Flail chest is a rare complication in pediatric patients with blunt chest trauma. There is no general consensus on which treatment is most appropriate for flail chest in pediatric patients, although it has been reported that surgical fixation is associated with beneficial outcomes for flail chest in adults.The present report described two pediatric cases of flail chest, which was rare in pediatric blunt trauma. In small children, functional residual capacity is smaller, and the thorax is pliable due to high thoracic compliance. Therefore, it is only advisable to select intubation and mechanical ventilation treatment. Likewise, in pediatric flail chest, the available evidence does not suggest that ventilator management protocols should be adopted routinely, and the treatment for pediatric flail chest was not established completely.There were not huge different between the described patients, including injury severity and ventilation setting. However, one had a relapse of flail chest after extubation and chest taping was required, while the other patient’s condition was stable after decannulation.As described above, it is difficult to predict a recurrence of flail chest in pediatric patients even if treatment goes well. Therefore, T-piece trial should be considered prior to extubation. Flail chest has been reported to occur in 2.2–4.4 % of pediatric patients with blunt chest trauma , 2. TherA two-and-a-half-year-old male pedestrian struck by a car was transported to our hospital by air ambulance. His height was 86 cm and his body weight was 14 kg. On arrival his Glasgow Coma Scale score was 11 . Both pupils were 3 mm, and pupillary light reflexes were normal. Physical examination revealed a body temperature of 37.6 °C, respiratory rate of 41 breaths/min, heart rate of 156 beats/min, and blood pressure of 106/47 mmHg. Paradoxical movement of the left thorax was detected.2 of 73.7 mmHg, PaCO2 of 49.3 mmHg, HCO3− of 22.5 mmol/l, base excess of −3.6 mmol/l, and lactate of 14 mg/dl.Laboratory investigations revealed an inflammatory process and muscle deviation enzyme consistent with blunt trauma. The serum creatinine kinase level was elevated at 1229 IU/l. Arterial blood gas analysis on 100 % oxygen revealed pH of 7.28, PaOChest computed tomography (CT) detected bilateral lung contusions, left pneumothorax and fractures of the left clavicle and left third to fifth ribs Fig. . Based o2O, pressure support (PS) 10 cmH2O, positive end expiratory pressure (PEEP) of 9 cmH2O and FIO2 of 0.4. The PaO2/FIO2 (P/F) ratio, which was 73 on admission, was improved to 375 on hospital day 8. In addition, the lung contusions had improved on chest CT. Then, ventilator mode was continuous positive airway pressure (CPAP) mode, and the patient was requiring minimal ventilatory support. Since paradoxical movement of the left thorax had also resolved, he was extubated on day 9.On admission, the patient was intubated using 4 mm cuffed endotracheal tube. Ventilation mode was synchronized intermittent-mandatory ventilation (SIMV) pressure-control and pressure-triggered ventilation. The initial ventilator settings were: inspiratory time of 0.7 s, respiratory rate of 20 breaths/min, pressure control (PC) 17 cmHSince his condition after extubation was stable, he was transferred to a local hospital for rehabilitation on hospital day 19.A 1-year-and-8-month-old girl who was run over by a car backing up into a parking spot was transported to our hospital by air ambulance. During transportation, the flail chest was suddenly caused in the air ambulance. In flight, we cannot perform intubation. So, the physician performed manual compression for the flail chest. It was effective and improved the flail chest. Her height was 80 cm and her body weight was 9.3 kg. On arrival her Glasgow Coma Scale score was 9 . Both pupils were 3 mm, and pupillary light reflexes were normal. Physical examination revealed a body temperature of 37.6 °C, respiratory rate of 50 breaths/min, heart rate of 170 beats/min, and a blood pressure of 120/90 mmHg.2 of 90.0 mmHg, PaCO2 of 31.9 mmHg, HCO3− of 18.7 mmol/l, base excess of −5.0 mmol/l, and lactate of 14 mg/dl.Laboratory investigations showed an inflammatory process and muscle deviation enzyme consistent with blunt trauma. The serum creatinine kinase level was elevated at 3110 IU/l. Arterial blood gas analysis on 100 % oxygen revealed pH of 7.38, PaOChest CT detected bilateral lung contusions, left hemopneumothorax and fractures of the left third to fifth ribs Fig. . Based o2O, pressure support (PS) 5 cmH2O, targeted tidal volume of 70 ml, positive end expiratory pressure (PEEP) of 7 cmH2O and FIO2 of 0.4.On the day of admission, the patient was intubated using 4 mm cuffed endotracheal Ventilation mode was synchronized intermittent-mandatory ventilation (SIMV) pressure-control and pressure-triggered ventilation. With an inspiratory time of 0.7 s, respiratory rate of 25 breaths/min, pressure control 13 cmHOn day 9, the patient was extubated because paradoxical movement of the left thorax had resolved, lung contusions were improved on chest CT, and the P/F ratio improved from 90 to 300 on minimal spontaneous CPAP ventilation. However, the flail chest relapsed a few hours after extubation. Then, we decided that chest taping was effective if it was short period of time, because the manual compression was effective for this case during transportation and conservative management of mechanical ventilation was performed for 9 days. After all, the presence of a paradoxical segment was disappeared on day 11.Since her condition was stable, she was transferred to a local hospital for rehabilitation on day 22.Several recent randomized controlled studies of surgical intervention of flail chest have demonstrated an improvement in the number of ventilator days, intensive care unit and hospital stays, incidence of pneumonia, and respiratory function and hospital costs, as well as faster return to work . Other rSurgical costal fixation is associated with a shorter duration of intubation and hospital stay compared with conservative management including chest taping and mechanical ventilation , 6, 7. IIn small children, functional residual capacity is smaller, and the thorax is drawn inside due to high thoracic compliance. It is difficult for small children to stay at rest. Therefore, it is only advisable to select intubation and mechanical ventilation treatment.Although ventilator management protocols in pediatrics were previously reported , in pediIn the case 2, even if flail chest and lung contusion have resolved, it is possible for ventilatory defects due to flail chest to relapse, especially after extubation. In other words, the recurrence is a sudden event and difficult to predict. In fact, although we compared the present cases profiles. Table , there wIn conclusion, the present report described two pediatric cases of flail chest, which was rare in pediatric blunt trauma. To manage ventilatory defects secondary to flail chest, conservative medical treatment using a ventilator is the basic treatment. However, it is difficult to predict a recurrence even if treatment goes well. Since chest taping was not universal treatment, the not always work well. Therefore, careful observation is required when extubation, and self-breath test using T-piece before extubation may be enforced.


