The effect of natural disasters on secondary sex ratio (SSR) and perinatal outcomes has been suggested. This study aimed to examine effects of the Great East Japan Earthquake on perinatal outcomes using vital statistics of Japan.Birth registration data from vital statistics of Japan between March 2010 and March 2012 were used. Pregnant women who experienced the earthquake were categorized according to their gestational period as of March 11, 2011, as follows: gestational weeks 4–11, 12–19, 20–27, and 28–36 (2011 group). Similarly, pregnant women who did not experience the earthquake were categorized according to their gestational period as of March 11, 2010 and used as controls (2010 group). We also categorized prefectures as “extremely affected”, “moderately affected”, and “slightly or unaffected” regions. SSR, birth weight, and gestational period were compared between both groups.P = 0.009). In the extremely affected region, children born to women who experienced the earthquake at 28–36 weeks of gestation had significantly lower birth weights.The number of singleton births was 688 479 in the 2010 group and 679 131 in the 2011 group. In the extremely affected region, the SSR among women at 4–11 weeks of gestation was significantly lower in the 2011 group compared with the 2010 group (49.8% vs 52.1%, The SSR declined among women who experienced the earthquake during early pregnancy, particularly in the extremely affected region. However, no apparent negative effect of the earthquake on perinatal outcomes was observed, although birth weight of infants who were born to women who experienced the earthquake at 28–36 weeks of gestation were lower. In Japan, Fukuda et al examined SSR after the Kobe earthquake in 1995; they concluded that at 9 months after the earthquake, the SSR was significantly lower than prior to the earthquake.4The effect of natural disasters, such as earthquakes, on perinatal outcomes has been previously examined. For instance, in Chile, expectant mothers who experienced the strong earthquake in 2005 were found to be likely to deliver babies before full term, especially for female children. As a result, the ratio of males to females at birth (secondary sex ratio [SSR]) was decreased among these women.5–7 or preterm births,8 none of the above studies strictly adjusted for seasonal changes in perinatal outcomes. Further, studies using individual data for analysis had relatively small sample sizes, while studies with larger numbers of subjects were designed as ecological studies. Thus, it is difficult to determine the causal association between natural disasters and perinatal outcomes.It appears to be widely accepted that the SSR decreases following natural disasters. However, this effect is not fully understood. In addition, these previous studies had certain limitations. For example, although an effect of seasonality has been noted for SSR9 By March 11, 2014, casualties included 15 884 deaths, 2633 missing, and 6148 injured, as confirmed by the National Police Agency of Japan.10 The most severely affected prefectures were Iwate, Miyagi, and Fukushima. Catalano et al examined the effect of this earthquake on SSR using birth registration data from the vital statistics data of Japan and suggested that sensitive periods during both early and late pregnancy led to a decreased SSR.11 Further, in the most severely affected prefectures, the rate of conception of males was reduced.11 However, these results were based on aggregate data, and these effects have not yet been examined on an individual level.On March 11, 2011, a huge earthquake occurred in eastern Japan, called the Great East Japan Earthquake, inducing a subsequent massive tsunami. Millions of people were affected by this earthquake and tsunami, which was determined to be the most severe natural disaster in Japan in recorded history.This study aimed to examine the effects of the Great East Japan Earthquake on SSR, birth weight, and gestational duration in weeks using individual birth registration data in the most severely affected prefectures and other prefectures in Japan.In Japan, every birth must be registered by law. Thus, the study participants consisted of all births that occurred during the study period. The birth registration data are filed at relevant city health departments and entered into computerized files at the Ministry of Health, Labour and Welfare of Japan. Individual birth registration data from these vital statistics of Japan between March 2010 and March 2012 were used for this study. These data were anonymously provided under the Statistics Act in Japan and contain the birthplace, birth date, child’s sex, birth weight, gestational age, parity, and ages of the father and mother. Except for the ages of the parents, the obstetrician who attended the birth provided this information on the birth certificate. In this study, it was not necessary for participants to provide informed consent because every birth in Japan is legally required to be registered, and birth registration data are available for researchers to use with permission from the Ministry of Health, Labour and Welfare under the Statistics Act in Japan.n = 679 131). Pregnant women who did not experience the earthquake were similarly categorized according to their gestational period as of March 11, 2010, and used as controls . The gestational duration at the time of the earthquake was calculated by using the birth date and gestational age from the birth registration data. Because an effect of the earthquake on preterm birth and a gender difference in this effect have been suggested,1 women who experienced the earthquake after 37 weeks of gestation were excluded to examine the effect of earthquake on SSR and preterm birth. In addition, stillbirths were also excluded because the purpose of this study was only to examine the effect of the earthquake on live births. We also categorized prefectures as “extremely affected” , “moderately affected” , and “slightly or unaffected” .To examine the effect of the earthquake on SSR and perinatal outcomes, we compared the above-mentioned 2011 and 2010 groups. Analyses were also conducted for the “extremely affected”, “moderately affected”, and “slightly or unaffected” regions. Further, only singleton babies were analysed because of known significant differences in gestational duration and birth weight between singleton and multiple births.The characteristics of the study population are described in Table P = 0.009) (Table P = 0.0011). However, there were no significant differences between the 2010 and 2011 groups during other gestational periods in this region.In the extremely affected region, the male-to-female ratio among the women at 4–11 weeks of gestation was significantly lower in the 2011 group than in the 2010 group  was statistically significant; however, no such significant difference was observed in the extremely affected region. In the extremely affected region, there was no significant difference in SSR among women who experienced the earthquake at 20–27 and 28–36 weeks of gestation, although these differences were larger than the differences among the women at 4–11 weeks of gestation in the slightly or unaffected region. We believe that the statistically significant difference seen in the slightly or unaffected region could merely be a result of the large study population. Therefore, it is difficult to assess whether or not this difference was a result of the earthquake.Some demographic differences were noted between the 2010 and 2011 groups. However, the total fertility rates of women during these years were similar.in utero.11 However, they only examined the number of births in each month, since they analysed aggregate birth registration data. Thus, their results did not consider the stressors of the earthquake at the individual level. Despite differing methodologies, our results concerning the effects of the earthquake during early pregnancy were consistent with their findings. Further, our results, which suggested that experiencing the earthquake during early pregnancy was associated with decreased SSR, were largely consistent with the results of Fukuda et al, although they also analysed aggregated birth registration data concerning the Kobe earthquake.4 However, our findings regarding the effect of the earthquake during late pregnancy differed somewhat from those of Catalano et al.11 Where Catalano et al suggested that there might be a sensitive period in late gestation, our results suggested that SSR was not significantly different and that the birth weight in males was likely to be lower when the mothers experienced the earthquake at 28–36 weeks of gestation. However, in our analysis, it was impossible to assess the effect of the earthquake after 37 weeks of gestation because we excluded women who experienced the earthquake after that point from the analysis. Therefore, in women who experienced the earthquake after 37 weeks of gestation, it was suggested by the previous reports that the gestational duration for male children was likely to be shortened because of intrauterine growth restriction,14 with a resultant decline in SSR during late pregnancy. However, because the adjusted difference in mean birth weight between 2010 and 2011 was only 16 g, the effect of the earthquake on foetal growth might be small.With respect to SSR, our results were largely consistent with those of previous studies. Catalano et al examined the effects of the same earthquake and concluded that rate of male births decreased because of decreased conception rates of male foetuses and increased selection of female foetuses 1 They also demonstrated that expectant mothers who