An Ebola outbreak started in December 2013 in Guinea and spread to Liberia and Sierra Leone in 2014. The health systems in place in the three countries lacked the infrastructure and the preparation to respond to the outbreak quickly and the World Health Organisation (WHO) declared a public health emergency of international concern on August 8 2014.The aim of this study was to determine the effects of health systems’ organisation and performance on the West African Ebola outbreak in Guinea, Liberia and Sierra Leone and lessons learned. The WHO health system building blocks were used to evaluate the performance of the health systems in these countries.A systematic review of articles published from inception until July 2015 was conducted following the PRISMA guidelines. Electronic databases including Medline, Embase, Global Health, and the Cochrane library were searched for relevant literature. Grey literature was also searched through Google Scholar and Scopus. Articles were exported and selected based on a set of inclusion and exclusion criteria. Data was then extracted into a spreadsheet and a descriptive analysis was performed. Each study was critically appraised using the Crowe Critical Appraisal Tool. The review was supplemented with expert interviews where participants were identified from reference lists and using the snowball method.Thirteen articles were included in the study and six experts from different organisations were interviewed. Findings were analysed based on the WHO health system building blocks. Shortage of health workforce had an important effect on the control of Ebola but also suffered the most from the outbreak. This was followed by information and research, medical products and technologies, health financing and leadership and governance. Poor surveillance and lack of proper communication also contributed to the outbreak. Lack of available funds jeopardised payments and purchase of essential resources and medicines. Leadership and governance had least findings but an overarching consensus that they would have helped prompt response, adequate coordination and management of resources.Ensuring an adequate and efficient health workforce is of the utmost importance to ensure a strong health system and a quick response to new outbreaks. Adequate service delivery results from a collective success of the other blocks. Health financing and its management is crucial to ensure availability of medical products, fund payments to staff and purchase necessary equipment. However, leadership and governance needs to be rigorously explored on their main defects to control the outbreak. Ebola Virus Disease (EVD) was first discovered in 1976, near the Ebola river in the Democratic Republic of Congo (formerly known as Zaire) . AccordiThe failure to contain Ebola has been argued to be a violation of the 2005 International Health Regulations (IHR) which urges member states to detect, assess, report and respond promptly to outbreaks and health emergencies . UNMEER’The unprecedented spread of Ebola in the region has been explained in many ways and has been linked to factors such as human mobility between the affected countries, behavioural and cultural practices like traditional burials or bush meat consumption, as well as inefficient health systems . Guinea,In Guinea, health workforce density  is less than 1.5 per 10,000 population , with a The aim of this study was to assess existing evidence on the links between the West African Ebola outbreak in Guinea, Liberia and Sierra Leone and the organisation and performance of the countries’ health systems by undertaking a systematic literature review completed by structured expert interviews. Two objectives were developed to achieve this aim: 1) identify effects of the health systems in Guinea, Liberia and Sierra Leone on the management of the Ebola outbreak, and 2) explore the impacts of the Ebola outbreak on the existing health systems in the three countries.a well-functioning health system working in harmony is built on having trained and motivated health workers, a well maintained infrastructure, and a reliable supply of medicines and technologies, backed by adequate funding, strong health plans and evidence-based policies” . Si. Si36]. Five articles argued that a lack of skilled health workforce was a major obstacle in containing the outbreak , 37–39. Five articles discussed the impact of the Ebola outbreak on existing health workforce , 42, 43.healthcare workers put their heart and soul in defending the lives of others. We have lost a huge resource there that would take years and years to build back.” [An expert argued that Ebola claimed more lives among healthcare workers than any other viral haemorrhagic fevers . Anotherd back.” . This wed back.” . Buseh ed back.” . A WHO rd back.” .Buseh et al. mentioned that a lack of adequate funds invested in health system infrastructure and purchase of supplies contributed to the poor management of the Ebola outbreak . AccordiA WHO report found that as a consequence to the outbreak, the international community and the three countries’ governments allocated additional financial support to medical supplies, human resources, beds, laboratory capacity, contact tracing, safe burials and increased transportation services . One expFour articles stated that shortage of information and research was a considerable problem during the outbreak , 42, 43.Three CDC reports highlighted the impact of Ebola on the information and research systems of the affected countries. Ebola led to the development of a Community Event Based Surveillance system to help widen and bolster Liberia’s Ebola surveillance and response systems . In SierStudies found that lack of medical supplies, resources, personal protective equipment, electricity and IPC led to an increased rate of infections and poor control of Ebola during the outbreak –39, 43. Four articles emphasised the role of leadership in the outbreak without providing specific information , 42, 46.Only two reports noted the impact of Ebola on leadership and governance in Liberia , 50. A pEbola’s burden has jeopardised the services being delivered and led to high numbers of comorbidities and fatalities from malaria. People who died from malaria were twice as much as Ebola. Babies died from diarrhoea and pneumonia” [the number of women giving birth in hospitals decreased causing a rise in maternal mortality. Immunization rates fell and other epidemics (as measles) emerged” [No article studied service delivery. However, five experts explained how Ebola impacted the delivery of health services during and after the outbreak , 45, 51.emerged” . Two expemerged” , 45.This systematic review, complemented by expert interviews, explored the nature of the link between the West African Ebola outbreak and health systems in Guinea, Liberia and Sierra Leone.The results from this study suggest that health workforce had a major effect on the control of the outbreak. In fact, other countries previously affected by Ebola effectively controlled their outbreaks by quickly deploying skilled health staff , 52, 53.Shortage of healthcare workers is also likely to be due to recent civil wars , 55. PooHealthcare workers face a particularly high risk of infection and death, as they are in direct contact with symptomatic patients –60. ThisThe WHO Emergency Committee on the 2014 Ebola outbreak in West Africa met throughout the outbreak to share updates and discuss actionable points to control the outbreak in affected countries in accordance with the IHR . Some ofHealthcare workers in the three affected countries lacked health education and knowledge to control and respond to the outbreak , 66. NigTraditional medicine is highly prevalent in West Africa, which has been known to sometimes conflict with modern medicine . CulturaAll three countries noted an extreme deficiency in medical supplies, efficient transport systems, communication methods and diagnostic tools , 64, 70.In line with the IHR, the Heads of States should activate their emergency management mechanisms and establish an emergency operation centre as soon as an outbreak starts . InformaGuinea, Liberia and Sierra Leone did not have the adequate policies or IPC strategies in place before the start of the Ebola outbreak . There wAfter the outbreak deprived these countries from staff, governments started working with international organisations and research institutions to strengthen capacity and educate the public , 77. LeaThe Emergency Committee advised heads of states of the affected countries to declare a national emergency and inform the public by sharing information on the situation and the importance of community engagement to control the spread of Ebola . The impDue to a lack of resources, programmes like vaccination campaigns were interrupted, which led to outbreaks of other infectious diseases , 40, 54.There was a very limited number of articles available and the included studies had a low CCAT score and did not evenly assess the health systems comprehensively, as per the WHO health system building blocks. No study offered quantitative metrics to assess the health systems and hence quantitative conclusions could not be drawn. Factors which led to the three countries’ weak health systems prior to the outbreak and those that were not linked to health systems were not explored and could have had an impact on managing the outbreak. This study did not conduct a thorough analysis of the political and economic problems in the three West African countries prior to the outbreak or that contributed to the outbreak, and thus a conclusion cannot be drawn on their links to health systems. The study only looked at articles published in English and therefore might have excluded other relevant articles, particularly French articles from Guinea.Since this study included expert interviews, some limitations were also associated with the ways experts were identified and invited. A problem with the snowball