Such routine use would make a big difference to investigations of pathogen transmission and prevention/control of  infections.Even with the advent of next-generation sequencing (NGS) technologies which have revolutionised the field of bacterial genomics in recent years, a major barrier still exists to the implementation of NGS for non-technical laboratory staff, are all critical requirements for routine use in a public health setting. There are currently no systems to answer positively to all these requirements, in an integrated manner.The inherent complexity and high frequency of data analyses on very large sets of bacterial DNA sequence data, the ability to ensure data provenance and automatically track and log all analyses for audit purposes, the need for quick and accurate results, together with an essential user-friendly interface for regular In this paper, we describe a system for sequence analysis and interpretation that is highly automated and tackles the issues raised earlier, and that is designed for use in diagnostic laboratories by healthcare workers with no specialist bioinformatics knowledge. Despite the development of effective antimicrobial drugs and anti-bacterial vaccinations, pathogenic bacteria continue to cause significant human morbidity and mortality in all regions of the world -4. The sGenomic sequences can be generated through the use of next-generation sequencing (NGS) technologies, which have been rapidly advancing in recent years. The application of these technologies is revolutionising diagnostic and public health microbiology due to the high yield and resolution, low turn-around time and falling costs of the data obtained ,7. IndeeThe challenge in making NGS a reality for routine diagnostic and public health laboratory use is that the analysis is far from trivial, comprising multiple steps  . Each stMicrobiology laboratories may process hundreds of bacterial isolates each week . ClinicaIdentification may be followed by further characterisation, whereby the required spectrum of tests is dependent upon the bacterial species or clinical situation in question. Such tests, for which the specific protocols also vary in a species-dependent manner, include antibiotic susceptibility testing, epidemiological typing, toxin and virulence gene screening. The necessary laboratory techniques may include microscopy, susceptibility testing by disc diffusion or E-test, biochemical assay, polymerase chain reaction and capilliary sequencing. As such, full bacterial characterisation may require several days or even weeks for completion ,7.Staphylococcus aureus infections in a British hospital identified a staff member as the focal point of transmission and led to the formulation of an appropriate intervention strategy. Crucially, it was shown that these findings could not be determined by the use of traditional characterisation techniques alone [In contrast to traditional methods, NGS data representing almost an entire bacterial genome can be generated in a matter of hours, independent of species classification ,13. Theses alone .Unfortunately given that microbiology laboratory staff should not be expected to possess advanced bioinformatics skills, the lack of automated and user-friendly NGS analysis tools is a major barrier to the routine use of NGS technologies in public health and diagnostic laboratories ,8. ThereOver recent years, there have been several commercial and open source initiatives that integrate specific NGS analysis components  Layer allows the user to upload data as required  and perform various searches. The user is also able to create, modify and run analyses by specifying the required input data and applicable parameters. The tool also allows creation and management of NGS analysis workflows in a visual (drag and drop) manner. A user can connect various analysis modules using arrows, thereby creating the analysis workflow. In addition to analysis modules (e.g. BWA), a workflow can include visualisation modules. If required, the user has the ability to run the same analysis workflow with different parameter sets, in parallel (e.g. to compare results), or run totally different analysis workflows at the same time. Reports can also be produced to detail or visualise results of any given analysis.The Web APIs (Application Programing Interfaces) layer is the link between the UI and the Middle Layer. For example, once the user sets up and starts an analysis, the applicable workflow description and requirements are passed to the Middle Layer via an API. By having a standard set of APIs that are exchanged in a standard format [The d format , the actMiddle Layer provides a runtime environment to execute the analysis workflows. Each request received from the UI layer  is coordinated by the Middle Layer and passed to the Physical Layer as required. For example, when a new analysis workflow definition is received from the UI, it is loaded and interpreted by the Middle Layer, and the required analysis modules are passed to the Physical Layer to be scheduled and executed in the appropriate order. If requested in the workflow definition, the Middle Layer also facilitates passing of the results for each module run, from the Physical Layer back to the UI Layer, to be visualised. The Middle Layer also ensures a solid file management and data provenance practice, by linking the information about each module of an analysis, the associated input files, parameters and results with any intermediate or output files.The Physical Layer has two major roles: one is to store all the relevant data in the system , together with workflow definitions and analysis results, in a database which is linked to a file management system. The other major role is to take care of scheduling and running the requests received from the Middle Layer. The Physical Layer also assesses the computational requirements for each request and allocates resources for parallel computing if required for a particular task  or a supercomputer).The Here we describe a hypothetical analysis flow which could be performed by a biologist in a generic microbiology laboratory on a regular basis  is available in a spreadsheet and uploaded into the system by a laboratory staff member.The microbiology laboratory has received a set of ng (MLST ) analysiSystem access: Upload Isolate Data;User Actions: Select one or more isolate data file; upload and review success or errors; edit records and re-upload as needed;The corresponding sequence data files (in Fastq format) are also uploaded and automatically linked by the system to the correct isolate records.System access: Upload Sequence Data;User actions: Select a folder or a subset of Fastq files; provide sequencing run details; validate the automated system matching of sequence files with the isolate data;L. monocytogenes isolates in the isolate database for which an MLST analysis has not yet been completed. The "Select All" feature can be used to select all of the identified isolates for inclusion in an MLST analysis run.Firstly, the laboratory staff member would like to conduct the MLST analyses; he/she can use the isolate search functionality to identify all System access: Search Isolates;User actions: Specify search criteria as needed; select one, some or all isolate records;The staff member can then navigate to the "Create New Analysis" screen, select the MLST analysis type and confirm the parameter values to be used . The appropriate species-specific MLST reference database is automatically selected by the system based upon the species designation of the nominated isolates. The raw sequence data files upon which the analysis is to be performed are also selected automatically by the system, using the isolate metadata - sequence data link information. Thus there is no need for the laboratory staff member to manually search for and identify isolates to be included in the analysis, nor is there a need for the staff member to manually locate, copy or move the appropriate raw sequence data files. The laboratory staff member can start the MLST analysis simply by clicking the "Start" button. There is no need for the staff member to select a specific analysis algorithm since the system stores and utilises a list of default 'preferred' algorithms  representatives through time.Upon completion, the results of the analyses are automatically linked to the appropriate isolate metadata records in the isolate database. The staff member would like to compare the results of their System access: Search Isolates;User actions: Specify search criteria as needed; select one, some or all isolate records; view and compare analyses results;L. monocytogenes outbreak. In order to confirm the relatedness of the suspected outbreak isolates in comparison to other L. monocytogenes isolates representing the same or closely related STs, the staff member can use the isolate search feature to identify and select all closely related L. monocytogenes isolates for which sequence data is available.This comparison indicates that there has been a recent increase in the number of isolates representing ST13 (multi-locus sequence type 13) and its closely related variants. Such a change in the frequency and distribution of clonal groups may indicate a local L. monocytogenes genome.The genomes of these isolates can be further investigated, e.g. by construction of a phylogeny through reference-based sequence mapping and variant calling across the wider Unlike the MLST analysis, which can be completed by the use of a single tool, this type of analysis requires a multi-module process including read-mapping to a reference sequence (e.g. using BWA ), varianAs above, the staff member does not need to think about the specific analysis tools that are required, since the default 'preferred' tools will be automatically selected by the system. Such tool (and parameter) preferences can be customised by the system administrator based on the current best-practice recommendations and laboratory preferences. However, users with the right knowledge and inclination do have the option to select alternative analysis tools for one or all of the analysis modules in the workflow.System access: Search References;User actions: Specify search criteria as needed; select the applicable reference files;As it can be seen in the above example, the actions which a non-bioinformatics laboratory user must take in order to fulfil his/her analysis task requirements using the system are quite simple. The system automates as much of the process as possible thereby reducing manual interaction of the user with the data and the potential impact of human error. For example, the sequence data is automatically linked to the correct isolate metadata records, the appropriate species-specific reference file and the raw data files are selected automatically by the system when the user creates a new analysis run. Additionally, the results of the analyses are automatically linked to the appropriate isolate metadata records and analysis record details. Moreover, all computation related information is completely hidden from the user .Our aim is to facilitate the routine use of NGS technologies in diagnostic and public health microbiology laboratories. In this paper we described a system which is user-friendly, flexible and scalable, and which could be used by regular laboratory staff members, without specific bioinformatics training. This system overcomes the difficulties met by existing approaches, in regards to usability, scale and variety of genomic data which could be processed, data management, automation of required tasks, as well as auditing capabilities which are critical for any system in the public health sector.NGS: Next Generation Sequencing, API: Application Programming Interface, MLST: Multi Locus Sequence Typing, ST: Sequence Type.The authors declare that they have no competing interests.LIR and KLW drafted the manuscript. CQ, TC, AB, LIR and SG work on developing the system described, in a prototype form. MR, DE, GH and KH were the initiators of the project and provided very useful feedback on the manuscript. All authors read and approved the final manuscript.


