Background. Despite decades of research and the availability of effective analgesic approaches, many children continue to experience moderate-to-severe pain after hospitalization. Greater research efforts are needed to identify the factors that facilitate effective pain management. The aim of this study was to explore the perceptions of Iranian nurses on facilitators of pain management in children. Materials and Methods. This qualitative study collected the data profoundly through unstructured interviews with 19 nurses in Amirkola Children's Hospital in Babol and Children's Medical Center in Tehran, during 2013-2014. Purposeful sampling and analysis of the data were conducted using conventional qualitative content analysis. Results. Four themes were extracted through data analysis: mother and child participation in diagnosis and pain relief, the timely presence of medical staff and parents, proper communication, and training and supportive role of nurses. Conclusion. Mother and child participation in the report and diagnosis of pain and nonpharmacological interventions for pain by the mother, the timely presence of medical team at the patient's bedside, and proper interaction along with the training and supportive role of a nurse enhanced the optimal pain management in hospitalized children. Pain is one of the most common reasons why people visit doctors or health team members and, in many clinical conditions, pain is a major symptom. In children, pain reduces the quality of their life, so pain preventive measures in all areas need to be taken . DespiteThe factors affecting children's pain management are influenced by cooperation , child , organization , and nurses  .Despite the fact that a variety of clinical studies on all aspects of pain have been conducted in many countries, factors affecting pain management, especially facilitating factors, have not been fully identified . This quContext. There is only a guideline on analgesia  in pediatric ward, according to which physicians act. Based on this protocol, oral analgesics and/or suppository of acetaminophen are initially used for pain relief. In the next stage, injectable acetaminophen (Apotel) and pyridamole are administered. In case of untreated pain, the third-stage analgesics like pethidine and morphine or methadone pills for severe pediatric pain are prescribed. Psychological counseling is the last pain relieving stage in this guideline. There are no specific protocols or guidelines on nonpharmacological pain interventions. There is also no pain control team or nursing pain committee in hospitals.This qualitative study was carried out aiming at understanding Iranian nurses' perceptions and facilitators of pain management in pediatric wards, using conventional content analysis. This method is usually used for describing a phenomenon where there are limited numbers of relevant theories or researches . The parSimultaneous data collection and analysis were performed to develop the themes related to the nurses' perceptions of facilitators of pain management. Data collection process was continued until data saturation was reached in the last three interviews. After obtaining nurses' written informed consent, interview appointments were arranged. The unstructured individual interviews were carried out in a quiet room in the hospitals. The interviews, lasting from 60 to 120 minutes, were recorded with the permission of the interviewees. Interviews began by asking questions such as the following: “Please, describe your routine work shift.” Questions were concentrated on pain management cases; if not, the next question was asked: “Have you ever encountered pediatric pain in your work shifts?” The interviewer then asked, “Please, tell us your experience with regard to pediatric pain.” Afterwards, more explanatory and in-depth questions were asked .Data collection and analysis were done at the same time. This study used conventional content analysis. Graneheim and Lundman have proposed the following steps to use content analysis with qualitative data: (1) transcribing the whole interview immediately after it is done, (2) reading the whole transcribed text to gain a general knowledge of its content, (3) determining the meaning units and initial codes, (4) categorizing similar initial codes in more comprehensive groups, and (5) determining the main theme per category  Table 2Table 2. The samples were informed about the purpose and method of the study. They were assured that they could withdraw from the study at any time without being penalized. Finally, written informed consent was obtained from the nurses who willingly declared their participation in the study.Four themes for facilitating pain management were identified: mother and child participation in diagnosis and pain relief, the timely presence of medical staff and parents, proper communication, and training and supportive role of nurses.Due to lack of work force, I cannot be with the patient, and I have to ask mothers to perform the non-pharmacologic interventions so I can perform my other patients' needs. (Nurse 9) According to mother's report to the nurse about the side effects after injection, mother helps the nurse perform nonpharmacological pain relief interventions, assesses immature and unconscious children's pain and reports pain to the nurse, reminds the nurse of child repeated pain, and also notifies the nurse in case the nurse herself forgets the pain because of shortage of nurses or crowded wards.When a child has pain, the mother reports to me about the location of the pain, when it started, having had a history and a series of information that a mother can provide to help me. (Nurse 3)If a child is not old enough to answer or not so alert, then I ask the mother. (Nurse 16)One of the facilitating points of mothers in pain management is their cooperation and assistance in examining the pain. Mothers have an active role in examining the pain in young and unconscious children, and pain is reported by the mother to nurse.Alert and mature child can help me find the pain such as what the pain is like, quality of pain, where the pain comes from and when it started. I ask these questions from the child. (Nurse 10)Nurses pay attention to the mature and conscious child's information and participation in reporting the location and severity of pain.If a mother says my child is in pain, I immediately go by the child's beside to see the severity of pain, when the pain is severe, I resort to medication. (Nurse 13)Nurses mentioned the timely presence of the medical team at the patients' bedside as an accelerator factor in pain relief, emotional support of the family, and better understanding of the patient and a precipitating factor in the patients' complaints of pain.Because this is a training hospital, doctors are always available for pain, and I call them immediately for pain relief. (Nurse 2)Easy access to doctor accelerates pain relief.Procedures such as venipuncture can be better performed beside a companion, so I call the security for patient's companion to calm down the child. (Nurse 19)Nurses report that meeting relatives and friends can be an accelerator for pain relief and boosting the morale of the children for pain, reduce stress and calm the child, and accelerate the consumption of housing and nonpharmacological interventions to pain.When I established a good relationship with the patient, they trust me about the non-pharmacological methods of pain relief. (Nurse 15)Sometimes residents are busy and when the patient is in pain, I have to call the hospital attendants since we have a good working relationship. (Nurse 7)One of the obtained themes was proper communication between nurses and patients, companions, and doctors. Friendly relationship between nurses and patients, companions, and physicians is the success factor in pain management and the use of nonpharmacological interventions.When mothers insist on analgesic injection, I explain the side effects of pethidine for them. (Nurse 6)When infant are fidgety, I teach the mother how to hug the baby and give the baby a proper position. (Nurse 9)Nurses have training and supportive role by explaining the side effects of painkillers and teaching the nonpharmacological interventions to the mother before painful procedures to endure pain better and also to give her peace of mind.When a child with a leukemia diagnosis is in pain, I go and cuddle the patient to calm him/her. (Nurse 17)A participant said the following about the supporting role of nurses for mother and child:In the Emergency Department, because of pain, children are restless, parents get fidgety too by watching their child in pain, then I explain the situation to parents and calm them down. (Nurse 5)Explanation of a nurse can give comfort to the mother.For the purpose of this study, the perceived meaning of the facilitators of pain management included the following: mother and child participation in diagnosis and pain relief, the timely presence of medical staff and parents, proper communication, and training and supportive role of nurses.The outcomes of this study suggested that mother and child participation in diagnosis and pain relief is one of the facilitating factors in pain management in pediatric wards. The role of the nurse is to encourage mother to participate in nonpharmacological interventions and cooperate with the nurse in daily physical care. This finding is consistent with previous studies on the cooperation of parents in nonpharmacological interventions of pain relief in helping nurses because they are accessible and familiar with the child's daily activities , 22. PölThe results also showed that mothers have active participation in pain assessment of young and nonconscious children, and pain is reported by the mother to nurse. These results are consistent with Lim et al.; in their study, parents regularly observed and evaluated children in terms of pain, its location, and severity and have active participation in pain monitoring, although they do not use pain assessment tools . The stuThe results of a recent study have shown that the highlighted presence of medical staff and parents is another factor facilitating the pain management in pediatric wards. But they are in contrast to Panahi et al.'s study which reported that identifying the lack of timely presence of nurse by patient is the source of conflict between doctors and nurses . The finIn fact, the interaction between nurse and patient can be used as criteria of efficient and effective care . But SimThe findings of a recent study have shown that nurses perform their training role by describing the side effects of analgesics and teaching the nonpharmacological interventions to parents. The results indicated that providing information to parents has been effective in reducing anxiety and feelings of unreality, and lack of sufficient information was identified as the main barrier to the parents' participation in the health care of a hospitalized child , 33. StuThe results showed that the supportive role of nurses is done through fondling and touching the child's face or giving an explanation to the children and families. Studies showed that nurses used emotional support such as reassurance and touching strategies and sometimes words like relax, please, or try to endure the pain to reassure the child. Moreover, parents try to search for information about procedures to prepare their children, including tips/knowledge of nurses , 37. ResRegarding nursing care plan in Iran, childcare is most often done by female nurses; therefore, noninvolvement of male nurses may drop some aspects of pain management that relate to nurse's unknown gender. The involvement of male nurses in future studies is recommended to explain the facilitators of pain management in pediatric wards.Mother and child participation in the report and diagnosis of pain and nonpharmacological interventions for pain by the mother, the timely presence of medical team at the patient's bedside, and proper interaction along with the training and supportive role of nurse enhanced the optimal pain management in hospitalized children.