experienced that earthquake were likely to deliver babies before full term, especially for female children,1 although we noted no significant effect of the earthquake on shortened gestational duration. However, only in Iwate Prefecture, which is part of the extremely affected region, a significant decrease in gestational duration for female children was observed among women who experienced the earthquake during early pregnancy (data not shown). Therefore, our results in this prefecture were similar to their results although the number of population in this prefecture was limited.The present findings were also largely consistent with results of a study by Torche and Kleinhaus concerning the impact on SSR of the 2005 earthquake in Chile, which analysed individual birth registration data and concluded that the SSR decreased among women who experienced that earthquake.15,16 Natural selection is hypothesized to include conservation mechanisms by which stressed pregnant females preferentially cull frail male foetuses. This hypothesis, known as the Trivers-Willard hypothesis,17 proposes that adverse maternal health shocks around conception or during pregnancy lead to a sex ratio skewed in favour of female offspring, and the present results support this hypothesis. One possible explanation for the hypothesis is that, because male foetuses grow faster and larger than female foetuses,18 male foetuses may require more resources from the mother and may be less likely to adapt their development to a stressful intrauterine environment.1 On the other hand, female foetuses might need fewer resources than males for development in utero1 and may show reduced growth and demands on the mother in response to maternal stress.19 Finally, male newborns are also more likely to die than females.20It has been suggested that cohorts that have experienced severe maternal stress during pregnancy, such as that caused by natural disasters, have lower-than-expected SSRs.2 In our analyses, some negative effects of the earthquake on gestational duration and birth weight were only observed in part of the extremely affected region. Moreover, no clear effect of the earthquake on perinatal outcomes was observed. This discrepancy between the results of our study and those of the study conducted in Chile might be caused by differences in geographical factors and medical support systems after natural disasters in each country.Previous studies regarding the effects of earthquakes on perinatal outcomes, such as the report regarding the Chile earthquake, have indicated that expectant mothers who experience the earthquake during early pregnancy are likely to have preterm deliveries.21 In addition, this kind of measurement error is non-differential. As a result, this study limitation would be expected to reduce the statistical power of comparison between 2010 and 2011 groups. Thus, it is unlikely that detected differences in SSR were due to chance, as non-differential errors generally make variance of distribution larger. Particularly in the analyses of perinatal outcomes, there might be certain type I errors due to multiple comparisons because many comparisons were made between the 2010 and 2011 groups in each gestational period and region. However, for the comparison of SSR in the extremely affected region, we expect our results to be robust because the P value was very small. Further, since the earthquake, emigration from the disaster-stricken areas has increased, particularly from Fukushima Prefecture.22 In addition, the number of deliveries, including deliveries of women who went to their parents’ home and delivered at a hospital in their parents’ town to obtain perinatal support from their parents , decreased in the extremely affected region after the earthquake due to problems of gaining access to medical facilities because of the shutdown of some facilities.23 These factors may have resulted in differences between the 2010 and 2011 groups. However, the effect of population movement might be limited because there was no significant difference between the 2010 and 2011 groups in other areas, though some people migrated from the extremely affected region. Further, it was impossible to examine differences in the effects between the coastal areas, which were affected by the tsunami, and other areas. The amount of data we obtained from municipalities in the coastal and mountainous areas was relatively small. Therefore, we could not differentiate between the effects of the earthquake versus those of the tsunami. However, if only the effects of the tsunami existed, the results would be underestimated because the effects of the tsunami was very few in other areas. Finally, we did not examine the effect of the earthquake on rates of abortions and stillbirths, which might be essential to clarify the mechanism of differences in SSR. However, our results support previous hypotheses about the mechanism of such differences that do not rely on abortions and stillbirths, since the present findings were mostly consistent with those of previous studies.This study has several limitations that warrant mention. First, to control for the seasonality of SSR and gestational duration, women who were pregnant at 1 year before the earthquake were used as controls. It is possible that this interval was not adequate to control for seasonality; however, very few studies have previously considered the seasonality of SSR and perinatal outcomes. Second, since Japanese birth registration data do not include information regarding maternal lifestyle and complications during pregnancy, it was difficult to adjust for potential confounders of perinatal outcomes, such as maternal smoking during pregnancy; however, we did control for maternal age at birth and birth order. In addition, the method of calculating gestational age was not specified in the vital statistics, although information concerning gestational age was provided by obstetricians. In any case, the method for determining gestational age is likely to have been the same in 2010 and 2011 as well as between each gestational week category of participants and among regions, because there is a guideline for obstetrical practice in Japan.Despite these limitations, we consider our results to be valuable for examining the biological mechanisms underlying the effects of natural disasters on SSR and perinatal outcomes, particularly since this study analysed huge datasets from national individual birth registration records.In conclusion, this study is the first to analyse the effects of the Great East Japan Earthquake on perinatal outcomes using individual data, with consideration of the seasonal patterns of perinatal indicators. Our findings suggest that SSR declined among women who experienced the earthquake during early pregnancy, particularly in the extremely affected region. However, with regard to perinatal outcomes, such as gestational duration and birth weight, no apparent negative effect of the earthquake was observed, although birth weight of infants who were born to women who experienced the earthquake at 28–36 weeks of gestation were lower.Abstract in Japanese.


It is evident that if something is not counted, and physical therapists (PTs) are not generally counted in international health statistics, no one knows how many there are, neither can they measure their contribution to population health or monitor their migration. The World Health Report [1] provides statistics on doctors and nurses primarily. Few data are reported on other health personnel.To address the burgeoning needs of populations living with non-communicable diseases, disability and older people every health professional will need to be involved. PTs with their expertise in maintaining and restoring people’s maximum movement and functional ability are well placed to take a key role. However with the paucity of information about the profession health, policy makers and planners are disadvantaged.To fill the information gap, the World Confederation for Physical Therapy (WCPT) has developed an annual data collection which generates a country profile that includes information on the WCPT member organisations (MOs), the number of PTs, scope of practice, education and regulation.WCPT MOs were asked for their top priority information requirements. Together with the priorities of WCPT this information provided the base for a set of questions. A sample of national health workforce surveys was reviewed for relevant data items. Where available, international standard classifications were used. A data advisory group involved people from all WCPT regions. Following feedback the data items were reviewed and pilot tested by representatives of the majority of the WCPT MOs. An online data capture tool was built and pilot tested. The first collection was made in 2012.In 2012, 69 of 106 WCPT MOs provided data, a 65% response rate. The analysis enabled reporting on numbers of PTs who were members of WCPT MOs and an estimate of the number of PTs in the country of the responding MOs, which paired with population data from the World Bank provided an estimate of the PT to population ratio. The ratio varied between 0.002 PTs per 1000 population to 2.82 per 1000 population.The WCPT collection is the only global collection on PT workforce, education, regulation and practice. Whilst the collection is in its infancy and data quality and reporting requires improvement, it can provide information to governments, inter- and non-governmental agencies, the profession and the public. In time, longitudinal data may illustrate the changes in the country profiles as a response to health workforce migration, policies and planning.