Neurogenic dysphagia is one of the most frequent and prognostically relevant neurological deficits in a variety of disorders, such as stroke, parkinsonism and advanced neuromuscular diseases. Flexible endoscopic evaluation of swallowing (FEES) is now probably the most frequently used tool for objective dysphagia assessment in Germany. It allows evaluation of the efficacy and safety of swallowing, determination of appropriate feeding strategies and assessment of the efficacy of different swallowing manoeuvres. The literature furthermore indicates that FEES is a safe and well-tolerated procedure. In spite of the huge demand for qualified dysphagia diagnostics in neurology, a systematic FEES education has not yet been established.The structured training curriculum presented in this article aims to close this gap and intends to enforce a robust and qualified FEES service. As management of neurogenic dysphagia is not confined to neurologists, this educational programme is applicable to other clinicians and speech–language therapists with expertise in dysphagia as well.The systematic education in carrying out FEES across a variety of different professions proposed by this curriculum will help to spread this instrumental approach and to improve dysphagia management. Neurogenic dysphagia is one of the most frequent and life-threatening symptoms of neurological disorders. Swallowing impairment is observed in at least 50 % of all patients with ischaemic or haemorrhagic stroke –3. TheseThe above-mentioned data indicate that swallowing impairment is a nearly ubiquitous problem in neurology. Affected patients are either treated on an outpatient basis, e.g. in specialised consultations for movement or neuromuscular disorders, or on an inpatient basis, where dysphagia is observed at all levels of care, from the general ward to the intermediate care/stroke unit and the intensive care unit.Traditionally, the first step in systematic evaluation of dysphagia is a clinical swallowing examination performed by appropriately qualified speech and language therapists (SLT). However, the validity and the reliability of this clinical approach are generally insufficient. Particularly the pharyngeal phase of swallowing and silent aspiration, often seen in patients with neurogenic dysphagia, are difficult to detect using this approach . TherefoAt present, the flexible endoscopic evaluation of swallowing (FEES) is probably the most commonly chosen method for the objective assessment of swallowing in Germany. It is used in more than 50 % of all certified stroke units  as well FEES was first described in 1988 by the American SLT Susan Langmore and colleagues  and defiOriginally, FEES was conceived as an alternative to the historical gold standard, the X-ray-based videofluoroscopic swallowing study (VFSS), to be used when VFSS was either not available or not applicable. However, besides being increasingly used in a clinical context, FEES has, within the last 15 years, established itself as an independent and efficient method alongside VFSS , 26. In Visualisation of the swallow by means of FEES involves introducing a flexible nasopharyngolaryngoscope transnasally into the pharynx via the inferior or middle nasal meatus. FEES provides an extensive picture of the pharyngeal phase of swallowing and enables the detection of indirect signs of impairment within the oral and oesophageal phases. The aims of FEES are, in particular, to identify pathological movement patterns, to assess the effectiveness and safety of swallowing, to determine suitable food consistencies or forms of nutrition and to guide the use of therapeutic manoeuvres for each patient. Data show that FEES is an exceedingly well-tolerated and safe examination. Of 6000 examinations performed, only 222 (3.7 %) were terminated prematurely at the patient’s request . The mosFEES has been successfully applied in diverse patient populations and disease patterns. Among others, studies describing stroke and traumatic brain injury patients , 38, patDespite the numerous possible applications of FEES in neurology and the undisputed strong need for qualified dysphagia assessment in this area of expertise, in Germany this technique is not yet systematically taught in neurological residency programmes or training programmes for SLTs. The FEES curriculum described hereafter aims to close this gap. In particular, two main objectives are linked to this step: on the one hand, the definition of quality standards aims to guarantee consistent and high standard performance of FEES. In the long run, the intended standardisation of terminology, examination algorithms and interpretation of results will not only facilitate professional communication within a given hospital, but will also contribute to the optimisation of understanding between the various sites involved in the treatment of an individual patient over time, e.g. acute clinic, rehabilitation clinic, outpatient care. On the other hand, the introduction of a formal curriculum also leads to a valorisation of FEES. Learning this method will thus become more attractive and will turn into an independent, clinically relevant and sought-after qualification.While this curriculum is therefore of interest to all clinicians practicing in Germany, it could also be used by other countries after adapting it to their specific needs.The diagnostics and therapy of swallowing disorders are relevant to many disciplines. This training curriculum is therefore not only intended for neurologists but is open to all clinicians with an interest in this topic. It also offers SLTs, in particular, the opportunity to acquire qualifications in the area of instrumental dysphagia assessment and to expand their range of activities.The curriculum and the qualification levels were developed in keeping with the guidelines of the Royal College of Speech and Language Therapists (RCSLT)  and the At this point, attention should explicitly be drawn to the fact that the present curriculum addresses neurogenic dysphagia. Therefore, neither the diagnostics of structural changes in the mouth and throat , nor the examination of swallowing disorders due to such ailments  are dealt with in this training programme.One year of clinical practice focused on the care of neurological patients is required for physicians and two years of that same clinical experience for SLTs. Three months of this period shall be completed in a neurological department.Along with the acquisition of the FEES certificate, the following requirements, specific to each professional group, must be fulfilled in order to attain the status of a FEES instructor: SLTs must be in possession of at least 5 years of experience in the area of diagnostics and therapy of neurogenic dysphagia. Clinicians must have acquired a specialist title.Willingness to participate in a trans-regional FEES registry.The following prerequisites have been defined for qualification in the area of FEES within this curriculum:Training in the field of FEES is divided into two stages: the FEES certificate and the FEES instructor certificate.WorkshopFEES under direct supervisionFEES under indirect supervisionThe holder of a FEES certificate is entitled to perform FEES, to prepare the related report and to define clinical consequences in collaboration with the treatment team. Training consists of the following sections .For becoming a FEES instructor further systematic practical training is required that comprises of a minimum of 150 FEES, 30 of which must pertain to complex cases. These evaluations, including complications, must be documented in the FEES training record book. Difficult diagnoses are to be discussed with the responsible instructor.At the end of this educational period, a practical examination will be taken in an external hospital. This test includes two FEES, one of which must be a complex case. Besides implementing the standard FEES protocol, the examinee must also adapt the examination as needed without external help, explain his examination procedure and be able to implement special FEES protocols. The examinee must also be able to develop diagnostic and therapeutic strategies without assistance. Additionally, he must assess five video sequences prepared by the examiner. Furthermore, findings documented throughout the preceding training period are discussed during the examination see Fig. . Apart fA person who has successfully passed the FEES-instructor examination and has actively worked at least 2 years in this function can, in turn, apply for the authorisation to administer FEES-instructor examinations. Prerequisites include having performed at least 500 FEES, having participated in the organisation and realisation of at least one curricular FEES seminar, the training of at least five FEES-certificate holders and, optionally, a relevant scientific occupation. The complete FEES-training curriculum is summarised in Fig. Regardless of the level of training, the required endoscopies can be performed in the candidate’s own institution and/or within the scope of work-shadowing opportunities and workshops in external institutions. Work shadowing is especially meaningful during the initial stage of training, during which the mediation of technical skills, requiring intensive personal supervision, is particularly important. For advanced users, workshops offering discussions on complex cases could be an option, as these are an ideal setting in which to discuss rare, subtle or difficult-to-interpret findings in a focussed manner.Complete documentation of the FEES education in the training record book is required.As stated above, this curriculum is also open to SLTs, a group of non-medical professionals. For this reason, the aspects of task assignment and delegation are briefly addressed here. In principle, this curriculum encourages the performance of FEES by a team of physicians and SLTs. Tasks can be assigned flexibly, taking into account the training level of each person involved. In all cases, however, a physician who is familiar with the disease at hand should be included in the interpretation of the findings and the planning of diagnostic and therapeutic consequences. In the authors’ and the involved professional associations’ view, the practical performance of the endoscopy can be delegated to a qualified SLT by the physician. The basic principles regarding the delegation of medical tasks to non-medical personnel must be respected. This above all implies that the responsible physician must be at calling distance and be able to intervene immediately in case of an emergency.Following completion of the different educational steps of this curriculum, requests for the FEES certificate and the FEES-instructor status can be submitted to the German Society of Neurology (DGN). The applications are evaluated by the “FEES curriculum” task force of the DGN and DSG.FEES certificate training events planned by FEES instructors must be evaluated and accredited by the “FEES curriculum”task force of the DGN and DSG.Until 31 December 2015, the FEES certificate and the FEES-instructor status, including full entitlement to administer examinations leading to the FEES instructor status, can be granted within the framework of a transitional arrangement under the conditions listed below.Proof of training in an institution with FEES expertise2 years of experience in the area of FEES with patients presenting neurogenic dysphagiaA minimum of 200 performed evaluationsFEES certificate:5 years of experience in the area of FEES with patients presenting neurogenic dysphagiaA minimum of 500 performed evaluationsEstablishment of examination standards within the applicant’s hospitalInternal advanced training for staff membersFor physicians: specialist titleFEES instructor:Neurogenic dysphagia is one of the most frequent and prognostically relevant neurological deficits in a variety of disorders, such as stroke, parkinsonism and advanced neuromuscular diseases. Flexible endoscopic evaluation of swallowing (FEES) is now probably the most frequently used tool for objective dysphagia assessment in Germany. The systematic education in carrying out FEES across a variety of different professions proposed by this curriculum will help to spread this instrumental approach and to improve dysphagia management.


