To perform a systematic review of literature data on gut microbiota and the efficacy of probiotics for the treatment of constipation in children and adolescents. The research was performed in the PubMed, the Scientific Electronic Library Online (SciELO) and the Latin American and Caribbean Health Sciences Literature (LILACS) databases in English, Portuguese and Spanish. All original articles that mentioned the evaluation of the gut microbiota or the use of probiotics in children with constipation in their title and abstract were selected. 559 articles were found, 47 of which were selected for reading. From these, 12 articles were included; they studied children and adolescents divided into two categories: a gut microbiota evaluation (n=4) and an evaluation of the use of probiotics in constipation therapy (n=8). The four papers that analyzed fecal microbiota used different laboratory methodologies. No typical pattern of gut microbiota was found. Regarding treatment, eight clinical trials with heterogeneous methodologies were found. Fifteen strains of probiotics were evaluated and only one was analyzed in more than one article. Irregular beneficial effects of probiotics have been demonstrated in some manifestations of constipation . In one clinical trial, a complete control of constipation without the use of laxatives was obtained. There is no specific pattern of fecal microbiota abnormalities in constipation. Despite the probiotics’ positive effects on certain characteristics of the intestinal habitat, there is still no evidence to recommend it in the treatment of constipation in pediatrics. Recommended treatment includes a combination of dietary interventions (adequate fiber and fluid intake), education, demystification and, where appropriate, toilet training and completion of a bowel movement diary. In the presence of fecaloma, fecal disimpaction and the use of oral laxatives for prolonged treatment are indicated. The effectiveness and safety of these procedures are well established..However, for a small portion of patients, conventional treatment does not provide satisfactory improvement, which leads to interest in other therapeutic strategies. There is also a great deal of concern from family members about the prolonged use of laxatives.,,,Bifidobacterium and Lactobacillus.Bifidobacterium spp., and reported a decrease in abundance of the Bacteroides species, when compared to the control group.It is suggested that prolonged fecal stasis in the colon of patients with constipation has an impact on gut microbiota, which may influence various intestinal functions, including motility.Faecalibacterium, Lactococcus and Roseburi, which are genus of the phylum Firmicutes, correlated with decreased colonic transit.In contrast, in 2016, it was observed in the colonic and fecal mucosa of women with intestinal constipation, that the fecal microbiota profile was not associated with increased colonic transit time, when confounding factors such as age, body mass index and diet were considered. On the other hand, .The abnormalities observed in the gut microbiota in patients with constipation have increased the use of probiotics for additional support in their treatment.bifidobacterium OR lactobacillus) AND constipation. In the LILACS and SciELO databases, no research period was defined. The oldest record in each one up until the last one from December 2017 was considered. The following terms and limits were used:  OR (probiotic$ OR bifidobacterium OR lactobacillus) AND (constipation OR constipação OR estreñimiento). References to articles and other relevant systematic reviews were also consulted.This review article was conducted according to the PRISMA criteria for systematic reviews and meta-analyzes.After reading the titles and abstracts, we selected all original articles that included children and adolescents. To evaluate fecal microbiota in constipation, the articles that compared children and adolescents with constipation and a control group were considered. Inclusion criteria for articles evaluating the use of probiotics in the treatment of constipation were: evaluating children or adolescents aged ≤19 years; including an intervention with any type of probiotic, regardless of the strain, dose and presentation. Research was not restricted to the exclusive evaluation of randomized controlled trials. This systematic review did not include review articles, editorials or commentaries.,,,,,,,,,,,At the beginning of the research on microbiota, probiotics and constipation, 559 articles were found, of which 47 were selected for reading. Of these, 12 articles that studied children and adolescents were included in this review.,,,Thus, four articles evaluated changes in fecal microbiota in constipation in children and adolescents.Clostridium and Bifidobacterium genres.Zoppi et al.Bacteroidetes is lower in constipation (mainly species of the Prevotella genus), while several families and genus of the Firmicutes phylum were in greater abundance.In the study performed by Zhu et al.,Bifidobacterium longum, B. fragilis and B. ovatus) in individuals with constipation. Fecal microbiota analysis could differentiate between the 76 patients with constipation and the 61 healthy controls with 82% accuracy.Meij et al.Lactobacillus and Bifidobacterium, a lower concentration of Lactobacillus was found per milligram of feces in children with constipation.In the study performed by Moraes et al.,,,,,,,,,,The use of probiotics in the treatment of functional constipation has been evaluated in eight articles,Bifidobacterium and Lactobacillus: B. lactis DN-173010,B. longum,L. reuteri DSM 17938,L. casei rhamnosus Lcr35,,LGG ATCC 531032,B. breve M-16 V®, infantis M-63®, e longum BB536®® .The probiotic strains used for the intervention were predominantly from the genera Lactobacillus casei rhamnosus Lcr35.,,,Of these articles, only one found a higher frequency of probiotic therapeutic success in the treatment of constipation with statistical significance, using the strain Despite the rapid growth of knowledge and scientific literature on gut microbiota and probiotics, the present systematic review has shown that information is very limited regarding the profile of gut microbiota in children and adolescents with constipation. No systematic review on this topic was found.As can be seen from It is evident that the results obtained on the fecal microbiota of children and adolescents with constipation are discrepant. The different methodologies used for the fecal microbiota analysis of the studied individuals and the different species of bacteria evaluated made it impossible to determine a specific pattern of fecal microbiota abnormalities in patients with constipation.,,Regarding the study conducted in the United States,,Other aspects that hinder the comparability of the obtained results are the high inter-individual variability of the fecal microbiota and the clinical heterogeneity of the studied populations.Therefore, further studies with larger and more homogeneous series, preferably using modern molecular biology techniques, are needed to establish the gut microbiota profile of children and adolescents with constipation, more accurately.,,,According to the literature, there are several mechanisms that can potentially explain the action of probiotics in the treatment of functional constipation: modification of the gut microbiota, considering the changes that have been shown in individuals with constipation; increased production of lactate and short chain fatty acids, reducing luminal pH, which could improve colonic peristalsis and decrease intestinal transit time.,,The definition of therapeutic success is an important criterion when evaluating the effectiveness of therapeutic interventions. In children and adolescents with constipation, it is important to evaluate not only bowel movement frequency but also stool consistency as parameters for therapeutic success.,,,As can be seen from L. casei rhamnosus Lcr35 was similar to that of magnesium oxide administered in a third group of the clinical trial (Among the clinical trials in which probiotics without laxatives were used, only one study found greater therapeutic success from the probiotic when compared with the placebo.al trial .,,,,In In these intervention studies using probiotics, the composition of the intestinal microbiota before and after probiotic administration was not evaluated. Thus, the observed clinical effects on motility and characteristics of intestinal habit attributed to the use of probiotics could not be associated with specific changes in the composition of the gut microbiota.wash-out between the intersection of the interventions. Thus, in the second stage of the study, there could have been residual effects of the probiotics. It is also important to report that several studies did not have an adequate sample size, as they were composed of convenience samples with a small number of participants, which makes comparison and the reliability of the data obtained, difficult.Regarding the methodological quality of the analyzed clinical trials, it is worth noting that the only randomized crossover clinical trial Thus, it was found that the intervention studies with probiotics included in this systematic review are heterogeneous with regard to the population studied, the probiotic strains used, the dosages used for treatment, the duration of the study, the follow-up, the definitions, and the parameters used to evaluate the effect of intervention on the control of constipation in children and adolescents. Therefore, the data obtained do not allow for specific recommendations to be made regarding the use of probiotics in the treatment of functional constipation.,,,,,,L. rhamnosus Lcr35 showed a beneficial effect for the treatment of constipation in children. A systematic review and meta-analysis published in 2014LGG, L. reuteri DSM 17 938 and VSL # 3® have been reported to have a better effect than placebo in the treatment of functional abdominal pain and irritable bowel syndrome. However, no evidence was found indicating the efficacy of probiotics in the treatment of functional constipation. A systematic review published in 2016 ,,,,,,,In the literature, five systematic review articles were found,,Given the heterogeneity of clinical trials conducted with children and adolescents, there is a need to standardize the criteria and definitions used to compare the effects of different therapeutic interventions, as mentioned in the literature.It was not possible to determine a specific pattern of fecal microbiota abnormalities of constipation in children and adolescents.Irregular beneficial effects of probiotics were evidenced in some clinical manifestations of constipation in this population. However, clinical trials are still scarce and heterogeneous, and their results are controversial.To date, there is no scientific evidence to support probiotic supplementation for the treatment of functional constipation in children and adolescents.Thus, further research with well-established and homogeneous methodologies is needed to determine causal relationships between fecal microbiota alteration and constipation, as well as on the effectiveness of using probiotics to treat children and adolescents