Reliability and validity of measurements are important for the interpretation and generalisation of research findings. Valid, reliable and comparable measures of health status of individuals are critical components of the evidence base for health policy. The need for sound information is especially urgent in the case of emerging diseases and other acute health threats, where rapid awareness, investigation and response can save lives and prevent broader national outbreaks and even global pandemics.Several successfully implemented health interventions have involved community health workers (CHWs) in reaching out to the community, and the Community Health Strategy is one such an intervention. The government of Kenya, through the Ministry of Public Health and Sanitation has rolled out the strategy as a way of improving health care at the household level. It involves CHWs collecting health status data at the household level, which is presented at community meetings in which the community discusses the results, identifies action areas, and plans activities for improving their health status.Ten percent of all households visited by CHWs for data collection in different sites  were systematically selected and visited a second time by technically trained research team members. The test-retest method was applied to establish reliability. The Kappa score was used to measure reliability, while sensitivity, specificity, and positive predictive values were used to measure validity.Inter-observer agreement between the two sets of data in both sites was good; most indicators measured slight agreement. However, some indicators demonstrated greater discrepancies between the two data sets (e.g. measles immunization). Specificity measures were more stable in Butere , which had more than 90% in all the indicators tested, compared to Nyalenda (peri-urban), which fluctuated between 50% and 90%. There were variable reliability results in the peri-urban site for the indicators measured, while the rural site presented more stable results. This is also depicted in the validity measures in both sites.The paper concludes that there are convincing results that CHWs can accurately and reliably collect certain types of community data which has cost-saving implications, especially for resource poor settings. Reliability and validity of measurements are important for the interpretation and generalisation of research findings . Valid, The government of Kenya, through the Ministry of Public Health and Sanitation has rolled out the community health strategy as a way of improving health care at the household level. This strategy involves CHWs collecting health status data at the household level, which is presented at community meetings in which the community discusses the results, identifies priority actions, and plans activities for improving indicators found to be low, in order to improve their health status.A lot of successful health interventions in many parts of the developing world have involved the community health workers in reaching out to the community . Large sWestern Kenya has consistently provided low health and development indicators despite an array of interventions initiated by NGOs and the Government of Kenya. These poor indicators beg for concerted efforts to ensure that a reversal of the poor trends is achieved. Future interventions require valid and accurate information on the health status of the population for effective planning, monitoring, and evaluation to track effectiveness. Available information may not always be timely, complete, or relevant to the local context .Population-based sample surveys and sentinel surveillance methods, such as Demographic and Health Surveys, are commonly used as substitutes for routinely collected data. Nevertheless, these methods have been criticised for being expensive, providing inadequate coverage of the population, and lacking in timeliness.With the rolling out of the Community Health Strategy, community health status information became readily available.Community health workers (CHWs) and other lay community workers collect a wide range of health information. However, little is known as to whether this information can be relied on to measure population health status, and the causes and distribution of disease. CHWs’ job description included health education and basic preventive services for family planning; maternal and child health; improving nutrition; basic hygiene, sanitation; and child immunization .Today it also includes mass immunization for polio eradication, newborn care, referral of eligible cases to health facilities, and regular record-keeping for updating the community health information system ,12. ThisA study by Kisia and others found that community health workers, with supervision from the facility staff, collect and analyze data, and produce information which was to be used to decide which health problems the community needed to address. The basic objective of data collection by CHWs was to improve their own work, management and output. Through such an arrangement, the community was enabled to address some of its health-related problems with its own resources  . This deIt is therefore necessary to determine the validity and reliability of the data collected by community health workers, in order to establish its usefulness for planning and policy formulation for the communities from which it is collected. This would go a long way to settle speculation on whether the data collected by these workers is robust enough for use in determining the health and disease distribution in a population .The purpose of this study was to determine the validity and reliability of data collected by CHWs in different socio-economic contexts in Kenya.Community Units that were implementing the Community Strategy as piloted by the Ministry of Health were purposely included in the study. Of these sites, the socio-economic context of each site was taken into consideration to reflect rural agrarian where the community relies on crop agriculture as a major economic activity, and peri-urban where the community relies on different economic activities. The peri-urban site exhibits a slum-like environment where social amenities are scarce and this is compounded by high population density.Community health workers registered and updated individual members of households’ information twice a year as required by the Community Strategy using the household register, a tool provided by the Ministry of Health. Special permission was sought to access this data from the community health committee. Ten percent of this data was re-collected using the same tool by a technically trained group of final year community health and development Bachelor of Science students, who were recruited as research assistants for the study, providing the standard for the data collection, in order to validate the data. Systematic random sampling was applied with the list of households being obtained from the CHWs data used as the sample frame. The research assistants visited the selected households and interviewed the same respondents that were interviewed by the CHWs. Where these respondents were unavailable, a call back was made at a time when they would be around. In case of migration, especially in the peri-urban site, the household was replaced with another household by the lead researcher. The first wave of the data collection by the CHWs was conducted in March 2011. The second wave followed at most two weeks later, depending on the site.This study analyzed the consistency in repeated self-reports of health indicators over two interview waves. A total of 9906 households were visited by CHWs. Of these 4612 were in Butere, the rural site, while 5294 were in Nyalenda, the peri-urban site. Apart from their training in community health and development, the students were also trained in research methods and data collection techniques. The sample size for this study was 1015, which is the total number of households visited by the research assistants, 472 in Butere and 543 in Nyalenda.The study used the Test-Retest/Stability Reliability which compares results from an initial test with repeated measures later on, the assumption being that if the instrument is reliable there will be close agreement over repeated tests if the variables being measured remain unchanged. The Kappa score, specificity, and positive predictive values (PPVs) were also used to measure reliability and validity, respectively . Table 1Kappa measures the difference between observed and expected agreement, and is standardized to lie on a -1 to 1 scale, where 1 is perfect agreement, 0 is exactly what would be expected by chance, and negative values indicate agreement less than chance, i.e., potential systematic disagreement between the observers. This was ranked as follows for this study, as in a study conducted by Rietveld and van Hout in 1993: < 0 Less than chance agreement, 0.01–0.20 Slight agreement, 0.21– 0.40 Fair agreement, 0.41–0.60 Moderate agreement, 0.61–0.80 Substantial agreement, 0.81–0.99 Almost perfect agreement .The study was conducted in two research sites: a peri-urban informal settlement , essentially a slum area, with many unplanned structures; and a rural site (Butere). The two sites differed in socio-economic characteristics and the composition of the community health workers recruited. The indicators tested were the measles vaccine, antenatal attendance by mothers four times or more during the last pregnancy with the youngest child under five years, and skilled attendant assisted delivery for the same youngest child under five years. These indicators are relevant to the fourth and fifth millennium development goals tracked by these communities.The observed difference for the age variable in Nyalenda was 0.66, portraying very little inter observer difference scores between the two types of data collectors. The gender variable showed slight agreement between the two sets of data. The maternal and child health indicators showed agreements ranging from less than chance to substantial agreement, with less than chance agreement in the measles variable and substantial agreement in health facility delivery. Table The maternal and child health indicators ranged from 59.67 to 98.5 for the specificity values and 88.53 to 99.2 for the PPV. Measles registered the lowest specificity values, as indicated in table The observed agreement in the mean age was 23.34 for the research assistant data and 21.69 for the test results in Butere giving an observed difference of 1.65. The Kappa rating ranged from chance to slight agreement, giving low reliability estimates for this site. Table Specificity and positive predictive values for the indicators in Butere ranged from 92.34 to 99.7 and 97.1 to 99.8, respectively. Generally, validity estimates for these indicators were very high, as shown in table Nyalenda had better agreement in all variables as compared to Butere. The Nyalenda scores spread out from less than chance agreement to moderate agreement while Butere scores clustered together at slight agreement. Generally, Butere presented better results than Nyalenda across the board. Nyalenda showed lower specificity for the immunization variable. Butere results presented better specificity measures as well as positive predictive value, while Nyalenda had an outlier (measles) in the specificity measures.This study analyzed the consistency in repeated self-reports of health indicators over two interview waves. Overall, there was a high level of agreement between the research assistant data and the test results. This suggests that the use of CHWs provides a reliable method for collecting data especially on maternal health indicators. The reliability of the measles vaccine which gave a Kappa statistic rating of less than chance in Nyalenda also had the highest inter-observer difference among all the variables. This may be due to the fact that inasmuch as the measles vaccine is administered at a particular time in the child’s life, the vaccine had been administered to all children under five years of age due to an outbreak in the region during the study, and not necessarily according to the schedule.et al. also found that there was consistency in the estimates of key health indicators when the national Behavioral Risk Factor Surveillance System data was compared to particular National health surveys [Therefore, recall may have been clouded or confusing for the respondent. This may have caused the variance between the observers. The remaining variables showed ratings of between chance to substantial agreements between the research assistant data and the test data. Viera and colleagues  observed surveys . The rel surveys  found thThe paradox presented by the measles and antenatal clinic (ANC) variables where the percentage difference between the two data sets (research assistant data and test data) were low (high agreement between the two observers) but the coefficient of Kappa was unexpectedly low can be explained as in ,10 high Reliability is a necessary, but not sufficient, component of validity. An instrument that does not yield reliable scores does not permit valid interpretations. Validity in this study was estimated using specificity, the probability of true negatives, and positive predictive values, which reflected the probability that an observation as classified from self-reported information was truly as observed.PPVs also varied between the sites with Butere having higher values than Nyalenda, but decreased slightly in the measles and skilled delivery variables. Sensitivity for detecting true positives in our study, as in other studies , was verThe data by community health workers was a complete census of the households by a large number of observers while the validation data was a 10% sample, collected by a small team of research assistants. It is possible that comparison of the two data sets was influenced by the huge differences in sample sizes as well as the number of observers, over and above the quality of data that was being measured. The study results may not be generalizable to other parts for the country due to contextual, social or cultural settings experienced by different communities. Factors affecting reliability and validity, such as heterogeneity of the group being studied, age, educational background, etc., may vary due to inherent differences in communities, and therefore CHWs.Results suggest that validity, as measured, does not vary significantly when the two sites are compared. The differences noted in the specificity ratings between the sites, especially in the immunization variable, are also consistent with the reliability measures within the same variable in the analysis.Although there was some variability in the measurements recorded by the CHWs and the research assistants, there is substantial agreement in maternal health data from both sources. This means that trained CHWs from communities can collect reliable data, especially on maternal and child health indicators. They are therefore a reliable, alternative source of data collection for community based studies. This data can therefore be used for planning and action at the source of collection and at higher levels, for example at the district level.Future research can be undertaken to establish factors that influence reliability and validity of such kinds of data. This would provide insight on the reasons for differences in the measures between the sites.ANC: Antenatal clinic; CHWs: Community health workers; NGO: Non-governmental organization; PPVs: Positive predictive valuesThe authors declare no competing interests.Both authors contributed equally in writing this article.