Visceral leishmaniasis (VL), a potentially fatal disease, is most prevalent in the Indian subcontinent, East Africa and South America. Since the conventional antileishmanial drugs have many limitations we evaluated a new ergosterol rich liposomal amphotericin B formulation, KALSOME™10 for its leishmanicidal efficacy, tolerability and immunomodulatory activity.Leishmania donovani amastigotes. Two months post infection they were treated with the above mentioned doses of KALSOME™10 and sacrificed one month after treatment for estimation of parasite burden in the liver and spleen by Limiting Dilution Assay. Leishmanial antigen stimulated splenocyte culture supernatants were collected for cytokine detection through ELISA. Flow cytometric studies were performed on normal animals treated with KALSOME™10, Amphotericin B (AmB) and AmBiosome to compare their immunomodulatory activities.Normal healthy mice were treated with 3.5 mg/kg single and 7.5 mg/kg single and double doses of KALSOME™10. Liver and kidney function tests were performed fourteen days after treatment. Next, normal mice were infected with + and CD8+ subsets of T cells, as well as from culture supernatants of splenocytes, compared to that of normal, AmB and AmBisome treated animals.The drug was found to induce no hepato- or nephrotoxicities at the studied doses. Moreover, at all doses, it led to significant reduction in parasite burden in two month infected BALB/c mice, with 7.5 mg/kg double dose resulting in almost complete clearance of parasites from both liver and spleen. Interestingly, the drug at 7.5 mg/kg double dose could almost completely inhibit the secretion of disease promoting cytokines, IL-10 and TGFβ, and significantly elevate the levels of IFNγ and IL-12, cytokines required for control of the disease. Mice treated with KALSOME™10 showed elevated levels of IFNγ and suppressed IL-10 secretion from both CD4Treatment of infected mice with 7.5 mg/kg double dose of KALSOME™10 was safe and effective in clearing the parasites from the sites of infection. The drug maintains the inherent immunomodulatory activities of AmB by effectively suppressing disease promoting cytokines IL-10 and TGFβ, thereby boosting IL-12 and IFNγ levels. This emphasizes KALSOME™10 as a promising drug alternative for lifelong protection from VL. Leishmania donovani and/or L. infantum/chagasi. An estimate of 0.2-0.4 million global VL cases are reported each year with more than 90% of them occurring in India, Bangladesh, Sudan, South Sudan, Brazil and Ethiopia [Visceral leishmaniasis (VL) or kala-azar, a disseminated infection of the lymphoreticular system, is caused by the protozoan parasite(s) Ethiopia  Human inEthiopia . Active Ethiopia . Thus a In the absence of a vaccine, chemotherapy is the mainstay to combat the disease. Until the year 2000, pentavalent antimonials (Sbv) were the frontline treatment for VL. However, with the emergence of antimony resistant parasites in parts of northern Bihar, India, amphotericin B (AmB) was introduced which renders high cure rates >95%) in VL patients . However5% in VL et al. demonstrates that exogenous cholesterol, if added in the culture, can enhance the growth of Leishmania promastigotes [Leishmania for its sustenance may be fulfilled by salvaging cholesterol from host macrophages. Hence, formulation of liposomal AmB devoid of cholesterol is a good strategy in designing antileishmanial drugs. Thus, new amphiphilic L-AmB, KALSOME™10 has been developed where AmB is intercalated with sterol and phosphatidyl choline. This is a sterol rich drug where ergosterol constitutes 50% molarity of total lipid in the liposome [L. donovani infection [Most of the L-AmBs in clinical use contain cholesterol as one of the constituents and is useful for stability and targeted delivery of the drug ,11,12. Cstigotes . Therefoliposome . Absencenfection . Here weKALSOME™10  was provided by Lifecare Innovations Pvt. Ltd., Gurgaon, India. Toxicity study kits  were purchased from Randox Molecular Diagnostics, London, UK. ELISA kits for cytokines IL-10, IL-12 and IFNγ were obtained from BD Biosciences  and TGFβ from eBioscience . The following fluorochrome tagged mAbs obtained from BD Pharmingen were used: anti-mouse CD4 PE-Cy7, anti-mouse CD8a Percp-Cy5.5, IFNγ Alexa fluor 488 and IL-10 APC.L. donovani strain AG83 (MHOM/IN/1983/AG83), originally isolated from an Indian kala-azar patient, was maintained by serial passage in hamsters [BALB/c mice (4–6 weeks old) used in the experiments were bred in the Institute’s animal house facility. The studies were performed according to the Committee for the Purpose of Control and Supervision on Experimental Animals (CPCSEA), Ministry of Environment and Forest, Govt. of India, and approved by the animal ethics committee (147/1999/CPSCEA) of Indian Institute of Chemical Biology. hamsters .KALSOME™10, a gift from Lifecare Innovations Pvt Ltd, India is a sterol enriched liposome, intercalating AmB, in an aqueous suspension. Ergosterol constitutes almost 50% of the total liposomal lipid, overall consisting of phospatidylcholine, ergosterol and AmB in 5:2:1.8 ratios. The composition was sonicated during manufacture and before administration for increasing plasma half-life and better bio-distribution .7 freshly isolated amastigotes [Thirty healthy BALB/c mice (4–6 weeks old) were infected with 2.5 × 10stigotes . Six micOne month after treatment all the mice were sacrificed, spleen and liver were removed aseptically, and parasite burden of the organs were quantified by Limiting Dilution Assay (LDA) as described earlier . BrieflyFor toxicity study, twenty four healthy adult (8–10 weeks old) BALB/c mice weighing approximately 25 g were randomly divided into groups of six mice each. One group was kept as control and rest were injected with 3.5 mg/kg single dose, 7.5 mg/kg single dose and 7.5 mg/kg double dose of KALSOME™10, respectively, in 200 μl of 0.02 M PBS through the tail vein. Liver  and kidney (urea and creatinine) toxicity tests were performed 14 days after drug administration  and compL. donovani promastigotes as described earlier [LAg was prepared from  earlier . Briefly4Cl. The remaining cells were washed twice in culture medium and viable mononuclear cell number determined by counting Trypan blue unstained cells in a hemocytometer. The cells (1 × 106/ml) were then cultured in duplicate in 96-well flat-bottom tissue culture plates (Nunc) and stimulated with LAg (10 μg/ml) for 3 days at 37°C in 95% humidified air with 5% CO2 [For cell proliferation and cytokine assay, spleens were aseptically removed from normal, infected and treated animals one month posttreatment. Single cell suspension was prepared in RPMI 1640 supplemented with 10% FBS, l00 U/ml penicillin G sodium, 100 μg/ml streptomycin sulfate and 50 μM β-mercaptoethanol. RBCs were removed by lysis with 0.14 M Tris buffered NHFlow cytometry was performed on various T cell subsets and the intracellular cytokines produced by these cells from normal and drug treated mice were analyzed as described . Splenocp < 0.05 were considered to be statistically significant.All data comparisons were tested for significance by One-way analysis of variance (ANOVA) and Tukey’s multiple comparisons using Graph Pad Prism version 5.0 . Results with i.e. liver and spleen. Treatment with 3.5 mg/kg and 7.5 mg/kg single doses of KALSOME™ 10 showed a substantial fall (~3-fold) in parasite levels in these organs compared to infected controls. Administration of 7.5 mg/kg double dose, on the other hand, resulted in almost complete clearance of the parasites from both liver and spleen , 7.5 mg/kg double dose appeared to be most effective with parasite clearance efficiency significantly higher (P < 0.001) than even 3.5 mg/kg single dose. The weights of infected liver and spleen also gradually decreased with increase in drug doses  were injected into 2 months infected BALB/c mice. One month after treatment LDA was performed to evaluate parasite burden at the sites of infection To detect any functional abnormality of liver due to KALSOME™ 10 treatment, the drug was administered into normal healthy BALB/c mice at three different doses  and SGPT, SGOT and alkaline phosphatase levels measured at 14 days posttreatment. Treatment with single drug doses of 3.5 mg/kg and 7.5 mg/kg resulted in comparable levels of SGPT and alkaline phosphatase whereas administration of 7.5 mg/kg double dose exhibited minor increase in these parameters compared to untreated controls  and TGFβ (P < 0.01) in comparison to normal mice, whereas there was no change in the levels of IL-12 and IFNγ when compared to normal controls  and TGFβ (P < 0.01) was observed in all the groups in comparison to infected mice. Nevertheless, 7.5 mg/kg double dose, which showed the most effective cure, resulted in almost complete inhibition of both of IL-10 and TGFβ  higher levels of IL-12 and IFNγ at 7.5 mg/kg double dose  elevation of IFNγ  doses of KALSOME™10 and AmBisome in groups of normal mice. Another group was injected with 2.5 mg/kg dose of AmB, the maximum tolerable dose of this drug, keeping an untreated group as control. After 10 days the animals were sacrificed and ConA stimulated splenocytes were cultured for cytokine ELISA and FACS analysis. In cytokine ELISA study, we found that IFNγ secretion was significantly high from 7.5 mg/kg double dose of KALSOME™10 treated mice compared to all other groups Figure A. This ee Figure C and D. e Figure B, supprel Figure E and F. Leishmania