The spread of early detection and the improvement of cancer treatment have led to an increased prevalence of cancer survivors, including in the working age population. Return-to-work (RTW) of cancer survivors has become a key issue for national cancer control plans. This study aims (1) to identify the factors that have an impact on RTW of cancer survivors and to draw a risk profile supporting health professionals in the screening of those at risk for barriers of RTW and (2) to sharpen these results with input from health, social security and academic Belgian experts and to provide evidence-based recommendations that facilitate RTW of cancer survivors.A rapid review was conducted, based on the methodology elaborated by The Knowledge to Action Research Programme and researchers from the University of York, including a quality assessment of retained studies. Next, the Delphi method was used to organize a consultation with experts in order to discuss, validate and complement the results.Forty-three out of 1860 studies were included. We identified nine risk factors grouped into four categories: socio-demographic, disease and treatment-related, work-related, and personal and subjective factors. Experts suggested dividing them into two even groups: factors which are modifiable and those which are not. The awareness of health professionals regarding the identified factors, a better assessment of work capacities, clarity on the rights and obligations of employers and workers alike, and the setup of a positive discrimination employment policy for cancer survivors were acknowledged as factors facilitating RTW of cancer survivors.The awareness of health professionals regarding barriers of RTW may improve the early identification of cancer survivors at risk for prolonged time to RTW and may allow early supportive intervention. Social and employment policies should be better tailored to support both employers and cancer survivors in the RTW process, providing incentives to positively discriminate cancer survivors on prolonged sick leave.The online version of this article (doi:10.1186/s13643-016-0210-z) contains supplementary material, which is available to authorized users. Over the last decades, progress in early cancer detection and treatment has led to a significant decrease of cancer mortality rates in developed countries . A lower1Despite the progress in treatment, cancer survivors have to live with adverse effects of treatment over the medium to long term. These effects—whether physical or emotional—can negatively affect all aspects of their lives, including their capacity to maintain a professional activity . In 2011The ability to remain  professionally active is an important added value to maintain a good quality of life, from an economic and social perspective . In BelgThe reintegration of cancer survivors into society needs to be one of the main goals of National Cancer Control Plans (NCCPs). At the moment, no such initiative exists in the Belgian NCCP. This has led the health, social security and employment policy decision-makers to call for evidence-based recommendations, in order to address this gap .First, this study aims to identify the factors that have an impact on return-to-work (RTW) of cancer survivors, and to draw a risk profile, that supports health professionals in the screening of those at risk to encounter difficulties to resume work. The second aim of the study is to sharpen these results with input from experts on health, employment and social security, in order to provide recommendations on RTW of cancer survivors.We conducted this rapid review, based on the methodology elaborated by The Knowledge to Action Research Programme  and by rworking age cancer patients (18–64), the indicators (I) are all those related to the employment of cancer patients, the comparison (C) is done among patients with different cancer sites or affected by other diseases or disease-free adults, and the outcome (O) of interest is RTW or employment. We limited our search to studies published in the period January 2000 until January 2015 We excluded studies involving patients with a poor prognosis  and focused on studies that primarily investigated the possible effects of cancer on RTW and employment status.To optimize the search, we framed a PICO. The population (P) is rehabilitation, employment status, survivorship, survivors, long-term survivors, cancer patients, return-to-work. In total, the primary search delivered 1860 papers as presented in the PRISMA flow chart of Fig. We searched through three databases: MEDLINE, Cochrane Library and Trip Database. The following MeSH and non-MeSH terms were used to perform the search: We first focused on systematic reviews and meta-analyses. The search resulted into 10 systematic reviews, three of which fitted our research questions: de Boer et al. 2009, van Muijen et al. 2013 and Banning et al. 2011 [Since we included all types of studies, we decided to assess their methodological quality and level of evidence, in order to value their relevance.To define the criteria for the quality assessment, we decided to merge three validated assessment tools: the checklist of Downs and Black, the MINORS instrument and the CASP checklist for qualitative research –14. The The quality assessment gave the following results: 10 studies scored a ‘high relevance’, 19 ‘a moderate relevance’ and 14 ‘a low relevance’ Table .In order to validate the factors identified through the literature review, we used the Delphi method  and presIn total, three rounds of discussion took place, and each lasted 3 h on average. The first session aimed at clearly defining the issue(s) to be addressed by the literature review, the target group and the timeframe and at identifying additional experts or stakeholders to be invited. The second session took place 4 months later and focused on the presentation of the first results of the literature review and on the results from unpublished national studies. In this session, experts and stakeholders were asked the following questions: “Do these results fit with your experience and expertise? To which extent do they apply in the Belgian context (what is their strength)? Which features from the healthcare or employment system would you add as impeding or facilitating factors?”The third session was dedicated to the final validation, combining the results from the literature, balanced and refined according to the Belgian social and economic context, and expert’s input.After each session, the content of the discussion was reported ad verbatim by the coordinator and sent to all participants who were given time to complete or refine their statements. The final versions of the reports, available in French and Dutch, were used to draft this paper.After merging the studies found in the three retained systematic reviews –11, and p ≤ 0.05). Results from the 12 studies were consistent and showed that in both female and male cancer survivors, aged over 50 and 55 years, respectively, there was an increased risk for delayed RTW or early retirement. In one study [Nineteen out of the 43 studies addressed age, 12 of which with significant results . Studies revealed that a high educational (university) level and a high income predict a shorter time to RTW. This association seemed particularly true for men. One of the studies [Since educational level and income are two related socio-demographic aspects, in analysis, the two factors were treated as one. Fifteen out of the 43 included studies considered the educational level and/or income, of which nine obtained significant results ( studies  reportedp ≤ 0.05). Results of the 11 studies converged and showed that cancer survivors with stomach, thyroid and skin cancers have higher employment rates compared to lung cancer, leukaemia and CNS cancer survivors. Others reported that kidney, bladder and thyroid gland cancer survivors had similar outcomes regarding time to job loss compared to disease-free individuals. In the studies also, a higher median time to RTW in breast cancer survivors was reported.Thirteen out of the 43 included studies investigated the impact of the cancer site on the employment outcomes of cancer survivors, of which 11 had significant results (p ≤ 0.05) regarding the association between stage and employment outcomes. In the case of advanced stages of the disease, all studies reported both a prolonged time to RTW and more disabilities that impeded the process of resuming work.Seven out of the 43 included studies dealt with the impact of the disease stage on the employment outcomes (being reported in stage or by the size of the tumour). Six of them had significant results (p ≤ 0.05). Of these, studies on breast cancer survivors reported differences in sick leave. Women who had a mastectomy or chemotherapy had a prolonged absence compared to women who underwent breast-conserving surgery.Twenty-one out of the 43 included studies reported on the association between treatment modalities and employment status of cancer survivors, of which 18 presented significant results  had a fourfold increased risk of not resuming work in the first (or even the three) following year(s) after treatment, compared to cancer survivors who had only surgery or one type of treatment. The responsibility of reduced cognitive ability caused by chemotherapy has been emphasized in all studies having questioned patients who had received chemotherapy. Also, in studies on the effects of chemotherapy, the association of reduced cognitive ability and chemotherapy treatment was reported.Eleven out of the 43 included studies addressed the impact of symptoms on the ability of cancer survivors to resume or maintain work. Only one presented quantitative results . Six repThirteen of the 43 included studies explored one or several aspects related to the type of job, sector of activity or job demands, 12 of which reported significant results. Several job characteristics were reported to influence the time to RTW of cancer survivors.Studies reported that manual work, self-employment and working in the private sector were factors that negatively affect the RTW of cancer survivors. One