Nanotechnologies are predicted to revolutionize: (a) the control over materials properties at ultrafine scales; and (b) the sensitivity of tools and devices applied in various scientific and technological fields. In this short review, we argue that dentistry will be no exception to this trend. Here, we present a dynamic view of dental tissues, an adoption of which may lead to finer, more effective and minimally invasive reparation approaches. By doing so, we aim at providing insights into some of the breakthroughs relevant to understanding the genesis of dental tissues at the nanostructural level or generating dental materials with nanoscale critical boundaries. The lineage of the progress of dental science, including the projected path along the presumed nanotechnological direction of research and clinical application is mentioned too. We conclude by claiming that dentistry should follow the trend of probing matter at nanoscale that currently dominates both materials and biological sciences in order to improve on the research strategies and clinical techniques that have traditionally rested on mechanistic assumptions. The reason for the omnipresence of the word “nano” as one of the most attractive prefixes in the contemporary materials science is simpler than it seems ,2. Namelversus realized in the transition of an emerging technology to the actual practice is not new; however, the pace of application of nanotechnology to dentistry has been less than revolutionary. In Many fields of science have throughout history rapidly made advantage of tools and techniques that allowed for the design of material properties at a finer scale. Many are hopes that nanotechnology will likewise bring tangible benefits to dentistry, from the bench to the clinical level . As descIn this review, we argue in favor of the fact that the upcoming methodologies in dental sciences are no exception to the trend of focusing onto ever finer details in material structures studied in parallel with maintaining the line of progress. In such a way, many routinely used approaches, reparative and exploratory alike, which have traditionally been used in practice will be substituted with finer, more precise and sensitive methodologies. Important questions can be raised about the true benefits of the firm reliance on research strategies and clinical techniques based on the traditional restorative mechanistic assumptions that currently dictate the dental sciences. The aim of this paper is to subject these assumptions to scrutiny and offer a few guidelines that fall into the scope of contemporary nanoscience and nanotechnologies as a way of improving and transforming them into solid bases for novel methods in dentistry.per se [Nanotechnologies are on the verge of initiating extraordinary advances in biological and biomedical sciences. These would be associated with both providing the tools for improved understanding of fundamental building blocks of materials and tissues at the nanoscale and designing technologies for probing, analysing and reconstructing them. It is not surprising that the development of novel technologies provides the foundations for creation and application of newer and more advanced ones. Expansion of novel technologies, particularly those involved in enriching methods of research, have already changed the way we view and define the standards of high-quality dental materials, tools and practices. A particularly interesting example comes from the improvement of our understanding of micro- and nano- leakages in resin-based restorations, resulting from the development of research methods that allow for visualization of material structures at nanometer scale resolution . Nowadayper se ,8,9. It per se ), as welvice versa is essential for the advancement of both fields. Basic research is the first step that leads to a better patient care, which is the final step of any biomedical endeavors. On the other hand, a timely feedback about the pros and cons of materials and technologies in usage from a clinical perspective is critical in directing the research efforts along the right path. As pointed out by Charles Bertolami, “Is the calling to be an outstanding clinician really any different from the calling to be an outstanding scientist? The passion to know is common to both. In the case of the clinician, that need serves the interest of the individual patient. For the biomedical scientist, that need serves the interest of all patients” [It is interesting to recognize at this stage how continual evaluation of clinical concepts becomes allied to the most recent advances in basic research. Perhaps, the connection between basic research and clinical practice is what some dental practitioners fail to recognize. And yet, clinical environment has many times been evidenced as fruitful and essential for the proper evolution along the line of basic research in life sciences. Feedback that researchers receive from clinicians and atients” . Neglectatients” . With suatients” ,14. It iatients” ,16,17. TAs we see, nanotechnologies have favoured our understanding of dental tissues at the nanoscale and enabled the design of materials with ultrafine architecture. There is a prospect that probing the structure of dental tissues at ever finer size scales and using the dynamic resolution capabilities of advanced nano tools will give us answers to some of the puzzles that occupy dental researchers of the day. In the next section, we will point out some of the significant advances in dental research that revealed the nano perspective of dental tissues. When viewed at the nanoscale resolution, these structures, otherwise considered as static and stagnant, were seen as exposed to fascinating structural dynamism. Moreover, we will try to yield insights into how this adoption of nanotechnologies may guide dentistry, particularly the reparative aspects of it, to finer, more effective and minimally invasive approaches. So let us start off by describing the cases of dental hard tissues that traditionally used to be viewed as structurally stagnant, but when observed at the nanoscale spatial resolution gained a markedly more dynamical physical appearance.in situ spectroscopic and light scattering techniques [in vitro [Enamel is composed of 92–94 vol % fibrous apatite crystals with approximately 20 nm in diameter and ultrahigh length-to-width aspect ratios . Precisechniques ,24,25, win vitro . With thin vitro ,28, ther6 unit cells), but this tiny amount of organic additive remarkably enhances the resistance of the material to fracture [Many questions regarding the fine structural details and their functional role in enamel exist. The exceptional roughness of enamel crystals and biological apatite in general, comprising surface irregularities of the order of size of single unit cells is another one of these. Hypothetically, their role is to increase the protein binding in the process of biomineralization . The samfracture . It alsofracture . The facfracture . Despitefracture .This perspective goes against the grain of the classical assumption that due to its highly mineralized composition, enamel presents the only tissue in the vertebrate body that, once formed, does not depend anymore on the biological supply of nutrients. All other tissues are built in such a way that every single cell within them needs to be no further than 200 μm away from a blood vessel ,35. Enamet al. [The microstructure of dentin, a composite mineralized tissue, suggests the necessity of a hierarchical approach to the understanding of its mechanical properties ,37. The et al.  performeet al.  confirmeet al. , indicatet al. , also uset al. in 1982 [i.e., acid-etched) dentin collagen fibrils. However, many studies have shown that nano-leakages, which are only around 20–100 nm wide [The concept of hybrid layer formation, first proposed by Nakabayashi  in 1982 , has lon nm wide ,50 compa nm wide . Later T nm wide ,53, sugg nm wide , confirm nm wide  and bone nm wide . Hydrate nm wide . Signifi nm wide . One of  nm wide . An impr nm wide , the co-vice versa [per se [As the ancient alchemists would have reminded us, the whole Cosmos is reflected in the tiny parts thereof and ce versa . Focusince versa ,62,63. D [per se , which a [per se , as exem [per se ,67.Yet, each detail of the oral microflora abounds with multiple molecular species that define the susceptibility of the subject to disease . Despiteetc.).Despite centuries of work, dating back to Galileo, the molecular basis of toughness and strength of hard tissues for long remained largely a mystery . A greati.e., microhybrids and nanofilled composites, comprise filler particles ranging from approximately 20 to 600 nm. Other dental nanotechnologies rely on the delivery of molecules that facilitate tooth structure remineralization by means of non-invasive dental techniques that forestall caries, the latter being an active area of nano-research in dentistry. Much of this work involves nanoparticles in conjunction with resin-based composite (RBC) systems. Xu et al. reported [As shown in reported  RBCs conreported . In agrereported , we too reported ,76.Quantum dots offer us an example of how the size of nanostructured domains in a semiconductor material can have a drastic effect on the material properties ,78. Nameet al. demonstrated that there may be no difference in the type and proportion of the present cariogenic bacteria between patients prone to caries and the caries-free ones, thus shifting the focus towards the synergetic interaction of multiple components that reside in the oral cavity [Nanosciences have also recently promoted emerging concepts in oral microbial ecology, which may soon redefine our understanding of biofilm formation and treatment. Recent analyses with ribosomal RNA-based technologies have revealed the diversity of bacterial populations within dental biofilms, and have highlighted their important contributions to oral health and disease . It has l cavity . As a col cavity .The field of diagnostics of oral diseases is also subject of rapid evolution. Proteomic analyses by mass spectrometry with their ability to identify proteins at ultralow concentration levels have a chance of drastically improving the diagnostic sensitivity and efficiency . PolarizFinally, in parallel with the strong shift in the field of chemistry away from the traditional reference to strong, chemical bonding effects to the control of weak physicochemical interactions  . It is our duty now to believe that dental sciences will not be led astray towards the way of the fools, but will equally well cultivate the way of the wise.


