International Committee of Medical Journal Editors (ICMJE) warned against sole reliance on NHST to substantiate study conclusions and suggested supplementary use of confidence intervals (CI). Our objective was to evaluate the extent and quality in the use of NHST and CI, both in English and Spanish language biomedical publications between 1995 and 2006, taking into account the International Committee of Medical Journal Editors recommendations, with particular focus on the accuracy of the interpretation of statistical significance and the validity of conclusions.The null hypothesis significance test (NHST) is the most frequently used statistical method, although its inferential validity has been widely criticized since its introduction. In 1988, the Original articles published in three English and three Spanish biomedical journals in three fields  were considered for this study. Papers published in 1995-1996, 2000-2001, and 2005-2006 were selected through a systematic sampling method. After excluding the purely descriptive and theoretical articles, analytic studies were evaluated for their use of NHST with P-values and/or CI for interpretation of statistical "significance" and "relevance" in study conclusions.Among 1,043 original papers, 874 were selected for detailed review. The exclusive use of P-values was less frequent in English language publications as well as in Public Health journals; overall such use decreased from 41% in 1995-1996 to 21% in 2005-2006. While the use of CI increased over time, the "significance fallacy"  appeared very often, mainly in journals devoted to clinical specialties (81%). In papers originally written in English and Spanish, 15% and 10%, respectively, mentioned statistical significance in their conclusions.Overall, results of our review show some improvements in statistical management of statistical results, but further efforts by scholars and journal editors are clearly required to move the communication toward ICMJE advices, especially in the clinical setting, which seems to be imperative among publications in Spanish. H0 - which, generally speaking, establishes that certain parameters do not differ from each other. He was the inventor of the "P-value" through which it could be assessed [significance testing theory considered the p-value as an index to measure the strength of evidence against the null hypothesis in a single experiment. The father of NHST never endorsed, however, the inflexible application of the ultimately subjective threshold levels almost universally adopted later on .The null hypothesis statistical testing (NHST) has been the most widely used statistical approach in health research over the past 80 years. Its origins dates back to 1279 [hypothesis statistical testing. The Neyman-Pearson approach is based on the notion that one out of two choices has to be taken: accept the null hypothesis taking the information as a reference based on the information provided, or reject it in favor of an alternative one. Thus, one can incur one of two types of errors: a Type I error, if the null hypothesis is rejected when it is actually true, and a Type II error, if the null hypothesis is accepted when it is actually false. They established a rule to optimize the decision process, using the p-value introduced by Fisher, by setting the maximum frequency of errors that would be admissible.A few years later, Jerzy Neyman and Egon Pearson considered the Fisherian approach inefficient, and in 1928 they published an article  that wouH0, is known. With these data the P-value is computed. Finally, the null hypothesis is rejected when the obtained P-value is smaller than a certain comparative threshold  and it is not rejected if P is larger than the threshold.The null hypothesis statistical testing, as applied today, is a hybrid coming from the amalgamation of the two methods . As a maThe first reservations about the validity of the method began to appear around 1940, when some statisticians censured the logical roots and practical convenience of Fisher's P-value . SignifiAlthough there are very comprehensive works on the topic , we list• The P-values are used as a tool to make decisions in favor of or against a hypothesis. What really may be relevant, however, is to get an effect size estimate  rather than rendering dichotomous true/false verdicts -11.• The P-value is a conditional probability of the data, provided that some assumptions are met, but what really interests the investigator is the inverse probability: what degree of validity can be attributed to each of several competing hypotheses, once that certain data have been observed .• The two elements that affect the results, namely the sample size and the magnitude of the effect, are inextricably linked in the value of p and we can always get a lower P-value by increasing the sample size. Thus, the conclusions depend on a factor completely unrelated to the reality studied  ,14.• Those who defend the NHST often assert the objective nature of that test, but the process is actually far from being so. NHST does not ensure objectivity. This is reflected in the fact that we generally operate with thresholds that are ultimately no more than conventions, such as 0.01 or 0.05. What is more, for many years their use has unequivocally demonstrated the inherent subjectivity that goes with the concept of P, regardless of how it will be used later -17.• In practice, the NHST is limited to a binary response sorting hypotheses into "true" and "false" or declaring "rejection" or "no rejection", without demanding a reasonable interpretation of the results, as has been noted time and again for decades. This binary orthodoxy validates categorical thinking, which results in a very simplistic view of scientific activity that induces researchers not to test theories about the magnitude of effect sizes -20.Despite the weakness and shortcomings of the NHST, they are frequently taught as if they were the key inferential statistical method or the most appropriate, or even the sole unquestioned one. The statistical textbooks, with only some exceptions, do not even mention the NHST controversy. Instead, the myth is spread that NHST is the "natural" final action of scientific inference and the only procedure for testing hypotheses. However, relevant specialists and important regulators of the scientific world advocate avoiding them.International Committee of Medical Journal Editors  incorporates the following recommendation to authors of manuscripts submitted to medical journals: "When possible, quantify findings and present them with appropriate indicators of measurement error or uncertainty . Avoid relying solely on statistical hypothesis testing, such as P-values, which fail to convey important information about effect size" [Taking especially into account that NHST does not offer the most important information , many experts recommend the reporting of point estimates of effect sizes with confidence intervals as the appropriate representation of the inherent uncertainty linked to empirical studies -25. Sincct size" .As will be shown, the use of confidence intervals (CI), occasionally accompanied by P-values, is recommended as a more appropriate method for reporting results. Some authors have noted several shortcomings of CI long ago . In spitAlthough twenty years have passed since the ICMJE began to disseminate such recommendations, systematically ignored by the vast majority of textbooks and hardly incorporated in medical publications , it is isignificance fallacy is present, an inertial deficiency that consists of attributing -- explicitly or not -- qualitative importance or practical relevance to the found differences simply because statistical significance was obtained.In addition to assessing the adherence to the above cited statistical recommendation proposed by ICMJE relative to the use of P-values, we consider it of particular interest to estimate the extent to which the Many authors produce misleading statements such as "a significant effect was (or was not) found" when it should be said that "a statistically significant difference was (or was not) found". A detrimental consequence of this equivalence is that some authors believe that finding out whether there is "statistical significance" or not is the aim, so that this term is then mentioned in the conclusions . This meInternational Committee of Medical Journal Editors recommendations, with particular focus on accuracy regarding interpretation of statistical significance and the validity of conclusions.The general objective of the present study is to evaluate the extent and quality of use of NHST and CI, both in English- and in Spanish-language biomedical publications, between 1995 and 2006 taking into account the We reviewed the original articles from six journals, three in English and three in Spanish, over three disjoint periods sufficiently separated from each other  as to properly describe the evolution in prevalence of the target features along the selected periods.Obstetrics & Gynecology and Revista Española de Cardiología); Public Health and Epidemiology  and the area of general and internal medicine . Five of the selected journals formally endorsed ICMJE guidelines; the remaining one (Revista Española de Cardiología) suggests observing ICMJE demands in relation with specific issues. We attempted to capture journal diversity in the sample by selecting general and specialty journals with different degrees of influence, resulting from their impact factors in 2007, which oscillated between 1.337 (MC) and 9.723 (BMJ). No special reasons guided us to choose these specific journals, but we opted for journals with rather large paid circulations. For instance, the Spanish Cardiology Journal is the one with the largest impact factor among the fourteen Spanish Journals devoted to clinical specialties that have impact factor and Obstetrics & Gynecology has an outstanding impact factor among the huge number of journals available for selection.The selection of journals was intended to get representation for each of the following three thematic areas: clinical specialties  analytical papers, or (3) articles that address theoretical, methodological or conceptual issues. An article was regarded as analytical if it seeks to explain the reasons behind a particular occurrence by discovering causal relationships or, even if self-classified as descriptive, it was carried out to assess cause-effect associations among variables. We classify as theoretical or methodological those articles that do not handle empirical data as such, and focus instead on proposing or assessing research methods. We identified 169 papers as purely descriptive or theoretical, which were therefore excluded from the sample. Figure Forty-nine of the 1,092 selected papers were eliminated because, although the section of the article in which they were assigned could suggest they were originals, detailed scrutiny revealed that in some cases they were not. The sample, therefore, consisted of 1,043 papers. Each of them was classified into one of three categories: (1) purely statistically significant. It was deemed that an article uses CI if it explicitly contained at least one confidence interval, but not when it only provides information that could allow its computation . Probability intervals provided in Bayesian analysis were classified as confidence intervals  since what is really of interest here is whether