method used is the exclusion of experts who are not within the same network of the experts being interviewed. This leads to selection bias. The number of experts interviewed was small due to their active involvement in the outbreak. Most experts commented on the situation in Sierra Leone which might have led to an under-representation of issues in Guinea and Liberia. Expert interviews are viewed as and should be treated as information and not data and thus, the results cannot be considered generalizable or representative. Experts based in one of three countries might have also had a biased opinion of the situation in their country which they could have generalised to other countries. Despite searching several databases, there still remains the risk of not capturing articles or reports that were not published and were kept for internal communications between organisations.This study offers several implications for practice and research. An already weak health workforce suffered a lot from this outbreak. Since nurses were the most involved and connected to the community, it would be useful to train them so that they can easily disseminate effective messages, for instance for case reporting . The worGovernments should acknowledge the need to respond quickly to outbreaks, learn from successful examples such as those from Nigeria and Uganda, and ensure community engagement is maintained. The IHR needs to be properly adopted and country leaders should ensure in country coordination, collaboration with others and flexible Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement are in place in case of outbreaks or public health crisis , 46. It This study does not offer a comprehensive analysis of the health systems of Guinea, Liberia, and Sierra Leone. Further research needs to be undertaken to conduct an extensive health system analysis of the countries before and after Ebola and to assess each building block using quantitative metrics to determine the exact magnitude of problems and the extent of support needed. More research should also focus on community barriers to care, in order to achieve a more patient centred health system.Shortage of health workforce was a major challenge in controlling Ebola during the West African outbreak, but was also severely affected by the outbreak. Further research needs to be undertaken to provide a comprehensive analysis of the health systems, including all building blocks, before and after the Ebola outbreak. The importance of community barriers to outbreak control measures also need to be emphasised, to place the patient at the centre of care and ensure a high uptake of interventions by the population.Ebola is now viewed as an opportunity to rebuild resilient health systems and invest more in capacity building to revive weakened health systems . Interna


Food insecurity is a significant issue in the United States and is prevalent in emergency department (ED) patients. The purpose of this study was to report the novel use of an integrated electronic medical record (EMR) order for food resources, and to describe our initial institutional referral patterns after focused education and implementation of the order.This was a retrospective, observational study, describing food-bank referral patterns before and after the implementation of dedicated ED education on the novel EMR order for food resources.In 2015, prior to formal education a total of 1,003 referrals were made to the regional food bank, Second Harvest Heartland. Five referrals were made from the ED. In 2016, after the educational interventions regarding the referral, there were 1,519 referrals hospital-wide, and 55 referrals were made from the ED. Of the 1,519 referrals 1,129 (74%) were successfully contacted by Second Harvest Heartland, and 954 (63%) accepted and received assistance.Use of the EMR as a tool to refer patients to partner organizations for food resources is plausible and may result in an increase in ED referrals for food resources. Appropriate education is crucial for application of this novel ED process. The United States Department of Agriculture (USDA) defines food insecurity as “limited or uncertain availability of nutritionally adequate and safe foods, or limited or uncertain ability to acquire acceptable foods in socially acceptable ways”. 3The prevalence of hunger and the impact of food insecurity in the emergency department (ED) is clinically important and likely underestimated. 7To address such issues, healthcare institutions reportedly are partnering with food resources for their patients. The purpose of this study was to report the novel use of an integrated EMR order for food resources, and to describe our initial institutional referral patterns after focused education and implementation of the order.This is a retrospective, observational study, describing food-bank referral patterns before (2015) and after (2016) the implementation of dedicated ED education on the novel EMR order for food resources. The study population was an urban, county ED with greater than 110,000 annual visits. This study was deemed exempt from review by our institutional review board.Feeding America is a network of food banks, food pantries, and meal programs providing food and services in the U.S. It is the nation’s largest organization to support hunger relief. Second Harvest Heartland, a midwestern member of Feeding America, is one of the nation’s largest food banks, and supports over 1,000 food shelves and other partner programs that distribute food to over 532,000 individuals in Minnesota and western Wisconsin annually.Our institution and Second Harvest Heartland have partnered to provide food assistance to our patients since 2010. As a result of this relationship, healthy food is available in our clinics in the form of bagged groceries, and on site through an institutional food shelf. Patients are able to receive food through clinics, at discharge from an inpatient stay, or delivered to their homes through a community paramedic program or visiting nurses.To determine eligibility for food services referrals in our institution, staff or providers screen patients for food insecurity with two questions. This two-question screening tool is a validated, abbreviated version of the 18-item U.S. Household Food Security Scale (HFSS), which is used to monitor national food security. If deemed food insecure by this screening process, providers will then order a “referral for food” in the EMR to connect the patient to Second Harvest Heartland for support. The patient must consent to the referral and state what specific contact information they are comfortable sharing with the partner organization. This referral provides the patient’s contact information to Second Harvest Heartland through an automated fax. The food bank staff will then assist the patient in enrolling in federal nutrition programs , a total of 1,003 referrals were made to Second Harvest Heartland; only five were made from the ED. From January 2016 through December 2016 , there were 1,519 referrals hospital-wide, and 55 referrals were made from the ED. This study sought to determine whether ED referrals for food resources for patients with food insecurity would increase after the implementation of an EMR referral order, as well as to introduce provider education about this referral program. To our knowledge, we report the first experience with such an institutional EMR order for food resources in the ED. While previous studies have documented the prevalence and ramifications of food insecurity in the ED,Although food resources are available through a variety of federal and state programs, healthcare providers may be unaware of how to successfully connect patients with these programs. It is not surprising that using an EMR referral tool improved access to food services in our patient population; the benefit of EMR communication for connecting patients to numerous types of medical and social services has been well documented in the literature. Another important consideration identified during the implementation of this process was realizing the knowledge gaps regarding food insecurity in our ED. Screening for food insecurity is not standardized at intake, nor is it part of the registration/rooming process. As such, in faculty and resident discussions surrounding use of the order, failure to consider food security as part of the ED assessment of patients was perceived to be a key limiting factor in making the food referral. Second Harvest Heartland began systematically visiting clinics and educating staff directly regarding the EMR order; while this helped increase referral volume in the clinics, the ED was targeted later in the rollout. We believe that this highlights the importance of provider education in the ED, as this patient population is at great risk for food insecurity and their needs may not be identified if they are not screened or if they do not use the clinic system. Even with education, concerted efforts and ongoing education are necessary.This study was subject to certain limitations, as it was only intended to describe referral patterns before and after implementing an institutional EMR order for food resources. We do not have patient data, such as demographics, as the data we present was provided from the food bank and thus protected. We also cannot account for whether referral increases were due to secular trends, rather than the provider education and the EMR order, though this is unlikely given the magnitude of the increase seen. We also acknowledge that 55 referrals in 12 months is not a substantial number given the prevalence of food insecurity; This study suggests that using the EMR as a tool to refer patients to partner organizations for food resources is feasible, and may increase the frequency of referrals for food resources made from the ED. Such food-resource referrals are potentially an important initial step in addressing food insecurity in patients seen in the ED.


