Nuclear medicine, a subspecialty of radiology, plays an important role in proper diagnosis and timely treatment. Multiple resources, especially short-lived radiopharmaceuticals involved in the process of nuclear medical examination, constitute a unique problem in appointment scheduling. Aiming at achieving scientific and reasonable appointment scheduling in the West China Hospital (WCH), a typical class A tertiary hospital in China, we developed an online appointment scheduling algorithm based on an offline nonlinear integer programming model which considers multiresources allocation, the time window constraints imposed by short-lived radiopharmaceuticals, and the stochastic nature of the patient requests when scheduling patients. A series of experiments are conducted to show the effectiveness of the proposed strategy based on data provided by the WCH. The results show that the examination amount increases by 29.76% compared with the current one with a significant increase in the resource utilization and timely rate. Besides, it also has a high stability for stochastic factors and bears the advantage of convenient and economic operation. Because of the persistent combination of rapid demand and slow supply, “difficulty and high cost to access medical service” has become one of the hot social issues in China, which draws extensive attention in the study of medical services. Nuclear medicine, a subspecialty of radiology, playing an important role in the proper diagnosis and timely treatment of diseases, has its unique problem in patient appointment scheduling. In the process of nuclear medical examination, short-lived radiopharmaceuticals (drugs that give off radiation) produced by special generators are administered to take high-quality images within the body with the help of ionizing radiation, and improper scheduling probably leads to its unavailability. Therefore, hospital managers are under a great pressure to manage such special resource efficiently and effectively.This problem is very critical in large tertiary hospitals which are heavily overloaded. For example, the demand for nuclear medicine in the West China Hospital (WCH) which is one of the largest single-site hospitals in the world, with 4,300 inpatient beds, and the major referral center for complex health problems for Southwestern China, grows rapidly at a rate of nearly 20% a year, intensifying the conflict between supply and demand of medical resources. One solution is to increase resource supply, such as purchasing more equipment. However, due to their high fixed cost and operation cost, expensive equipment has been strictly controlled by the authorities to control healthcare costs. Furthermore, according to our investigation, the current scheduling strategy based on experience does not make full use of resources. For instance, under the condition of current scheduling strategy, the contradiction of supply and demand of two key resources (equipment and medicine) involved in the process of nuclear medical examination is prominent. During a week, the bottleneck of nuclear medical examination shifted from equipment to medicine. From Monday to Tuesday, excessive production of medicine resulting in low medicine utilization (the average utilization rate is only 64.1%) causes an equipment bottleneck. From Wednesday to Friday, however, insufficient medicine production leads to poor efficiency of the resource use (idle equipment and staff) and low patient satisfaction. In this case, medicine becomes another bottleneck. Furthermore, at weekends, the fluctuation of the patient flow makes the resource utilization instable. Therefore, applying scientific methods to achieve appointment scheduling of radiology resources at the Nuclear Medicine Department in the WCH has important applicable significance.Patient requests in nuclear medicine arrive in an online fashion during the day as the scheduling proceeds, which makes it unique with very limited research reported in the literature. Stochastic planning techniques are an alternative to address this problem. However, unlike common online problems considering only one kind of resource, such as devices working hours or plane capacity, this one is more complex under multiple resource constraints within the time window originating from the short half-life of the radiopharmaceuticals. Adopting a method similar to that of Pérez et al. , we solvThe contributions of this paper are as follows. First, we develop a nonlinear integer programming model considering the characteristics of the nuclear medicine department, such as multiresources constraints and time window constraint, and get optimal solution by MPGA. Second, we design a stochastic online algorithm considering the demands of various types of patients and arrival unpredictability, which is close to the greatest level of reality by removing many assumptions in previous studies, such as the risk-neutral and predicable assumption about the patient demands.These contributions will help the practice of nuclear medicine by providing increased patient throughput and higher utilization of resources and will improve the methodology of the appointment scheduling in nuclear medicine.The rest of this paper is organized as follows. As healthcare expenditures and demand have been rising dramatically worldwide, increasing attention from many academicians and practitioners has been paid to the efficiency of health service, such as medical personnel staffing, medical resource allocation, and appointment scheduling. Appointment scheduling is an important determinant of efficiency, timely access to health services, and patient satisfaction . In receRegarding the literature, there are two common approaches to schedule an appointment, namely, offline scheduling and online scheduling. The offline scheduling approach, static  or allocIn conclusion, the characteristics of multiresources constraints and specific time window in nuclear medicine constitute a unique problem with very limited research reported in the literature. Moreover, there is hardly any research in radiology appointment scheduling applying online algorithms considering patient's demand and arrival distribution. For this reason, this paper not only has guiding significance for nuclear medical departments in practice, but also is a supplement to the theory.The practice in the Nuclear Medicine Department of the WCH can be divided into two categories: treatment and examination. The latter includes PET/CT and SPECT/CT. We focus on SPECT/CT for its heavy use. The resource constraints include equipment and medicine. Technetium and iodine are the two major medicines involved in SPECT/CT scans see . I131 isExamination items in the Nuclear Medicine Department of the WCH are up to 24 types. Among them, whole body bone scan, kidney scan, thyroid scan, salivary glands scan, I131 therapeutic agent scan, bone dynamic scan, assessment of glomerular filtration rate (GFR), and I131 whole body scan account for 95.59%, while the rest account for less than 5%. For this reason, the top eight are studied and then are divided into four groups according to similar resource consumption and injection method see .Compared with other kinds of online scheduling problems, this one has its unique characteristics by considering the multiresources constraints and the time window. A similar scheduling problem has been deeply researched in the field of revenue and production management, though only one resource constraint  is considered. In the nuclear medicine department, two key resource constraints are involved, which makes the scheduling more difficult. In addition, this scheduling problem has a time window of 1–3 days. On the one hand, for the timely examination being the premise of timely medical practices and care, the examination date is fixed within 3 days after their arrival day; on the other hand, patients will not be examined on the arrival day due to the particularity of nuclear medicine.xgpd) is used as input to the model. Each patient p requests an examination in group g on day d with binary value .In the offline problem, all patient requests are assumed to be known in advance. Thus, patient scheduling is made by considering all requests for the day. Considering multiresources and time window constraints, we propose a nonlinear integer programming model aiming at maximizing the weekly examination amount while satisfying all constraints. A set of patient requests  is one of the best tools for satisfactory solution with advantages like good convergence, low computational complexity, high robustness, and so forth. Practices show that the GA is quite effective in the nondeterministic polynomial complete problem (NPC) solving. For this reason, we apply the genetic algorithm to solve this problem.(1) Algorithmic Design and Implementation. The logic diagram of the algorithm is shown in ∧600 (2∧1800). Fitness is represented by objective function value, but to better satisfy all the constraints, the evaluation function of individual fitness is adjusted by penalty value to limit functions which do not meet all the restrictions. Roulette selection is used as a selection operator, two-point crossover is adopted as crossover operator, and adaptive mutation and basic bit mutation are introduced as mutation operators.Here, the floating-point coding method is adopted for not producing larger redundant space and being good at satisfying complicated constraints of decision variables in large space searching, compared to the binary encoding method. The string length of chromosomes is set as the weekly demand and is divided into 28 parts, each of which is for one type of patient decided by arrival day and examination item. Each position on the chromosome is for an unprocessed demand and is expressed numerically as 0–7. 