This study aimed to describe the neuromuscular activity of elite athletes who performed various roller figure skating jumps, to determine whether the muscle activation is greater during jumps with more rotations and in which phase the muscles are more active. This study also aimed to analyze if there is any difference in the muscle activity pattern between female and male skaters. Four elite skaters were evaluated, and each participated in two experimental sessions. During the first session, anthropometric data were collected, and the consent forms were signed. For the second session, neuromuscular data were collected during jumps, which were performed with skates at a rink. The following four roller figure skating jumps were evaluated: single Axel, double Axel, double Mapes and triple Mapes. The neuromuscular activity of the following seven muscles was obtained with an electromyograph which was fixed to the waist of each skater with a strap: biceps femoris, lateral gastrocnemius, tibialis anterior, rectus femoris, vastus lateralis, vastus medialis and gluteus maximus. The signal was transmitted wirelessly to a laptop. During the roller figure skating jumps, the lateral gastrocnemius, rectus femoris, vastus lateralis, biceps femoris and gluteus maximus, showed more activation during the jumps with more rotations, and the activation mainly occurred during the propulsion and flight phases. Female skaters demonstrated higher muscle activities in tibialis anterior, vastus lateralis, vastus medialis and gluteus maximus during the landing phase of the triple Mapes, when compared to their male counterparts. The results obtained in this study should be considered when planning training programs with specific exercises that closely resemble the roller figure skating jumps. This may be important for the success of elite skaters in competitions. Figure skating is a sport that may be performed on ice or on other surfaces. Because the surfaces vary, different skates are used for each of the two types of figure skating . The frequadriceps muscle group, the hamstrings, the gluteus maximus and the gastrocnemius . According to ocnemius . Howeverquadriceps femoris and hamstrings muscles differs for the take-off and landing legs of ice skaters. In agreement with this suggestion, rectus femoris and biceps femoris of the take-off leg compared to the landing leg, during the double toe-loop jump. The gluteus maximus also appears to have an important role in figure skating jumps. gluteus maximus is most likely the main hip extensor used during skating jumps. Thus, specific training of this muscle may be a crucial factor for the realization of high jumps with many rotations  were invited to participate in the present study, with the consent and collaboration of the respective coaches and the Roller Figure Skating Federation. One female and one male who compete at the Junior level  and one female and one male who compete at the Senior level . It was not possible to evaluate skaters of different levels, since the analysis included triple jumps that only these elite skaters were able to perform. The skaters were free from any injury that could prevent them from executing the jumps, and the participants reported taking no medications that could affect their performance. Once informed about experimental procedures and risks, all athletes provided written consent for participating in this investigation. The skater that had the age of 17 years provided written parental consent as well. The athletes’ coaches also gave their written consent.The athletes participated in two sessions for measuring anthropometric and neuromuscular data. During the first session, anthropometric data were collected, personal data were recorded, and the consent forms were signed. The second session was dedicated to measuring muscle activity during the skaters’ jumps, at the skating rink.Helsinki Declaration. The body mass and height measurements were obtained using an analog medical scale and a stadiometer . Skinfolds were measured using a plicometer  and to estimate the corporal density we used the The protocol was approved by the Research Ethics Committee of the Federal University of Rio Grande do Sul, respecting the rectus femoris, vastus lateralis, vastus medialis, gluteus maximus, gastrocnemius lateralis, tibialis anterior and the short head of the biceps femoris was obtained from the left leg of skaters while they performed the following jumps: single Axel, double Axel, double Mapes and triple Mapes , was low (<3 kΩ) . SurfaceThe performances were videotaped to align the movements and the EMG signal. A marker in the Miograph software and an LED, which was placed on the camera, were used for the alignment . The aliFurthermore, the EMG values were normalized by the maximal voluntary isometric contraction (MVIC) of each of the various evaluated muscles. Subjects were instructed about the procedures and they were familiarized with the protocol. Each MVIC was performed within 5 s against resistance and it was repeated three times, with a 2 min rest interval. We provided verbal encouragement to motivate all subjects to achieve their maximal voluntary contraction levels. Subjects were positioned on exercise machines, fitted with a load cell coupled to the cable that displaced the load. The load cell was connected to an A/D converter  and was calibrated prior to the data collection, according to the manufacturers’ instructions. The load cell was used to allow the analysis of the EMG signal in the most stable phase of the force production. Hip, knee and ankle angles were measured with a goniometer .EMG signal during MVIC for the knee extensor muscles rectus femoris, vastus lateralis and vastus medialis, was obtained while the subjects were seated on a knee extension exercise machine  with the hip flexed at 90° and the left knee flexed at 120° (180° represented the full extension). For the biceps femoris muscle (short head), EMG signal during MVIC was obtained while the subjects were in a prone position with the left knee flexed at 120°, and for the gluteus maximus, it was obtained while the subjects were in a supine position with the left hip flexed at 90° and the left knee fully extended. Finally, for the tibialis anterior and lateral gastrocnemius, EMG signal during MVIC was obtained while subjects were in a standing position, placed on the top of a bench, with the left foot forward and the ankle in a neutral position.Hamming moving window was used for the EMG signal analysis, and each window represented 15% of the total duration of each jump. The EMG signals during the MVIC were filtered with a Butterworth low-pass filter at a cut-off frequency of 9 Hz. In order to determine the highest MVIC, signals were sliced into 1 s segments. Each segment corresponded to the most stable phase, as verified by the signal obtained from the load cell that was used during the MVIC. The root mean square value (RMS) was then calculated for each muscle. Test-retest reliability coefficients (ICC) values were previously obtained for this method and ranged from 0.6 to 0.8.The EMG signals that were obtained during the skaters’ jumps were analyzed using the videotaped performances. The EMG signals were analyzed using SAD32 software and filtered using a fifth-order Butterworth band-pass filter with cut-off frequencies ranging between 20 and 500 Hz. These signals were cut, and the slices corresponded to the duration of each jump, which was observed in the kinematic analysis. An RMS envelope with a Due to the limited number of subjects in the present study, only descriptive analysis was performed in this study. EMG activity patterns were evaluated for the group of skaters as a whole and were compared between each type of the jump as well as between the different phases of the jumps.The results of the electromyographic activity of each jump are depicted in gastrocnemius lateralis, rectus femoris, biceps femoris and vastus lateralis muscles presented greater activity and longer duration  during the jumps with more rotations (double Axel and triple Mapes). There was also more activity in the gluteus maximus during the triple Mapes jump than during the double Mapes jump. The gluteus maximus also appeared to be more active during the triple Mapes than during the double Axel. The muscle activity during the different phases of the Axel and Mapes jumps was compared, and almost all muscles showed greater activity during the take-off and flight phases, especially for the jumps with more rotations (double Axel and triple Mapes). For these jumps, especially the triple Mapes, the biceps femoris appeared to be active most frequently during the flight phase.Analysis of the muscle activity curves indicated that, in general, the Differences between male and female skaters were observed during the landing phase of the triple Mapes. It appeared that female skaters demonstrated higher muscle activities in TA, VL, VM and GM during this phase, when compared to their male counterparts.quadriceps, hamstrings and gastrocnemius, as well as the activity of the gluteus maximus, is critical to the success of figure skating jumps  for jumps with the greatest number of rotations, mostly during the take-off and flight phases, was greater than that for the jumps with fewer rotations. These results are consistent with those obtained in the study by gastrocnemius medialis, rectus femoris, biceps femoris and adductors muscles of a national-level ice skater performing single and double toe loop and flip jumps.Analysis of the neuromuscular pattern of the jumps that were evaluated in the present study indicated that the activity in the gastrocnemius lateralis appeared to be greater during the take-off phase of the jumps analyzed in the present study, which may indicate a greater use of plantar flexion during this phase. Moreover, the biceps femoris muscle appears to be frequently activated during the flight phase of the jumps with more rotations . A greater contraction of this muscle may occur to maintain a closed position during the flight phase, during which participants compress the left leg against the right. This position may also explain the longer activation duration of some muscles during the jumps with more rotations. Furthermore, the greater BF activity during the flight phase of the triple Mapes might be a result of anti-inertial moments. The hip extensor moment might work to overcome the hip flexor inertia seen in faster rotations.From the analysis of the various phases of the jumps, the contribution of the During the landing phase of the triple Mapes, the female skaters appear to activate more the TA, VL, VM and GM muscles, when compared to their male counterparts. It is interesting to note that these are all uniarticular muscles and that the differences of the biarticular muscles RF and GL, do not appear to be as strong. These muscles seem to demonstrate greater activity during the landing of both male and female