strains in India. This drug has proved to be very effective against VL with a cure rate of almost 100% [Leishmania infection [AmB, a polyene macrolide, has emerged as the main antileishmanial drug following the prevalence of SAG resistant ost 100% . Howeverost 100% . Severalnfection ,25. Unfonfection ,27 demonnfection . Interesnfection  suggestiLeishmania is unique in having the ability to survive and multiply within host neutrophils and macrophages. AmB promotes leishmanicidal activity by virtue of its high intercalation affinity for ergosterol or its precursor present on the parasite [Leishmania infection. One of them is cholesterol, present mostly in human kidney cell membranes and the other is ergosterol, present in parasite. It is noticeable that affinity of AmB for ergosterol is aproximatly 8.5 times more than that of cholesterol [Leishmania. Thus ergosterol encapsulated AmB has a definite edge over cholesterol encapsulated AmB due to its slow release and greater target specificity. Also due to higher affinity of AmB towards ergosterol than cholesterol, greater amount of AmB can be tightly packed inside the liposome and it can be targeted to the macrophages more efficiently [parasite . It, howparasite . In KALSparasite . Mechanilesterol . For efficiently . In our iciently ,31 and Aiciently ,32 theseL. donovani infected BALB/c mice [The parasiticidal efficacy of KALSOME™10, at 7.5 mg/kg triple dose, has already been established in B/c mice . Our intB/c mice . While 5B/c mice . Even inB/c mice ,36. ThusL. donovani infection is modulated by a range of T cell responses and cytokine network. Extensive studies have identified IL-10 as the major player in the disease pathology of VL [It is well established that the course of disease progression following gy of VL . It can gy of VL . TGFβ hagy of VL . Effectigy of VL ,37,38. Igy of VL ,7,39. He+ and CD8+ T cells in 7.5 mg/kg KALSOME™10 treated groups led to maximum suppression of IL-10 production from these cells. Such an elevation of IFNγ was almost absent in AmBisome at all comparative doses. Although some immunomodulatory activity was detected by AmB treatment, the best results were observed only with KALSOME™10. Therefore, encapsulation of AmB in our formulation not only maintains the inherent immunomodulatory effects of AmB, but also enhances it, which is a prerequisite for long term protection.Notably KALSOME™10 showed marked immunomodulatory effect at single and double doses of 7.5 mg/kg by significantly increasing IFNγ level leading to suppression of IL-10. Elevated production of IFNγ from CD4L. donovani infected mice with KALSOME™10 at 7.5 mg/kg double dose resulted in almost complete parasite clearance from both liver and spleen without inflicting any liver and kidney toxicity. The decline in parasite number was supported by a curative immune response with a significant fall in disease promoting cytokines (IL-10 and TGFβ) and subsequent increase in protective cytokines (IL-12 and IFNγ). These results with KALSOME™10 at 7.5 mg/kg double dose could match the immunological profile obtained with AmB as early as two days posttreatment without showing any infusion related side effects. However, the role of KALSOME™10 in prevention of reinfection after cure and long term protection from VL need further investigation. Till date KALSOME™10 has only been used in experimental animals, but when it is marketed its price is expected to be 25% less than AmBisome by virtue of its 10 times more AmB associated with liposome in comparison to AmBisome.In conclusion, we can say that treatment of


Dyslipidemia is one of the most important independent modifiable risk factors for cardiovascular diseases. The objective of this study was to determine the prevalence and risk factors for dyslipidemia in Shenzhen, a special economic zone and large metropolitan area neighboring Hong Kong.A cross-sectional survey of 1,995 adults with a mean age of 46.56 years was conducted between February and July 2011 using a multistage stratified cluster random sampling. All the subjects were administered questionnaires regarding socio-demographic characteristics and other possible factors associated with the prevalence of dyslipidemia. Fasting venous blood samples were collected to assess the lipid profile. Weight, height, waist circumference, and blood pressure were measured.The mean concentrations of total cholesterol (TC), triglycerides (TG), high density lipoprotein cholesterol (HDL-C), and low density lipoprotein cholesterol (LDL-C) were 5.11 ± 1.15 mmol/L, 1.59 ± 1.47 mmol/L, 1.42 ± 0.33 mmol/L, and 3.22 ± 0.84 mmol/L, respectively. High values of TC, TG, low HDL-C, and high LDL-C were obtained in 14.49 %, 16.14 %, 8.82 %, and 12.13 % of the 1,995 participants, respectively. The prevalence of dyslipidemia was 34.64 %, among which 25.04 % of subjects were aware. Presence of dyslipidemia was significantly associated with increasing age, smoking status, hypertension, diabetes, and body mass index.High prevalence of dyslipidemia with relative low awareness in Shenzhen was found. A comprehensive strategy is required for the prevention, screening, treatment, and control of dyslipidemia in Shenzhen. Dyslipidemia is defined as the derangements of one or more of the lipoproteins in blood, such as elevated in total cholesterol (TC), low density lipoprotein cholesterol (LDL-C) and/or triglycerides (TG), or low levels of high density lipoprotein cholesterol (HDL-C) alone . The resSeveral clinical trials have indicated that the treatment of dyslipidemia is effective in both primary and secondary prevention of cardiovascular events , 7. Treast century metropolis housing over millions of people. Unprecedented social and economic development in Shenzhen has led to changes in patterns of diet, physical activity, and other socio-demographic characteristics that are contributing to large increases in the prevalence of cardiovascular disease and other chronic diseases [As China’s first Special Economic Zone to spur economic growth after the near collapse of the socialist centrally-planned economy in 1978, Shenzhen has transformed from an agriculture-based Baoan County into a 21diseases . Dyslipidiseases , 12, 14.The present study was conducted as a part of the China Health and Nutrition Survey at the Center for Chronic Disease Control of Shenzhen. In brief, the survey used a multistage stratified cluster random sampling method to select a representative sample of permanent residents in 8 different districts in Shenzhen city. The first stage of sampling was stratified by district and population distribution on the basis of Shenzhen population data from 2010, which involved the random selection of 12 streets from those 8 districts. In the second stage, one residential community was randomly selected from each selected street. In the third stage, about 75 households were randomly selected from the residential communities selected in the earlier stage. In the last stage, eligible family member from each designated household was chosen.Volunteers were recruited from selected households from February 2011 to July 2011. The eligibility criteria were set as following: aged 20 years or above, living in Shenzhen for more than 5 years, men or non-pregnant women, confirmed not to present with cancer, severe liver disease, pancreatitis, polycystic ovarian syndrome, systemic lupus erythematosus, and kidney diseases.From February 2011 to July 2011, 1,995 participants were recruited according to the eligibility criteria. All participants received information and publicity about the health risk that may result from dyslipidemia exposure. All participants have the chances to receive the health check and biochemical determination results if they provided their telephone number or other contact information. The study received ethnicity approval of the Center for Chronic Disease Control of Shenzhen. Written informed consent was obtained from all participants before the study.Structured questionnaires were administered to collect information on potential risk factors for elevated blood lipids, as well as possible factors associated with dyslipidemia. Volunteers were interviewed in person 1 to 2 hours after blood collection and each questionnaire took approximately 20 min to complete. Questions covered general information , socioeconomic status (household per capita income and education level), health behaviors , and personal medical history.The age groups were classified according to results from Shenzhen 2010 census as 20 to 29 years, 30 to 39 years, 40 to 49 years, 50 to 59 years, 60 to 69 years, 69 to 79 years, and ≥80 years. Employment status was classified into one of the followings: homemaker, employed, unemployed, retired, and others. Marital status was categorized as single, married, widowed, and divorced. Educational level was categorized into 5 groups according to the number of years of education . Subjects were asked to choose 1 of 10 income categories that best represented the household per capita income for the past 12 months: < 5,000 RMB; 5,000 to 9,999 RMB; 10,000 to 14,999 RMB; 15,000 to 19,999 RMB; 20,000 to 24,999 RMB; 25,000 to 29,999 RMB; 30,000 to 34,999 RMB; 35,000 to 39,999 RMB; ≥ 40,000 RMB; and unclear. The questions regarding smoking, which are described in details elsewhere, permit stratification of participants into categories such as ever-smokers (including: current smokers and ex-smokers) and never smokers . In the Anthropometric examinations