0 is for denial and 1–7 is for what day of the week the examination day is. Since the demand is about 600 a week, the solution space will be up to 8(2) Parameter SettingEquipment Constraint. Based on a real situation, working hours are set to about 10 h a day.Medicine Constraint. Medicine production varies from day to day within a week as in Time Window Constraint. The examination day is fixed within 1–3 days after the arrival day.Arrival Rate. Data analysis indicates that most of the data obey Poisson distribution by K-S test while only a few do not but can be fit by uniform distribution, so we take stochastic arrival sequence as an input as in (3) Results. The problem is solved by GA program on Matlab with a total running time of 721 s and the optimum of 576. The rest of the other results are shown in Aiming at solving the existing problems of standard genetic algorithm (SGA) like premature convergence, multipopulation genetic algorithm (MPGA) is proposed to improve the algorithm efficiency. The logic diagram of the algorithm is shown in As shown in We study the influence of increased demand on outputs which are shown in Figures As seen in As seen in As seen in Being two key constraints in scheduling, the equipment and medicine constraints are studied for how their changes might affect the target value. The equipment working time is set at 8 to 12 hours every half hour and the medicine production is set at 80% to 120% of the original production every 5%. Since there are nine equipment constraint values and nine medicine constraint values, the combination of both has 81 values.The online schedule strategy mainly aims at adjusting the daily amount of each item to maximize the resource utilization. Three online scheduling strategies together with the current one are compared and analyzed to obtain the optimum solution. In addition, for the offline optimal scheduling programming rule, hereinafter referred to as “Offline” for short, being an ideal one , it is added as the highest standard.This is the current scheduling strategy see .Making no reservation for any items, scheduling is based on constraints of equipment and medicine with FCFS discipline.This is the offline optimal scheduling strategy solved by MPGA based on history data see .This is the optimal dynamic scheduling strategy.The target value is the weekly examination amount which is the key indicator of the strategy assessments. As seen in Due to the distribution of examination items, strategies with the same target value will have different utilization of equipment and medicine. The essential characteristic of optimization is to improve resource utilization. Therefore, the utilization of equipment and medicine is another indicator in strategy assessment. As seen in Figures Patients who cannot get an appointment within a week (the scheduling period) are regarded as being refused. Therefore, the acceptance rate, the percentage of received patients to patients' arrivals in a week, measures the ability to satisfy time window constraints. However, even when people get an appointment during the scheduling period, their examination date may not be within the time window. Therefore, timely rate, the percentage of patients getting an appointment within the time window to received patients, is another index for estimating the ability to satisfy time window constraints.As seen in Figures The data in this paper contains information of arrival date without exact arrival time, so the daily arrivals of each item are known and the arrival sequence is unknown. Considering weak statistical regularity of real arrival sequence, we generate arrival sequence by random method based on history data. Then, the effect of the random arrival sequence on output result is analyzed. To be more detailed, 10 arrival sequences are generated with the daily arrivals of each item group being fixed and the effects on the target value of the four strategies are compared under two supply and demand situations.As shown in As mentioned in From the above analysis, we can see that, in the current situation, the gap between To solve this problem, Due to the special characteristics of multiresources and time window constraints, scientific and reasonable appointment scheduling in the nuclear medicine department is not an easy task. In this paper, a stochastic online appointment schedule strategy is derived considering multiresources allocation, the time window constraints imposed by short-lived radiopharmaceuticals, and the stochastic nature of the patient requests. A series of experiments are conducted to show the effectiveness of the proposed strategy based on data provided by the WCH. The results show that the examination amount increases by 29.76% compared with the current one with a significant increase in the resource utilization and timely rate. Besides, it also has a high stability for stochastic factor and bears the advantage of convenient and economic operation. Although the study and the related results are based on the nuclear medicine department, the online appointment scheduling system can play a reference and instructive role for the other radiology departments. There are some limitations in the present study which has a wide range of the time window (1–3 days), hoping that the research can get a more accurate scheduling strategy by refining the time window constraints in the next step.


The aim of this study is to explore the pattern of change in multiple measures of cognitive abilities in a sample of oldest-old adults, comparing two different time metrics  and therefore examining both underlying conceptual assumptions . Moreover, the association with individual characteristics as sex, education, and dementia diagnosis was also examined. Measures of cognitive status  and tests of crystallized (knowledge and synonyms), memory , and visuospatial ability were included. The sample consisted of 671 older Swedish adult participants of the OCTO Twin Study. Linear mixed models with random coefficients were used to analyse change patterns and BIC indexes were used to compare models. Results showed that the time to death model was the best option in analyses of change in all the cognitive measures considered (except for the Information Test). A significant cognitive decline over time was found for all variables. Individuals diagnosed with dementia had lower scores at the study entrance and a faster decline. More educated individuals performed better in all the measures of cognition at study entry than those with poorer education, but no differences were found in the rate of change. Differences were found in age, sex, or time to death at baseline across the different measures. These results support the terminal decline hypothesis when compared to models assuming that cognitive changes are driven by normative aging processes. Increasing levels of population aging turns research about aging related cognitive decline into a worldwide priority. Although it is well known that cognitive abilities decline with age, a better understanding of the underlying processes and individual differences in cognitive aging remains a main objective in current cognitive aging research .Cognitive decline in aging studies is often explored using linear mixed models . These mMoreover, choosing the most appropriate time metric to model cognitive change is not only a statistical issue, but also a theoretical one. Different time metrics assume that the changes are driven by different underlying processes. For example, selecting age as time metric assumes that all the individuals at each age are in the same stage of the causal process (aging) that is driving the cognitive changes. Therefore, when changes are modelled using chronological age, these changes are considered as age-related changes, which are often conceptualized as normative aging changes . HoweverMost of the studies explored measures of cognitive abilities using only one time metric making an a priori assumption to conceptualize the change in these abilities e.g., , 17). Jo. Jo17]).The aim of this study is to explore the pattern of change in measures of cognitive status and specific measures of cognitive abilities in a sample of oldest-old adults, comparing two different time metrics  and therefore examining both underlying conceptual assumptions . Two brief and well-known measures of cognitive status , memory , two tests of crystallized cognitive abilities (knowledge and synonyms), and visuospatial ability are included. In addition, the association with individual characteristics as sex, education, and dementia diagnosis is also examined.The sample consisted of 671 older Swedish adults (229 women and 442 men) that were participants of the Origins of Variance in the Old-Old (OCTO Twin Study). Further details about Swedish Twin Studies can be found in Pedersen et al. , 23.The OCTO Twin Study includes a number of cognitive and behavioural measures including two general measures of cognitive status, four measures of memory, two of crystallized abilities, and one of visuospatial abilities. We included standard measures to screen dementia in clinical settings , for exaCognitive status was measured using the Mini-Mental State Examination (MMSE ) and theVerbal memory was assessed by a Prose Recall Test . This teNonverbal long-term memory was assessed with the Thurstone Picture Memory Test . RespondMemory recognition and memory correspondence were assessed by the two subtests of the Memory in Reality Test . This test was developed as an alternative to standard list-learning tasks and asked the participants to place real-life objects at the same location as they were previously placed. Higher scores are indicative of better memory.Short-term memory was assessed by the Digit Span Forward and Backward Test (WAIS ). The paVisuospatial ability was assessed with the Kohs Block Design Test . RespondThese abilities can be described as the knowledge and skills acquired through education and other cultural experiences over the life span , 35. In R2 [Linear mixed models, with random intercepts and slopes, were estimated using SAS Proc Mixed , 37, as R2 . When exFor each cognitive measure, the BIC indices for the four models were compared. As can be seen in With regard to baseline age, results showed that people older at study entry had lower initial scores on the MMSE and the Clock Test but only showed a faster decline in MMSE over time. For the memory tasks and visuospatial ability, older people also performed worse in the Memory Recognition, Memory Correspondence, and Block Design Tests, but age differences in