The non-territorial approach in all three crownlands, however, was an instrument to reorganise multi-ethnic provinces that increasingly became the model for national compromises in other Austrian provinces.In the early twentieth century, three provinces of the Austrian half of the Habsburg Empire enacted national compromises in their legislation that had elements of non-territorial autonomy provisions. Czech and German politicians in Moravia reached an agreement in 1905. In the heavily mixed Bukovina, Romanian, Ukrainian, German, Jewish and Polish representatives agreed on a new provincial constitution in 1909. Last but not least, Polish and Ukrainian nationalists compromised in spring 1914, just a few months before the outbreak of the First World War vitiated the new provisions. Even though the provisions of these agreements varied substantially, new electoral laws introducing national registers were at their heart. These were designed to ensure a fairer representation of national groups in the provincial assemblies and to keep national agitation out of electoral campaigns. The earliest compromise in Moravia went furthest in consociational power sharing. However, the national bodies within the provincial assembly had no right to tax their respective national communities, and the provisions of the provincial constitutions kept the non-nationally defined nobility as an important counterbalance. The compromises in Bukovina and Galicia, even if they categorised  Despite its federal structure, its central institutions (government and administration) had been very strong ever since the centralising efforts of the enlightened absolutist rulers of the second half of the eighteenth century. The most significant change in the country's structure was the Austro-Hungarian Compromise in 1867 when the Empire, up to then a relatively centralised state, split into two formally equal entities: the Kingdom of Hungary, also referred to as Transleithania (a reference to the little river Leitha separating the two parts), and the Austrian Empire, also referred to as Cisleithania.Reichsrat .The Habsburg Monarchy was not only a multi-national empire, it was also a This article concentrates on the Austrian part of the Empire, its struggle to deal with its multi-national structure and its innovative approaches to the management of ethnic conflict. The article first sketches the ethno-national landscape and its conflict lines as well as the legal preconditions for nationalities policy. Then it analyses provincial compromises enacted in the early twentieth century in the provinces of Moravia, Bukovina and Galicia and provides an overview of developments in Bohemia and Bosnia-Herzegovina. Even though these agreements differed considerably in the motivations of those who were party to them, in their mechanics and in their ultimate outcomes, they all had a sort of non-territorial component. In the concluding section, the article discusses the influence these models had on the central state's approaches to the reduction of national conflict.National conflicts in Cisleithania appeared at local, provincial and state levels. The stages on which they were fought out were the political representative bodies , the courts, the schools and school boards, and, increasingly, the public space. Key elements of the national conflicts included language issues and the struggle to widen or to limit language use within the municipal and provincial administration and jurisdiction, as well as at all levels of education. Thus, nationalists on all sides frequently used language data to support their claims and complaints. These language data were provided by the Austrian Central Bureau of Statistics based on a population census every 10 years. From an early stage, these censuses, their criteria and their methods were hotly disputed by national activists. The Bureau of Statistics did not collect data on citizens’ ethnic affiliation or mother tongue, but only on their language of daily use. This clearly introduced a bias in favour of Cisleithania's lingua franca, German, but also favoured more socially prestigious languages such as Polish in Galicia and Italian in the coastal provinces  and the Administrative Court of Justice . This shows that the struggle for national rights was not only conceived as a political issue but also as a legal matter within the Austrian legal system. As article 19 of the basic law put it,Volksstämme] of the state are equal in their rights, and each people has the inviolable right to maintain and to cultivate its nationality [Nationalität] and language.All peoples [For all languages whose use is customary in the land, the state recognises equality of rights in schools, public offices, and public life.In those crownlands inhabited by more than one people, public institutions of education shall enable each of the peoples to be educated in its language, without being compelled to learn a second language of the land.The key legal document behind most of the national conflicts was article 19 of the Basic Law on the General Rights of Citizens, part of the Austrian Constitution of 21 December 1867. This proclaimed the equality of all peoples of Cisleithania, but commingled ethnicity, nationality and language. A similar provision had already been discussed during the Habsburg Empire's first but brief constitutional period between 1848 and 1849. Ever since then, the equality of peoples developed into a sort of a guiding constitutional principle, if with uneven application. Conflicting parties recurrently referred to the three clauses of this 1867 law and periodically alleged infringements of their rights in Cisleithania's supreme judicial institutions, the Imperial Court of Justice  in particular. For centuries, German was the language of upward social mobility and of the urban bourgeoisie to which newcomers assimilated. As the provincial parliament was meant to represent noble and bourgeois interests, German speakers  had dominated the provincial assembly ever since the Empire's return to constitutionalism in 1860–1861. However, as the Czech bourgeoisie grew in economic and social importance in the late nineteenth century it increasingly articulated its national demands  could Germans maintain their majority. Most German parties understood that it was only a matter of time before Czech representatives would prevail and have the capacity to out-vote them. They therefore agreed on negotiations to reach a compromise under which they would voluntarily give up their existing majority in exchange for a national veto on key issues. A crucial role in these negotiations was played by the ‘middle’ party, which, in the person of Alfred Freiherr von Skene, also chaired the parliamentary reform committee. The governor of Moravia, who represented the crown and central government, was a fourth participant; the negotiations for this compromise were thus in reality multilateral ex officio mandates. Still, to pass a law in the diet each side would have to win over some representatives from the nationally unaligned 30 representatives of the great landowners. Thus, the great property holders were not only heavily overrepresented in the provincial parliament; they also had the power to tip the scales , the rural taxpayers (39 Czech and 14 German) and a common curia for all the others (14 Czech and 6 German). Hence, Czechs would gain an assured 73 and Germans an assured 40 representatives. In addition, six nationally unaligned but de facto German or German-Jewish seats were reserved for representatives from the chambers of commerce in Brno and Olomouc , which constituted the provincial government. In this tripartite system the nationally unaligned representatives of the great landowners elected two members, German representatives from all other social curia were assigned two, and the Czech deputies chose four members. Aside from designating the members of the provincial government and of parliamentary commissions, the three blocks did not play any role in the legislative procedure. They had the right neither to levy taxes on their co-nationals nor to pass specific legislation for them. However, the quorum for revision of key elements of the Compromise was high enough to give each of the three blocks a de facto veto in key issues. The constitution required four-fifths of all members of the diet to be in attendance, and support from a two-thirds majority of all delegates present, in respect of the following matters: changing the electoral system, abolishing the national division of the school administration and of the agricultural councils, changing the language of instruction in any schools or closing them, and amending the language of the provincial administration , arguing that their fathers’ claims to be of German nationality were not justified. This view contradicted the stated right of a person to choose his or her national affiliation freely. This 1910 decision can, therefore, be understood as a paradigm shift in Austrian legal practice. While public authorities earlier had also sometimes investigated people's private lives in order to determine their nationality or that of their children, the Administrative Court of Justice had stuck to its earlier definition of nationality as an individual's free choice. After 1910, however, the Austrian supreme courts increasingly confirmed the view that a person's ethnic belonging can and must be assessed by others in cases of conflict, and that a nation has a right to claim its own members  and Hungarian (1.3%) Austria, .Czernowitz, Romanian Cernăuţi, Polish Czerniowce) with its more than 25,000 members. However, in the smaller towns and villages, Yiddish clearly prevailed . The Austrian constitution of 1867 did not acknowledge Jews as a nationality but only as religious group. Article 19 of the constitution, discussed above, thus did not apply to them, and neither Yiddish nor Hebrew were recognised languages. Therefore almost all (95%) Bukovinian Jews indicated German as their language of daily use. This was particularly the case for the large assimilated Jewish community in Chernivtsi , elaborated a new provincial constitution modelled after the Moravian Compromise. In October 1909, the Diet unanimously passed a new electoral law that would have introduced five different classes of members of parliament: unelected ‘virilists’ (high office holders with ex-officio membership—the archbishop and the university rector), and representatives of four electoral classes . Within these four classes, everybody was originally enlisted in one of five different national rolls: Romanian, Ruthenian, Polish, German or Jewish , two Ruthenians, one (Armeno-)Pole, one German and one Jew.On the other hand, unlike in Moravia, all Bukovinians including the landed nobility were registered in national rolls, often called cadastres, not least because in the fourth  curia everybody was enfranchised, even those who were allowed to vote in other curiae. In this respect the Bukovinian Compromise went further in nationalising the entire population than its Moravian predecessor. The national categorisation of all citizens was more difficult. Bukovinian Jews, who had a strongly distinctive but not necessarily national identity, were unhappy at having to join the German register. Some minor groups were also included in other nationalities’ cadastres: Hungarians had to join the Romanian cadastre, Lipovans the Ruthenian and Armenians the Polish one. The Armenian landowners, however, gained representation together with the Poles through a ‘Polish and