were administered in the morning after fasting overnight, followed by body measurements, which were taken by trained examiners using a standardized protocol. Height, body weight, waist circumference, and blood pressure of all participants were recorded. Height and weight were measured with the participants wearing light dress without shoes using analog scales. Waist circumference (WC) was measured at the midpoint level of midaxillary line between the 12th rib head and the superior anterior iliac spine, with measuring time at the end of normal expiration. Body mass index (BMI) was calculated by dividing body weight (in kilograms) by the square meters of height. Blood pressure was measured using a mercury sphygmomanometer on the right arm of each of the participants in a comfortable sitting position after a 30 min rest period. Three consecutive blood pressure measurements were performed, and the mean of these three measurements was applied in the subsequent analysis.Vein blood samples were collected after 10 to 14 hours of fasting. Each glass automatic hemostix was marked with the volunteer’s identification code and placed into ice in a portable refrigerator before transporting to laboratory. In our laboratory, the blood samples were separated by centrifugation at 1000 × g for 15 min at 4 °C, and then supernatant serum was collected. Serum glucose (fasting blood glucose), TC, TG, LDL-C, and HDL-C concentrations were measured by using commercially available kits  by autoanalyzer . Serum TG were measured using the glycerol-3 phosphate oxidase-phenol + 4-aminophenazone enzymatic colorimetric method and TC by the cholesterol oxidase method. HDL-C was estimated in a series of reaction steps using an enzymatic cholesterol reagent after precipitation of non–HDL-C with magnesium/dextran, and LDL-C was estimated using a third-generation direct LDL cholesterol assay. The laboratory variation coefficient of TC, TG, HDL-C, and LDL-C was 1.5 %, 4.3 % , 3.0 %, and 3.9 %, respectively . Furthermore, as measures of quality control and assurance, analytical duplicates, and reagent blanks were routinely included in the analytical sequence for detection of precision and signs of contamination, respectively. In all cases, analyses were performed after the correct values had been confirmed by the instrument. All blood samples were analyzed within 4 hours after being collected.Dyslipidemias were defined according to Chinese criteria . High TC2 were classified as underweight, those with BMI of 18.5 to 23.9 kg/m2 as normal weight, those with BMI of 24 to 27.9 kg/m2 as overweight, and those with BMI of ≥28 kg/m2 as obese [Body mass index (BMI) was used as a measure of body size. Participants with BMI <18.5 kg/mas obese . Two setas obese .Hypertension was defined as mean systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg, and/or self-reported antihypertension treatment in the last 2 weeks. Diabetes was defined as fasting blood glucose (FBG) ≥7.0 mmol/L, and/or self-reported treatment of diabetes with antidiabetes medication in the previous 2 weeks.t-test. The chi-squared test or Fisher’s exact test was used to determine significant differences in proportions among categorical variables. Normal distribution of the serum lipid concentration was tested by Kolmogorov-Smirnov test, and showed a highly skewed. Changes in outcome measures between the different groups not following normal distribution were tested by Mann-Whitney U test or Kruskal-Wallis H test for independent variables.The mean and standard deviation of continuous variables were expressed as mean ± SD, and percentage was calculated for categorical variables. Age and other anthropometric examination characteristic differences between groups defined by gender were evaluated using Student's P value of <0.05 was considered to be statistically significant. We estimated age standardized prevalence rate, and the standard population used in the direct method was the Shenzhen 2010 census population.The univariate and multivariate logistic regression models were used to investigate the probability to having dyslipidemia according to socio-demographic and other variables. Statistical analysis of the data was performed by Statistical Package for Social Sciences (SPSS) version 21.0 software . A n = 885) were men, 55.64 % (n = 1110) were women, the mean age was 46.56 ± 15.26 (20-96) years, 83.26 % attained a junior high school or higher education, 88.77 % were married, and 48.27 % were employed. The rate of smoking was 20.75 %, and drinking was 35.09 %, and 79.75 % of the study subjects reported having regular physical activities. In terms of anthropometric, the mean levels of average BMI, SBP, DBP, WC and FBG for all 1,995 participants were 23.52 ± 3.49 Kg/m2, 115.65 ± 17.58 mm Hg, 74.97 ± 10.11 mm Hg, 82.04 ± 10.51 cm, and 5.39 ± 1.32 mmol/L, respectively.The Socio-demographic and other characteristics of the participants are summarized in Table Significant differences were found in different gender groups for BMI, SBP, DBP, WC, FBG, physical activity, smoking status, drinking habit, marital status, educational level, and employment status Table . SubjectThe mean concentrations of TC, TG, HDL-C, and LDL-C were 5.11 ± 1.15 mmol/L, 1.59 ± 1.47 mmol/L, 1.42 ± 0.33 mmol/L, and 3.22 ± 0.84 mmol/L, respectively, in the general Shenzhen population aged from 20 to 96 years.P = 0.083). In addition, we found that serum lipid concentrations were significantly positively  or negatively (HDL-C) correlated to diabetes, hypertension, body size, and age  of the participants. A positive history of dyslipidemia disease in the past year, and/or currently receiving treatment with lipid-lowering medications was described by 55 subjects, so that the total prevalence of dyslipidemia was 34.64 %. Adjusted for age on the basis of Shenzhen census 2010, the prevalence of dyslipidemia was 25.98 %. This represents 2.2 million Shenzhen adults aged from 20 to 96 years with dyslipidemia. Among subjects with dyslipidemia, 173(25.04 %) were aware of the diagnosis of their condition.P = 0.022), and participants with hypertension had 1.595 fold increased prevalence of dyslipidemia (P <0.001). With regard to health behaviors, ever smokers more likely to had dyslipidemia . Evaluation of body size suggested that, participants with high body size had a greater prevalence of dyslipidemia . Compared with participants 20 to 29 years of age, those who were 50 to 59 years of age had a greater prevalence of dyslipidemia .A number of potential independent factors that might influence the prevalence of dyslipidemia were evaluated by univariate logistic regression model. The results revealed that the variables of gender, diabetes, hypertension, central obesity, smoking status, body size, marital status, educational level, employment status, household per capita income (data not shown), and age were significantly associated with the prevalence of dyslipidemia Table . On the With economic growth and adverse changes in lifestyle , cardiovascular diseases have become the leading cause of death in China . DyslipiThis study was conducted in 8 districts of Shenzhen to comprehensive assess the prevalence of dyslipidemia as well as the associated risk factors. Our results indicated that the prevalence of high TC, high TG, high LDL-C, and low HDL-C were 14.49 %, 16.14 %, 12.13 %, and 8,82 %, respectively. It was also revealed that the prevalence of dyslipidemia was about 34.64 % (standardized rate per 2010 Shenzhen population: 25.98 %). Furthermore, our results suggested that the presence of dyslipidemia was significantly associated with age, diabetes, hypertension, body size, and smoking status.Several previous epidemiological studies reported serum lipid concentrations in Chinese populations , 21, 22.During the past several decades, favorable trends in lipid levels have occurred among adults in the United States . For exaThe prevalence of high TC 14.49 %) and high LDL-C 12.13 %) found in this study were significantly higher than average Chinese national standards , whereas the prevalence of low HDL-C (8.82 %) was significantly lower than the national average 22.30 %) [.30 % 22, Delhi [.49 % and.13 % fouThe prevalence of dyslipidemia in our study was partially comparable to figures reported in previous epidemiological studies , 12, 24.Previous studies reported that age did appear to influence dyslipidemia risk , 14, 24.Several well established risk factors for dyslipidemia, including hypertension and diabetes have been evaluated , 33, 37.Other researchers observed associations between dyslipidemia and smoking , 40, 41.Potential limitations of our study should be mentioned. First, no dietary intake was measured. Therefore, our study cannot show their effect on serum lipids. Second, potential recalled sources of bias including recall bias and self-reported information. Finally, other risk factors  were not taken into account.Dyslipidemia was present in about 34.64 % of the study population in Shenzhen, and the awareness rate of dyslipidemia was 25.04 %. Risk factors associated with dyslipidemia were aging, higher body size, hypertension, diabetes, and smoking. Dyslipidemia is becoming an important public health problem. Obesity can be used to screen for dyslipidemia along with other coexisting risk factors such as hypertension and diabetes. There is an urgent need to institute more positive public health measures and screening programs and to treat patients diagnosed with dyslipidemia.