Here, we report a case with successful treatment of inferior pancreaticoduodenal artery aneurysm rupture due to celiac artery trunk compression caused by the median arcuate ligament. When clinicians see visceral aneurysms, the possibility of arcuate midline ligament compression syndrome (MALS) and ligamentectomy for MALS should be considered. One month earlier, he was hospitalized in our department and underwent omental patch repair for gastric ulcer perforation. Emergent contrast‐enhanced CT revealed a retroperitoneal hematoma in the pancreatic head Figure A, aneuryIn this case, collateral perfusion pathways from the SMA developed to compensate for the reduced CA blood flow due to MAL compression, and the aneurysm might have generated in the PDA due to the abnormal changes in hemodynamic flow. Preservative treatment did not appear to relieve the CA compression. In addition, we considered that new aneurysms may form following new collateral circulation after IVR hemostasis. Therefore, incision of the MAL was necessary to release extraluminal compression of the CA. The surgery was performed 3 months following IVR hemostasis. Attributable to the patient's past medical history of peritonitis due to perforation of the gastric ulcer and the upper abdominal operation, we decided to perform conventional laparotomy instead of laparoscopic surgery. The laparotomy was performed with a midline abdominal incision, and the wall adhesion to the abdominal organs was peeled off, the lesser omentum incised, and the aortic fissure of the diaphragm exposed. In addition, the MAL on the anterior surface of the CA forming the aortic fissure was incised after taping the left and common hepatic arteries, respectively, Figure A,B.3The MAL consists of the arcuate ligament and diaphragmatic crura, which forms an attachment from the diaphragm to the vertebrae. MAL connects the diaphragmatic crura crossing the aorta superior to the CA at the level of the first lumbar vertebrae.Midline ligament compression syndrome is a rare disease that occurs in 0.002% of the populationAneurysms of the abdominal visceral arteries are relatively rare.Some authors have described hemodynamic changes in aneurysm formation due to increased blood flow in the collateral arteries from the SMA to the CA perfusion area, and that increased arterial wall shear stress is responsible for aneurysm initiation, growth, and rupture.In conclusion, we report a rare case of MALS caused by PDA aneurysm rupture and retroperitoneal hemorrhage. Blood flow to the arterial arcade in the pancreatic head from the SMA to the area of CA perfusion might be the cause of this rare and exceptional aneurysm formation in the PDA. Although there is no consensus on the necessity of surgical intervention for MAL compression of the CA, the present case suggests a potential benefit for operative MAL incision to decrease the abnormal blood flow causing shear stress in the arterial arcade in the pancreatic head, which is a possible cause for aneurysm formation.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor‐in‐Chief of this journal on request.HT: gathered the patient data, performed a literature review, and wrote the manuscript. FS and OM: are the referring physician and provided clinical data. TA, YT, US, EK, and SK: revised the manuscript. NS and IM: were involved in overall supervision of the paper. All authors read and approved the final manuscript.The authors declare that they have no conflicts of interest.


Tendons are soft tissues of the musculoskeletal system that are designed to facilitate joint movement. Tendons exhibit a wide range of mechanical properties matched to their functions and, as a result, have been of interest to researchers for many decades. Dimensions are an important aspect of tendon properties.Change in the dimensions of tissues is often seen as a sign of injury and degeneration, as it may suggest inflammation or general disorder of the tissue. Dimensions are also important for determining the mechanical properties and behaviours of materials, particularly the stress, strain, and elastic modulus. This makes the dimensions significant in the context of a mechanical study of degenerated tendons. Additionally, tendon dimensions are useful in planning harvesting for tendon transfer and joint reconstruction purposes.Historically, many methods have been used in an attempt to accurately measure the dimensions of soft tissue, since improper measurement can lead to large errors in the calculated properties. These methods can be categorised as destructive (by approximation), contact, and non-contact and can be considered in terms of in vivo and ex vivo. Tendons are a soft connective tissue designed to efficiently transfer loads generated by muscles to the skeletal system, facilitating joint movement , 2. ThesTendons primarily consist of water (65–70% wet weight) and collagen type-I (70–80% dry weight), with different types of collagen fibres, elastin, proteoglycans, and glycolipids making up the remainder , 9–13. CTendons exhibit properties such as stiffness, resilience, and strength, which allow for efficient transfer of forces from muscle to bone . It has The Achilles tendon is generally regarded as the strongest tendon in the human body , 29–31. Musculoskeletal conditions are common, with 30 million cases of injury reported annually worldwide . DespiteDisease of the tendon, known as tendinopathy, is characterised by pain and reduced mobility and functionality. The pathology is complex, including disordered healing causing fibre disruption and disorientation, generally with an absence of inflammatory cells. The aetiology and progression of the disease are not well known, leading experts to coin the term ‘tendinopathy’ to describe the clinical presentation of the condition , 49. TheTendinopathy is traditionally considered an overuse injury caused by repetitive strain of the tendon , 18, 53.The consequences of tendon injuries are pronounced, and the underlying causes and tissue responses must be better understood in order to develop improved treatment and prevention techniques. Due to a lack of evidence-based management, treatment has traditionally been conservative, with surgery considered the last resort due to the lack of evidence for its efficacy , 57. ConChanges in the dimensions of tissues are often seen as a sign of injury and degeneration, as an increased area may suggest swelling, inflammation, and general disorder of the tissue. This is true in tendinopathy, where affected tendons have exhibited larger CSA compared to controls . CSA is σE = F/A0, where σE represents the engineering stress, F is the force, and A0 is the original area). According to Poisson’s effect, the transverse strain changes with axial strain, resulting in changes to CSA. In many situations, the engineering stress gives a reasonable approximation; however, even at low loads, a difference can be detected [σT = F/Ai), to better estimate the stress experienced by soft tissue. This requires measurement of both instantaneous and local CSA along a sample, which can be used to better define the relationship between stress and strain [One assumption commonly made when assessing the mechanical properties of tendon is that the CSA remains constant and is uniform along the length of the specimen. Thus, CSAs are measured at a single location or averaged over several measurements, thereby allowing for loads to be converted to engineering stresses post-testing  uses a combination of two-dimensional US (2DUS) and 3D motion capture to generate a 3D reconstruction of tissues. This technique has been shown to be accurate and reliable against MRI and phantoms , 117, anFan  demonstrWhile there are various ways to measure tendon in vivo, the choice of measurement technique must be evaluated for its suitability to the experiment. The importance of accurate measurement has been well described . In addiThe lack of consensus in the literature is a confounding factor in deciding which technique to use. For example, it has been reported that tendon dimensions differ between US and MRI , 113 andThis limitation is a recurring theme in the literature. The lack of high-quality control measurements when assessing the accuracy of in vivo measurement techniques makes it difficult to adequately compare between studies and between methods. This limitation is in part due to the inherent difficulty in acquiring physical measurements in vivo. A significant opportunity to acquire these physical measurements is in the form of intraoperative measurements. However, these measurements tend to be performed using graft sizing blocks and rulers, which do not provide sufficient accuracy to determine the ‘true’ dimensions of the tendon. Studies by Hamada et al.  and CoupMany advanced measurement techniques are incompatible with the in vivo environment. However, these may be useful in providing control measurements of phantom or intraoperative measurements.Historically, specimens were sectioned and traced, and the areas are measured using a planimeter . This me‘By estimation’ techniques have ranged from estimating the shape of the specimens and measuring the height and width of the sample to ‘fit’ the shape, to the gravimetric method of calculating the area based on the length and volume and even ocular micrometry . These tArea micrometry allows for irregularity in the shape of soft tissue by using adjustable blocks to compress the tissue into a channel with known size, from which the volume can be calculated –128; howRace and Amis  approachNon-contact methods of measuring tendon dimensions offer significant advantages in terms of speed and usability. Shadow amplitude was developed in the 1960s to measure whole tissues. Of the aforementioned techniques, it was identified as the only non-destructive method able to be adapted to measure local CSAs . It was Technological changes have led to improved non-contact devices, such as laser micrometres developed by Lee and Woo , 132, viLangelier et al.  developeTranslucency of tendon is a known issue in microscopic investigation of tissue and may inhibit laser-based measurement due to refraction of light at the surface. Langelier et al.  discusse2. It was noted that the improvements over other measurement techniques were negligible for rabbit ligaments and tendon [Moon et al.  trialledd tendon .Salisbury et al.  sought tThe importance of understanding the local variations in shape and area in soft tissues has previously been identified in relation to the development of CSA measurement systems , 141. ThPokhai et al.  developeRecent developments in 3D laser and structured light scanning (SLS), as well as advanced digital image correlation (DIC), have made these techniques affordable and suitable options for research.Hashemi et al.  utilisedThree-dimensional structured white light (SWL) scanners have been used by Nebel  to creatHayes et al.  reportedDIC has been used to investigate the deformation of biological materials under load –153. TheKnowledge of tendon dimensions has been shown to aid in the identification of tendon disorders and in planning for tendon grafting. Accurate measurement of tendon dimensions is important for calculating tendon stress and strain, as well as determining the difference between normal and degenerated tendon. Additionally, reliability, repeatability, and reproducibility are important considerations in the selection of measurement techniques, as they affect the ability to compare results within and between studies. Understanding these factors, as well as the environment of operation, is a key to determining the suitability of a measurement technique.A recurring theme in the study of in vivo tendon measurements is the lack of control measurements to confirm the accuracy of the described techniques, thereby limiting the ability to compare between techniques and studies. Consensus on the results of in vivo techniques in the literature is limited and is affected by the lack of control measurements to determine the accuracy of these techniques. This severely limits the ability to compare between techniques and studies. Therefore, the use of control measurements is recommended to improve the reporting of tendon dimensions in literature.


