This paper provides a perspective on epidemiological research on radiation and cancer, a field that has evolved over its six decade history. The review covers the current framework for assessing radiation risk and persistent questions about the details of these risks: is there a threshold and more generally, what is the shape of the dose-response relationship? How do risks vary over time and with age? What factors modify the risk of radiation? The example of radon progeny and lung cancer is considered as a case study, illustrating the modeling of epidemiological data to derive quantitative models and the coherence of the epidemiological and biological evidence. Finally, the manuscript considers the need for ongoing research, even in the face of research over a 60-year span. Ionizing radiation was discovered in 1895 by Wilhelm Conrad Roentgen, and its utility for diagnostic purposes was quickly recognized. By 1902, the first radiation-caused skin cancer was identified and the first radiation-caused leukemia case followed in 1911. Several clusters of radiation-caused cancer were described over the ensuing decades: radon and lung cancer in underground metal miners in eastern Europe, and osteogenic sarcoma in radium dial painters. In 1944, based on more formal epidemiological inquiry, an excess of leukemia was reported among radiologists in the United States [Radiation epidemiology was launched when a program of studies was initiated by the then Atomic Bomb Casualty Commission  to determine the consequences of radiation exposure from the nuclear blasts at Hiroshima and Nagasaki ,4. A larRisk Assessment in the Federal Government: Managing the Process (widely referred to as the "red book") set out four elements of risk assessment: hazard identification (is there a problem?), dose-response assessment (how does risk vary with dose or exposure?), exposure assessment (what is the population's pattern of exposure?), and risk characterization (what is the magnitude of the problem and what are the key uncertainties in that understanding?) [Radiation exposures are ubiquitous, coming from medical and industrial applications and from naturally occurring sources. Exposures are regulated through an evidence-based approach that is used to characterize risks, drawing primarily on the epidemiological evidence Figure . Risk asanding?) . Many suanding?) .Risk assessment has become fundamental to strategies for limiting cancer risks associated with radiation exposures. There is a need to minimize risk at the population level and to assure that risks to individuals do not reach unacceptable levels, particularly for workplace exposures. Determination of the acceptability of risk requires an assessment of the magnitude of risk and a societal judgment as to acceptability of the estimated risk . We are For ionizing radiation, the principal uncertainty at present lies in the form of the dose-response relationship. There is no doubt as to the existence of a hazard and exposures are known with reasonable accuracy. However, at "low levels" uncertainty persists as to whether the dose-response relationship is linear and whether there is a dose threshold, below which there is no risk. Some have proposed that "low" exposures to radiation may be beneficial, a hypothesis referred to as "hormesis" . This coRadon, a noble gas resulting from the decay of naturally occurring uranium-238, has been extensively studied using epidemiological methods, initially to characterize the risks faced by radon-exposed underground miners so as to promulgate protective standards and subsequently to estimate the risks of radon exposure in homes so as to develop guidelines for acceptable indoor concentrations . The halRadon, the first occupational respiratory carcinogen to be identified, is an alpha-emitter that decays with a half-life of 3.5 days to a short-lived series of progeny . SeveralWhen the evidence on radon and cancer is considered within a causal assessment framework, the evidence was sufficient to identify radon as causally associated with lung cancer by the 1960s. By then, the substantial excess of lung cancer in radon-exposed Eastern European miners had been documented and the findings of several, more formal epidemiological studies of underground miners had been published, most notably the study of Colorado Plateau uranium miners in the United States . AdditioThe resulting epidemiological data were sufficiently robust to support analyses to develop epidemiologically-based risk models. As the epidemiological data strengthened, the models moved from being based in single studies to pooled data from multiple studies  IV and BEIR VI reports of the US National Research Council ,15). TheMost analyses were based on a linear excess relative risk (ERR) model:RR = 1 + ßw or ERR = ßw,where RR is relative risk, ß is a parameter measuring the unit increase in ERR per unit increase in w, and w is cumulative exposure to radon progeny. As in the BEIR IV analysis, ERR was linearly related to cumulative exposure to radon progeny without threshold. The ERR per unit exposure varied significantly with other factors; it decreased with attained age, time since exposure, and time after cessation of exposure but was not affected significantly by age at first exposure. Synergism with tobacco smoking was documented in analyses of data from the cohorts with smoking information available, but the interaction was submultiplicative. Over a wide range of total cumulative exposures to radon progeny, lung cancer risk increased as exposure rate declined, supporting the prior hypothesis of an inverse dose-rate effect . The invBecause the first estimates of the lung cancer risk associated with indoor radon were based on the epidemiological studies of miners, the attendant uncertainties motivated epidemiological studies of radon and lung cancer in the general population. The initial studies were ecological and inherently limited such that multiple case-control studies were initiated subsequently. One ecological study, however, merits consideration because its findings were considered by some as countering the linear no-threshold models that had been applied to the miner data. The US ecological study carried out and extended periodically by Cohen ,19 was wCohen continued to publish ecological analyses on radon and lung cancer, using multivariate models with multiple factors in an attempt to control confounding . An analThe initial wave of ecological studies was soon supplanted by case-control studies of lung cancer carried out in the general population to directly estimate the risk. The principal methodological problem in these studies was estimating domestic radon exposure during the relevant time span, possibly extending across the full lifespan. In some early studies, exposures were indirectly estimated based on surrogates such as type of residential construction or residence location . In the et al. in 1990 [As the initial findings were reported and new studies were initiated, potential limitations of the individual studies were reported. A need for pooling of study results was predicted based on sample size calculations published by Lubin  in 1990 . The sam in 1990  confirme-3 increment in the concentration at which exposure occurs in a home. The estimate from the pooling of 13 European studies involving 7,148 cases and 14,208 controls was similar: an increment of 8% (95% CI 3-16%) per 100 Bq m-3 increment in home concentration was estimated. The estimates from the two pooled analyses are comparable and are close to estimates projected models based in the data from underground miners. There was no indication that the risk of radon varied across a number of potential modifiers, such as age and smoking , remediation of their homes to eliminate radon may lead to a substantial increase in their lung cancer risk!”[Thus, the evidence on radon and lung cancer risk is substantial and coherent and indoor radon is widely considered to be carcinogenic. Nonetheless, some remain skeptical, perhaps primarily because of the adoption of a no-threshold relationship between lung cancer risk and radon exposure. Critics of this model and of radon control initiatives have turned to the results of one recent study as providing countering evidence. In a case-control study in Massachusetts, Thompson and colleagues  estimateer risk!”.The example of radon and lung cancer provides a number of "lessons learned" concerning the use of epidemiological evidence to control cancer. First, the identification of unacceptable levels of lung cancer risk was readily identified in single cohorts of highly exposed underground miners. Second, as exposures came under control, there was a need to characterize the exposure-response relationship so as to set workplace standards with an acceptable level of risk. The individual studies did not provide a robust data base for this purpose, but the pooled data bases did. Third, as for other exposures, extrapolations of the exposure-response relationship observed in underground miners to the general population were subject to substantial uncertainty and that uncertainty entered into policy discussions. Fourth, the prospective plan for pooling of the indoor radon studies led to the most informative data base possible from the diverse under-powered studies that were implemented. Fifth, integrative syntheses of epidemiological evidence with other research findings, as carried out by the BEIR Committees, are critical for robust interpretation of epidemiological evidence. Sixth, even very strong evidence and scientific consensus may not quiet all critics, particularly those motivated by the policy implications of the scientific evidence. In the example of radon, critics continued to claim that uncertainties abound, even as the evidence became firmer .Turning to radiation generally, a century after we learned that radiation can cause cancer and with a half-century of accumulated observational evidence on the risks of radiation, why is more research needed? Two main reasons can be cited: 1) the need for an ever stronger base of evidence on the risks of radiation to protect the public and workers from unnecessary risk of cancer; and 2) the exposure of the population to new forms of radiation for which information on risks is still uncertain. Additionally, the emergence of genomics offers the possibility of identifying genetic determinants of risk, leading to the prospect of identifying those at high risk for cancer caused by therapeutic irradiation. Additionally, debate about the nature