Most of the population (83.3%) showed As urinary levels exceeding the normal (<50 ng·mg−1). These results indicate the possibility of arsenicosis symptoms in residents of the areas studied. Among the three biomarkers tested, hair has shown to be a reliable indicator of metal exposures. The levels of As (2r = 0.633), Ba (2r = 0.646), Fe (2r = 0.595), and Mo (2r = 0.555) in hair were strongly positively associated with the levels of those metals in groundwater. In addition, significant weak correlations (p < 0.01) were found between levels of exposure to As and As concentrations in both nails (2r = 0.544) and urine (2r = 0.243).Chemical analyses of metal  concentrations in hair, nails, and urine of Cambodians in arsenic-contaminated areas who consumed groundwater daily showed elevated levels in these biomarkers for most metals of toxicological interest. The levels of metals in biomarkers corresponded to their levels in groundwater, especially for As, whose concentrations exceeded the WHO guidelines for drinking water. About 75.6% of hair samples from the population in this study contained As levels higher than the normal level in unexposed individuals (1 mg·kg In complex modern societies, humans can be exposed on a daily basis to a wide range of chemicals and pollutants. These come not only from environmental sources such as air, soil, water, and food, but also from a variety of lifestyle and occupational activities . ExposurSince 1999, numerous incidents have been reported of groundwater contamination in Cambodia by metals such as arsenic (As), manganese (Mn), and barium (Ba), occurring in provinces located along the Mekong delta floodplains ,6,7,8,9.One way to assess the extent of environmental exposure to chemicals, and to screen their potential impacts on humans, is by conducting human biomonitoring (HBM). HBM has been a tool of interest for quantifying human exposure, and body responses, to environmental pollutants from as far back as the 19th century ,14,15,16−1, were selected as As contaminated areas. The village of Kampong Toul (KT) in Kandal Province was selected as a non-polluted (control) area. Four villages located in two provinces in the southern part of Cambodia were selected for this present study . Based oThe ethical approval for conducting health risk assessment using hair, nails, and urine of Cambodia residents in all areas studied was approved by the National Ethics Committee for Health Research (NECHR), Ministry of Health, Cambodia (Reference No. 180 NECHR). A total of 180 individuals (50 from each contaminated area and 30 from the control area) were recruited as study subjects. The subject inclusion criteria used in this present study were a period of habitation in the study areas, as well as a period of continuous groundwater consumption, of at least one year. Prior to collection of biomarkers, each subject was informed by a local researcher about the purpose of this study with a document written in Khmer. In addition, the informed consent of each subject was obtained before the collection of hair, nails, and urine samples. Hair samples of about 1 cm were collected from the region of the head close to the scalp behind the ear. Nail samples were collected primarily from toenails. In very rare cases, (one case from CK and three cases from KT) samples of other nails supplemented these when the amount of toenail sample was not enough. For the urine samples, spot urine was collected from each subject and immediately kept on ice. After that, all urine samples were transferred to a liquid nitrogen tank and delivered to a laboratory.At the same time, as the biomarker collection, 76 groundwater samples were collected from tube-wells used as a source of drinking water by subjects in the study. All groundwater samples were collected after 5 min of pumping. Once collected, each sample was filtered, acidified with nitric acid to a pH of less than 2, then stored in an acid-washed tube until analysis.et al. (1999) [In the laboratory, hair and nail samples were first cleaned according to the method described by Chen . (1999) . In brie. (1999) . The finIn addition, a certified reference material (CRM) of cod fish tissue  CRM 7402-a, No. 20) was also digested and analyzed by ICP-MS in the same manner as all biomarker samples to ensure the effectiveness of metal recovery by the digestion method. The percentage recoveries of all metals of interest were in the range of 83.6% to 86.9%. Procedural blanks were also treated and analyzed in the same manner as all samples pre-treatment. The accuracy of instrument analysis was conducted by analyzing the standard reference material (SRM) of trace elements in water (SRM 1643e) purchased from National Institute of Standards and Technology (NIST), USA and analytical blanks after the analysis of every 20 samples. The percentage recoveries of instrumental analyses obtained were in the range of 85.7% to 105.1%. Levels of all metals in procedural and analytical blanks were found to be lower than the limits of quantification as reported in Concentrations of metals contained in all water samples and in digested biomarker  samples were determined by ICP-MS with an online addition of germanium (1 ppm) as an internal standard. The ion signal for germanium at m/z 72 was found. The limits of quantification for metals in groundwater, hair, nail, and urine samples are summarized in −1 creatinine.Metal concentrations in urine were also determined by ICP-MS. Afterward their metabolized concentrations were adjusted with urinary creatinine and measured by a specific gravity method, to finally obtain the metal levels in urine in units of ng·mgn > 50). Since the distributions of the data sets were not normal, a nonparametric test, the Kruskal-Wallis H, was applied to assess the regional differences in metal concentrations in groundwater, hair, nails, and urine. The correlation between each metal’s concentration in groundwater and its corresponding concentration in a given biomarker, as well as the correlation of concentrations across biomarkers for a given metal, were analyzed by the Spearman’s rho correlation statistic. The value of p < 0.01 was used to judge the significance of differences and correlations for the parameters mentioned.All statistical analyses were performed using the Statistical Packages for Social Sciences (IBM SPSS) Software (version 15.0). Prior to statistical analysis, all data sets were tested for normality of distribution by the Komogorov-Smirnov test  and Ba (700 μg·L−1) concentrations in groundwater [−1. Ranges of concentrations of As in groundwater from the villages were 16.02–959 μg·L−1 for PS, 57.9–997 μg·L−1 for PC, and 402–923 μg·L−1 for CK.  [−1) in groundwater collected from As contaminated areas. The levels of Ba in groundwater found in the present study were similar to those reported earlier (24.55–2631 μg·L−1).Overall, significant differences could not be found among concentrations of all metals except Fe, As, and Mo in groundwater collected from all areas studied. Compared to the control area (KT), significantly higher concentrations of Fe, As, and Mo were found in samples collected from contaminated areas. This finding confirmed that the mobilization of As in study areas, floodplains along the Mekong River, was mainly caused by the desorption of As from As-bearing Fe oxides in sediments . For thiundwater , only pe for CK. . For Ba,ectively ,26. Phan−1 for Cr, 17.92 mg·kg−1 for Mn, 79.98 mg·kg−1 for Fe, 0.06 mg·kg−1 for Co, 0.70 mg·kg−1 for Ni, 12.52 mg·kg−1 for Cu, 255.4 mg·kg−1 for Zn, 4.18 mg·kg−1 for As, 0.07 mg·kg−1 for Mo, 10.39 mg·kg−1 for Ba, and 2.64 mg·kg−1 for Pb. The orders of metal concentrations found in hair were Co < Mo < Cr < Ni < Pb < As < Ba < Cu < Mn < Fe < Zn. Statistical analyses revealed significant differences in concentrations of all metals in hair samples collected from the areas studied. Only two areas (CK and PC) were identified with metals concentrations in hair which were statistically higher than the other areas. Hair samples collected from PC were found with Mn, Fe, Cu, As, Ba, and Pb higher than in the samples collected from the other three areas  (p > 0.01). Along with the hair samples from KT, the groundwater samples from KT also yielded the lowest levels of Fe, As, Mo, and Ba among the four areas. It has been observed that the level of metals in groundwater is not the only factor affecting the accumulation of metals in biomarkers; other important factors include age, gender, individual susceptibility, period of groundwater consumption and amount of daily groundwater consumption [The median concentrations of metals in all collected hair samples were 0.29 mg·kg and PS) . The higsumption .Generally, As is the element whose concentration is most often observed in hair and other types of biomarkers. Because earlier studies did not include levels of metals other than As in hair, only the hair As concentrations in this study could be compared to previous researchers’ findings. −1 [−1. The percentage of subjects in the non-control areas measuring As in hair higher than the 1 mg·kg−1 level was 90% in CK, 94% in PC, and 88% in PS. These figures indicate the possibility of As toxicity among residents of the areas who chronically consume groundwater. The range of As concentrations in hair in this study (0.03 to 56.75 mg·kg−1) was comparable to those reported for Cambodian subjects’ hair in previous studies. For example, the range of As concentrations in hair collected from the residents of As contaminated areas had been previously measured at 0.01–57.21 mg·kg−1 [−1 [−1 [et al. (2008) [−1. The ranges of As in hair in CK, PC, and PS were respectively 0.65–56.75 mg·kg−1, 0.27–22.69 mg·kg−1, and 0.23–12.94 mg·kg−1, (The ATSDR (Agency for Toxic Substances and Disease Registry) recommends the normal level of As in hair of unexposed individuals should be less than 1 mg·kg−1 . This As [−1 [−1 . Sampson. (2008)  found hamg·kg−1, . The thr2r = 0.633) (2r = 0.646) (2r = 0.595) (2r = 0.555) (−1) in hair was in a male resident who had been exposed to the highest level of Fe in groundwater . The results clearly indicated that groundwater used as drinking water was the source of various metal exposures. Since the desorption of As from As-bearing Fe (-Mn) oxides in sediments was the key factor mobilizing As in groundwater, the higher exposure and accumulation in biomarkers was observed. In addition, = 0.633) a, Ba (r2= 0.646) a, Fe (r2= 0.595) b, and Mo= 0.555) c in hair−1 Mo, 0.35 mg·kg−1 Co, 1.30 mg·kg−1 Pb, 1.40 mg·kg−1 Ni, 1.64 mg·kg−1 Cr, 3.04 mg·kg−1 As, 4.95 mg·kg−1 Cu, 10.07 mg·kg−1 Ba, 25.46 mg·kg−1 Mn, 113.0 mg·kg−1 Zn, and 875.7 mg·kg−1 Fe. Concentrations of Cr, Mn, Fe, Co, Ni, Cu, and Ba in nails collected from the PC area were significantly higher than in those from the other study areas. This is in agreement with the metal concentrations measured in groundwater samples, where the higher concentrations were usually detected in the PC area  as noted by Hughes (2006) [For As concentrations in nails, the ATSDR also recommends 1 mg·kgividuals . In thiss (2006) . However2r = 0.544)  a.−1 Co, 1.23 ng·mg−1 Mn, 1.69 ng·mg−1 Cr, 2.38 ng·mg−1 Pb, 8.85 ng·mg−1 Ni, 11.10 ng·mg−1 Cu, 12.33 ng·mg−1 Ba, 38.63 ng·mg−1 Fe, 65.87 ng·mg−1 Mo, 86.77 ng·mg−1 As, and 388.7 ng·mg−1 Zn. However, Mn, Fe, Ni, and As concentrations were found to be statistically different among the study areas  and arsenicosis patients (78.74 ± 69.84 ng·mg−1) were not significantly different [−1) were not statistically different from those of subjects consuming As-enriched groundwater, the results of urinary As obtained from this present study could not solely be used to indicate the level of As exposure or predict the development of individual As health impacts. Phan et al. (2014) [2r = 0.243), which was for As, was found between levels of metal exposure and concentrations of metal in urine   concludein urine b.et al., 2004 [et al., 2012 [Two other studies, by Samanta l., 2012 , have lol., 2012 . These rp < 0.01) in the individual median concentrations of Fe, Co, Ni, Zn, As, and Mo in all three biomarkers. The negative Z-values shown in negative ranks, meaning when there was an increase in a specific metal concentration in one biomarker, there was a significant decrease in the same metal concentration in the other biomarker. This finding fits with the notion of extensive biotransformation of ingested As by the human body. Specifically, because the body can excrete about 40% to 70% of the total ingested inorganic As within about 48 h [To compare the different levels of metals contained in different biomarkers within each individual studied, a Wilcoxon Signed-Rank Test was performed. A statistical analyses (by pairwise comparisons) revealed significant differences (p < 0.01), though weak, correlations between concentrations found in hair and nails occurred for Ba (2r = 0.341), Mn (2r = 0.315), Fe (2r = 0.358), Co (2r = 0.203), and Pb (2r = 0.276). Since hair and nails are rich in keratin, which has a high affinity for As, elevated concentrations of As were, as expected, found. Thus, keratin containing cysteine residue with sulfhydryl groups can result in As and sulfur complexation in both hair and nails [et al. (2004) [2r = 0.721 . For Cr, Ni, Cu, Zn, and Mo, such strong relationships between amounts in hair, nails, and urine pairs could not be observed. It can be concluded from the results of such correlation analyses that hair can be considered a good biomarker for degree of environmental exposure to a variety of metals. In particular, As levels in hair and in nails can be used to indicate chronic exposure arsenic [As shown in o r2 = 0.3, and Pbo r2 = 0.3, and Pb = 0.721 , Hair-Ur arsenic . Levels  arsenic . The sam r2 = 0.3, Fe  and those collected in the contaminated areas  were not statistically different can be explained by the consumption in KT of contaminated food, especially fish and rice cultivated in Kandal, the province where KT village is located. It was reported by Wang et al.  that the−1. Elevated levels of As in biomarkers among the local population were therefore expected. Measured concentrations of As in the hair, urine, and nails of subjects in these areas were higher than for a control area or background levels. Other metals, including Fe, Mn, Cr, Ni, and Pb, were also detected at elevated levels in all biomarkers. The levels of metals accumulated in biomarkers corresponded to the levels of those metals in the groundwater of each study area. This study, while dealing with As-enriched groundwater, demonstrates the importance of measuring the concentrations of other elements along with As. This study was conducted in As-contaminated areas of Cambodia, where most groundwater drinking water sources contain As concentrations higher than 10 μg·LThe levels of As in all biomarkers among exposed subjects indicate medical examinations with diagnostic procedures for arsenicosis should be regularly conducted to allow timely intervention for symptomatic individuals. In addition, the consumption of As-enriched groundwater should be banned and As-free drinking water provided in the affected areas to reduce the level of As exposure. For a better understanding of metals toxicity, how the interactions among these elements may alter their toxicological effects should be further studied.