Armeno-Polish’ electoral body. The local authorities were required to draw up the preliminary national registers and make them public. As in Moravia, everybody on the list was allowed to challenge any other registered person or claim non-registered persons as part of the cadastre; such cases would eventually be decided by the authorities. However, if an individual were to personally delete his name from one national list and sign onto another one, this decision could not be contested by anybody.In fact, during the first elections according to the new provincial constitution in 1911, approximately 2,000 complaints were filed among the almost 25,000 voters in Černivci, because national labelling proved to be very difficult Leslie, . Most naThe non-territorial provisions of the Bukovinian Compromise and their implementation in the province's realpolitik in general need further investigation. The new provincial constitution did not call for proportional representation of all nationalities in public office as in Moravia; neither did it provide for partition of the provincial school board, and it certainly did not include financial autonomy. However, the law stated at least vaguely that only the respective national members of the provincial government should exercise political control over institutions dedicated to their national group.Lwów, German Lemberg) that would operate through the medium of Ukrainian.After many decades of conflict, on 14 February 1914 a compromise between Poles and Ruthenians finally passed the Galician Diet. In addition to a new suffrage law that would allow Ruthenians greater representation in the provincial parliament, this compromise suggested the foundation of a second university in L'viv  prevailed. Yiddish-speaking Jews lived in both parts of the crownland; only in the larger cities did progressive Jews assimilate linguistically, to German in earlier decades, and to Polish increasingly after the 1880s. While in Western Galicia the Polish-speaking population was socially more diversified, in Eastern Galicia the social dividing lines between Ukrainian-speaking peasants and Polish-speaking landlords largely coincided with the ethno-confessional ones.As in the rest of the Empire, language statistics were one of the battlefields of national activists. Collecting data on people's language of daily use clearly favoured the Poles, because Polish had been the dominant language in the public sphere ever since the 1870s, not least because the law did not permit identification with Yiddish in the census. Consequently, the Ruthenian national movement preferred to rely on census data reporting religious denomination in accounting for their share of the total population, identifying all Roman Catholics as Poles and all Greek Catholics as Ruthenians. By the early twentieth century, non-Jewish German speakers were not very numerous and mostly lived in either Protestant or Catholic rural settlements . The Board first replaced German by Polish as the language of instruction in almost all Galician secondary and higher education institutions, and later only very reluctantly approved Ukrainian schools, especially gymnasia (high schools).Galicia enjoyed a certain degree of de facto self-rule since the 1870s, mostly in educational, cultural and administrative matters, even though constitutionally it did not enjoy any special status different from that of the other crownlands. Hence, ‘Galician autonomy’ resulted largely from non-interference on the part of the central government Binder, . Adding Although Ruthernians traditionally had few social advancement opportunities apart from clerical careers, a small Ruthenian middle class was beginning to emerge by the late nineteenth century, and increasingly claimed national rights. Talks about a new provincial constitution started in 1905. The Ruthenian National Democrats but also the Polish Peasant Party and the Social Democrats called for the introduction of universal and equal suffrage on the model of that introduced for the Austrian central Parliament in 1907. However, as in Moravia, Bukovina and other crownlands, the Austrian government as well as the regional elites clearly wanted the provincial assembly to be a forum for the representation of corporate interests. So, when intensive negotiations between the Polish parties and the leading Ruthenian representatives began in 1912, the central issue was the distribution of representatives between the national groups. The solution that was found in Galicia was a modified and moderated version of the Moravian and Bukovinian models. After a first draft bill to introduce fairer political representation failed in 1913, in February 1914 the Galician Diet finally approved a new electoral law enfranchising for the first time all male  Austrian citizens permanently living in Galicia. As mentioned earlier, votes were not equal. Every citizen was assigned to one of six curiae according to their place of residence (town or countryside), their income and/or their social status  and the curia of the craft corporations (V), which were organised non-nationally but depended on membership in these institutions; and a Polish and a Ruthenian one for each of the other four curiae . In order to put every voter on the correct list, the local authorities had to take into account their tax records on the one hand, and the language data from the last census on the other. Once the local authorities published all 10 voters’ lists, everybody concerned was entitled to appeal against this assignment.Even more complicated than the curia system was the assignment of electoral districts to a specific nationality see . Very muEven though the Galician Compromise did not award any national representation to the Jewish population, the way in which the ‘Polish’ constituencies were drawn in the curia of the taxpaying urban dwellers guaranteed at least a certain representation of the Jewish bourgeoisie. Furthermore, among the five representatives of the curia of Galicia's chambers of commerce – which was legally nationally unaligned, but counted as Polish – it is probable that at least three Jewish candidates would have been elected Kuzmany, . In addiIn general, Ruthenians continued to be heavily underrepresented, because they could realistically gain only 27% of the total 228 seats in the Galician Diet. Within the provincial government, their representation would have been even lower. Only two out of eight members would be Ruthenian.The electoral system was cleverly devised to minimise the chance of surprise results, and the ratio of 166 Polish to 62 Ruthenian deputies would not be likely to be violated. It was partly based on a territorial and partly on a personal principle. Whereas all Galicians had to register in either the Ruthenian or the general (and thus in effect Polish) cadastre, not all constituencies were ethnically homogeneous. In the predominantly Polish western part of Galicia, voting districts were territorial; consequently, Ruthenians who had migrated, for example, to Cracow could in practice vote only for Polish candidates. In Eastern Galicia, on the other hand, even the smallest Polish pockets in Ruthenian villages were transferred to the net of Polish constituencies according to the personal principle. In other words, this system fostered assimilation in Western Galicia and strengthened national diversity in Eastern Galicia  agreed to split the German and Czech electorate into autonomous national bodies. This settlement went further than any of the earlier compromises. As in Bukovina and Galicia, it registered all inhabitants according to their nationality but tremendously enlarged the agency of the autonomously elected national representatives. For the first time, they would have received the right to separate national taxation and spending , Bukovina (1909), Bosnia (1910) and Galicia (1914), as well as the new municipal charter in Budějovice (1914), allowed each national group to elect its representatives autonomously. Therefore, they all introduced national or ethno-confessional registers and a fixed number of representatives for each national group. This allowed a fairer but also less flexible national representation in the provincial assemblies and governments, and partly also in the administration of these crownlands.Applying the principle of national affiliation to all nationalities living in the province, these regulations made no legal distinction between majorities and minorities within the province, but simply tried to reorganise it along multi-ethnic lines. If we look into the matter in detail, however, these regulations were essentially instruments designed to secure national rights for all members of recognised nationalities, even in areas where they were in a minority. Thus, these compromises recognised nationalities as non-territorial agents but hardly granted them autonomous agency. Nowhere did the new constitutions introduce financial autonomy, separate political representative bodies or separate laws for the different ethnic groups. The Bohemian lands appeared poised to move in this direction: the 1914 Budějovice Compromise foresaw national taxation, and in the same year Czech and German politicians were negotiating a revision of the 1905 Moravian Compromise to include budgetary autonomy. But these developments were overtaken by the outbreak of war Malíř, .The role of the Viennese central government in these five cases is interesting as well. It strongly approved of all of these negotiations, and insisted that no agreement should be reached without the consent of all national groups concerned (Urbanitsch, Yet, the degree of intervention varied considerably. In Moravia, the Austrian government remained largely aloof, and eventually accepted provisions, in such areas as schooling, that contradicted Cisleithania's long established liberal handling of national affiliation. In Bukovina, on the other hand, the government bluntly overruled the unanimous wish of the negotiators to introduce a Jewish curia, arguing that this would be unconstitutional and a negative development for the entire state. In Bosnia, in contrast, the government introduced a ready-made constitution based on de facto ethno-confessional registers without consulting local politicians. In Galicia, the Cisleithanian government frequently intervened when the negotiations were in a deadlock, not least because it wanted to pacify this province at a time when tensions with neighbouring Russia were steadily increasing. In the final months before the agreement, the Austrian prime minister, Karl Stürgkh, engaged in almost daily correspondence with the Galician governor, with key politicians and with church dignitaries in order to bring the adversaries together (Kuzmany, While federalist solutions were discussed as well, in the early 1910s non-territorial concepts were at the top of the agenda in the Habsburg Empire as a mechanism for reducing national conflict. The Emperor himself imposed a cadastre-based model on Bosnia-Herzegovina, the Cisleithanian government strongly pushed the Galician Compromise, and public opinion expected that only a similarly knit compromise could bring peace to Bohemia. More crownlands might have experimented with these ideas in the years to come; however, the outbreak of the First World War brought the further evolution of this approach to an abrupt end. The dissolution of the multi-national empire in 1918 gave way to newly created nation-states that officially dismissed earlier Habsburg experiences with non-territorial autonomy.