Now a days the utilization of Acceptance / Commitment and Emotion Regulation Strategy as a comprehensive treatment plan has been discussed in both the prevention and the control of destructive and risky behaviors. Treatment based on Acceptance/Commitment and Emotion Regulation was effective in both the improvement and the control of high-risk behaviors of students with dyscalculia.The purpose of this study was to investigate the effectiveness of Acceptance and Commitment, and Emotional Regulation training in high-risk behaviors of students with dyscalculia.This research was experimental, with pre-test, post-test and a control group. The statistical universe of this study included all sixth-grade male students in Ardabil city in the academic year of 2012-2013 (A.H.). The subjects of this study involved 800 sixth-grade elementary students in Ardabil province, selected using a multi-stage cluster sampling. From among them, 60 students with dyscalculia were selected using random sampling method after the initial diagnosis by structured clinical interview and the Keymath Mathematic test. Twenty pupil were selected for either the experimental or the control group. To collect data, the questionnaires of "Keymath Mathematic test" and High-risk Behavior" were used.The results of Multivariate Analysis of Variance (MANOVA) showed that "Acceptance / Commitment and Emotion Regulation" treatment trainings were effective in reducing high-risk behaviors, in a manner that they led to a reduction in negative emotions, self-destructive and impulsive behaviors of students with math disorder .It can be concluded that teaching these skills to the students has been influential in enhancing awareness level and change or positive attitude creation in the subjects. Therefore, it is essential to design and implement interventions based on "prevention caused by the peer group, in collaboration with the parents either at the school or at home among the family members". According to the definition of "Individuals with Disabilities Education Act" (IDEA), learning disability is a disorder in one or more basic of the psychological processes that involve understanding a language or its use. The disorder shows itself in the forms of disability in listening, thinking, speaking, reading and writing, spelling, and math calculations. However, it does not include those learning difficulties primarily resulting from visual, hearing or mobility disabilities, mental retardation, emotion disturbance, adverse environmental cultural or economic conditions .Mathematical ability is as important as reading is important in the human life. However, researchers believe that the studies conducted regarding psychological processes, for math competency, or underlying failures of dyscalculia, have been much less than those conducted to study the inability to read. Math disability  prevalence is estimated to be between 5% to 8% . StudiesHigh-risk behaviors are among the psychological variables which show possibly due to the inability of the students in math learning. High-risk behavior is defined as behavior that results in increasing and devastating physical, psychological and social consequences to the individual. In adolescents these behaviors are strongly correlated with each other and follow the Co-variation Model. Presenting the term "Problematic Behavior Syndrome",  Mohammadi and Abadi  believe Among the treatments that can could reduce high-risk behaviors of students with math learning disabilities effects, while they have not been considered by researchers, we could refer to Acceptance and Commitment training as well as Emotional training. Accepting an important alternative to avoid in accordance with experience includes active and conscious acceptance of personal events related to the history of an individual. In fact, the main goal of this treatment is making psychological flexibility; meaning to create the capability of practical selection from among different choices which is more suitable . Considering the novelty of this treatment method, no research has examined its efficacy directly on improving the problems of students with dyscalculia. However, regarding the efficacy of this treatment on reducing social-psychological problems, along with the fact that students with learning disabilities are also involved with these troubles, it is expected that this drug could be effective in reducing the problems of this group of disorders. Empirical evidences about the efficacy of therapy based on Acceptance and Commitment in disorders like psychosis , risky bEmotion regulation is among the trainings that its educational aspects has less been used on children with learning disabilities, especially those with dyscalculia . EmotionA research conducted by Narimani and Rajabi  showed tAs indicated in various researches, Acceptance and Commitment training, in which mindfulness was its essential component had been effective on variables such as anxiety, depression, stress, health, adaptation and reduction of behavioral problems in children. Solaman  showed iIn general, bearing in mind the long-term consequences of mathematical disorder  and its increasing prevalence among school students and fundamental role of mathematics in modern life, proper planning in their rehabilitation and remediating their learning problems is necessary. In addition, if the disorder is diagnosed and treated in elementary schools, it would be much less problems in adulthood. Otherwise, the stricken individual may suffer from different problems in adulthood including compatibility, emotional and social issues , 11. Most significantly, considering different emotional problems of this group of students, using given methods in this respect is of high importance. Also, performing few studies on this issue and the lack of research on the effectiveness of these approaches on the emotional and social problems of students with learning disability, using the results of this research in treatment, counseling and providing basis for further researches are among the reasons for doing this study. Hence, in this study we are seeking to answer the question: "Are Acceptance, Commitment and Emotion Regulation therapies effective in reducing risky behaviors of students with math learning disabilities ?"The purpose of this study was to investigate the effectiveness of Acceptance and Commitment, and Emotional Regulation training on high-risk behaviors of students with dyscalculia. This research is experimental pre-test and post-test study with a control group. In this study, treatment methods at three levels of treatment training based on Acceptance and Commitment, Emotion Regulation and lack of training (the control group) were considered as active independent variable, and high-risk behaviors as dependent variables. The statistical universe of the study included all sixth grade elementary male students in Ardabil city in the academic year 2012-13 (A.D). The study sample consisted of 800 sixth-grade students in Ardabil province, selected through a multi-stage cluster sampling from among the sixth-grade elementary school male students in Ardabil city. These students were evaluated by key-math mathematics test and the cases suspected to mathematical disorders  were being interviewed clinically in a structured way. Finally, 60 cases were simply and randomly selected from among the students having math problems. Despite the fact that in experimental investigations the minimum number of sample should be 15 people  were randomly assigned to two experimental groups and one control group. Justifying the subjects and expressing the objectives, the subjects were requested to participate in the treatment course of this disorder. Before starting the training methods, all three groups under study were be pre-tested and were asked to complete the predetermined questionnaires. The duration of therapy sessions in each treatment method was eight sessions, each lasting for one and a half hour. It was performed in groups once a week, in an area determined by the Department of Ardabil City Education. After completing the course of training, the treatment and control group were post-tested. Finally, the collected data was analyzed by multivariate analysis of variance (MANOVA). In addition, assurances about information confidentiality and freedom of choice for taking part in the study were among the ethical principles which driven the research.The intervention method has shown in the form of a Mean and age standard deviation (Mean ± SD) of students with math problems  in the test and control groups were (12.28 ± 1.63), and (11.67 ± 1.35), respectively.As it can be seen in The results of Wilks’ Lambda test indicated that the group effects on the composition of high-risk behaviors’ components was significant error . The above test could allow the use of multivariate analysis of variance (MANOVA). The results showed that there was a significant difference at least between one of the investigated variables existed in the two studied groups. Before using parametric test of covariance analysis to meet its assumptions, the Box’s and Levene’s tests were used. According to the Box’s test which has not been significant for any of the variables, the condition of variance/covariance matrix homogeneity has properly been observed .The results of The purpose of the present study was to determine the effectiveness of Acceptance and Commitment trainings and Emotion Regulation on high-risk behaviors of students with dyscalculia (math learning disability).The results showed that treatment based on Acceptance and Commitment is effective on the improvement and control of high-risk behaviors of students with dyscalculia. Compared with the control group who were on a waiting list, the experimental group who received treatment based on acceptance and commitment, showed a more consistent and more significant improvement in the dependent variable. The results of this study are consistent with other research findings .In explaining these findings, we can say that "acceptance", which is often considered a form of mindfulness, is awareness of each thought, simply and without details, in the absence of judgment, prejudice, and present-oriented. In this way, thoughts, feelings and sensations are accepted as they are .In fact, the treatment program teaches patients to reevaluate behaviors those do not directly threaten life, but menace the sound quality of life and tries to find flexible solutions to apply some changes in these conditions. This is a chance and an opportunity for the patients to receive the first stage of therapy with a commitment to change. For instance, among the behaviors that threaten the quality of life we can refer to the following:Excessive impulsivity, fearless driving, unrestrained sexuality, keeping on destructive and dysfunctional interpersonal behaviors, high-risk behaviors, substance abuse, and interpersonal problems associated with lack of emotional control and leads to behaviors which menace the individual quality of life level. During the treatment, the therapist instructs the patient about traumatic properties of these behaviors. She/he explains the reason why the treatment invading behaviors have to be stopped. Therefore, in dealing with such behaviors, foremost the patient must be committed to changing herself/himself. Moreover, she/he should accept that she/he holds these behaviors and only she/he has the ability to change them. The patient and therapist discuss the issue or problem and focus on the solution to experience new emotions. This treatment gives a person the second opportunity to view, describe and explain emotional states without any judgment. In this way, the therapist is mostly focused on guiding the patient towards the full consciousness and the patient takes the responsibility. The therapist encourages the patient to experience perfectly the thoughts and emotions associated with a particular thinking, feeling or behavior, without suppressing them, making value judgments about, and experience the secondary emotions such as shame and guilt after experiencing this behavior, thought and emotion .The results also showed that students who had received treatment based on emotion regulation, compared with their counterparts in the control group not receiving any treatment could better control their emotions. These results are consistent with other research findings . Empirical researches conducted in this area have shown that people with thrill-seeking behavior, impulsivity and risky behaviors were more successful to control their ruminative thoughts, tempting narcotics, aggression and anxiety when they had participated in a treatment course of emotion regulation skills.Therefore, using emotion regulation strategies at present as a comprehensive treatment plan has been discussed both in the prevention and control of destructive and risky behaviors. To explain these findings, one could say that the difficulty in self-regulation of emotions or inability to cognitive processing of emotion regulation or proper revealing of emotions , in otheOn the other hand, the empirical evidences show that parents having close relationships with children create more positive emotions in them . These eOn the other hand, when parents do not express their emotions properly, and not only do not support their child in situations where he/she fails, but also make use of contempt and reproach, the child will not be able to identify the emotions properly. This is called Alexithymia in psychology. They only see themselves in situations, and relate their success to the situations, and not to their capabilities. Moreover they relate their failures to individual factors.In explaining these findings, we can say that "parenting style", which is associated with high control or rejection, leads to the development of anxiety and depression in children through the growth of non-functional cognitive schemas that are biased towards the risk and negative consequences .This causes the individual to turn to high-risk and inappropriate behaviors in order to get rid of these emotions and reset them, since substance abuse, alcohol and intrapersonal difficulties because a person to be freed momentarily and there will be a world of calm and receptive. In a practical point of view, this research could have bilateral effects on family psychology as well as educational psychology. The findings of this study could aid Education and Higher Education officials to improve learning problems and impulsive behaviors of these students. Considering the role of family and parenting processes in positive emotions, negative emotions and emotion regulation of these students, the necessity of holding special training courses for parents and the necessity of creating closer relationship between family and school to optimize the performance of students in mathematics in education system is very important.The study is about Ardabil city students, and the studied sample includes elementary school male students. Therefore, the generalizability of the results is limited. Lack of follow-up, the time limit for providing education, and lack of control associated with pre-test effects are among the other limitations of the present study. It is suggested that future researches should consider these issues.