or not the authors quantify the findings and present them with appropriate indicators of the margin of error or uncertainty.To estimate the adherence to ICMJE recommendations, we considered whether the papers used P-values, confidence intervals, and both simultaneously. By "the use of P-values" we mean that the article contains at least one P-value, explicitly mentioned in the text or at the bottom of a table, or that it reports that an effect was considered as substantive, relevant or important. The use of the term "significant effect" when it is only appropriate as a reference to a "statistically significant difference," can be considered a direct expression of the significance fallacy [In addition we determined whether the "Results" section of each article attributed the status of "significant" to an effect on the sole basis of the outcome of a NHST . Similarly, we examined whether the term "significant" (applied to a test) was mistakenly used as synonymous with  fallacy  and, as We also assessed whether the "Conclusions," which sometimes appear as a separate section in the paper or otherwise in the last paragraphs of the "Discussion" section mentioned statistical significance and, if so, whether any of such mentions were no more than an allusion to results.To perform these analyses we considered both the abstract and the body of the article. To assess the handling of the significance issue, however, only the body of the manuscript was taken into account.The information was collected by four trained observers. Every paper was assigned to two reviewers. Disagreements were discussed and, if no agreement was reached, a third reviewer was consulted to break the tie and so moderate the effect of subjectivity in the assessment.Clinical Medicine, Primary Care, and International Journal of Epidemiology) was performed. The results of this pilot study were satisfactory. Our results are reported using percentages together with their corresponding confidence intervals. For sampling errors estimations, used to obtain confidence intervals, we weighted the data using the inverse of the probability of selection of each paper, and we took into account the complex nature of the sample design. These analyses were carried out with EPIDAT [In order to assess the reliability of the criteria used for the evaluation of articles and to effect a convergence of criteria among the reviewers, a pilot study of 20 papers from each of three journals  were found to be analytic, while the remainders were purely descriptive or of a theoretical and methodological nature. Five of them did not employ either P-values or CI. Consequently, the analysis was made using the remaining 869 articles.The percentage of articles that use only P-values, without even mentioning confidence intervals, to report their results has declined steadily throughout the period analyzed Table . The perWhile the percentage of articles referring implicitly or explicitly to significance in an ambiguous or incorrect way - that is, incurring the significance fallacy -- seems to decline steadily, the prevalence of this problem exceeds 69%, even in the most recent period. This percentage was almost the same for articles written in Spanish and in English, but it was notably higher in the Clinical journals (81%) compared to the other journals, where the problem occurs in approximately 7 out of 10 papers Table . The kapThe percentage of papers mentioning a numerical finding as a conclusion is similar in the three periods analyzed Table . ConcernA similar pattern is observed, although with less pronounced differences, in references to the outcome of the NHST (significant or not) in the conclusions Table . The perThere are some previous studies addressing the degree to which researchers have moved beyond the ritualistic use of NHST to assess their hypotheses. This has been examined for areas such as biology , organizall findings as potentially eloquent. This is probably the frequent denunciations of the tendency for those papers presenting a significant positive result to receive more favorable publication decisions than equally well-conducted ones that report a negative or null result, the so-called publication bias [At first glance it is puzzling that, after decades of questioning and technical warnings, and after twenty years since the inception of ICMJE recommendation to avoid NHST, they continue being applied ritualistically and mindlessly as the dominant doctrine. Not long ago, when researchers did not observe statistically significant effects, they were unlikely to write them up and to report "negative" findings, since they knew there was a high probability that the paper would be rejected. This has changed a bit: editors are more prone to judge ion bias -50. ThisThe results did not show a significant difference between groups; however, with a larger sample size, this difference would have probably proved to be significant". The problem with this statement is that it is true; more specifically, it will always be true and it is, therefore, sterile. It is not fortuitous that one never encounters the opposite, and equally tautological, statement: "A significant difference between groups has been detected; however, perhaps with a smaller sample size, this difference would have proved to be not significant". Such a double standard is itself an unequivocal sign of the ritual application of NHST.Consequently, even though it was not an aim of our study, we found many examples in which statistical significance was not obtained. However, many of those negative results were reported with a comment of this type: "significance fallacy is huge.Although the declining rates of NHST usage show that, gradually, ICMJE and similar recommendations are having a positive impact, most of the articles in the clinical setting still considered NHST as the final arbiter of the research process. Moreover, it appears that the improvement in the situation is mostly formal, and the percentage of articles that fall into the The contradiction between what has been conceptually recommended and the common practice is sensibly less acute in the area of Epidemiology and Public Health, but the same pattern was evident everywhere in the mechanical way of applying significance tests. Nevertheless, the clinical journals remain the most unmoved by the recommendations.The ICMJE recommendations are not cosmetic statements but substantial ones, and the vigorous exhortations made by outstanding authorities  are not In some cases, the role of CI is not as clearly suitable , butThe inherent resistance to change old paradigms and practices that have been entrenched for decades is always high. Old habits die hard. The estimates and trends outlined are entirely consistent with Alvan Feinstein's warning 25 years ago: "Because the history of medical research also shows a long tradition of maintaining loyalty to established doctrines long after the doctrines had been discredited, or shown to be valueless, we cannot expect a sudden change in this medical policy merely because it has been denounced by leading connoisseurs of statistics ".It is possible, however, that the nature of the problem has an external explanation: it is likely that some editors prefer to "avoid troubles" with the authors and vice versa, thus resorting to the most conventional procedures. Many junior researchers believe that it is wise to avoid long back-and-forth discussions with reviewers and editors. In general, researchers who want to appear in print and survive in a publish-or-perish environment are motivated by force, fear, and expedience in their use of NHST . FurtherJournal of the American Medical Association published a bibliometric study [British Medical Journal and Annals of Internal Medicine. The data analysis is characterized by methodological orthodoxy. The authors just use chi-square tests without any reference to CI, although the NHST had been repeatedly criticized over the years by two of the authors:For example, ic study  discussiDouglas Altman, an early promoter of confidence intervals as an alternative , and SteThe present effort is certainly partial in at least two ways: it is limited to only six specific journals and to three biennia. It would be therefore highly desirable to improve it by studying the problem in a more detailed way , and continuing the review of prevailing patterns and trends.Overall, results of our review show some improvements in statistical management of statistical results, but further efforts by scholars and journal editors are clearly required to move the communication toward ICMJE advices, especially in the clinical setting, which seems to be imperative among publications in Spanish.The authors declare that they have no competing interests.LCSA designed the study, wrote the paper and supervised the whole process; PSG coordinated the data extraction and carried out statistical analysis, as well as participated in the editing process; AFS extracted the data and participated in the first stage of statistical analysis; all authors contributed to and revised the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2288/10/44/prepub


Adolescents are the most vulnerable population to initiate tobacco use. It is now well established that most of the adult users of tobacco start tobacco use in childhood or adolescence. There has been a perceptible fall in smoking in the developed countries after realization of harmful effects of tobacco. The tobacco companies are now aggressively targeting their advertising strategies in the developing countries like India. Adolescents often get attracted to tobacco products because of such propaganda. There has been a rapid increase in trade and use of smokeless tobacco products in recent years in the country, which is a matter of serious concern to the health planners. It is important to understand various factors that influence and encourage young teenagers to start smoking or to use other tobacco products. The age at first use of tobacco has been reduced considerably. However, law enforcing agencies have also taken some punitive measures in recent years to curtail the use of tobacco products. This paper focuses on various tobacco products available in India, the extent of their use in adolescents, factors leading to initiation of their use, and the preventive strategies, which could be used to deal with this menace. Tobacco use in children and adolescents is reaching pandemic levels. The World Bank has reported that nearly 82,000–99,000 children and adolescents all over the world begin smoking every day . About hIndia is the second most populous country in the world. It is a secular country but the Hindus form the majority. Hinduism traditionally advocates abstinence from all intoxicants. Even then, India is the third largest producer and consumer of tobacco in the world. The country has a long history of tobacco use. Tobacco is used in a variety of ways in India; its use has unfortunately been well recognized among the adolescents -15. TobaConsidering the enormous health complications associated with tobacco use, it is of utmost importance to understand the factors leading to its use and to plan strategies to reduce its intake. This is especially relevant for the developing countries like India, where tobacco use continues to be common notwithstanding the recognition of harmful consequences of its usage. This paper reviews the patterns of tobacco use in