Clinical assessment of hypotonia is challenging due to the subjective nature of the initial clinical evaluation. This poses dilemmas for practitioners in gaining accuracy, given that the presentation of hypotonia can be either a non-threatening or malevolent sign. The research question posed was how clinical assessment can be improved, given the current contentions expressed in the scientific literature.This paper describes the development and critique of a clinical algorithm to aid the assessment of hypotonia.An initial exploratory sequential phase, consisting of a systematic review, a survey amongst clinicians and a Delphi process, assisted in the development of the algorithm, which is presented within the framework of the International Classification of Functioning, Disability and Health. The ensuing critique followed a qualitative emergent–systematic focus group design with a purposive sample of 59 clinicians. Data were analysed using semantical content analysis and are presented thematically with analytical considerations.This study culminated in the development of an evidence-based clinical algorithm for practice. The qualitative critique of the algorithm considered aspects such as inadequacies, misconceptions and omissions; strengths; clinical use; resource implications; and recommendations.The first prototype and critique of a clinical algorithm to assist the clinical assessment of hypotonia in children has been described. Barriers highlighted include aspects related to knowledge gaps of clinicians, issues around user-friendliness and formatting concerns. Strengths identified by the critique included aspects related to the evidence-based nature of the criteria within the algorithm, the suitability of the algorithm in being merged or extending current practice, the potential of the algorithm in aiding more accurate decision-making, the suitability of the algorithm across age groups and the logical flow. These findings provide a starting point towards ascertaining the clinical utility of the algorithm as an essential step towards evidence-based praxis. Accurate assessment for early detection and appropriate intervention remains a priority for all clinicians involved in the field of paediatrics. Over the last decade the clinical assessment of hypotonia has been problematic, primarily due to the subjective nature of clinical evaluation. This has posed dilemmas for practitioners in reaching consensus on the veracity of the clinical assessment, given that the presentation of hypotonia in paediatric neurological morbidities can be either a benign or malignant sign , who indicated those tests and methods that are currently used in practice. These items were then exposed to a Delphi process, which aided in the reduction of items based on a consensus process. Twenty-four clinical characteristics, organised into 11 clusters, were determined as relevant for inclusion. For each characteristic, one test (as a first-line assessment method) had been identified. Using a desktop approach, the principal author used logical speculation from this data set with a level of abductive reasoning  to formulate and format the clinical algorithm in line with the technical regulations proposed by the International Organization for Standardization (ISO) norm . Paediatric clinicians were those practitioners who had experience with and were currently working with children with neurological disorders on a weekly basis. Additional selection criteria included a current registration with the Health Professions Council of South Africa and greater than 2 years of experience. Participants were recruited at different geographical locations over a year via the following methods: a workshop session at a national conference, special interest groups, multidisciplinary team meetings, district-level meetings and institutional fora. Data gathering occurred over a period of 12 months at sites convenient to the group of clinicians. These included forum meetings, a national conference and at hospital departments. Composition of the groups was by geographic working teams. Each group, by default, contained a mix of both newly trained clinicians as well as more experienced clinicians.Ten focus group discussions were held, varying between five and eight participants in each group and lasting 90–120 minutes. For the larger groups, a facilitator was included to aid the process. Each individual within the group were presented with an A3 printout of the algorithm, with a 10-minute didactic input on the development of the algorithm. This was followed by a set of 10 open-ended questions related to the scope and purpose, applicability and clarity of presentation.et al. The multiple focus group discussions allowed for the assessment of data redundancy in general and across-group redundancy and/or saturation in particular . The majority of the participants (n = 53%) were employed in a public hospital setting. The experience of participants ranged from newly qualified clinicians with less than 5 years of experience (17%) to greater than 20 years of experience (19%).The second aspect of this study considered a critique of this algorithm with a purposive sample of 59 participants. Demographic data are presented in A description of the semantical content analysis  has to be made. Each of the no responses lead to the next characteristic for consideration; if all responses are no, they lead directly to the next level of evaluation (activity and participation). The yes responses feed into the loop that indicates a finding, based on the patient’s developmental age, with a process box for the number of characteristics found to be problematic.The algorithm proceeds with clinical characteristics, which are represented within decision symbols in which a binary decision .It is a concern that almost a decade and a half later clinicians remain unaware of this taxonomy, given that the ICF is the WHO’s international standard for measuring health and disability, in addition to being adopted by all 191 WHO member states in 2001 , as well as the loop from the no response on the clinical characteristics in determining low muscle tone then feeds into the activity and participation impairment decision symbol. This decision symbol has play within parenthesis, as this was indicated as being an important component from the preceding study . Multiple end points and outputs may have been restrictive; hence all three were combined as opportunities for output.If intervention does not occur, it feeds into the loop that ends in et al. The initial prototype of the clinical algorithm described in this paper contributes towards the holistic diagnosis of children who present with hypotonia. It was developed in response to the challenges expressed by the scientific community, given the value of the initial clinical assessment. The need for a common diagnostic language has been indicated in the literature for at least the last three decades (Coffin-Zadai et al. et al. An evidence-based clinical algorithm was a suitable method of choice for ensuring a common language for decision-making in the assessment of hypotonia. Formulation of evidence-based algorithms is said to be an increasing practice in both scientific papers and textbooks; however, their usefulness has been questioned, as many of the authors have been found not to adhere to the formal requirements (Eitel, Kanz & Ma et al. (et al. et al. et al. Seeking agreement amongst clinicians should be seen as a starting point for establishing criteria that are likely to have significant clinical sensibility and that can be tested to ensure validity. As a result, the initial critique was deemed a necessary procedure towards determining the potential pitfalls and strengths prior to plans for implementation. A number of factors that may affect the clinical usefulness of the algorithm were highlighted. Barriers that were highlighted included aspects related to knowledge gaps of clinicians, issues around user-friendliness and formatting concerns. Knowledge gaps were associated with the symptom of hypotonia itself, where there was a lack of understanding amongst some clinicians around the difference between phasic and postural tone, as well as in isolating the presence of hypotonia with or without weakness. Previous studies (Bodensteiner et al.  introduc. et al. , 2007, a. et al.  also reiet al. et al. Strengths