The NADL battery was found to have satisfactory construct validity and reliability, across a wide age range. This enabled us to calculate appropriate criteria for impairment that took into account age and education. It was found that neurological patients tended to overestimate their abilities as compared to the judgment made by their caregivers, assessed with objective tests of numerical abilities.The aim of this study was to build an instrument, the numerical activities of daily living (NADL), designed to identify the specific impairments in numerical functions that may cause problems in everyday life. These impairments go beyond what can be inferred from the available scales evaluating activities of daily living in general, and are not adequately captured by measures of the general deterioration of cognitive functions as assessed by standard clinical instruments like the MMSE and MoCA. We assessed a control group ( Number processing and calculation are an essential part of our culture. We use numbers for counting, measuring, comparing, putting things in order, etc. Moreover, we constantly need to calculate, understand fractions, proportions and ratios, and to understand and remember PIN codes, telephone numbers, addresses, shoe sizes, and so on. Of course, many occupations need relatively high levels of numerical skill, and poor skills will have an adverse effect on life chances in education and employment, indeed a larger effect than poor literacy skills, as a large-scale cohort study in the UK demonstrates .The Patient Interview .The Caregiver Interview.The Informal Test, which is designed to offer a brief clinical assessment to determine whether the Formal Test of numerical abilities needs to be administered.The Formal Test. This is a detailed assessment of the numerical abilities critical to daily living; these abilities are typically assessed in neuropsychological investigation of numerical and mathematical impairments. Thus, this test may be considered as an external criterion for the other subtests. In clinical practice, this only needs to be administered if there is evidence in the first three parts indicating a deficit in numerical abilities. However, for this study, it was always administered in order to evaluate the validity of the first three parts.These brief interviews, administered separately to the patient and to the caregiver, are meant to provide a rough assessment of the patient's awareness about his or her numerical deficit. The comparison of the patient's answers with those of the caregiver is designed to provide such information. These interviews consist of 10 simple questions ” on how well the participant uses numbers in everyday life, with equivalent questions asked of the participant and, in reference to the participant, of the caregiver. The activities were selected as relevant activities of daily living that are likely to be influenced by numerical abilities on the basis of previous literature and of clinical experience (frequent complaints about what patients cannot do any more and similar information).This test is meant to assess the numerical competence likely to be necessary in everyday life. It encompasses questions in the domains of Time (current date?), Measure (amount of pasta or rice in an average portion?), Transportation , Communication (own telephone number?), General Knowledge (days in a week?) and Money (cost of a car?). When the question implied an estimate rather than a precise number, the answers was considered correct if within a reasonable quantity interval , The choice of these domains was made in consideration of previous literature and available instruments , Number Line marking (The participant is asked to mark a number on a line defined by its end points), and Digit Comprehension .The aim of this section is to assess the ability to transcode between written and spoken numbers. This section is separate from that on calculation, since a dissociation has been observed in individual patients . This section consists of three subtests: Mental Addition , Mental Subtraction , and Mental Multiplication .This section assesses in detail the components of calculation. The section consists of six subtests grouped in two subsections. The first subsection, named Understanding Arithmetical Rules and Principles, assesses the ability to use basic rules  and principles  in written form. It consists of subtests for Arithmetical Rules , Addition Principles , and Multiplication Principles (94 × 5 = 470 → 93 × 5= ?). The second subsection assesses the ability to perform more complex operations in writing. This latter subsection, named Written Operations consists of three subtests: Addition , Subtraction (548 − 231), Multiplication (429 × 53).The MMSE  and a patient group (n = 175).A total of 323 volunteer participants took part in the study: a control group , a mean education of 11.16 years . Eighty-one were female.Participants of the control group were recruited in Italy. They were autonomous in their activities of daily living and, at the time of the assessment, they had no pathologies that could have influenced their cognitive status or its assessment. They had no record of developmental learning disorders. This group had a mean age of 53.05 years  and a mean education of 10.371 years . Eighty-nine were female.Participants in the patient group were mostly recruited at the I.R.C.S.S. San Camillo on the Venice Lido or in the Policlinico of Padova. They gave their informed consent according to the Helsinki Declaration. The diagnosis of these patients was established through the standard protocols for their pathologies. The patient group had a mean age of 58 years , while writing number to dictation and reading number aloud showed the lowest Cronbach's alpha . All results are reported in Table Test–retest reliability was assessed in a subsample of 19 participants, from the sample of patients with a neurological disease. All participants were tested within a month interval between the two observations. A Spearman correlation was utilized as an index of test–retest reliability. The test–retest reliability of the single subtests ranged from 0.20 to 0.98. As in the case of Cronbach's alpha, the low values in some subtests are a consequence of the scores almost at ceiling observed in the sample considered. These results, rather than indicating a low reliability, indicate that the large majority of participants performed at ceiling in both test and retest; the few participants that departed affected the results, given the relatively small score range of the subtests. These data should be taken into account when using those tests in the assessment of change in the ability of the patient due to recovery, intervention or both.Inter-rater reliability of NADL was assessed by means of Intra-Class correlations (ICC) on a subset of 14 patients. Two examiners separately scored their performance. The ICC was very high in almost every test, supporting a high objectivity  of the overall battery.The age and education effects). The residuals of the regression models built can be conceived as adjusted scores, i.e., what remains of the observed scores after the effects of demographic variables are removed. Cut-off were calculated as 5th percentile of adjusted scores in the control sample, for those tests in which a significant effect of demographic variable was found. The advantage of a regression method approach is that it allows using the whole normative sample to have a single cut-off for each score . Before comparing an observed subtest or test score with a cut-off, the effect of demographic variables is removed (if significant), utilizing the same regression model that was used to obtain the cut-offs, with the following procedure: first a predicted score of the participant is calculated by entering his/her values for the relevant demographic variables  in the regression model obtained on the control group sample  on cut-offs we used the results of regressions with the subtest or test scores as dependent variables and the demographic variables as predictors . The error bias in patients was further explored by comparing the scores on the interviews by means of paired The main purpose of this study was to obtain an instrument able to assess numerical activities of daily living. The instrument described here, the NADL battery, has been normed on a sufficient number of participants, including control participants varying in the age, and its psychometric properties have been tested on participants affected by a wide variety of pathological conditions.We have found that the NADL battery shows a good reliability both in terms of test-retest and inter-rater reliability. The internal consistency was satisfactory as well. Construct validity was also satisfactory, as tested by the correlation between NADL parts and cognitive status as assessed by MoCA and MMSE, and with IADL. Importantly, the Patient Interview and Caregiver Interview correlated well with IADL, and with the Informal and Formal parts. The Caregiver Interview was a better predictor of actual numerical ability, with additional finding that the Patient Interview overestimated numerical abilities. This confirms the NADL strategy of using these interviews as a brief clinical screening tool to see whether a more detailed investigation of the patient's numerical abilities is indicated.Since patients tended to overestimate their own numerical competence, a specialized numerical battery, such as NADL, can be employed to evaluate numerical competence for financial or legal decisions about the ability of an individual to manage his or her own affairs, especially financial affairs. The need of such evaluation is likely to increase with the elderly, irrespective of clear neurological damage (Webber et al., It is known that distinct patterns of numerical deficits have been identified for a number of neurological conditions, including progressive diseases, such as Alzheimer's disease, Temporal Lobe Epilepsy, Fronto-temporal Dementia, Semantic Dementia and other forms of Primary Progressive Aphasia, Amyotrophic Lateral Sclerosis, Posterior Cortical Atrophy, Parkinson's Disease and other diseases of basal ganglia (see Palmieri et al., In our study, we were able to compare for the first time on the same battery Parkinson's Disease and Multiple Sclerosis. On Total Written Calculation, patients with Parkinson performed worse than patients with Multiple Sclerosis, irrespective of the severity of the condition, general cognitive impairment, age or education. Similarly, neurofibromatosis, a pathological condition for which no previous investigation of numerical abilities was available, and where the pathology shows much earlier than in the above-mentioned degenerative diseases, is characterized by a distinct profile of numerical deficits, especially mental calculation, again independently from severity of the disease, age, and education.NADL may also be useful in the assessment of “cognitive or brain reserve” the resilience of function in the context of neural damage (see, for example, Nucci et al., The NADL battery is an initial step in developing an efficient assessment tool. A shorter version of the Formal part may be needed. However, the detailed and extensive investigation presented here provides the basis on which to proceed. Subsequent analysis of the data from patients and controls may eventually enable us to include only the most discriminating items, and thereby reduce the length of the battery. Importantly, however, the interview with the caregiver seems to provide a first, rough but quite reliable, estimate of a patient's numerical skills. It may thus be used when a thorough evaluation cannot be done, or to guide a screening decision.The present battery enables the investigation of the consequences of a given numerical defect on numerical activities of daily living. This is work in progress. Factors such as the influence of relative severity will be the focus of subsequent studies. At the present stage, however, this battery can already be employed in its present form to assess patients for their rehabilitation or retraining and to monitor and assess the outcome of rehabilitation and retraining in a real life setting.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.