skaters, indicating their importance during this phase. Perhaps the greater activity observed only for the female skaters for the uniarticular muscles reflects more difficulty while finalizing the jump, and a greater effort that these skaters probably had to make to better control the left leg during landing. During the beginning of the landing phase, the skaters are controlling the left leg, so that the left skate does not touch the ground. After, they move the left or free leg, backwards, to end the jump properly. Analyzing the video recordings, it can be observed that the females evaluated in the present study control the left leg with much more effort and tension, since they land with the left skate closer to the ground. The TA is probably active to control the left skate, eccentrically, so that it does not touch the ground and the VL and VM muscles are probably active to maintain the knee extended, helping to control the movement of the left leg. The GM is probably active because of the hip extension during the jump’s finalization. In contrast, the males appear to perform the landing with less effort, having a more natural movement of the left leg during landing, i.e. the left skate is not that close to the ground, and they are more ready to end the jump moving the left leg backwards. Therefore, the male skaters in the present study did not need to activate the TA, VL, VM and GM to better control the left leg during landing. This could be one reason for the greater muscle activity observed during the landing phase for the females in the present study. However, more studies evaluating the control of the free leg during the landing phase of roller figure skating jumps are required to better understand this process.gastrocnemius lateralis and soleus muscles before and after eight weeks of plyometric training. The researchers found an increase in both vertical jump height and muscle activity, although the increase in the activity was only statistically significant for the soleus. In the present study, the technical elements of figure skating were not evaluated after a specific type of training. Nevertheless the information regarding the main muscles that were activated during roller figure skating jumps may be of great value for prescribing plyometric training. Furthermore, it is important for future studies to examine the effects of specific training programs, such as plyometric training, on roller figure skaters. Forinstance, the result of the present study, in which an increase in muscular activity was observed during the landing phase of the triple Mapes, specially for the female skaters, suggests that higher volumes of exercises which develop the leg muscles eccentrically for landing, such as box landings and balancing on a wobble board while imitating the landing motion of the free leg (left leg for the Axel and Mapes jump)  , will prbiceps femoris, gastrocnemius lateralis, rectus femoris, vastus lateralis and the gluteus maximus muscles during jumps with a larger number of rotations for the athletes in this study, especially during the take-off and flight phases. Furthermore, the activity of the gluteus maximus muscle appeared to be greater during the triple Mapes than during the double Axel, and the biceps femoris demonstrated more activation during the flight phase of the jumps with more rotations, especially during the triple Mapes jump. The results in the present study cannot be generalized because only a small number of elite skaters were evaluated; however, these results may provide a useful contribution to understanding the muscle activity pattern during figure skating jumps at the highest level of competitive performance.In conclusion, there was more activity in the quadriceps and gastrocnemius muscles. To increase the activity of the evaluated muscles during jumps with more rotations, exercises that simulate the flight phase may be performed. During the flight phase, the athlete holds the left leg against the right, activating the BF muscle as a result of anti-inertial moments. This situation may be simulated by applying resistance to the left leg, making possible for the skater to work on overcoming the hip flexor inertia, seen with faster rotations.For practical applications, these results are important in identifying which muscles are more involved in roller figure skating jumps. The results are also helpful for planning specific training programs for these muscles, which may provide benefits to elite athletes and, most likely, to skaters of other levels who aspire to perform triple jumps and succeed at international level. Plyometric exercises performed in a manner that closely resemble the movements used in figure skating  may be used. Thus, these exercises might emphasize concentric knee extension and plantar flexion during take-off, with the goal of increasing the activity of the gluteus maximus activity in a specific manner.Moreover, the specific training programs may mainly exercise muscles that are essential for performing the jumps in the skater’s routines. For instance, exercises that simulate the movements of the left leg during the triple Mapes jump, in which the skater jumps from the toe pick of the skate, may be imperative for increasing the Finally, there have been no studies investigating neuromuscular activity during roller figure skating. Roller figure skating is becoming more popular, and information regarding the muscle activation during different types of figure skating jumps may be important for coaches. In addition, figure skating on ice and roller figure skating may be similar in many technical and biomechanical aspects. We cannot find studies in which these parameters have been measured in roller figure skaters, and those measurements are necessary to compare the two types of skating. This paper is the first attempt to provide information concerning the movements practiced by roller figure elite skaters and provides further insight regarding differences and similarities between roller and ice figure skating. Unfortunately, it was not possible to evaluate skaters of different levels, since the analysis included triple jumps that only elite skaters are able to perform. We suggest that further studies evaluate the neuromuscular response of roller figure skating jumps that are made by both elite and intermediate level skaters.


The number of surface water pollution accidents (abbreviated as SWPAs) has increased substantially in China in recent years. Estimation of economic losses due to SWPAs has been one of the focuses in China and is mentioned many times in the Environmental Protection Law of China promulgated in 2014. From the perspective of water bodies’ functions, pollution accident damages can be divided into eight types: damage to human health, water supply suspension, fishery, recreational functions, biological diversity, environmental property loss, the accident’s origin and other indirect losses. In the valuation of damage to people’s life, the procedure for compensation of traffic accidents in China was used. The functional replacement cost method was used in economic estimation of the losses due to water supply suspension and loss of water’s recreational functions. Damage to biological diversity was estimated by recovery cost analysis and damage to environmental property losses were calculated using pollutant removal costs. As a case study, using the proposed calculation procedure the economic losses caused by the major Songhuajiang River pollution accident that happened in China in 2005 have been estimated at 2263 billion CNY. The estimated economic losses for real accidents can sometimes be influenced by social and political factors, such as data authenticity and accuracy. Besides, one or more aspects in the method might be overestimated, underrated or even ignored. The proposed procedure may be used by decision makers for the economic estimation of losses in SWPAs. Estimates of the economic losses of pollution accidents could help quantify potential costs associated with increased risk sources along lakes/rivers but more importantly, highlight the value of clean water to society as a whole. Surface water pollution accidents (abbreviated as SWPAs) have become the most dominant type of environmental accident in China ,2,3,4. TOne problem decision makers usually encounter in accident assessment and risk prevention is that the degrees and costs of surface water accidents are hard to be totally and well understood and identified. The influence of major water pollution accidents is widespread and they can cause damages to multiple aspects, including financial losses, environmental deterioration and negative social influence. Economic losses in surface water accidents can be related to social, ecological, and policy-related factors . When reEconomic estimation of loss in SWPAs has been one of the focuses in China and has been mentioned many times in the Environmental Protection Law of China promulgated in 2014 . PotentiWetlands (lakes and rivers) play a critical role in the global water cycle, carbon cycle, nitrogen cycle, climate change and ecological development and they provide habitats for wildlife ,7,8. TheThus the aim of this study is to establish a methodology for evaluating of the damage, both direct and indirect, caused by surface water accidents. Economic losses of accidents, classified in various types based on the various aquatic environmental functions mentioned above, were estimated referring to environmental value estimation techniques. At the end of the paper, we apply the proposed estimation method to the Songhuajiang River accident, the most important surface water pollution accident that has occurred in recent years in China.etc. Furthermore, indirect damages, such as public panic, distrust, suspicion of the government, managers and enterprises may occur after an accident. Detailed explanations of these eight components are provided below.The damages were classified in eight types . The potHere human health damage refers to both the loss of human lives and the people poisoned  due to a pollution accident. The number of damaged people could be determined during the process of the accident’s remediation. Further some cumulative and persistent substances discharged in SWPAs may bring potential long-term negative effects on human health via environmental media. It is difficult to assess this potential hazard and in this study this damage was seen as a part of damage to environmental property, the valuation method of which is discussed in HHL: the economic loss of damage to human health (CNY)dV: the economic valuation of one fatality (CNY )dN: the number of fatalities (-)k,pV: the economic valuation of one person poisoned in the category k (CNY )k,pN: the number of poisoned people in the category k (-)k = 1: slightly poisoned people; k = 2: severely poisoned people; k = 3: very severely poisoned people.The economic assessment of human health is a rather