rate of decline were only found for Digit Span. With respect to the crystalized abilities, there were no age differences at intercept or slope level.Significant sex differences were found for Memory Correspondence and the Information Tests. Women performed better than men on Memory Correspondence but worse on the Information Test. No sex differences were found on the slope for any of the tests examined, except for the Information Test.Time to death at the baseline was significantly positively associated with the level of MMSE, Clock, Memory Correspondence, and Digit Span Test and negatively associated with Prose Recall and the Information Test. Individuals who agreed to participate in the study when they were closer to death had higher cognitive scores than those who were further from death. Significant slope differences were found for all these variables, where individuals closer to death at study entry declined faster than individuals who entered the study further from death.The aim of this study was to explore the pattern of change in cognitive status and specific measures of cognitive abilities in a sample of oldest-old adults, comparing two different time metrics  and therefore examining both underlying conceptual assumptions . Moreover, the association with individual characteristics as sex, education, and dementia diagnosis was also examined.With respect to the time metrics, results showed that the time to death model provided a better representation of change for cognitive status, memory, and visuospatial ability. However, the results in the change in crystallized abilities did not follow such a consistent pattern. Although the trajectories of the scores in the Synonyms Test were better explained by a time to death model, the model that better described change in the Information Test was chronological age. Overall our results are consistent with those studies supporting the terminal decline hypothesis , 17, 18 With respect to the predictors of change for each cognitive measure fitted to the time metric that provided the best fit, results showed a common pattern in all the studied variables. First, a significant decline in cognitive abilities over time was found regardless of the time metric used, consistent with previous research , 20. SecAssociations with age, sex, and time to death differed across measures of cognitive abilities. On average, older people had poorer performance but baseline age associated differences in speed of decline were only found for MMSE and short-term memory. These results are partially consistent with previous research , 18, 42 One of the strengths of our study is that it is one of the first, to our knowledge, to explore such a large number of measures of cognitive performance including measures widely used in clinical settings (MMSE and the Clock Test) and measures of memory, visuospatial, and crystallized abilities. The variety of cognitive measures considered does not only increase the comparability of our findings with previous research, which have only considered a single cognitive measure, but also enable us to address Bosworth and Siegler  and LaukIn sum, our results support the fact that studying change according to terminal decline models might be the best option when compared to models that assume that changes are mainly driven by age-related changes , 17. Mor


This study critically examines the role of brand culture in influencing the perceived value of offerings to customers within the hospitality industry in Nigeria. In today's competitive market, the extent at which organizations disregard the importance of developing a strong brand culture before communicating their value to the outside world has become worrisome. Hence, this study filled in the gaps and a total of 434 customers drawn from six different hotels in Lagos state, Nigeria, were sampled. The data were analysed using Structural Equation Modelling (SEM). Management of these hotels were able to define their expectations in order to deliver a consistent brand experience to their customers. The result showed that brand culture has positive significant influence on the perceived value of offerings to customers. Important recommendations have also been made. The study population of this research comprises customers of selected six (6) hotels from a list of 131 hotels adjudged to be the top performing/most popular hotel brands in Lagos State by Tripadvisor (2017). The items in the questionnaire were adopted from brand culture profile (BCP) developed by The value of RMSEA is 0.055, which is considered satisfactory (less than 0.08). On top of that, the incremental fit, NFI, TLI, CFI, and GFI were above 0.90 as suggested by Before conducting the analysis to infer the hypotheses, the data were already tested for linearity, normality, homoscedasticity and multi-collinearity. All these basic assumptions were acceptable and prove that the data meet the conditions of basic assumption in regression analysis 3The data presented was based on a quantitative study. A descriptive research design was adopted in this study to obtain the opinions of customers on their understanding of brand culture of the selected hotels and the extent to which it influences customers’ perceived value.Survey method was considered appropriate as data collection method based on the fact that it allows for the collection of standardized data that permits the researcher to produce information for answering the how, who, what and when questions regarding the subject matter. Customers of The Wheatbaker Hotel, Ikoyi; Southern Sun Hotel, Ikoyi; Radisson Blu Anchorage Hotel, Victoria Island; Royal View Hotel and Suites, Mafoluku-Oshodi; Westland Hotels and Suites, Ikotun and West View Hotel, Mafoluku-Oshodi were selected for the study.The use of primary source of data (questionnaire) was used for collecting data from a cross section of customers across sample hotels. The study employed a combination of structured and unstructured question items. The collected data were coded and entered into SPSS version 22. Data analysis was done; using Statistical Package for Social Sciences-22. Although Statistical Package for Social Sciences may be limited when it comes to advanced modeling and development of statistical approaches.Statistical Package for Social Sciences makes in-depth data analysis quicker because the programme knows the location of the cases and variables. It also comes with more procedures of screening the information in preparation for further analysis. More importantly, Statistical Package for Social Sciences is designed to make certain that the output is kept separate from the data itself particularly because it stores all results in a separate file that is different from the data. Data was analyzed using inferential statistical tests which involved structural equation modelling (SEM).4The researchers ensured that respondents were well informed about the background and the purpose of this research and they were kept abreast with the participation process. Respondents were offered the opportunity to stay anonymous and their responses were treated confidentially.5This study revealed that brand culture has significant influence on the perceived value of offerings to customers within the hospitality industry. The requisite for hospitality industry to develop different elements useful in the identification and differentiation of service as complex as the environments in which they operate becomes necessary on a continual basis. Some of these elements include: logos, names, designs, icons, norms, cultural traits and phenomena embedded inside the elements, as well as cultural traditions, perceptions and emotional characteristics which these cultural traits represent. Hence, this present study has extensive implications for the hospitality sector, managers, government, researchers and undergraduate students in this regard. To this end, the data presented in this article is imperative for more comprehensive analysis or investigation.


Rift Valley fever (RVF) is a viral mosquito-borne disease with the potential for global expansion, causes hemorrhagic fever, and has a high case fatality rate in young animals and in humans.Using a cross-sectional community-based study design, we investigated the knowledge, attitudes and practices of people living in small village in Sudan with respect to RVF outbreaks. A special One Health questionnaire was developed to compile data from 235 heads of household concerning their knowledge, attitudes, and practices with regard to controlling RVF. Although the 2007 RVF outbreak in Sudan had negatively affected the participants’ food availability and livestock income, the participants did not fully understand how to identify RVF symptoms and risk factors for both humans and livestock. For example, the participants mistakenly believed that avoiding livestock that had suffered spontaneous abortions was the least important risk factor for RVF. Although the majority noticed an increase in mosquito population during the 2007 RVF outbreak, few used impregnated bed nets as preventive measures. The community was reluctant to notify the authorities about RVF suspicion in livestock, a sentinel for human RVF infection. Almost all the respondents stressed that they would not receive any compensation for their dead livestock if they notified the authorities. In addition, the participants believed that controlling RVF outbreaks was mainly the responsibility of human health authorities rather than veterinary authorities. The majority of the participants were aware that RVF could spread from one region to another within the country. Participants received most their information about RVF from social networks and the mass media, rather than the health system or veterinarians. Because the perceived role of the community in controlling RVF was fragmented, the probability of RVF spread increased. Rift Valley fever (RVF), is a neglected, emerging, mosquito-borne disease that has caused outbreaks in Africa and the Arabian Peninsula. RVF outbreaks have a severe negative impact on livestock, human health and economy, placing further demands on communities already experiencing high levels of