study  on canceStudies also revealed that the workload, as assessed by cancer survivors, was an important factor that negatively affected their RTW.Seven out of the 43 included studies explored the support provided by colleagues and employers to cancer survivors. In the quality assessment, all seven studies scored a low relevance, probably because of their study design, as they all collected data from a small group of respondents. Despite the weakness of the study designs, we observed some of the results to concur. That is, keeping in touch with colleagues at work helped cancer survivors to RTW  quicker. It also allowed a better understanding of colleagues regarding the cancer survivors’ limitations and helped them to tailor their work adequately as to fit their capacities to job demands . OppositSeven out of the 43 included studies examined the meaning of work for cancer survivors.Of these, the one with a high relevance (a survey of 646 women with breast cancer)  reportedThe one study with moderate relevance  observedThe five studies with a low relevance confirmed these tendencies and reported that the most impeding factors of RTW were symptoms, e.g. especially fatigue and pain, and the changed relations with colleagues.Each of the nine risk factors identified in the literature review was presented and discussed with the experts. In addition to these nine factors, experts added three main aspects to be considered in facilitating the RTW of cancer survivors: (1) the role of health professionals in the screening of cancer survivors at risk and their early sensitization to consider the existing options for RTW and to consult with their GP, social security physician and occupational physician; (2) a thorough and systematic evaluation of the (remaining) work capacities; and (3) revised employment policies that promote maintaining and hiring cancer survivors with prolonged sickness absence. These results are described hereafter.Based on the results of the literature review and from national unpublished work, the experts divided the four main categories of factors into two even groups, i.e. non-modifiable factors and factors open to positive change that may enhance RTW of cancer survivors.Regarding socio-demographic factors, experts acknowledged that cancer survivors aged over 50 years and less than 35 years had the highest risk of facing difficulties in employment. For the younger ones, difficulties mainly are related to their lack of experience combined with the seriousness of their disease. Also, reluctance of employers to keep them on board or to hire them, fearing relapse and lower productivity, may play a part. For the elderly, difficulties are mostly due to comorbidities, the burden of symptoms and side effects of treatment.Related to education, experts confirmed, as found in the literature, that cancer survivors with a low level of education often have physically demanding jobs and that the level of their income  does not present an important incentive to resume work, as to preserve a high standard of living.Regarding cancer site and stage, experts emphasized the importance to assess these together to draw conclusions on their impact on work ability. These two factors assessed together were believed to provide more accurate information related to the physical and emotional burden of the disease.The group of experts reported that in the Belgian context, it is important to take into account the region the patient lives in, as employment policy is a regional prerogative. The most remarkable and unique example comes from the Province of Limburg, where employers have been sensitized to physical, cognitive and emotional difficulties of cancer survivors and have been invited to sign a charter committing their company to better support the employed cancer survivors and to positively discriminate others by hiring them.Regarding the work-related factors, the consulted experts reported the need for more effort to adapt the workload  or the workstation to the capacity of survivors or to their treatment and recovery needs. In parallel, cancer survivors also need to be better prepared, physically and emotionally, offering them more medical and paramedical support.Experts emphasized that besides the physiological aspects, the workplace (e.g. the direct supervisor and colleagues) also needs to be prepared for the RTW of cancer survivors who can present temporarily limited capacities or emotional distress. Experts reported it is best to avoid a long period of rupture with the social and professional environment. That is, the length of the absence has a negative impact on the quality of the RTW, making it harder for cancer survivors who were alienated from the workplace to RTW.Small-sized companies and the private sector have been presented in the literature as risk factors for RTW of cancer survivors. However, experts have reported that national investigations and surveys have shown the contrary . ExpertsRelated to the more personal and subjective factors, though they are difficult to assess and modify, experts reported that in cancer survivors, addressing RTW issues at an early stage may positively influence the evaluation of the meaning of work. To simply address the work issue with cancer survivors just before the end of their (curative) treatment seems to already raise awareness and questions, for which they can be referred to social security advisers. Also, in case of good prognosis, the reassurance about their future abilities to resume their daily activities, can facilitate the RTW process.This rapid review aimed to collect information in order to provide recommendations to the Belgian government as to facilitate RTW of cancer survivors. Results were validated, rated and put into the Belgian context. Nine risk factors that seem to hinder RTW of cancer survivors were identified. In discussing the literature, the consultation of experts resulted into the categorization of the risk factors into two groups, i.e. those being modifiable, offering room for enhancement of RTW of cancer survivors, and those which are not. Next, based on expert consultation, we identified features of the healthcare, social security and employment systems that can be adjusted to minimize the (negative) influence of risk factors on RTW of cancer survivors.Most socio-demographic and health-related factors are non-modifiable, but their assessment is important, since it allows the identification of those workers who would be at risk, leading to the early planning of adequate rehabilitation plans, tailored to the physiological or psychosocial needs of the worker.The majority of studies that included breast cancer survivors reported very poor outcomes, at all stages. This brings us to the hypothesis that beyond site and stage, gender could be a risk factor. None of the studies included a report on gender differences. But we know from the literature that significant differences related to sickness absence between genders exist, presenting more and longer sickness absence among women, irrespective of cancer site . FurtherThe work-related, subjective and personal factors can be modified to ensure the ability and readiness of (ex) cancer patients to resume work. Indeed, the emotional and physical workload may include aspects that can be modified, temporarily or permanently. These modifications could be managed and coordinated by different health professionals, in agreement with the employer, the line manager, direct supervisor or the human resources service. The number of involved actors actually contributes to the lack of clarity on their prerogatives , and at intra-mural healthcare professionals in the early screening and referral to occupational supportive care. Albeit the identification of cancer survivors at risk is possible, there is a need to assess the feasibility and acceptability of such a role and to foresee adequate tools and training for those involved.The group of experts emphasized two more important aspects: first, the role of the remaining capacities of cancer survivors can lead to tailor-made rehabilitation and reintegration plan.The second important aspect concerns the responsibility of employers, medical advisors and occupational physicians in maintaining or hiring (ex) cancer survivors at the workplace. A better and systematic evaluation of the At the moment in Belgium, as in Spain and in Sweden, employers cover 1 month of sick leave pay, contrary to the Netherlands where 24 months are covered . The finThis rapid review and the insights from experts enabled the identification of a list of factors impeding the RTW of cancer survivors. The awareness of health professionals with regard to modifiable factors leads to early identification of survivors at risk and may support them better.From the healthcare system perspective, the list of risk factors that we drew Table  can be uAn improved communication between physicians is required to ensure tailored multidisciplinary care. Training to use existing and validated tools for assessing work capacities should be offered to health professionals and to all those actors involved in the RTW process.reasonable adaptation of the work or the role of actors. Social security and employment policies should support both employers and survivors. The Internal Services for Prevention and Protection at Work or the unions could develop recommendations on how to prepare and inform the direct supervisor and colleagues.At the moment in Belgium, no consensus clearly exists either on the The choice not to focus on randomized control trial studies made it impossible to quantify the strength of the identified factors. Nor was it possible to prioritize the factors according to their relevance related to the professional reintegration process of cancer survivors. We encourage future cohort studies to quantify, compare and demonstrate the impact of the risk factors.Unlike systematic reviews, at the moment, no quality insurance checklist exists regarding the rapid review process. The development of a PRISMA checklist for rapid reviews, taking into account expert opinions, could increase the quality and comparability of such studies.


Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA) in 2002. This reporting guideline was updated in 2010, and was applicable to a broader range of acupuncture research, including uncontrolled trials and case reports. Subsequent evaluations have noted limitations on the impact of STRICTA in the reporting quality of acupuncture trials, and the description of acupuncture details remains poor. Thus improvement in the efficacy of the STRICTA guidelines is called for.In order to facilitate the completeness and transparency of reporting on randomized controlled trials undertaken using acupuncture interventions, a consensus group of international experts developed the We explored the STRICTA guidelines from four aspects, including the development procedure, validity assessment, endorsement and adherence, and citation situation. Based upon these findings, we provided five potential suggestions for further development of STRICTA.STRICTA are valid reporting guidelines based on robust methodology and scientific content. However specific implementation strategies including: updating the STRICTA checklist; improving the STRICTA reporting efficiency; consistency with implementing the “Instructions for authors” for journals; establishing global STRICTA research centers; and expanding the STRICTA website, are needed. Such strategies will improve their utilization and impact positively on the quality of reporting on acupuncture research outcomes.The online version of this article (doi:10.1186/s12906-015-0714-4) contains supplementary material, which is available to authorized users. Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA) to address reporting issues of controlled trials using acupuncture. It was expected that the use of STRICTA would bring better quality reporting on acupuncture interventions, help the interpretation and analysis, and enable research replications.In 2001, an international group of acupuncture researchers developed a recommendation entitled et al explored the possible impact of STRICTA on the reporting of acupuncture interventions. They conducted systematic reviews with before-and-after approaches to examine whether more STRICTA items were fulfilled in randomized controlled trials (RCTs) over time. Their findings showed that the publication of STRICTA did not have the anticipated impact in that the description of acupuncture trials and the reporting quality remained poor [et al developed a comprehensive reporting quality assessment tool (Oregon CONSORT STRICTA Instrument) to evaluate the quality of reporting of RCTs on the use of acupuncture. It was found that although the STRICTA-based reporting improved by 17 % over the period from 1997 to 2007, there was a continual need to enhance the quality of reporting details specific to acupuncture intervention [Seven years after the initial introduction of STRICTA, Prady ned poor . Four yervention –5.In order to investigate a potential way forward to improve on the reporting, we considered the STRICTA guidelines from four different aspects , and have made recommendations for potential approaches for further development.Acupuncture in Medicine, Clinical Acupuncture and Oriental Medicine, Complementary Therapies in Medicine, Journal of Alternative and Complementary Medicine, and Medical Acupuncture). The STRICTA guidelines were subsequently published in late 2001 and early 2002 [Consolidated Standards of Reporting Trials (CONSORT) statement [In July 2001, a consensus group of international experts worked on the development of a standard for reporting on RCTs undertaken using acupuncture interventions. The experts comprised academic researchers and experienced acupuncturists, as well as editors of five key Complementary and Alternative Medicine (CAM) journals  [Through a multi-staged procedure of expert consultation, consensus workshops, draft editing, and finalization, the revised STRICTA guidelines were agreed upon, and the final document was co-published in 2010 by six medical journals (edicine) –19. As ahttp://www.equator-network.org) [Guidance for Developers of Health Research Reporting Guidelines [Template for Intervention Description and Replication (TIDieR) [Any reporting guidelines should meet minimum standards for validity including a robust methodology and scientifically validated content. A large number of reporting guidelines have been developed during the past decade ; howeverork.org) : 1) Guididelines  which pr(TIDieR) , which rhttp://www.stricta.info) [The STRICTA guidelines 2010  were useta.info)  were scata.info) , 23 intoFour relevant papers , 12–14 phttp://www.stricta.info/journals.html [Currently nine international medical journals endorse the STRICTA (2010), including seven CAM specialties and two general medicine journals. A full list of participating journals and their STRICTA publications are available at als.html .Instructions to Authors” on the websites of those journals that endorse the standard, and extracted relevant information. In addition, in order to examine the awareness of reporting guidelines of those journals, where there was mention of other research reporting guidelines and/or the EQUATOR network this was also extracted. Of the nine journals, six mentioned STRICTA in the online version of “Instructions to Authors”  referred to the current STRICTA website, but one referred to a URL currently inaccessible. Two journals included the full STRICTA (2010) Guidelines (one of which was via the STRICTA website). The EQUATOR network was referenced by only two of the endorsing journals, and other relevant reporting guidelines  were also recommended for use by six journals.In order to investigate adherence to STRICTA, we scanned “s” Table . HoweverThe availability of reporting guidelines by itself is not sufficient to drive improvements in the completeness of reporting: journal practices clearly have a major role to play , 27. HowAs fourteen years have elapsed since STRICTA were first published, we think it is timely to examine the utilization and potential impacts of STRICTA.Although it is possible to measure the impact of STRICTA in numerous ways, perhaps the most logical (if novel) approach is examination of citations for STRICTA. Furthermore a broad search of the literature has shown that previous reviews of STRICTA have been limited to English-language papers (and papers published in English) . We therWeb of Science and Scopus), one Chinese database  and one Japanese database  to explore citations for STRICTA 2002 and STRICTA 2010 from 2002 up to January 2015. For the literature in English, full titles of publications were used as search terms. Due to potential limitations on the dissemination of the English STRICTA in non-English speaking countries, the key word and/or the topic of “STRICTA” were used as additional search terms in both Chinese and Japanese databases. Two standardized spreadsheets were used to record the basic characteristics of articles regarding the publication year, study type, and the journal type  [In our approach we used Cited Reference Search and/or Citation Tracker (slight differences in different databases) for two English databases  the following concepts could be considered. Firstly, it may be beneficial to update the STRICTA checklist. As an official extension of the CONSORT statement 2010 (item 5), the content integrity of the STRICTA guidelines may be improved by embedding all the items suggested by the TIDieR guidelines (which specify a minimum set of items to describe an intervention) in the checklist. For the STRICTA to remain credible it may be helpful to collaborate with the TIDieR group, and to refer to the other relevant reporting guidelines in the EQUATOR network. The revision process might also benefit from solicitation of a wider range of expert opinions. It is argued by Chinese scholars that several Traditional Chinese Medicine characteristics of acupuncture  have not been clearly articulated in STRICTA . FurtherA second strategy may be to improve the efficiency of reporting by using a flowchart. As print journals have limitations on manuscript length, full reporting of all intervention details within one primary paper is almost impossible, especially when the study protocols or relevant papers have not been previously published. Although hosting the specific components in relevant