Public trust is critical in any project requiring significant public support, both in monetary terms and to encourage participation. The research community has widely recognized the centrality of public trust, garnered through community consultation, to the success of large-scale epidemiology. This paper examines the potential utility of the deliberative democracy methodology within the public health research setting. A deliberative democracy event was undertaken in Tasmania, Australia, as part of a wider program of community consultation regarding the potential development of a Tasmanian Biobank. Twenty-five Tasmanians of diverse backgrounds participated in two weekends of deliberation; involving elements of information gathering; discussion; identification of issues and formation of group resolutions. Participants demonstrated strong support for a Tasmanian Biobank and their deliberations resulted in specific proposals in relation to consent; privacy; return of results; governance; funding; and, commercialization and benefit sharing. They exhibited a high degree of satisfaction with the event, and confidence in the outcomes. Deliberative democracy methodology is a useful tool for community engagement that addresses some of the limitations of traditional consultation methods. A key development in the era of personalized medicine is the ability to dissect the interactions of lifestyle and environmental determinants of disease incidence, disease course and treatment response , and to One of the cornerstones of medical research in the personalized medicine age is the generation of big data. “Big” epidemiology can encompass a range of large studies such as those with large numbers of participants  or those that require storage and analysis of massive amounts of genomic data ,10,11,12The government of Iceland, in partnership with deCODE Inc., created a “national genomic databank” , full ofOne criticism that has been leveled at these more participatory approaches is that there tend to be deficiencies in the consultative process, including restrictions on the scope of discussion to certain topics, and focus on garnering support for the project design rather than engaging in genuine consultation to improve it ,22,23. ATraditional surveys, focus groups and interviews, whilst useful, have recognized limitations particularly when the subject matter is complex or unfamiliar, requiring iterative dialogue to address these shortfalls ,25. In tCommunity consultation and engagement in the study design phase of a research project has long been common in research involving indigenous populations and particularly in genetic research, but is becoming more widely employed ,27. FurtWithin the context of the present study, “deliberative democracy” is used to describe a method for community engagement in complex ethical issues surrounding emerging technologies, stemming (but distinct) from the political theory of the same name. This method is distinguished from focus groups by the purposeful provision of information to participants, and by the emphasis on dialogue leading to iterative revision of opinions by the participants as they integrate new information and others’ perspectives . Public In the policy context relevant to the present study, although the Australian National Health and Medical Research Council has developed a National Biobanking Strategy , there rTasmania has proven to be a rich resource for both genetic and epidemiological studies ,40,41,42The purpose of this event was to engage the Tasmanian community in dialogue regarding the potential establishment of a state-wide Tasmanian biobank.Ethical approval for this project was received from the Tasmanian Human Research Ethics Committee.i.e., 4 days), which largely followed the design of the earlier Canadian events . Sm. Sm24]. The event was designed primarily to gauge public perceptions of biobanking and inform policy. People in positions to influence policy and practice were invited to attend as observers, such as representatives from the National Health and Medical Research Council, Department of Health and Ageing and the Tasmanian Data Linkage Unit. Those attending in these capacities were available for the Q&A interactive large group sessions with the participants. These professionals directly observed and participated in the event, and have been able to incorporate participant recommendations into future policy decisions.Participants were given an identical satisfaction survey at the conclusion of each weekend’s proceedings see . This suAll statistical analyses were undertaken in SPSS v. 21 . Binary logistic regressions were used to investigate factors influencing withdrawal from the event. Participant satisfaction survey responses were summarized using proportions (for yes/no responses) or medians and ranges for ordinal variables.p < 0.05). Withdrawal was not associated with age, country of birth, education, experience of a genetic or serious illness, location or employment status, but results should be interpreted with caution due to the small sample sizes.Of the 36 individuals who were invited to attend the event, 25 attended in full, giving an attrition rate of 30.6 percent (11/36). Of the 25 attendees, there were 16 females and nine males, with only the Indigenous male category unrepresented. A series of logistic regressions predicting drop out status revealed that males were 79 percent more likely to withdraw than females  believed it is sensible for researchers to rely on deliberative events when trying to develop policy. Most participants (over 60 percent) described the event as informative, challenging, stimulating, enjoyable, and organized. These results suggest, on the whole, that participants felt positively about all aspects of the deliberation, though they found the experience challenging. See Results of the two participant perception surveys of the event are summarized in National Statement on Ethical Conduct in Human Research) currently provide little guidance regarding the return of results within the context of biobanking, with the current advice aimed primarily at more traditional study designs that are more limited in size, scope and duration. Departure from this traditional model is not simple, requiring public support for a change of this significance. The vigorous debates that have ensued have resulted in calls to more effectively engage the public in informed deliberation.There has been a paradigm shift in the way we approach studies into the causative factors for common diseases, particularly with large scale population based studies that collect large volumes of epidemiological, medical and biological samples. In parallel, we are seeing significant changes in the ethical, legal and social landscape surrounding the collection, storage, use and sharing of tissue and data arising from these large, often very costly, studies. But controversy continues to cast a long shadow over many key features of these large scale studies. For example, the ethical guidelines (in Australia, the Deliberative democracy is a useful tool to facilitate public engagement , used alPublic trust is an essential component in any project requiring public support both in monetary terms and to encourage participation. Deliberative democracy distinguishes itself from other forms of public consultation by facilitating informed discussion, through the provision of information from a range of sources. The creation of a culture of freedom to comment and engage is essential, and all perspectives are encouraged. As such, the process facilitates dialogue between participants. Every participant spoke, of his or her own accord, at some point during the Tasmanian event. The research team noted that a benefit of having both small and large discussion groups was that perspectives of participants who did not feel comfortable speaking in the large groups were noted by more confident members of their small groups and communicated to the full group.Deliberative democracy events of this nature culminate with identification of points of resolution and recurring disagreement, providing invaluable information, from the many voices within society, for policy and procedure formation. The presence of end-users, particularly those in positions of power regarding policy formation and implementation, is important in generating trust as their presence validates the idea that participants’ views are important and have some consequence.It is important to note that this method of consultation is resource intensive. The Tasmanian deliberation was a product of a 14-member team that included academics in law, social science, and genetics as well as event coordinators, research assistants and recruiters. Moreover the process took a substantial amount of lead-time and was relatively expensive compared with other forms of consultation. Nevertheless, the investment of time and resources produced an event that was successful in terms of participant experience, as demonstrated by the results of the participant satisfaction survey (particularly see The deliberative democracy event reported here sought to capture the geographical and social diversity of Tasmania. The aim was not to achieve a randomly selected, unbiased sample, one of the mainstays of epidemiological research, but rather to hear varied Tasmanian voices. A similar deliberative democracy event on biobanking was conducted in Western Australia and informed our deliberation ,47,48. HA key difference between this deliberative event and previous events is in the method used for recruitment. Previous events have highlighted difficulties in achieving representation of diversity ,49, wherThis event produced recommendations that informed policy makers and biobanking stakeholders responsible for biobank developments in Tasmania. The benefit of this approach over survey methods for capturing public opinion lies in the informed nature of the opinions, derived from the discussion-based format and diverse range of participants. The utility of large-scale prospective epidemiology and biobanking studies is well established, but requires large investment and long-term commitment. Deliberative democracy presents an appropriate vehicle to manage community input into these projects. It has been proposed that deliberative democracy events may be employed whenever broader population participation or support is required. By undertaking a deliberative democracy event prior to the commencement of a study of this nature, areas of trust and concern can be ascertained and monitored throughout the life of the study. Additional deliberative democracy events during the course of the study could be used to examine changing social norms as society evolves and scientific advancements continue to be made. Deliberative democracy events are particularly useful for enhancing participation of those not normally represented, including people from remote, disadvantaged or rural areas. They may also be useful where valuable datasets have been collected under a previous consent model and require consultation to consider current ethical norms for ongoing use.