poverty. We believe there is an immediate need to develop new approaches that will tackle the ongoing spread of RVF. One such approach would prioritize outbreak prevention by involving local communities in the surveillance of emerging zoonotic diseases, empowering local communities as agents of change rather than relegating them as passive victims. RVF is a disease with global implication, but it starts at a local level. Therefore, to control zoonotic disease such as RVF, it is important to understand the local communities’ knowledge, attitudes and practices related to RVF. Using a bottom-up perspective, we investigated the factors that keep the local community from participating in the control of RVF outbreaks at the interface between humans, animals, and the environment. By devising acceptable and cost-effective interventions, we believe local communities can be encouraged to be the first line of defense against RVF outbreaks. Furthermore, policies aimed at curtailing RVF outbreaks would benefit from involvement of the local communities. Global outbreak of zoonotic infections, not only affect human and animal health but also affect food security, and socio-economic stability. To control such outbreaks require local as well regional cooperation. Most zoonotic outbreaks begin and occur in settings where resources are poor and where the outbreak severely affect the local community , 2. ThesRift Valley fever (RVF) is a mosquito-borne viral disease affecting both humans and animals. It can be transmitted by mosquito bites or by direct contact with infected animals, their fluids, or products derived from them . The disSudan is an agricultural country with diverse ecology and has the second largest livestock population in Africa. Most of the Sudanese population depends on livestock for food and income. Our previous studies of the RVF 2007 outbreak in Sudan found a gap in knowledge regarding the role of the local community . In thisIn accordance with the guidelines of strengthening and reporting of observational studies in epidemiology (STROBE), a cross-sectional community-based study was conducted in March 2013 at the Mabroka Sagadi village in the Managil locality, Gezira State, Sudan .The Managil locality is close to irrigation canals. The local people are mainly farmers and shepherds and the locality is home to about 2 million livestock . The annual rainfall in the region varies between 100 and 350 mm; however, in 2007 the rain level reached up to 400 mm . The raiThe study area included all the states affected by the 2007 RVF outbreak . Most ofTo develop the One Health questionnaire to collect data about RVF at the human-animal-environment interfaces, we intensively searched the literature for information that would help us develop questions regarding the disease and we searched for the best possible answers to these questions supported by the medical literature. This research resulted in the One Health questionnaire that was designed to compile relevant data on RVF in humans, animals, and the environment. Originally written in English, the questionnaire was eventually translated into Arabic . The queA two-day training workshop was held for data collectors  to discuss the objectives of the study, the contents of the questionnaire, and the methods of the study.A pilot study was conducted in the village of Algila . Algila A pre-study field visit to the study area was conducted to build trust, explain the study objectives, mobilize the community leaders, and ask the community to be involved in all parts of the study. This led to a sense of ownership and empowerment. Thus, successful face-to- face interviews with the heads of households at their home could take place in a friendly environment.The thematic areas covered by the One Health questionnaire were socio-demographic considerations, knowledge of RVF in animals and humans, attitudes and practices regarding RVF, and environmental aspects of RVF .The data were coded, entered into Microsoft Access, and checked for data entry errors by re- entering 10% of the data from the questionnaires. The data were exported and analyzed using STATA version 12 .Ethical clearance was granted from the Ministry of Health, Gezira State, Sudan. All participants were informed about the objectives of the study and about the confidentiality of the information and results. The participants signed an informed consent document for participation and they were free to leave the study at any time.The study included slightly more women (53%) than men (47%), and almost 67% had a low level of education (less than higher secondary school level) with no significant gender difference. Just over half (55%) were above 35 years of age, the vast majority (87%) of the heads of households were married, and their household had at least six members . Most woMost of the households bred animals (72%) . Cattle The awareness about RVF in general was high: 80% of the heads of households heard about the disease. About 9% of the heads of households had seen people who had contracted RVF during the 2007 outbreak. More than half of those interviewed stated that RVF is a zoonosis that affects both animals and humans, and that RVF had been a serious health problem in the area during the 2007 outbreak. The most common sources of information in the community about an RVF outbreak was their social networks of relatives and friends (54%) and mass media (23%); a less common source of information was the health system (6%) or others such as veterinarians (5%).According to the respondents, there was higher livestock mortality in the area during the 2007 RVF outbreak than the year before (2006) and the year after (2008) the outbreak. During the 2007 RVF outbreak, 34% of the heads of households had experienced death of livestock; in 2006 and 2008 only 17% had experienced death of livestock. This difference, however, could not be confirmed from official reports.Although the community experienced higher livestock mortality, only some mentioned known symptoms in livestock that died, such as nasal and ocular discharge and hemorrhagic diarrhea . RegardiMost of the respondents did not know how livestock become infected with RVF. For human infection, (21%) stated that humans are infected through uncooked meat while 13% suggested direct contact with livestock. Only a few respondents suggested other mode of transmission such as raw milk (9%), and mosquito bites (6%). The most common answer on how humans should avoid RVF, was to avoid uncooked meat and handling of sick livestock. Avoiding livestock that had suffered miscarriage was the least important according to the results of the survey.Although few thought that RVF is a contagious disease, more than half of the respondents expected to get RVF when it was present in their area―either due to animal-to-human contact or human-to-human contact . One-quaThe survey revealed that two-thirds of the participants had a positive attitude about medical treatment against RVF in humans. However, only one-third thought that medical treatment could be used for livestock. They also indicated that veterinarians should diagnose RVF in livestock and health workers should diagnose RVF in human. Around 75% of the heads of households knew where to seek medical treatment, either in the public or the private health sector.If an outbreak occurs, about 40% said they should notify the veterinary authorities about the death of livestock. Almost all the respondents (99%) stressed that they would not get any compensation for their dead livestock if they notified the authorities. When asked if any of their own livestock had had RVF during the 2007 outbreak, 13% said yes. These suspected cases were not confirmed by the authorities. When we asked which disciplines need to work together in order to control RVF, only eight participants (3%) stated that veterinary and health authorities should work together. The majority believed that human health authorities (50%) rather than veterinary authorities (15%) should work to control RVF. With regard to the community’s role in confronting RVF, the respondents suggested that the community should improve its hygienic measures (22%), its health education (18%) and its vector control (8%).The majority of the study participants (70%) were aware that RVF could spread from one region to another within the country. In addition, 66% of the participants revealed that they were aware of the livestock trade ban associated with RVF outbreak inside and outside the country.We used the 2007 RVF outbreak in Sudan as a case study to investigate, the knowledge, attitudes and practices, from the One Health perspective that affect the involvement of the local community in disrupting an emerging zoonotic infection. Most of the measures aimed to control RVF were formulated by authorities  to be implemented by the local communities (a top-down). For RVF, it seems as these actions are not enough as disease emergence continues. We believed that insights from the local community (a bottom-up approach) about RVF prevention and control could help stop the spread of RVF outbreaks. This bottom-up approach could be a tool to better combat the transmission and the spread of RVF in the regions where the outbreaks are initiated, and could enhance a top down approach. To identify the important factors we used the unique One Health approach to gather information about livestock, people, and the environment. We also investigated whether the community considered the integration of the One Health approach of health, veterinarians, and environment authorities as the best strategy to confront RVF and how they could contribute to RVF control.Although the community studied had experienced a large outbreak, few had proper knowledge of RVF regarding cause, mode of transmission, symptoms, prevention, and control. This lack of knowledge increases the chances of RVF spreading to neighboring areas and would prevent the community from confronting the disease. The knowledge of risk factors for RVF was insufficient, because the community only practiced some of the measures known to prevent RVF  Click here for additional data file.S1 Table(DOCX)Click here for additional data file.