websites may seem to be a rational solution, there are inherent risks such as resourcing, and responsibility for maintaining the website. Such problems were revealed in a recent review which evaluated the description of non-pharmacological interventions in randomized trials . A more et al [Instructions to Authors” for the relevant journal. In addition, an appropriate reference to the STRICTA guidelines and an accessible URL of the STRICTA web site, as author support resources would also be expected to be provided by the journal. As it is argued by some that reviewers and editors unfamiliar with STRICTA may be responsible for the missing details relating to acupuncture in the final publications [Thirdly, there is potential for journals that endorse STRICTA to be more consistent with their requirements for authors to adhere to the Guidelines. The benefits of reporting in accordance with the guidelines, and in publications that use the guidelines was reinforced by Hopewell et al  in theiret al , 38. Thiet al . We suggications , health ications .Although STRICTA is designed mainly for clinical trials, its application may also be usefully applied to systematic reviews. The reporting quality of RCTs has been shown to be better than that of systematic reviews , and forFourthly, as there is evidence of a lack of consistency among journals not published in the English language, it may be beneficial to implement a strategy where the Guidelines are more strictly endorsed in non-English speaking countries. Our findings showed growing levels of uptakes of STRICTA in the English literature, but the citations of STRICTA in Asian articles, such as Chinese and Japanese, appeared inconsistent and remain low. It seems that other strategies besides the STRICTA translations are worthy of consideration. As there is a large amount of acupuncture research undertaken in non-English-speaking countries, for example in China, Japan, Korea, and Germany, it may be feasible to develop a global network of STRICTA research centers. Possible missions of these centers would be to organize regular education and training workshops or seminars (including webinars) which concentrate on the efficient use of the STRICTA guidelines and good research reporting practices, seek users’ feedback, handle criticism from all stakeholders, and maximize endorsements and adherence to STRICTA in local journals. et al in which the authors noted the problems of non-transparent processes for the development of, and reporting on, guidelines [Fifthly, consideration could be given to updating and expanding the STRICTA website. Our findings show that details on key elements of the development procedure of the STRICTA guidelines, such as the pre-meeting activities and the face-to-face consensus meeting, is not publicly available (or is hard to locate). This finding concurred with the previous systematic review by Moher idelines . It may idelines . It may http://www.equator-network.org) [Finally, we recommend providing the linkage to the EQUATOR network (ork.org) , a reposA complete description of complex interventions is challenging ; the proWe believe that the quality of reporting of the interventions in clinical trials of acupuncture will only be improved by wide dissemination and strict adherence to the STRICTA guidelines. Beyond the current implementation measures such as co-publications and translations into other languages, more effort is needed to disseminate and promote the more widespread use of STRICTA. All stakeholders  should take a shared responsibility to collaborate to implement STRICTA to a greater extent. This will, in turn, ensure the quality of reports of acupuncture studies is improved, thus assisting the potential for research results to be efficiently translated into clinical practice. As there is a lack of sufficient funding for developing reporting guidelines , we partIt may be argued by some that if the reporting guidelines themselves are deficient, this would undermine their impact on improvement in scientific quality and thus the benefits to clinical practice. However, it may also be argued that improvements in the reporting guidelines are based on their wide utilization and exposure to critical appraisal. Continual improvement in the quality of reporting related to particular treatment interventions will also benefit clinical practice and drive research further forward.Guidance for Developers of Health Research Reporting Guidelines [TIDieR [TIDieR, and kept the 18 primary items of the Guidance for Developers of Health Research Reporting Guidelines. Our two validity checklists are helpful but do have limitations, as some items are optional and there is no weighting criteria of individual items. Hence, in order to reduce bias, we call for more researchers to participate in the evaluation, provide critical appraisements, and help with the optimization of the STRICTA guidelines.As yet there are no formal tools to assess the validity of the reporting guidelines; the idelines  and the  [TIDieR  are desi


Nycticebus spp.) are one of few known venomous mammals, yet until now only one published case report has documented the impact of their venomous bite on humans. We describe the reaction of a patient to the bite of a subadult Nycticebus kayan, which occurred in the Mulu District of Sarawak in 2012.Asian slow lorises , followed by intravenous injection of hydrocortisone (400 mg) and then intravenous fluid therapy of normal saline (500 mg). By 8 h10 the next day, the patient’s condition had significantly improved with no nausea, and with blood pressure and pulse rate stable.A handful of anecdotes further support the real danger that slow loris bites pose to humans. As the illegal pet trade is a major factor in the decline of these threatened species, we hope that by reporting on the danger of handling these animals it may help to reduce their desirability as a pet. The owner reported that although she had been nipped before, on this occasion, the loris bit deeply to the bone and injected venom. She reported symptoms arising within 30 minutes including: dull sensation from the feet, front leg, and belly; facial numbness; extreme swelling of the hands and feet, and associated red rash on the legs; inability to walk and difficulty breathing. The patient reported being admitted to Samitvej Sukhumvit Hospital Bangkok at 0500, injected with adrenaline, and released at 1500 the same day. She reported swelling and pain for an additional four days.This case, the second medically evaluated case of anaphylaxis following a slow loris bite and the first reported from of death , 10. Sevof death  reportedThe difference between our case, the Wilde  report aUnlike the captive  loris in the Wilde  case, thet al. [N. javanicus), and another villager from West Java Province reported the loss of an entire arm [N. bengalensis in Singapore; the bite took more than 20 days to heal. Whether this is due to the nature of the venom, species-specific characteristics of the venom, or consequence of poor healing conditions in the moist tropics is yet to be elucidated. We do know that slow lorises bitten in the wild suffer severe wounds that heal whereas loris wounds in captive lorises are one of the most common causes of death [Of interest are several descriptions of severe necrosis following loris bites. Streicher  and Nekaet al.  refer totire arm . One of of death . In the Internationally lorises are threatened with extinction due to habitat loss, hunting for traditional medicine and poaching for the illegal pet trade. Illegal pet traders, aware of the potency of loris venom, cruelly cut out the front teeth to make them more appealing pets . Recent Written informed consent was obtained for the publication of this report and any accompanying images.GM is a freelance wildlife ecologist based in Australia. He specializes in fauna surveys and wildlife monitoring programs across Australia and has also undertaken survey work in Southeast Asia, Central America and the Middle East. After his experience with the slow loris, he now works to raise awareness of the plight of this enigmatic species. KAIN is a Professor in Primate Conservation at Oxford Brookes University and Director of the Little Fireface Project, and international research consortium to understand and conserve Asia’s lorises.