India, its prevalence in Indian adolescents, role of psychosocial factors in initiation and prevention, and the steps taken by the State to control its use.Human beings have been using tobacco since 600 A.D. . It was Harmful effects of tobacco have been recognized over the last 1000 years. Historically, three contemporary rulers, King James I of England, Shah Abbas of Persia and the Mughal emperor Jahangir of India  in 16th century had noticed the harmful effects of tobacco and tried to ban it. King James had commented on smoking as being "a custom loathsome to the eye, hateful to the nose, harmful to the brain, and dangerous to the lungs". Jahangir had even passed orders prohibiting smoking tobacco. Khalil Pasha was more stringent and had passed a prohibitory decree against tobacco smoking that "anybody caught smoking tobacco would have his lips cut and eyes taken out". In 1014 Hijri, Russia had also passed certain regulations against smoking ,22,23.India has a distinct tradition of enforcements against tobacco use being initiated by the past kings (like Jahangir) and the religious leaders at different times in the history. The great Indian Sikh Guru Gobind Singh prohibited smoking for the members of the Sikh community. He said, "Wine is bad, Indian hemp (bhang) destroys one generation, but tobacco destroys all generations" ,23. TobaIn the modern medicine, its harmful effects have been recognized over the last 4 decades ,24. AlthTobacco is used in a wide variety of ways in India including smoking and smokeless use.beedis and cigarettes or by using devices like hooka, hookli, chhutta, dhumti, or chillum [Tobacco is smoked in the forms of  chillum ,25,26. SCigarette smoking is common in urban areas. Both locally manufactured and imported brands of cigarettes are available. However, because of relatively higher cost of cigarettes as compared to other forms of tobacco, cigarette smoking is more common among the upper and middle socioeconomic classes than among the poor population.Beedi is a cheap smoking stick, handmade by rolling a dried, rectangular piece of temburni leaf (Diospyros melanaxylon) with 0.15–0.25 g of sun-dried, flaked tobacco filled into a conical shape and the roll is secured with a thread. The length of a beedi varies from 4.0–7.5 cm. Beedis are commercially available in small packets.Hooka (a hubble bubble Indian pipe) is an indigenous device, made out of wooden and metallic pipes, used for smoking tobacco. The tobacco smoke passes through water kept in a spherical receptacle, in which some aromatic substances may also be added. Hooka smoking is a common method of socializing among the village folk, especially in the Northern and Eastern parts of India, and is a part of the rural cultural life. Its use is more common among the adults and older generation. However, it is not popular among adolescents, because the adults generally discourage younger population from using hooka.Hookli is a short clay pipe-like device, being about 7 cm long, and is used for smoking tobacco in some parts of the country.Chhutta is a coarsely prepared roll of tobacco (cheroot), smoked with the burning end inside the mouth (reverse chhutta smoking). Its use is prevalent in coastal areas of the province of Andhra Pradesh in southeastern India.Dhumti is a cigar-like product made by rolling tobacco leaves inside the leaf of jackfruit tree. Occasionally, dried leaf of a banana plant is used. Males smoke dhumti in conventional manner, whereas females smoke it in a reverse manner, i.e., keeping the burning end inside the mouth. Dhumti smoking is quite popular in the Goa province of the Western India.Chillum is a conical clay-pipe of about 10 cm long. The narrow end is put inside the mouth, often wrapped in a wet cloth that acts as a filter. This is used to smoke tobacco alone or tobacco mixed with ganja (marijuana) in northern parts of the country.betel quid chewing, mishri, khaini, gutka, snuff, and as an ingredient of pan masala.Tobacco is used in a number of smokeless forms in India, which include Betel quid is a combination of betel leaf, areca nut, slaked lime, tobacco, catechu and condiments according to individual preferences. Tobacco is an optional component. Its use is prevalent all over India. However, there are differences in the components used in different regions of India.Khaini consists of roasted tobacco flakes mixed with slaked lime. This mixture is prepared by the user keeping the ingredients on the left palm and rubbing it with the right thumb. The prepared pinch is kept in the lower labial or buccal sulcus. Its use is common in eastern India.Mawa is a mixture of areca nut, tobacco and slaked lime and is chewed. Its use is common in rural areas of Gujarat province. It is quite popular among the young population of ages 15–19.Snuff is a black-brown powder obtained from tobacco through roasting and pulverization. Snuff is used via nasal insufflation and is popular in eastern parts of the country. It is also applied on the gum by finger  in the Western India, where it is known as bajar and mishri.Gutka is a manufactured smokeless tobacco product (MSTP), a mixture of areca nut, tobacco and some condiments, marketed in different flavors in colorful pouches.Pan masala is a betel quid mixture, which contains areca nut and some condiments, but may or may not contain tobacco. The mixture is chewed and sucked. Unlike cigarettes, tax levied on pan masala is low. Low cost and not being associated with smoke have led to an enormous increase in the use of all types of areca nut and smokeless tobacco among the Indian population including adolescents. It has also been promoted as a "post meal mouth freshener", making it quite popular. Initially, it was more popular in the Northern India, but with a massive advertising, it is now being used all over the country. Pan masala is as harmful as smoking, although the nature of harmful effects are different. Its use has been associated with high risk of oral cancer and submucus fibrosis in mouth, which also has a high potential for cancer development. It is made by the use of waste tobacco, mid-ribs of tobacco leaves and floor sweepings from cigarette factories. It is available in the forms of small packets and cans, sold at affordable prices with attractive, shiny colored wrappings [rappings ,25,27,28Beedis, khaini, and mishri are commonly used in rural areas and cigarettes are mainly used in urban areas. Pan masala was initially popular in the urban segment only, but over the last few years, it has been consumed in rural areas as well.pan masala and chewing of tobacco in different forms. Tobacco is also smoked using indigenous devices like hooka, chhutta or dhumti in different parts of the country [According to the most recent Government of India's National Sample Survey data, there are 184 million tobacco consumers in India. About 40% of them use smokeless tobacco, 20% consume cigarettes, and another 40% smoke beedis. Smokeless tobacco use includes Adolescents and children are the prime targets of the tobacco industry when recruiting new smokers. About 20 million children of ages 10–14 are estimated to be tobacco-addicted according to a survey done by the National Sample Survey Organization of the Indian Government. To this astounding figure, about 5500 new users are added every day, making two million new users every year . AdolescDuring the last three decades, a number of epidemiological surveys has been conducted in different parts of India to study the prevalence of tobacco use by adolescents. The study populations have included school and college students, medical students and street children :Table The prevalence figures vary according to the criteria used to define tobacco use habits. For example, in one study ever-smokers constituted 14.2% of the study population and current smokers (defined as having smoked in the last week) formed 7.1% of the study sample . More thThe girls had a very low (1.1%) prevalence of tobacco use. Most boys who were using tobacco were smokers (86%). Significantly higher proportion of boys smoked if their father or best friend smoked. Generally, boys were more sensitive to the best friend's or elder brother's disapproval rather than the parental. They were well informed about the general harmfulness of smoking but there was no knowledge on any specific health hazard.Although smoking is rare among female students, the use of snuff is not uncommon. Gavarsana et al. found tobacco-snuff-use in 38% of males and 12% of females in a sample population of 599 college students [et al. found 26.4% to be smokers [Most students enter medical schools in India in their late adolescence. A number of researchers in India have investigated the use of drugs and smoking among medical students ,8,31-33.Venkatraman et al. studied time trends in smoking behavior among the alumni enrolled in MBBS course of a medical school in South India during the period 1955–1988 [gutka. Initiation of tobacco use peaked at class ten (32%) or classes 11 and 12 (32%), equal to the ages of 15–17. The factors found significant in leading to a higher tobacco consumption included lack of family supervision among hostels, peer influence, lack of awareness about the harmful effects of different tobacco products, no exposure to clinical cases of tobacco related disorders, and easy availability of these products.In another recent study on tobacco use among 400 male medical students from the state of Bihar in north India , 43% of It appears that from 1970 to 1998, there has been changes in patterns of tobacco use with a fall in cigarette smoking and an increase in MSTP consumption. This may be due to changes in social structure and behavior, increasing awareness about the hazardous effects of smoking and marketing effects of MSTP. Family influences remain an important factor among tobacco users.India has probably the largest population of street children in the world. The metropolitan cities like Delhi, Mumbai (Bombay), Kolkata  and Bangalore have each around 100,000 of street children. The majority of them maintain tenuous ties with their families, but many have no families at all, having an extremely stressful life.gutka and khaini) mixed with other drugs as adulterants, followed by beedis and cigarettes. Older children of ages 15–16 use nicotine along with other hard drugs. There is scanty data on age at the first use of drugs, but anecdotal reports indicate that the age is very low and is getting further younger. The youngest age at the first use of a socially sanctioned drug has been reported to be five [Drugs of abuse give these kids excitement and relief from the all pervasive gloom of street life and serve to suppress hunger and helplessness. Tobacco-based products stimulating the CNS to improve alertness are used by these children to get relief from insomnia due to long working hours. The usual pattern of drug abuse by male and female kids of ages 5 to 10 is through chewing tobacco , current cigarette smoking was found to vary from 10% to 33% and ever-smoking from 15% to 70% across different countries. In Russian Federation, Sri Lanka and Ukraine, smoking was found to be more common among boys than in girls, whereas it was more common among girls in China, Fiji, Jordan, and Venezuela [Tobacco use and especially smoking is a male-dominated phenomenon among children and adolescents in India. This is unlike the West, where its distribution is equal among both genders. In