Aims and method For many trainees, an obstacle into psychiatry is the challenge of an imprecise job design and uncertainty about the psychiatrist’s job design across many complex, often ad hoc care situations involving multiple professions and organisations. The UK’s National Health Service (NHS) has introduced inductions for trainee psychiatrists geared towards improving that. Are the induction programmes effective? This article presents an analysis of the outcomes (n = 1115) of inductions about the care programme approach, dual diagnosis, carer support, mental health risk assessment, psychological therapy and suicide risk assessment.Results Univariate analyses of variance revealed a consistent interaction of care programme approach, dual diagnosis, carer support and psychological therapy inductions. Psychiatrists who attend all four inductions have the best perceptions about their job design, strongest teamwork approach, and highest motivation.Clinical implications The NHS and hospitals outside the UK should note these results when prioritising inductions for trainee psychiatrists. Psychiatric practice in healthcare systems such as the UK’s National Health Service (NHS) involves a complex multiprofessional and multi-organisational network and this creates job role uncertainty for trainees who have not been well inducted. Psychiatrists writing in the early 1990s called for better provision of induction programmes,2 as only 68% were being provided with a comprehensive induction programme that addressed the multiprofessional aspects of psychiatric practice.3 Health systems globally have since increased their spending on human resource development; for instance, the NHS has outlined a new policy framework which encourages training, professional development, lifelong learning and induction programmes to increase staff motivation, generate positive impressions of the organisation, facilitate team development, and help staff learn about their job role.5 Is this working in psychiatry? Questions have been raised before about the usefulness of some of the induction programmes used within the NHS, such as the care programme approach induction.6 Over 10 years after the introduction of these induction programmes, we need a fresh analysis of their simple and combined effects. Clarifying the usefulness of different induction programmes has implications for mentors, the NHS and mental health systems in other countries, as they review the induction process for trainees.There is a global shortage of psychiatrists.7 There were 134 967 NHS employees who responded and data were extracted from the 1115 medical doctors who completed one or more of six psychiatric inductions. These were:This analysis began with an extraction of data from the NHS staff survey conducted by the Care Quality Commission and Picker Institute Europe in 2011.A, a care programme approach (CPA) inductionB, a mental health risk assessment inductionC, an induction about suicide risk assessmentD, an induction about carer supportE, a dual diagnosis inductionF, an induction about psychological therapies.The variables were recoded so that a value of ‘1’ was assigned if a doctor had completed the induction within the past 12 months or before, and ‘0’ if not. This analysis also utilised doctors’ responses to questionnaires which measured perceptions about job design, teamwork and feelings of motivation at work.Univariate analyses of variance using SPSS/PASW 18 software for Windows calculated the main and interaction effects of the inductions as independent variables.F = 5.10, P = 0.024, η2 = 0.005; A × C × D = job design: F = 5.10, P = 0.024, η2 = 0.005; A × C × E = job design: F = 5.63, P = 0.018, η2 = 0.006; A × D × E = job design: F = 6.37, P = 0.012, η2 = 0.007; A × B × C × D = job design: F = 4.23, P = 0.039, η2 = 0.005; A × D × E × F = job design: F = 14.55, P = 0.000, η2 = 0.015. 2).The first univariate analysis showed the effects of the induction programmes on the psychiatrists’ appraisal of the quality of their job design. The following effects were significant, all of which were interactions: A × B × E = job design: F = 3.80, P = 0.05, η2 = 0.004; B × F = teamwork: F = 4.73, P = 0.03, η2 = 0.005; A × D × E = teamwork: F = 3.95, P = 0.047, η2 = 0.004; B × E × F = teamwork: F = 4.46, P = 0.035, η2 = 0.005; C × E × F = teamwork: F = 4.06, P = 0.004, η2 = 0.004; A × D × E × F = teamwork: F = 7.05, P = 0.008, η2 = 0.008. This four-way interaction replicated the results of the first univariate model which predicted the psychiatrists’ perceptions about the quality of their job design, also showing that this interaction had the largest effect size. The next univariate analysis of variance showed the effects of the induction programmes on psychiatrists’ appraisal of their teamwork and its quality, including team members having shared objectives, team members meeting to discuss team effectiveness, and team members communicating closely. The significant effects were as follows, all of which were interactions: A × B = teamwork: F = 3.76, P = 0.05, η2 = 0.004; C × D × F = feel motivated: F = 4.10, P = 0.04, η2 = 0.004; A × D × E × F = feel motivated: F = 4.09, P = 004, η2 = 0.004. Therefore, the four-way interaction of inductions A, D, E and F found in the first two models was replicated. As The third univariate analysis of variance showed the effects of the induction programmes on the psychiatrists’ feelings of motivation at work. The following were significant effects, all interactions: A × E = feel motivated: In summary, the combination of induction programmes with consistently good outcomes, noting the significance of an interaction across different outcomes and the effect size, is A × D × E × F. This comprises the CPA induction, carer support induction, dual diagnosis induction and psychological therapies induction. Looking at 9 in the context of psychiatric training. One meta-analysis of 52 studies found that realistic job previews increase employees’ perceptions of their job role clarity.8 Another meta-analysis of studies totalling 35 265 employees found that ambiguity about one’s job role is one of the most serious work stressors that has an impact on job performance.9This is the first analysis of the effectiveness of induction programmes for psychiatrists. The most consistently effective combination, across three outcomes, comprises the CPA induction, the carer support induction, the dual diagnosis induction and the psychological therapies induction. The three outcomes are: the psychiatrists’ perceptions of the quality of their job design, the quality of teamwork and their motivation at work. These four induction programmes give trainee psychiatrists realistic previews of their job role and workplace, boosting the positive outcomes. This finding extends robust empirical evidence about the worth of realistic job previews and job role unambiguityFurther research should explore the reasons for non-uptake of each induction programme. One reason is a lack of access, and another reason is a trainee’s initial level of motivation. Trainees who present a high level of motivation might be more likely to take up an induction than other trainees. A follow-up study should therefore use an experimental design and code the element of choice as an independent variable, as well as measuring the trainees’ motivation before and after each induction. This would allow an analysis of both the between-subjects effects analysed in the present study and within-subjects effects not analysed. The issue of access also warrants a national audit of the availability of different induction programmes. The present results should be taken into consideration in prioritising particular inductions. This analysis has shown that a CPA induction works well only in combination with other induction programmes. Alone, it is only marginally better than a control group on three outcomes . This analysis has also revealed that the induction provision with the worst outcome is that whereby psychiatrists only attend a carer support induction. The NHS, and hospitals outside the UK, should note this evidence when planning inductions of trainees.


