI was 7.0% . The prevalence of TT was 1.8%  among the total examined population.The prevalence of TF.9%) see . Prevalendar see , TF1–9 p1–9 for the combined 13 woredas was higher than the baseline zonal estimate in 2006  but did not change significantly from the estimate in 2006 (p = 0.509). The current TI prevalence among children in South Gondar was lower than previous estimates, 35.8% in 2003 (p<0.001) and 23.3% in 2006 (p<0.001).In South Wollo, the prevalence of TFrd GSM report suggested that, after woreda-level surveys indicated a prevalence of TF1–9 below 10%, sub-district-level estimates were required before making an ultimate decision to cease MDA 1–9 at the sub-district level in all districts eligible for outcome surveys to avoid an additional round of surveys. We chose this strategy for one main reason: to obtain a definite answer for all areas in the two zones within a timeframe feasible for mobilizing and implementing an annual MDA. Planning and implementing impact surveys are vital but compete for financial and human resources against the ongoing implementation of program interventions, which require decisions for planning well ahead of scheduled activities. For instance, submission of the application for donated azithromycin and planning of its distribution occurs 8–20 months in advance of the intended distribution. Instead of having a scenario where two surveys need to be completed prior to the forecasting of drug needs, we felt a single survey, powered to estimate the prevalence of both the sub-district and the district was preferred. However, in this trachoma hyper-endemic region of Ethiopia, conducting impact assessments first at the woreda level would have provided necessary data for making the decision to continue SAFE in 20 of the 25 woredas avoiding the need to survey as many communities as was assessed.Recommendations of the 3gotts are accessible only on foot or horseback. Once in the community, teams walked long distances between houses within a selected DT to survey each household and often slept overnight in the community to repeat the process the next day. Accessibility in the field is further constrained when surveys are conducted in the rainy season; however, due to MDA forecasting needs and program implementation schedule, carrying out the survey in the rainy season was unavoidable in South Gondar. In South Wollo, around 12,000 paper-based surveys were distributed to survey teams for data collection. The printing, sorting, labeling, and distribution of these forms took 18 person-days. Double data entry, comparison, and correction took over 200 person-days and seven rental laptop computers. Electronic data collection in South Gondar streamlined data management and saved substantial time According to the latest WHO guidelines, trachoma control programs will eventually need to implement sub-district-level surveys. The experience from implementing these large-scale surveys in both zones, demonstrates that such surveys designed to simultaneously measure disease prevalence at the sub-district and district levels to evaluate impact of the SAFE strategy are indeed feasible. However, the process was neither without challenge nor the outcome without limitations. For instance, over 50 people were required to implement each survey, including data recorders, clinical examiners, drivers, supervisors, logisticians, and a coordinator. During the training in both zones, only about half of the clinical examiners met our pre-set criteria to participate in the study even after several days of applied training. The final number of survey teams is dependent on the number of examiners who can accurately apply the trachoma grading system. If fewer examiners meet the criteria, fewer teams can be deployed, which increases the number of clusters each team must cover and the total number of days in the field. In Amhara, the majority of 1–9 would be reduced to less than 10%. Implementation of the full SAFE strategy, including five consecutive, annual mass azithromycin distribution campaigns did not result in a reduction of TF1–9 prevalence below the UIG targets in any sub-district within the trachoma hyper-endemic setting of South Gondar. The impact on TF1–9 after 3 consecutive years of SAFE implementation was not as clear in South Wollo, where the overall prevalence of TF1–9 was higher than the zonal-level prevalence estimated prior to SAFE interventions. Yet, TF1–9 prevalence in a fraction of the sub-districts assessed and two of 13 woredas were below the 5% UIG. According to WHO guidelines these areas are eligible to stop MDA for trachoma. Our sample of 9,708 children aged 1–9 years across 360 communities in South Wollo provided much more accurate and precise estimates than at baseline surveys. Indeed, the baseline prevalence estimates for the entire zone of South Wollo were derived from 484 children across 16 communities 1–9 estimate for South Wollo in 2006 was the lowest for all 10 zones in the region and the only zone estimated below 20% TF1–9 prevalence. In South Wollo, the observed difference in TF1–9 prevalence compared to the baseline survey was likely the results of an underestimate of the true TF1–9 prevalence at baseline due to chance. Four of the randomly selected communities in 2006 were from woredas where the current prevalence was lowest which might have contributed to a lower prevalence estimate if TF1–9 prevalence was also less common at baseline in these areas.Our decision to test this novel approach was also influenced by an assumption that perhaps after 3–5 years of SAFE interventions, TF1–9 from 2006 to 2011 was not observed in the recent survey. Reduction in TF1–9 below 5% has been documented in other programs after SAFE implementation, but in those settings the prevalence of TF1–9 at baseline was lower than in Amhara 1–9 prevalence in South Sudan  was reduced to below 5% after high community uptake of SAFE interventions but this was observed only in one of four intervention sites Additional prevalence data from South Gondar prior to 2006 suggest a decline of TF prevalence since the initiation of the program , but a r1–9 indicates that trachoma has not been controlled and continued MDA is needed. Alternatively, trachoma research studies from another region of Ethiopia have documented slow resolution of clinical signs after MDA has successfully reduced infection C. trachomatis infection woredas after 3 years of SAFE implementation in Amhara One conclusion that could be made from the results is that a lack of reduction in TFworedas of South Gondar warrant ongoing MDA with antibiotics C. trachomatis infection is uncertain, but data from other studies in the Amhara region raise the question of whether additional rounds will provide further specific trachoma-related benefits C. trachomatis infection was observed 6–24 months after no evidence of infection could be determined post-azithromycin distribution According to current WHO guidelines, all Although these surveys are a landmark for trachoma control, our results should be interpreted in the context of the following limitations. The actual sample size achieved at the sub-district level was lower than the estimated sample size desired. We assumed a household size of five persons based on our prior work in Ethiopia, when in fact the mean household size was smaller . The number of households in a DT was not 50 households as projected, but varied greatly within a district. In South Wollo, we found the DTs to be much smaller than anticipated. To correct for this observation in South Gondar, multiple DTs were randomly selected in each cluster. Yet, even in South Gondar the actual sample size did not meet expectations. Selecting different numbers of segments per cluster results in unequal probability sampling which had to be adjusted for by weighting the analysis according to the selection probabilities and doing so decreases the precision of the estimates. If the actual point prevalence findings for TF at the sub-district level had been near the stopping threshold, then this may have been a reason for concern; however, most of the sub-districts were well above 5% so this should not bias decisions regarding MDA implementation. Another limitation inherent with utilizing clinical signs of the simplified trachoma grading system is that diagnosis is subjective and has high variability between examiners of the same patient woredas geographically surrounded by areas where the prevalence of TF warrants continued MDA  to exempt part of the district while the other part continues to receive a perceived benefit from the intervention. Scientifically, these six EUs are within nued MDA . The spaThe total cumulative output of SAFE activities through December 2010 in Amhara, as reported by the Health Bureau include: 192,922 persons operated to correct trichiasis, 50.9 million doses of azithromycin distributed, 3,428 kebeles with ongoing trachoma-specific health education and over 1.8 million household latrines constructed (unpublished data). Facial cleanliness was specifically promoted in 1,324 schools. The proportion of children with clean faces had not changed since 2006 In conclusion, this study demonstrated that our methodology was capable of providing estimates at both the district and sub-district levels in a single survey, although minor adjustments would be needed to consistently meet the required sample size at the sub-district level. Implementing the survey at the sub-district level irrespective of the district-level TF prevalence might identify sub-districts which have met the control threshold for TF when the district level prevalence remains above 10%, but this was rare. Sub-district-level surveys would not have been warranted in most of the districts assessed, even after 5 years of SAFE interventions. This supports the current recommended approach of conducting impact assessments at the district level first in similar trachoma hyper-endemic settings. To obtain the sub-district-level estimates, 360 communities in a single zone had to be surveyed. While more feasible than surveying every village as suggested by the previous WHO recommendations, this number of clusters surveyed in each zone was greater than that surveyed in some national-level standardized surveys such as the multiple indicator cluster survey and malaria indicator survey. Realizing the logistical challenges posed by carrying out sub-district-level surveys and the difficulty of interpreting TF prevalence to make program decisions, begs the question: is there a better way to determine whether MDA could be stopped?Checklist S1STROBE checklist.(DOC)Click here for additional data file.Table S1Prevalence* of trachoma clinical signs by sub-district evaluation unit (EU) and woreda in South Wollo, Ethiopia, 2010.(DOCX)Click here for additional data file.Table S2Prevalence* of trachoma clinical signs by sub-district evaluation unit (EU) and woreda in South Gondar, Ethiopia, 2011.(DOCX)Click here for additional data file.