This survey focuses on relevant issues needed to understand how to setup a WBSN for medical emergencies. These issues are: monitoring vital signs and video transmission, energy efficient protocols, scheduling, optimization and energy consumption on a WBSN.This survey aims to encourage the multidisciplinary communities to join forces for innovation in the mobile health monitoring area. Specifically, multidisciplinary innovations in medical emergency scenarios can have a significant impact on the effectiveness and quality of the procedures and practices in the delivery of medical care. Wireless body sensor networks (WBSNs) are a promising technology capable of improving the existing practices in condition assessment and care delivery for a patient in a medical emergency. This technology can also facilitate the early interventions of a specialist physician during the pre-hospital period. WBSNs make possible these early interventions by establishing remote communication links with video/audio support and by providing medical information such as vital signs, electrocardiograms,  Life expectancy around the world has increased in the last years , which iLife expectancy is not the only important factor for better medical care, e.g., traffic accidents also call for better and opportunistic emergency health services. Adequate and immediate medical assistance after an accident can minimize the possibilities of permanent injury or even death. Traffic accidents in Mexico are one of the main causes of injuries according to INEGI 2011, and are the second leading cause of death . Table 1Emergency Remote Pre-Hospital Assistance (ERPHA), a telemedicine system to deliver medical care to the patient at the location of an accident [Therefore, availability of an efficient Wireless Body Sensor Network (WBSN)-based platform, capable of reporting data remotely to a medical center, is very important to increase the chances of survival. These networks are capable of transmitting data from images, vital signs and video. Information is acquired from sensors and cameras and upgraded through an electronic process for transmission and processing in a hospital using a friendly interface to the user. A platform example, is the accident . To succetc.) requires the reporting of PHI and video to be every 10 s, and the amount of data produced is incremented in a very short time. The scenario just introduced is an emergency assistance scenario, capable of saturating the WBSN, with different technological challenges including mobile computing, medical sensors, video technologies and communication for mobile healthcare  systems [Consider a WBSN with sensors reporting data remotely to a medical center through a mobile device such as a smartphone with video conference capabilities. Under a stable health condition, the Personal Health Information (PHI) of the patient should be reported to the medical center every 5 min. However, occurrence of an emergency event , these f 10,000 , the autThis paper presents a survey of current trends in WBSN for emergency scenarios. Our paper also presents facts that play different roles for each medical scheme and have an impact on the network performance and the reduction of the WBSN lifespan. This paper also discusses issues about the medical emergency scenario such as WBSN architecture, recent studies in power efficient MAC protocols and the main communication protocols for m-Health. We also understand that efficient use of energy is the dominant factor in the design and implementation of protocols in wireless sensor networks for MAC/PHY and network layers in order to reduce power consumption and latency, and to increase throughput. An energy inefficient protocol may become the main source of energy waste . AdditioIn etc.). The authors also indicated that power inefficient protocols are the main source of energy waste. Additionally, they presented an efficient routing protocol integrated with the MAC layer and indicated important implementation issues such as: security, authentication, data integrity, confidentiality, availability and privacy. Previous surveys have concentrated on the analysis, discussion and global overview of WBSNs with the intention of orienting readers for future research work. It is important to say that there are many topics involved in the study of WBSN platforms, which makes difficult the standardization of ideas for the correct development of WBSNs. The authors in  presenteet al., in [Production of microelectronic chips with new sensing elements and systems for embedded data processing and energy harvesting are important for efficient implementation of WBSN applications . Micek,  al., in  are concIn , the autIn , the maiA study of effective routing protocols in WBSNs is given in , where iIn , the autFinally, relevant studies have been conducted with the objective to optimize the BSN lifetime. In MEDISN , althougOur objective is to give readers a relevant overview of important issues in WBSNs in order to set into motion the development of an optimization model. Literature reviewed in this section helps us to understand each part conforming a wireless system for medical care delivery. Unlike the articles reviewed in this section, in our consideration, the meaningful impact is first to recognize the relevance and the influence of the WBSNs application for medical care delivery, especially in emergency situations. The need for opportune and accurate parameters could very well depend on the optimization of the time parameters as in In this section, we present the elements and context of the m-Health emergency scenario. The transmission of vital signs from a remote place is a key feature to save lives in emergency events, also video streaming or videoconference support has become an important tool in emergency situations. In most cases, the paramedics who are the first to handle this events do not have the required expertise, with visual and audio support the specialist located at the hospital can give directions for proper patient care. Frequency, security and compression of the physiological signals are important for this purpose. We discuss briefly these issues. Electrocardiography (ECG): An electrical recording of the heart signal to detect anomalies.Electroencephalography (EEG): the electrical recording of the brain’s activity.Pulse: Measurement of the heart rate, that is, the number of times the heart beats during a determined period.Respiratory Rate: Inspiration and expiration activity within a specific time interval.Blood pressure: Pressure of the heart pushing blood, to distribute it against arteries resistance.Temperature: Measure of the body's ability to generate and get rid of heat.Oxygen saturation: Measure of the oxygen levels in the blood.Vital signs are those that make possible to evaluate the basic functions of the human being. The vital signs indicate the health condition of a person. The typical vital signs are:The testing frequency of the vital signs depends on the health condition of the patient. Inpatients should be checked for long periods of time, for example, a heart attack risk or post-surgery condition patient requires continuous 24-hour monitoring. For injured and stable patients, the test frequency is every hour. A table showing the different signal requirements of body temperature, pulse oxygen, blood glucose, blood pressure, ECG and EEG in a wireless body monitoring system, is presented in . The samThere are physiological signals with great demand in data collection and transmission rate, for example in , sample Compression has been used in WBSNs, with the most common method being wavelets. It is reported that this method can achieve nearly 80% compression in combination with neural networks . For thiData security is a major problem for healthcare and medical emergency systems due to the handling of significantly delicate information. Sharing and transmitting private patient records via Internet can lead to interception of information by unauthorized parties. Security and integrity of the medical information is an important issue to be considered in the development of WBSNs. We briefly describe some important security considerations from the reviewed literature.The Health Insurance Portability and Accountability Act (HIPAA) Security Rule was created for regulation of different kinds of medical services, and specifically focuses on the safeguarding of Electronic Protected Health Information (EPHI) . The EPHInformation security can be seen from different perspectives such as privacy, integrity, and authentication. Privacy of patient’s data is an important issue of systems for healthcare. In terms of integrity, information needs to be intact and complete to ensure an accurate diagnosis. By authentication, the system must provide protocols where only authorized medical staff has access to information. In the emergency scenario, it is necessary to provide and define data security components due to the handling and transmission of patient information via public wireless networks, e.g., GPRS, 3G, 4G.Continuing and improper communication between devices.Housing resources and memory.Inefficient use of battery supply.Excessive traffic data and other types of information such as video and audio in real time.Interference and a large number of retransmissions.Inefficient network design that reduce power consumption of each node.Energy consumption of sensors according to the measured physiological parameter.Wireless personal area networks (WPANs) with intelligent physiological sensors allowing data acquisition and processing , and a wIntra-WBSN Communication: This layer considers communication between sensors and personal servers . Sensors have a direct wireless communication with PS through ZB or BT (star topology). The PS has capacity to take video of the patient’s condition, and collect and/or compress the physiological signals. The PS can directly transmit the video and physiological data, e.g., via 4G LTE to the second layer, but if the PS do not have this technology, the PS transmits the information to an ambulance via Wi-Fi or BT, and later the ambulance rebroadcasts the information via 4G LTE or Wi-Fi (modem enabled). According to [rding to , this tiInter-WBSN Communication: This tier corresponds to the communication between the PS to the internet or between PS and one or more RPs and then to the internet. If the signal drops, data could be sent to an RP/PC server (inside the ambulance) and afterwards, the information will be sent wirelessly (Wi-Fi) to the data base server. At this level, a gateway, PDA, PC, or 4G antennas are the link between de Intra-BAN and Beyond-WBSN layers. This tier needs some hardware and software requirements due to the specifications of the device, in terms of developing friendly user interfaces, and collecting and processing efficiently the sensors’ data in real-time [eal-time .Beyond-WBSN Communication: This is the final layer which facilitates the real time medical attention. Medical staff could handle through internet video conference or mobile calls an emergency situation of an accident. With the help of a database server, all patient data collected will be stored to create the patient health profile, which could be consulted at any time needed. The inclusion of this tier depends on the application of the platform for a specific situation [ituation . Some spANT+: It is an expanded version of the original ANT protocol to make the devices interoperable in a managed network. It was developed by the sensor company Dynastream in 2004 and it is considered a low power wireless technology. This protocol operates in the 2.4 GHz spectrum. ANT was created with the objective to communicate sports and fitness sensors with a display unit , which eNFC: NFC is for short-range wireless links operating at 13.56 MHz in the high-frequency (HF) band. His range of operation is approximately 4 cm and for this reason and its higher energy consumption compared with other low power wireless technologies (BLE or ANT+), it cannot be considered a direct