of the cancer risk associated with radiation has become almost ideological on some matters, such as the nature of the dose-response relationship, and further evidence may help to bring this distracting debate to a close.Radiology is illustrative. Little and colleagues [The "low-dose" controversy persists and will likely remain, absent a new level of mechanistic understanding that identifies the biophysical process underlying radiation carcinogenesis with even greater certainty. Even for radon progeny for which a high level of certainty on the mechanism of DNA damage by alpha particles has been reached, there is still debate on risks at lower levels. A recent point-counterpoint in lleagues , under tlleagues . Tubianalleagues  in theirFurther epidemiological research is unlikely to bring this now-lengthy discussion to closure. At lower doses, even large data sets are not informative as to alternative forms of the exposure-response relationship. Additionally, as the range of evidence extends to lower doses, critics will likely continue to claim uncertainty, but at ever lower doses. The combination of more robust epidemiological evidence and deepening mechanistic understanding may eventually silence critics, as has apparently occurred with radon.The more recent debate concerning potential risks of high frequency electromagnetic radiation from cell phones illustrates another need for further research: the emergence of a nearly ubiquitous exposure with uncertain consequences. Cell phone ownership has surged over the last 20 years, with worldwide penetration. As the technology and making calls have become cheaper, usage has surged. Children now have cell phones from an early age and ever-increasing amounts of time are spent using them. Public concern about the possibility of carcinogenesis by electromagnetic radiation generally, like that emitted by cell phones is not new -39. FromNew England Journal of Medicine[Even in the 1990s, although exposures of users were of relatively brief duration, epidemiological studies were initiated. The case-control design was used to compare cell phone use of people with brain cancer with use by controls. Inskip and colleagues, for example, at the U.S. National Cancer Institute carried out a multi-site case-control study that was reported in the  Medicine. The Int Medicine. The ove Medicine, althoug Medicine, Denmark Medicine, Germany Medicine, the U.K Medicine, and Nor Medicine). The fi Medicine,48.Further research is also needed because of the potential for "surprises". For example, the Chernobyl disaster was shortly followed by an epidemic of thyroid cancer among children, an epidemic that was not anticipated based on then extent epidemiological data and knowledge of the radionuclides to which the children were exposed . ChanginFinally, there is the major scientific opportunity for identifying genes that increase risk for radiation carcinogenesis. Investigation of gene X environment interaction is a burgeoning area of research. Compared with some other environmental agents to which the public is broadly exposed, radiation exposure is measured more feasibly and with greater accuracy. Studies of therapeutic exposures have the strength of a precisely administered and recorded dose. The BEIR VII report, the last review by the US National Research Council, pointed to genetics as an area for further research .Looking ahead, consideration needs to be given to the best models for carrying out radiation epidemiology research. The research is inherently multidisciplinary, drawing on the expertise not only of epidemiologists, but biostatisticians and risk assessors, health physicists, and radiation biologists. Studies on the genetic basis of susceptibility need additional expertise in genetic epidemiology and genomics. Epidemiological research on radiation risks is centralized in a small number of centers worldwide, including the Radiation Epidemiology Branch of the US National Cancer Institute, the Radiation Effect Research Foundation, and IARC, and several universities. The field needs to be maintained and strengthened and transitioned beyond an emphasis on quantification of risk to integration of genetics in the search for genes affecting cancer risk associated with radiation. Epigenetic approaches may also prove useful. Surveillance approaches based in administrative systems are also needed to track the consequences of changing patterns of exposure to medical radiation.While the identification of cigarette smoking as a cause of lung cancer is touted as one of the key, early successes of epidemiological research, cohort studies were documenting the risk of cancer associated with radiation during the same decades--the 1950s and 1060s. The need to move quickly from hazard identification to dose-response assessment to support radiation standards development motivated the application of quantitative models to the epidemiological data. The data from the LifeSpan Study of Atomic Bomb Survivors provided an early opportunity for dose-response modeling and the exploration of dose-response relationships over time.The example of radiation points to one potential failing of the IARC Monograph series for control of environmental carcinogens: the purpose is to assess carcinogenicity and classify the strength of evidence for causation, and not to quantify risk associated with a carcinogen. However, regulation of many carcinogens is increasingly based in quantitative risk models. This restriction of the IARC approach is well recognized, as are the consequences. A move to developing risk models would necessitate a different approach by IARC, and possibly the addition of a group within the Agency that could carry out the modeling. If IARC were to move in this direction, building on the legacy of Lorenzo Tomatis, radiation would be the right starting point.The author declare no competing financial or non-financial interests.


Globally, mental health promotion related to psychological distress in the workplace has become a great concern, and a focus of much research attention. However, a sense of contribution to society and sense of bonding with the workplace have not been examined in relation to psychological distress. Thus, the purpose of this study is to examine whether these two factors are associated with psychological distress.We conducted a cross-sectional survey of 1137 full-time employees who worked in systems engineering, sales, or administration at a Japanese company. Participant's sense of contribution to society, sense of bonding with the workplace, psychological distress, and qualitative job stress  were assessed with a questionnaire. We performed multiple logistic regression analyses to examine associations between psychological distress and sense of contribution to society and of bonding with the workplace.A high sense of contribution to society was significantly associated with a high sense of bonding with the workplace . A sense of contribution to society was negatively associated with psychological distress after adjusting for job stress factors  or sociodemographic characteristics of participants . After adjusting for job stress factors as well as sociodemographic characteristics, the association became weaker. A sense of bonding with the workplace was negatively associated with psychological distress after adjusting for sociodemographic characteristics . However, this association was not observed after adjusting for job stress factors.Psychological distress in the workplace was associated with sense of contribution to society. Therefore, workplace mental health promotion should consider the workers' sense of contribution to society. Globally, mental health promotion related to psychological distress in the workplace has become a great concern. In Japan, there is evidence that mental illness in the workplace is increasing . The ILOPsychological distress is often expressed as depression, which is the most common mental illness in the workplace . In receJob stress is considered to be related to various factors, including control latitude and quantitative workload ,8. KarasPsychological wellbeing is predicted by meaningful work . Jahoda An annual questionnaire-based survey of business enterprises regarding the mental health of their employees' revealed the following characteristics of the current circumstances of the Japanese workplace : traininIn modern society, workplace stress factors have become more complex ,2. It isThe participants of this study were full-time employees in three major offices of a Japanese company located in Tokyo, Nagoya and Osaka. This company has three departments: systems engineering, sales, and administration. We conducted a questionnaire-based survey using the company intranet from November 18 to December 14, 2009. A total of 1137 employees between 20 and 59 years old were invited to participate, and responses were received from 1002, a response rate of 88.1%. Of the 1002 respondents, 937 (93.5%) had complete data. Incomplete data appeared to be due to random error.The questionnaire included items assessing sense of contribution to society and sense of bonding with the workplace, as well as measures of psychological distress, job stress factors, and the sociodemographic characteristics of participants. Sense of contribution to society and sense of bonding with the workplace were assessed using the following questions: "Have you ever felt your job contributed to society?" and "Have you ever felt a sense of bonding with your workplace?" Each of the questions was answered on a four-point scale: Always, Often, Rarely, Never.Severity of psychological distress was assessed using a translated Japanese version of the Kessler Psychological Distress Scale (K10) -19. In tTo assess job stress factors we used the Japanese Brief Job Stress Questionnaire, which consists of 57 items in 6 domains: quantitative and qualitative workload, job-control latitude, and support from supervisors, co-workers and family . The Japχ2 tests. We performed multiple logistic regression analyses to examine the associations between psychological distress and sense of contribution to society and sense of bonding with the workplace. First, these associations were analysed without adjustment for other variables (model 1). Then, we analysed the associations with adjustment for job stress factors (model 2) or sociodemographic characteristics (model 3). Finally, we analysed the associations with adjustment for job stress factors and sociodemographic characteristics (model 4). Finally, we