We studied transmission patterns of severe acute respiratory syndrome (SARS) among medical students exposed exclusively to the first SARS patient in the Prince of Wales Hospital in Hong Kong, before his illness was recognized. We conducted a retrospective cohort study of 66 medical students who visited the index patient’s ward, including 16 students with SARS and 50 healthy students. The risk of contracting SARS was sevenfold greater among students who definitely visited the index case’s cubicle than in those who did not . Illness rates increased directly with proximity of exposure to the index case. However, four of eight students who were in the same cubicle, but were not within 1 m of the index case-patient, contracted SARS. Proximity to the index case-patient was associated with transmission, which is consistent with droplet spread. Transmission through fomites or small aerosols cannot be ruled out. Severe acute respiratory syndrome (SARS) is a newly recognized clinical entity associated with infection by a novel coronavirus (SARS-CoV)  could not provide useful information because most were affected by SARS, and other groups  could not recall all of their exposures to the index patient. However, a group of medical students who visited the ward had limited, well-defined exposures that could be accurately recalled. These included 20 third-year medical students who performed a bedside clinical assessment in the ward on the mornings of March 6 and 7, supervised by a team of assessors from the university. Each student was assigned to examine specific patients in the ward during a 40-minute interval on 1 of the 2 days. The locations (bed numbers) of the patients assigned to each student were precisely known, as well as the relative location of these patients to the index SARS case-patient. In addition to the students who appeared for the assessments, several other students (mostly fifth-year students) visited the ward for bedside teaching or clinical training March 4–10. We analyzed the epidemiologic features and patterns of transmission of SARS among these students.We conducted a retrospective cohort study of medical students who visited the index patient’s ward from March 4 to March 10, 2003. To define the study cohort, all 474 medical students of the university who were in their clinical years (years 3–5) were contacted to inquire whether they had visited the patient’s ward during this period. Because the university classes were suspended in response to the outbreak at the time this investigation was begun, the students were contacted by electronic mail.Students who reported visiting the patient’s ward during the period were given a detailed questionnaire that sought information about demographic characteristics, history of recent illnesses, activities in the ward (including specific exposure to the index patient), use of personal protective equipment, and history of travel March 1–10. Students who contracted SARS were interviewed in the hospital wards where they were admitted. To facilitate the recall of exposures to the index patient, a map showing the location of the index patient on the ward was distributed with the survey. Survey responses were validated by a follow-up telephone interview or electronic mail communication. Data provided by students regarding the bed numbers of patients they examined during their bedside clinical assessment were cross-checked with the university records. The medical (including nursing) records of the index patient and the students who were ill with SARS were reviewed.A case of SARS was defined by the presence of fever (temperature >38°C) and evidence of pneumonia on either a radiograph or computed tomographic image of the thorax, with or without respiratory symptoms .>4-fold rise in antibody titer in the paired serum specimens) or a convalescent-phase antibody titer of >1:40.Paired serum specimens were obtained during the acute phase and convalescent phase (day 21 from onset of fever) of illness from ill students, and single serum samples were obtained during April 26 to May 3 from students who visited the ward during March 4 to 10 but did not acquire SARS. The serum specimens were tested for anti–SARS-CoV immunoglobulin (Ig) G by indirect immunofluorescence, by using SARS-CoV–infected Vero cells fixed in acetone. A positive test was defined as either seroconversion   (measurement range 24–945 L/s with an accuracy of 3%). Air velocity, air temperature, and relative humidity at all supply diffusers and exhaust grilles were measured by an portable VELOCICALC Plus air velocity meter Model 8386A (TSI Inc.). Information on the location and opening sizes of supply diffusers and exhaust grilles, as well as information on the distribution of heat sources such as lighting and the number of persons in the ward, were also collected during the site visits.Epidemiologic data were entered into a predesigned database and analyzed by using SAS Version 6.12 software . Attack rates among persons with and without specific exposures were calculated. Dose-response relationships were also evaluated with respect to the proximity to the index patient and duration of these exposures.Data on ventilation, temperature, relative humidity, and heat sources were analyzed by computational fluid dynamics (CFD) simulations. The industry standard CFD package, Fluent,  was used to predict (reproduce) the average airflow pattern in the ward during the outbreak, taking into consideration the effect of thermal buoyancy.On February 24, the index case-patient had onset of an illness characterized by fever, cough, runny nose, and malaise. His symptoms worsened over the next few days, and he sought treatment at the Accident and Emergency Department of the Prince of Wales Hospital on February 27, when he was treated as an outpatient and discharged. He visited the Accident and Emergency Department again on March 4 with the same symptoms and was admitted to a general medical ward. His fever (range 38°C–40°C) did not diminish after he received various antimicrobial drugs and persisted until March 11, when it gradually subsided. His cough was frequent, low-pitched, and unproductive, with occasional scanty, whitish sputum, and it persisted from March 4 to March 13; the cough was most severe during the first 4 days of his hospitalization, March 4–7. His chest radiograph on admission showed consolidation of the right upper lobe and patchy haziness in the right lower zone. He was weak, was given an intravenous drip, and remained bedridden during his first week of hospitalization. To relieve his respiratory symptoms, he was administered salbutamol through a jet nebulizer four times per day  starting from 2 p.m. on March 6 until March 12, lasting about 30 min each time. His arterial oxygen on admission was 99%; it dropped to 95% on March 6, and gradually returned to 98% on March 12. He was identified as the index patient for the outbreak of SARS in Prince of Wales Hospital on March 12 and was transferred to an isolation room within the ward. He remained in isolation for 17 days after his symptoms subsided and was discharged on March 30. The patient was not treated with either ribavirin or steroids.Of the 474 medical students, 334 (70.5%) responded to the survey. Of the 334 respondents, 66 (20%) reported visiting the index patient’s ward during the study period. Respondents and nonrespondents did not differ in age and gender. SARS did not develop in any of the nonrespondents or in any of the respondents who did not visit the index patient’s ward. A detailed survey to assess illness and exposures was completed by these 66 students, which included the group of 20 third-year medical students who performed a bedside clinical assessment, supervised by a team of assessors from the university, in the ward on March 6 and 7, and 46 other students who visited the ward for clinical training on one or more occasions from March 4 to 10. None of the 20 students who appeared for the bedside clinical assessment visited this ward after March 7 or had any contact with other SARS patients in this hospital or in the community.Sixteen (24%) of the 66 students reported an illness that met the case definition for SARS. Their mean age was 22.3 years, and 8 (50%) were male. The mean age of the 50 other students who visited the ward but did not acquire SARS was 23.2 years, and 23 (46%) were male. The most common symptoms of illness among the patients included fever (100%), chills or rigors (94%), and headache (75%); cough and shortness of breath were reported by 38% and 33% of patients, respectively . All illPaired serum specimens were collected from 15 of the 16 students during their illnesses, and all had demonstrable IgG antibodies to SARS-CoV at a titer of >1:40 in the convalescent-phase serum. The antibody titer ranged from 1:80 to 1:1,280, with a geometric mean titer of 1:440. Antibodies to SARS-CoV were absent in the serum specimens obtained from all 50 healthy students.The dates of onset of illness of the 16 students with SARS and the,[Carol: word is missing? Or comma shouldn’t be there?] dates they visited the ward are shown in We examined the attack rates of the illness among students based on whether they could recall entering the index patient’s cubicle, a semi-enclosed section of the ward containing 10 beds . SARS deTo further assess the proximity of exposure associated with illness, we analyzed data from 19 of 20 medical students  who appeared for the bedside clinical assessment (lasting 40 minutes for each student) on March 6 or 7. SARS developed in 7 of these 19 students. None of the students examined the index patient. All three students who examined patients located in beds within 1 m of the index patient contracted SARS; four of eight students who examined patients located in the same cubicle but in beds >1 m from the index patient contracted SARS, but none of eight student who examined patients in other cubicles fell ill  .As mentioned previously, the index patient