competitor . NFC invNike+: It is a wireless technology created by Nike and Apple in 2006, (it will only work with devices of these brands) and operates in the 2.4 GHz spectrum supporting 250 Kbps or 1 Mbps transmission rates . It was ad hoc self-organizing network, and it was created for short range large-scale networks  with lomobility . Some mead hoc mode. It is ideally suited for large data transfers, but unfortunately, it needs large batteries [Wi-Fi: Wi-Fi is based on the IEEE 802.11 standards, letting users surf the Internet at broadband speeds when connected to an access point (AP) or in atteries . WirelesLong Term Evolution (4G LTE): 4G LTE is a technology that optimizes communications with transmission speeds of 100 Mbit/s for high mobility and 1 Gbit/s for low mobility. This technology uses transmission with Multiple Input-Multiple Output (MIMO) and Orthogonal Frequency Division Multiplexing (OFDM) techniques, transmitting more data in the same time period. On the negative side, 4G LTE is less power efficient than 3G and Wi-Fi for small data transfers, while for bulk data transfer is more power efficient than 3G .Bluetooth Low Energy (BLE): BLE was adopted and developed by the Bluetooth Special Interest Group aimed at novel applications in healthcare, fitness, security, and home entertainment industries . The mosBluetooth and ZigBee can be used for data transmission between sensor nodes and PS, while Wi-Fi and 4G LTE technology are used for data transmission from PS to a medical center. In this section, we provide a brief descriptive comparison of existing communication protocols for WBSNs including Bluetooth Low Energy, ZigBee, Wi-Fi and 4G LTE, ANT+, NFC and Nike+, see Power efficiency is the dominant factor in the design and implementation of protocols in WBSNs, see When the communication is from BAN coordinator to body sensors, the BAN coordinator uses a feedback frame to synchronize the attached body sensors to the BAN coordinator. In addition enabled power management solutions and energy-aware radio activation policies among different time intervals is proposed with the intent to increase network lifetime. The protocol has been extended to have a fuzzy logic system in order to reduce scheduling collisions . Each sei.e., nodes receiving data from neighboring nodes, and nodes that perform data processing for subsequent transmission to the destination. In LEACH, the nodes organize themselves into local clusters, with one node as Cluster Head (CH), and each node determines its CH by choosing the CH that requires the minimum communication energy. Once all the nodes are organized into clusters, each CH creates a schedule for the nodes in its cluster. However, LEACH presents some problems at this collection points or CHs; a possible bottleneck is responsible for different tasks and data aggregation could be lost and never sent to the base station. A new improved LEACH protocol is developed to solve the potential problems in [Another way to increase the lifetime of the network is through the use of the Lower Energy Adaptive Clustering Hierarchy (LEACH) protocol. It consists of introducing collection points in the network, blems in  which adBODY MAC is proposed in , as an eClass 0: Low grade data .Class 1: Medium grade data .Class 2: High grade data .The medical medium access control, MEDMAC in , is a TDResults indicate that MEDMAC can work more efficiently for low and medium data rate than IEEE 802.15.4 MAC. IEEE 802.15.4 has higher power consumption due to overhead; at medium grade data, MEDMAC performance is stable up to 24 nodes, while IEEE 802.15.4 is unstable for more than 13 nodes. Also, MEDMAC consumes less than 10% of the energy that IEEE 802.15.4 MAC protocol does.An energy efficient MAC protocol using wake up radio is presented in . Two basAn energy efficient and QoS (EQ-MAC) protocol is presented in . This prThe reduction of energy consumed for communications between sensors is treated in . A schedInefficient use of battery because of retransmissions, data loss, high latency and excessive traffic data are some of the issues that we could face if scheduling conflicts for sensor transmissions are not resolved. An efficient scheduling design brings a very important reduction in power consumption of each node. An intelligent scheduling algorithm must be applied to allow the maximization of efficiency in performance, acceptable packet delay levels, and minimum power consumption. An example would be to form a characteristic vector for each sensor , as:{Iime slot . N sensor nodes and a base station, which is able to compress, gather and process information received from each node in the network. The nodes are able to wirelessly communicate among themselves and also with the base station [WBSNs need to carry out processes that are energy efficient, therefore, it is important to develop a model of energy consumption that is suitable to be optimized. The variables of the model can be compared according to the needs and behavior of the WBSN at any given moment . We consider having a WBSN with  station .N sensors to carry out their sensing and communication tasks. For this, we consider that a sensor I = 1, 2, ..., N, consumes b bits of length is produced. It also consumes b bits of information, and it consumes b bits of length in a link with sensor j with separation distance N sensor network, i.e., E [Nodes in the WBSN have mainly three different subsystems to operate, the first for vital parameter measurement, the second for sensor data recording, and the third for data sensor communications. Considering tradeoffs between latency and power consumption, we can formulate a model that can be used for performance optimization of the WBSN. Since energy efficiency is a main concern, the objective function represents the energy consumed in the WBSN. The decision variables of the optimization problem are the time intervals for each of the  i.e., E ,49, is gb bits of information, n is the path loss exponent of the environment, and AI represents the active mode current consumed; i (samples per second); DR; i, respectively.From the subsystems belonging to each node, the highest energy consumption is in the subsystem responsible for the transmission and reception of data. The term on model , only bEi.e., the time interval for sensor i, will satisfy 0T size, which gives 1/T partitions in a time interval unit. Since each sensor is 1/T partitions in this interval, and each partition can be assigned at most to one sensor, we get the restriction DT, Data Rate and the Overhead Based on a patient's condition and the level of monitoring required, the physician can specify a monitoring interval of 1N1Ti≤1T . Sample i in a time interval is given in Equation (3), which can be simplified into [L, which is the time it takes a sensor between collecting a sample and transmitting it to the base station and is given by:The cost function is composed of energy consumption and latency. The energy consumption of sensor ied into :(4)bEcii, i, and The final cost function is given by:Constrained to:The optimization problem considering the research work done in ,49, is tVideo technology continues to enhance safety and effectiveness in medical care. For emergency cases, the use of wireless video transmission or video conferencing is expected to have a significant impact on the procedures to be taken by the paramedics during the first hour (golden hour) after the accident. The specialist can provide instructions to paramedics based on video images of the victim and his physiological parameters, to sustain a better treatment that can have positive implications for the patient’s survival ,51.Furthermore, it can be of critical importance to the specialist to be aware of the situation of the victim prior to arrival at the hospital. Video transmission continues to be more efficient thanks to the advances in wireless networks and video compression technology. One of the emerging video coding standards is H.264/Advanced Video Coding (AVC) which has been developed and standardized collaboratively by both the International Telecommunication Union (ITU-T) and the International Organization for Standardization/ International Electrotechnical Commission (ISO/IEC) . i.e., better quality compressed video, and greater flexibility in compressing, transmitting and storing video. The fact that the specialist from the hospital could have a video image of the situation of the victim from the accident, e.g., to see his face color, his reactions, his injuries, helps to a faster treatment when the patient arrives to the hospital, where the specialist is already prepared. Thus, the use of video is a significant step for the emergency medical care scenario. The H.264/AVC standard is built on the concepts of MPEG-2 and MPEG-4, and it offers the potential for better efficiency, The literature includes a variety of platforms for m-Health support systems. In one, the standard H.264/AVC has been applied to telemedicine support situations of ambulance transferring emergency patients, where Ubiquitous Health  is currently utilized without breaking medical law. Remote Medical Support System (RMSS) used in ambulances enables a doctor at a remote place to identify the patient status through video, and supply remote support to the emergency . AnotherThe transmission of medical data traffic and video over the network, includes an adaptive rate scheme for multimedia medical data  multiplexing in order to reduce the required resources from the telemedicine application . The quaThe combination of data and video plays an important support role. Improvements in the health delivery process in the context of tele-health requires the synchronization of video and physiological signals to make possible for the physicians located in a Hospital to simultaneously observe the face and the vital signs of the patient located at the place of the accident. Also, effective procedures for medical treatment, diagnosis, feedback and research require the synchronization of both video and biomedical signals. Performing feedback procedures to enhance patient safety in anesthesia operating rooms requires the creation of a permanent and accurate record of clinical events containing synchronized video, audio and vital signs for future offline analysis . ProceduThe biomedical signals being synchronized with the video are usually more than one to provide sufficient medical and visual information to the physician. This information supports the physician in improving the accuracy and effectiveness of medical treatment, diagnosis and feedback. Observing one or more biomedical signals simultaneously with the video of the patient is necessary for assessment and correlation. Many signal- and image-processing challenges lie in the joint processing and transmission of biomedical signals and images. We see challenges in three areas: (i) multi-modality signal synchronization; (ii) joint signal, image and video compression; and (iii) interactive collaborative environments. There are significant synchronization issues for joint decoding. Clearly, one-dimensional biomedical signals should correspond to video images. As an example, we note the synchronization of ECG, respiratory, two-dimensional, and Doppler signals in ultrasound systems. In addition, we note that two-way voice communications must be synchronized to all clinical signals, as well as to real-time video images of the patient and the doctor. Resynchronization in the presence of wireless-communication errors will require innovative error-resilience methods. For well-synchronized signals and images, methods for joint-signal, image, and video compression can be developed .Scheduling: Design a transmission scheduling for the WBSN in relation to the transfer rate of each vital sign. Characteristics of a model in monitoring and data transmission must be provided. We know that sampling frequency of each sensor, required bandwidth and amount of data are very particular according to the vital sign measured.Adaptability: A WBSN must be dynamic and