some countries like China, Fiji, Jordan and Venezuela, smoking is rather more common among females. In India, the use of smokeless tobacco has become popular during the last few decades. A decline in tobacco use, as evident in the USA and some European countries, does not seem to be observed in near future in India. In contrast, the use of chewing tobacco seems to follow a rising trend, particularly among the street children and college students, which is a matter of serious concern.A number of factors influence the use of tobacco by children and teenagers. Some of these are the family history of tobacco use by elders, peer influence, experimentation, easy access to such products, personality factors, underlying emotional and psychological problems, accompanied risk-taking behaviors, and most importantly, the aggressive marketing strategies of the tobacco industry.beedis or cigarettes from a nearby shop or kiosk. By this way, children are often introduced to such products at their very early life stages. A child growing in such a family watching his elder brother, father, uncles or grandfather using tobacco may perceive it as a family tradition that is to be followed. On the other hand, it is interesting to know that as an Indian tradition, younger individuals are not expected to smoke in the presence of elderly, because smoking by a younger person is taken as in contempt of the older people. Therefore, it is a paradox that the same elderly people, who passively show the way to smoke, are prohibitive of the same behavior by the younger generation in their own presence. However, this value system does not apply to the use of smokeless tobacco products.Family plays a very important role in initiation of tobacco use by a young child or adolescent. Tobacco use by parents or an elder sibling increases the likelihood that a child begins smoking ,11. As aAlthough children may start smoking for psychosocial reasons like peer influences, curiosity, desire for experimentation or as a remedy for stress, the pharmacological motives take on place very early in their smoking career . Consequbeedi by a friend initiates the conforming process with a tobacco-using peer-group network [Peer pressure is an important determining factor for initiation of tobacco use among children and adolescents. There are several processes by which being associated with drug-using peers contributes to drug-abusing behavior. Here, modeling and social approval play an important role. When one is distressed due to any reason, an offered cigarette or  network ,28.Beedis are a bit cheaper than the cigarettes and hence are preferred by the poor who cannot afford cigarettes. The newly introduced MSTP are also cheaper than cigarettes and do not carry the trouble of lighting, and therefore, are more convenient to use, which makes it popular among the users [Tobacco products are socially sanctioned but are freely available in every nook and corner throughout the country. he users .Poor school performance, truancy, low aspiration for future success, and school dropouts have been found to be associated with smoking at an early age . ChildreAdvertisements of various tobacco products are very common in all forms of media including the print media, television, and the roadside hoardings and banners. Tobacco advertising and promotion effectively target the young people with images of smokers as trendy, sporty and successful ,43. CharSome multinational tobacco companies are also involved in sponsoring of mega sport events like international cricket matches and some even have instituted bravery awards. These attract the vulnerable child or adolescent towards smoking with an idea that it may be a heroic or desirable activity to adopt because of the apparent positive associations. Advertisements and promotion of cigarettes have been reaching its peak in developing countries like India due to a sharp decline in sales in Western countries .khaini, mishri or smoking beedis are common. In rural areas, smoking by hooka and tobacco chewing are common. Over the last 2–3 decades, particular chewable tobacco products are being highly promoted for sale and their use is being linked with the society's upper-class business-community in order to popularize them among the masses. Therefore, the socio-cultural influences are quite complex in these regards and in establishing changes in tobacco use among the public.To summarize, multiple factors determine initiation of tobacco use. These factors are both promoting and prohibitive and have been constantly changing over the time depending on several economical and marketing forces. Traditionally, cigarette smoking had an association with the upper class of the society, reminiscent of the British colonial era. Though in the recent past it has percolated to all strata of the society, it is still more common among the upper and middle classes. Among the lower income groups, smokless tobacco like Considering the enormous adverse health consequences accompanying tobacco addiction, it is very important to develop preventive strategies to reduce tobacco consumption. Preventive strategies especially focused towards children and adolescents need to be initiated on emergent basis. This is more important for the developing countries like India, which have become the main targets of advertisement and promotional propaganda of various multinational tobacco companies ,4.Preventive approaches include spreading awareness about the actual hazards of tobacco in the community especially among the vulnerable children and adolescents, curbs on advertisement and promotional campaigns, early identification of the users and providing treatment ,29,44,45hooka and beedis, and by the smokeless forms like gutka. In fact, a majority of Indian people are not aware of the health consequences caused by smokeless tobacco products. Added to this, a wrong belief is being spread throughout the country that beedis are less harmful than cigarettes. Some indirect promotional efforts even spread an untruth about some beneficial effects of beedis such as being abdominal gas and constipation reliever! Thus, in a country like India, widespread community awareness program on the hazards of local and cheaper tobacco products like beedis and gutka are more essential than few school based programs.The benefits of early educational programs have been well reported for school children . Such prA couple of programs are already in progress for the street children in India. A training module has been prepared for the non-governmental organizations (NGOs), for offering need-based intervention to the street children. The work was conducted under the auspices of WHO, UNICEF, and the Ministry of Health & Family Welfare of the Indian Government. Drug abuse and high-risk behavior have also been studied among the street children. UNICEF is conducting training courses for NGOs and street educators who are expected to find and help the street children abusing drugs ,33.A very important step in primary prevention is the revamp of the existing tobacco policies of the government. The Government of India has recently taken some important legal measures, but there are still many problems in the enforcement of tobacco related law. Restrictions have been imposed on sales and on tobacco use in public places like railway stations, airports, hospitals and governmental offices. However, the more important aspect would be the strict observation and control of such restrictions. The sales of all tobacco products including the MSTP and their easy access strongly need to be banned for children and adolescents. An initiative in this regard has been taken by stopping tobacco sale in vicinity of schools. Countries like UK have imposed age restrictions in purchase of tobacco products. Stopping sales of tobacco to children is an important step towards reducing the number of tobacco users among the new generation .The limitations of the long-term success of the school-based interventions  have ledTobacco industry has been facing strong opposition from the legal and public forums similar to those in the Western countries like USA. As the dangers of smoking began getting more and more identified, legal enforcements for prohibition of tobacco advertisements and declaration of nonsmoking zones have become a worldwide phenomenon, especially in the last 2–3 decades. India has recently passed the Tobacco Products Bill 2001 ,46, whicThe effectiveness of many of these steps is now well documented. Long term studies have shown that a ban on advertising tobacco products is effective in reducing their consumption . It is aEnforcements of laws have often been a problem in India. For example, although nonsmoking zones exist at important public places, especially in the large cities, there is an utter disregard for them. Nobody minds smoking by others, particularly in villages or small cities. There is a need to initiate massive public awareness campaigns educating people about serious health consequences of smoking, passive smoking, and smokeless tobacco use. Steps towards this direction have been taken, but it may take some time to obtain the results.Humans have used tobacco in many forms for several centuries. Its use often starts early in life. In recent years, there has been a rising trend in tobacco use, more in smokeless forms in India. There are no nationwide data available in India on the exact extent of the tobacco use among adolescents, although a number of surveys have been reported from different parts of the country. These show a general tendency towards an increase in tobacco use by the youth for the past few decades, with an emphasis on the use of smokeless tobacco. This is a matter of great public health concern. Psychosocial factors have an important role to play in initiation of this habit. It has been observed that a large number of adolescents pick up this habit from their family members or the peers. Advertisements of tobacco products and promotional campaigns by the manufacturers also play an important role in initiation of the habit by adolescents. This has attracted the attention of health professionals, media and law enforcement agencies. The local governments are also taking steps in putting curbs over the sales of tobacco products to children, and in regulating tobacco advertisements.There is a need to collect nationwide data on the use of different forms of tobacco by children and adolescents, and the factors leading to initiation of such harmful habits. There is an urgent need to take effective steps, especially on launching community awareness programs for the school children and public to educate them about the consequences of tobacco use, and on assessing their effectiveness in curbing the problem. It is also necessary to keep abreast of the policies and conventions of the international agencies like WHO, UNDCP and other similar agencies on tobacco use, in order to utilize their expertise for curbing this problem.* English medium schools are the ones where English is the primary language of instruction for all subjects except for the modern Indian languages, whereas in Indian language schools, one of the Indian languages is the language of instruction for different subjects. Municipal schools are the ones run by the State, whereas the private schools are run by private organizations and not financed by the State.The authors declare that they have no competing interests.