was administered nebulizer therapy four times per day starting from 2 p.m. on March 6 until March 12, lasting about 30 minutes each time. Among all the students, no significant association was noted between their risk for illness and presence in the ward when the nebulizer was in use. To further study the potential role of nebulizer therapy in disease transmission, we studied the temporal patterns of illness among these 19 students who appeared for a bedside clinical assessment, excluding the student with a long incubation period . Six outThe medical students were assessed by a total of 11 assessors. Five assessors evaluated students on March 6 only, five on March 7 only, and one was present on both days. SARS was reported by all five assessors for March 6 only, by three of five assessors for March 7 only, and by the one assessor who was present on both days.None of the students had traveled to mainland China, the only location with suspected community transmission of SARS during the study period. None of the ill students reported contact with another ill student or other person with SARS in the 10 days before illness onset. None wore masks or gloves while examining patients, and no notable differences in risk for disease were observed among students who reported washing their hands before and after examining patients. Apart from one hepatitis B carrier (who contracted SARS), no other students had any chronic illness. The clinical course and severity of illness in the hepatitis B carrier were similar to the experiences of other students.The hospital is centrally air-conditioned. Fresh air is drawn from outside the hospital building into a primary air unit situated in a room adjacent to the ward, where it is cooled by chilled water and then supplied to this ward  through air ducts. The air is then distributed to five fan-coil units (one in each of the four cubicles and one at the nurses’ station), where it is mixed with recirculated air, cooled by chilled water, and blown into the cubicle/nurses’ station via air supply diffusers (0.6 m by 0.6 m) located at the center of the cubicle in the false ceiling and over the nurses’ station. An exhaust grille, a rectangular opening 0.3 m by 0.6 m, located in the false ceiling in the corridor outside each cubicle and outside the nurses’ station, recirculates 70% of the air supply back into the fan-coil unit. Excess air escapes through two extraction fans inside the toilet, two extraction fans in the store/cleaning room, and through the door of the ward to the outside.The air exchange was 7.79 air changes per hour for the whole ward. The supply and exhaust airflow rates are summarized in The supply and exhaust airflow rates through diffusers and exhaust grilles were found to be imbalanced. The exhaust and air supply for the nursing station did not function properly. The air supply from the diffuser in the index patient’s cubicle had the highest supply flow rate (336 L/s), while the adjacent exhaust grille had the lowest exhaust flow rate (87 L/s) among all four functional exhaust grilles.At the time of the outbreak (March 4–10), the weather in Hong Kong was moderate with an ambient temperature ranging from 10.5°C to 22.3°C. The heat gains in the ward should be mainly from people, lighting, and equipment. In our computational fluid dynamics simulations to reproduce the average airflow pattern in the ward during the outbreak, we excluded the washroom and storeroom in our computational domain; and the exhaust flows through the two rooms were modeled as exhaust flows through their doorways. A free boundary condition was imposed on the ward entrance. Our computational fluid dynamics package could also consider the movement and evaporation of the aerosols. We found that aerosols would rapidly evaporate and the size of droplets would decrease rapidly after they originated from the index patient’s bed. The average air speed in the room was pproximatelyaround 0.2 m/s. The normalized concentration contours of hypothetical aerosols are shown in We utilized a unique opportunity provided by an unrecognized SARS patient who was the only known source of infection for a large cluster of secondary cases in an institutional setting to examine the transmission patterns of this novel disease. Proximity to the index case was associated with transmission, and all three students who examined the patient in bed 12 (within 1 m of the index patient) contracted SARS. As the index patient was bedridden during this period, this observation is compatible with transmission by droplets. However, that a few ill students were never within 1 m of the index patient raises the possibility of transmission by other mechanisms. Spread by contaminated fomites is a possibility, especially in light of recent data indicating that SARS-CoV survives well in the environment (At the time this investigation was begun, jet nebulizer therapy given to the index patient was widely believed to have facilitated transmission. However, our findings demonstrate efficient transmission even before nebulizer therapy was begun on the afternoon of March 6. First, 6 of the 10 students who attended the bedside clinical assessment on the morning of March 6 contracted SARS, compared with 1 of the 9 who attended the assessment on March 7. Second, all five of the assessors who assessed students on March 6 alone became ill, compared with three of the five assessors who were present on March 7 alone. Lastly, for the students with SARS who were present on the ward for reasons other than the bedside assessment, no association was observed between their stay in the ward at the specific periods when the nebulizer was used and the development of SARS. However, because nebulizer therapy could theoretically exacerbate symptoms of coughing in SARS patients, we recommend avoiding the use of nebulized medications and other potential aerosol-generating patient-care procedures if possible and using appropriate infection control precautions if such procedures are deemed necessary (–. While the mechanisms for these phenomena are largely unknown, possible explanations include a larger number of contacts of these superspreaders, inherent differences in the virus-host relationship, or the presence of a more virulent strain or higher levels of virus shedding (Similar large “superspreading events” of SARS associated with a single patient have been described in several countries (In conclusion, this cluster demonstrates the potential for widespread nosocomial spread of SARS among a previously healthy population in the absence of specific infection control precautions. SARS is likely spread through direct contact and respiratory droplets in most instances, and others have demonstrated that specific infection control precautions to prevent transmission by these mechanisms are effective (1


Pre-eclampsia/eclampsia usually resolves after delivery but sometimes hypertension persists and cardiovascular disease develops later. Our objective was to determine the incidence and maternal socio-demographic and obstetric risk factors for persistence of hypertension in women with pre-eclampsia/eclampsia.This was a prospective cohort study conducted from July 2009 to June 2011 at Mulago Hospital labour ward and postnatal clinics. We followed up 188 women admitted with pre-eclampsia/eclampsia until 3 months after delivery. Data was collected using interviewer-administered questionnaires, examination of participants and review of medical records. Stata (version12) software was used for data analysis. Univariable analysis was used to compute the relative risk of persistent hypertension at the 95% confidence level. This was followed by multivariable logistic regression analysis to determine factors independently associated with persistence of hypertension.64 (34%) out of the 188 women analysed had persistent hypertension three months after delivery. Maternal age, gestational age at delivery and parity were predictors of persistent hypertension. The proportion of women with pre-eclampsia/eclampsia at risk of persistent hypertension at three months after delivery was high, with nearly one of three mothers remaining hypertensive. Follow up of mothers who develop pre-eclampsia is important so that early diagnosis and management of chronic hypertension can be made to avoid long term morbidity and mortality. Pre-eclampsia is a life threatening multi-system disorder of pregnancy ,2 that iKIR genotypes and fetal HLA-C genes have been associated with pre-eclampsia among people of European descent [KIR genotype that may reflect natural killer cell activity. However, the association of maternal KIR genotype and resolution of pre-eclampsia has not been investigated before. Pre-eclampsia is a major cause of maternal death globally [Although chronic hypertension is the major clinical problem to develop after pre-eclampsia ,12, othe descent . It has  descent . This orglobally -34. In Mglobally . Very liKiller Immunoglobulin-like receptor (KIR) and Human Leukocyte Antigen C (HLA-C) and their role in development of pre-eclampsia in an African population was investigated. The study was conducted at Mulago, Uganda’s national referral hospital, located in Kampala with a catchment area of Kampala District and the surrounding districts of Wakiso, Mukono and Mpigi. These surrounding districts are within a radius of 10 to 20 km from Mulago Hospital. Few obstetricians are available in the public hospitals in the districts and therefore women with complications such as pre-eclampsia are referred to Mulago Hospital where the obstetricians are and the health care services are free. Mulago Hospital occasionally receives referrals from other parts of the country. In addition to the referred women, local women routinely deliver in Mulago Hospital and there are 80-90 deliveries daily and more than 30,000 deliveries per year. This was a prospective cohort study conducted in the labour ward and postnatal clinic between July 2009 and June 2011 and was linked to a larger case-control study primarily designed to study the genetics of pre-eclampsia . The genes studied were  Participants in the case-control study were women with pre-eclampsia or eclampsia consecutively recruited after admission to Mulago Hospital. Pre-eclampsia was defined as presence of hypertension and proteinuria occurring after 20 weeks of gestation. Hypertension was defined as a blood pressure (BP) measurement of 140/90 mmHg or more, measured at rest on more than one occasion at least 4 hours apart. Proteinuria was defined as urine protein measurement of +2 or more by dipstick on more than one occasion at least 4 hours apart. Severe pre-eclampsia was defined as presence of hypertension of 160/110 mmHg or more and proteinuria of 3+ or more at any time during management. Mild pre-eclampsia was defined as presence of hypertension of less than 160/110 mmHg and proteinuria of 2+ at any time during management. Eclampsia was diagnosed when a patient with pre-eclampsia had generalized tonic-clonic convulsions. All cases were at 20 weeks of gestation or more at the time the diagnosis of pre-eclampsia was made, assessed by weeks of amenorrhoea or ultrasound scan.  