Ensuring a sufficient nursing workforce, with respect to both number and relevant professional competencies, is crucial in rural Arctic regions in Norway. This study examines the continuing education (CE) of nurses who graduated from a decentralized nursing programme between 1994 and 2011.This study aims to measure the extent to which the decentralized nursing education (DNE) in question has served as a basis for CE that is adapted to current and future community health care service needs in rural Arctic regions in northern Norway. More specifically, the study aims to investigate the frequency and scope of CE courses among the graduates of a DNE, the choice of study model and the degree of employment with respect to the relevant CE.This study is a quantitative survey providing descriptive statistics.The primary finding in this study is that 56% of the participants had engaged in CE and that they were employed in positions related to their education. The majority of students with decentralized bachelor's degrees engaged in CE that was part time and/or decentralized.More than half of the population in this study had completed CE despite no mandatory obligation in order to maintain licensure. Furthermore, 31% of the participants had completed more than one CE programme. The findings show that the participants preferred CE organized as part time and or decentralized studies. Globally, there is a shortage of human health resources , and theNorthern Norway is facing specific challenges regarding health care service delivery . ApproxiFurthermore, the challenges of developing skilled and motivated health care personnel are critical to the provision of high-quality health services worldwide. The need for health services is complex because of the ageing population, which has complex health service needs that require advanced levels of care . ContinuThis study presents an overview of the CE undertaken by nurses who graduated from the DNE in northern Norway between 1994 and 2012. It aimed to measure the extent to which the DNE has served as a basis for CE that is adapted to the current and future community health service needs. Specifically, this study investigates the frequency and scope of CE among graduates from the DNE, the choice of study model and the degree of employment in accordance with the applicable CE in rural Arctic areas in northern Norway.Competency is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served(The Coordination Reform (CR)  implemeng served. The guig served emphasizThe CR was implemented because of the challenges of ensuring both equity and quality in health care services in a country characterized by a scattered population and 430 small municipalities . There aThe Norwegian nursing education is a 3-year bachelor (BA) programme covering 180 European Credit Transfer System (ECTS) points ,16 proviOnce RNs are qualified with a BA in nursing, no CE is required to uphold the licensure. However, university hospitals require CE in anaesthetic nursing, operating theatre and intensive care nursing before employment in such units.The term CE is frequently used synonymously with continuing professional development, continuing professional education, life-long learning and knowledge transition . In thisCE programmes for RNs are provided by universities and university colleges in Norway . MastersIn the Arctic region, CE programmes are generally offered as full-time programmes on campuses, yet certain programmes are provided on a part-time basis . Formal This study is a quantitative survey providing descriptive statistics.The participants in this study attended a DNE at The Arctic University of Norway (UiT), from 1990 to 2011. The graduated RNs responded to a questionnaire posted to their private addresses. From the sample of 356 former students, 41 questionnaires were returned because of unknown addresses. In total, 233 respondents returned questionnaires. Because of the missing participants, the findings cannot be considered representative of the entire population of graduated RNs who attended the DNE.Because no validated questionnaires related to the study topic were found, the researchers developed a questionnaire . The queThe data were collected from RNs who had graduated from the DNE at the UiT. A research assistant recorded and coded the data from the questionnaires to ensure the anonymity of the respondents. An informational letter and a pre-paid return envelope were enclosed with the questionnaire. One reminder was posted to non-responders 2 weeks after the original reply date.www-01.ibm.com/software/analytics/spss/) with cross-sectional and descriptive univariate statistics for multiple variables. Summary statistics included frequency, mean, percent, and range for the cross-sectional and descriptive data  approved the study , and the department head for the university's Department of Health and Care Sciences allowed the study to occur by releasing the names and addresses of the former students. The participants were then informed of the purpose of the study in an explanatory letter, and they were asked to participate in the study by completing and returning the provided questionnaire. The respondents’ informed consent was given by completing and returning the questionnaire in the attached envelope. Confidentiality and anonymity were guaranteed.Of 315 RNs who graduated from the DNE between 1990 and 2011 and received questionnaires, 233 answered the questionnaire, for a response rate of 73.9%.Improved access to CE is important for nurses in rural areas because the cost of travel and time away from home increase the effort necessary to attend CE programmes , and proOn a national level, 21% of the nurses have completed more than one CE course .The participants predominantly attended CE programmes closely related to municipal health care responsibilities, such as geriatric and mental health care. Public health care and midwifery services are also important tasks in municipal health services, but fewer positions are available in these areas relative to elderly and mental health care. To have a hospital specialization, RNs must have a clinical specialization of 60–90 ECTS points in areas such as intensive care nursing, anaesthetic nursing, paediatric care and operating room nursing. Clinical specializations of shorter duration cover 15–30 ECTS points. Four of the respondents held master's degrees in subjects related to nursing management and clinical specializations. The categories of CE are presented in Part-time and/or decentralized models of CE programmes are preferred among the respondents holding a bachelor's degree in nursing from a decentralized education model in northern Norway.In municipal health services, RNs constitute the largest proportion  of healtCE is available to a large proportion of the nursing workforce in Norway, as most of the programmes  are deliAccording to the CR , local sIn this survey, 56% of the respondents had completed CE . Thus, tIncreasing life expectancy in conjunction with chronic conditions will also increase the need for competence in palliative care. Philips et al.  reportedTo achieve the aims of the Coordination Reform, RNs will need to attend CE as a part of life-long learning  to ensurIn rural Arctic regions of Norway, municipal health services are the primary providers of services to the population . Before In total, 186 CE programmes were completed by the RNs in this study (n = 131). Furthermore, 41 of the respondents completed more than 1 CE, and 17 completed 3 different CE courses. These results show the need for competencies to safeguard and facilitate the execution of complex and varied tasks in municipal health services. The findings indicate that the participants experienced a need for more than 1 specialization in a health service that is characterized by diverse and complex tasks and responsibilities. The findings can also be understood to indicate the ongoing need to upgrade skills and competencies from a life-long learning perspective . Based oSince the 1990s, delivery of study programmes has been characterized by policy guidelines emphasizing distributed education and blended learning . The parSmyth et al.  found thHealth care services are rapidly changing ,26,33. PThe results of this study are limited because of the lack of data from RNs who did not receive the questionnaire and non-respondents. The small sample and the fact that no similar studies were found for comparisons imply that the findings cannot be generalized.In a society with a rapidly changing health care system, policy makers and nurse educators must evaluate and revise their approaches and programmes to ensure that current and future needs are met. Multifaceted and interdisciplinary CE programmes based on health care needs in rural Arctic areas should thus be developed. Close cooperation between educational institutions and health services should be established to secure that CE programmes match the needed competencies for rural Arctic health services. Furthermore, regulatory, financial, personnel and professional support interventions are vital factors to promote and sustain an appropriate workforce in rural Arctic areas. Research among RNs working in rural areas is recommended in order to obtain knowledge about factors that promote and limit conducting CE. This is pivotal in order to contribute to equity in rural Arctic and urban health services with respect to the special challenges in the Arctic regarding recruitment, retention and relevant professional knowledge and competencies.The results of this study show that more than half of the participants were motivated for CE. Regarding future needs for competencies in rural Arctic health services, this relatively high number needs to increase. The fact that 31% of the participants attended more than 1 CE is understood as a consequence of the wide range of tasks and responsibilities for RNs in rural Arctic areas. Furthermore, the findings indicate that the participants’ previous experiences with a decentralized, flexible study model were positive and that they preferred CE organized as part time and/or as decentralized studies.