To the Editor: The letter to editor by Hänscheid et al. addresses our suggestion that polymerase chain reaction (PCR) could serve as a reference test for screening blood donations. At present, PCR is the most sensitive and specific method for parasite detection in malaria-endemic areas. However, additional measures should be taken into account, such as serologic testing, refining donor history, defining at-risk locations, and delimiting malaria-endemic areas. Therefore, we do not suggest that only PCR should be used as a reference method to exclude blood donors at risk, but it could help shorten the deferral period for blood donor . PCR should be accompanied by serologic tests and the elimination of actual or possible plasmodial infection in the blood donor.In our laboratory, we use the indirect fluorescent antibody test (IFAT) for antigens of the four plasmodia species, in addition to PCR screening. At present, we have analyzed a total of 531 blood samples (406 more than the 125 described in our previous letter to the editor) from possible donors at risk for malaria, and only the five described in the letter were malaria positive. Moreover, 40% (50 of 125) of these sera were negative by IFAT (unpub. data), a fact that indicates the importance of having a complete donor history and being certain of the patient’s origin in the context of malaria endemicity .On the other hand, with a standard 450-mL blood donation, parasitemias <90 could test negative by PCR; but, as previously described, this technique should be accompanied by careful questioning, serologic testing, and eliminating parasites from the recipient during blood processing and storage.We take for granted that, theoretically, any method would have to detect a single parasite per unit of blood to be safe and that little is known about the frequency of low parasitemias. In nature, and in accordance with the parasitologic definition of equilibrium between parasite and host (defined over thousands or millions of years according to different phylogenetic theories), one of the main strategies for parasite survival is sustained malaria transmission, which allows low parasitemias to be ingested by the anopheline vector  In two-thirds of the cases cited by Mungai et al. Moreover, two of the three cases described by Slinger et al. Serologic tests in Spain indicate that approximately 50% of the referral donations could be used in transfusion, and travel histories should distinguish the specific destinations or the level of malaria transmission in the area. Most histories are based on the wide areas of transmission listed in travel guidelines. These data should decrease the cost of testing per blood donation when we add the value of the blood donation to the real cost of death prevented.In conclusion, our initial results, now accompanied by serologic results, justify the exclusion criteria we first reported Finally, the study of donors at risk could serve as indirect surveillance for asymptomatic infections and could play an important role in detecting autochthonous malaria transmission in the United States


To evaluate the effectiveness and safety of water aerobics during pregnancy.A randomized controlled trial carried out in 71 low-risk sedentary pregnant women, randomly allocated to water aerobics or no physical exercise. Maternal body composition and perinatal outcomes were evaluated. For statistical analysis Chi-square, Fisher's or Student's t-tests were applied. Risk ratios and their 95% CI were estimated for main outcomes. Body composition was evaluated across time using MANOVA or Friedman multiple analysis.There were no significant differences between the groups regarding maternal weight gain, BMI or percentage of body fat during pregnancy. Incidence of preterm births , vaginal births , low birthweight  and adequate weight for gestational age  were also not significantly different between groups. There were no significant differences in systolic and diastolic blood pressure and heart rate between before and immediately after the water aerobics session.Water aerobics for sedentary pregnant women proved to be safe and was not associated with any alteration in maternal body composition, type of delivery, preterm birth rate, neonatal well-being or weight. The association between good health and physical activity is not recent. Studies report that both the public in general and scientists and physicians in particular are concerned with the regular practice of moderate physical exercise, which is believed to contribute towards the length and quality of life -3. TodayDuring pregnancy, considerable anatomical and physiological changes take place in the expectant mother, including weight gain, and these changes are necessary for the development of the fetus -7. HowevToday, the practice of physical activity is recommended as part of a healthy pregnancy ,4,11. ThThe concerns regarding the benefits of physical exercise during pregnancy are related to the child's birthweight, maternal and fetal cardiac changes, risk of abortion and preterm delivery, and of injury due to increased maternal weight . AnotherAnother concern is related to the intensity of the practice of physical exercise, particularly land-based exercise, since the expectant mother may be subject to any of the aforementioned risks . AlthougThere has currently been an increase in the number of pregnant women interested in carrying out physical exercise during pregnancy, particularly water-based exercise. More studies are therefore required to clarify the benefits and the risks of these activities, both for the expectant mother and for the fetus. The objective of this study was to evaluate the effectiveness and safety of a program of water aerobics for low risk, sedentary pregnant women on the evolution of pregnancy, maternal body composition and perinatal outcomes.An open, randomized controlled clinical trial was carried out and its methods are described in detail elsewhere . The minLow-risk, sedentary pregnant women between 16–20 weeks of gestation were selected from among those attending the prenatal outpatient clinic of the institution or at a neighboring basic healthcare center. Women with a history of two or more Cesarean sections, those with medical conditions contraindicating the practice of physical exercise and/or with some practical impediment to participating in the program were excluded from the study. Women fulfilling admission criteria were identified at the beginning of their prenatal care and invited to participate in a meeting with one of the investigators. At this meeting, the expectant mothers received information on the objectives of the study, as well as an explanation of the evaluations and protocols that had to be carried out. Those who agreed to participate in the study signed an informed consent form and filled out an admission questionnaire. The study was approved by the local Institutional Review Board prior to initiation.The volunteers were randomly allocated to one of two groups according to admission order and following a computer generated randomization list. To guarantee the concealment for the randomization procedure, each sequential number corresponded to a sealed opaque envelope containing the questionnaires and information regarding the randomization group: Water Aerobics Group, women who would practice water aerobics regularly throughout pregnancy; and Control Group, consisting of women who would not carry out any physical exercise during pregnancy. The intervention consisted of the regular and moderate practice of water aerobics for 50 minutes three times a week in an indoor swimming pool with water at 28–30°C, initiated after enrollment and continued up to delivery . The mod® to measure skinfold thickness). These variables were evaluated three times during pregnancy: 1) between 18 and 20 weeks; 2) between 22 and 26 weeks; and 3) between 32 and 36 weeks of pregnancy, at the same time when physical fitness was also evaluated [The following variables were evaluated in the two groups: age, parity, previous abortions and Cesarean sections, education level, gestational age at delivery, preterm birth rate, type of delivery, vitality of the newborn infant, weight of the newborn infant, low birthweight rate and birthweight adequate for gestational age. Other variables measured were: maternal weight gain, body mass index (BMI), percentage of non-fat and fat mass  were calculated. For the repeat variables over time (percentage of body fat and non-fat mass), MANOVA multiple analysis was used with Wilk's Lambda statistical test to evaluate the statistical significance of the differences according to time and group. Friedman's non-parametric multiple analyses were used to evaluate BMI. Significance was established at 5% and the software programs Epi Info, version 6.0, and SAS were used for analysis procedures.For the statistical analysis, distribution of control variables was initially evaluated to verify comparability of the two groups. A bivariate analysis was carried out in which qualitative variables were compared using the χThe study started in March 2002 and terminated in November 2004. Of the 78 pregnant women initially eligible for participation, 7 were excluded . Therefore, 71 pregnant women were randomized, 34 to the water aerobics group and 37 to the control group. By the time of the second evaluation, 9 women in the water aerobics group and 5 in the control group had discontinued. By the third evaluation, another 4 and 5 women had discontinued from the water aerobics and control groups, respectively. All discontinuations in both groups occurred because the women were unable to participate in the water aerobics program or attend the evaluation sessions, with the exception of one woman in the water aerobics group who was discontinued because of lost-to-follow-up. Data on her delivery and on the newborn infant are not available. The flowchart of study participants, as well as the demonstration that the two groups were similar with respect to the general characteristics of the women enrolled, are already included in the first article [The weight gain of the women was similar in the two groups. BMI and the proportion of fat mass increased significantly during pregnancy, while the proportion of fat-free mass decreased significantly; however, there was no statistically significant difference between the two groups Figure , Table 1There were no statistically significant differences between the pre-exercise resting values and values of systolic and diastolic blood pressure and heart rate measured 3 minutes