The majority of the women recruited to the larger genetic case-control study were included in the prospective follow up study apart from those who had no reliable residential address or phone contact and those living beyond a radius of 20 Km from Mulago Hospital due to difficulties in follow up. Women who missed reviews were traced by phone or midwives were sent to trace them personally to minimize loss to follow up. Women with prior chronic hypertension, renal disease before or during that pregnancy were also excluded because they already had the outcome of interest (persistent hypertension). These were self reported diagnoses and not backed my medical records. Some women reported using antihypertensive medication. Women with BP measurements of 140/90 mmHg or more before 20 weeks of gestation were also excluded as these are considered to have chronic hypertension. Participants were followed up for 3 months after delivery and persistent hypertension was diagnosed if by 3 months after delivery a woman had a blood pressure of 140/90 mmHg or more, or if antihypertensive medication was required to keep the BP below 140/90 mmHg. Approval to conduct the study was given by the Higher Degrees Research and Ethics Committee of Makerere University College of Health Sciences and the Uganda National Council for Science and Technology (UNCST). The participants gave written informed consent to participate in the study. Permission was sought to study minors (below 18 years of age) from the ethics committees. Minors signed assent forms while their next of kin or caretakers signed the consent forms. Withdrawal from the study never jeopardized health care and this was provided free to all women. The women were interviewed and BP measurement taken by the same medical attendant (AN). Additional information was obtained from participants’ medical charts. The data collected included socio-demographic characteristics, ethnic group, obstetric, medical and present pregnancy history . The Ethnic group was determined by asking women what their fathers’ languages were and this information was not used as a basis for recruitment in to the study. No biochemical data was collected as part of this study. Blood pressure measurements were done using manual mercury sphygmomanometers in a sitting position. Urine protein was measured using dipsticks. 5 mls of blood was taken from women and maternal genomic DNA was isolated using the QIAmp DNA Maxi Blood Kit (QIAGEN). KIR genotyping was based on the primers and methods described previously ,35. KIR AA genotype) had persistent hypertension and that the risk was twice among the exposed (with KIR AA genotype). A sample size of 127 gave the study 80% power to detect the effect of KIR genotype on persistence of hypertension, including 8% loss to follow up. The sample size was estimated according to Kesley at al using OpenEpi version 2.3.1 software . The incThe clinical management of all the participants was according to Mulago Hospital’s standard protocols. All women with diastolic blood pressures of 110 mmHg or more were diagnosed as severe pre-eclampsia and were given magnesium sulphate therapy as follows: a loading dose of magnesium sulphate of 14 g was given (4 g intravenously and 10 g intramuscularly), followed by 5 g intramuscularly four hourly for 24 hours. Intravenous hydralazine 5 mg was also given every 30 minutes until the diastolic pressure was 100 mmHg or less. Thereafter, the blood pressure control was achieved using oral nifedipine 10 mg with or without aldomet 250 mg. Those diagnosed as mild pre-eclampsia (diastolic blood pressure of less than 110 mmHg) were given oral nifedipine 10mg with or without aldomet 250 mg or atenolol 50 mg. The decision to deliver the women and mode of delivery plus subsequent care was also according the hospital’s standard protocols. For the first week all the pre-eclamptic women were left on antihypertensive drugs. In subsequent reviews the doses of the antihypertensive drugs were changed or the treatment was stopped altogether, depending on the blood pressure measurements. Treatment was stopped in those women whose blood pressure measurements fell below 120/70 mmHg and they were followed up weekly for three weeks. Those whose blood pressure measurements remained at or below 120/70 mmHg during this period were told to return or call in case of complaints like headache, but if all remained well they were told to return at 3 months post delivery for the final evaluation.On the other hand, the women whose blood pressure measurements fluctuated between 120/70 and 140/90 mmHg continued with fortnightly reviews and if the blood pressure measurements went above 140/90 mmHg they were put back on antihypertensive treatment. Fortnightly follow up reviews continued until the measurements fell below 120/70 mmHg or until 3 months post delivery, whichever came first. Data was entered into Access databases and the datasets were later imported into and analyzed using STATA version 12. First, we investigated the normality of the data for the continuous variables graphically using histograms and in addition we used the Shapiro-Wilk tests for normality. Then baseline characteristics were compared between those who had persistent hypertension and those who resolved within three months after delivery. Categorical data was compared using the chi-square test while for numerical data the Student’s t-test. To assess risk factors for persistence of hypertension, univariable analysis was performed to compute risk ratios at the 95% significance level. To assess independent contribution of these risk factors to persistent hypertension, multivariate analysis was performed, where all independent variables with a p-value of less than 0.2 at univariate analysis were considered for multivariable logistic regression. Associations with p values less than 0.05 were considered statistically significant.KIR genotyping results. Out of the 188 women, 64 (34%) had persistent hypertension at three months post delivery. A total of 200 were recruited into this prospective cohort study. All the eligible women had reliable mobile phone contacts but 4 were excluded from the study because they intended to reside beyond a radius of 20 Km after delivery. Of the 200 women recruited, 12 failed to attend for post-natal review leaving data for 188 women for analysis 2 women had no All continuous variables  were normally distributed, with p-values of less than 0.001 for all variables from the Shapiro-Wilk tests. KIR genotype was not associated with persistent hypertension.We then analysed for factors independently associated with persistent hypertension and the results are shown in In this cohort we defined a group of high risk women for persistent hypertension: multiparous, 25 years of age or more and with early onset pre-eclampsia . From the analysis 21 of the 188 women (11.2%) were high risk and a higher proportion of these, 12 (57.1%), had persistent hypertension compared to 52 (31.1%) of the others. This difference was statistically significant . In this study we assessed the incidence and factors associated with persistent hypertension after delivery among women with pre-eclampsia/eclampsia who delivered in Mulago Hospital. The incidence of persistent hypertension three months after delivery was 34% (64/188). Women’s age , gestational age at delivery and parity of the women were the factors predictive of persistent hypertension in this cohort. The incidence of persistent hypertension we found (34%) is higher than that found among similar women in Mulago Hospital (28%) in an earlier study in which the follow up period after delivery was six weeks . Our sliWe also found that the increased risk of persistent hypertension was highest in women aged 35 years and above. Higher maternal age was associated with persistent hypertension and later cardiovascular disease in other studies ,24. Mult When women with pre-eclampsia deliver at term, there was a significantly reduced risk of persistent hypertension in our study. Other studies have also found that it is particularly early onset pre-eclampsia (before 34 weeks of gestation) that is a risk factor for later cardiovascular disease ,21,23,46KIR genes have been implicated in development of pre-eclampsia in some studies [KIR genotype and therefore NK cell activity. In this study we found no association between maternal KIR genotype and persistent hypertension. This could be explained by the fact pre-eclampsia is a disease of multiple aetiologies and placentation defects, where KIR and HLA-C genes may play a critical role [NK cells through their Killer Immunoglobulin-like receptors (KIR) are believed to play a key role in placentation ,51 and p studies ,51,52 an studies . The rescal role ,54, are In this study there are several other limitations. All women received antihypertensive therapy before and after delivery but we did not, however, collect the data detailing the therapy given such as; the number of drugs, doses, duration of treatment before delivery. This would have been informative since antihypertensive therapy modifies the progression of pre-eclampsia ,56 and pThere are still few studies on the persistence of hypertension following pre-eclampsia, with most published literature describing risk of later disease long after delivery ,12,58. IThe proportion of women with pre-eclampsia/eclampsia at risk of persistent hypertension three months after delivery in our setting is high, with nearly one of every three mothers remaining hypertensive. This trend could be similar in other African countries, contributing to the increasing burden of non-communicable diseases that has been observed ,39. Mate