adaptive. Each patient according to his/her condition, shall imply different priorities in terms of the energy consumption, the collection and transmission of data from each sensor.Communication: wireless communication is an important factor to evaluate. Each sensor can communicate wirelessly with other sensors or with the base station, however, there are factors that can influence this communication to be successful to optimize energy consumption:a)Collisions if two sensors try to transmit at the same time (inefficient communication).b)Retransmissions caused by collisions or loss of information with direct impact on the energy consumption.c)etc.) data loss or retransmissions could occur if protocol is not designed with mobility support.Mobility of patient: when a patient is moving within different areas in a hospital External factors such as a monitoring environment with heavy traffic information  or geographic areas that prevent proper communication between network devices.e)The need to guarantee access to the transmission channel for each sensor according to the priority that involves each of the scenarios for monitoring.Quality of service: It is of utmost importance in the monitoring and vital sign transmission; data must be available at the right time, without errors and in real time, so reliability of the network is not affected. Security: The security and privacy of patient-related data are two relevant components for the system security of the WBSN. By data security, it means the protection of information from unauthorized users while data being stored and transferred and data privacy means right of individuals to control the collection and use of personal information. Security and privacy issues are raised automatically when the data is created, transferred, stored and processed. The Health Insurance Portability and Accountability Act (HIPAA) mandates that, as the sensors in WBSN collect the wearer’s health data , care needs to be taken to protect it from unauthorized access and tampering [ampering .Critical time parameters: For diagnosis, it is very important that health data  of patients arrive within the expected time to accurately indicate the actual health condition of the patient. Delay, packet errors, and packet losses are some factors that could alter the correct medical diagnosis. If one of the vital sign parameters gets lost, arrives with delay or in a different time slot, a critical condition could be ignored. So, these factors are needed to evaluate a WBSNs through critical time parameters [rameters .The specific technical challenge is to study, analyze and optimize the behavior of energy consumption in a wireless sensor network for medical monitoring. It is necessary to increase efficiency per node, in other words, a greater data transmission per node with respect to a quantity of energy available. It would be relevant to establish different strategies for data transmission over a wireless network with reconfigurable topology. These strategies will use the parameters of the sampling frequency, frequency for sending data, as well as the "priorities" of data to send. There are parameters that are more critical than others in a WBSN, therefore the priority in sending data from each sensor is different, e.g., in an emergency situation or critically ill patients. A model of analysis that carry out energy consumption estimations in sensors and personal servers must be considered to create a low energy consumption algorithm for transmission and reception of data with the aim to increase the battery lifetime in a WBSN. Some energy conservation challenges in WBSN must be attained to reach a reliable performance:This research has presented information to develop an adaptive system optimization. This is important because the energy consumption could be altered by multiple factors when the monitoring is conducted in a patient, e.g., it is not the same to monitor three patients as eight, two or five vital signs or to carry out the WBSN monitoring in a rural area as in an urban area with 4G cell phone network. It is necessary to take into account that each patient’s condition represents different needs and priorities to evaluate, in other words, there is a big difference of patients being monitored in an emergency situation from that of inside hospitals or in their homes. By developing a system which is sensitive to changes of variables such as polling interval, traffic generated by sensors, priorities for monitoring or energy remaining in the system, we will make a significant contribution towards improving performance to maximize the WBSN lifetime. The aim of the development for this proposal is based on contributing in the area of telemedicine that seeks to provide better care to patients in each of the above scenarios allowing a more reliable doctor-patient relationship. Having a WBSN with high performance and in real-time, we can improve the disease control practices resulting in the improvement of patient health status.etc. The joint-transmission of the streams can be achieved via multiplexing, that is common for an audio/video streaming in a media context. In terms of network optimization for the transmission of data and video over limited bandwidths, that is common for m-health scenarios, it is necessary to reduce the required resources from the network. A common approach to minimize the physical data channels of the network is the joint-transmission of different elementary streams like: video, audio, physiological signals, personal data, Recently, data hiding techniques have been implemented for media context, like those based on different block sizes taking the rate-distortion into account to achieve good performance in the audio-video synchronization, one stream of information (audio) embedded into the video signal ,62. The In this survey we have reviewed the state of the art of WBSN providing a wide overview of features, practices and the most important issues that researchers will face for emergency scenarios. Unlike other surveys we have presented information that helps to contemplate development of an adaptive system optimization according to the needs and behavior of the network at any given moment. The development of the proposed system would allow extending its application to diverse scenarios as patients with chronic-degenerative illnesses, preventive monitoring or patients in intensive care. Additionally, we consider the video transmission as an important feature into a WSBN in an emergency scenario. The visual interaction between the paramedic and the doctor in this context is very helpful to enhance the medical treatment of the victim. We introduce some aspects like the video and vital sign joint-transmission in real time, and the synchronization between them, supporting the physicians to have a better picture of patient’s condition in order to have a better diagnosis. However, our research helps us to understand the existence of some issues ignored, for example, in the MEDISN , the coeNevertheless, situations as mobility of sensors, wireless technology coexistence and noise are not addressed. So in addition with the above issues the following question arises: is it possible that by using different technologies applied in WBSN, communication protocols and capabilities of network devices, a reduction of energy consumption can be achieved? Surely it can be attained, but it will be necessary to develop new schemes and methodologies that allow analyzing and optimizing the exchange of information between the devices. Strategies like these will help to determine the characteristics that a model or system must have within the framework of energy efficiency. Once the last question is resolved, patients could increase their survival possibilities because they will have specialized medical care starting at the scene of the accident or emergency event.


Structural health monitoring with wireless sensor networks has been increasingly popular in recent years because of the convenience. In this paper, a real-time monitoring system for cracks on the surface of reactor containment buildings is presented. Customized wireless sensor networks platforms are designed and implemented with sensors especially for crack monitoring, which include crackmeters and temperature detectors. Software protocols like route discovery, time synchronization and data transfer are developed to satisfy the requirements of the monitoring system and stay simple at the same time. Simulation tests have been made to evaluate the performance of the system before full scale deployment. The real-life deployment of the crack monitoring system is carried out on the surface of reactor containment building in Daya Bay Nuclear Power Station during the in-service pressure test with 30 wireless sensor nodes. Civil infrastructure usually plays an important role in society’s prosperity . The safet al. [et al. [et al. [et al. [et al. [et al. [et al. [et al. [Currently, many SHM systems based on WSNs have been implemented on various civil structures including bridges, tunnels, and tall buildings and so on. Utilizing 64 Micaz nodes with two different accuracy accelerometers that measure ambient vibrations, Kim and Pakzad et al.  implemen [et al.  deployed [et al. ,9,10 pre [et al.  proposed [et al.  As for t [et al.  designed [et al.  utilized [et al.  installeIn this paper, we implement a wireless monitoring system for nuclear power plants, especially for monitoring changes in crack width on the surface of reactor containment buildings during pressure tests. Customized WSN platforms are developed and the sensors used include crackmeters and thermometers. Issues like route discovery, time synchronization, data collection and duty-cycling schemes are considered in software design. After some simulation tests, full scale deployment is made at the Daya Bay Nuclear Power Station with 30 sensor nodes. The paper is organized as follows: The generation of electricity through nuclear energy has many advantages such as lowering greenhouse gas emission, being reliable, and being independent from natural aspects. However, the safety of nuclear power plants are most important, as any slight mistakes could lead to severe disasters. Chernobyl and Fukushima nuclear accidents are just two good examples. Reactor containment building (RCB), as the fourth and final defense layer for a nuclear reactor, is designed to keep radioactive substances from getting into the environment in operational states and in accident conditions like loss of coolant accidents (LOCAs), and protect the nuclear power plant against external natural and human induced events . Then, uConsidering that cracks to be concerned about may appear anywhere of the RCB, on the dome or on the perimeter wall, it is impractical to carry out the monitoring task with wired systems. Currently, used battery powered devices that store data locally and gather them after pressure tests also have drawbacks. The monitoring data cannot be obtained by users in real-time for further analysis and users are not informed if some devices stop working during the test, thus leading to incomplete data. The advantages of WSNs and the successful cases of using them to monitor other structures motivate us to introduce this technology for real-time crack width changes monitoring on the surface of RCBs. As far as we know, this is the first time to use wireless sensor networks technology for RCB monitoring. We develop customized platforms and corresponding software. The deployment in Daya Bay Nuclear Power Station shows the effectiveness of the system.Each wireless sensor node in a structural monitoring system is responsible for three primary functions: data acquisition, signal processing and wireless communication. Correspondingly, a sensor node usually consists of a microprocessor, radio transceiver, data storage, batteries and sensor boards. Up to now, many commercial wireless nodes have been used for structural monitoring. In addition, some researchers have also designed their own platforms to carry