identified by the critique included aspects related to the evidence-based nature of the criteria included within the algorithm, the suitability of the algorithm in being merged or extending current practice, the potential of the algorithm in aiding more accurate decision-making, the suitability of the algorithm across age groups and the logical flow. These highlighted aspects contribute to our understanding of therapists in developing a diagnostic language for human movement systems and as being different from those articulated by physicians, which are often based in cellular pathology (Martin In this paper, the process of development of an initial prototype of an evidence-based clinical algorithm is described, together with a process of scrutiny and critique. As with any new development, this study has been useful in identifying important aspects that are essential to revision of the algorithm for practice. Aspects that have emerged include positive feedback with respect to the algorithm’s applicability and acceptability for practice, in addition to aspects critical for revision, such as concept clarification and a few practical issues. Although this paper presents an initial critique, the algorithm continues to require peer review and critique, and thus the authors invite readers to engage with the current proposal, so that continued work towards refinement through feedback may be realised, prior to initiating a process of validation.


Alex Pokorny's 1983 prospective study of suicide found that 96.3% of high-risk predictions were false positives, and that more than half of the suicides occurred in the low-risk group and were hence false negatives. All subsequent prospective studies, including the recent US Army Study To Assess Risk and Resilience in Servicemembers (STARRS), have reported similar results. We argue that since risk assessment cannot be a practical basis for interventions aimed at reducing suicide, the alternative is for mental health services to carefully consider what amounts to an adequate standard of care, and to adopt the universal precaution of attempting to provide that to all of our patients. In the next 5 years, 30 (3.7%) high-risk patients and 37 (0.9%) of the 3997 lower-risk patients died by suicide, an odds of suicide that was 4 times greater in the high-risk group.It is over 30 years since the publication of Alex Pokorny's landmark prospective study of suicide among consecutive first admissions to the Houston Veterans Administration Medical Center.1‘We might tolerate 50% false negatives; if we could apply a screening test that would correctly identify only half of the future suicides without false positives that would be very helpful. However, with currently known tests to identify the actual suicides, we will also have to make a great many false-positive identifications, labeling up to a quarter of the total group as future suicides when only 1% to 5% actually are. From a cost-benefit standpoint, the application of such a test is simply not feasible.’The 37 suicides among lower-risk patients were in effect false negatives. Pokorny considered false negatives to be inevitable because patients sometimes conceal their suicidal plans and their circumstances change over time. What concerned him more was the overwhelming proportion of false positives, because 96.3% of the patients categorised as high-risk did not commit suicide. He concluded:et al3 followed up a cohort of 1906 patients diagnosed with affective disorders and found that none of the 46 suicides occurred among the group, albeit smaller than in Pokorny's study, defined as being at high risk. More recently, two prospective studies examined the proportion of suicide deaths among those considered to be at high risk.6 Madsen et al5 reported a suicide rate of 0.14% among those defined as high risk in a national study of the suicide of psychiatric in-patients in Denmark, and Steeg reported the suicide of 0.5% of patients identified as being at high risk among a large cohort of people who presented to emergency departments in three English counties after self-harm.6There have been relatively few prospective studies of the factors associated with subsequent suicide, probably because of the methodological and logistical difficulties involved. Not long after Pokorny, Goldstein 7 As part of the Study to Assess Risk and Resilience in Servicemembers (STARRS), Kessler and associates then examined factors associated with suicide among 53 769 American soldiers in the 12 months after discharge from military psychiatric hospitals,8 with the benefit of the very detailed longitudinal US Army personnel database and highly sophisticated statistical techniques derived from artificial intelligence research. They identified a high-risk group comprising 2689 admissions, or 5% of the sample, from which there were 36 suicides, corresponding to a 22 times increased risk of suicide in that group. However, in other respects the results were eerily familiar, as nearly half of the suicides occurred among the 51 080 low-risk patients, and only 1.3% of the high-risk group died by suicide, leaving an overwhelming number of false positive cases.Faced with growing concern about suicides among veterans and current serving members of the U.S. Armed Forces, the U.S. Department of Veterans Affairs and the U.S. Department of Defense included the use of risk stratification in clinical practice guidelines.5 our ability to distinguish between groups of patients with respect to the probability of subsequent suicide risk is, at best, quite modest.The problem remains of the disturbingly high suicide rates among psychiatric patients as a whole. For example, in the Madsen study, the rate of suicide of psychiatric in-patients was 72 times that of the general community, at 860 per 100 000 patient years, and in the Steeg study the suicide rate among all patients presenting to hospital after self-harm was 622 per 100 000 patient years. Hence, although we know that all of the patients under our care are at greatly increased risk of suicide compared with the wider community,9 If risk stratification is to be a part of how mental health services approach suicide prevention, we need to carefully consider the interventions offered to patients believed to be at high risk but denied to those assessed to be at lower risk. Because the vast majority of high-risk patients will not die by suicide, any intervention has to be shown to be somewhat effective, but also benign enough so as not to infringe on the rights of the many with false positive assessments. However, if we do have an effective and benign intervention, it is then hard to justify denying this to low-risk patients, who, after all, are still many times more likely to die by suicide than the general community.This observation has important implications for mental health services, given the unrealistic expectations for risk assessment to prevent serious adverse events, and the way risk assessment has changed professional practice.If there is no effective and yet benign intervention to justify offering different treatments to groups of patients on the basis of risk stratification, how can mental health services respond to the knowledge that our patients are at greatly increased risk of suicide compared with the wider community?10 the provision of community treatment for all patients in the weeks after discharge from hospital,11 and safety planning at the point of contact in emergency departments.12 Most importantly, every patient should have access to timely, individualised, high-quality treatment for psychiatric disorder. Modifiable factors associated with suicide should be addressed in all patients, not only those considered to be at greatest risk. Moreover, no intervention can be justified on the basis of the assessed risk alone. We go so far as to suggest that the assessed risk of suicide on its own is not a sufficient reason for restrictive interventions such as involuntary detention in hospital or other coercive treatment,14 which would then need to be justified on additional grounds, including the patient's inability to recognise the potential benefit of treatment and their particular circumstances and treatment needs. In any case, preventive detention in hospital of all patients assessed to be at high risk of suicide would be impossible, because of the huge numbers of patients identified