Internet support groups (ISGs) are popular, particularly among people with depression, but there is little high quality evidence concerning their effectiveness.The study aimed to evaluate the efficacy of an ISG for reducing depressive symptoms among community members when used alone and in combination with an automated Internet-based psychotherapy training program.Volunteers with elevated psychological distress were identified using a community-based screening postal survey. Participants were randomised to one of four 12-week conditions: depression Internet Support Group (ISG), automated depression Internet Training Program (ITP), combination of the two (ITP+ISG), or a control website with delayed access to e-couch at 6 months. Assessments were conducted at baseline, post-intervention, 6 and 12 months.There was no change in depressive symptoms relative to control after 3 months of exposure to the ISG. However, both the ISG alone and the combined ISG+ITP group showed significantly greater reduction in depressive symptoms at 6 and 12 months follow-up than the control group. The ITP program was effective relative to control at post-intervention but not at 6 months.ISGs for depression are promising and warrant further empirical investigation.ISRCTN65657330Controlled-Trials.com  The Internet is increasingly recognised as a valuable self help resource for people with depression. It has been estimated that as many as 21% of US citizens have accessed online information about depression, anxiety, stress or mental health issues face-to-face support groups for depression concluding that mutual support was more effective than treatment as usual and that there was no statistically significant difference in the efficacy of support groups and cognitive behaviour therapy However, Internet usage for depression is not limited to information seeking. Recent systematic reviews have concluded that guided and unguided online psychotherapy applications are effective for preventing and treating depression The current study therefore sought to evaluate the efficacy of and adherence to a depression Internet Support Group (ISG), an automated psychoeducational and skills Internet training program (ITP), and the ITP combined with an ISG relative to each other and a plausible Internet Attention Control condition (IAC).The protocol for this trial and supporting CONSORT checklist are available as supporting information; see Participants comprised 311 adults aged 18 to 65 years recruited in three waves between August 2008 and May 2009 via a screening survey posted to 70,000 adults randomly selected from the electoral rolls of eight Australian electoral divisions  with moderate to high Internet access. To be included in the intervention study, respondents were required to have obtained a Kessler Psychological Distress (K10) Randomisation to one of the four trial conditions was undertaken following verbal consent on the telephone prior to the return of written consent Each of the three interventions and the Control program comprised 12 modules, one module delivered per week over a 12 week period. Once opened, these programs remained accessible to participants during the trial and 12 month follow-up period. For ethical reasons, participants in the control condition were provided with access to the ITP after the 6-month follow-up assessment. The ITP, ISG and IAC conditions employed the e-couch, WellBeing Board and HealthWatch websites respectively. The content of each intervention website is summarised below and described in detail in the WellBeing protocol paper http://ecouch.anu.edu.au). The intervention consisted of (i) a depression literacy module containing consumer information about the diagnosis, epidemiology and treatment of depression; and (ii) a self help module comprised of online versions of cognitive behaviour therapy; interpersonal therapy; applied relaxation; and physical activity.The ITP comprised a research version of the depression stream of e-couch, an automated online psychological intervention application (http://blueboard.anu.edu.au). Each week one or two new forums or topics were introduced to one of the three main WellBeing Board categories: Your WellBeing, Feeling Better, or General The ISG was a closed, moderated bulletin board purpose built for the trial. The structure and rules for the board were based on our public depression forum BlueBoard (This condition involved the simultaneous delivery of e-couch (ITP) and a dedicated WellBeing Board (ISG) over the 12 week intervention period. To prevent contamination between the ISG only and the ISG+ITP conditions, separate ISGs were established for the two conditions. The ISG for the combined condition incorporated an additional forum that enabled participants to discuss their experiences with the ITP e-couch condition.The control condition was purpose-built for the current study Participants who supplied their written consent for participation in the study were provided with a user ID and password via automated email. One week prior to commencement of the intervention these participants were prompted via another automated email to complete the online baseline survey. Thereafter participants in each of the four conditions received a weekly automated email informing them of the availability of their next module. A reminder email was sent 4 days after the initial email if the participant failed to login to the weekly module. Participants who still failed to log in received a telephone reminder to do so from their assigned project interviewer in the following week. The current week's module could only be accessed once all modules assigned in the preceding weeks had been completed. At the end of the trial, participants were advised by automated email to complete an online post intervention survey. Further emails were sent 6 and 12 months after the commencement of the intervention requesting that the participants complete follow-up online surveys.http://www.randomization.com).Participants were randomised using a stratified block design procedure to the four conditions by the trial biostatistician (AM) who was not involved in the day-to-day conduct of the trial. Stratification variables were level of psychological distress (high/low distress level on K10), gender , age, and location of residence . Randomisation sequences with a fixed block size of four were generated for each strata using the Randomisation.com website , all CES-D data were first dichotomised into caseness . This outcome was analysed on an intent-to-treat basis using a mixed effects logistic model with factors of intervention arm and occasion of measurement and a random participant intercept using gllamm in Stata 10.1. Planned contrasts of model parameters tested hypotheses regarding differences in odds of change over time between interventions.Associations between outcomes and demographic variables and dropout were investigated using t-tests and chi-square tests. ANOVAs, t-tests, Pearson chi-square, and Fisher Exact Probability tests were employed to identify any differences between conditions in baseline attributes or scores and also to compare attrition across the conditions in order to investigate attrition bias and potential threats to internal study validity.The number needed to treat (NNT) was calculated for participants above caseness criteria at baseline with confidence intervals estimated using the method proposed by Bender The participant flow for the trial is shown in Demographic, clinical status and symptom scores were similar across conditions. The mean age of participants across conditions was 43.9 (sd = 12.1) years, and consistent with the relative prevalence of depression in men and women, 67.4% (n = 201) of the participants were women. Just over one-third  of the respondents had completed at least an undergraduate tertiary degree, approximately half  were from a rural region, the majority were employed  and more than half were married or in a de-facto relationship .Overall, 87.9% (n = 259) of the participants self-reported a history of depression, 68.7% (n = 204) indicated that they were currently suffering from depression and of these 62.3% (n = 127) indicated that they had sought help for depression. The mean CES-D score for the participants fell at the upper end of the mild range for depression  with 79.6% (n = 234) of the participants scoring above the cutoff for clinically significant symptoms. Approximately one-quarter  had experienced time in the past 30 days when they were totally unable to work due to depression, over half  experienced periods where they could work but at a reduced level of productivity due to depression and a similar number experienced at least one of these problems .Although the pattern of pre-trial preferences for the four interventions was similar across conditions, the distribution of interest in the four websites differed with 180 (64.1%), 146 (52%), 135 (48%) and 85 (30.2%) participants overall indicating an interest in the ITP, Control, ISG+ITP combined, and ISG conditions respectively.Of the 311 participants who provided consent, 17 (5.5%), 85 (27.3%), 109 (39%), and 141 (45.3%) at baseline, post-test, 6 months and 12 months respectively either failed to complete the survey or did not provide sufficient data to calculate a CES-D score (non-completers). At post-test, attrition was significantly lower in the Control group than each of the intervention conditions and at 6 and 12 months completion rates remained significantly lower in the control group than the two conditions involving an Internet Support group see . HoweverMost baseline scores and clinical and demographic characteristics were similar for CES-D completers and non-completers. In particular, the baseline CES-D scores were not significantly different for completers and non-completers in any group at any time point except that the baseline CES-D was lower among 12 month completers in the Control condition. Similarly, in most cases, K10 scores did not differ significantly for completers and non-completers except that ITP participants who completed the CES-D at 12 months had a higher baseline K10 than non-completers and the reverse was true for ITP+ISG participants; those completing the CES-D at 12 months had a lower baseline K10 level than non-completers. There were no significant differences between completers and non-completers for caseness (CES-D>16), self-reported history of depression or current levels of depression or for whether they had experienced disability due to depression (unable to work or lowered productivity last 30 days). However, ITP CES-D completers at post, 6 months and 12 months were more likely to indicate at baseline that they had sought help for depression and a similar pattern was obtained for ISG CES-D completers at post and 6 months. The majority of demographic comparisons demonstrated no difference in dropout. In particular, there were no significant differences between the age of completers and non-completers or their location of residence . However, men were more likely to drop out of the ITP condition at each assessment point and out of the ISG condition at 12 months. Those with a tertiary education were less likely to drop out of the ITP condition . Finally, for the ISG condition participants who completed the CES-D at 6 months were more likely to be unemployed  and the Control condition completers at 6 months were more likely to be married than non-completers. There were no other gender, educational, employment or marital status differences between completers and non-completers.The adherence data for the 298 participants who provided at least one baseline CES-D score are summarised in On average, over the initial, structured, 12 week-intervention period, participants from the control, ITP, ITP+ISG and ISG conditions logged-in on 96%, 83%, 70% and 52% of weeks respectively. ITP and Control participants logged-in on significantly more weeks in the intervention period than participants in the conditions incorporating an ISG .2(1) = 6.55, p = .01). In addition, three ITP participants and one participant from the ITP+ISG group completed at least one additional module following the 12 week intervention phase during which period two of the ITP participants and the ITP+ISG participant finished all 12 modules.During the 12 week intervention period, the control and ITP participants completed the majority of the automated modules . The participants in the ITP+ISG group completed two-thirds of the ITP modules during the 12 week intervention period, significantly fewer than were completed by the ITP alone or the Control group ; Control vs ITP+ISG difference = 3.24, 95% CI = 2.12–4.37, p<.001). In addition, the ITP group completed significantly fewer modules than the Control group . Sixty-five percent of the ITP-alone group completed all 12 modules in the first 12 weeks of the trial compared with less than half of the ITP+ISG group, a difference which was statistically significant  = 2.22, 95% CI = 2.17–40.39, p = .03; Number of weeks≥1 post: difference = 2.05, t(148) = 3.08; 95% Confidence Interval = .74–3.36, p = .002). Participants in the ISG conditions were able to continue to post to the ISG at the end of the 12 week intervention phase. A significantly greater percentage of the ISG alone group (26%) compared to the combined ISG+ITP group (2.7%) opted to post at least once to the board in the 3 months following the intervention phase (χ2 (1) = 16.16, p<.001).Participants in the ISG conditions were asked to make 4 posts per week to the Board. Few contributed this many posts in a week and only one participant  did so in each of the 12 weeks. However, on average the ISG alone participants made at least one post on each of 50% of the weeks in the intervention period; the ISG+ITP participants made at least one post on a third of the intervention period weeks. Participants in the ISG+ITP group made significantly fewer posts and logged-on in significantly fewer weeks during the intervention phase than those in the ISG alone condition  who provided at least one data point accessed the intervention between 1 and 5 times of whom the majority  logged onto e-couch only once. The 19 participants comprised 37.3% of the 51 Control participants who provided a 12 month CES-D.Excluding participants who withdrew and therefore did not receive telephone call reminders, participants received an average of 1.74 (sd = 2.21) telephone reminders over the 12 week period of the intervention. This included 0.86 (sd = 1.53), 2.39 (sd = 2.38), 1.48 (sd = 1.97) and 2.42 (sd = 2.55) reminders for the Control, ITP, ISG, and ITP+ISG conditions respectively.The current study raises the possibility that over the long term an online peer-to-peer support group may be an effective intervention for reducing depressive symptoms among members of the community with elevated depressive symptoms and a self-reported history of depression. There was no change in depressive symptoms relative to the control condition after 3 months exposure to the ISG. However, both the Internet support group alone and the Internet support group combined with an automated Internet depression training program did show a significantly greater reduction in depressive symptoms at 6 and 12 months follow-up. The training program alone was effective relative to control at post-test but the effect was not significant at 6 months. Adding an ISG reduced rather than improved adherence to the training program. The Control group was provided with the opportunity to access the automated depression training program after the 6 month follow-up; at 12 months there was no significant difference between this group and the group which received the training program from the outset.To our knowledge, this is the first randomised controlled trial of the effectiveness of an online peer-to-peer support group for reducing depressive symptoms and the first to compare the effect of such a group with the effectiveness of an Internet-based automated psychotherapy intervention for depression. The intervention was associated with minimal human guidance with reminders to undertake the program being primarily delivered by automated email. Further, the study employed a credible Internet-based control condition which was associated with a high level of adherence. However, there were limitations. Uptake of the trial invitation was lower than anticipated and long term attrition was high. Given the high costs of the recruitment technique employed, it was not feasible to recruit the intended sample size. In addition, as has been frequently documented in other studies Control-arm of an RCT of a CBT-based Internet intervention for depression The findings of this RCT are consistent with evidence from a previous quantitative depression ISG study reported by Houston and his collaborators While inviting replication, the findings of the current study have substantial practical implications for consumers, clinicians and policy makers. They suggest that ISGs may be of benefit for people with a history of depression and with current depressive symptomatology. Thus, clinicians might consider referring interested clients to such groups and policy makers have a stronger basis for funding and promoting depression ISGs. The findings further suggest that there may be value in combining standard Internet training programs with an Internet support group since the effect of the ITP occurred immediately post-intervention and tapered off and the effect of the ISG was delayed and increased over time.Further research is required to confirm the outcomes, to determine who might benefit most from an ISG and to identify methods for increasing participation in ISGs. There is also a need to investigate the reliability and nature of the delayed improvement effect. Participants did not log onto the ISG boards frequently following the intervention. Thus, the mechanism underlying the delayed improvement in depressive symptoms is unclear. It is possible that participants developed communication skills that they then transferred to and practised in face-to-face situations which in turn resulted in a delayed reduction in depressive symptoms. It is also possible that participation in the ISG prompted subsequent formal help seeking. Alternatively, frequency of logins may not be the only or most important indicator of participant use of the board. For example, it is possible that simply reading posts is beneficial for this group. Finally, the current study employed an ISG founded and developed for the specific purposes of the project. The culture, mechanisms of action and effectiveness of well established public ISGs may differ from that of a research ISG. Such public depression ISGs are the most widely employed and accessible services for consumers. Accordingly, we are currently undertaking a randomised controlled trial to investigate the effectiveness of an ecologically valid, established depression ISG.Checklist S1CONSORT Checklist(DOC)Click here for additional data file.Protocol S1Trial Protocol(PDF)Click here for additional data file.