complex and controversial issue. Nevertheless, it is the only way to establish a cost when a pollution accident has direct consequences on people. The most readily available and simplest procedure to follow in the estimation of human health losses is probably the analytical scheme proposed by Ronza . This methe year of potential life lost” proposed by the U.S. Centers for Disease Control and Prevention in 1982, life is valued in proportion to a person’s potential economic production [Obviously, the problem of attributing an economic value to human life has important moral and social implications. A number of methods have been developed to assess the cost of a fatality ,16. Qualoduction . The cosoduction . Based ooduction .per capita and the life expectancy, which is a similar measure to the LQI method proposed by Jatin [etc. Thus the economic valuation of one fatality contains two parts: the victim’s own loss and the cost of the dependents’ living needs  or annual net per capita income of rural residents (RI) of the region where the victim resides. The life expectancy is assumed to be 80 and the same expectancy was used in the road accident compensation standard prescribed in the Road Traffic Safety Law of China [UI or RI value is just the consumption expenditure standard per capita and the duration of compensation dependents obtained is the same as in the victim’s own loss estimation.The victim’s own loss is standardized according to annual disposable of China . For theof China . Dependeless than 60 years old” category  in the region. The cost of sick leaves is the product of average daily wage of the region and the duration. In addition, medical fees must be included. If realistic fees are not available, the average hospitalization expense in the region has been used.Poisoned people’s own loss and the living cost of the dependents are included in the loss estimation. The previously mentioned criteria used in death valuation are also applicable in this part, with multiplication by a grade of poisoning coefficient. The coefficients of slight, severe and very severe poisoning are 0.4, 0.7 and 1, respectively . The durless than60 years old” category  was selected as the substitution for the tap-water.per capita per day in the emergency situation.Considering that people will consciously save water during a crisis situation, the minimum value, which is expressed in the standard water quantity for a city’s residential use (GB/T 50331-2002)  and much3 [The replacement for irrigation water is artificial rainfall . The che3 . Water c3 .3/m2/d), which is obtained from the total sprinkling area in cities divided by the annual sprinkling water consumption over the nation, was deemed as the water demand for greening belt sprinkling in the city [Artificial rainfall is also the most rational replacement for greenbelt sprinkling suspensions. An empirical datum fAI: the annually gross income from fisheries in the polluted water (CNY/year)rt: the recovery time of aquatic products (years)The loss here refers to the direct damage to fisheries caused by surface water pollution, which has been divided into two parts: aquatic species deaths poisoned by pollutants and decreases in yield because of environmental changes and reduced food supplies. The death proportions in accidents and yield reduction after accidents are both difficult to be precisely and directly distinguished, but the recovery time of aquatic products in polluted water can be roughly estimated by the AQUATOX model, an aquatic ecosystem model developed and proposed by USEPA . Assuminetc.) is one of the primary functions of surface water. The replacement cost method is used in this section. It is assumed that all the recreational activities are interrupted for the duration of the pollution episode and the losses due to the recreational activities’ interruption can be expressed as the sum of the four parts: losses of swimming, boating, angling and other activities rfC: the cost of releasing aquatic fingerlings annually after an accident (CNY/year)T: the duration of the biodiversity resumption (year)The recovery cost method (RCM) is used in this study to assess the economic losses from damage to the biological diversity. Recovery measures mainly refer to releasing fingerlings to the water for a period of time. Correspondingly, the recovery cost is the expense for the aquatic fingerlings. Thus the losses of biodiversity can be expressed as:Annual costs for releasing aquatic fingerlings after an accident can be obtained from local statistics departments and the duration of this release behavior can be approximately equal to the period of the biodiversity resumption.Pollutants released in the accident deteriorate the water quality and decrease the value of the surface water. Pollutants may also settle in the sediments and the groundwater nearby might also suffer negative consequences due to pollutants’ penetration. Environmental property losses here are defined as these damages and denote the impairment of the value of environmental media, including the surface waters, groundwaters and sediments.Pollutant clearance cost (PCC) analysis has been applied in this section. We use the cheapest price of pollutant removal from environmental media as the loss of environmental property .As the volume of polluted groundwater is generally not available, a ratio of the volume of polluted surface water, which can be easily reckoned by way of summing the extension of pollutants’ diffusion, has been used to estimate this parameter. The ratio 1:1 is considered to be moderate .2 in 2000 according to reference [The prices of removing pollutants from environmental media can be obtained by asking related environmental consulting companies devoted to environmental remediation. If this way cannot do, the price of groundwater remediation can be regarded as much as 100 times the cost of surface water remediation to convey the message that it is pretty expensive and the real price might be higher. If accurate information for the price of sediment remediation is not available, it could be obtained using an interest rate based on 1600 CNY per meference .This part refers to the real and financial loss of accident origins. For the accidents that originate at manufacturing enterprises, it includes damage to equipment, the cost of lost wages for closed workshops, the loss of profits for discontinued production, the cost of recruitment and training costs for replacement workers, the reduction in product quality following the accident. For the accidents caused by traffic accidents, it may include the damage to vehicles and the loss of carried materials. Based on the survey of accident causes, the loss of this part can be simply summed according to the actual conditions.etc.SWPAs could bring some other negative consequences, such as human panic, fishery order reduction due to decreased confidence, residents’ suspicion of governments’ decisions, morale effects on coworkers, administrative costs , the loss of image for government and enterprises, Although these indirect losses evidently exist and have an important impact on society, they are related to personal psychology and perspectives. It is hard to exactly reckon their economic values. The simplest way to estimate these losses is to estimate them as a ratio of the sum of the direct losses, which is the loss of human health, water supply suspension, damage to fisheries and recreation. Lanoie and Tavenas proposed a 1:1 ratio between direct and indirect accidental costs . RikhardIn 13 November 2005, a major surface water accident happened in China as a result of an explosion at the biphenyl production workshop of Jilin Petrochemical Company, one of branches of Petro China, in Jilin City, Jilin Province, . The accThe data used in the economic loss estimation was mainly obtained from the 2006 Statistical Yearbook of Jilin Province, the 2006 Statistical Yearbook of Heilongjiang Province and the 2006 statistical yearbooks of the five polluted cities ,36. All The proportions of loss items in the total losses and in the direct losses were both listed in the fourth and fifth column . The majThe details of the economic losses itemized by region were also described . HaerbinFor real accidents, the economic assessment of damage could vary greatly. This is due to diverse reasons and among them the most relevant is that the living standards, fishery income and the prices of replacements of the area where the accident occurs do not have the same value. These factors make them little comparable to each other.The estimates on the economic valuation of human health losses are probably conservative. Only deaths and poisoned persons were included in the damage. In fact, human health might suffer long-term damages through polluted drinking water, aquatic products, grains and vegetables if the pollutants are persistent and have cumulative effects. Because this damage is hard to value alone, this part was not included in the loss of human health.In the economic estimation of the damage to water’s recreational functions, we assumed that people do not substitute a nearby and unpolluted lake or river for the polluted water while they go to different sites. In fact, most users may have other free alternatives but the data on these substitutions are not available. Thus this assumption might overestimate these losses.The loss of environmental property in the case afforded the biggest proportion of the total loss in the accident. However this estimation using the expense for environmental media remediation probably still underestimated the real losses because some media, especially the groundwater and the sediment can hardly be repaired due to the lack of mature on-site remediation technologies ,38,39,40The number of SWPAs has increased substantially in China. Estimates on the economic losses of accidents could help society quantify potential costs associated with increased risk sources along lakes/rivers but more importantly highlight the value of clean water to all society. However, it is nearly impossible to devise an exact method to perform a valuation of the losses caused by SWPAs. The procedure proposed in the paper should be a good approximation.In the valuation of damages to people’s life, compensation in traffic accidents in China was analyzed as appropriate to be used. The replacement cost method is used in the economic estimation of the damage to water’s recreational functions. Moreover, it has to be noted that the economic lossess estimated for real accidents can sometimes be influenced by social or political factors, such as the authenticity and accuracy of data obtained from governmental statistical departments, and accident origins. Besides, one or more aspects in the method might be overestimated, underrated or even ignored. However, the results of this assessment may be important to help decision makers comprehensively interpret potential costs associated with SWPAs.