Evidence-based decision making is essential for appropriate prioritization and service provision by healthcare systems. Despite higher demands, data needs for this practice are not met in many cases in low- and middle-income countries because of underdeveloped sources, among other reasons. Emergency departments (EDs) provide an important channel for such information because of their strategic position within healthcare systems. This paper describes the design and pilot test of a national ED based surveillance system suitable for the Pakistani context.The Pakistan National Emergency Department Surveillance Study (Pak-NEDS) was pilot tested in the emergency departments of seven major tertiary healthcare centres across the country. The Aga Khan University, Karachi, served as the coordinating centre. Key stakeholders and experts from all study institutes were involved in outlining data needs, development of the study questionnaire, and identification of appropriate surveillance mechanisms such as methods for data collection, monitoring, and quality assurance procedures. The surveillance system was operational between November 2010 and March 2011. Active surveillance was done 24 hours a day by data collectors hired and trained specifically for the study. All patients presenting to the study EDs were eligible participants. Over 270,000 cases were registered in the surveillance system over a period of four months. Coverage levels in the final month ranged from 91-100% and were highest in centres with the least volume of patients. Overall the coverage for the four months was 79% and crude operational costs were less than $0.20 per patient.Pak-NEDS is the first multi-centre ED based surveillance system successfully piloted in a sample of major EDs having some of the highest patient volumes in Pakistan. Despite the challenges identified, our pilot shows that the system is flexible and scalable, and could potentially be adapted for many other low- and middle-income settings. Although the use of data for prioritization of healthcare programs and services is often touted as the cornerstone of sound decision-making in public health, in many low- and middle-income countries (LMICs), this is simply not the case-3. This Emergency departments (EDs) are located at the boundary between hospitals and the communities that they serve . They caIn LMICs, however, the potential of EDs as a source of vital information to guide and improve the provision of healthcare services, and public health in general, has not been fully harnessed. Studies from Pakistan have shown poor pre-hospital and facility-based care systems , which hIn this paper, we describe the development and pilot test of the Pakistan National Emergency Department Surveillance System (Pak-NEDS) in seven major tertiary healthcare centers across Pakistan including the development of data collection tools, methods, and processes.Information gained from health information systems supports evidence based decision-making at multiple levels Figure  and is cHealth information systems can be considered to have subunits or 'subsystems' gathering information from different sources including the health sector, surveys and research, and other sectors such as census bureaus or departments of transport and safety, department of labor, etc. . An impoUsefulness is maximized by considering the different consumers and the utility of the information generated by the surveillance system. The surveillance system not only needs to generate information satisfying local data needs, but also needs to complement the overall health information system for it to be an effective tool for use in health systems planning and policymaking. The system needs to be flexible so that it may adjust for changing needs over time. It should be acceptable to all stakeholders including the consumers of the information, in order to ensure validity of the information produced from the system and for maximal uptake by the intended users. The system needs to be portable for it to be replicated in other settings, which is generally accomplished with simpler systems. Portability contributes to standardization and coalescing capacity for surveillance systems in different locations to form regional or national databases. Other considerations include system stability and costs. Stability can be gauged by the uninterrupted operation of such systems over time under varying conditions, while costs can be analyzed using economic evaluations such as a cost-benefit analysis. All of these factors are vital for the long-term sustainability of the system [Timely collection and processing, and analysis of valid information are important elements of any surveillance system. Other qualities are also essential if these systems are contextualized within the larger health information system and the health system itself, as proposed by the Centers for Disease Control and Prevention (CDC) . Usefulne system ,20. Pak-Seven major tertiary care centers from across the country were selected for the study Table . The JinA systematic process was used to understand the needs, to design, and to initiate Pak-NEDS in the selected hospitals. The study was conducted over four months in each participating ED between November 2010 and March 2011, during which period active surveillance occurred 24 hours every day, for 7 days a week.The sections below describe this process in more detail:Society of Emergency Physicians of Pakistan (SEPP). Most of the study sites did not have adequate clinical records for clinical or research purposes, although the situation was markedly better for private institutions.We reviewed both published and grey literature and our search did not reveal any similar surveillance efforts implemented or underway in Pakistan. The finding was further confirmed by consultation with other emergency medicine experts, identified through the membership of the Engaging all stakeholders from the beginning of any major initiative such as this one is key to its success and sustainability . Prior tThe ED administrators were identified and contacted through SEPP. One administrator from each institution was appointed as a representative of the study in the host institution. These personnel then facilitated the introduction and approval of the study by the hospital administrators and the ED staff.The representatives were individually consulted during every stage of the surveillance design to make it compatible with the varying ED systems and protocols across the institutions, including the design and content of the standardized study questionnaire used for the data collection. A one-day ED surveillance system workshop was conducted at AKU with participants from the partner institutes. The agenda was to identify data needs that were essential to the surveillance and to identify potential sources of data already present in the EDs to minimize duplication of data collection efforts, e.g. registration information, clinical records, etc. The study data collection methods were modified accordingly and all study personnel approved the final surveillance protocols and questionnaire before the pilot testing began.Emergency Department Patient Record questionnaire of the National Hospital Ambulatory Medical Care Survey (NHAMCS) of the Centers for Disease Control and Prevention, USA [Our aim was to develop an ED surveillance system model that could be replicated in other institutions and be integrated into an ED patient record form. This is reflected in the content of the questionnaire, which collected information on a wide range of issues. Table ion, USA . It was All data collectors involved in Pak-NEDS were required to undergo training on the study questionnaire and all relevant data collection procedures including ethical conduct during the data collection process. There was significant variation in the demographic and expertise profiles of data collectors between institutes. Priority was given to individuals who had experience in similar projects or those who had some previous training in healthcare. A number of data collectors were paramedics or nursing students. Study staff who did not have any previous clinical exposure were required to demonstrate adequate understanding of study protocols in order to continue in the project. Two-day workshops were conducted at each study site . A post-training assessment including an individual verbal assessment was completed by every team member. This step was put into place to ensure complete understanding of the study questionnaires, the components, and the potential sources of data. This was further supplemented by mock interviews conducted between the trainees to ensure accurate understanding of all questionnaire components and categories.This was followed by an on-site one-day performance assessment for the data collection team ensuring satisfactory skills. The performance of each individual and that of the whole team was observed and assessed. Compliance with study data collection procedures, and accuracy and completeness of information collected was monitored until every member consistently demonstrated complete understanding of the data requirements of the study questionnaire, and of the sources and protocols for data collection. All trainings were conducted by AKU researchers.Patient flow patterns, in terms of volume and direction, were observed prior to the start of the data collection. Based on this assessment, data collectors were appointed different 'locations' within the EDs such as the triage counter, fast track clinics, critical care beds, or surgical and medical emergency rooms. These locations were different between institutions as there were differences in the distribution of services. The study questionnaire was attached to the initial registration slip or the ED record form of a patient presenting to the ED. The data collectors then proceeded to fill in the questionnaire based on information available from the clinical records, the healthcare providers, and from the patients or their attendants, in stages according to the progress of the patient within the ED until the final disposition Figure . InformaData was collected 24 hours a day, 7 days a week in almost all of the study EDs with workers working in 8-hour shifts. Any cases which did not have a final disposition at the shift change were reported to the next shift data collectors who then followed up on those patients. Twenty-four hour coverage could not be achieved in MHL, where the number of data collectors was only sufficient to cover two 8-hour shifts every day. Weekly shifts to be covered were based on a predetermined schedule ensuring equal coverage for morning, evening, and night shifts at the end of the four-month surveillance period for MHL.Study questionnaires were printed and disbursed from AKU to the other study centers. Unique IDs on each questionnaire were used to keep track of