Methods. This observational study was carried out to compare the bone mineral density (BMD) in transfusion dependent thalassemics with that of healthy controls. Thirty-two thalassemia patients, aged 2–18 years, and 32 age and sex matched controls were studied. The bone mineral concentration (BMC) and BMD were assessed at lumbar spine, distal radius, and neck of femur. Biochemical parameters like serum calcium and vitamin D levels were also assessed. Results. The BMC of neck of femur was significantly low in cases in comparison to controls. We also observed significantly lower BMD at the lumbar spine in cases in comparison to controls. A significantly positive correlation was observed between serum calcium levels and BMD at neck of femur. Conclusion. Hence, low serum calcium may be used as a predictor of low BMD especially in populations where incidence of hypovitaminosis D is very high.Chronic hemoglobinopathies like thalassemia are associated with many osteopathies like osteoporosis. The management of patients with thalassemia has improved markedly over the past few decades with the use of optimized transfusion programs and chelating therapy. There has been a considerable improvement in the life expectancy and the quality of life of these patients. With prolongation in the life expectancy, it has been observed that this hemoglobinopathy is associated with a variety of bone disorders like deformities, bone pains, delayed bone age, growth failure, rickets, scoliosis, spinal deformities, nerve compression, pathologic fractures, osteopenia, and osteoporosis . Apart fOsteoporosis is a significant cause of morbidity in these patients . It is cThis study was carried out to evaluate the bone mineral density (BMD) in children with thalassemia major by DEXA and to compare with healthy controls.t-test and α-error = 5%. Assuming mean BMD to be 0.63 ± 0.076 g/cm2 in patients and 0.78 ± 0.3 g/cm2 in controls, the sample size was calculated to be 32 in each group.This cross-sectional observational study was conducted in a tertiary care center in Delhi from November 2011 to January 2013. Clearance was taken from the institutional ethical committee. The primary objective of the study was to compare the BMD of thalassemia major patients with that of age and sex matched controls. The sample size was calculated considering a power of 80% using a 2-sided Student's Thalassemia patients, aged 2–18 years, attending the thalassemia clinic of the hospital, were enrolled consecutively. The patients who were taking medicines like antiepileptic drugs, oral calcium, vitamin D, and so forth that affect bone mineral density were excluded. A total of 32 patients and 32 age and sex matched healthy controls were recruited after an informed written consent was obtained from the parents. Assent was taken from children older than 7 years.The details of all the subjects were recorded including age, sex, weight, height, and body mass index (BMI). In addition, details like duration of disease, blood transfusion, chelation, and other treatment histories were recorded for the patients. The biochemical assessment included determination of serum calcium, phosphorus, and 25-hydroxy vitamin D levels.2, and volumetric BMD in gram/cm3. The “T score” and the “Z score” were also calculated at these 3 sites after DEXA scan. The T score refers to the number of standard deviations above or below the mean for a healthy 30-year-old adult of the same sex and ethnicity as the patient. A T score of −1.0 or higher is considered normal. Osteopenia has been defined as a “T score” between −1.0 and −2.5 while osteoporosis has been defined as score of  −2.5 or lower.  T score does not have clinical utility in children and adolescents. Z score is the preferred parameter in children which is calculated as the number of standard deviations above or below the mean for the patient's age, sex, and ethnicity. The diagnosis of osteoporosis and osteopenia in childhood is not made on densitometric data alone especially in absence of a clinically significant fracture history.All the subjects underwent DEXA scan using HOLOGIC (Discovery QDR series) bone densitometer. Bone Mineral Content (BMC), areal bone mineral density (aBMD), and volumetric bone mineral density (vBMD) were obtained at lumbar spine, femoral neck, and distal radius. BMC was expressed in gram, aBMD in gram/cmt-test, whereas the Mann-Whitney U test was used for those variables that were not normally distributed. Categorical variables were analyzed using either the chi square test or Fisher's exact test. Spearman's correlation was also performed between BMD, age, sex, body mass index (BMI), chelation, ferritin, calcium, and vitamin D in cases and controls. P < 0.05 was considered statistically significant.Statistical analysis was performed by the SPSS program for Windows, version 17.0. Normally distributed continuous variables were compared using the unpaired 2) of cases were lower in comparison to controls but only weight (P = 0.023) and BMI (P = 0.030) were statistically significant. The mean age of receiving first blood transfusion in the patients was 3.72 ± 1.14 years (range = 2–6 years). The mean serum ferritin value of the thalassemia patients was 3349 ± 2012.9 ng/mL (range = 1082–9002 ng/mL). The mean value of total serum iron in children was 459.13 ± 119.47 µg/dL (range = 320–765 µg/dL).A total of 32 thalassemic patients  between 5 to 16 years of age (mean ± SD = 10.03 ± 3.03) were studied along with 32 age and sex matched controls. The mean height (133.84 ± 13.40 cm), weight (32.28 ± 10.25 kg), and BMI (17.70 ± 3.86 kg/mP = 0.001). The mean serum phosphorus levels were 3.97 ± 0.53 mg/dL (range = 3.1–4.9 mg/dL) in cases and 3.73 ± 0.60 mg/dl (range = 2.5–4.9 mg/dL) in controls and the difference was not statistically significant (P = 0.094). The mean serum alkaline phosphatase values were 241.54 ± 89.30 IU/L (range = 112–432 IU/L) in cases and 287 ± 101.94 IU/L (range = 112–607 IU/L) in controls and it was not statistically significant (P = 0.056). The mean levels of vitamin D were 19.74 ± 10.71 nmol/L (range = 12–63.4 nmol/L) in cases and 23.21 ± 11.10 nmol/L (range = 11.4–63.4 nmol/L) in controls and the difference was not statistically significant (P = 0.144). Analysis of serum 25-hydroxy vitamin D demonstrated that none of the subjects in both groups had levels in the normal range (>75 nmol/L) and there was no significant difference in the mean values between the two. Majority (59.4%) of the cases demonstrated moderate 25-OH Vit D deficiency (12.5 to 25 nmol/L), 21.9% were severely deficient (<12.5 nmol/L), and the rest had levels in the minor deficiency (25–50 nmol/L) or insufficient range (50–75 nmol/L).Comparison of biochemical profile in the two groups revealed a significantly lower mean serum calcium level in cases (8.69 ± 1.04 mg/dL) (range = 7–10.4 mg/dL) in comparison to the controls (9.44 ± 0.61 mg/dL) (range = 8.3–10.8 mg/dL) (P < 0.001). The mean BMC at lumbar spine (LS) as well as distal radius (DR) was also lower for the cases  in comparison to controls  but the difference was not statistically significant . The mean BMD for thalassemia cases (0.48 ± 0.17 gm/cm3) at lumbar spine was significantly low in comparison to controls (0.568 ± 0.110 gm/cm3) (P = 0.013) but the difference was not statistically significant at distal radius (P = 0.933) and neck of femur (P = 0.495). The difference in mean BMD at lumbar spine was more marked in children aged more than 10 years.The BMC and BMD were assessed at lumbar spine, distal radius, and neck of femur and the values are depicted in r = 0.116, P = 0.526), distal radius , and neck of femur . However, the difference was statistically significant only at neck of femur. A positive correlation was also observed between vitamin D level and BMD at all the three sites but the difference was not statistically significant  but at distal radius and neck of femur in cases and controls it was not statistically significant (P = 0.933). It is likely that the differences in the BMD of cases and controls would have been more striking if the control population had normal serum Vit D levels. This is a limitation of the present study that the majority of the control group too had vitamin D deficiency. We also observed that the bone mineral density was most affected at lumbar spine which is in accordance with a previous study by Jensen et al. [In this study, there was a significant difference in bone mineral density at lumbar spine between cases and controls (n et al. .Bone mineral density at all the sites showed a negative correlation, though not statistically significant, with age. This suggests that BMD decreases with advancing age, as previously observed in a study of Indian thalassemia children between 10 and 25 years of age . We alsoThalassemia International Federation  suggests