Objectives. Korean medicine, an integrated allopathic and traditional medicine, has developed unique characteristics and has been active in contributing to evidence-based medicine. Recent developments in Korean medicine have not been as well disseminated as traditional Chinese medicine. This introduction to recent developments in Korean medicine will draw attention to, and facilitate, the advancement of evidence-based complementary alternative medicine (CAM). Methods and Results. The history of and recent developments in Korean medicine as evidence-based medicine are explored through discussions on the development of a national standard classification of diseases and study reports, ranging from basic research to newly developed clinical therapies. A national standard classification of diseases has been developed and revised serially into an integrated classification of Western allopathic and traditional holistic medicine disease entities. Standard disease classifications offer a starting point for the reliable gathering of evidence and provide a representative example of the unique status of evidence-based Korean medicine as an integration of Western allopathic medicine and traditional holistic medicine. Conclusions. Recent developments in evidence-based Korean medicine show a unique development in evidence-based medicine, adopting both Western allopathic and holistic traditional medicine. It is expected that Korean medicine will continue to be an important contributor to evidence-based medicine, encompassing conventional and complementary approaches. Korean medicine originates from prehistoric times and shares its origins with Chinese and Japanese medicine. However, compared with traditional Chinese medicine, Korean medicine is much less well-known. Although Korean and Chinese medicine have much in common, Korean medicine has developed on its own as a whole-person-centered medicine system , developWhat follows is a brief introduction to the characteristics of Korean medicine with a focus on evidence-based approaches, along with a historical review of a standard disease classification in Korean medicine as a representative example of the efforts being made to implement evidence-based medicine.As indicated previously, the tradition of Korean medicine features an individualized approach based on constitutional energy traits of healthy qi , with siEvidence-based medicine is about the best decision-making based on the best available evidence  and highIn addition to the idea that traditional knowledge itself is an important source of evidence , the issIn the history of complementary and integrative medicine, Korea's situation may be a unique and exemplary case. Although many countries still lack national regulation of CAM, Korea established the parallel operation of two independent medical systems (Western medicine and Korean medicine)  in 1951,Korean medicine may be described as a form of integration of Western allopathic medicine and traditional medicine by considering the following points. (1) Educational programs for Korean medicine students and practitioners cover not only traditional knowledge but also the same basic and clinical medical sciences and research as in Western medicine. (2) Korean medicine practitioners are fully licensed to diagnose both disease entities of Western medicine origin and those of traditional medicine origin. (3) Treatment modalities provided by Korean medicine practitioners include those common in both Western and traditional medicine, as well as those specific to traditional medicine, such as acupuncture and yinyang balance concepts.The Korean government has been promoting the evidence-based development of the national health system, especially with regard to Korean medicine, by means of standardization, research funding, and new drug development from herbal medicines. The Korean government has been expanding its research funding for such projects as Korean medicine diagnosis , 19 and As a fundamental platform for an evidence-based approach in modern Korean medicine, the history of a standard disease classification is briefly examined here. A standard disease classification alone does not mean, and cannot justify, the notion that Korean medicine is an evidence-based approach. However, a standard disease classification may be an indispensable fundamental basis for evidence-based medicine.If any evidence of medical practice is collected, interpreted, and incorporated into evidence-based medicine, the clinical pictures of that medicine have to be captured, classified, and documented. A clinical picture that has not been captured and documented may not be used as evidence. If we are to capture the clinical picture of different systems of medicine, we may need different classification systems of the clinical entities targeted, evaluated, and treated with each system of medicine.In an effort to capture the clinical picture and produce statistics on allopathic medicine and Korean medicine, different disease classification systems have been developed and stipulated as national standards in Korea. In the allopathic medicine field, a Korean adaptation of the World Health Organization (WHO) international classification of diseases (ICD) has been stipulated as the allopathic medicine volume for the Korean standard classification of diseases (KCD). The first edition of KCD appeared in 1952. It was revised in 1972, 1979, 1993, 2002, 2007, and 2010. In the Korean medicine field, the Korean medicine volume of KCD was first published in 1973 and was revised in 1979, 1995, and 2009. Recently, the KCD allopathic medicine volume and the KCD Korean medicine volume were integrated into one volume, “KCD6” in 2010 .Although pattern identification for the overall analysis of symptoms and signs is a core component of the theoretical context and clinical practice of Korean medicine as well as traditional medicine in China  and JapaIn the Joseon dynasty, about four centuries ago, there was already a comprehensive disease classification, which was usually composed of descriptions on related anatomy, physiology, etiology, manifestations, pattern differentiation, self-discipline, qigong, and the simple herbs prescribed. However, the concepts of diseases, disorders, and patterns were not so clearly defined or differentiated . Over thRecently, WHO has also sought to integrate the International Classification of Traditional Medicine (ICTM)  into itsThe standard classification of diseases will be an essential part of capturing the clinical pictures of medicine and a systematically organized classification will facilitate objective documentation, production of related statistics, and the contribution of complementary and integrative approaches to the general health of world citizens. In that sense, Korea's experiences in revising the national standard disease classification may well be an exemplary case to support and embody an evidence-based approach in institutionalizing complementary and integrative approaches and integrating them with conventional allopathic medicine.According to the coding guidelines for the WHO ICD-10, a main condition is defined as the condition primarily responsible for the patient's need for treatment or investigation. A main condition is diagnosed at the end of the episode of health care. If there is more than one condition that may be considered as a “main condition,” the one that was most responsible for the greatest use of resources is selected as a “main condition.” If no diagnosis was considered to be made, the main symptom or problem may be selected as a “main condition” .Disease codes of Korean medicine are a combined form of Western medicine codes and traditional Korean medicine codes. Korean medicine codes are regulated by the law. According to the existing guideline for Korean medicine classifications , the folIn the first place, a “main condition” code is selected. Disease classification codes may be selected from the conventional Western medicine codes based on the conditions that patients appeal most or the amount of resources consumed in the clinical management. If the practicing physician does not consider the conventional Western medicine codes to be appropriate for the clinical picture of the patient, then the traditional Korean medicine codes, that is, U-codes in KCD, are used. When traditional Korean medicine codes in the U-codes are considered to be appropriate, the practicing physician should decide which category codes in the traditional Korean medicine codes are appropriate for the clinical picture of the patient: disorder codes, pattern codes, or “Four Constitution” medicine-related codes . In addiBy following this practice, the practicing physician in Korean medicine may select a code that is considered to be most appropriate for the clinical picture of the patient, not only from the conventional Western medicine codes, but also from the traditional Korean medicine codes. Thus, selected disease coding may reflect the body of knowledge in Western medicine disease classification and traditional Korean medicine disease classification. In this sense, Korean medicine may be considered as an integration of conventional allopathic medicine and traditional holistic medicine.A disease may be a set of dysfunctions in any of the body systems that may be defined by symptomatology, etiology, course and outcome, treatment response, linkage to genetic factors, and linkage to interacting environmental factors. A disorder/syndrome may be defined as a common pattern of similar symptoms in clinical practice. As to a disorder/syndrome, the etiology is not known or multiple etiologies are related in the clinical manifestations .A disorder in traditional medicine is a clinical picture that is relatively constant throughout the duration of that disorder. A pattern in traditional medicine is relatively temporary (constant/temporary).A disorder in traditional medicine usually delivers information reflecting the local manifestation of the pathology. A pattern in traditional medicine usually delivers information reflecting the systemic manifestation or the systemic response of the patient .A disorder in traditional medicine is a concept that summarizes findings that are specific to the pathologic process under investigation. A pattern in traditional medicine means the pattern of combination of the manifestations that encompasses both specific symptoms/signs and nonspecific findings such as pulse diagnosis and tongue diagnosis (specific/nonspecific).A disorder may be applied for a time span. A disorder coding may be based on the main pathologic process which may show a causal relationship with the main manifestations in the patient. A pattern may be applied for a specific time span too. However, a pattern coding is based on the summarized whole picture that may be observed in the patient based on the perspectives of traditional medicine theories. A pattern is recognized based on the analysis of the systemic findings in the patient's body and mind which reflect the pathologic processes, responses to the pathologic processes, other concomitant findings, and innate or acquired constitutional traits of the patient .A disorder in traditional medicine is usually described with general terms of anatomy-physiology together with terms of signs and symptoms. A pattern in traditional medicine is usually described in terms of the traditional medicine theories that are used to summarize the whole picture findings in the patients such as yin and yang balance, cold and heat, meridian, or constitution .A disorder in traditional medicine is used to describe the general characteristics considered to be relatively common to general population. A pattern in traditional medicine is used to describe the individual characteristics considered to be relatively specific to the patient at that time .Disorders and patterns in traditional Korean medicine that are coded in the clinical practice of Korean medicine are the health care conditions that are responsible for the patient's need for treatment or investigation. Both the disorder and the pattern are diagnosed for the sake of treatment or investigation by practicing physician. Both are similar in that they are named after the body structures, causes, properties, severity, and so forth. However, the naming and concept of the disorder and the pattern in traditional Korean medicine usually deal with differential aspects of clinical pictures based on the theories of traditional medicine:The concept of a pattern may reflect constitutional characteristics of the patient in addition to the disease or disorder characteristics. In other words, the systemic active response and individual characteristics of the patient's body and mind may be the target of the concept of a pattern diagnosed in traditional Korean medicine. However, the disorder in traditional Korean medicine and the disorder or disease in conventional Western medicine primarily target the disordered or pathologic process itself disregarding the patient that is actively trying to recover from that disordered process and to maintain balanced state of health. Considering the abovementioned concepts, the pattern and the disorder-disease may be considered as two complementary aspects that may be targeted when trying to capture the clinical picture of health care conditions.Korean medicine has been an active player, at the forefront, in the implementation of evidence-based medicine. Korean medicine, an integrated conventional allopathic medicine and traditional holistic medicine, is exemplary in developing complementary and integrative approaches into an essential part of evidence-based mainstream medicine, implementing a national standard disease classification encompassing both allopathic and genuine traditional concepts. In this paper, recent developments regarding the biological activities of herbal medicines, diagnostic evaluations, and clinical applications are introduced. Korean medicine is expected to be an important contributor to the establishment and implementation of evidence-based, tailored medicine, integrating complementary and conventional approaches.