Public hospitals have come under heavy scrutiny across the world owing to rising expenditures. However, much of the focus has been on cutting down costs to raise efficiency levels. Although not denying the importance of efficiency measures, this article targets a performance issue that is relevant to address the quality of services rendered in public hospitals. Thus, it is important to focus on the effectiveness of resource utilization in these hospitals. Consequently, this article seeks to examine the impact of average length of stay (ALOS) and bed turnover rates (BTR) on bed occupancy rates (BOR).Public hospital inpatient utilization records during the period 2006 to 2013 were gathered from the Ministry of Health, Malaysia. A 2-step generalized method of moments (GMM) statistical method was used to analyze the data. BOR was adopted as the dependent variable, whereas BTR and ALOS were used as the explanatory variables. The logarithm of total bed count (BED), admission (ADM), and patient days (PD) was deployed as control variables. Three regression models were developed to explore the correlates of BOR as a hospital performance measure. Ethics committee approval was waived because no patients were identified in the study.The statistical analyses show that ALOS and BTR are inversely correlated with BOR, with both coefficients significant at 1%. The control variables of BED, ADM, and PD had the right positive signs and they were significant in both sets of equations. Hence, reducing ALOS and BTR can help raise performance of public hospitals in Malaysia.In light of the robust results obtained, this study offers implications for improving public hospital performance. It shows a need to reduce ALOS and BTR in public hospitals to improve BOR. Public hospitals serve as a major conduit in the delivery of medical services, as well as account for the largest share of total health care expenditure of countries. Given rising expectations of patients and other stakeholders, the need for improvement in health care delivery has become paramount, especially in the effective use of resources. However, scholars have been divided on the best approaches to assess health care performance,,4 which consequently has led to the advocacy of different health care management strategies.Public hospital management has been an insufficiently explored area of study despite its importance in meeting the health care needs of society. Although organizational behavior theory Under this approach, health care is defined mainly by dollars and cents to protect stakeholders’ interests. Hence, financial measures are used as indicators of performance. The underlying estimation method has been to model the maximum attainable outcome through a production function, and to consider any distance from the production possibility frontier as a measure of inefficiency.,7 Although being efficient is good for any organization, conventional efficiency measures are not bereft of shortcomings, especially when applied to public hospitals. Given that public hospitals exist mainly to service the health care needs of society,,7 their assessment therefore should be tied to their objectives.The most widely applied approaches are built around the concept of efficiency. This concept originated from the “economic good” theoretical viewpoint.,10 BOR represents the percentage of installed beds occupied in hospitals within a given year, which is used as an indicator of utilization and productivity. The influence of BOR on hospital outcomes has been reported in a number of studies.–13However, identifying the appropriate performance measures for public health care organizations, especially public hospitals, has been a challenging task for researchers. Nevertheless, a safe way of addressing the problem is to look inward and focus on the internal dimensions underpinning organizational behavior rather than to simply use the traditional efficiency concepts used in economics. Thus, several studies have relied on bed occupancy rate (BOR) as a major indicator of hospital performance. Studies in this line of thought suggested risks inherent in a hospital's inability to provide sufficient number of beds to patients. This will then result in BOR overshooting, which will generate negative impacts.,11,15,16 An innovative study by Bagust et al established that when BOR exceeds the safe level of 85%, it results in increased chances of access block, long waiting times, and high mortality. BOR above the threshold of 85% would generate overstretched quality of hospital care. This will produce negative consequences, which does not bode well for public hospitals. However, a BOR of <80% is considered to be low and it indicates idleness of facilities.Efforts have been made in the past to model the relationship between hospital service demand and available capacity. is appropriate. However, its correlates with the average length of stay (ALOS) and bed turnover rates (BTR) have not been statistically proven. Therefore, this article attempts to contribute to the literature on the use of BOR as a hospital performance measure. Because BOR is not a stand-alone measure, understanding its correlates with ALOS and BTR is necessary to contextualize it as a public hospital performance measure. Thus, the overarching goal of this study is to produce estimates that better reflect true, underlying BOR effects as a measure of public hospital performance. This study is relevant because apart from filling the gap in knowledge, it will help policy-makers in hospital capacity planning and utilization.From the foregoing arguments, the application of BOR as a measure of hospital performance22.1The data used in this study were obtained from the Ministry of Health (MOH), Malaysia, and consist of all public hospitals in Peninsular Malaysia during the period 2006 to 2013. Peninsular Malaysia consists of 11 out of the 13 states that make up the country. Public teaching hospitals, public military hospitals, public clinics, private hospitals, polyclinics, and other private health care providers are excluded because the objective is to assess the performance of public hospitals under MOH. It is believed that stronger conclusions on public hospital performance would warrant widening the study period instead of simply carrying out a cross-sectional assessment undertaken by many previous studies. Hence, the article uses longitudinal data and follows panel data analysis model.2.2 BOR is adopted as the dependent variable, whereas ALOS, BTR, BED, ADM, and PD serve as independent variables as in earlier studies.,19 These measures, which span across utilization, productivity, and quality, serve as proxy indicators of performance and qualify as performance assessment measures. They are hospital-wide measures that denote the general performance of hospitals rather than specific areas of clinical concern. Furthermore, these variables seek to offer insights into some aspects of wastefulness in the use of resources.t−1) of the dependent variable was presented to control the lagged effect and limit its estimation bias as in Fan et al.BOR represents the percentage of all licensed and installed beds within a given year, and it is used as an indicator of utilization and productivity. Because performance assessment is a continuous process in any organization, the effects of the previous performance status on the current cannot be discountenanced. Hence, in the ensuing analysis, the first-order lagged term of the BOR  in all hospitals during a given year. A lower value means a better quality of service, which is helpful in making more beds available to incoming patients. Evidence suggests that significantly lower levels of ALOS and greater number of admissions indicate sound management. This implies that higher BOR which results from higher admissions will have negative correlation with ALOS. Hence, its coefficient is expected to be negative.ALOS has been widely used as an indicator of quality of services provided by hospitals. A lower rate may be due to high ALOS; however, when both are very low, it might imply either underutilization or overcapacity. BTR is measured by dividing the total discharges (including deaths) by the total number beds. Because it seems to be of less effect on the dependent variable, its coefficient is expected to be negative.BTR denotes the number of times each hospital bed changed occupants. It indicates the use made of available hospital beds and has been defined as a measure of productivity.BED includes all installed hospital beds which are regularly maintained, equipped, and staffed, and readily available for the care of admitted patients. Emergency stretchers/bed and beds designated for same-day outpatient care are excluded. This study encompasses different types of public hospitals with varying capacities defined by the number of beds. These variations result in skewness. To limit the effect of the skewness, logarithm (log) of bed is applied. The coefficient associated with bed variable is expected to be positive and statistically significant given that higher capacity will lead to higher admission and utilization and consequently high BOR.patients accepted for inpatient services in any of the public hospitals within the period under consideration. As mentioned above, because capacity differs, admissions as well differ and there is skewness in the number recorded in different hospitals. As admission depends on the number of beds which have been found to be skewed, log of ADM is applied.ADM refers to PD refers to units of measure denoting accommodating facilities provided and services rendered to inpatients within the census-taking period. It reflects the volume of services provided by each hospital within a given year. PD impacts the BOR by changing both output and input amounts. So, under the same conditions, higher PD would mean higher utilization and higher BOR. It is assumed that because admission has a potential utilization of hospital resources, increasing PD may generate a larger increasing effect of BOR, and thus can increase the rate of utilization. For these reasons, PD is considered an important factor of BOR. It is calculated as ADM multiplied by ALOS. Its coefficient is expected to be positive.The analysis considers the following variables: BOR, ALOS, BTR, number of beds (BED), admission (ADM), and patient days (PD). It is believed that these constitute a reasonable set of performance measures tailored to public hospitals’ goals of providing care to all and serve as macrolevel hospital performance measures.BED is used as a proxy to capture hospital size effect on