The World Health Organization emphasized that climate change is a significant and emerging threat to public health, especially in lower income populations and tropical/subtropical countries. However, people in Asia and Africa were the least likely to perceive global warming as a threat. In Vietnam, little research has been conducted concerning the perceptions of effects of climate change on human health.The aim of this study was to explore the perceptions on climate change and its impact on human health among people in Hanoi.We applied a combined quantitative and qualitative approach to study perceptions on climate change among people in Hanoi. A total of 1,444 people were recruited, including 754 people living in non-slum areas and 690 people living in slum areas of Hanoi. A structured questionnaire was used to collect quantitative data on their perceptions. In a parallel qualitative study, two focus group discussions and 12 in-depth interviews (IDs) were carried out involving 24 people from both slum and non-slum areas.The majority of the respondents in the study had heard about climate change and its impact on human health . About one third of the respondents reported that members of their family had experienced illness in the recent summer and winter compared to the same seasons 5 years ago. The most common symptoms reported during hot weather were headaches, fatigue, and dizziness; hypertension and other cardiovascular diseases were also reported. During cold weather, people reported experiencing cough, fever, and influenza, as well as pneumonia and emerging infectious diseases such as dengue and Japanese encephalitis.The observed high level of awareness on the links between climate change and human health may help to increase the success of the National Prevention Program on Climate Change. Moreover, understanding the concerns of the people may help policy makers to develop and implement effective and sustainable adaptation measures for Hanoi City as well as for Vietnam as a whole. Climate change has already been observed globally, including increases in air and water temperatures, reduced number of frost days, increased frequency and intensity of heavy downpours, a rise in sea level, and reductions in snow cover, glaciers, permafrost, and sea ice . In 1990The link between population health and climate change has been demonstrated by scientists who stated that climate change poses a wide range of risks to population health. As noted by the World Health Organization, climate change is not just a threat to biological systems and the environment but a ‘significant and emerging threat to public health’, especially in lower income populations and tropical/subtropical countries , 4. ProtVietnam is one of the developing countries most affected by climate change , 16. TheNonetheless, to the best of our knowledge, very little research has been conducted in Vietnam about peoples’ perceptions of the effect of climate change on human health. Therefore, the aim of this study was to explore Hanoian's perceptions of climate change and its effect on their health. We also looked for relationships between peoples’ perceptions and a set of socioeconomic characteristics that might influence their knowledge and experiences. The results of this study could be used to inform decision makers in Hanoi responsible for developing or adapting programs of action to cope with climate change.Hanoi, the capital of Vietnam, comprises 29 districts, 10 of which are urban and 19 rural. As of 2009, Hanoi's population was estimated at 6.5 million, of which 2.6 million (41%) lived in urban districts  consisted of area of household (slum or non-slum area), education, age group, and socioeconomic status. Significance level was set at Data for qualitative study was transcribed and described according to the above themes of perceptions of climate change and perceptions of impact of climate change on health. Content analysis was used to analyze the interview transcripts. Content analysis is a procedure that organizes transcribed material by coding interview data into blocks that represent a common theme or new themes that emerge from the interviewee quotes .People invited to participate in the study were asked for their informed consent before they were interviewed. They were also informed that they were free to withdraw from the study at any time.Of the 1,444 people selected by the sampling procedure, 1,412 (97.8%) were available and agreed to participate and provided information. Most of the survey respondents had heard about climate change and its impact. The proportion of people having heard about climate change and its impact on people was significantly higher in the non-slum area. Among those who had heard about climate change in both slum and non-slum areas, two thirds were aware of the term ‘climate change’ and interpreted it as storms, floods, deep cold, and long heat waves. The impact of climate change most often mentioned by both groups was the impact on human health (92.3 and 91.3% for slum and non-slum areas). However, a small number of respondents were not aware of this term and mentioned other phenomena such as earthquakes or air pollution as manifestations of climate change  .This incorrect perception was explained by one man, aged 39 years: ‘I heard from the television that the areas affected by earthquake are often highly vulnerable to climate-related problems, for example more extreme storms’.Key informant interviews and FGDs revealed that most of the people perceived that ‘climate change is occurring’ in the form of changes in rainfall and temperature; one third perceived it as a change of strong wind during the rainy season. We also asked the participants in a FGD to give their views on the main reason for the changes in climate. Two people said, ‘It is caused mostly by human activities’, while others mentioned that ‘it is caused by both the natural changes in the environment and human activities’.As shown in Participants in the qualitative study were also asked to reflect on their perceptions of any changes in illness among their family members compared to 5 years earlier. Most of those interviewed said that their family members, especially children, became ill more easily now than in the past.One member of health staff said: ‘The number of children coming to our health center has been increasing recently. The hot and humid environment in Hanoi is favorable for the development of bacteria, insects and other disease carriers such as flies and rats. Children are more vulnerable to these diseases’.According to the respondents, the most common symptoms due to hot weather were headache, fatigue, and dizziness. Hypertension and other cardiovascular diseases were thought to have become more common. The symptoms most often mentioned in relation to cold weather were cough and fever, while common diseases were pneumonia, influenza, and emerging infectious diseases such as dengue fever or Japanese encephalitis.For example, a male house owner said, ‘Nowadays, there is an increase of infectious diseases such as dengue fever. It occurs periodically throughout the year. The hot weather and rainfall have created favorable conditions for breeding of dengue mosquitoes’.Most of those living in non-slum areas and more than half living in slum areas had some perception of changes in climate and of the effect on health. According to the majority of respondents, climate change is occurring and results in an increase of temperature during the summer and decrease of temperature during the winter, compared to 5 years ago. They also had the perception that storms, floods, deep cold, and long heat waves were manifestations of climate change. Similar observations have been reported in various reports about climate change from both developed and developing countries, including Japan, Laos, the Philippines, Bangladesh, and several African countries , 12, 23.Different population groups may have different opinions about climate change , 23, 24.The impact of climate change on human health has been seen in several studies worldwide , 28. In A high level of awareness on the links between climate change and human health may help to increase the success of the National Prevention Program on Climate Change. Moreover, understanding the concerns of the people may help policy makers to develop and implement effective and sustainable adaptation measures. However, our results also showed that about 10% of respondents had incorrect ideas, that earthquakes or air pollution were caused by climate change. According to Dr. Nguyen Huu Ninh of the Center for Environment Research Education and Development of Vietnam , not many people in Vietnam fully understand about climate change, even among policy makers. Many people are still not aware of the threats of climate change and misunderstand that it is primarily an environmental issue .Re-framing climate change as a threat to human health can be the principle catalyst for people to change their behavior and increase their support for climate change mitigation and adaptation policies. The public will need to learn to appreciate that climate change is a public health issue too, as it affects people's health and well-being.This study does have some limitations. Firstly, the study was conducted in four urban districts in Hanoi, so it may not represent the perceptions elsewhere in Hanoi or Vietnam. Secondly, the issue under study is complicated and difficult to measure. People's perceptions on changing health could not be checked against real data on health and possible changes related to climate in this study. Such data could be collected in future to give more precision to the accuracy of people's perceptions. There is, however, evidence for an increase in emerging infections such as dengue and Japanese encephalitis in recent years, as shown in another study by Toàn et al. .Our study revealed that a high proportion of surveyed respondents in the capital city did perceive that climate change is occurring and could mention possible consequences such as heavier rainfall and higher temperatures. The most influential factor on such awareness was the level of education of the respondent; those with higher education had more knowledge about climate change and its impact. Recent climate change has affected Hanoi and may have led to an increase in health problems for its inhabitants.More education and raising awareness is needed for people to appreciate that climate change is a public health issue. A high level of awareness on the links between global environmental change and human health may help to increase the success of the National Prevention Program on Climate Change.The Program should make use of community groups as climate change communication channels, especially for the more excluded groups such as women and people with lower levels of education who presently have less awareness of the issues.Understanding local perceptions and concerns will assist policy makers to develop effective communication strategies for each location in Vietnam. In this regard, the main lessons emerging from this study are the following:


In order for Informed Consent to be ethical and valid each clinical trial participant must be able to make a voluntary decision to participate, free from pressure or coercion. Nonetheless, many factors may influence the decision reached, and such influences may be different for male and female volunteers. Being aware of these differences may help researches develop better processes for obtaining consent that safeguard the right of autonomy for all participants. The goal of this study was to evaluate potential gender-based differences in the factors influencing clinical trial participation.This cross-sectional study was conducted in the Northeast region of Minas Gerais, Brazil, in October 2011. A structured questionnaire was administered to 143 volunteers  screened for participation in a clinical study of an investigational functional food with potential anthelminthic properties. Answers regarding their decision to participate in the study were compared, by gender, using chi-square and Mann Whitney tests. Odds ratios (OR) was used to measure association.A majority of subjects  listed the desire to collaborate with the development of a product against parasitic worms as their main reason for participation. Females were significantly more likely to report a decision influenced by friends, family, or researchers . Females were also significantly more likely to report a decision influenced by general altruistic considerations . There was no difference, by gender, in the report of decisions influenced by informational meetings, understanding of the disease, or the availability of medical treatments or exams. There was also no difference in knowledge of the rights of research participants.Study results indicate that there is a strong difference between male and female participants regarding social influences on the decision to participate in clinical research. Further research into the impact this may have on autonomy is warranted. Obtaining the informed consent (IC) of potential clinical trial participants is an essential element of ethical human subjects research . A critiAdditional research is needed to better understand the external influences on taking voluntary decisions to participate in clinical trials, as well as the groups that are more or less likely to experience these influences, and what steps may be taken in the informed consent process to minimize coercive influences and maximize autonomous decision making. Of particular concern in some clinical trial settings are patriarchal family structures that may result in gender-specific decision-making processes, with female participants under pressure to please male family leaders , 8.The concept of gender encompasses the structure of social relationships institutionalized in a society, as well as individual relationships between males and females, their commonly accepted roles in society, and their everyday habits . TherefoBased on this background, the hypothesis of this study is that the decision to participate in a clinical trial may differ by gender due to preexisting social influences on the decision-making process. There are socio-behavioral arguments, particularly relevant to clinical trials in Brazil, which support this hypothesis. Historically, many families in rural communities in Brazil have been structured with significant gender inequality and male dominance over the behavior of female family members , 17. SucPrevious studies have examined the factors influencing the decision of individuals in these communities to participate in clinical trials, as well as levels of knowledge about the rights of research subjects , 20; howA Double-blind, Randomized, Controlled Evaluation of the Tolerability of a Proprietary Oil Blend in Adults Residing in Areas Endemic for Helminth Infections” , the primary objective of which was to evaluate the tolerability of a functional food with potential anthelminthic qualities among adults residing in an area of Brazil endemic for intestinal helminth infections. The clinical study took place in the district of Novo Oriente de Minas in the northeastern region of Minas Gerais, Brazil, between October 2011 and March 2012. Written informed consent was obtained from all volunteers who were willing to be screened for participation in the study. The Informed Consent Form (ICF) was read to each participant, or if the subject was literate, staff and the participant read the ICF together. After obtaining IC, participants were asked to complete a structured questionnaire to evaluate factors influencing their decision to participate in the clinical study.Across-sectional, descriptive and quantitative questionnaire was administered to willing individuals who were consented to participate in a clinical study entitled “One hundred and sixty-nine volunteers were screened for participation in the clinical study, and all agreed to complete the questionnaire. Due to a delay between obtaining consent and the administration of questionnaire (approximately one month), only 143 of 169 originally consented participants completed the questionnaire sub-study. The reasons cited for non-participation following original consent were anticipated or actual change of residence to a different municipality (15) and the withdrawal of consent (11).Study approval was received from the ethical review committees of the George Washington University, the René Rachou Research Center, and the Federal University of Minas Gerais.Data for this sub-study were collected via a structured questionnaire designed to evaluate the voluntariness of the decision to participate in the clinical study and the participants’ understanding of clinical research. In order to assess voluntariness, the questionnaire addressed possible factors influencing the decision to participate in the study, the primary reason for participating, and the level of knowledge about the rights of research participants. Questions were developed with guidance from other questionnaires used for similar purposes , 32, theQuestionnaires required 10 minutes on average for completion, and were administered in an interview format in the residence of the participant. Interviewers were trained to standardize the information collection process in order to maximize reliability of the data and minimize bias. Following collection the data were coded and entered into an SPSS database . Error was reduced through independent double data entry. In the case of discrepancies, the data in question were confirmed by review of the original questionnaire.Data were described by absolute frequency, while quantitative variables were summarized by arithmetic means and standard deviations. Differences in socioeconomic, demographic, and motivation factors were compared by gender using the chi-square test for categorical data and the independent t-test for quantitative variables. Odds ratios (OR) and associated 95% confidence intervals were used to estimate associations, and the chi-square test used to verify the significance of associations.To analyze the combined influence of all factors on the decision to participate in a clinical study an index called the General Influence Index was created. Each factor marked as influential to a participant’s decision received a score of 1, and each factor marked as not influential received a score of 0. Eight factors of influence were assessed for each participant, resulting in total scores ranging from 0 to 8. Higher scores indicated greater influence by the evaluated factors and lower values lower influence. At the extremes, a total score of 0 indicated that the participant was not influenced by any factors evaluated in the questionnaire, whereas a total score of 8 indicated that the participant was influenced by all factors evaluated. Differences in the General Influence Index for male and female participants were compared using the Mann–Whitney test. P values of less than 5% were considered statistically significant.th grade education, had a family income of over BRL 545 (USD 247), and accessed electronic media more than five times per week. There were no statistically significant differences in demographics or socioeconomic status by gender  as a motivation for participating in the clinical trial . The potential of overcoming difficulties in accessing medical care was cited by 39.8% of male participants and 35.7% of female participants as being a motivating factor for study participation. A small minority of subjects in both gender groups  indicated the desire to please researchers as a reason to participate in the study Figure . DiffereIn regard to the rights of study participants, both male and female participants were most knowledgeable of the right to withdraw from the clinical trial at any time. Participants also displayed an understanding of the availability of medical treatment that was available outside of participation in the clinical study . Knowledge of these rights did not significantly differ by gender (p =0.46). Both genders showed low knowledge of the right to continued medical treatment to which they are otherwise entitled in the case of withdrawal of consent, with no significant difference by gender p =0.82)  with a median of 7.0, and male participants an average of 5.0 (SD: 1.97), median of 5.0 . Both gender groups included participants with minimum scores of 0 (no influence) and maximum scores 8 . Figure Female participants were significantly more likely than male participants to report a decision influenced by friends, family, the researcher and the altruism , while no decision-influencing factors were significantly more likely among male participants (Table The results of this study indicate that male and female participants differed in the factors that influenced their decision to participate in the ABS-00-02 clinical trial. Most importantly, female participants were more likely than male participants to have their decision to participate influenced by their partner or their families. These results support the theory that the decision to participate in clinical research may be impacted not only by the individual characteristics of participants, but also by interpersonal relationships and social norms of the community where the study is conducted . A similIt is hypothesized that the influence of a partner or family member is greater in clinical trials taking place in developing countries than in developed countries. This is supported by the results of a multicenter study of hypertension and genetics, in which no female participants enrolled in the US solicited the advice of a partner before participation, compared to 47% of female participants enrolled in Nigeria that solicited the advice of their partner prior to participating in the trial .Taken together, these studies indicate that the need or desire to solicit advice from domestic partners or other family members as part of the decision making process may be greater for female participants in developing country settings, but is likely to be observed to varying degrees across settings. Although undue pressure by a partner or family member to participate or not participate in clinical research is an impediment to autonomy, consultation in itself may not be an impediment, and may in fact lead to greater contemplation and a more informed decision. Additional research is needed to understand the extent to which the differences in social influence seen in this study relate to undue pressure or coercion, or a difference in personal preference to seek consultation with others prior to reaching an independent decision.Although low for both groups, another important finding of this study was the difference, by gender, in the reported influence of researchers on the decision to participate. It is thought that in Americaninhas, the site of the ABS-00-02 study, this researcher influence is comparable to the influence of health professionals on patient decisions in hospital environments. This interpretation is supported by studies conducted in the same region, which found that participants considered study researchers as equivalent to standard care medical doctors , 31. A nThis study also examined motivating factors for voluntary participation, and may provide insight into the question raised by Diniz  in an biAlthough cited as a challenge to IC in developing countries, nearly all participants in this study understood the right to withdraw from the study at any time. Unfortunately, a lack of knowledge regarding alternatives to participation may compel subjects to continue in studies despite knowledge of the right of withdraw , 42. TheA possible limitation of this study is non-differential recall bias due to the 1-month lag between volunteers making a decision to participate in the clinical trial and administration of the sub-study questionnaire. Intentional responder bias is also possible if volunteers perceived a particular response to be more desirable. The potential for these biases was minimized by a relatively short 1-month lag time between clinical trial consent and questionnaire administration, the use of simple closed-end questions, administration of the questionnaire in a standardized fashion by trained interviewers, and exclusion of highly sensitive or culturally taboo topics.In certain settings female participants appear to be more likely than male participants to solicit the advice of domestic partners or family members prior to providing consent to participate in clinical trials. Even where the informed consent process meets national and international standards if such consultation includes undue pressure the right to autonomy will be impacted , 46. GivAdditional evaluation of gender differences on the decision to voluntarily participate in clinical research is thus warranted, particularly to examine the degree to which differences in social influence relate to undue control over or decreased autonomy of female participants versus individual preference for external consultation or decision-making support. Additional research to assess the perception of voluntariness using validated instruments such as the Decision Making Control Instrument is also encouraged .