allocation and retrieval from the different sites. The on-site supervisors were responsible for sending the completed study forms to AKU (coordinating center) on a weekly basis. These forms were then entered into a computer database built using Microsoft Access. On average, computerized data was available within 10-15 days after receiving the hard copies of study forms from the field. AKU was responsible for aggregating and safekeeping the study data, including the physical forms which were catalogued and stored under lock and key in the Department of Emergency Medicine at AKU.Individual identifying information was not collected from any of the study subjects. Confidentiality and anonymity were ensured for all individuals throughout the study. All data collected were unlinked to clinical or any other records which could be used to identify the individual patients. All electronic information was encrypted and password protected.A daily report of the number of cases registered in the surveillance system and those presenting to the EDs was compiled by the field supervisors and sent to AKU. A daily coverage rate (%) of the surveillance system (registered (n)/total presented (n) × 100) was calculated using this information. The total number of patients presenting at the EDs was taken from the ED registration records. These rates were used to monitor the performance of the surveillance system in terms of coverage. Any unusual deviations from the coverage trends were promptly investigated, and the reasons rectified if required.Quality assurance processes were built in at different stages in the design and testing of Pak-NEDS Table . Random Over 270,000 cases were registered in the surveillance system over a period of four months Table . CoveragHealth care in Pakistan is provided by both government and private sectors; according to estimates, 70% of care is provided by private health care providers  This is Information on the occurrence and outcomes of various illnesses and injuries in Pakistan has not been available at this level before, and would be invaluable for identifying any gaps in the quality and appropriateness of services being provided in these EDs. The surveillance information could also be used to assess the effectiveness of and/or to guide improvements in interventions  employed to improve healthcare services, even including those used at the community level.ED surveillance for individual diseases has been successfully implemented in different settings. This is particularly relevant to injuries which comprise a major portion of cases presenting in EDs ,25. EstiED databases have traditionally suffered from fragmented information coming from different sources . Among tWe identified many challenges that should be considered for similar efforts in the future Table . In addiLimited and incomplete clinical records were another issue contributing to missing data in the study. The overwhelming volume of patients in some of the participating centers resulted in overburdened staff who in many cases were not able to adequately complete the clinical documentation. Almost none of the partner institutes had any electronic records other than registration information. This, coupled with illegible handwriting and misplaced forms, was a significant challenge for data collection. Despite the team's efforts to standardize coding for presenting complaints, many were recorded as free text, as were the provisional diagnoses. Abbreviations and misspellings, illegible handwriting, and data entry errors all led to these variables becoming a challenge to analyze. As mentioned earlier, the use of electronic devices in future systems would eliminate such issues.Personnel management was another challenge in the study. One of the centers insisted on hiring their own data collectors and supervisors due to institutional policies. Although the same training and monitoring procedures were put in place as for the other institutes, coordination between the staff at this center and AKU staff was more challenging and required additional effort. The personnel that were hired at that center were government employees, which further limited control on their performance by the coordinating center. Frequent changes in personnel was another concern, which required additional trainings in some instances. These were conducted by local supervisors. In two of the public centers, ED managers who were serving as co-PIs of Pak-NEDS were locally re-assigned. Our study lasted four months and this did not have a significant impact on the pilot phase, but this could potentially be problematic for any permanent system in place requiring supervision by a specific individual. This only emphasizes the importance of ensuring local ownership of the system by the institutions themselves with protocols in place, so that any changes in the leadership do not disrupt the surveillance system.Pak-NEDS is the first comprehensive multi-center ED-based surveillance system that was developed and pilot-tested for Pakistani EDs. The system was successfully tested in a sample of the major EDs in the country, seven major tertiary care units across Pakistan having some of the highest patient volumes in the country. Through this pilot, we have shown that the system is contextually modifiable and scalable, and could potentially be adaptable for other LMIC settings.The study was reviewed and approved by the institutional review boards of AKU and the Johns Hopkins Bloomberg School of Public Health. It was also given clearance by similar ethical approval committees at each partner site.The authors declare that they have no competing interests.MM was the national coordinator for Pak-NEDS. He was responsible for developing the study materials and methods, and for its pilot-testing at the national level, in collaboration with investigators from participating institutions. He wrote the first draft of the manuscript. AMB was involved in the conception of the study, analysis of the findings, and critical review and writing of the manuscript. SJ, SQA, HK, FAS, MMK, and SA were local Pak-NEDS collaborators from the participating sites. They contributed to the study design, oversaw its local activities, and critically reviewed the draft manuscript. AAH participated in the conceptualization of Pak-NEDS, and was responsible for the overall analysis plan, interpretation, and critical review of the draft. JAR was the PI of the study and was responsible for all the activities of the project conception, implementation, data collection, analysis, and manuscript review. All authors read and approved the final manuscript.


In 2010 an estimated 31% of the food in U.S. stores and homes went uneaten, and Americans shipped approximately 34 million tons of food waste to landfills.In recent years U.S. policy makers have begun to take action to reduce the flow of food into landfills, in part to stem greenhouse gas emissions but also to save businesses the cost of disposal. In 2011 Connecticut became the first state to initiate such action, prohibiting the landfilling of food waste by entities that generate at least two tons per week and are located within 20 miles of a food-recycling facility.But if food is banned from landfills, where can it go? The primary options have been to give unsold food to food pantries or ship it to composting facilities. But recently anaerobic digestion has been drawing attention as a method that can not only accomplish greenhouse gas reduction but also use the food waste as an energy source.Anaerobic digestion is not a new technology. According to the American Biogas Council, 1,241 wastewater treatment plants in the United States have anaerobic digesters, as do 239 farms.The process of anaerobic digestion is akin to the digestive processes that occur within mammals. Microorganisms break down biodegradable material in the absence of oxygen , buildup of volatile acids that can prevent the digester running smoothly, and undesirable changes in the quality and characteristics of the residual digestate. DEP is partnering with the New York State Energy Research and Development Authority, Manhattan College, and Bucknell University to study these issues.In response to the new Massachusetts ban, John Fischer, branch chief for commercial waste reduction and planning at the state Department of Environmental Protection, says several companies and cities have applied for grants or low-interest loans from the state to build anaerobic digesters. He says there’s room for more digesters in the marketplace. But the flow of food waste is finite, he adds, and once adequate infrastructure is in place to handle that flow, there won’t be room for much more.Meanwhile, large food retailers are beginning to take advantage of anaerobic digestion. In 2013 Kroger Company became the first grocery company to convert its food waste into energy when it built a digester capable of handling 150 tons of food waste per day.Universities also see the benefit of using food waste for energy. On 22 April 2014 the University of California, Davis, opened an anaerobic digestion facility with a daily capacity of converting 50 tons of food waste from the campus and area restaurants into 12,000 kWh of energy.In late 2013 a group of researchers from the University of Cincinnati initiated an anaerobic digestion project to produce not just biogas and fertilizer solids but also biodiesel. Tim Keener, a professor in the university’s Department of Biomedical, Chemical, and Environmental Engineering, says that school’s project is unique because it couples anaerobic digestion with algaculture, extracting the carbon dioxide portion of the biogas to grow algae. Lipids isolated from the algae are then converted to biodiesel fuel. The researchers hope to team with the city of Cincinnati, which has expressed interest in a food waste diversion program, to create a facility utilizing the technology.Thomas Trabold, director of the Center for Sustainable Mobility at the Golisano Institute for Sustainability, Rochester Institute of Technology, is a strong proponent of food waste conversion via anaerobic digestion, but he also points out that the outflow of gas and digestate must be properly managed. For instance, the gas must be captured, not leaked to the atmosphere, and digestate may contain chemical and biological contaminants that must be controlled carefully if the material is to be used as a fertilizer.,,Analyses of waste-to-energy opportunities in New York State by Trabold and colleagues indicate significant potential for and interest in expansion.Fiore adds that anaerobic digestion is also a relatively simple way to affordably implement a steady supply of renewable energy into dense urban areas. The beauty of biogas, he says, is that it helps address energy security by taking advantage of local resources, while fostering the resilience of critical infrastructure and reducing harmful emissions.