Every year > 450,000 individuals are diagnosed with cancer and approximately 350,000 die of it in India. The Ministry of Health and Family Welfare has released an Operational Framework for the Management of Common Cancers that highlights population-based cancer screening programs in primary health care facilities by health care providers (HCPs) and capacity building of HCPs. The purpose of this study is to present a low-cost training model that is highly suitable for resource-deficient settings, such as those found in India, through Extension for Community Health Outcome (ECHO), a knowledge-sharing tool, to enable high-quality training of HCPs.An in-person, 3-day training program was conducted for 27 HCPs in the tribal primary health care center of Gumballi in Karnataka, India, to teach the basics of cancer screening in oral, breast, and cervical cancer. The training of HCPs was done using the ECHO platform while they implemented the cancer screening, thus enabling them to build the much needed knowledge and skill set to conduct cancer screening in their respective communities.The knowledge level of the HCPs was tracked before the intervention, immediately after the 3-day training program, and 6 months after the ECHO intervention, which clearly showed progressive acquisition and retention of knowledge. A marked improvement in knowledge level score from an average of 6.3 to 13.7 on a 15-point scale was noticed after the initial in-person training. The average knowledge further increased to a score of 14.4 after 6 months as a result of training using the ECHO platform.ECHO is an affordable and effective model to train HCPs in cancer screening in a resource-constrained setting. At present, screening in India is limited to sporadic opportunistic screening for malignancies of the cervix, breast, and oral cavity. The Ministry of Health and Family Welfare has recently (August 2016) launched operational guidelines for screening and prevention of the most common cancers.2 This population-based cancer screening program is going to be rolled out using the existing health care providers (HCPs) at the various facility levels of the Indian Public Health System.The three most commonly occurring cancers in India are those of the breast, uterine cervix, and lip or oral cavity, together accounting for approximately 34% of all cancers.3 From past studies, we know that one-time training elevates the knowledge level of the attendees exponentially, but a substantial amount of knowledge is lost by 6 to 12 months after training.5 This highlights the need for repeat training programs to sustain the knowledge levels gained. Iterative training has been shown to help HCPs retain and use the knowledge obtained in training.6 However, such iterative training needs the HCPs to take time off their regular work and travel to district or state headquarters and is a financial drain on the health system.Although there is an emphasis on prevention of noncommunicable diseases (NCDs), HCPs are not actively involved in NCD control, which also includes cancer. However, training HCPs can make them invaluable in implementing the cancer screening program and making gains toward the larger mission of NCD control in the nation.8 Many ECHO projects are currently being conducted around the world for various diseases and health systems such as bone health,9 pain management, substance use disorder,10 and diabetes.11 The University of Texas MD Anderson Cancer Center has adapted the ECHO model to educate local providers in the management of cervical dysplasia in a low-resource region of Texas and to inform strategies for the management of advanced cervical and breast cancer in Latin America and sub-Saharan Africa.12 The goal of our study was to evaluate whether HCPs could sustain knowledge to implement population-based cancer screening.Extension for Community Health Outcome (ECHO) is an online knowledge-sharing platform aimed at moving knowledge rather than moving patients or doctors. ECHO was started by Dr Sanjeev Arora to treat hepatitis C patients in rural areas of the state of New Mexico.The aim of this study was to evaluate the knowledge scores of HCPs before and after training in cancer screening and to determine the impact of the ECHO model on knowledge retention after 6 months of training.13This pilot study was conducted at the Gumballi primary health care center (PHC), located in Chamarajanagar in the state of Karnataka in southern India. The PHC caters to a population of approximately 22,000 people, which is composed predominantly of a rural population with an approximately 17% tribal population that is managed by the Karuna Trust, a nongovernmental organization.The HCPs at the PHC who underwent training were as follows: one medical officer, one dentist, three staff nurses, five auxiliary nurse midwives (ANMs), three male health workers, and 14 accredited social health activists workers. Their roles and responsibilities of these HCPs in implementing the cancer screening program are listed in This is an interventional study of pre- and post-test design. This study was approved by the Institutional Ethics Committee at the National Institute of Cancer Prevention and Research .This training session was evaluated using a self-administered questionnaire in vernacular language (Kannada) and was pretested in a small group of HCPs. The questionnaire consists of 15 multiple-choice questions divided into various sections covering all aspects of cancer including general information, such as risk factors and etiology, and in-depth knowledge about various forms of cancer  and their symptoms, screening tests, detection methods, and treatment.The same questionnaire was administered anonymously before and after training. It was administered again 6 months after implementation of the ECHO platform, after the completion of the initial training program.The training was done by a trained gynecologist from the National Institute of Cancer Prevention and Research, in the vernacular language of Kannada, with which all of the HCPs were familiar.At the start of the training program, a baseline evaluation of knowledge was conducted using the predesigned questionnaire. The training started with sharing knowledge about cancer screening  and the purpose and objectives of cancer screening in the primary health care setting.The following topics were discussed using PowerPoint  presentations along with pictures: normal anatomy and physiology of the vulva, vagina, and cervix; cervical cancer epidemiology, risk factors, and symptoms; human papillomavirus and cervical cancer; diagnostic tests for cervical cancer ; abnormal cervical lesions; management of screen-positive patients; negative patients to be requested to return for repeat screening after 3 years; protocol to refer screen-positive patients to tertiary cancer care facilities for further evaluation and treatment; knowledge of treatment modalities; and sterilization procedure for all the devices used in the process.These topics were discussed along with hands-on demonstration of preparation of 5% acetic acid, the reagent used for the VIA test. The VIA test was also demonstrated to ANMs and staff nurses on women who attended the PHC. Because the visual impact of pictures is always better than just description, various pictures of different types of physiologic and pathologic cervical lesions were shown along with VIA-positive and -negative images for better understanding of diagnosis of cervical cancer. Throughout the training session, the trainees were encouraged to stop and clarify their doubts, as and when required. Toward the end of the training session for that day, many more queries raised by participants were clarified.On day 2, breast and oral cancers were discussed. The following topics were discussed using PowerPoint presentations along with pictures: breast cancer epidemiology; risk factors and symptoms of breast cancer; clinical breast examination; breast self-examination; abnormal breast lesions; and knowledge of treatment modalities. Role play of counseling sessions was done, and afterward, there was a question-and-answer session.Next, anatomy of the oral