constructed a model with both sense of contribution to society and sense of bonding with the workplace as explanatory variables. Trends in the odds ratios for sense of contribution to society and sense of bonding with the workplace were tested using constrained linear models [The associations between sense of contribution to society, sense of bonding with the workplace, job stress factors, and sociodemographic characteristics were tested using Spearman's rank-order correlation analyses or Pearson's r models . All anaThis study was approved by the ethics committee of Akita University Graduate School of Medicine in July 2009. We had the cooperation of the company in this study and obtained written informed consent from the participants.The characteristics of the participants are shown in Table χ2 test p < 0.001, other variables Spearman's ρ = 0.07 to 0.23). Sense of bonding with the workplace was significantly, positively associated with age group, job position, support from supervisors, support from co-workers, support from family, and job control latitude . Sense of bonding with the workplace significantly differed by each department. The sum totals of "Always" and "Often" were 56.1% for systems engineers, 65.3% for sales staff, and 66.9% for administration staff.Table Table Trends on the odds ratios were found for sense of contribution to society (p = 0.01), and sense of bonding with the workplace (p = 0.04) in model 1; in model 2 ; in model 3  and in model 4 . Although the associations between having a sense of social contribution and psychological distress after adjustment for job stress factors (models 2 and 4) weakened, they showed a similar tendency as the results of models 1 and 3, as shown in Table Table Our results indicate that a sense of contribution to society is an explanatory factor relevant to psychological distress that is independent of existing job stress factors. The perceived level of contribution to society was significantly associated with psychological distress, even after adjustment for sociodemographic characteristics or job stress factors. The association was attenuated when both sociodemographic and job stress factors were included simultaneously in a logistic regression model, but the tendency remained. A low sense of bonding with the workplace was also associated with psychological distress after adjustment for sociodemographic characteristics, but no association was found after adjustment for job stress factors. When both sense of contribution to society and sense of bonding with the workplace were entered simultaneously into a logistic regression model, only sense of contribution to society was significantly associated with psychological distress.The association between sense of bonding with workplace and psychological distress disappeared after adjusting for job stress factors. This indicates that the association was confounded by the effects of job stress factors. It is possible that stressful work environments contribute to both a low sense of bonding with workplace and high psychological distress.The significant associations between sense of contribution to society and job stress factors suggest that they are related. However, our results indicate that these factors are independently associated with psychological distress.To our knowledge, in conventional work stress models, a sense of contribution to society has not been considered as a factor affecting worker's mental health. Based on our findings, we suggest that a sense of contribution to society is a factor worthy of consideration in the promotion of mental health in the workplace. As a management strategy, a company demonstrates its business meaning to society as "the company vision" to motivate and encourage employees to do their job. The theory of business management for motivating an individual  or the mThe sharing of a sense of contribution to society among employees may help to improve their mental health. Shared values in the workplace are similar to the concept of social capital that has been reported in association with mental health of local residents or in workplaces ,30. In sIn this study, we used the K10 to measure psychological distress. Untreated psychological distress may lead to premature morbidity and mortality . The assIn this study, having a higher sense of contribution to society was significantly associated with age group as well as job position. This suggests that a deep involvement in a person's task through practical business experience or management experience leads to a high sense of contribution to society. We did not investigate the way that employees acquire a sense of contribution to society, or whether it was promoted by the corporation. An alternative explanation is that scores on the sense of contribution to society could be considered a reflection of one's self-justification to continue to engage in current tasks, or could be related to a sense of meaninglessness with their task because of psychological distress. These perspectives need to be examined in future investigations.The response rate in this study was relatively high (88.1%). Differences in response rates by location and department were not observed . Therefore, minimal bias was likely to be introduced through non-response. However, several study limitations need to be considered. Firstly, the sense of contribution to society and sense of bonding with the workplace were assessed with only one question each. Additional research is required to validate the accuracy of these measures, but here we have confirmed their relevance. Secondly, this study was conducted within only one company with a cross-sectional design. The prevalence of psychological distress in this study is higher than that reported by previous research of employees in Japan  or in otPsychological distress in the workplace was found to be associated with sense of contribution to society. It seems that sense of contribution to society is a factor to be taken into consideration in mental health promotion in the workplace.The authors declare that they have no competing interests.KO, YM, and YK made substantial contributions to the conception and design of the study and were involved in drafting and reviewing the manuscript. KO and YK contributed to the data acquisition process. KO, YM, YK, and KF contributed to the analysis and interpretation of the data. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/253/prepub


A Common Denominator: Calculating Hospitalization Rates for Ambulatory Care–Sensitive Conditions in California by Camillia K. Lui and Steven P. Wallace is the winner of the first annual Preventing Chronic Disease (PCD) Student Research Contest. Ms Lui is a fourth-year doctoral student at the University of California, Los Angeles, in the Department of Community Health Sciences. Her advisor is Dr Steven Wallace.I am pleased to announce that Student Research Contest as a way to engage students in the publication process and recognize the outstanding work of the next generation of the public health workforce. In July 2010, we announced our first annual call for student papers and reached out to multiple partners to distribute the call and encourage students to submit their work to PCD.PCD is dedicated to being the venue for sharing advances in public health research, practice, and policy, and we are committed to the development of young public health professionals as part of this effort. To this end, we have instituted the PCD’s founding editor (Dr Lynne Wilcox), and I reviewed the submitted manuscripts. In March we selected the paper by Ms Lui and Dr Wallace as the winner.Papers were due in January 2011, and we received submissions on a range of topics from institutions throughout the United States. In February and March, a small team of editorial board members , www.chis.ucla.edu/) and hospital patient discharge files of the California Office of Statewide Health Planning and Development (www.oshpd.ca.gov/). This analysis is important to health care resource planning because it uses the population at risk rather than the total population in calculating hospitalization rates.Lui and Wallace examined the prevalence, hospitalization rates, and geographic variability of hypertension and congestive heart failure, 2 chronic health conditions that are considered to be manageable with effective outpatient treatment , in California. Their analysis makes use of 2 large datasets, the California Health Interview Survey (With these 2 common conditions, 2 different scenarios emerged. In the case of hypertension, approximately 74% of the geographic areas did not change in ranked quintile when comparing age and age/disease prevalence rates, which suggests that resources are meeting the needs of the at-risk population. However, in the case of congestive heart failure, 31 of the 55 geographic areas in California changed quintile rank — approximately 72% by 2 or more ranks. In this case, the geographic distribution of the population at risk does not mirror that of the general population. This finding has implications for planning and targeting public health programs and health care services in areas where the population at risk resides.As with any analysis that uses administrative and self-reported data, this study has limitations, and the results do not identify the one area that should be changed to inform policy and programs to reduce health care spending and rates of illness and death. This analysis is thoughtful and identifies several issues that need further investigation. What are the reasons for increased rates of age/risk-adjusted hospitalizations in some geographic areas? Are these observed differences a function of demographic, economic, geographic, or access factors? What are the interventions needed to ensure that people receive adequate and appropriate care? This analysis demonstrates the need to consider disease prevalence when examining hospitalization rates and that, depending on the condition, resources may need to be redistributed.Congratulations to Ms Lui on winning the first annual PCD Student Research Contest. Several outstanding papers were submitted, and the decision was not an easy one. We thank all of the students who submitted papers for this contest and recognize the hard work that goes into publishing scientific work. Please listen to the short podcast with Ms Lui to hear her discuss her article. Manuscripts for the second annual PCD Student Research Contest are now being accepted, and the winning manuscript will be published in 2012.