and the long duration of secure detention that would be required to protect such patients.The alternative is the application of universal precautions to all patients, including the design of in-patient facilities that minimise the opportunity to attempt suicide,Addressing the modifiable risk factors in populations of patients involves ensuring the adequate identification, assessment and treatment of patients with a range of mental disorders, addressing substance use and, wherever possible, limiting the availability of potentially lethal means to die by suicide. Treatment should be with the patient's consent, or provided on the basis that the patient lacks the capacity to consent, rather than being based on perceived risk, which we now know we are not able to reliably assess.15 Instead of guessing the probability with the help of hindsight bias,16 negligence claims after suicides should hinge on the accepted standard for care of people with various psychiatric disorders, regardless of the presence of known risk factors. Services should be concerned about the adverse consequences of failing to provide an adequate standard of care to any patient they assess or treat, not only those considered to be at high risk.A further implication for mental health services of the demonstrated limitation of risk assessment is in responding to lawsuits for failing to predict the suicides of individual patients. While the suicide of any patient might be foreseeable in the legal sense of being not fanciful or far-fetched, mental health services cannot be reasonably expected to be able to identify which patients will die by suicide. Expert evidence in one recent case on the estimated probability of suicide after discharge included absurdly high estimates of between a 5 and 70% chance of suicide within days of discharge.Pokorny's complaint that the overwhelming number of false positives renders suicide risk assessment unfeasible is just as valid in 2016 as it was in 1983. His finding, which has been replicated in all subsequent studies, poses a challenge to military and civilian mental health services that have been developed around a model of identifying and managing risk. In response, we recommend abandoning attempts to design interventions based on risk stratification and instead aim to provide an adequate standard of care to all of our patients.


The correct and rational use of medications can have a positive direct impact on disease outcomes, as well on the utilization of the health system resources. Unfortunately, 50% of the patients do not take their medications as prescribed, largely due to lack of patients’ understanding of their medical condition, as well as the lack of reliable medicine information.There are multiple strategies implemented in many countries to tackle this challenge including: disease awareness campaigns (DAC) to raise the public awareness to specific diseases, direct-to-consumer advertisement (DTCA) to raise the public awareness to prescription medicines, specific treatments and over-the-counter (OTC) products to improve the accessibility of patients to specific medicines.Prior to 2013, the Israeli policy prohibited prescribing medication advertising and prevented the flow of information from pharmaceutical companies to the patient. In the last five years, the Pharmaceutical division in the Israeli Ministry of Health, as part of the “empowering the patient” agenda, has taken new innovative approaches to raise public awareness to diseases, medications and appropriate usage, as well as promotion of information to improve patient adherence to the prescribed medication.This paper elaborates on the aforementioned strategies implemented in developed countries, and specifically focuses on newly implemented strategies and regulations in Israel regarding pre- and post-prescription information, to improve patient appropriate utilization and adherence to medication. Medicines have the potential to benefit the individuals who use them. Nevertheless, the use of medicines may be associated with undesired adverse effects. The decision to prescribe and take prescription medicines, as well as OTC medications, and subsequently achieve desirable therapeutics outcomes, requires additional knowledge and expertise, not only by health care providers but also by the patients.Available information about health conditions, medicines, and their use can principally be obtained from two main sources: (a) healthcare providers: primarily physicians, pharmacists and nurses, and (b) the pharmaceutical industry. Additional sources of information are available in the media including: press, internet, social media, medical and general literature, etc. The first two sources of information are regulated in Israel by the Ministry of Health (MoH).Prior to 2013, the MoH focused mainly on prohibiting prescribing medication advertising, while allowing OTC advertising only. General information about disease awareness and the contact between pharmaceutical companies and patients were not clear. Due to the rise of social networks and the penetration of the internet, the MoH had decided to provide guidance to involved stakeholders and especially the pharmaceutical companies in order to avoid inaccurate and false information.The law recognizes that medicines should not be handled as an ordinary consumer product. This is achieved by a variety of restrictions, in particular prohibiting advertising to general public. Such limitation of pharmaceutical advertising is due to the concern that misleading or inaccurate advertising may lead to misuse of pharmaceutical products, including increase pressure on health care providers to prescribe specific drugs, which may put patient’s health in risk.According to The Israeli ‘Regulation of the Pharmacists’ , advertising of non-prescription pharmaceuticals is allowed only after authorization is granted by the Pharmaceutical Division (PD) of the MoH, while direct-to consumer advertising (DTCA) of prescription pharmaceutical products is illegal, unless approved by the director general of the MoH.initiation i.e.: filling the prescription, collecting the prescribed medication and starting treatment, implementation: how the patient is taking his medications, and discontinuation of treatment [One of the major goals of the Israeli MoH, as set by the “pillars of fire” (the ministry credos), is centralizing patients’ needs and care, empowering their knowledge, as well as fulfilling their rights for high quality standard of care. Based on this pillar, the efficient use of pharmaceutical products was set as a key objective by the PD of the MoH. The PD is the governing authority for the pharmacy profession in Israel and serves as the regulating body of the pharmaceutical industry. One of the major methods to enhance appropriate use of medicines is to improve patient adherence. Adherence could be defined as the process by which patients take their medications as prescribed . This prreatment . The chareatment . Non-adhAdherence issues are also seen in over the counter (OTC) medicines, where patients treat themselves for minor ailments and conditions. This in turn may lead to additional drug related problems such as possible overdose.The following paper describes international and Israeli approaches to improving adherence by raising public awareness to diseases, medications and their usage. The paper focuses on the impact of Disease Awareness Campaigns/Communications (DAC), promotion of information to improve adherence in patients who were prescribed a medicine (Adherence Campaigns - AC), OTC Direct to consumer advertisements (OTC - DTCA) and the role of the pharmacist in this process.Currently, direct-to consumer advertising (DTCA) and promotion of prescription drugs is permitted only in the USA and New-Zealand. The following section focuses on different approaches and policies in developed countries regarding DAC, DTC and DTCA.Guidance for Industry, Consumer-Directed Broadcast Advertisements [As from 1985, The Federal Food, Drug, and Cosmetic Act permits advertising of prescription medicines, as long as the advertisements are accurate and not misleading. In 1997, U.S. Food and Drugs Administration (FDA) published a rule obliging companies to offer a detailed list of side-effects in their infomercials . The main FDA guidance on DTCA was issued in 1999, isements , 4. The According to the