Quadrilateral space syndrome (QSS) is a rare nerve entrapment disorder that occurs when the axillary nerve and posterior circumflex humeral artery (PCHA) become compressed in the quadrilateral space. QSS presents as vague posterolateral shoulder pain that is exacerbated upon the abduction and external rotation of the shoulder. Diagnosis of QSS is difficult because of the vague presentation of QSS. In addition, even though MRI and MR angiography can be used in QSS diagnosis, there is currently no “gold standard” diagnostic imaging studies for QSS. In this case report, we describe a novel ultrasound-guided technique for a diagnostic quadrilateral space block and present a case where the diagnostic block was used to diagnose QSS. We believe that a diagnostic block of the quadrilateral space is a useful adjunct in the evaluation of patients with suspected QSS, especially in cases where examination findings and other diagnostic modalities are indeterminate. Quadrilateral space syndrome (QSS) is a rare disease caused by the compression of the axillary nerve and possibly the posterior circumflex humeral artery (PCHA) as they course together through the quadrilateral space. QSS is a diagnosis that is difficult to achieve by history and physical exam alone and there are no tests which considered the diagnostic “gold standard” .In some musculoskeletal conditions, due to the low specificity of physical examination maneuvers and lack of a good diagnostic study, local anesthetic blocks often remain as the diagnostic “gold standard” , 3. In tIn this case report, we describe a novel ultrasound-guided technique for a diagnostic quadrilateral space block and present a case where the diagnostic block was used to diagnose QSS. We believe that a diagnostic block of the quadrilateral space is a useful adjunct in the evaluation of patients with suspected QSS, especially in cases where examination findings and other diagnostic modalities are indeterminate.A 42-year-old female with no significant past medical history presented to our outpatient musculoskeletal clinic with left posterior-lateral shoulder pain for 9 months. Prior to her consultation in our clinic, she was evaluated by the orthopedic surgery service, who ordered an MRI of the left shoulder. The MRI revealed edema and enhancement of the teres minor muscle and posterior part of the deltoid muscle. There was also evidence of degeneration of the superior glenoid labrum. The patient desired nonoperative management, so a subacromial bursa steroid injection was performed by the orthopedic surgeon, which was ineffective for pain relief. The patient was then referred to our service for further nonoperative management.On presentation to our clinic, the patient reported pain in the posterior-lateral shoulder. The pain was described as a constant dull ache without any radiation. Examination of the shoulder revealed a mildly protracted left scapula with no visible atrophy of the shoulder or spine musculature. Range of motion was within normal limits, and results of Neer, Hawkin, Scarf, and Obrien test were negative. There was mild tenderness to palpation at the posterior aspect of the glenohumeral joint inferior to the acromion. Due to the examination findings and MRI evidence of edema in the teres minor and posterior part of the deltoid muscles, we suspected a diagnosis of QSS. An ultrasound-guided local anesthetic block of the quadrilateral space was performed. Subsequent to the block, the patient received 100% relief of her pain and the diagnosis of QSS was confirmed.The patient was placed in a prone position with both upper extremities at her side. The transducer was placed medial to the glenohumeral joint in an orientation perpendicular to the axis of the spine of the scapula . The spiAnatomically, the quadrilateral space is bordered superiorly by the teres minor, laterally by the proximal humerus, medially by the long head of the triceps tendon, and inferiorly by the teres major . These bThe signs and symptoms of QSS are typically secondary to the compression of the axillary nerve. On examination, patients may demonstrate point tenderness in the quadrilateral space . PatientDiagnosis of QSS using history and physical exam alone is difficult since it may present as shoulder pain that is not necessarily localized to the quadrilateral space. Furthermore, paresthesias may or may not be present in patients suffering from QSS . AdditioCurrently, there is no “gold standard” diagnostic test for QSS. However, magnetic resonance imaging of suspected QSS patients is often used as it may show selective fatty atrophy of the teres minor and possibly the deltoid muscles, both of which are innervated by the axillary nerve , 10. In In addition to MRI, angiography may be used as a diagnostic test for QSS. There is currently no data regarding the sensitivity of angiography in diagnosing QSS. Multiple studies have used subclavian arteriogram or MR angiography to confirm QSS diagnosis , 12. PCHWith the advancement of ultrasound, sonographic evaluation has also become a recent option to aid with QSS diagnosis. Axillary nerve compression can manifest as teres minor fatty change in ultrasound as well as diffuse increase in teres minor echogenicity, in addition to a small loss of muscle bulk with the absence of rotator cuff abnormalities , 14, 15.In the case above, our patient presented with nonspecific signs and symptoms of posterior-lateral shoulder pain. On MRI, the patient had findings of enhancement in the teres minor and posterior part of the deltoid muscles. Even though these findings were suggestive of QSS, the patient had evidence of degeneration of the superior glenoid labrum, a condition which may also manifest as posterior-lateral shoulder pain. These nonspecific findings ultimately led to our decision to perform an ultrasound-guided diagnostic block of the quadrilateral space. After the successful block, we were able to confirm the rare diagnosis of QSS.We strongly believe that the procedure is an extremely helpful adjunct in the evaluation of patients with suspected QSS. More studies should be conducted to assess the sensitivity and specificity of an ultrasound-guided diagnostic block of the quadrilateral space in the diagnosis of QSS.