after the end of physical activity in the intervention group . Prevedel et al.  also fouOne of the main concerns with respect to the practice of aerobic exercise during pregnancy has been the possible greater occurrence of preterm associated with this practice. Indeed, the systematic review of data available on the subject reveals an estimated risk of preterm delivery attributed to aerobic exercise of 1.82 (95% CI 0.35 – 9.57) . CombiniThe results of the present study may therefore contribute towards justifying the need to elaborate programs of moderate, water-based physical activity for sedentary, low risk pregnant women. This kind of physical exercise should improve the quality of life of the expectant mother, while providing her with an opportunity to participate actively in society, and may also reduce the occurrence of medical problems that result in lost working days.The practice of physical exercise during pregnancy, mainly in water, seems to help reduce lower back pain in expectant mothers . Women pThe main limitation of this study is probably related to the difficulties the women had in regularly attending the scheduled water aerobics sessions. On the other hand, this may represent a more realistic picture of the possibilities involved in recommending a program such as this for sedentary women, even those with low-risk pregnancies, especially in under resourced settings. The women reported various kinds of difficulties and impediments such as household duties, commitments with children, husbands prohibiting their wives to attend classes, job-imposed limitations to schedule, embarrassment at having to wear a swimsuit or to use the fitness club pool together with the other women, lack of transportation, distance between the woman's home and the fitness club, and fear of water based on no previous experience. These difficulties were responsible for a relatively high rate of discontinuation in our study, leading to a situation where the sample size for the second and third evaluation of body composition was smaller than previously calculated, and could imply that the study is underpowered to draw firm conclusions. However, these are relatively new outcomes using a randomized controlled design and perhaps the current results could be combined with others already available  to draw If the majority of these impediments could be overcome by making it easier for women to exercise in a suitable pool at a convenient location near the maternity hospital or in community centers, by making sure that transportation is available, providing convenient exercise schedules and trained instructors to counsel women, With more women participating in these exercise programs, wider-ranging studies could perhaps then be carried out to clarify the outstanding issues with respect to the practice of physical exercise during pregnancy.Up to this time, no scientific data have been published showing any concrete detrimental effect to the mother or the fetus of moderate, water-based physical exercise, and the results of the present study again confirm previous data. In view of today's trend towards a more physically active society, the emphasis of these programs should be to assure the expectant mother that the state of pregnancy is not synonymous with confinement, and also that the practice of physical exercise, although gives no guarantee of a complication-free pregnancy, may result in a healthier pregnancy should a program of moderate physical activity be included as an integrated part of her prenatal care.ACOG: American College of Obstetricians and Gynecologists; BMI: body mass index; CI: confidence interval; DBP: diastolic blood pressure; HR: heart rate; MANOVA: multivariate analysis of variance; RR: risk ratio; SBP: systolic blood pressure; UNICAMP: University of Campinas.The authors declare that they have no competing interests.SRC, JGC and RICP participated in all steps of the study, including research planning, data collection, analysis and writing the manuscript. EPB, ALB and CS participated in data collection and review of the manuscript. All authors gave suggestions, read the manuscript carefully, fully agreed on its content and approved its final version.


Enzymes are responsible for the catalysis of the biochemical reactions in metabolic pathways. Analogous enzymes are able to catalyze the same reactions, but they present no significant sequence similarity at the primary level, and possibly different tertiary structures as well. They are thought to have arisen as the result of independent evolutionary events. A detailed study of analogous enzymes may reveal new catalytic mechanisms, add information about the origin and evolution of biochemical pathways and disclose potential targets for drug development.In this work, we have constructed and implemented a new approach, AnEnPi , using a combination of bioinformatics tools like BLAST, HMMer, and in-house scripts, to assist in the identification, annotation, comparison and study of analogous and homologous enzymes. The algorithm for the detection of analogy is based i) on the construction of groups of homologous enzymes and ii) on the identification of cases where a given enzymatic activity is performed by two or more proteins without significant similarity between their primary structures. We applied this approach to a dataset obtained from KEGG Comprising all annotated enzymes, which resulted in the identification of 986 EC classes where putative analogy was detected . AnEnPi is of considerable value in the construction of initial datasets that can be further curated, particularly in gene and genome annotation, in studies involving molecular evolution and metabolism and in the identification of new potential drug targets.AnEnPi is an efficient tool for detection and annotation of analogous enzymes and other enzymes in whole genomes. It is available for academic use at:  Enzymes catalyze biochemical reactions and are classified according to the recommendations of the Nomenclature Committee of the International Union of Biochemistry . Each enHowever, comparisons between computational reconstructions of metabolic pathways from different organisms revealed the existence of gaps . An orgaHowever, most often such genes are not characterized as analogous in the accompanying annotation, for Example in public databases such as KEGG .Previous work performed by other groups suggest that the fraction of enzymatic activities where multiple events of independent origin have occurred may be substantial, in the order of 25% . HoweverAnalogous enzymes may also constitute a huge and largely untapped resource for the identification of drug targets. Strategies to find candidate genes as potential targets for drug development usually focus on parasite-specific genes and even complete biochemical pathways , or for To help in the process of identification and annotation of analogous enzymes, we implemented a web based Tool named AnEnPi. It analyses and compares genomic datasets for analogous enzymes, by clustering the primary structures of enzymes with the same described activity and using a Blastp similarity raw score of 120 as cut-off . This reAnEnPi was programmed in Perl using the CGI-interface. All clusters as well as their HMMer-models are available for download on the web page.An overview of AnEnPi is shown in Figure We have applied AnEnPi to cluster a dataset composed of 311 reference metabolic pathways and 1,871,732 protein sequences of 36 eukaryotes, 398 eubacteria and 31 archaeabacteria obtained from the KEGG database . In totae-6) [The clustering algorithm was implemented similarly to the method proposed by Galperin . First, e-6) . This pae-6)  was implDataset a, the less conservative, is composed by all clusters formed after the initial clustering step. This dataset was further refined, using more stringent criteria. Filters were applied in four successive steps: Firstly, all clusters with only one sequence (singlets) were excluded (dataset B). Secondly, all enzymatic activities not defined up to the fourth level of the EC classification were also excluded (dataset C). Thirdly, all clusters of a determined function with proteins annotated as subunits of this function and Belonging to the same species were joined (dataset D). Finally, all clusters displaying putative intragenomic analogy  were also joined (dataset E).Each result can be visualized as a metabolic map by using an external resource (a KEGG tool – ). FurtheIn this work, we define a potential case of analogy if the sequences from a given enzymatic activity present in the genome of a single organism or between two organisms are placed in different clusters after grouping . Orthologs or recently duplicated paralogs would be placed in the same cluster. Therefore AnEnPi compares, within a single species or between two species, the presence of a given function in each cluster, for all species currently represented in KEGG database. In the metabolic reconstruction step, the presence of a given enzymatic activity in a genome, the presence of analogy and the degree of significance of similarity searches can be highlighted. The result is an interactive list (in HTML or text format) with links to the EC classes and the metabolic maps.For the purpose of annotation and identification, the user can perform similarity searches either by BLASTp or HMMSearch. In the first case, the database is composed of all proteins present in the clusters; in the second case, the database is composed of the probabilistic models constructed for each cluster, if the cluster has more than one element. For the construction of the latter, a multiple alignment was executed with ClustalW  and thenTherefore, we have introduced filters allowing the construction of different datasets, minimizing the number of wrongly identified cases of analogy and wrongly attributed functions. To our knowledge, AnEnPi is the only tool that provides annotation functionalities with emphasis on analogous enzymes.All components described so far Figure  were inc called AnEnPi  that can be used for the annotation and visualization of metabolic pathways, and for the detection of events of analogy. As an example, we applied AnEnPi to identify possible cases of analogy between enzymes present in the genome of L. major [We implemented a web based interface L. major  and the Clustering of the dataset obtained from KEGG produced 6,701 clusters, with 986 enzymatic activities  having more than one cluster (approximately 40.5%)  and H. sapiens are displayed.However, further identification of subclusters will be