FDA, DAC can provide important health information to consumers and health care practitioners, and can encourage consumers to seek, and health care practitioners to provide, appropriate treatment. The guidance prohibits mentioning a particular drug or device .The New Zealand authority never enacted legislation about DTCA, seemingly more by accident than design, because prescription medications were simply not being advertised in 1981. A consultation document from 2006 reviewed the policy debate on DTCA in NZ, outlining the current policy for DTCA and the Therapeutic Products Advertising Code . DTCA waThe EU legislation prohibits the advertising of prescription-only medicines directly to patients and consumers. Directive 2001/83/EC of the European parliament relates to medical products for human use and states that EU members must prohibit the advertising to the general public of medicinal products which are available by prescription only . Councilthe Blue Guide: advertising and promotion of medicines in the UK [The British Authority has the most comprehensive policy on DAC, which are outlined in n the UK . MedicinBlue Guide encourages DAC, but does not allow the use of brand names or restrict the range of treatments described in the campaign. The provided information should help the public to be able to recognize the disease or its risk factors, and take preventive measures, if appropriate. Additionally, DAC should point out what the patient needs to do immediately, if necessary, and where to get appropriate advice on management options [The  options .Regulations of therapeutic goods advertising in Australia, prohibits DTCA of prescription only medicines. Advertising of prescription only medicines to health professionals is permitted and is regulated by a self-regulatory scheme operated by Medicines Australia, an Australian pharmaceutical manufacturers association. In addition, information about a medical condition or specific treatment (not brand name) may be distributed to the general public, as a “community service” [The service” .Food and Drugs Act and the Food and Drug Regulations prohibits DTCA for health products  which make claims to treat, prevent or cure any of the serious diseases. In addition, these regulations prohibit DTCA beyond the drug’s name, price and quantity. DTCA of Prescription medicines and DAC in Canada are regulated by the two agencies: Advertising Standards Canada and Pharmaceutical Advertising Advisory Board [The Canadian ry Board , 14.Promoting diseases to sell medicines is a common and venerable practice among pharmaceutical companies that try to expand their market size by implying that large parts of the population suffer from the disease or condition. Although some people may legitimately suffer from a particular disorder and require medicine treatment, others might be mistakenly diagnosed with a disorder they do not actually have, or start taking medications that might not ultimately benefit them . DAC havIn 1995 researchers analyzed the response to DTCA of a new migraine medicine  and showed an association between the advertising campaign and a significant increase in new prescriptions for that medicine. The study showed that men and high incomes individuals were significantly more likely to respond to DTCA .Dutch Society of General Practitioners objected to this campaign but recommended terbinafine, even though another medicine (itraconazole) was also available as an oral treatment for onychomycosis. Novartis discontinued the campaign two years later. The unbranded campaign resulted in a considerable increase in terbinafine prescription rate, and in a slight decrease in itraconazole prescription rate, despite the fact that the campaign did not specifically mention terbinafine. Furthermore, the campaign was successful in motivating people to seek care for onychomycosis which is strongly suggested by the concurrent increase in the consultation rate for onychomycosis. After the campaign was discontinued in 2002, rates of consultations and prescriptions dropped [A Dutch campaign for terbinafine that was initiated in 2000 by Novartis, included television advertisements advising people with onychomycosis to consult their general practitioner. The  dropped .There are evidence that disease awareness advertisements (DAA) increases awareness of the advertised health conditions. A recent content analysis examined the prevalence of DAA in top circulating Australian women’s magazines and concluded it constituted approximately 12% of all therapeutic advertisements . This finding suggests its potential exposure is at least moderate .s healthy people into patients, waste precious resources, and causes iatrogenic harm [GlaxoSmithKline launched a massive campaign to promote awareness of “restless legs syndrome”. The campaign included press releases which suggested that a known Parkinson medication (Requip (Ropinirole)) is also suitable to treat restless leg syndrome. The campaign included news articles and radio shows that exaggerated the prevalence of the disease and the need for treatment. All of the above contributed to over-diagnosis of the syndrome and over-usage of this medication, while according to physicians the recommended treatments for the syndrome include stretching exercises and less caffeine for intermittent disease, and various prescription medications (e.g. benzodiazepines and dopamine agonists) for daily symptoms [In fact, DAC are controversial: several scientists and physicians consider them as medicine mongering and claim that they turnnic harm . They alnic harm . For exasymptoms .Health in Action, a quarterly publication of the American School Health Association, and currently undertakes educational programs for teachers. This may influence teachers who have a formal role in the diagnosis of ADHD in the U.S, U.K and Australia, and may increase a false diagnosis of ADHD and over-usage and unnecessary usage of ADHD medications [An example of a potentially problematic aspect of DTCA is an advocacy group for people with ADHD (named CHADD – Children and Adults with ADHD) that is partially supported by the pharmaceutical industry. CHADD acted in the past as the lead editorial consultant of a special issue on ADHD in ications .However, there are significant advantages to DAC, which can improve the public health and even save lives. One such example is a DAC implemented in rural areas of East Africa  to promote the use of artemisinin-based combination therapy (ACT) to treat Malaria. The programs assessed retail sector ACT subsidies combined with supportive interventions that included community awareness and mass media campaigns. The programs increased the usage of ACT in children aged 0–5 years, and are believed to increase the usage by 19% - 41% over a one year period. These programs also reduced the use of older antimalarial drugs among febrile children aged 0–5 .Another example is the Mycobacterium ulcerans infection that can cause Buruli ulcer, one of the most rapidly emerging diseases in West Africa in recent decades. Recent research showed that antibiotic therapy with rifampin and streptomycin may reduce the extent or prevent excision when initiated during the early phases of the disease. Analysis of epidemiological data from existing Buruli ulcer control programs in West Africa indicate that active public awareness campaigns are successful in increasing awareness and understanding while decreasing delays in treatments and disease progression .The Israeli national health insurance (NHI) system provides universal coverage. Every citizen or permanent resident of Israel can choose from among four competing, non-profit health funds, called Health Maintenance Organizations (HMOs). The HMOs must provide their members with access to a statutory benefits package. . More thVarious efforts are under way to promote the use of generic medications and of the lowest cost pharmaceuticals. By law, generics may be prescribed and dispensed generically and substituted by the HMO for brand-names medication whenever clinically appropriate.According to the Israeli Pharmacists Regulations (article 28), advertising of non-prescription pharmaceuticals is allowed only after a permit by the PD, practically making the DTCA of prescription pharmaceuticals illegal. The prohibition to advertise applies to the registration holder as well as to any individual or third