A well-formulated program theory enables an understanding of how interventions could bring about improvements and an evaluation of the intervention. In the refined program theory of the intervention, we identified various factors at individual, institutional, and environmental levels that could interact with the hypothesized mechanisms of organizational change, such as staff’s perceived self-efficacy and commitment to their organizations. Based on this program theory, we formulated context–mechanism–outcome configurations that can be used to evaluate the intervention and, more specifically, to understand what worked, for whom and under what conditions. We discuss the application of program theory development in conducting a realist evaluation. Realist evaluation embraces principles of systems thinking by providing a method for understanding how elements of the system interact with one another in producing a given outcome.Performance of local health services managers at district level is crucial to ensure that health services are of good quality and cater to the health needs of the population in the area. In many low- and middle-income countries, health services managers are poorly equipped with public health management capacities needed for planning and managing their local health system. In the south Indian Tumkur district, a consortium of five non-governmental organizations partnered with the state government to organize a capacity-building program for health managers. The program consisted of a mix of periodic contact classes, mentoring and assignments and was spread over 30 months. In this paper, we develop a theoretical framework in the form of a refined program theory to understand  The local health system at the district level is an important organizational unit for management of health services. In India and many other low- and middle-income countries (LMICs), doctors are usually in charge of the management of local health systems. As health managers, doctors lead a team of health workers that includes other doctors and clinical specialists, nurses and midwives, pharmacists, laboratory and other technicians, and administrators. A well-functioning local health system is able to translate its inputs  into processes and outputs . In addition, it should ensure that the health care provided is organized and managed in such a way that it is physically and financially accessible, equitable, of good quality, and responsive to local needs .Many district health systems in LMICs do not have the capacity to allocate their financial resources equitably and manage their technical resources optimally . Furtherwhat works for whom and under what conditions  are few [Ref. , see Boxnditions –12.Box 1As an alternative to systematic reviews, realist synthesis is emerging as a way to expand our knowledge base, especially when attempting to answer context-sensitive and policy-relevant questions , 14. A rWe have developed a realist evaluation study to understand how capacity-building of health managers translates into improved performance with respect to their planning and supervision in Tumkur district of Karnataka state in southern India . A realiBox 2what works, for whom, and under what conditions. The current understanding of context and mechanism in realist evaluation is summarized below ; the initial program theory is based on the assumptions made by the designers/implementers on why the inputs of the program will bring about the desired output. The evaluator seeks to refine this initial program theory in order to understand the local contextual conditions that influence the outcome, as well as the possible causal mechanisms that could have resulted in the outcome. Data are collected and analyzed using the conjectural context–mechanism–outcome (CMO) configurations; configurations consisting of causal mechanisms that explain the observed outcome, in relation to specific contextual conditions that allow for these mechanisms to operate. The CMO configurations are an analytical tool consisting of testable conjectures drawn from the program theory that help in generating an explanation for ed below .Context – actors or other factors that occur in the setting where the intervention/policy was implemented, that occur independent of the intervention/policy, and affect the implementation of the intervention/policy.Mechanisms – psychological or social explanations for human behavior that explain the interaction between social structure and individual/group agency.how a given intervention could bring about positive organizational change, the interaction between and among the various individuals within the sub-units of the system needs to be analyzed. A systems’ approach to address complexity within a district health system requires that the relationships between the sub-units of system, and the possible ways in which they could interact and affect the production of the outcome, should be understood and made explicit , is critical for the manifestation of the outcome . A detaiIn India, local health systems at the district level are generally organized in three tiers. The first point of contact between people and healthcare professionals is a network of Primary Health Centers (PHC), which depend on a hospital at the sub-district level  for secondary care. A district hospital is supposed to provide tertiary specialty care. On average, a district in India has a population ranging from 500,000 to a few million people. A sub-district  would generally have a few hundred thousand inhabitants. The production of healthcare outputs of hospitals and health centers is complex; it is influenced by the internal dynamics of the workforce in these organizations, by the relationships among individual health workers, as well as by their external environment . EnvironWe developed the program theory in a step-wise fashion based on guidance in literature , 17, 26.(1)Understand the intervention : we started with eliciting the IPT of the intervention. These are the assumptions and hypotheses of the designers of the intervention and other stakeholders. To do so, we reviewed program documents  to identify the implementers’ main assumptions, to understand the perceptions of the key actors and to identify potential mechanisms – if any – as identified by the implementers. Implementers are the people and organizations who designed and are in charge of the implementation of the intervention. At this stage, we were looking for assumptions of the designers on how and why the program would bring about the expected outcomes. In a second step, we interviewed 16 actors using an interview guide : 2 program designers, 2 policymakers, 10 participants , and 2 health services staff during the early phase of the implementation of the intervention. The interviews focused on the process of planning health services, the perceived scope for change given the current decentralization process, and the possible role of the intervention in this change. The program documents and interview transcripts were imported into NVivo 10 . Portions of text reflecting implementation assumptions, possible contextual factors (see step 3 below), and actors’ perceptions were coded and analyzed using thematic analysis. These themes were then summarized and the IPT was gradually constructed.(2)Literature review to identify possible mechanisms: we reviewed the published literature and identified possible steps through which capacity-building can lead to organizational change. We began the literature search on the basis of four themes highlighted in the IPT: organizational commitment, self-efficacy, workplace learning, and evaluation of training programs. We conducted the search initially on Google Scholar and PubMed; we also scanned the references and carried out citation tracking of some of the papers we had retained, to identify other key publications . We fina(3)Identify contextual factors: we reviewed government reports and program documents related to performance of district health services . We also analyzed the interview transcripts with participants of the intervention, co-workers of the participants, policymakers, and implementers to identify contextual factors that could possibly influence the actors, the implementation, and the outcomes of the intervention. Key events that affected the implementation of the capacity-building intervention were also identified from the interview transcripts and these were mapped. The interview transcripts were imported into NVivo10  and free coding was done to identify important factors presenting at various levels of the health system. The codes were then organized into trees and the themes emerging were summarized.(4)Refine program theory: we integrated possible mechanisms (from step 1 and 2) and contextual factors (from step 3) into the refined program theory.(5)Formulate CMO configurations: a framework for plausible configurations of CMO was constructed from which empirically testable hypotheses can be drawn.The steps followed are described below and summarized in Table multipolar performance framework to analyze and discuss the refined program theory , and the implementation timelines . For the purpose of this study, we will focus on two of the key expected outcomes of the capacity-building program viz. improved annual action plans at district and taluka level and improved supervision practices. These were the two major outcomes that the designers sought to influence through the capacity-building program. An interim self-evaluation of the intervention by the implementers, as well as an external evaluation, highlighted planning and supervision as possible key outcomes , 32. We The IPT is readily available – see the publication of the study protocol  – reproda priori guided the design and implementation of the intervention. These assumptions have had implications on how the program was structured , its content , and the implementation . These assumptions are the following:Based on documentary review and thematic analysis of the interviews with the designers of the intervention, we identified three key assumptions that can-do attitude. This was based on the perception of the designers that there was apathy and lack of desire to change things at the district and taluka level. The implementers assumed that the participation of experienced health professionals in mentoring visits could trigger such an attitude among the participants, and hence create an environment where the knowledge and skills would be put to effective use.The program implementers noted that improved public health management knowledge and skills are insufficient by themselves in bringing about change. They thought that an attitude toward creating organizational change among the participants is essential. The implementers sought to encourage or bring about such an attitudinal change by using particular styles of teaching , letting participants identify examples of glaring gaps in existing services, and mentoring participants at their own workplaces. The mentors were either the teachers from the contact classes or experienced public health professionals. They would visit the participants at their workplace, discuss topics raised in the contact classes, and offer to demonstrate or help implement the acquired knowledge and/or skills in the participants’ workplace. The implementers described the changed attitude that they aimed for, as a The Indian government’s flagship health program, the NRHM, is being implemented since 2005. The NRHM sought to bring about an architectural correction in the health system through improving financing arrangements and reforms in planning and supervision of health services. One of the reforms was decentralized planning and management of health services to the district level . Our anaThe implementers identified health management teams at hospitals, talukas, and disease-control programs as the unit for change within the health services. These teams included medical doctors and administrative staff, but also the newly introduced BPMs and DPMs. The implementers (and NRHM) expected that the induction of these new cadres and the building of teams at taluka and district levels would improve local annual action plans; earlier, action plans were largely made at the state-level in a top-down fashion. The program implementers specifically targeted these enlarged management teams.The program theory incorporating the assumptions of the implementers is represented in Figure Human resource management interventions can be important drivers of health service provision and thus good health outcomes. However, studies on HRM in health are few; they focus mainly on continuing education, supervision, payment of incentives, decentralization of HRM functions, or a combination of these , 34. An Contrary to the evidence base on HRM in the public health literature, much has been written on the topic in management sciences, particularly in the corporate business industry . In a reCapacity-building programs inject new resources, i.e., knowledge, skills, and experiences, in organizational settings. A variety of individual, institutional, and environmental factors determine who benefits from such programs and who does not, and who applies what they learnt in terms of organizational change, and who does not. Among the frameworks proposed to evaluate the effect of training programs, the Kirkpatrick and Kirkpatrick framework is one of the most frequently used . The fracan-do attitude among the participants. The implementers