BOR. Large-sized hospitals are defined as those having high number of beds. Although ADM depends on other factors, such as location, specialty, and the like, it does represent the quality of the services provided. Better quality of services attracts patients from far and near, and hence could influence BOR. On the contrary, hospitals with reports of poor quality of services will have lesser number of patients in comparison with those providing better quality. Similarly, PD captures the number of days in totality that patients stay in hospitals as inpatients within a given time period. Table The maximum BOR was 132.8%, the minimum was 14.7%, while the mean was 58.0%  estimation. Hence, to investigate the determinants of BOR, the following static panel data model is considered: Table 2.3This article deploys a partial adjustment model to bring the econometric analysis close to practicality. However, the lagged dependent variable (LDV) can lead to endogenous problems because of the correlation between independent variables and the error term. Hence, fixed and random effects are not adopted in order not to bias the results of the panel data estimation. Rather, the GMM estimator, which takes the LDV and past values of other potentially endogenous variables in the regression as instruments, was adopted. In this study, LDV and endogenous variables are used to form GMM-type instruments. LDV is applied purposely to provide robust estimates of the effects of independent variables and yield more accurate parameter estimates. Adding LDV to a regression model has been demonstrated as a veritable way of helping purge error autocorrelation.Generally, GMM estimation takes account of heteroskadesticity and serial correlation between exogenous variables and error terms. The Arellano–Bond (AB) test is applied to judge the validity of the instruments.Furthermore, considering that the endogenous problem is crucial for the robustness of the estimated results, the system GMM is deployed to ensure that the instruments and moment conditions are rational. It assumes that if the instruments are well selected, there is a first-order serial correlation in the error term, but no second-order correlation. The endogeneity test of the endogenous regressor supports the preference for a 2-stage GMM as applied. Ethics committee approval was waived because no patients were involved in the study.In the diagnostic tests, the Hansen test of overidentification which examines the appropriateness of the instruments used is employed. Similarly, the Arellano–Bond AR (2) test was applied to test the existence of the first- and second-order serial correlation in the first-difference residuals. First differences of the exogenous variables are used as standard instruments as in Roodman.3 The results are shown in Tables To observe the influence of the independent variables on BOR and increase the robustness of the empirical results, the independent variables were introduced into the regressions as shown in models (i) to (vi) above following the practice as used by Fan et al.3.1In models (i) to (iii), we examine the impacts of the lagged BOR and ALOS in all 3 of them, and the control variables of log of BED, log of ADM, and log of PD separately in each of them to avoid collinearity problems. The Arellano–Bond test indicates that the error terms in all regressions are significant at the first-order, and are serially correlated at the 1% level, but not at the second-order level. Therefore, the above assumption of the system GMM is satisfied. The Hansen test shows that there is no overidentification problem of instrumental variables in all regressions. This implies that the instrumental variables are valid and effective, and thus the estimated results are credible. All coefficients in the 6 models are statistically significant. Thus, the empirical analysis is robust, and the selected determinants are pivotal to BOR.3.2 this finding indicates that a reduction in ALOS improves hospital performance. Although thresholds of ALOS vary with different kinds of treatments, it will require a new study to address such variations as the data used here is aggregated at the hospital level.As models (i) to (iii) show, the coefficients of ALOS variable (which vary between −0.01 and −0.03), are negative and statistically significant (1%), which confirms our first hypothesis. This implies that an increase in ALOS will not necessarily lead to an increase in BOR, ceteris paribus. Another possible explanation is that keeping patients longer than clinically necessary to increase BOR may not result in better overall public hospital performance. When ALOS is high, it could mean that patients stay longer in hospitals and the same bed cannot be occupied by fresh patients until they are discharged. Furthermore, the evidence shows that lower ALOS enhances BOR performance. In line with previous studies,As models (iv) to (vi) show, the coefficients of BTR variable (which vary between −0.001 and −0.002) are negative and statistically significant (5%), which confirms our second hypothesis. This implies that an increase in BTR will lower BOR, ceteris paribus. These results show that the raising of BTR, especially involving uncritical treatments, may not lower ALOS  as both variables are inversely correlated with BOR.Hence, ALOS and BTR can both be raised in Malaysian public hospitals to lower BOR. The evidence shows that higher ALOS and BTR enhance BOR performance. A certain threshold of ALOS and BTR may be necessary to establish the optimal BOR of hospital performance. However, such estimations can only be done for the same kind of treatments, which will require a new study as the data used here are aggregated at the hospital level as mentioned above. Such a study would require more direct fieldwork on hospitals, so that a control variable by type of treatment and degree of health danger can be introduced as a control variable.4,39 this exercise went further to analyze the statistical impact of ALOS and BTR, on BOR controlling for BED, ADM, and PD.Based on the panel data of public hospitals in Malaysia during the period 2006 to 2013, and the GMM regressions, this article estimated the influence of ALOS and BTR on BOR as a hospital performance measure. The results show that there is an inverse relationship between ALOS and BOR on the one hand and between BTR and BOR on the other hand. The results are highly significant after controlling for BED, ADM, and PD. Unlike some previous studies that simply presented the 3 measures of performance separately without a statistical link between them, that is BOR, ALOS, and BTR, Both ALOS and BTR influence BOR strongly. That ALOS and BTR can be raised to lower BOR suggests that the measurement of efficiency in public hospitals must address effectiveness rather than simply relying on only financial measures related to costs and profits, which should be used when dealing with profit-oriented organizations. During the study period of 2006 to 2013, a maximum of 132.8% and minimum of 14.7% BOR were recorded, which indicates that both overcapacity and undercapacity have characterized public hospitals in Malaysia. This implies poor planning, which calls for better management of the public hospitals in Malaysia.The results call for a better understanding of the performance of public hospitals, so that its properties as a social good (public good) can reach everyone. However, while the results on ALOS was significant and the coefficient negative in our study of public hospitals, a positive and significant coefficient of ALOS was reported on private hospitals. Thus, it is clear that the management of ALOS in public hospitals may have to address them as created to a social objective without having to comprise on hospital performance (BOR).Another major implication that could be drawn is that the strong inverse relationship between BTR and BOR obtained in this study is also consistent with another finding on private hospitals. Therefore, health care policy-makers should ensure a coordinated action plan toward the promotion of health care facility utilization to enhance overall health care delivery.The evidence provided in this study suggests that targeted efforts at increasing utilization rates of public hospitals can increase their overall performance, which is in sync with a previous study that showed that reducing hospitalization rates leads to an improvement in efficiency.Following the robust findings, this study proposes some policy measures to improve BOR as an indicator of performance in public hospitals. First, efforts must be taken at increasing the utilization of and improvement of coordination of inpatient admissions at public hospitals. Because the allotment of resources, especially the distribution of hospitals, is highly skewed as evident from differences in the capacity and admission by hospital categories, prudent allocation of resources should be followed by governments and other relevant stakeholders. Second, it is advisable to stimulate the utilization of public hospital facilities carefully as raising ALOS in this study shows improvements in BOR. Thus, health care policy-makers should formulate policies targeted at increasing access to care.Like any epistemological assessment this study has limitations. Future research is necessary, so that the results are controlled for best practice hospitalization periods on the basis of degree of criticalness (severity) among the patients admitted. Also, future studies should examine the extent to which public hospital performance is influenced by BTR, and how it mediates the relationship between ALOS and BOR.Our appreciation goes to Dr. Ali Boerhonnoeddin for his unrelenting advice, to University of Malaya for providing the platform to carry out this study. Finally, we wish to thank officials of the Ministry of Health for assisting us in getting the necessary data that helped shape this study.