studied in another work, as a refinement of the present methodology. As an example of a potential case of analogy, for this EC function the location of the corresponding enzymes of H. sapiens and L. major, thirty-five potential cases of analogy were found using dataset D  with sequences from the same species are joined. These cases of intragenomic analogy were not related to a particular metabolic pathway.As described above, EC 2.1.1.17 is also a case of intragenomic analogy in L. major genome. A bibliographic search revealed almost no data besides the identification of these twelve enzymatic Activities in L. major, neither were we able to find systematic studies of intragenomic analogy in general.One example of intragenomic analogy can be seen in the fructose and mannose metabolism (KEGG map 00051), where two unrelated sequences of phosphomannomutase (EC 5.4.2.8) were found in the We described in this work AnEnPi, a tool that can be used for the annotation and detection of analogous enzymes , improviOther tools like KAAS  or KOBASThe identification of structurally unrelated enzymes sharing the same enzymatic activity may reveal new catalytic mechanisms, lead to studies on the origin and evolution of biochemical systems and pathways, and also provide new candidates for drug design and development . AnEnPi It is not a simple task to determine if two different proteins are derived from the same ancestor. Two homologous proteins may lack major sequence similarity and yet share a common origin, for example after many years of evolution . The cutStill, it is possible that two enzymes assigned by AnEnPi as analogous are in fact derived from the same ancestor but have diverged up to a point where their primary sequences no longer share recognizable similarity. Molecular modeling techniques, together with appropriate evolutionary methods, could be used to ascertain that the tri-dimensional structures and sequences of the enzymes assigned as analogous are indeed different, suggesting their independent origin.To overcome some of these difficulties, methods to deduce functional information from a certain gene in the absence of sequence data have been recently proposed . NeedlesAlthough we have so far no automatic way to further refine our dataset, the distribution pattern of species over the clusters of a given enzymatic activity may indicate the presence of false positives and therefore serve as a criterion for their identification: the presence of representatives (proteins) from the same organism in several clusters would mean that that organism has several unrelated enzymes able to fulfill the same metabolic step. While this may be real, it is likely that a substantial part of these events are indeed annotation artifacts. In general, our results were congruent with the available literature on the subject Table .It is thus important to discriminate between i) two (or more) subunits of a given heteromultimeric enzyme encoded by unrelated genes and ii) two (or more) enzymes actually sharing the same function, also encoded by unrelated genes. Table T. brucei data produced 14 singlets. The annotation of the metabolic pathways in this organism was done manually [Most likely, the majority of the clusters with only one representative sequence are possibly cases derived from wrong annotations or cases of very divergent sequences, which are not included in other clusters due to the cut-off used. As an example, analysis of manually , and resThe user should choose the best dataset for his purposes. To be conservative, we have employed in most of our analyses the dataset D, minimizing the number of false positives . Using the dataset E, though very restrictive and probably an underestimation, we obtained a set of analogies with a higher probability of being true cases, without possible errors due to multimeric proteins; in fact, even after applying all these criteria for data filtering, still 8.6% of all enzyme classes have potential cases of analogy. No doubt, a better handling of inconsistencies generated during the annotation of multimeric enzymes would improve the identification and provide a better estimation of the frequency and distribution of the cases of intragenomic analogy.H. sapiens and L. major, whose sequences were assigned to distinct clusters. AnEnPi can help by producing a list of shared enzymatic activities between the two organisms without detectable similarity at their primary level, reflecting substantial differences between their folding patterns. Also, the overall pattern of similarity scores shown in Figure The ability to identify potential cases of analogy between genes from two different species Figure , as wellCurrently, we are developing a database with all putative analogy events stored in a comprehensive way, linked to information from drug databases. AnEnPi is also being updated, with the inclusion of information from hundreds of new organisms.AnEnPi is a versatile tool designed to assist the user in the identification, clustering and annotation of analogous enzymes. Its modular structure allows its utilization in other contexts. Addition of color codes to represent biological attributes allows for a better visualization of metabolic pathways, with more meaningful biological information, facilitating the interpretation of the results..AnEnPi is freely accessible at • Project name: AnEnPi – Analogous Enzyme Pipeline (Webserver)• Project home page: • Operating system: Linux• Programming language: Perl and HTML• Licence: AnEnPi is accessible under a GPL licenseEC: enzyme commission; AnEnPi: Analogous Enzyme PipelineThe tool was developed and implemented by TO. He and AG designed the web interface and carried out the experiments. All authors analyzed together the data, discussed the results, wrote the manuscript and approved the final version.


For some years now, we have been living with the fear of an impending pandemic of avian influenza (AI). Despite the recognition, in 1996, of the global threat posed by the highly pathogenic H5N1 influenza virus found in farmed geese in Guangdong Province, China, planning for the anticipated epidemic remains woefully inadequate; this is especially true in developing countries such as Saudi Arabia.These deficiencies became obvious in 1997, with the outbreak of AI in the live animal markets in Hong Kong that led to the transmission of infection to 18 humans with close contact with diseased birds; there were six reported deaths. The pres The influenza virus is known to have an unstable character, with the ability to acquire new genetic material from other influenza viruses of similar or different serotypes, thus giving rise to new strains of influenza viruses with different genetic material. That such phenomena occur has been recognized for many years, and it is known to be responsible for the cyclical episodes of transcontinental outbreaks of influenza that have taken place. The best known is the 1918 Spanish influenza outbreak, which claimed more lives than were lost in World War I. Though bThe most common transmission is from birds to humans. Humans exposed to infected poultry will remain in the disease incubation period from 3 to 7 days. Dead poultry seems to be the most infectious; while, handling ill poultry or defeathering, slaughtering, or cooking infected birds is believed to involve less risk. Herein lies the challenge of containing the spread of AI: in many countries back-yard farming remains a common practice and an important source of domestic income. Most disease transmission occurs from domestic animals. however,9et al. in Vietnamese patients and included the preparation of sick or dead poultry for consumption and having sick poultry in the household at any time within the last 7 days; in addition, the lack of an indoor water source was also identified. It  It 32] IEfforts to control such outbreaks require intense collaboration between many governmental and non-governmental agencies. In the Kingdom of Saudi Arabia the consequences of an outbreak during the hajj will have a global impact as the Kingdom hosts over 2.5 million pilgrims a year from all over the world.34 The MOAt the Ministry of Health (MOH) level, many educational programs are now in place to educate HCWs on the importance of standard and extended precautions, isolation policies and procedures, and hand hygiene. Such efforts are vital in this phase of the pandemic, when no human cases have yet been identified. Even though these measures will be helpful, successful compliance and adherence to these policies calls for a change in HCWs' behavior and this has its own unique barriers to implementation, a discussion of which is beyond the scope of this review.The MOH has identified a number of protocols to be followed in the event of human cases being suspected or identified. These include standard operating procedures for individuals under investigation for HP H5N1, case definitions, data collection forms, emergency contact numbers, public health measures, and educational material for HCWs and the public. All efforts have been in collaboration with the concerned governmental bodies in order to standardize these approaches.Fortunately, during the outbreak in the Kingdom of Saudi Arabia, none of the human contacts of infected birds were identified as having AI. As we remain in the early phases of the pandemic, we should bear in mind that once the virus acquires the genetic material that allows for more efficient human-to-human transmission the number human infections will rise and we can expect an explosive pandemic.Even as we hope that AI will remain a serious problem involving only birds, it is crucial to prepare for a possible major outbreak of human disease, especially since we have historical evidence that influenza pandemics do recur, typically several times each century. This obs37