expected that mentoring by experienced public health professionals at the workplace of the participant would bring about such an attitudinal change. The initial program documents, however, did not elaborate on how the implementers expect such a change to take place in the individual participants. We had hypothesized that, in addition to organizational and environmental factors, such a positive organizational change could be linked to individual attributes of the participant, like the organizational commitment of the individual and the confidence that the individual places in his ability to produce such a change  the outcome – they are crucial in refining the program theory. Contextual factors have been shown to influence organizational change in healthcare settings –52. WhilWe identified three key themes from the contextual analysis: the local effects of the ongoing decentralization of planning to district level in India, the acceptance and role of newly introduced non-medical program managers, and the local actors’ conceptualization of the district health services as a system. Below, we discuss these in more detail and analyze implications for our evaluation.old recommendation  on the role of program managers in enabling better planning and monitoring definitely needs to be examined in relation to existing team dynamics.The implementers’ conception of a district health system as a complex system has guided the design and implementation of the intervention. Whether this approach resulted in creating truly functional teams of health managers depends on many individual and workplace factors. The implication of the team assumption on the performance of taluka and district participants therefore needs to be critically examined. In India, there is not much information on what a district health manager requires in terms of inputs, skills, and knowledge . NeitherStructurally, the district health services are separated into a health and hospital wing. Both wings have independent reporting relationships to the state , BPMs and DPMs, the administrative officers of the hospitals, and senior nurse-administrators at taluka and district levels. Although the implementers’ assumption was that the participants were members of a team of health managers, these teams were in fact not necessarily functional. Doctors are viewed as the health managers in charge, automatically sliding into and being accepted into positions of leadership and responsibility in their teams. New staffs are thus expected to enter into a reporting relationship with the doctors and are seen as subordinate in knowledge and in function. The factors related to the age gap, to the team relationships between medical and non-medical members of the teams, and to the relative power positions of members of the management teams all influence the functionality of the teams, and the degree to which non-medical team members will take up responsibilities.Capacity-building of district health managers and its contribution to organizational change is influenced by relationships between actors and among the components of the district health system. In Figure The program theory enables us to formulate a number of CMO configurations that can be subsequently used in guiding the analysis of data collected in course of the intervention  four functions (attributes or properties of an organization)”: attaining the organization’s goals and adaptation to its external environment on one hand and its internal environment  and its production  on the other  and the expectations of local actors  on the other . In such a scenario, capacity-building interventions could operate through triggering changes in alignments, for example, by decreasing tensions in the allocation alignment through better negotiation skills provided to the taluka. The Tumkur capacity-building intervention implemented within the existing policy context of NRHM aimed to improve both allocation alignment  and strategic alignment (strengthening role of districts in making their own action plans). However, our program theory shows that in the present Indian district context, improved organizational performance would also need better contextual alignment  and operational alignment .The pushes and pulls of the four Programs for capacity-building of health workers operate at and across several levels – individual, institution, and system – with the positive outcomes, in this case, improved management of health services vary from one institution to another, and across different healthcare delivery teams. In a hospital where the doctor would be able to decrease the perceived social distance between herself and the BPM, there is likely to be a better operational alignment and higher chances of the BPM’s improved knowledge and skills manifesting as improved organizational performance. These plausible explanatory CMO configurations need to be tested using program data to understand which of the many possible organizational change mechanisms is operating in the Indian district setting.Capacity-building programs in health systems are an important HRM intervention, especially where adverse health outcomes are linked to poor management of health services. However, HRM studies in health and in other sectors have shown that training does not automatically generate positive organizational change. Efforts to understand the conditions under which capacity-building results in positive organizational change are limited by methodological difficulties, insufficient descriptions of the context under which interventions operated, and lack of attributability of changes observed to the intervention inputs. In this paper, we have described the process of building a revised program theory beginning from the IPT of the implementers, based on a thorough understanding of the local context and integrating relevant theoretical knowledge. This is helpful in understanding how, for whom, and under what conditions the intervention works. The resulting refined program theory clarifies the plausible causal links in the intervention, making it amenable for evaluation.Although the design and delivery of HRM interventions could be standardized, the institutional  contexts and socio-political contexts vary from one institution/taluka to another and across districts. The plausible mechanisms through which a capacity-building program in health could bring about organizational change lie at the individual , teams (workplace characteristics), organization or district level , and interaction with other talukas or healthcare organizations . The Tumkur intervention has provided us with an opportunity to improve our understanding of these plausible mechanisms and their interactions with the context to produce a desirable outcome. The refined program theory can be used to further investigate how the capacity-building intervention worked, for whom it worked, and why.The first author was involved in the early implementation of the capacity-building intervention. All authors declare that there is no commercial or financial relationships that could be construed as a potential conflict of interest.http://www.frontiersin.org/Journal/10.3389/fpubh.2014.00089/abstractThe Supplementary Material for this article can be found online at Click here for additional data file.


Tetramine, or tetramethylenedisulfotetramine, is an internationally banned compound that had been used primarily as a rodenticide. Despite its regulatory status, there are widespread reports of its intentional use in human poisonings, primarily in China, and often in mass poisonings. Enhanced governmental regulations were implemented in 2003 to further reduce the availability of tetramine, though the effects of these regulations, and the current use of tetramine, remains unknown.Reports from the website of the China News Agency were collected from 2000 to 2012. Details such as the location, date, and intent of the events were compared before and after the regulations were implemented.There were a total of 148 events during the study period . There were a total of 3526 victims, including 225 fatalities. The majority of the events were homicidal/terroristic in nature. The incidence of events fell after 2006. More poisoning events occurred in central China, such as Henan and Jiangsu province, and an increase was noted in April and September.Tetramine poisoning events, as reported in the national Chinese media, fell after the implementation of strict regulation on tetramine. The causal relationship is not known. Tetramine (tetramethylenedisulfotetramine) is a highly toxic compound that was previously used as a rodenticide. This use has been widely discontinued across the globe due to the risk and severity of human exposures. Tetramine is on the World Health Organization’s list of “extremely hazardous” pesticides, and it is believed that as little as 10mg can be lethal to an adult. As a “cThe most consequential use of tetramine as a nefarious poison occurred on September 14, 2002 in Nanjing, Jiangsu province. In this single event, more than 300 persons were poisoned with tetramine by food consumed at a contaminated snack bar. There were 42 deaths, all children. In respWe were interested in evaluating the media coverage of tetramine poisoning within China to gain a better understanding of the epidemiology of such poisonings, such as the regional variation, demographics of both perpetrators and victims, and the effect of governmental controls on the availability of tetramine implemented in 2003. We hoped to assess the impact of enhanced regulation on the availability of this dangerous, and largely banned, substance.The website of the China News Agency (CNA) was searched using the term “tetramine” inclusive of the years 2000 (the date of inception of CNA) to 2012. This neA total of 148 events involving exposure to tetramine was reported; 95 occurred before 2003, and 53 after. A total of 3526 persons were affected, including 225 deaths. All of the reported events involved the ingestion of the toxin. The typical reported clinical findings were nausea, vomiting, dizziness, seizure, or coma. The peak in both the number of poisoning events and the number of victims occurred in 2002. When the enhanced regulatory efforts were implemented in 2003, the number of events dropped precipitously and remained low from 2006 through 2012 ; all occurred prior to 2003. Five provinces  had more than 5 events after 2003. Hebei and Zhejiang had more events after 2003 than before . It is not clear what accounts for the differences, although the small numbers may simply represent random events. Interestingly, a report in the Chinese literature shows that all the seven tetramine events in Anhui province in 2005 occurred in the Fuyang. This ciEvents occurred primarily in public places such as restaurants and schools, and were primarily homicidal in nature Table . There wThe majority of events occurred in central China, such as Henan or Jiangsu province, which are highly agrarian regions. There were no or few events in the Western or the Northeast areas of China. The climate in the northern provinces may limit the need for outdoor rodenticide use in farming, reducing the availability of tetramine for impulsive use. Similarly, the seasonality of poisoning, with the greatest frequency in April and September, may arise from the high rate use of the rodenticide during cultivation or harvest seasons. Similar findings are reported by Xian.The data update and expand a previous study using similar methodology. Using open source data from Xinhua News Agency from 1998 to 2002, Coddy, et al. identifiThe most important finding of our research is that the reported use of tetramine for poisoning events decreased following the expanded 2003 regulations. Although we cannot state with certainty why this occurred, it is most likely a result of this public health intervention. It is generally accepted that the primary prevention of any poisoning occurs through the reduction and control of the availability of the toxin. However, it is also possible that the media attention and the seriousness of the harm caused may have reduced the use in poisoning.To our knowledge, our study is the first to attempt to evaluate the effect of this specific intervention on the public consequences of the availability of tetramine. Other public health efforts have shown similar beneficial results, such as the prevention of pesticide poisoning in Sri Lanka and the Poisoning events are not always identified or reported by the media, limiting the completeness of the data we collected. We have tried to minimize the limitation by comparing the three year data (from year 2002 to 2004) between CNA and Xinhua News agency, and found no extra report from the later. Though there are other news agencies’ websites, they suffer similar limitations. There is no reason to believe that there has been selective reporting of tetramine poisonings nor that reporting was systematically misleading. However, the accuracy of the reports themselves could not be validated. Although we attempted to identify duplicative reports, the variations in reporting style and content may have prevented recognition.Tetramine poisoning events are common in China and have resulted in thousands of deaths, primarily homicides, over the past 13 years. There are seasonal and regional differences in the poisoning events. The implementation of intensive regulation in 2003 coincided with a decreased number of media reported events and reported numbers of victims.