cavity, risk factors for oral cancer, and symptoms of oral cancer were explained. Some pictures of precancerous lesions were shown to the participants. The dentist posted at PHC explained detailed oral examination to all participants and demonstrated the examination on a patient who attended PHC. Treatment modalities of precancerous and cancerous lesions were explained.On the final day, all of the topics discussed were reiterated, as follows. Oral, breast, and cervical cancer risk factors and symptoms, examination procedures, and counseling were reviewed. Images of different types of physiologic and pathologic cervical lesions were shown, and each participant was asked to identify the lesions. Each ANM and staff nurse performed a VIA test, clinical breast examination, and oral examination and taught breast self-examination to women. Accredited social health activists did the motivation part for oral and breast examination through role play. Male health workers performed oral examinations on patients attending the PHC. ANMs, staff nurses, and male health workers filled out clinical forms to ensure that all the parameters were understood without any difficulty when filling out the form during screening. An ECHO session was conducted at Gumballi PHC to demonstrate how the telementoring aspect of the program would continue for further training on the ECHO platform. Positive outcomes and shortcomings of the training were discussed. After training, the same evaluation questionnaire was given to the participants of the training program to gauge the knowledge gained through training.After the initial 3-day training session, the training continued every 2 weeks on the ECHO platform. ECHO sessions were scheduled on the days when the HCPs visited the PHC for their weekly meeting. These sessions were conducted in the afternoon, when the HCPs had completed their field visits, so that they did not interrupt their routine work schedule. The PHC was equipped to conduct ECHO sessions, with a desktop computer, Web camera, microphone, speakers, and broadband Internet connectivity. During these sessions, all the topics discussed during the in-person training were reiterated. In addition, any new challenges encountered by the HCPs while implementing cancer screening in the population were discussed in detail. In particular, the challenges faced by the HCPs in implementing cervical cancer screening were addressed during these virtual sessions. A total of 10 ECHO sessions were conducted. Six months after the initial training and after 10 ECHO sessions, an evaluation was conducted using the same questionnaire that was used for before and after the 3-day training session . This evThe questionnaire consisted of 15 questions on five topics; three questions pertained to general information about cancer, seven questions were related to cervical cancer, three questions were related to breast cancer, and one question each pertained to oral cancer and sterilization of instruments. Each question had five choices with one right answer. Every right answer was given a score of 1 point, whereas wrong answers and unattempted answers were given a score of 0. Scores for each person were calculated according to the topic of question, as discussed earlier.Univariate analysis was performed to assess the significance of various determinants. Data were analyzed using SPSS software version 21 , and percent increase was calculated using the formula. The graph was prepared in Excel (Microsoft). Frequency distribution tables were generated. The number of questions asked per topic amounted to the highest score that could be allocated to that topic. Average scores were calculated.We compared the change in the knowledge level between the post-training questionnaire and the questionnaire given after 6 months of intervention . In thisOur study demonstrates that the knowledge level of HCPs can be improved by training in cancer screening, which can then be effectively sustained using an economical telementoring model such as ECHO for the much needed iterative training. To the best of our knowledge, this is the first study that has used a virtual training platform like ECHO to retain the knowledge of HCPs after training.ECHO has proven to be an effective tool to mentor and continue to train HCPs while they implement cancer screening in the community and to help troubleshoot any challenges they face in the field. ECHO is cost effective because it is on a virtual platform, thus eliminating the costs of travel for training, including resource persons, food, accommodations, and venue rentals, in addition to the costs of time taken off to travel to and attend such sessions. The total cost of setting up ECHO at a PHC includes only the additional cost of a good broadband or wireless Internet connection to an already existing desktop computer, which is available at all PHCs. These training sessions were conducted over ≤ 1 hour when the HCPs came to the PHC to attend their weekly meeting. Most importantly, ECHO eliminates travel time of the HCPs—time that can be used in screening the population. It also helps in reiteration of the study material and to update the cohort of any recent research development, which HCPs can then apply in the field to enhance the quality of cancer screening without having to wait for the next in-person training session.ECHO is a low-cost tool that can be easily accessed on a desktop or laptop computer, tablet, or smartphone with broadband or wireless Internet connectivity, and most PHCs are equipped with a desktop computer. ECHO can be set up by adding a Web camera, microphone, and speakers at nominal cost. Many HCPs also carry smartphones with them, through which they will be able to download the software required for ECHO, which is free of cost. With the improvements in Internet connectivity and the drastic reductions in cost of Internet packages in India, this tool can be easily accessed by HCPs working in remote areas, if needed. Often, subcenters are at a significant distance from PHCs or training centers. It is a challenge for HCPs to take time off from their busy work schedule for training that is organized at the district or state level at the respective capitals. If conducted on the ECHO platform, such training will prove to be beneficial because it can save cost, time, and effort on the part of trainers and trainees. In addition, ECHO clinics allow joint problem solving to develop practical solutions for implementation challenges in the field.The ECHO model enables trainers to convey the latest updates in research in the field to the distant HCPs, who would never be able to access such information on their own. Guiding the HCPs through the cancer screening process and troubleshooting any issues while implementing the cancers screening program will ensure high-quality screening, which is truly needed in resource-constrained areas.One of the limitations of our study is that we do not have a control group with which to compare the results. However, no such cancer screening training was conducted for HCPs in the state until our training program. We conducted this study in only one PHC because it was a pilot program. On the basis of the success of this program, we intend to carry out a similar training program in multiple PHCs around the country. The other limitation is the participation of only 18 HCPs at 6 months after intervention evaluation. This was a result of various causes including competing priorities such as vaccination programs being conducted by the state government. Although ECHO is an effective model for iterative training, the initial in-person training is vital and cannot be eliminated.In-person training is essential before HCPs implement a population-based cancer screening program because their knowledge about cancer and screening tests is minimal. The ECHO model is effective for continued training and reiteration of knowledge to accomplish effective population-based cancer screening in India. Using a widely spoken language, in this case Kannada, as the medium for teaching and conducting the training plays a huge role in the HCPs’ understanding of the information being taught.