Objectives: Placing implants in the posterior maxillary area has the drawback of working with scarce, poor quality bone in a significant percentage of cases. Numerous advanced surgical techniques have been developed to overcome the difficulties associated with these limitations. Subsequent to reports on the elevation of the maxillary sinus through the lateral approach, there were reports on the use of the crestal approach, which is less aggressive but requires a minimal amount of bone. Furthermore, it is more sensitive to operator technique, as the integrity of the sinus membrane is checked indirectly. The aim of this paper is to review the technical literature on minimally invasive sinus lift and compare the advantages of different techniques with Intralift™, a new technique.Study Design: The present study is a review of techniques used to perform minimally invasive sinus lift published in Cochrane, Embase and Medline over the past ten years and the description of the crestal sinus lift technique based on minimally invasive piezosurgery, with the example of a case report.Results: Only eight articles were found on minimally invasive techniques for sinus lift. The main advantage of this new technique, Intralift, is that it does not require a minimum amount of crestal bone . The possibility of damage to the sinus membrane is minimised by using ultrasound based hydrodynamic pressure to lift it, while applying a very non-aggressive crestal approach.Conclusions: We believe that this technique is an advance in the search for less traumatic and aggressive techniques, which is the hallmark of current surgery. Key words: Sinus lift, surgical technique, minimally invasive surgery, ultrasound surgery. An essential condition for success in dental implant treatment is the amount and quality of bone in the area on which we decide to place the implant after careful diagnosis and planning. The posterior area of the upper jaw has anatomical features that make it unique compared to other areas, mainly due to the presence of the maxillary sinus . After tTo overcome this loss of bone height, sinus lift techniques have been used (Boyne and James) , which iAnother step in the search for less invasive techniques was the use of compressive osteotomes (Summers) to lift the sinus membrane with a closed technique using a crestal approach ,7, and aAn important contribution to oral surgery in general and the development of such techniques in particular, was the introduction of piezoelectric surgery. Thus, Torrella et al.  proposedThe aim of this paper is a review of the literature on the Intralift ™ technique, with descriptions and case reports to illustrate and assess this technique. To carry out this review we focused our search on articles published in the last 10 years, indexed in Cochrane, Embase and Medline, using the Pubmed search engine in this last case. The search terms were: sinus lift, maxillary sinus lift, sinus lift technique, minimally invasive sinus lift. We also carried out a manual search of the following journals available in the Health Library of the Faculty of Dentistry (Universidad de Sevilla): The Journal of Craniofacial Surgery, The International Journal of Prosthodontics, Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics, Journal of Oral Maxillofacial Surgery, Implant Dentistry, Journal of Oral Surgery, Dental Clinics of North America, Compendium of Continuing Education in Dentistry, Journal of Esthetic Dentistry, International Journal of Oral and Maxillofacial Implants and Cochrane Database Systematic Review. Regarding the technique presented in this paper, the preparation of the hole to access the floor of the sinus floor is performed at the crest, sequencing the Intralift™ system of pints Fig.  and the At this point it is necessary to follow the manufacturer’s instructions, using the following drill sequences: 1. ‘Pilot drilling’; a conical diamond tip (TKW 1 - Ø 1.35mm) is used in D2 mode, with irrigation of 70-100 ml/min  is used in D2-D3 mode with an irrigation of 70-100 ml/min  is used in a D2-D3 mode with irrigation of 70-100 ml/min  is used in D2-D3 mode with an irrigation of 70-100 ml/min  Fig.  is used.The first 4 drills are only used for widening the preparation, and drill 5 (trumpet) is the only one that really elevates the Schneiderian membrane. As a result of our search we only found eight articles on sinus lift using minimally invasive surgery. All of them have been cited in the literature and included in the discussion to compare these techniques with the one presented. With regard to the clinical application of the technique described in the ‘Material and Method’ section, this is illustrated by the following clinical case.  Case Report We report the case of a female patient aged 48, without any previous history of note. Insertion of an implant in the 2.6 region was indicated to rehabilitate the edentulous space. The bone was 3-4 mm high in this area , to reach the sinus and broaden the preparation . After preparing the hole and detaching the Schneiderian membrane, we put in place the first portion of augmentation material Fig.  using thAfter all the filling material was put in place we used a collagen membrane to cover the hole, prior to the replacement and suturing of the flap Fig. . After sIt is possible to find descriptions of many techniques for sinus lift in atrophic maxillae cases in the literature, and most of them are invasive or aggressive. However, the current trend in medicine, and especially in dentistry, is to promote the use of less invasive techniques . For this reason new sinus lift procedures following this line of thought have been developed and reported. Thus, in 2006, Halpern, Halpern et al.  publisheKfir et al.  proposedIn all these techniques with reduced visibility, the surgeon’s experience is a key factor for successful treatment. Furthermore, careful planning of the intervention and a right selection of each case are essential when carrying out these procedures. What is no longer in doubt, in light of published evidence, is the advantage of minimally invasive surgery . The technique described in this paper has many advantages. Simplifying the procedure by using piezoelectric surgery tips minimises the risk of introducing instruments into the sinus cavity, and by using ultrasound cavitation patient discomfort is reduced, there is no osteotome hammering or lifting of large flaps. The use of ultrasound to perform these surgeries means that we can carry out less traumatic and conservative bone incisions, reducing bleeding and achieving better visibility during surgery. In addition there is a reduction in the risk of perforation of the Schneiderian membrane, since accidental instrument contact with the membrane, as the instruments used are less aggressive than rotary instruments, carries less risk of injury. This problem can be controlled at all times and membrane integrity can be checked using the Valsalva manoeuvre. Even if small perforations are caused, surgery can be completed using a small collagen sponge or collagen membrane to close them. Compared with other techniques which use rotary instruments, and minimally invasive techniques such as Summers’ technique, we think that the Intralift™ technique is safer and poses less risk of tissue injury  Furthermore, by using the cavitation effect there is no need for bone debridement in the surgical site, so there is no risk of bone fragments entering the cavity. This technique proved more effective in achieving greater and more homogeneous membrane elevation. Regeneration material is seen very distal and mesial to the preparation. Furthermore, the incision does not depend on the force exerted by the surgeon, the ultrasound does all the work. While the membrane undergoes tensile forces when the balloon technique or Summers’ technique are used, when the Intralift™ technique is used there is no traction because microcavitation gently detaches the membrane in all directions, not just at a pressure point. Minimum aggression means that there is less postoperative discomfort, reducing the postoperative pain , bleeding and wound infection rates. Therefore we think that the minimally invasive Intralift™ maxillary sinus lift technique described can be an effective minimally invasive alternative for atraumatic elevation of the sinus, and therefore must be considered as a possibility which could replace other more aggressive techniques.However, the lack of comparative clinical trials and the absence of long-term monitoring mean that it is necessary to be cautious and wait for further studies to support the excellent clinical performance seen so far. We also consider that this is an operator sensitive technique and therefore requires a learning curve to achieve its maximum potential and avoid unnecessary damage to patients.