party.DTCA in Israel is allowed for OTC medications, in order to empower the patients and enable them purchasing medications, in an informed manner, without the need to visit or consult their physician. Of note, most of the OTC medications are taken to treat minor medical problems.In the past 5 years, the PD initiated several services and enterprises in order to improve patients’ access to pharmacological information. Of note, similar initiations and services are enforced worldwide, especially in the countries which are recognized by the Israeli legislation: EU countries, Switzerland, USA, Canada, Australia, New Zealand, and Japan.The Hebrew language is spoken by the majority of the Israeli population. According to a public survey from 2011, 18% of the Israelis speak Arabic, 15% speak Russian, 2% speak English and 8% speak other languages (including Amharic) . In accoThe Israeli Drug Registry website consists of all commercial pharmaceutical products and the terms of registration, including the commercial name, the manufacturer, the active ingredients, dose, indications, the physician leaflet, the patient’s leaflet, a picture of the packaging, and an updated medication price. It includes additional information items such as information regarding gluten free medications. The website is updated every month and is widely used by patients, health care professionals and the general public.Recently, a new query regarding the inclusion of commercial pharmaceutical products in the national list of health services  has been added to the Israeli drug registry database. Future development will address the issue of generic substitution, information regarding optional actions (such as medication grinding), as well as images of all registered drugs.As already been mentioned, the Israeli law prohibits DTCA of prescription medications but allows the advertisement of non-prescription pharmaceuticals . Prior to 2013 there was only general guidance regarding advertising policy of medicines in Israel, in which only OTC medications were allowed to be advertised. Thus, without official guidance, the pharmaceutical companies used various marketing strategies which were controversial and unregulated. In 2013, new regulations for OTC advertisements were issued, and consequently the number of applications for approving OTC advertisements increased by more than 40% in the last three years  which was published in 2014, and non-promotional medicine information for patients who are prescribed prescription only medications  which was published in 2015.The MoH and the PD provide national leadership in a broad range of public health domains, including empowerment of patients and rational use of drugs, health promotion, preventive health care and consulting on other medicine related issues.The MoH has recently established regulations regarding DAC so that consumers can be empowered with information about the availability of treatments for diseases (medications or preventive treatments) in a manner that does not involve the promotion of a particular commercial product. For example: annual campaigns run by the MoH regarding influenza and recommendations for vaccinations, and campaigns and information regarding cancer, provided and run by the Israeli cancer association .This procedure regulates how pharmaceutical companies are allowed to encourage compliance among patients who have been prescribed medications (i.e. after the prescription is issued). In order to improve adherence with medicinal product, the patient receiving the prescribed drug can receive non-commercial information in various ways as specified in this procedure including digitally. The media and patient associations play an important role in increasing awareness to adherence with medicinal treatment. The information provided to the public must be balanced, factual, free of advertising and free of promotion to particular brand names. Of note, the information must not be intimidating and mustn’t create stress to the patients.The objective of this procedure is to promote adherence to the prescription instructions, to improve patient’s collaboration with physician, to ensure the patient’s ability to manage the treatment prescribed to him, to supply the patient with scientific reliable information, and to increase awareness to reporting side effects (should they occur), in order to maximize the treatment’s efficiency and to protect the patient’s health.The marketing registration (MAH) holder is responsible to comply with this procedure and must ensure conformity with all relevant laws. The information and instruction services specified in this procedure should be provided free of charge and under no condition or limitation. Patient consent must be attained per local Israeli law with emphasis on privacy issues and when applicable complying with database establishment and maintenance regulations.After the patient gives his/her consent, a third party medical-information/adherence center, which is approved by the MoH and funded by the pharmaceutical company, contacts the patient. The center supplies two major services to the patients: (i) a call center that supplies information regarding the disease, the medication, and the correct way to take the medication. The telephone receptionist helps the patient with monitoring side effects. (ii) home visits for personalized training on appropriate usage of treatment, as well as reporting any adverse drug reaction that may be related to the product. Such services may be also deployed by the MAH, but a written justification for not employing third party should be sent to the ministry for consent.and as such, adherence support may be crucial to the successes of the treatment prescribed for them.It is important to keep in mind that some of the patients are people with disabilities who according to the law must be given access to the information Anatomical Therapeutic Chemical (ATC) classification index  in ordeThree hundred forty-eight submissions according to procedure 134 were handled and 242 submissions according to procedure 137. The submissions were in a variety of pharmacological groups. Figure 2 = 0.86).Most of the activities were related to diabetes and cancer. Analysis of the results shows that the pharmaceutical companies’ activities were similar in both procedures (134 and 137), there is a correlation between the pharmacological groups of 134- and the 137-submission  defines the activities that need to be taken by pharmacists, while consulting and questioning patients during dispensing of medication in community pharmacies. The procedure is based on two legislations: (a) The patient rights law (from 1996), according to which, patients should receive adequate medical treatment, while pharmacists are defined as health care providers, and (b) The “Pharmacist ordinance” which defines the information that should be given to patients with the medicinal product. The procedure emphasizes which information should be provided to the patients by the pharmacist while dispensing OTC and prescription only medicines .Recently the PD launched a software application aimed at promoting rational and safe use of OTCs and General Sales List products. This application enables the patient to search the database by product trade name or symptoms experienced, and to scan the package barcode for product information. Information available for patients include: product picture, product information leaflet, indication, package size, indication and price. The application is being updated continually and is available for download free of charge from Google Play Market and Apple App Store .An effective pharmaceutical policy should ensure that patients have access to reliable, scientific, evidence based and relevant information. One of the major challenges of the Israeli MoH is to focus on the patients’ needs, to empower patients and to provide them with the necessary pharmaceutical knowledge. As such, an effective pharmaceutical policy should also concentrate on chronic patients treated with multiple drugs. These patients require more attention in terms of detection of side effects. Thus, the MoH preemptively published procedures promoting the provision of information to patients, using a variety of media and approaches: websites and a cellular application, in addition to new innovative regulations. These issues are also emphasized