Interprofessional education (IPE) is a concept that allows students from different health professions to learn with and from each other as they gain knowledge about their chosen professions and the professions of their colleagues. The purpose of this systematic review was to determine the effectiveness of IPE in the academic preparation of students of the health professions.A search was conducted of the PubMed and CINAHL databases using the following eligibility criteria: IPE including students from 3 or more healthcare professions, IPE exposure within academic coursework, measurement of attitudes and/or perceptions as outcomes, and quantitative reporting of results. Articles were screened by title, abstract, and full text, and data were extracted.The search yielded 870 total articles. After screening, 7 articles remained for review. All studies reported a positive impact of IPE on the education of students of the health professions.Evidence showed that IPE activities were an effective tool for improving attitudes toward interdisciplinary teamwork, communication, shared problem-solving, and knowledge and skills in preparation for collaboration within interdisciplinary teams. The World Health Organization has cited interprofessional education (IPE) activities as a powerful learning tool in efforts to improve healthcare delivery . EffectiDue to the complex nature of the health issues that many patients face, there is an increasing need for interprofessional collaboration among healthcare practitioners. Interprofessional practice contributes to knowledge of effective communication, the importance of distinguishing team roles, and efficient solutions for resolving conflict . HealthcIPE is a concept that allows students from different health professions to learn with and from each other as they gain knowledge about their chosen professions, as well as the professions of their future colleagues ,5. VarioThe objective of this systematic review was to determine the effectiveness of IPE among students of the health professions.This report examined previously published work. Therefore, it did not require approval from an institutional review board.The preparation of this systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, which outline specific criteria to be included in written format. The PRISMA tool consists of 27 items that have been created to ensure that essential information is expressed .Articles that were included in this review required participation in IPE activities by students from 3 or more healthcare professions, and the IPE exposure must have been included within academic coursework. Additionally, the studies must have reported quantitative measures of student attitudes and/or perceptions about their IPE experiences as outcomes.A search of the literature was performed in October 2018 using the PubMed and CINAHL databases. The search included terms related to healthcare, healthcare professionals, students, and IPE. Searches were limited to articles in the English language published within the last 10 years.Duplicate articles in both databases were eliminated from one set of the search results. Titles were screened by 4 of the authors divided into 2 groups. If title screening resulted in a tie, it was presented to the opposite group for a final decision. This process was followed by a screening of the abstracts utilizing the same methodology. After the abstracts were screened, the full text of the remaining articles was screened by all authors in order to determine which articles would be included in the review.The articles chosen from the screening process were analyzed by the authors for data extraction, and the findings were discussed with the group. The data extracted from the articles included the number of participants and the specific type of health profession training program in which they were enrolled, the type of interprofessional learning activity that was included, the specific outcome measures used, and the authors’ findings.The quality assessment tool for before-after (pre-post) studies with no control group was used to assess the quality of the articles included . This isThe article search yielded 870 articles, of which 24 were eliminated due to duplication. The titles of the resultant 846 articles were screened; through this process, 632 articles were eliminated, resulting in 214 articles for the abstract screening. Screening of the individual abstracts yielded 14 articles that underwent full-text screening. Following the complete screening process, 7 articles were selected to be included in the review .The 7 studies consisted of participants from a wide variety of health professions who took part in IPE activities within their academic coursework. The number of health professions included within each study ranged from 3 to 11, and the number of participants ranged from 30 to 291 .The results from the quality assessment tool for before-after (pre-post) studies with no control group are shown in The evidence from this review showed that IPE activities were an effective tool for improving attitudes toward interdisciplinary teamwork, communication, shared problem-solving, and knowledge and skills in preparation for collaboration with other members of interdisciplinary healthcare teams. All 7 studies yielded significant results in regard to IPE among students of the health professions and its positive impact on students’ attitudes related to interprofessional teamwork ,5,8-12. The works by Ruebling et al.  in 2014 Publications within this review were limited to the English language; therefore, important work published in other languages may not have been represented. Additionally, studies that consisted of participants from only 2 healthcare professions were excluded, which may also have led to the omission of important works.The information gleaned from these studies supports the incorporation of IPE in the educational preparation of healthcare professionals. Important aspects of healthcare delivery, such as working within a team environment, the ability to work together in a way that promotes shared decision-making to find positive solutions, effective interpersonal communication, and excellent knowledge and skills, may be positively influenced by the utilization of IPE activities across health professions within academic programs.


To describe the nursing capacity-building process within the foundation of a hematopoietic stem cell transplantation (HSCT) centre at the Hiwa Cancer Hospital (HCH), Sulaymaniyah, Iraqi Kurdistan, referring to nursing education, empowerment and leadership.1) Capacity building, the process by which individuals, organisations, institutions and societies develop abilities to perform functions, solve problems and set and achieve objectives, was implemented; 2) Nurse intervention was based exclusively on training and coaching on site, which is an innovative approach, since more often experts are brought to the centre to train people on site; 3) Nurses’ personal skills, knowledge and training needs in the field at the HSCT centre were preliminarily explored through an online survey, and intervention was also addressed considering personal preferences and challenges; 4) Clinical documentation implementation and nursing professional organisation improvements were developed.1) up to June 2018, 98 patients have been transplanted . The centre at the HCH represents the first in Kurdistan and the only centre carrying out allogeneic transplants in the whole of Iraq; 2) twenty-two staff nurses; three nurses in charge and one head nurse are employed in the HSCT centre. Nurses currently have good capability to manage daily care for patients in the HSCT centre. There are still training needs to be addressed; 3) and 4) implementation of organigram, job description and nursing plans. The situation, background, assessment, recommendation method for nursing handover was introduced. Nursing shifts duration was changed.Capacity building cooperation is a powerful means to successfully establish a high technology medical programme, and is a feasible method to enhance skills and expertise even in low resources contexts. The programme is still in progress and consolidating actions are still required. Nurses need to enforce professional leadership and work organisation. The HSCT centre local team needs to improve teamwork and shared decision making. Hematopoietic stem cell transplantation (HSCT) is an advanced procedure, performed on patients affected by a variety of haematological and non-haematological diseases, including acute leukaemia, malignant lymphomas, multiple myeloma (MM), thalassemia major (TM) and neuroblastoma. In an autologous transplant, stem cells are collected from the patient himself, frozen, stored and then given back to the patient after a conditioning regimen. In an allogeneic transplant, the patient receives stem cells from another individual who is a genetically matched donor . HSCT anIraqi Kurdistan  is a region with considerable oil and mineral resources but currently in a deep financial crisis due to the conflict with the Islamic State and the fall of the price of the oil. Iraqi Kurdistan is experiencing a huge immigration with a very high number of Syrian and Iraqi refugees living in the territory. The Italian Ministry of Foreign Affairs (IMFA) has been supporting the Kurdish people with Health and Social Projects. Due to the absence of HSCT activity in Iraqi Kurdistan and the cost to the government of sending patients  to India and Jordan for HSCT, in 2015, thanks to the financial support of the Italian Agency for Development Cooperation, an Italian non-governmental organization (NGO) submitted a capacity building proposal for the foundation of the first HSCT Centre in the Iraqi Kurdistan Region. Furthermore, the growing number of refugees has led to an increase in the number of people  affected by TM, raising the need for transplant activity within the Kurdish borders. In 2016, the project received other funds managed by a different Italian NGO, thanks to a second call of the IMFA—General Direction for Development Cooperation.Twinning between a centre in a high-income country and one in a low–middle income country (LMIC) can improve patient care significantly. Progress is made despite the critical challenges , 4. One This paper is about the foundation of the first HSCT unit in the Iraqi Kurdistan Region, from a nursing perspective and considering the nursing training programme, challenges and future developments.At the end of 2015, an exploratory mission by an Italian medical doctor, an expert in HSCT, was performed at the Hiwa Cancer Hospital (HCH)  in order to evaluate the presence of the essential criteria to start an HSCT activity, as elements and services are always needed in that clinical field , apheresis service, blood bank and immunohematology) . The sitFunding: the project was funded by the Italian Agency for Cooperation Development. Funds were administered consecutively by two Italian NGOs. HCH contributed to the final budget, providing existing instrumentation, laboratory facilities and accommodation for the volunteers.The capacity building process was chosen as the leading methodology to set up the programme: after experts’ involvement, local professionals were trained at HCH and continuous education was promoted as a strategy to keep the quality of work and care high , 8. ThisFrom the very beginning, efforts were dedicated to staff training: this takes the form of lectures in classrooms, bedside consultations, rounds in the clinics and coaching for