Theresults of this study reinforce the importance ofsocial connectedness in creating and maintainingelder-friendly communities for older adults, as wellas soon-to-be retired individuals, wishing to maintainlife connectedness to their community. The studysuggests the possibility of using more nontraditionalresearch techniques (such as the World Caféprocess) for gathering community level data.The purpose of this paper is to further elucidatethe importance of social relationships and socialconnectedness with aging in place and in developingelder-friendly communities. The process used in thisstudy was inclusive of younger adults (age40–65) as well as older adults (65+) in order tofurther understand how they envision a community thatcould support their own aging in place. A communityforum, using the World Café format, was conductedin order to engage community members, 40 years andolder, in conversation about the importance of socialconnectedness in elder-friendly communities. A secondpurpose of this forum was to obtain data on what wouldkeep aging boomers in their community as they age.Three major themes emerged from qualitative analysisof the forum:  Increasingly, gerontological researchers, practitioners, policy makers, and planners are concerning themselves with the growing importance of aging in place. Aging in place does not have one single definition but broadly is considered to be the ability to continue to live in the environment of one's choice, even when declining competence reduces or threatens independence , while aBefore embarking on a discussion of elder-friendly communities, it is important to discuss a number of theoretical frameworks and conceptualizations from gerontology that help inform our understanding of aging in place. There are numerous frameworks that are relevant to aging in place including ecological theory, person in environment, and social inclusion/exclusion. In addition, the area of environmental gerontology has specific relevance to this discussion.  Ecological theory  suggests Also of relevance to this discussion is the theory of social inclusion/exclusion. In social gerontology, the theory of social inclusion/exclusion examines the role of older people and highlights the social costs when individuals, families, or communities are excluded from or become disengaged from larger society due to characteristics such as poverty, gender, ethnicity, or neighborhood . Scharf In addition to several theoretical frameworks, the field of environmental gerontology has specific relevance to the topic of aging in place. Wahl and Weisman  suggest With regard to elder-friendly communities, we can draw upon the work of Lawton  who posiIn recent years, the concept of elder-friendly communities has become central to the notion of aging in place. Described in various ways, an elder-friendly community is a place where “people can live their entire lives, if they so desire, rather than having to relocate and lose their social capital” , page 6.AdvantAge Initiative demonstrated that elder-friendly communities must address basic needs, optimize well-being, maximize independence, and promote civic engagement. The City of Calgary Elder-Friendly Community Project noted that feeling safe, being valued and respected, staying active, and building community were important elements of an elder-friendly community  lack of transportation isolates seniors.” The view communicated by these participants was that improved transportation can foster and enhance social connectedness by decreasing barriers of distance and reducing the need for use of one's personal vehicle. One important distinction between younger and older participants was noted relevant to transportation. While younger participants voiced interest in improved transportation as a means toward improved social connectedness and as an environmentally friendly alternative to automobiles, older participants expressed a more urgent need for improved transportation, as well as having a more specific personal need. For example, one couple who was likely in their 70s expressed the need for improved transportation services for their parents (in their 90s) as they identified gaps in transportation services as personally problematic.  The purpose of this research project was to analyze data gathered from aging individuals (including baby boomers) on the importance of social connectedness in the creation of elder-friendly communities through a naturalistic method of inquiry. By engaging in a more naturalistic conversation utilizing the World Café format, the participants in the study were able to utilize conversation in meaning making without the confines of any a priori assumptions about social connectedness. AdvantAge Initiative as well as other literature on elder-friendly communities and point to the utility of several important theories. First, these findings echo the original framework from the AdvantAge Initiative [ The findings from this community forum and the subsequent focus group reinforce earlier data from the original itiative , which eitiative  who suggitiative , page 9.itiative . Forum pitiative  define pitiative  environmAdvantAge survey, residents from this community volunteered at a rate substantially lower than the national average for the 10 AdvantAge communities [ This study also reinforces both the importance of volunteer opportunities and that those opportunities be purposeful and meaningful. As suggested by Scharlach , in an emunities . What wemunities , but as munities  points omunities  is relevmunities . Older pmunities  who suggmunities  found ormunities  noted comunities  assert, munities  environm Community-based research is particularly useful when it is able to identify problems and move toward a resolution of that issue. Researchers can partner with communities to study areas of interest, interpret results , and ass In addition to the importance of civic engagement, the philosophy of aging in place supports the continued importance of maximizing independence for not only the frail and disabled, but for aging adults of all abilities. In particular, these findings point to the need for accessible and available transportation, an issue that city officials and community advocates should attempt to improve through partnerships. As Feldman and Oberlink  noted in The results of this study provide important information on social connectedness in elder-friendly communities. Still, this study has several limitations that must be acknowledged. First, as a qualitative and naturalistic study, the findings are the specific views of those individuals involved and cannot be generalized to any larger population of aging adults. Second, a further limitation is that those who responded to the invitation to participate in the community forum may have had a greater interest in the topic, or a vested interest in having their voices heard as compared to those who did not or could not attend. However, the study results provide a new dimension to the subject area and support previous studies and theories on aging in place, thus adding to the picture of what needs to be done to support the creation of elder-friendly communities. Because of the homogeneous makeup of forum participants, the voices of other communities such as communities of color were not clearly heard. It must be acknowledged that the opinions and concerns of this group do not likely represent all older adults in this community. Finally, because sociodemographic data was not collected on individuals, distinctions between older (65+) and younger participants are based upon educated guesses about participant's age. The results of this study reinforce the importance of social connectedness, participation, and integration in creating and maintaining elder-friendly communities and suggest that the findings are areas of concern not just for the old-old, but for recent and soon-to-be retired individuals wishing to maintain life satisfaction. The study suggests the possibility of using more nontraditional research techniques for gathering community level data such as the kinds of findings generated from the World Café process. While creating and fostering elder-friendly communities can be a long and ongoing process, small incremental change can occur from such studies as is illustrated by the case of the annual volunteer fair now established in this community.  If a national agenda of enabling our aging population to age in place is to be accomplished, creating elder-friendly communities has a logical and important role. Scharf et al.  suggest


Public Health Systems Research is an emerging field of research that is gaining importance in Canada.Accelerating Public Health Systems Research in Ontario: Building an Agenda think tank to develop a research agenda for the province.On October 22 and 23, 2012, public health researchers, practitioners, and policy-makers came together at the This agenda included the identification of the six top priorities for research in Ontario: public health performance, evidence-based practice, public health organization and structure, public health human resources, public health infrastructure, and partnerships/linkages.This paper explores the priorities in detail and hopes to bring more attention to this area of research. The public health (PH) sector has made substantial gains in population health and longevity over the past century. Key accomplishments can be found in the areas of vaccination coverage, control of infectious diseases, and recognition of tobacco use as a health hazard, among others -4. HowevPHSR is a relatively new field of research that has gained momentum in the last decade. In 2003, Mays et al. defined the area as “a field of study that examines the organization, financing, and delivery of public health services within communities, and the impact of these services on public health” , and the definition has since been updated to emphasize the link between PHSR and health services research . To dateThe US has been an international leader in PHSR thanks, in part, to strong encouragement from the Institute of Medicine, sustained funding from the Robert Wood Johnson Foundation, and the establishment of a research network dedicated exclusively to PHSR – the Academy Health PHSR Interest Group . In 2003http://www.uvic.ca/research/groups/cphfri/projects/currentprojects/rephs/index.php), held a National Think Tank in order to establish a pan-Canadian Public Health Systems and Services Research agenda. Top priorities that emerged from this Think Tank included data development/PH information systems, PH system performance and governance, and system/organizational structures [In Canada, the process of setting a research agenda has just begun; in May 2011 the Renewal of Public Health Systems research team, comprised of researchers and knowledge users from British Columbia and Ontario  philosophy was embraced from the start ; IKT engAccelerating Public Health Systems Research in Ontario: Building an Agenda Think Tank (hereafter referred as ‘the Think Tank’) was to bring together a group of key stakeholders from across Ontario with an interest and expertise in PHSR, as well as national and international PHSR experts, to engage in