P=0.0081), the number of women (P=0.0023) and somewhat with the country surface area (P=0.077). There is considerable variation in the density of MU across countries and the number of MUs in service are often well above what would be necessary according to local screening recommendations. High number of MUs in some countries may have undesirable consequences, such as unnecessarily high screening frequency and decreased age at which screening is started.In the 2000s, most of the female population of industrialised countries had access to mammography breast cancer screening, but with variable modalities among the countries. We assessed the number of mammography units (MUs) in 31 European, North American and Asian countries where significant mammography activity has existed for over 10 years, collecting data on the number of such units and of radiologists by contacting institutions in each country likely to provide the relevant information. Around 2004, there were 32 324 MU in 31 countries, the number per million women ranging from less than 25 in Turkey, Denmark, the Netherlands, the United Kingdom, Norway, Poland and Hungary to more than 80 in Cyprus, Italy, France, the United States and Austria. In a multivariate analysis, the number of MUs was positively associated with the number of radiologists ( Biennial mammography screening is considered to reduce breast cancer mortality by 25% in women aged 50–69 years . In womeFor 34 countries, using address lists obtained from the International Agency for Research on Cancer (IARC) and through internet searches, we gathered a list of potential sources of information. For some countries, the data were readily available in published reports or on websites; it was nonetheless verified through direct contact with the sources. We wrote to all potential sources of information we identified, asking for information on (i) the total number of MUs  and (ii) the total number of radiologists, with numbers specialising in mammography.The letter clearly stated that data sent to the IARC would be used to make a comparison among countries. If a contact could not provide relevant data, he or she was asked to provide us the details of an appropriate institution or to forward our letter directly to this institution.We considered an MU to be any X-ray machine used for breast examination, through either analogical or digital modalities. As the same equipment could serve for both diagnosis and screening purposes, we made no distinction between MU declared as serving these purposes or reported as being part of a national screening programme or a medical facility .a priori reliable sources were received for a country, we verified the information by re-sending the letter to these sources and, when possible, to other contacts. If for a country, no source of MU data was found, we used data from the European Coordination Committee of the Radiological and Electronical Industry . We received data from 123 institutions or companies. When we obtained data from several sources for one country, we gave priority to radioprotection institutes, as registration of X-ray-emitting devises is compulsory in all countries. Sometimes, however, governmental radioprotection offices are established at a sub-national rather than at a national level precluding the identification of any single body having the relevant information for the entire country. When radioprotection institutes did not answer, or were not available at a national level, we turned to alternative sources of information. When several sources responded, we used the one most likely to be aware of MU in the country. Information from social security offices was usually not considered, as for these institutions, a clinic or a radiological facility is usually considered as a single ‘mammography centre’ although it may comprise more than one mammography unit. When dissimilar data from at least two Industry  or from Industry . If the As only five countries  provided separate counts of MU used in national screening programmes and in other medical facilities, we did not use these in our analysis. Some countries gave data on digital MU; given the rapid changes in digital mammography equipment during the 2000s, it was considered premature to provide these statistics.We collected information of country breast screening practice through literature search . We then examined how female population size, the number of radiologists and country surface influenced the number of MUs by fitting a linear regression (Eleven countries reported the number of radiologists specialised in mammography examination , ranginggression . Both feIn Member States of the European Union, the number of MUs was a good predictor of attendance to mammography screening when attendance was due to self-reference or due to doctor's prescription, but not after invitation by a breast cancer screening programme .This study shows the considerable variability in density of MU across countries, and the number of MUs in service often exceeds what would be necessary to fulfil local screening recommendations. Country-specific volumes of breast cancer screening activities were not examined because reliable quantitative data were not generally available .The few data we had on the number of radiologists specialised in mammography examinations suggested that the total radiologists registered in a country could represent a reasonable approximation to those specialising in mammography. But the variability in radiologists specialising between countries probably reflects differences in what this entails. In some countries, geographical distances may lead to installation of more MUs for easier access to screening. The multivariate model we fitted showed borderline statistical association between country surface and the number of MUs, once the number of radiologists and of women was taken into account. However, similar densities observed in countries much larger than the Netherlands, Norway and the United Kingdom indicate that geographical factors cannot account for all the difference in density of MU. Hence, all countries considered together, both total female population and the number of radiologists established in the country were the essential determinants of the number of MUs, irrespective of country size.Our data are more recent than the COCIR report  and coveExamination of MU density in relation to the most recent mortality data  shows noCoverage of the female population at ages 50–69 years was not achieved in Turkey and Denmark in 2003, though in Turkey, the number of MU may have been underestimated , in 1997Sixteen of the 31 countries included had more than 46 MU per million women and five have about twice this density. These data suggest that in many countries the number of MUs is well above what would be necessary according to local screening recommendations, and oversupply of MU may exist, peaking in France, Cyprus, the United States, Austria and Italy. An oversupply of MU may have undesirable consequences (The enforcement of the Mammography Quality Standard Act in the United States in 1992 did not notably reduce the number of MUs, but probably led to the creation of mammography facilities that could better apply quality assurance requirements (The European Guidelines for Quality Assurance in Breast Cancer Screening and Diagnosis exist since 1993 (


Conjoined twins have been viewed with fascination since antiquity. There are numerous reports in the literature documenting anesthetic management strategies for the separation of conjoined twins. There are also reports in the literature detailing anesthetic approaches for surgical procedures not involving separation. This is the first report of the anesthetic management of a set of omphalagous presenting for palliative repair of omphalocele in Nigeria. Conjoined twins have been viewed with fascination since antiquity. Interest has ranged from suspicion and fear of the birth being an omen of impending disaster to exhibitionism and more recently as a subject of intense media interest. The twin2The exact incidence of conjoined twins is unknown, but the estimated incidence is 1 in 50 000 live births. The rate in the United States is 1 in 100 000 births. Increased incidences range from 1: 14 000 to 1: 25 000 in Asia, India, Pakistan, Thailand, and in Africa, especially East Africa, Nigeria and South Africa. There arWe report the case of a pair of twins joined at the upper abdomen  who were delivered at a peripheral hospital by cesarean section and referred to the University of Nigeria Teaching Hospital as an emergency . TogethePrior to induction of anesthesia we tested for cross circulation between twins. Glycopyrrolate was given intravenously to twin B causing an immediate increase in heart rate. However, there was no change in twin A’s heart rate for a 5 min interval following the administration of the glycopyrrolate. With no evidence of cross circulation between the twins, we felt it unlikely that twin A would become apnoeic shortly after drug administration to twin B. We evaluated our theatres to determine how best to position equipment that would be duplicated , and we color coded all the monitoring cables, breathing circuits and intravenous lines to avoid the potential for confusion about what was going to whom.Two anesthetic machines and anesthesia teams were available . The theAnesthetizing conjoined twins involves three major anesthetic considerations. First, two anesthesia teams need to be available, cooperating closely in a limited workspace with clearly separate and duplicate equipment and at times interfering with each other. Second, the degree and clinical significance of crossover between the two circulations must be considered. Drugs administered to one twin may have effects on another twin. Intravenous drugs can be administered on a combined weight basis and the relative size. Testing the cross-circulation between twins can be performed by administering drugs such as glycopyrrolate to one twin and detecting the effect on the other twin.Finally, care appropriate to the surgical procedure must be provided in this unique setting. Most published reports concern anesthesia for the separation of conjoined twins, including the use of combined general with epidural anesthesia. Warming Anesthesia for procedures on conjoined twins is a demanding, exacting, and meticulous exercise, whether prior to or during separation. Anesthesia forms part of the multidisciplinary management of the babies. Emphasis is laid on preoperative assessment, goal-directed planning of theatre and the staff involved in the surgery, duplication of all equipment necessary for anesthetizing and monitoring two infants in one operating room, and having plans in place to avoid overcrowding. Challenges encountered in anesthesia for these twins include identifying anatomical conjunctions, airway management, acquiring vascular access, the potential for enormous blood loss, and maintaining normothermia. Planning for the postsoperative period and the reconstruction and rehabilitation of the babies is essential from the time of their initial admission. Meticulous attention to detail, monitoring and vigilance are mandatory. Successful management of conjoined twins relies on close communication and cooperation of all members of the multidisciplinary team.