focussed on the job training and task shifting .In April 2016, a 3-week educational course was provided to the all HSCT staff. It was delivered in English for the local professionals with an English proficiency between A2 and C1 .Five months after the training, to understand nursing adherence, satisfaction with the educational programme and perceived training needs, staff who were educated completed an anonymous questionnaire online, based on 25 questions , to evaluate the HSCT programme learning and implementation process. The questionnaire was especially created for this aim, considering the topics of the training course. In addition, the qualitative data were collected through open questions about personal satisfaction and perceived unmet educational needs.In addition, examination of bedside daily activity in the unit allowed Italian nurses to understand the emerging and existing problems. Interventions were carried out to enhance nursing organisation and leadership.Currently, the HSCT unit has eight beds (four double rooms) for pre-HSCT patients (conditioning regimen) and six single rooms for transplanted patients (high-efficiency particulate air filtered). They are all positive pressure rooms.n = 1; successful surgical treatment performed), cytomegalovirus (CMV) enterocolitis (n = 1), low-grade microangiopathy and posterior reversible encephalopathy syndrome.In June 2016, the first autologous transplant was performed in an MM adult patient . In October 2016, the first allogeneic HSCT was carried out on a child affected by TM. The donor was a compatible sibling . In May 2017, the first allogeneic HSCT on adults was performed in a patient with acute myeloid leukaemia. Up to June 2018, 98 HSCTs have been performed. Data are illustrated in All the patients had a tunnelled CVC (Hickman or Broviac line) inserted. Considering adults, all the CVC were removed within 2 months from the HSCT because of the high risk of infection, once at home. In fact, frequently the living arrangements of patients coming from rural areas or even the domestic settings of the ones living in urban areas did not meet the necessary hygienic criteria and the patients or caregivers were not able to take care of the devices or to identify signs and symptoms of infections to be promptly referred to the healthcare team.The educational programme was developed to provide haematology and HSCT education to the local staff . Education sessions were delivered by Italian or local experts in the field. At the end of the course, participants received a certificate of attendance. Content covered in the lectures related to HSCT indications, principles and practise; complications and follow up; infections and stem cells collection and processing . SeveralOral careCVC management–no-touch techniqueFood and diet around HSCTChemotherapy extravasation: prevention, management and treatmentPain management, 14Isolation rulesGVHD management, 17In the meantime, verification of clinical protocols dedicated to the transplantation programme was conducted. A preliminary list of nursing protocols has been developed:Training in the field used a coaching method: for almost the whole duration of the project an expert Italian nurse was in the unit, supervising nurses and addressing their training needs, to enhance knowledge and technical skills. Considerable effort has been made to enhance the teamwork within the HSCT team . This has been done through regular meetings: morning briefings (every working day), weekly seminars on clinical and scientific issues and transplantation meetings (once a week) with discussion of all the transplantation cases. The morning meetings were regularly attended by the head nurse and at least two of the three nurses working during the previous night shift. About 60% of the nurses attended the other seminars or meetings. The hospital nurse coordinator joined the BMT nursing staff to discuss specific topics requiring his involvement and responsibilities . The aim of these meetings was to enforce a decision sharing method and develop a good communication process. Moreover, these meetings enhanced the teamwork strategies because all the clinical professionals , registered nurses (RNs), pharmacists, lab technicians and apheresis team) attended the morning rounds and the afternoon outpatient clinic have been attended simultaneously by nurses and doctors in charge of the patients. Within the team meetings and the clinical training, a problem-solving attitude was encouraged and, at least partially, developed.n = 17/20 nurses). Nurses were mainly female (70.6%) with a median age of 23 years. Fifty-three percent of the sample were College Nurses (4-years University Education—bachelor of science in nursing (BSN)) and the others were Diploma Nurses (2-years Education). Almost all of them (94.1%) had previous work experience, mainly in a hospital setting (Emergency Department and Operating Room). Some of them were employed by HCH itself on the oncological units. One of the nurses worked as a pharmacist assistant. Eighty-eight percent of the HSCT staff nurses spontaneously applied to be in the team, motivated by the originality of this field in Iraqi Kurdistan and the opportunity to ‘give patients a second life’. All the respondent nurses would apply for the HSCT position again. Nurses reported their appreciation of their role in HSCT because of new and challenging technical skills and knowledge , teamwork and nursing responsibilities. On the other hand, they reported ‘responsibilities’, ‘lack of knowledge’ and ‘management of critically ill patients’ as the biggest challenges.The online survey dedicated to nurses had an overall response rate of 85% (drugs management (82%)critical care in BMT (70%)GVHD and its nursing care (41%)pediatric nursing (30%)devices, particularly referring to non-invasive ventilation techniques and peripherally inserted central catheters (52%)Nurses were asked to rate their perceived knowledge about different topics, illustrated in online survey about training and skills/knowledge showed that nurses perceived a high level of improvements on topics they were already familiar with  while they still needed training about HSCT specificities . Interestingly, 53% of the participants did not feel safe and confident about working with children, because of a lack of skills and experience.The results of the A clinical chart has been implemented with the local nurses and doctors, for daily patient assessment. Charts have been created for data registration: vital signs and fluid balance, drug prescription and administration, pain assessment and other daily events . Dedicated procedures and documentation have been produced to create an infection control programme.Nursing handovers tended to be very poor and resulted in fragmented nursing care. Nurses reported struggling with complex patients and the amount of detailed information to be collected and handed to colleagues. A new handover method, Situation, Background, Assessment, Recommendation (SBAR), was introduced and tested with a simulation of clinical cases, nursing handover and filling in the SBAR documentation provided , 19. It Kurdish health authorities are generally concerned about nursing training, absence of defined nursing competencies, roles and responsibilities. This results in lack of care and inefficient use of nurses in clinical care . Job desOutpatient clinic + infection control.Inpatients: HSCT unit + nurse educator.Inpatients: pre-HSCT unit + new admissions.An organigram, representing the responsibility tree, was depicted and built on a functional organisational concept  so that Up to October 2018, HSCT nursing staff includes 22 nurses (11 College Nurses + 11 Diploma Nurses), three Lead Nurses and one Head Nurse. International staff considered it to be essential that the nursing staff developed theoretical knowledge in the field and the ability to explain the rationale of its activity.The hospital direction and the Head Nurses shared this policy and different evaluations were organised up to October 2018. Nurses were evaluated with multiple choice questionnaires to test their knowledge and about nursing and the specific clinical field. Some nurses failed the test and were replaced together with others who were not interested in being involved in the professional activity requiring personal effort, study time and extra shifts.At the beginning of the transplant activity, nurses were working on a 12/24-hours schedule. Few patients were admitted in the unit and long shifts seemed to be functional, responding to the local personnel’s needs. As time goes by, the clinical activity in the unit has improved, requiring more energy and attention from nurses. Tiredness and a high risk of errors were reported. Thus, in May 2017, nurse shifts were changed to an 8-hour rotation. The introduction of the new rotation caused the resignation of 8 nurses out of 20, who did not want to share the new working times.A technical programme is ongoing to allow nurses to improve their technical skills. It includes a first aid course  and a basic life support course (including the obstructed airways management) held by an Italian nurse. High skills to be developed are: PICC insertion and the use of continuous positive airway pressure and noninvasive ventilation Transplant activity is slowly increasing: local doctors from HCH and other institutions are starting to identify HCH as a referral centre for their own patients. Moreover, a new regulation should be shortly approved so that autologous transplants are no longer authorised nor financially supported by the government if done outside the whole Kurdistan region.Considering the complexity of this medical field and the related nursing care, these results seem reliable and understandable.As of June 2018, nurses can autonomously manage routine activity and stable patients in HSCT, especially adults. They still need supervision and advice about unexpected events and how to manage clinical emergencies.Currently, over 100 documents have been published as official documents of the HSCT unit and included in the quality manual. The list includes procedures, clinical protocols, attachments and forms. Documents belong to functional units within the HSCT unit: collection and processing facilities, blood bank, clinical unit and nursing. Several flowcharts and algorithms (Alg.) have been produced and stuck on the unit walls to be rapidly consulted by staff .cultural differences emerged during the coaching training and the writing of the job description. Kurdish nurses are not used to caring for patients’ personal hygiene and patients do not expect them to do that. A signed agreement, involving the hospital’s general director, was needed to state when the nurses should deliver hygiene and personal care (as in the case for skin inspection for GVHD manifestations) [Some tations) . AnotherNurses are currently the most committed and well-defined professional team in all of the HSCT units and have started to be proactive, suggesting interventions and activities. Some conflict with medical staff is emerging together with the growing abilities and capacities of nursing staff. Nurses would like to be more actively involved in patients’ care plans and they are starting to be independent in making some clinical decisions . This is new to the local dynamics in the healthcare team and appears to cause discomfort to the medical staff. Moreover, the implementation of a written clinical documentation made nurses more aware of their professional responsibility related to the record of patient