discussion and debate about PH systems research priorities at the provincial level. This meeting was designed to move toward consensus on the Ontario PHSR agenda, initiate the development of a five-year plan to advance the agenda, and establish a nascent PHSR network. In preparation, an environmental scan of emerging trends in public health and healthcare was conducted to identify relevant contextual issues for a PHSR agenda. An online survey on PHSR priorities in Ontario was also conducted, with participation from a wide range of PH networks across the province, such as health units, PH researchers, research units, PH organizations, academic programs in health studies/PH, and selected non-governmental organizations. This was an attempt to solicit broad input into the priority-setting process.The purpose of the The Think Tank took place on October 22 and 23, 2012 at the Public Health Ontario building in Toronto, Ontario. Overall, 39 participants attended the Think Tank, including 2 invited international guests from the US and the UK chosen for their expertise in PHSR, and 37 Canadian researchers, practitioners, and policy makers  to practitioners? How can we track inequities in populations as well as the incorporation of equity into policy and practice?Evidence-based Practice focused on the challenge of using existing evidence appropriately to guide PH services and decision-making processes, and inform future research initiatives. The group identified the following research questions: Who uses evidence, how is it used at PH units and what are the enablers/barriers to using it? What is the quality of the data/evidence being used? What exactly are the most effective evidence-based practices? How do health units successfully incorporate evidence informed decision making at all levels of the health unit?The PH Organization and Structure priority examined how the size, boundaries, and structures of PH agencies/departments impact the delivery and performance of PH services. Some of the research questions relevant for researchers, practitioners, and policy-makers were: What is the relationship between the way PH is organized  and PH performance? Are there international “best practice” governance models that result in better PH performance? Are there preferred organizational models that allow for intersectoral collaboration?The PH Human Resources priority focused on how to recruit and retain PH professionals, while addressing the issues of education and accreditation. Participants highlighted the importance of the PH workforce in every PHSR priority, but key questions centered on the core competencies, for example: Are the core competencies being used? Where and to what effect? What are the core competencies required in the workforce to take action on the social determinants of health? Do PH practitioners have the necessary competencies to implement the Ontario Public Health Standards effectively? Questions about surge capacity in PH and the types, numbers and distributions of PH professionals across Ontario were also asked.The PH Infrastructure priority was concerned with ensuring that the necessary infrastructure resources  are in place to implement effective and appropriate interventions for individuals and communities, as well as at the provincial and national levels. Important research questions relating to infrastructure were listed as: What is the population size, geography required to achieve ‘critical mass’? Is there an ideal population size for each PHU ? What components  of PH infrastructure are most influential and how do they influence each other across the province?The last priority, Partnerships and Linkages, is related to creating and mobilizing partnerships/linkages to improve PH system performance . Research questions focused on assessing the meaning, values and outcomes of partnerships, as well as techniques for partnership building across different sectors and evaluating partnership outcomes. Some examples of questions were: What are the factors enabling/hindering effective partnerships at different levels ? What is the role of PH as a convener and steward of partnerships across community organizations with health and among other sectors? How can we use partnerships effectively to reach equitable service delivery and ultimately health equity?A brief evaluation survey was conducted with participants several months after the Think Tank (May 2013) to understand the short-term impacts of the conference. Sixteen out of 36 invited participants responded, leading to a response rate of 44.4%. This level of participation was expected given the many priorities juggled by these high-level stakeholders. Although the survey was anonymous and it was not possible to identify who exactly participated, the demographic information showed that a mix of policy-makers, researchers, and practitioners were represented in the responses. Respondents noted that they became more familiar with PHSR as a result of the Think Tank . Respondents also prioritized PHSR more as a result of the Think Tank . A full 40% of respondents gave the highest possible ranking (10) for the importance of PHSR. Further, 58.3% of respondents indicated that they developed new professional relationships as a result of the Think Tank, 25% formed new partnerships, 41.7% participated in research proposals related to the PHSR agenda that came out of the Think Tank, 75% advocated for or encouraged attention to PHSR priority areas in their professional practice, 33% became more immersed in PHSR literature, and 16.7% participated in program development related to the PHSR agenda.The priorities generated by the Ontario Think Tank had some similarities and differences with the most recent research agenda generated in the US. While there is some overlap between the top six Ontario priorities and the US’ broad domains of PH Workforce, PH Structure and Performance, PH Financing, and PH Information and Technology, the US agenda contained a total of 72 research questions that were split into 14 thematic areas . While sIn the US PHSR agenda, the social determinants of health and health disparities were categorized as a thematic area within PH performance and structure. In Ontario, the priority ‘health disparities’ was ranked as a top priority on the online survey and discussed as an extremely important topic in the Think Tank; however, it failed to be included in the top six priorities. This may have been due to a discussion during the Think Tank to remove ‘health inequities’ as an individual priority because addressing health inequities was assumed to be integral to PH  by participants. As such, the agreement on the importance of health inequities may not be immediately apparent in the choice of the top priorities for those who were not involved in the discussion.This integrated knowledge translation process was seen as a first step in a collaborative research program. While not all participants will become part of future research project teams under each thematic area, the collaborative process of identifying relevant priorities from the perspective of researchers, practitioners, and policy-makers will hopefully pave a smooth path for those with the capacity to take part in research. The Think Tank had a measurable impact on the knowledge, attitudes, and practices of those who attended.The aims to build connections between individuals and organizations in this field, bring more attention and awareness to PHSR, and build consensus on Ontario’s PHSR agenda, particularly in the priority areas identified in the Think Tank, were achieved. The core Think Tank team is also in the process of creating an Ontario PHSR website and reaching out to additional stakeholders to expand and diversify a budding PHSR network. While Think Tank participants brainstormed steps in further developing the research agenda , currently there is not sufficient infrastructure to develop and implement a concrete 5-year plan. In order to reach its full potential in Ontario, PHSR needs to be acknowledged and prioritized in funding opportunities. The US has been able to achieve significant advances in this field due to sustained financial support from the Robert Wood Johnson Foundation and dedicated funding. In Canada, while PHSR research can be integrated with mainstream health services research, there are no dedicated requests for proposals from our national funding body. The authors recommend that the Canadian Institutes of Health Research put out a strategic call for PHSR proposals, so as not to lose the opportunity to systematically strengthen PHSR in the province.There were some limitations to the Think Tank agenda-setting process. Although efforts were made to invite a diverse range of key players with a stake in PH in Ontario, it was recognized at the meeting that some important stakeholders were not represented in the room Table . CommuniAnother limitation lies in the time constraints inherent in a 2-day Think Tank. The process that led to the selection of the top six priorities was based on group brainstorming followed by voting. The time limitations placed upon the group precluded an exhaustive discussion and a completely rigorous voting method. Although participants were provided with criteria upon which to base their decisions , criteria may have been weighted differently by different participants. Efforts were made, however, to ensure that everyone’s voice was heard in the discussion and voting process, which was enabled through Group Decision Support Software.Despite these limitations, the majority of participants were very satisfied with the Think Tank and felt committed to the agenda that was developed, based on the evaluation results. Some strengths include international input, key players knowledgeable about the Ontario context, stakeholders from the previous National Think Tank, and efficient generation of ideas through an expert facilitator, all of which helped to result in the accomplishment of the meeting objectives.In conclusion, the Think Tank was meant to bring together key stakeholders from research, policy, and practice to develop a structured agenda for PHSR in Ontario, identify partners and research methods for top priorities, and build momentum for the next steps forward. The process of consensus-building to create a collective program of research has successfully advanced PHSR agendas in the US, British Columbia, and now Ontario. The authors can recommend this process with confidence to other regions and countries looking to strengthen their PHSR agendas, provided efforts are made to include representation of all important actors in the given PH system. It is hoped that the publication of the Ontario PHSR priorities will spark interest, bring focus, and lead to collaborative inquiries in this important area of research.PH: Public health; PHSR: Public Health Systems Research; IKT: Integrated Knowledge Translation; ON: Ontario; US: United States.The authors declare that they have no competing interests.All authors contributed equally to this work. All authors led the conceptualization, implementation and analysis of the Think Tank. All authors also contributed to the writing of the manuscript and read and approved the final version.