out monitoring tasks. μm. The output of the sensor is digital with RS485 interface and the work voltage is 12 Volt direct-current. It also has a built-in temperature compensation mechanism. The precision of the sensor is tested through comparison with the linear comparator, and the result shows that it meets the monitoring requirement. Besides crackmeters, we also use PT100 platinum resistance temperature detectors  to capture the temperature of the environment for data analysis purposes. The resistance of PT100 remains 100 Ω at 0 The most commonly used sensors for structural monitoring are accelerometers, with which the structural vibration response can be captured. In addition, two or three axes, high or low accuracy accelerometers are selected based on specific monitoring requirements. Our monitoring targets are width changes of the cracks on the surface of RCBs, then crackmeters are chosen, and they are based on linear variable differential transformers (LVDTs). LVDTs are displacement transducers and are widely used in industrial applications. They are made up of a central core, a primary coil and a secondary coil with two equal parts that are connected with opposite polarities. The primary coil is supplied with an alternating current, and the two parts of the secondary coil induce different voltages because of different mutual inductances when the core moves between the coils. The difference between the two voltages is the output voltage of the sensor. LVDTs have the advantage of high immunity to electrical noise, and as there is no mechanical contact between the core and coils, LVDTs could increase the expected life. The LVDT  we choose can be seen in The components used by nodes mentioned in The sensor nodes are usually battery-powered; therefore, the energy of them is limited, which means that it should be used properly. Energy consumption is one of the most important issues in wireless sensor networks. Every operation of the sensor node affects its life span and the lifetime of the whole monitoring network, respectively. In our system, the sensor nodes are powered by rechargeable lithium batteries with a total capacity of 4000 mAh. In order to make sure that the capacity is large enough to work through pressure test periods, the operation current under idle mode, sampling mode and transmitting mode is measured. We find each sampling state lasts about four seconds and transmitting one packet costs approximately two seconds. According to the typical 30 min sampling period, sensor nodes only sample and transmit twice in one hour. Then, the power consumption under each mode is calculated. The sensor node in the monitoring system can do nothing without software. Software is the soul of the sensor node to execute sensing, computing, and communication. In addition, the operating system of sensor networks is the cornerstone of software. Taking the features of WSNs into account, many embedded operating systems special for sensor networks like TinyOS, SOS, MANTIS OS and Contiki have been developed by researchers. TinyOS ,24 is anIn the initialization stage, nodes need to prepare for data collection, and there are two main things they should complete during this stage: one is route discovery and the other is time synchronization. Route discovery is very important as it is the precondition of data collection. In our monitoring system, we implement a hierarchy routing protocol similar to LEACH protocol . The difThe main task for sensor nodes in the monitoring stage is to measure changes of crack width and send them to cluster heads. As the widths of concerned cracks change slowly during pressure tests, a 30 min sampling period is enough for capturing the variation of cracks. In addition, duty cycling schemes are employed by sensor nodes. Every 30 min, sensor nodes wake up to get data from LVDT crackmeters and PT100 temperature detectors, store it and send it to cluster heads. Then, they go into idle mode and turn off their sensors and radios. In this way, sensor nodes can save a lot of energy, as they sleep most of the time. Although cluster heads do not need to monitor the cracks, they may need to always keep their radio on to receive packets from sensor nodes. Then cluster heads may consume much more power than sensor nodes, and they need to be powered by batteries with more capacity or use alternating current (AC) power when possible. Thanks to the time synchronization scheme, TDMA is used by sensor nodes for media access control to prevent transmission interference. Sensor nodes turn off their radio after sending messages out in order to save energy, which means usually they do not receive messages from cluster heads during the monitoring stage. Then, an unreliable data transfer protocol is used to adapt this feature. Sensor nodes just send measured data once to cluster heads, and there is no feedback from cluster heads about packet loss and thus no retransmission occurs. Data loss is inevitable in wireless transmission, and tests in When the wireless monitoring system is implemented, transmission tests are carried out before full scale deployment to find out the transmission range of sensor nodes and the data loss rate of the system.The purpose of transmission range test is to determine how far the radio we choose can transmit at most in the open air and guide the deployment of cluster nodes. Considering the structure of RCB and the place where the sink node has to be put, both horizontal and vertical transmission range tests are carried out. In horizontal tests, the sink node is connected to the laptop for receiving messages from sensor nodes, and one sensor node is placed near the sink node to send messages as references. Three other sensor nodes are placed at a horizontal distance of 30 m from the sink node to send messages, and then at the distance of 50 m, 70 m, 100 m, 120 m and 150 m, respectively. The transmission power levels of these sensor nodes are kept the same during the test, the sampling period is 1 min, and three sensor nodes are placed at each distance for 5 min. Test results show that the sink node can receive all messages when sensor nodes are placed at the distance of 30 m, 50 m, 70 m and 100 m, and it cannot receive all the messages at the distance of 120 m, while no messages are received at a distance of 150 m except those from the reference sensor node. From this test, we know that our sensor nodes ensure a horizontal transmission distance of 100 m. Most sensor nodes will be deployed at the dome area of the RCB, but the sink node needs to be placed on the ground, which is at a vertical distance of 50 m from the dome due to space and power supply constraints. Then, a vertical transmission range test is conducted on a 20-story building. Similar to the horizontal test, the sink node and reference sensor node are placed on the ground, three sensor nodes are placed at level 5 with line of sight, then at level 10 and 15. The sampling period and duration at each level are the same as the horizontal test. Results show that even when sensor nodes are placed at level 15, a vertical distance of about 50 m, the sink node on the ground can receive all the messages from them, which means that it is feasible to put the sink node on the ground for convenience.As mentioned in Daya Bay Nuclear Power Station is located in Guangdong province, which is the first commercial nuclear power station in mainland China. As one of the earliest and largest joint venture projects launched under China’s Open Door Policy, it began to be built in 1987 and was completed in 1993, and French and British technology were used during the construction. The plant has two pressurized water reactor generating units with a total electrical capacity of 1968 MW. It produces around 14 billion kWh of electricity per year, and the primary consumers of this nuclear power station are Hong Kong and Guangdong province, consuming 70% and 30%, respectively. Daya Bay Nuclear Power Station is under strict management and operation to maintain safety. Our full scale deployment is carried out during its every ten years’ in-service pressure test.The pressure test is conducted to check the integrity and leak rate of the concrete containment building that houses the nuclear reactor. In addition, one important task during the test is to inspect the surface of the RCB and measure the changes of crack width on the concrete structure. Before the pressure test, a manual inspection is conducted to find out cracks that need to be monitored on the surface of the RCB. Then, the locations of concerned cracks are reported and the deployment of sensor nodes is based on the report. Sensor nodes with LVDT crackmeters are installed on the surface of concerned cracks. The details of installation are illustrated in The quantity and function of nodes used in the full scale deployment is shown in When the deployment of the wireless monitoring system is completed, the pressure test starts. The reactor is shut down and compressed air is pumped into the containment building, the building is pressurized to predetermined pressure under several measurement phases at different pressure levels, which can be seen in Just before the pressure test, the wireless monitoring system runs route discovery and time synchronization algorithms to prepare for data collection. Then, the monitoring stage starts along with the pressure test, and sensor nodes record the changes of cracks’ width due to thermal and pressure impacts and send them to cluster heads every 30 min. Cluster nodes help sensor nodes relay data to the sink node. The sink node collects, stores and displays all the data in real-time. The monitoring stage lasts seven days until the pressure test stops. The sink node can acquire data from all of the 30 sensor nodes, and the average data receiving rate is similar to the transmission test that we have done before, which verifies the efficiency of the wireless monitoring system. In addition, only about 10% of the energy is consumed on average, which is consistent with our previous theoretical calculations.The advent of wireless sensor networks brings both opportunities and challenges for structural health monitoring. We enjoy the convenience of wireless transmission but suffer limited resources at the same time. In this paper, we present a real-time monitoring system for cracks on the surface of reactor containment buildings during pressure tests based on wireless sensor networks. Sensors like crackmeters and temperature detectors are chosen and customized platforms are designed and implemented to meet the monitoring requirements. Meanwhile, software protocols like route discovery, time synchronization and data transfer are developed to take the limited resources into account. A graphical user interface is programmed to receive, store and display data. The monitoring system is evaluated with several experimental tests before real-life deployment. In addition, the full scale deployment of the system at Daya Bay Nuclear Power Station with 30 sensor nodes is quite successful. Despite the successful deployment, there are still some improvements that can be made for our system. Currently only crackmeters and temperature detectors are used in our nodes, and more sensors may be added for multiple purposes in the future. The topological structure of the monitoring network is established at the initialization stage and is static; thus, it is not robust to failures, especially for cluster head errors. Therefore, dynamic topology will be a better choice for the system. The system is mainly designed for low sampling frequency tasks as tailored time synchronization protocols are developed. However, it may need to be redesigned to suit some high sampling frequency monitoring projects. Similarly, the unreliable data transfer protocol only works well with low sampling frequency, reliable protocols or data recovery mechanisms that are required for high sampling frequency tasks. We believe our system can be easily adapted to many monitoring tasks if these improvements are made.