conditions and care delivered. This forced doctors to be more careful and precise about written drug prescriptions that were previously incomplete or even absent.The nursing job description defines criteria to be selected as an HSCT nurse and a training course has been defined. This made BMT nursing, a special field of practise, requiring dedicated competences and skills. This is something unique in the entire Kurdistan region, where specialisation courses exist  but do not have a real influence or application in practise. In the past 14 months, the nursing HSCT staff has changed several times due to all the reasons mentioned above. The training course was, then, entirely run three times by local staff.Currently, HSCT nurses are recognised as well trained by the entire hospital so they are often consulted for clinical issues. In June 2017, they started delivering courses for nurses and patients/caregivers regarding issues related to chemotherapy. Initially, these were dedicated to the units where neutropenic patients are admitted. Going forwards, the programme will be extended to the entire hospital to share evidence-based protocols and practise.Nurses reported that working alongside the international staff contributed to making nursing a challenging and gratifying discipline because they had the chance to identify their own competences and responsibilities. They asked for the training about scientific database consultation, critical appraisal of articles and literature review, showing an increasing empowerment and involvement even in higher fields, such as research. The co-operative project supported the hospital offering access to scientific databases and some journal subscriptions. However, information technology still represents a barrier to be faced: Internet connexion is not always available and IT technologies and resources are few. However, good IT consultants work in the hospital and have been in contact with the nursing staff, for the first time.shifts. At the time of writing, the changed implementation of shifts is still very new and probably not yet fully accepted. Some reasons can be identified: first, due to the financial crisis, nurses are not receiving their salary on a regular basis. Many of them need to have a second job to earn a decent salary. The new rotation seems to make this more difficult. Second, transportation challenges were reported: nurses mainly use taxis to reach their workplace. Shorter shifts mean more frequent shifts and higher costs. To solve this problem, the hospital administration has provided the nursing team with a car to be shared, thus taking care of transportation costs. This strategy has been approved by the nursing staff: they are happy about the solution, especially female nurses who were the ones also experiencing a cultural barrier that considers it to be strange and inappropriate for a woman to be out and about by herself during the evening or even the night.Less than one-third of the nurses reported limited compliance with 8-hour In June 2018, most of the nurses were doing two jobs because of money or professional local policies: due to this, they have to complete a 2 years post-BSN rotation, with paid shifts in different hospitals. They reported being very tired because of these activities and workload. The administration of HCH is trying to reduce the number of rotation hours due and to reward them with a small increase in salary. The situation is still in progress and it is unique: it demonstrates that BMT nursing care is considered to be highly specialised: the idea of a nurse as a professional, with a defined field of competence, is slowly developing among the nurses themselves and the hospital administration.Reagrding the literature, there are many cooperative and twinning projects involving hemato-oncology in LMICs, in many geographic areas . The main highlights of the programme presented in this paper are that the programme permitted the implementation a very high specialised field of care such as BMT, not focussing on primary care pathways that are very much common in the LMICs. In addition, this project was based on training in the field meaning that experts worked side by side with the local team. In this daily shared work, it was possible to promptly identify and manage issues, resources, areas needing implementation, cultural issues and differences, influencing the clinical job . This is not very common: many cooperative programmes are based on very brief periods of time spent in the foreign country, and mainly the support is provided by online supervision, shared documentation and clinical cases discussion. These strategies are currently used by the team in Kurdistan as well as a final step, before leaving them completely autonomous and just to be available in case of need.International cooperation has been successful in setting up the first HSCT centre in Iraqi Kurdistan. The capacity building programme proved to be a feasible method to enhance skills and expertise even in low resource contexts. Nonetheless, the programme is still in progress and improvements and consolidating actions are required.Nurses still need support and encouragement. They are currently developing a stronger leadership and the capacity to take care of their own professional and educational needs.Since 2016, HCH has been included in the European society for BMT (EBMT) network giving its staff the chance to be in contact with global experts and greater opportunities.Between 2016 and 2018, three nurses, three doctors and a biologist won scholarships  and received focussed training in different Italian HSCT Centres. Moreover, they had the chance to attend international HSCT meeting and network in their specific clinical field.HSCT is a highly specialised and challenging field of practise for nurses. This experience demonstrates that high specialty cooperative projects can be promoted and successfully performed in LMICs. Nurses can develop skills and knowledge and be leaders in their own institution, changing the current professional nursing role in their country, being considered as professionals and experts by their teams.Within this programme, enhancing the expertise of nurses working in BMT also influences nurses working in the oncology, haematology and paediatric unit. In fact, the nursing staff at the HCH is strongly committed to the care of patients and willing to improve the quality of care. Thus, it was possible to change daily practises in the out-patient and in-patients units . In fact, nursing care in BMT includes many principles of nursing in onco-haematology and patients undergoing HSCT are usually under the supervision of the onco-haematology staff, before they are admitted to a BMT unit. Thus, it was particularly important to try to also align their practise to the latest evidence and the newly created protocols and documentation of the BMT in the same institution.The authors declare the absence of any conflict of interest.This project was funded by the Italian Development Cooperation Agency (AICS), thanks to the support of two Italian non-governative organizations. It has also been funded by the local institution Hiwa Cancer Hospital.


Background: There is limited international as well as national research on suicide events in prisons and in forensic psychiatric hospitals. This retrospective study compares completed suicide events within these two high-risk populations in state institutions over a time period of 5 years from 2000 to 2004.Material and Methods: Data was collected through a nationwide survey: all forensic psychiatric hospitals within Germany were contacted via postal mail and received a questionnaire concerning the suicide events from 2000 to 2004. All federal lands of Germany were similarly assessed by a survey endorsed by the respective federal ministries of justice. All prison institutions (100%) participated in the survey, while 84% (53 units) of the forensic psychiatric hospitals nationwide contributed. A comparative statistical analysis was conducted using Fisher's exact test or the Mann-Whitney U-test (age). A multivariate logistic regression analysis was done to assess adjusted effects. For the Kaplan-Meier analysis, the months until suicide were analyzed followed by a Cox-regression analysis.Results: There was no statistically significant difference between the mean suicide rate in forensic psychiatric hospitals  and in the prison system . Patients who committed suicide in the forensic hospitals were, in comparison to the prison system, more likely to have committed a violent offense and have had a prior history of suicide attempts. The duration from admission into the institution to the suicide event was significantly shorter in the prison group. Also, younger people commited suicide earlier during their stay in a forensic psychiatric hospital or prison.Conclusions: While the results suggest a necessity to optimize data collection in the prison system , it is important to discuss the current discharge arrangements within the forensic hospitals. All European legislations recognize the concept of criminal responsibility as a prerequisite for punishment. Most European countries require some degree of reduced responsibility for the crime committed for entry into the forensic psychiatric system, while offenders with full responsibility can be subject to a prison sentence. In the UK, access to forensic psychiatric care is determined only on the basis of the mental condition at the time of assessment . RegardiAlthough specialized forensic institutions exist in many countries, most offenders with mental disorders are found in prison settings . The intIn correctional settings, suicide is often the single most common cause of death , 10. SuiSuicide rates per 100,000 prisoners have been found to range from 58 to 147 in a review of 12 studies from Western countries compared to figures of 16 to 31 in the general population  and prisIn a comparative study, Otte et al.  demonstrAlthough it is known that over the course of time, the number of patients in the forensic psychiatric system has increased significantly not only in Germany , 29 but This study compares completed suicide events in two high-risk groups: the group of prison inmates and of the patients in the forensic psychiatric institutions in Germany (2000–2004). Due to the immense lack of information on suicide events in forensic psychiatric hospitals we want to determine a suicide rate for this specific setting. In our opinion, it is important to understand the impact of institutionalization on suicidality in forensic hospitals as well as in the prison system.Our first hypothesis is that the rate of completed suicide events in forensic psychiatric hospitals is higher than that in prison. All patients in these settings suffer from a mental disorder and are exposed to the same general and specific risk factors as the prisoners are. Furthermore, in Germany, the duration of stay in a forensic hospital is potentially unlimited in comparison to a prison sentence. Considering this, we also hypothesize that in forensic hospitals, the time from admission to suicide is longer than in the prison system. This could lead to a new direction in suicide prevention in forensic hospitals pointing to the duration of stay in comparison to prison suicide, where literature suggests a higher risk in the first weeks of admittance. In addition, our aim is to describe the potential differences and similarities between the two high-risk groups.Forensic psychiatric hospitals in Germany consist of two departments. According to §63 