Nearly two decades ago, researchers first reported that endocrine disrupting chemicals in the environment were affecting reproductive health in the general population. The purpose of this article is to examine the evidence of adverse reproductive health trends in Israel and to explore implications for environmental health policy in Israel. We reviewed studies and data in Israel regarding trends in reproductive health indices, specifically: breast and testis cancer, hypospadias, sperm quality, male factor infertility, and age at menarche. The data provide some evidence of adverse reproductive trends in the Israeli population: an increase in testicular cancer from 1990 to 2007, a decrease in age at menarche from 1986 to 2000, an increase in the prevalence of male factor infertility, and some evidence of decreasing sperm counts. However, we note that much of the evidence is limited.The policy implications of reported adverse reproductive health trends possibly related to environmental exposure have been radically different in Europe and the United States. In Europe, such reports led the Parliament of the European Community to adopt a resolution on endocrine disruptors, which emphasizes the application of the Precautionary Principle. U.S. Environmental Protection Agency policy is focused on screening chemicals for endocrine disrupting properties and does not specifically refer to the Precautionary Principle. To date, there has been no formal governmental policy or strategy in Israel regarding endocrine disrupting chemicals. Environmental health policy on endocrine disruptors requires integrating evidence on human reproductive health trends, evidence on adverse reproductive outcomes in wildlife and experimental systems, and data from biomonitoring studies. Despite gaps in evidence and current data, we support a precautionary approach to regulating potential endocrine disrupting chemicals and reducing public exposures, especially in sensitive groups such as children and pregnant women. Nearly two decades ago, researchers first reported that endocrine disrupting chemicals (EDCs) were affecting reproductive health, citing evidence from experimental animal studies, investigations of wildlife populations, reports on increased incidence of certain pathologies in men and women, and adverse health outcomes in girls whose mothers were treated with the estrogenic drug diethylstilbestrol (DES) . The recThe group of compounds identified as endocrine disruptors is highly heterogeneous and includes, for example, industrial solvents/lubricants and their byproducts , plastics ), plasticizers , pesticides , fungicides , pharmaceutical agents , and natural chemicals found in human and animal food  .While the evidence for adverse reproductive outcomes  from exposure to EDCs is strong , it is uin vitro fertilization (IVF) cycles out of 53 countries participating in the World Collaborative Report on Assisted Reproductive Technology [In 2002, Israel had the highest rate of The purpose of this integrative article is to establish whether there is evidence of adverse reproductive health trends in Israel and to explore implications for environmental health policy in Israel. The first part of the paper will characterize Israeli databases containing data relevant to reproductive health trends in the Israeli population and will summarize trends in breast and testis cancer, hypospadias, male factor infertility, sperm quality, and age at menarche. The second part of the paper will explore the environmental health policy implications of these trends: How have the European Commission and the U.S. Environmental Protection Agency (EPA) responded to indications of adverse reproductive health trends in the population? What is the appropriate health policy response in Israel to possible adverse reproductive health trends?We identified the following Israeli databases as containing data relevant to reproductive health trends in the Israeli population Table . In thisBased on data from the Ministry of Health National Cancer Registry, which includes an estimated 94% of solid tumors and 85% of nonsolid tumors, age adjusted testicular cancer rates in Israel more than doubled in Jews and Arabs during 1990–2007, with age adjusted rates twice as high in Jews as in Arabs .In situ breast cancer incidence has increased in both Jewish and Arab women from 1990 to 2007 (110% increase in Jewish women and 150% increase in Arab women) . The incData from the Israel Birth Defects Registry, which includes reports on an estimated 70% of total birth defects in Israel, shows that hypospadias incidence rates in Israel were unstable between 1974 and 2008 [In 1977, Dor and others reported on 655 infertile couples in Israel over a 15-year span and found that male infertility factors were involved in 28% of the cases . The disp < .0001) and motility was reduced by 0.50 ± 0.14% per year (p < .0003). This trend remained strongly significant when men with normal parameters were evaluated separately, in order to control for the increase in oligoazoospermic patients in later years. In a longitudinal analysis, where each man’s earliest semen sample was compared to his latest one, a decrease in sperm counts was observed (decrease of 5.3 ± 4.5 million each year) although results were not significant.There have been few studies on trends in sperm quality in Israel. Almagor et al. showed a significant downward trend in sperm count and motility in Jerusalem men providing sperm samples for intrauterine insemination treatment during the years 1990–1999 . Sperm cp < 0.0001) and a decline in normal morphology in semen from young Jerusalem donors between 1980 and 1995  [Results of studies in sperm donors in Israel have been conflicting. One study, published in 1997, found an increase in total motile sperm count  . The stu 0.0001) . Over thA population-based survey among female recruits to the Israeli army from 1986 to 2000 found a decrease in age at menarche, unadjusted for BMI . ReporteThe data presented in the first part of this paper provide some evidence of adverse reproductive trends in the Israeli population: an increase in testicular cancer from 1990 to 2007, an increase in the prevalence of male factor infertility, a significant decrease in age at menarche in female recruits to the Israeli army from 1986 to 2000, and limited evidence of decreasing sperm counts.However, we note that much of the evidence is limited. While the increase in testicular cancer in 1990–2007 is salient, additional types of cancer not associated with endocrine disruptors have increased in Israel during this time period. Data on changes in sperm quality in Israeli sperm donors is valuable, but such studies are inherently limited by the small sample sizes and the fact that sperm donors are not representative of the general population. The studies conducted by Dor and Farhi and Ben-Haroush on male factor infertility focused on specific clinics, which might introduce a certain selection bias; therefore it is unclear if the upward trend in male factor infertility reflects a national trend. In addition, it is possible that technological advances in diagnosis affected the difference in incidence of male factor infertility reported in 1977 and in 2011. Data on age at menarche in female recruits were unadjusted for BMI, and it is unclear if changes in obesity and life style during this period or other factors explain this trend.In addition, other factors that are potentially related to reproductive health trends in Israel have changed in the population over the period that these adverse reproductive health trends were observed: increased recreational drug use ; a steepDespite the limitations in the data, the fact that adverse reproductive health trends have been reported in other populations worldwide suggests that there is some plausibility to the hypothesis that these trends are indeed occurring in Israel. Testicular cancer has been increasing worldwide in the majority of industrialized countries in North America, Europe, and Oceania, particularly among Caucasians . In seveEndocrine Disrupting Chemicals: EU and U.S. Policy Initiatives and Responses: The policy implications of reported adverse reproductive health trends possibly related to environmental exposure have been radically different in Europe and the U.S.In 1996 scientists and policy-makers in Europe convened the Weybridge Workshop and reached the conclusion that “sufficient evidence exists for increasing testicular cancer rates, and the apparent decline in sperm counts in some areas was unlikely to be attributable to the known confounding variables.” Despite the fact that they concluded that existing exposure information was generally insufficient to definitely associate the human changes seen with chemical exposure, they noted that measures to reduce exposure to endocrine disrupters should be in line with the Precautionary Principle .The EU Community Strategy for Endocrine Disrupters, which was adopted in 1998, emphasizes the application of the Precautionary Principle and calls on the Commission to identify substances for immediate action . ActionsIn the U.S., the Endocrine Disruptor Screening Program Policy Statement from 1998 cited “conflicting reports … concerning declines in the quality and quantity of sperm production in humans over the last 4 decades, and … reported increases in certain cancers ” but added that there is “considerable scientific uncertainty … regarding the actual causes of such effects.”  The U.S.proving harm in humans prior to regulating a chemical, without addressing the uncertainty involved in endocrine disruption and without mention of the Precautionary Principle [According to these acts, if a substance is found “to have an endocrine effect on humans, the Administrator shall … take action under such statutory authority as is available to the Administrator … as is necessary to ensure the protection of public health.” In other words, the statutes requiring testing for endocrine disruption provide no new process by which to regulate those chemicals. In addition, this approach demands scientifically rinciple .Additional policy actions in the U.S. related to potential endocrine disruptors have included banning the use of phthalates in toys  and “takImplications for Environmental Health Policy in Israel: In both the EU and the U.S., evidence regarding adverse reproductive health trends in the general population was considered when developing environmental health policy on EDCs. However, this data was considered within the broader context of evidence on the impact of EDCs on wildlife and experimental systems. To date, there has been no formal governmental policy or strategy in Israel regarding EDCs. Current actions in Israel have focused on three main aspects: monitoring, research/surveillance, and policy/legislation.In the U.S., there is on-going surveillance of population exposure to environmental chemicals, including estrogen disrupting chemicals within the framework of the National Health and Nutrition Health Survey . This suIn Israel, the Ministry of Health recently conducted the first national biomonitoring study to measure exposures to BPA, phthalates, organophosphates, polyaromatic hydrocarbons, the phytoestrogens genistein and daidzein, and cotinine in the Israeli adult population . The stuCurrently, there is lack of surveillance on reproductive health outcomes for the Israeli population. We emphasize the need for further study in Israel on reproductive health trends and on possible associations between adverse reproductive outcomes and exposures to environmental chemicals. Researchers at the Hebrew University of Jerusalem have recently initiated studies on associations between organophosphate exposure and endocrine outcomes related to male infertility, and on associations between prenatal exposure to phthalates and BPA and birth outcomes. We note that endocrine disrupting chemicals may interfere with endocrine systems other than the reproductive system and emphasize the need for study on trends of thyroid conditions, obesity, and diabetes and possible associations with