Drosophila, encoded by the CG33988 gene, is coordinately expressed with NALCN, and that knockdown of either protein creates identical phenotypes in several behaviors associated with NALCN function. The relationship between Mid1 and leak channels has therefore persisted over a billion years of evolution, despite drastic changes to both proteins and the organisms in which they exist.Neuronal resting potential can tune the excitability of neural networks, affecting downstream behavior. Sodium leak channels (NALCN) play a key role in rhythmic behaviors by helping set, or subtly changing neuronal resting potential. The full complexity of these newly described channels is just beginning to be appreciated, however. NALCN channels can associate with numerous subunits in different tissues and can be activated by several different peptides and second messengers. We recently showed that NALCN channels are closely related to fungal calcium channels, which they functionally resemble. Here, we use this relationship to predict a family of NALCN-associated proteins in animals on the basis of homology with the yeast protein Mid1, the subunit of the yeast calcium channel. These proteins all share a cysteine-rich region that is necessary for Mid1 function in yeast. We validate this predicted association by showing that the Mid1 homolog in  This channel has garnered growing interest because of its involvement in the regulation of neural excitability underlying rhythmic behaviors . An increase in the activity of NALCN channels can boost the gain of the neuron, which in turn increases the likelihood that the neuron will fire. These effects can cause a pacemaker neuron to fire continuously.Ion channels are the workhorses of neuronal excitability. By controlling the passage of ions across the cell membrane of neurons, ion channels produce and propagate action potentials that transmit information throughout the brain. The best studied families of neuronal ion channels are the ligand-gated and voltage-gated ion channels. These channels initiate, shape, and propagate action potentials Hille, . In geneors Ren, . A gene ors Ren, . These cors Ren, . They enC. elegans . The programs used for secondary structure prediction are described in Supplementary figure We initially used BLASTp to search for homologs of Mid1 in animals in the RefSeq database. While BLASTp is sufficient to find a significant hit in insects, the more sensitive search algorithms PSI-BLAST and HMMER were needed to identify the Mid1 domain-containing protein in most other animal lineages. Conservation analyses were performed on the AL2CO server , fz4, and Act5C, were obtained from the Drosophila database FlyBase ; the UAS-RNAi lines naJF01826  and CG33988HMS03014 ; and the isogenic host strain for the RNAi library w1118 . All stocks were obtained from the Bloomington Drosophila Stock Center at Indiana University . For RNAi induction, males from each UAS-RNAi line were crossed to the virgin females from the elav-Gal4 line and the male progeny  tested. Each of the RNAi line and the elav-Gal4 line were also crossed to the w1118 isogenic host strain. The male progeny of these crosses  and  were used as controls and tested for comparison. The elav-Gal4/UAS-RNAi males that we examined carry the w1118-bearing X chromosome inherited from their mothers. They did not inherit the y1v1-bearing X chromosome from their fathers. As a result, the w1118-bearing X chromosome is an important genetic control but the y1v1-bearing X chromosome is not a relevant genetic control. Quantitative RT-PCR analysis of mRNA abundance of the respective knockdown lines indicates that the mode of action of the knockdown mechanism for each gene may be different. Induction of RNAi against na results in na specific mRNA degradation, but the RNAi against CG33988 fails to induce CG33988 mRNA degradation  using standard procedures  and analyzed for nearest neighbor distances. Flies in each chamber were rendered as particles and assigned 2D coordinates. These coordinates were used to determine the distance from each fly to its nearest neighbor using the Nearest Neighbor macro developed by Yuxiong Mao: https://icme.hpc.msstate.edu/mediawiki/index.php/Nearest_Neighbor_Distances_Calculation_with_ImageJ. The nearest neighbor distances were exported to Prism 5  for frequency distribution analysis. Distances were divided into 5 mm bins, and the percentage of flies in each bin was calculated for each chamber. The average of the 5 images captured for every chamber was used to determine the frequency distribution of each population. Social space index (SSI) was determined by calculating the difference between the percentage of flies in the first bin (0–5 mm from the nearest neighbor) and the percentage of flies in the second bin (5–10 mm from the nearest neighbor) as described by Simon et al.  starts at 8 pm.Social clustering was monitored by introducing 40 male flies of each genotype in horizontal circular chambers as described by Simon et al.  with minn et al. . A totalDrosophila gene CG33988. We later noted that these proteins are identified as Mid1 in the public databases RefSeq and PFAM, both of which use HMMER for annotations, and the Drosophila gene database FlyBase, which uses InterPro , which have been previously linked to na and are regarded as potential accessory subunits , which has also been identified as a potential homolog of the yeast Mid1 ; and the second spanned from the beginning of the pupae stage to adulthood.The developmental series data Figure  reveal ana and CG33988, we performed Pearson correlation analysis using both gene expression profile datasets on all pair wise combinations of these genes, as well as to the other putative na accessory genes. This time the expression profiles of the Act5C gene were also included as a non-related example. This analysis confirms that in both cases  the expression patterns of the genes na, CG33988, unc79 and unc80 are highly correlated. In addition, the fz4 and Act5C genes show little or no correlation with na, or the other 3 genes  that expresses primarily within the neural tissue of the fly . The gene brp encodes a pre-synaptic active zone component shown to be a critical player of evoked neurotransmitter release at chemical synapses. Also, mutants in the core circadian clock genes per or Clk also fail to anticipate the “lights-on” and “lights-off” transitions , and the other parts of the protein do not appear to be homologous. If the secondary structure caused by disulfide bonds between the cysteines is the most critical element of Mid1 function, it may not be surprising that the other areas of the protein are not well conserved.Caenorhabditis, which are the most divergent homologs we sampled, have apparently not perturbed Mid1's function. In yeast Mid1 localizes to the plasma membrane and endoplasmic reticulum where it is involved in trafficking the calcium channel Cch1 to the plasma membrane (Yoshimura et al., C. elegans NLF-1 traffics NALCN from the endoplasmic reticulum to the plasma membrane of neurons. Xie et al. found that FAM155A can complement C. elegans lines deficient for NLF-1. We have shown that NLF-1, FAM155A, and also its uncharacterized paralog FAM155B, are all members of the Mid1 superfamily. The only regions truly conserved between these genes are the cysteine-rich areas in the Mid1 domain. Thus, an independent functional study in a different model organism confirms our bioinformatic predictions and genetic experiments in Drosophila. The data from yeast suggests an ancient function for Mid1 in trafficking Cch1/NALCN.The loss of key cysteines in vertebrates and CG33988 in high-throughput screens for circadian associated genes in insects. CG33988 in flies was found to be up-regulated in neurons that express a molecular clock relative to whole-head and eye (Nagoshi et al., Our finding that both Mid1 and NALCN are required for a normal circadian motor phenotype in flies fits with earlier studies that have identified The comparative approach offers a powerful method for untangling complicated interactions for which one model system may not meet all requirements. Although this system awaits more concrete evidence for a direct, physical interaction between Mid1 and NALCN, the identification of Mid1 as a superfamily of fungal and animal proteins should enable a fruitful cross-species basis from which to study NALCN function in the future.