StGB , the duration of stay depends on the treatment prognosis. If the patient is no longer “dangerous” to the public, the institutionalization may be suspended on probation. According to §64 StGB, offenders with a leading psychotropic drug dependence syndrome and sufficiently concrete therapeutic prospects are confined to special detoxification centers in forensic psychiatric hospitals. Here, the duration of stay is generally limited to 2 years. In this study, patients of both departments were included.Data was collected through a nationwide survey: all forensic psychiatric hospitals within Germany were contacted via postal mail and received a questionnaire concerning the completed suicide events from 2000 to 2004 in their hospitals. Attempted suicide events were not considered in this study. The questionnaires were sent directly to the head of the department of each forensic hospital. They were then completed directly by the medical staff of the forensic hospital and sent back to us via postal mail. This questionnaire was not standardized, and it asked for specific information regarding the patients who committed suicide: gender, age, nationality, relationship status, date of admittance to the hospital, date of suicide, school degree, legal status , type of offense, mental disorder, former detention, and former suicide events. The type of offense was categorized as violent offense and non-violent offense. Violent offenses included homicide, murder, manslaughter, aggravated battery, arson, rape, and sexual violence. Mental disorders were defined by the medical staff of the forensic hospitals, on the basis of the Tenth Revision of the International Classification of Diseases for the classification of mental and behavioral disorders.The numbers of prison suicide events on all federal lands of Germany were assessed by a survey endorsed by the respective federal ministries of justice. Data on the prison suicide events was collected through the use of a specific questionnaire. The respective federal lands rated the questionnaires. Information was attained using the reports on exceptional events from the routine documentation . Official data on occupancy rates in both institutions on a yearly reference date was used as a basis for the calculations of the mean suicide rates , 31. Forp < 0.0001). In 52% of the suicide events in prison, the reason for detention was a violent offense, while this was the case in 70% of the suicide events in the forensic psychiatric hospitals.A total of 53 from 63 (84%) forensic institutions completed the questionnaire, while all German prisons 100%) participated in the survey. In total, the sample consisted of 519 completed suicide events: 479 prison suicides and 40 suicides in forensic psychiatric hospitals  in the forensic psychiatric hospital, this was reported in only 7% in the group of prison suicides. In addition, former suicide attempts in the prison group were documented for 15% of the inmates who committed suicide, while this was known for 48% of the patients who committed suicide in the forensic setting. There was no statistical difference regarding the item of “former detention”.p = 0.005, 95% confidence interval: ), pre-trial status , and former suicide attempt .The multivariate logistic regression analysis found significant effects for gender (p < 0.0001) shorter in the prison group in comparison to the forensic hospital group  and a significant effect for age (p < 0.001), indicating that younger people tend to commit suicide earlier during their stay in a forensic psychiatric hospital or prison  . In comparison, the rate in the prison system was 130/100,000 prisoners per year . This difference is not statistically significant  offense and in 48% of the events, former suicide attempts were known.It is not surprising that most of the cases of reported suicide events in our study were committed by men. First, the male gender is an established risk factor , and secIn both groups, then majority of suicide events were commited by German citizens. Compared to the prison group, the proportion of non-German patients who committed suicide in forensic psychiatric hospitals was smaller, but this difference was not statistically significant. We didn't find comparable data regarding suicidality in forensic psychiatric settings, specifically regarding nationality.It is interesting that the proportion of suicide events during pre-trial detention was significantly higher in the prison group (53 vs. 18%), which matches the findings of Bennefeld-Kersten  that preThe duration of stay from the admission to the suicide event differed significantly in both groups. Suicide events occurred earlier in prison than in forensic hospitals. In addition, in both institutions, the younger inmates and patients committed suicide earlier than older ones. Thus, young age could be understood as a potential risk factor for early suicide in forensic hospitals and in prison. It may be discussed if the later onset of suicide events in the forensic hospitals correlates with the distribution of diagnoses in the groups. Suicide risk in men with schizophrenia increases with the number of admissions to a hospital and thus over the course of time , while iThere was a small amount of information available on potential mental disorders in the group of prison suicide events; in only 7% of the cases was a psychiatric disorder registered. This is in stark contrast to the international literature , 4, 22 tIn summary, institutional suicide events can be considered multifactorial in nature. While in a prison setting, suicide events tend to occur at an earlier stage of the secure confinement, it is important to consider the influence of specific life events as “imprisonment” and “conviction” on suicidal thoughts and impulses. The use of a specific screening tool for suicidality at the beginning of imprisonment, as well as during critical landmarks  consequently seems recommendable. Mental health in general, as well as the specific former psychiatric history, should be frequently addressed and documented by the personnel in charge. In forensic psychiatric hospitals, because of the plentitude of patients with schizophrenia, the natural (and often chronic and complicated) course of the disorder must be considered when interpreting the results. Apart from the higher suicide risk within this disorder itself, a possible lack of future prospects due to the uncertain duration of stay may relate to a higher suicide rate and later onset of suicide events in forensic psychiatric institutions. This should be a possible starting point for further research activities aiming for an optimization of suicide prevention in forensic institutions.Our study has a number of significant limitations. It was not possible to compare our findings with the total numbers within each institution separately, as this data was not obtainable. In addition, the presented numbers in the groups were very small and, in respect to certain items, incomplete (“former detention”). The data concerning mental disorders in prison seemed to be vastly underreported, which makes a comparison with inmates of a forensic psychiatric hospital, where every patient has a mental disorder, especially difficult.According to current legal regulation, no approval from the local ethics committee was required for the current study.AV and AO-W designed the study. AV, NaK, and AO-W collected the data. AV, NK, and AO-W analyzed and interpreted the data. AV and AO-W wrote the initial draft of the manuscript. AV and AO-W had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of data analysis. All authors have contributed to, read, and approved the final version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The partial success of an attempt to repeat findings in cancer biology highlights the need to improve study designs for preclinical research into metastasis and the targeting of cancer cells. Related research article Sheen MR, Fields JL, Northan B, Lacoste J, Ang L-H, Fiering S, Reproducibility Project: Cancer Biology. 2019. Replication Study: Biomechanical remodeling of the microenvironment by stromal caveolin-1 favors tumor invasion and metastasis. eLife8:e45120. doi: 10.7554/eLife.45120Cancer metastasis results from the escape of cancer cells from the primary tumor, followed by circulation in the blood or lymph system, and then seeding in distant organs. In 2011 researchers at the CNIC in Madrid and other institutions in Spain and the United States reported the results of in vitro experiments and experiments in mice that highlighted how the mechanical properties of the stromal cells around a tumor can influence cancer progression and metastasis . In partReproducibility Project: Cancer Biology, Fiering et al. published a Registered Report which explained in detail how they would seek to replicate some of these experiments (In 2015, as part of the eriments . The reseriments . Sheen eExperiments with mice and other animals are stopped at a 'humane endpoint' to prevent unnecessary suffering. The original experiments to monitor metastasis were stopped 75 days after the breast cancer cells had been implanted in the mice. However, the tumors grew much faster in the replication, which meant that the humane endpoint was reached after just 45 days. Tumor growth and metastasis are both nonlinear processes, with long periods of relatively slow growth being followed by periods of rapid growth. It is possible, therefore, that the low levels of metastasis seen in the replication are due to the duration of the experiments being significantly shorter than the original experiments.So what lessons might we take away from this Replication Study? First, the differences between the two studies with respect to the link between ECM remodeling in the primary tumor site and metastasis might indicate that factors other than ECM alignment have an influence on the outcome. In particular, the orientation of the ECM relative to the tumor may be important: it is known that the invasion of neighboring tissue by cancer cells, metastasis and poor prognosis are all supported when the ECM is perpendicular to the tumor surface, whereas a capsule-like orientation of the ECM parallel to the tumor surface can limit tumor cell evasion .Second, it is possible to design experiments where faster-than-expected growth of the primary tumor does not limit our ability to study metastasis. This can be done by monitoring each mouse individually and resecting the primary tumor during exponential growth, before the humane endpoint is reached, while also continuing to measure metastasis and other outcomes . PreclinThird, multiple experimental details that are difficult to control may affect tumor growth and metastasis. For example, tumor cells may change their growth characteristics, and grow more or less efficiently, as a result of continued culture. Other factors that influence tumor growth rates in mouse experiments include: the use of fetal calf serum to cultivate cells before implantation ; the conIn conclusion, we do not know for sure in which tumors and to what extent the expression of caveolin-1 and the subsequent remodeling of the ECM in the tumor stroma has an influence on metastasis. However, the efforts to replicate previous work in this field provide an opportunity for self-reflection, and make clear that there are strong reasons to refine workflows in preclinical metastasis research and to improve the way we carry out research into anti-cancer pathways and drug discovery.Peter Friedl was a peer reviewer for Registered Report  and the