Schools have become a key figure for the promotion of health and obesityinterventions, bringing the development of critical awareness to theconstruction and promotion of a healthy diet, physical activity, and themonitoring of the nutritional status in childhood and adolescence.To describe a study protocol to evaluate the effectiveness of an interventiondesigned to improve knowledge of food choices in the school environment.This is a cluster-randomized, parallel, two-arm study conducted in publicelementary and middle schools in Brazil. Participants will be children andadolescents between the ages of 5 and 15 years, from both genders. Theinterventions will be focusing on changes in lifestyle, physical activitiesand nutritional education. Intervention activities will occur monthly in theschool’s multimedia room or sports court. The control group arm will receiveusual recommendations by the school. The primary outcome variable will beanthropometric measures, such as body mass index percentiles and levels ofphysical activity by the International Physical Activity Questionnaire.We expect that after the study children will increase the ingestion of freshfood, reduce excessive consumption of sugary and processed foods, and reducethe hours of sedentary activities.The purpose of starting the dietary intervention at this stage of life is todevelop a knowledge that will enable for healthy choices, providingopportunities for a better future for this population. Being an educational environment thatcontributes to build personal values, schools become a key figure for healthpromotion and obesity interventions, bringing the development of critical awarenessto the construction and modification of eating habits.15Nutritional intervention studies have shown a positive effect on preferences forhealthy foods and a decrease in daily consumption of sugary drinks.18 In Brazil, the School HealthProgram is designed to promote the comprehensive health care of public schoolstudents and is structured in four blocks that seek to: assess health conditions;perform actions of prevention and promotion of health conditions; promote continuingeducation for professionals and the young; present evaluation and monitoring ofhealth conditions of the students. The responsibility for planning and carrying outthese actions is upon the primary care health team, and the objective is tointegrate the educational system and the Brazilian Unified Health System(SUS).19 However, thisgovernment action does not have coverage of all schools in the country yet.A number of international agencies, such as the Centers for Disease Control andPrevention (CDC) and the Institute of Medicine (IOM), launched campaigns withguidelines for health promotion in schools aiming to address the epidemic of obesityand its consequences.In order to implement educational interventions in a large scale, it is important toadequately test their effectiveness. It is also important to look for simple andlow-cost alternatives that can reach the largest possible number of schools.Improving the knowledge about food choices may be an important basis for children toacquire and maintain a healthy lifestyle from an early age, and possibly to sustainthese healthy habits in subsequent stages of life.Thus, the purpose of this study protocol is to evaluate the effectiveness of anintervention designed to improve knowledge of food choices in the schoolenvironment.This protocol is reported according to the SPIRIT  statement.This is a cluster-randomized parallel two-arm study conducted in Brazil. Theunits of observation are individual children, and the units of randomizationare schools. Randomization will be performed at the school level to avoidcontamination. After the baseline assessment, enrolled schools arerandomized to one of two study arms: the intervention arm focusing onchanges in lifestyle, and the control group arm, that receives usualrecommendations by the health care team. A summary of the study design,interventions and timelines is shown in 2), and the secondary outcomes are behaviors related tohealthy eating, increased preferences for fruits and vegetables, increasedphysical activity and reduced screen time. The Institutional Research EthicsCommittee approved the protocol for the study, which is registered in theBrazilian Registry of Clinical Trials, Register Number RBR-97bztb, and named“Intervention program for health promotion in schools of public elementaryschool in the state of Rio Grande do Sul: randomized clinical study”. TheUniversal Trial Number of this study is U1111-1155-7731.The primary outcome for the participants is change in body mass index  and post-treatment (month9).2). That will be calculated andnutritional status will be classified, both using the AnthroPlus software, according to the reference of the World HealthOrganization (WHO) 2006/2007.Weighing electronic scales with a maximum capacity of 150 kg and precision of100 g, properly checked for tare weight, will be used for weight measures.The individual will be weighted barefoot and wearing light clothes. Ametallic measuring tape with a capacity of 2 m/0.1 cm, set in an existingflat wall in the room, will be used to measure height, with the individualin the upright position, during maximum inspiration, barefoot and with emptypockets. These data will be used for the following calculation of BMI,obtained by weight, measured in kilograms, divided by the square of theheight, measured in meters ,22 will be used for all ages to classify the level ofphysical activity, in spite of the fact this instrument has being validatedonly for adults and adolescents, since there is not yet a validatedquestionnaire that can suit the needs of this study and adequately classifyphysical activity levels in Brazilian children.International Physical Activity Questionnaire (IPAQ)Screen time refers to the amount of time individuals spend in front oftelevision, video games and computer, and is considered to be a sedentaryactivity. It will be measured by hours per day and number of days in theweek of screen time.23 consisted of knowledge about food and healthyactivities in daily life.The acquisition of knowledge about healthy habits will be evaluated through aquestionnaire validated for age,24 which includes: age;educational attainment of the family head; questions about householdappliances and other family properties; street paving and treated water inthe house.During baseline assessment, parents will be asked about a series ofdemographic data included in the Brazilian Economic Classification Criterionby the Brazilian Association of Research Companies,2on BMI, with a standard deviation of 0.05, statistical power of 90% andalpha error of 0.05. An estimate of mean 19 kg/m2 is used asobtained from our pilot study. A number of 99 participants per group wasestimated using these parameters. To compensate for losses, the sample sizewill be increased by 10%.The sample size was calculated to detect a difference in 0.2 kg/mCollected data will be entered and analyzed using the Statistical Package forSocial Sciences, version 17.0. Quantitative variables will be expressed asmean and standard deviation in the presence of normal distribution or medianand interquartile range in the presence of asymmetric distribution.Qualitative variables are expressed as absolute and relativefrequencies.Adjusted analysis for primary and secondary outcomes will be performed usinggeneralized estimating equations (GEE). The comparison between secondaryoutcomes will be performed using the nonparametric Wilcoxon test.The level of significance for all tests will be 95% (α = 0.05) andwill follow the intention to treat principle. P-values will be reported upto three decimal places with p-values < 0.005 reported as p < 0.005.The outcomes will be evaluated by a blind adjudicator.25nutrition graduate students and health professional contributors employed bythe City Hall . Allinterventionists will undergo extensive training on: intervention protocol;overall intervention objectives, content and format; and specificinstructions for each intervention session.The interventions in this study will be delivered by the nutritionists of theChildren and Adolescents Cardiovascular Prevention Group(PREVINA),Intervention activities will occur monthly in the school multimedia room orsports court . AllactParticipants randomized to the control group will not receive any guidanceduring the study. Children will receive the usual care and recommendationsthrough the school and health authorities.Should the intervention prove to be effective, at the end of the study, theinstitutions allocated to the control group will receive all interventionactivities if they wish.26 Inspite of the need for individual approaches for children who are already overweightor obese, the international consensus is that prevention is the most realisticapproach and the best value for money.27 It is therefore necessary to develop preventive interventionsthat can reach a larger number of children.This randomized clinical trial is intended to help filling a gap in the literatureregarding simple, low-cost and effective interventions to deal with the epidemic ofobesity and overweight in developing countries. Numerous studies show thatoverweight and obesity rates in the young in Latin America bring important economicand health consequences.Facilitators and barriers for the development of healthy habits should be consideredwhen designing a childhood overweight program. Adaptation to local culture andreality should also be a concern. One of the most important challenges of this studywill be changing the approach to nutrition and physical activity. On that account,we designed interventions that include parents, teachers and students aimed atcreating a positive impact on the health of children and adolescents.The young need appropriate information to make healthy choices and change theirsedentary behavior, but their parents and teachers are not always prepared to givethat information. Therefore, involvement of trained health professionals specializedin the field is necessary in order to adequately provide that information. Giventhat children are exposed to the environment we create for them and that in Brazilthey usually spend about 25 hours a week in school, it is important to designactions that seek to improve the school environment and create a healthy growthstrategy.The study also has some limitations, that must be addressed in future work. First,there is a possibility of cross-contamination of participants in the twointervention arms, since both interventions are delivered in a small city. Second,the trial does not evaluate the pubertal maturation, whose changes may impact on thebody composition in childhood and early adolescence, such as weight gain in girlsand a decline of body fat in pubertal boys.In conclusion, we have described the basic rationale and design of the ongoingHealthy School, Happy School cluster-randomized trial. The study intervention aimsto increase the ingestion of fresh food, reduce excessive consumption of sugary andprocessed foods, and reduce the hours of sedentary activities. The purpose ofstarting the dietary intervention at this stage of life is to develop a knowledgethat will enable for healthy choices, providing opportunities for a better futurefor this population.