exposure to environmental chemicals. We also note that many epidemiological studies on the associations between exposures to environmental chemicals and adverse reproductive outcomes have been hampered by the lack of individual exposure assessment.The precautionary approach has been applied in Israel in a number of recent policy decisions concerning EDCs, including for example the ban on use of BPA in baby bottles and the decision to severely restrict the use of the herbicide atrazine. In the case of BPA, quantitative risk assessments showed that little or negligible risk was expected following normal use of baby bottles ,40. HoweIn addition, the Ministry of Health recently recommended the ban of the herbicides atrazine and simazine in Israel, based on concerns regarding possible effects on reproduction and fetal development from chronic low dose exposure via drinking water. In this case, current levels of these herbicides in drinking water in Israel are far below the Israeli Drinking Water Standard, suggesting that there is negligible risk to the population. In fact, the World Health Organization recently recommended an increase in the drinking water standard in light of evidence that atrazine is not carcinogenic in humans. However, given emerging suggestive evidence of adverse effects on reproduction and development at very low levels of exposure, and given that there were available alternatives, the Ministry of Health adopted a precautionary approach.We argue that environmental health policy on EDCs should be informed by a broad range of evidence, including data on trends in reproductive health, evidence from wildlife and experimental systems, and biomonitoring data.increases when the exposure or harm is widespread, when the incidence of the harm  is increasing and is otherwise unexplained; when the suspected harm is serious; when the suspected harm is not easily treatable or reversible; when the economic and social costs of removing the exposure are small relative to the suspected harm; when the health costs of removing the exposure are minimal; and when, in addition to the uncertain harms, there are known health, economic, or social harms caused by the exposure [Despite gaps in evidence and current data regarding adverse effects of environmental chemicals on reproductive health in Israel, we support a precautionary approach to regulating EDCs and reducing public exposures, especially in sensitive groups such as children and pregnant women. We argue that this principle should be invoked following a) identification of potentially negative serious or irreversible effects resulting from a phenomenon, product, or procedure; b) a scientific evaluation of the risk; and c) evaluation of the extent of the scientific uncertainty . We emphexposure .We note also that the public-health strategy for dealing with potential effects of EDCs must reflect governing national and international legalities. In the international trade environment in which Israel is obligated to operate by its treaty obligations  there are restrictions on the ability to apply any measure without scientific justification .In the cases of BPA in baby bottles and atrazine in drinking water, in-depth scientific evaluation of the potential risk revealed significant uncertainties that made it impossible to determine that current exposure levels would result in negligible or no risk to the general population. In addition, in both of these cases potential exposure of the general population was widespread and the potential health outcomes were both serious and irreversible. However, we note the significant challenges in application and logical consistency of the Precautionary Principle in environmental health policy. For example, with regard to food contact uses of BPA, the Ministry of Health, in light of European and U.S. policy, has yet to determine whether there is a case for applying the Precautionary Principle and restricting or banning this use.There is limited evidence of adverse reproductive trends in the Israeli population. However, relative absence of evidence regarding adverse effects of environmental exposure on Israeli reproductive health does not equal the evidence of absence of such a problem. This is especially true in Israel, where there has been little research on associations between environmental exposures in the general population and adverse reproductive outcomes. We emphasize the importance of applying the Precautionary Principle in environmental health policy, monitoring exposure of the population to environmental chemicals, and monitoring trends in reproductive health outcomes in Israel. The Ministry of Health is currently evaluating research and policy development needs.The authors have no competing interests to declare.TB and HL conducted the data and literature search and drafted the manuscript. IG and RG made significant contributions to the text and provided insight regarding policy implications. All authors read and approved the final manuscript.Tamar Berman, PhD, is currently the Chief Toxicologist for Environmental Health at the Ministry of Health.Hagai Levine, MD, MPH, is a public health physician and epidemiologist at the School of Public Health, Hebrew University–Hadassah, and is a member of the Center of Excellence for Environmental Research on Agriculture and Health at the Hebrew University of Jerusalem.Ronni Gamzu, MD, is a gynecologist who specializes in Health Management and has a PhD from Tel-Aviv University. He is currently the Director General of the Israel Ministry of Health. He is also an Associate Professor at Tel-Aviv University.Itamar Grotto, MD, PhD, is a public health physician who also has a PhD from Ben-Gurion University of the Negev. He is currently the Director of the Public Health Services in the Israel Ministry of Health. He is also an Associate Professor at Ben-Gurion University of the Negev.


Southern Med Review (SMR) into the Journal of Pharmaceutical Policy and Practice[Journal of Pharmaceutical Policy and Practice (JoPPP) will reach a greater number of readers. Open access will lead to a wider readership, higher downloads, higher citations, and a higher Impact Factor [We are happy to announce the metamorphosis of the  Practice-3. As an Practice-7, Journt Factor . ArticleSMR was published on 23rd Dec 2008 [access  as well as medicines use  [While rejoicing the start of an exciting new phase, it seems appropriate to review where we have come from and where are we heading with this new Journal. The first issue Vol 1 Issue 1) of  Issue 1 SMR was to promote pharmaceutical policy research from low and middle income countries - a job which the journal did well. SMR provided opportunity and support to emerging researchers with 30 to 40% of the contributors being first time authors [SMR was commended by the World Health Organisation (WHO) and its policy impact was evident from published studies which were instrumental in changes in the medicines pricing policies of Vietnam and Thailand [The main aim of  authors . The jou authors -12. SMR Thailand .Journal of Pharmaceutical Policy and Practice (JoPPP) [JoPPP.Now the journal is entering a new phase and is renamed the  (JoPPP) . This chSMR was an internationally focussed journal with a wide geographic and socioeconomic flavour; although most of the research centred on the developing world [JoPPP flagship. However, in line with the broadening remit we expect to receive more pharmaceutical policy related work from those in high-income countries.ng world ,2. AcadePharmaceutical was also chosen with care; to be intentionally broad and to differentiate from Pharmacy per se. The term pharmacy encompasses the physical structure of the community or hospital pharmacy and the practices within that. However, pharmacies are only one component of a larger complex health system which influences global access to, and use of, medicines. The term pharmaceutical encompasses pharmacy but is broader in that it involves wider aspects of medicines access and use including: technology, the pharmaceutical industry, other health professionals that influence use such as doctors and nurse prescribers and so forth. Pharmaceutical policy includes such areas as national pharmaceutical policy, pharmacoeconomics [The word conomics , regulatFrom a practice viewpoint, international policy has been churned out of government departments in high income countries; particularly in the commonwealth . HoweverJoPPP title warrants consideration. There are a number of contexts that encompass pharmaceutical practice and we will be particularly interested in the studies related to community pharmacy setting. This could range from the papers discussing policies and their impact on pharmaceutical practice. Also, the interest would be in medicines compliance, concordance, rationale use of medicines, medicines use among minorities and the disadvantaged groups as well those in the disaster or conflict zones.Finally, adding the word ‘practice’ to the JoPPP continues to grow and morph. We encourage our readers to keep their contributions rolling in!We believe pharmaceutical policy is encompassing and directing activities which are related to access to medicines and their use. We look forward to receiving more of these papers as


PLoS Biology, a team led by Thilo Womelsdorf of York University in Toronto, Canada, addressed this issue by recording from neurons across a large portion of the monkey brain. They found that two regions—the ventromedial prefrontal cortex (vmPFC) and the anterior cingulate cortex (ACC)—are involved in guiding attention to the most valuable objects in a scene. The findings provide a more complete understanding of the roles of different brain areas and their interactions during this crucial task.In a paper published this week in In the study, the researchers trained two monkeys to perform a visual attention task. The animals fixated on a gray dot in the center of a screen and saw a circle filled with red and black stripes on one side and another circle with green and black stripes on the other side. Next, the color of the dot changed to red or green to cue the monkeys to pay attention to the corresponding pattern, which then rotated either clockwise or counterclockwise. The animals indicated the direction of motion by moving their eyes up or down, respectively, and they received juice for correct decisions. But the amount of the reward depended on the color of the pattern, and accuracy was higher for stimuli linked to a larger reward than for those associated with less juice.While the monkeys were engaged in the task, the researchers recorded from more than 1,000 neurons in the frontal and cingulate cortex. The activity of some neurons carried precise information about the location of the attended pattern, and these cells were clustered in the ACC, vmPFC, and lateral prefrontal cortex. A subset of these neurons showed transient changes in their firing rates immediately after the dot changed color, suggesting that they help to shift attention to task-relevant stimuli. By contrast, a separate set of ACC neurons showing delayed and prolonged responses could play a role in maintaining attention to relevant locations while filtering out distractions.The research team also examined how neuronal activity was affected by reward magnitude. Neurons that were sensitive to the value of the attended pattern formed a distinct set of clusters in the vmPFC and ACC, but some cells in these two regions responded to both the location and value of the stimulus. Because the ACC is connected with brain areas involved in directing eye gaze and planning other movements, and the vmPFC shares connections with areas that are critical for memory and emotions, these two regions are ideally positioned to integrate information about location and value to focus attention on the most important objects in the environment.Kaping D, Vinck M, Hutchison RM, Everling S, Womelsdorf T (2011) Specific Contributions of Ventromedial, Anterior Cingulate, and Lateral Prefrontal Cortex for Attentional Selection and Stimulus Valuation. doi:10.1371/journal.pbio.1001224