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To the Editor: In late November 2009, a 3-year-old immunocompromised boy experienced an upper respiratory tract infection caused by influenza A pandemic (H1N1) 2009 virus, as demonstrated by a positive result for real-time PCR on a nasal swab specimen. His medical history was notable for a congenital intracardiac tumor; an ABO–incompatible heart transplant at 2 months of age; and an Epstein-Barr virus–related humoral rejection 20 months later that was treated with anti-CD20 and plasmapheresis and continuous immunosuppressive therapy with tacrolimus and everolimus. Thus, a 5-day regimen of oseltamivir treatment was undertaken, and the patient’s clinical signs improved.However, 3 days after drug treatment was suspended, the child had a relapse and exhibited fever, cough, and mild respiratory distress. The patient had fine crackles in the left posterior basal lung, normal oxygen saturation, and an infiltrate in the left basal lung, observed on chest radiograph. Infection with pandemic (H1N1) 2009 virus was confirmed. He was then transferred to an isolated ward of the pediatric department, and oseltamivir treatment was again initiated and dosages of immunosuppressive drugs were reduced. However, no clinical or virologic responses were observed during the 3 weeks of drug administration.Over the next month, the oral dosage of oseltamivir was increased twice, without substantial effects on clinical course and viral clearance of the infection . BecauseAnother notable point is that the clinical course of the disease was not severe, although the child was immunocompromised and the infection persisted for almost 2 months. However, influenza virus persistence, possibly caused by inability of the child’s immune system to clear the infection, and prolonged treatment with oseltamivir, led to the appearance of the H275Y mutation. H275Y has been described as the most common mutation that confers oseltamivir resistance in pandemic (H1N1) 2009 infection and has been found in all the resistant isolates reported worldwide (Zanamivir represents the therapeutic option for patients infected with the H275Y mutation of pandemic (H1N1) 2009 virus. Its licensed formulation as a dry powder is suitable only for patients who can actively use inhaled drugs and thus cannot be used in children <7 years of age (Despite these results showing the efficacy of zanamivir intravenous administration, the inhalatory route for influenza virus–specific drugs should be the first choice, whenever possible, because it delivers therapeutic molecules directly to the site of viral replication, resulting in low systemic exposure. For this reason and because of the mild severity of the patient’s disease, we decided to use zanamivir solution nebulized by aerosol. The compliance to this treatment was easily achieved, and the therapy showed good efficacy and was well tolerated by the child. The minor side effect observed has already been reported in the literature (In conclusion, our experience supports the view that in immunocompromised patients with persistent infection, emergence of resistant viral strains should be strictly monitored. In this context, recently developed real-time PCRs for rapid screening of H275Y could be useful (


Case report.The authors present the case of a 14-year-old boy with Rubinstein-Taybi syndrome (RSTS) presenting scoliosis.There have been no reports on surgery for RSTS presenting scoliosis.The patient was referred to our hospital for evaluation of a progressive spinal curvature. A standing anteroposterior spine radiograph at presentation to our hospital revealed an 84-degree right thoracic curve from T6 to T12, along with a 63-degree left lumbar compensatory curve from T12 to L4. We planned a two-staged surgery and decided to fuse from T4 to L4. The first operation was front-back surgery because of the rigidity of the right thoracic curve. The second operation of lumbar anterior discectomy and fusion was arranged 9 months after the first surgery to prevent the crankshaft phenomenon due to his natural course of adolescent growth. To avoid respiratory complications, the patient was put on a respirator in the ICU for several days after both surgeries.Full-length spine radiographs after the first surgery revealed no instrumentation failure and showed that the right thoracic curve was corrected to 31 degrees and the left lumbar curve was corrected to 34 degrees. No postoperative complications occurred after both surgeries.We succeeded in treating the patient without complications. Full-length spine standing radiographs at one year after the second operation demonstrated a stable bony arthrodesis with no loss of initial correction. Rubinstein-Taybi syndrome (RSTS) is characterized by mental retardation and physical abnormalities such as broad thumbs and halluces, short stature, and a peculiar facial expression - 'comical face' which is characterized by a beaked nose, down-slanting palpebral fissures and hypoplastic maxilla -5. ThereA 14-year-old boy was referred to our hospital for evaluation of a progressive spinal curvature. He had already been diagnosed with RSTS and noted to have spinal deformity at age one in a regional hospital. Since then he had undergone brace treatment, which failed to halt progression of the scoliosis. There was no mention of either RSTS or scoliosis in his family history. He manifested a peculiar facial appearance, broad thumbs, broad halluces, short stature, and mental retardation Figure  L and R.We planned a two-staged surgery. The first operation was front-back surgery because of the rigidity of the right thoracic curve. The second operation, a lumbar anterior discectomy and fusion, was arranged 9 months after the first surgery in order to prevent a crankshaft phenomenon induced by his natural growth.The patient was laid in the left lateral decubitus position. We partially resected the right 8th rib and entered the pleural cavity. Anterior discectomy from T8/9 to T10/11 was performed, and we used the resected rib as a bone graft in that region. A chest tube was inserted into the pleural cavity. Immediately after the anterior surgery, halo-femoral traction was applied to facilitate the posterior surgery, and then the patient was turned to the prone position. Smith-Petersen osteotomy was performed from T8/9 to T10/11, followed by a posterior corrective fusion and instrumentation with a pedicle screw system from T4 to L4. We used the combination of an allograft and local bone graft in the instrumented region. Preoperative evaluation revealed that the lumbar curve could be manually corrected to only 42 degrees, and the inclination of L4 in the coronal plane was residual, so we extended the fusion to L4. Transcranial electrical stimulation motor-evoked potential monitoring showed no significant intraoperative change in potentials. The operation time was 421 minutes and the estimated blood loss was 2240 ml. No additional transfusion was needed because of the autologous blood banked before surgery and because an intraoperative cell saver was used. Full-length spine standing radiographs at 2 weeks after surgery revealed no instrumentation failure and showed that the right thoracic curve from T6 to T12 was corrected to 31 degrees and the left lumbar curve from T12 to L4 was corrected to 34 degrees.The patient was laid in the right lateral decubitus position. We used the anterior retroperitoneal approach by resecting the left 11th rib, and then performed a discectomy from L1/2 to L3/4 was performed. A combination of the risected rib and hydroxyapatite spacers was used for bone grafting in that region. The operation time was 146 minutes and the estimated blood loss was 500 ml.He entered the ICU immediately after both the first and second surgeries and was maintained on a respirator for several days in order to prevent respiratory complications. The patient wore a thoracolumbar spinal orthosis for 6 months after the first surgery. Full-length spine standing radiographs at one year after the second operation demonstrated a stable bony arthrodesis with no loss of initial correction Figure  L and R.RSTS is a rare human genetic disorder  and is aWiley  made a fThere have been several reports of surgery on RSTS patients but no reports of surgery on scoliosis have been published. Limited to orthopedic or spine surgery, there were 5 reports of knee surgery for patella dislocation -10,13,14We succeeded in treating the patient without complications even though two major surge-ries were performed. The first surgery was front-back surgery with thoracotomy, and the second surgery was performed using retroperitoneal approach with a rib resection. We had to pay the closest attention to the patient whose mental retardation prevented him from adequately complaining of any symptoms. Therefore, in order to prevent any respiratory complications, we judged that the patient should be maintained on a respirator in the ICU after both surgeries. Consequently, no postoperative problems oc-curred.The crankshaft phenomenon is a complication known to occur after spinal fusion in skeletally immature patients with scoliosis. When asymmetric anterior growth continues after solid posterior fusion, it causes the crankshaft phenomenon. Risser sign, Tanner stage, triradiate cartilage, peak height velocity, and chronologic age have all been used as elements to predict the occurrence of a crankshaft in idiopathic scoliosis -27.The preoperative films revealed that the triradiate cartilage was open and the Risser grade was 4. His secondary sex characteristic had not emerged yet at the time of surgery even though he was 14 years old. The patient's growth spurt had not reached its peak height velocity, but still he had a large secondary lumbar curve. We had discussed extensively with the parents about the importance and necessity of a second operation. The parents feared that even if the crankshaft phenomenon caused correction loss of the lumbar curve, the patient's mental retardation might possibly prevent a manifestation of clear symptoms. Therefore, in order to minimize the possibility of a crankshaft, we performed a secondary procedure of anterior lumbar discectomy and fusion. As a result, x-ray films at one year after second surgery demonstrated a stable bony arthrodesis with no loss of initial correction.Rubinstein  reportedWe succeeded in treating the patient without complications. Full-length spine standing radiographs at one year after the second operation demonstrated a stable bony arthrodesis with no loss of initial correction. Spinal disorders in RSTS patients must be carefully assessed and treated if necessary.Written informed consent was obtained from the parents of the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review from the Editor-in-Chief of this journal.The authors declare that they have no competing interests.YT conceived the study and drafted the manuscript; NK performed surgeries, and performed critical revision of the manuscript and gave final approval of the version to be published; TT, KM, and AN performed surgeries, and collected and reviewed clinical and radiographic charts. All authors read and approved the final manuscript.