The newborn infant with atypical genitalia presents a challenging clinical scenario and requires expert input. There have been appreciable advances in our knowledge of the underlying causes that may lead to a mere difference or a more serious disorder of sex development (DSD), the natural history of conditions, as well as the short and long-term complications of these conditions themselves, together with the clinical interventions that are associated with these conditions. With this information, the DSD expert can be more confident when discussing options with the parents of the newborn infant. By working within a multidisciplinary team, the expert should be able to support the family whilst individualising the management plan so that it is also cognizant of the shifts in societal attitudes and expectations around concepts of diversity and openness. It is, therefore, likely that the practice of assigning sex, especially in those cases where sex assignment is unclear on expert assessment, will continue to show temporal, social and geographical variations. It is imperative that clinical data for rare conditions such as these are collected in a standardized format and shared through a common registry so that any evidence that is used for future shifts in practice has a stronger foundation than that which is currently available. When sex development is affected in early life, the involved infant often presents with atypical genita-lia in the neonatal period. This presentation raises the possibility of a disorder of sex development (DSD) . The undSex development is a process that can be broadly divided into the development of the gonads and the development of the reproductive organs and the genitalia. This process is under the control of molecular networks of male- and female-specific gene expression, dosing and interaction . Presenc “DSD” is an umbrella term for a group of conditions that arise due to a biological variation in chromosomal, gonadal, or anatomic sex. The current classification of DSD in three subgroups, sex chromosome DSD, 46, XX DSD, and 46,XY DSD, was recommended by the international consensus group on management of intersex disorders in Chicago in 2005 . These dThe first step in sexual differentiation is the activation of the SRY gene to trigger testicular development at 7-8 weeks of fetal development. When there is a mutation or deletion of SRY, or one of the early downstream genes in gonadal differentiation, then the gonads fail to mature into either ovary or testis and become nonfunctional streak gonads. Failure of testicular development leads to absent male hormones required for masculinization of both internal and external genitalia. This leads to regression of the Wölffian duct and preservation of the Müllerian duct. The external genitalia continue on the female developmental pathway, leading to a normal external female phenotype at birth. Whilst the vagina and uterus form normally in the absence of AMH, the formation of functioning ovaries requires the activation of critical ovarian development genes.In females with non-disjunction of the sex chromosomes, leading to the 45, X genotype (Turner syndrome), the primitive germ cells are displaced from the caudal yolk-sac into the indifferent gonad. Therefore absence of the second X chromosome leads to abnormal development of the follicles. This in turn leads to premature senescence in early childhood. The germ cells undergo premature death, sometime between late foetal life and the first few years after birth. Early biopsy of the gonad, at birth or shortly afterwards, may show some primary follicles which degrade over the next few years. As a result, for patients with 45, X/46, XX mosaicism ovarian function may be occasionally sustained until later in life. In some rare forms of abnormal sex determination, there is complete sex reversal, with XY females or XX males. In the latter case, the common cause is translocation of a small segment of the Y chromosome, which includes the SRY gene, onto the X chromosome, usually at Xp11 .3. Currently this is identified by fluorescent in situ hybridisation with a marker for the SRY gene  who had a very low external masculinization score were raised as a girl, more recently, these infants are more likely to be raised as a boy . Whilst The birth of a child with suspected DSD is a challenging situation for parents and health professionals . In manySociety often plays a major role in the decision for sex assignment and the sex of rearing decision is often considered to be the parents’ right, obligation and responsibility. Strong social pressures influenced by cultural, traditional and economic factors persist in some social groups, where the male may have a dominant role in financial and social life. In such communities where a man is the traditional breadwinner, choosing the male gender is often considered to be more preferable for the affected offspring than the individual’s sexual potential ,16,17. TIt is not unusual that adults with DSD experience discontent with the assigned sex. This may be attributed to several reasons including medical interventions such as surgery or hormone replacement therapy, impact of delayed or precocious development, experience of stigmatization or psychological trauma, social expectation of gender role behavior and other coexisting mental health conditions. Some studies found that girls with CAH show masculinization of behavior, such as spatial orientation, visualization, targeting, personality, cognitive abilities, and sexuality ,22,23. ODue to an androgen biosynthesis problem, children with 46,XY who have 5a reductase-type 2 deficiency or 17b-hydroxysteroid dehydrogenase-type 3 deficiency are usually born with female-appearing or ambiguous genitalia. In general, these infants are raised as girls and at puberty, when they start to masculinize, transition to the male role has been described . An incrIn Complete Androgen Insensitivity syndrome (CAIS) the complete female appearance at birth usually masks the condition completely and the infants are raised without any doubt as girls. These children display typical girl behavior and female gender development, with no signs of gender dysphoria ,34. HoweMany affected children with DSD undergo feminizing or masculinizing genitoplasties as well as gonadectomies. There are several reasons for these surgeries including aligning a child’s phenotype more closely with their sex of rearing, determining future fertility potential, and removing the risk of malignancy . In thosRecent investigations of outcomes of gonadectomy and vaginoplasty in girls and women affected by CAIS range from satisfaction with surgery ,41 to prMasculinizing surgeries for DSD include release of ventral chordee, hypospadias repair, gonadectomies and placement of prosthetic testes in the scrotum at puberty. Many studies have found that men with hypospadias repair in childhood still report at least some degree of dissatisfaction with their genital appearance and size, which may lead to psychosexual distress and jeopardize sexual well-being . In 46 XDifferences in DSD management will result from a combination of traditional beliefs, folk remedies and prejudices, fed by rumour and discrimination and available healthcare resources and expertise . NeverthFinally, healthcare workers should share expertise and collaborate globally in prospective studies as it is essential to gain insight into the outcome of individuals affected by these rare conditions. The variations in practice can be decreased through networks of clinical and research centers. Disease registries are playing a significant role in development and improvement of networks. Establishment of the DSD registry in 2007, initially as the ESPE DSD Registry, followed by the Euro-DSD Registry and currently as the I-DSD Registry, is a perfect example of how registries can evolve and also be used to address issues ranging from fundamental mechanisms to clinical practice and health care outcomes . It is l


The characteristics of carbon fibre reinforced laminates have widened their use from aerospace to domestic appliances, and new possibilities for their usage emerge almost daily. In many of the possible applications, the laminates need to be drilled for assembly purposes. It is known that a drilling process that reduces the drill thrust force can decrease the risk of delamination. In this work, damage assessment methods based on data extracted from radiographic images are compared and correlated with mechanical test results—bearing test and delamination onset test—and analytical models. The results demonstrate the importance of an adequate selection of drilling tools and machining parameters to extend the life cycle of these laminates as a consequence of enhanced reliability. Their ability to be tailored for use and endless possibilities provided by the combination of reinforcements together with their alignment and fiber fraction, allow design engineers to have almost total freedom in the design of new parts. Unique properties such as low weight, high strength and stiffness are normally referred to whenever the advantages of these materials are listed. Nevertheless, some problematical issues remain concerning the use of composite laminates, thus providing arguments for the selection of conventional materials instead of composites, mainly in structural parts. Some of these issues are cost-related, but considerations about reliability or fatigue resistance also cause some difficulties for a wider usage of these materials.However, the importance of composite materials has been growing steadily over the last decade, which can be confirmed by their intensive use in the new Airbus A380 or Boeing 787 airplanes. In the latter, 50% of the weight of its primary structure will be made of composite materials , an unprTaking the main problematic issues related to laminate parts into account, it is possible to find different arguments for the selection of conventional materials. One of them is associated with the relative complexity and cost of the production process. In the later stage of parts production, machining operations like drilling are frequently needed in composite structures, as the use of bolts, rivets or screws is required to join the parts. Generally, machined parts have poor surface appearance and tool wear is higher. One of the problems related with composites’ machining is the nature of the fibre reinforcement, which is usually very abrasive and causes rapid tool wear and deterioration of the machined surfaces . As earlet al. ..26].The final goal of the image processing and analysis performed was to automatically measure the damaged diameters and areas in each radiographic image. This was achieved by using in the image segmentation step a neuronal network with 1 input layer with 3 neurons, 1 hidden layer with 7 neurons , 1 outpuFd, [Fda, [The values obtained from the radiography images can be used to determine the delamination factor, Fd, , the DamFd, , and thed, [Fda, , accordiSo, taking advantage of the computational techniques of imaging processing and analysis, the adjusted delamination factor was used in this work for damage assessment.4.3.In all the tests performed in this work, a Shimadzu AG-X/100 kN Universal Testing machine  equipped with a Trapezium X software for data registration was used.Ic.The DCB tests according to ASTM D5528 -13  were car2 were cut and drilled under the same experimental conditions.The mechanical test carried out to assess the damage effects on plate resistance in the area of the mechanical joint was the “Bearing test” according to ASTM D5961M-10 . This teet al. [Finally, for the delamination onset test, a device based on the work of Lachaud et al.  was desiet al. . To carr5.Carbon fiber reinforced laminates were drilled with the objective of comparing the performance of three different tool geometries regarding the bearing stress and delamination onset load. Relevant results considered for assessment were the delamination extension and the mechanical strength by the bearing stress test and delamination onset test. A batch of plates was prepared to perform DCB tests. According to the experimental findings, it was possible to make the following conclusions:As expected, when dealing with composite materials, some dispersion on the results was found;The results of the DCB test to determine the interlaminar fracture toughness were within the predicted values;The synchronization system developed for the DCB test allows for an easy trace of the load-displacement curve and crack opening measurement, reducing error hazard;The feed rate influence is well known and the results confirmed that higher feeds correspond to higher delamination extension and lower values of bearing resistance. So, in conventional drilling, the feed rates should be kept as conservative as possible;In the delamination onset test, as the uncut thickness increases, the delamination onset load also increases. This was an expected outcome.Also in the delamination onset test, as testing speed increases, the delamination onset result tends to decrease. For this test, there is a need to establish a standardized speed and to enhance the procedure for test results robustness:The influence of the punch geometry (drill) has to be thoroughly investigated as no clear trend was found.In future works, the effect of alternative stacking sequences, like cross-ply or quasi-isotropic, deserve some attention.Future development of the present work will have the purpose of adding analytic and FEM models for the simulation of drilling with delamination onset determination.