in a circular published by the Israeli MoH medical administration in 2013 .The pharmacist’s role in dispensing medications and providing information is essential for safe, effective, and successful treatment. To implement this, the MoH uses various types of legislations regarding both dispensing medications and providing information for chronically ill patients. Additionally, the PD published the aforementioned procedure  for patients requiring further guidance, support and training.An innovative approach promoted by the MoH includes the pharmaceutical industry in policy efforts aimed to improve adherence at the post prescribing phase. The pharmaceutical industry has a clear financial incentive to increase its sales rate. Following the guidelines issued by the MoH, will benefit the industry by allowing them to keep investing in marketing, but at the same time to empower the patients. Providing patients with reliable and useful information will allow them to better adhere to recommended treatment regimes, achieve desired clinical outcomes, and most importantly - improve their health. An additional added value to implementing this new patient-oriented policy is in lowering the risk for unnecessary medico-legal litigation by improving the accuracy of the information reaching the patients. The Israeli experience suggests that the pharmaceutical industry has quickly and efficiently adopted the regulations and implemented them successfully.In addition, it is important to safeguard the interests of the patients and to ensure the system’s transparency, reliability, and integrity. Hence, DTCA of prescription medications is not legal in Israel and physicians in Israel must not be paid for prescribing specific medications by law. Furthermore we believe that DTCA may lead to unwanted “disease mongering”, increased pressure on healthcare providers to prescribe unnecessary treatments as well as providing the patients with non-accurate and missing information regarding their condition. These may lead to unnecessary increased pressure on the health system as well as on its expenditures.Non-adherence is a significant issue that has direct negative outcomes on patients’ health. Currently there are knowledge gaps regarding the rates of non-adherence in Israel. In order to fill the gaps, more research is needed: collaboration with the HMOs that collect data regarding subscriptions of medications and how many of them were actually purchased, in addition to national surveys to reveal the rates of non-adherence due to implementation problems and discontinuation of treatment.It should be noted that the physicians are responsible for monitoring the patient’s adherence and that procedure 137 (and the industry’s involvement) is intended to support this process rather than replace it. in the last 5 years there has been a significant progress in regulation of medicine advertising and in patient’s information. Furthermore, there is an ongoing process of learning and improving: the MoH keeps on monitoring and self auditing its’ procedures, compares the regulation to other developed countries, continues holding discussions with involved stakeholders, and keeps on developing and amending its policy in this matter.In our opinion it is highly important for the regulator to issue guidelines and procedures to regulate the transfer of accurate, reliable and useful information to patients. Such means should address key stakeholders in the process of medication adherence: healthcare providers, patients and the pharmaceutical industry.


Stipules are leaf structures common in many groups of plants that can take a variety of forms. In Gentianales, interpetiolar stipules are considered a synapomorphy of Rubiaceae but in this study we detected two lateral expansions at the base of the leaf primordia (stipules) that give rise to colleters in many genera of Apocynaceae, similarly to Rubiaceae species. Through ontogenetic study it was possible to prove for the first time that Apocynaceae is a stipulate family whose stipules are modified into colleters, and their absence might be a secondary loss, changing the interpretation of stipule evolution in Gentianales. Stipules are leaf structures common in many groups of plants that can take a variety of forms. In Gentianales, interpetiolar stipules are considered a synapomorphy of Rubiaceae; however, some reports in the literature refer to their presence in other families. The goal of this study was to analyze the development of leaf primordia to investigate the possible presence of reduced or modified stipules in Apocynaceae. Shoot apices of 12 genera were analyzed under light and scanning electron microscopy comparatively with one species of Rubiaceae. Early in their development, leaf primordia form two lateral expansions at the base of the petiole (stipules) that give rise to colleters in 11 of the 12 genera of Apocynaceae studied, similarly to the Rubiaceae species. The basal genera have pairs of stipules modified into colleters positioned laterally to the petiole, while other species belonging to the derived subfamilies have interpetiolar stipules that each project towards the opposite stipule and merge, forming a sheathing stipule and from this arc the interpetiolar colleters originate. The ontogenetic study proved for the first time that Apocynaceae is a stipulate family whose stipules are modified into colleters and their absence might be a secondary loss, changing the interpretation of stipule evolution in Gentianales. Stipules are usually small, inconspicuous projections of the petiole base of leaves with protective function mainly in the bud, and there might be other functions as well. Often they appear as a pair of leafy appendages located on each side of the leaf base, but in some plants they may be modified into thorns or glands .Stipules occur in many families of Eudicots and are especially important in some orders, such as Gentianales, which is composed of the families Apocynaceae, Gelsemiaceae, Gentianaceae, Loganiaceae and Rubiaceae . Among tThose reports raise doubts about the occurrence and development of stipules in this group, especially in relation to Apocynaceae, generally characterized as not having stipules . ApocynaIn spite of the centuries of knowledge of the group and several structural studies performed in Apocynaceae, few studies have suggested the presence of morphologically distinguishable stipules in Apocynacean species , with EnColleters are secretory structures present in vegetative and/or reproductive organs that produce a sticky fluid, composed only of mucilage and/or lipophilic compounds, which protects meristems . In ApocOn the leaves, colleters were recorded on the apex or base of the petiole and along the margin and/or midrib of the lamina in many genera of Apocynaceae belonging to all five subfamilies . HoweverThe homology among the traits of different taxa may be identified by different survey techniques, but when the morphology is profoundly altered, the only studies on the developmental mechanisms are able to perceive their common origin . TherefoThe goal of this study was to verify the presence of reduced or modified stipules in the leaves of 12 genera of Apocynaceae belonging to different subfamilies, focusing on the beginning of leaf development and the ontogeny of interpetiolar colleters occurring on the petiole base to evaluate their possible stipular nature. One species of Rubiaceae was selected to compare the colleter/stipule origin.Mussaenda erythrophylla, was sampled at Universidade de São Paulo, São Paulo, SP, Brazil for comparison.Twelve species belonging to 12 genera were selected for this study  to repreShoot apices were collected and promptly fixed in FAA  for 24h  or BNF  and subsThe anatomical analyses were performed under a Leica DMBL light microscope  using the Scan System Images (IM50).Morphology: The leaves of all species have opposite phyllotaxis, being alternate only in Aspidosperma. The morphological analysis of leaves was not able to detect any stipule in the species of Apocynaceae studied, but colleters are easily observed on leaves of all species  the stipules grow as a pair laterally to the petiole and become glandular with the base fused to the stem  near the petiole, and the tip of the stipules is also modified in colleter  and Universidade de São Paulo.D.D. designed the research, B.A.R. and D.D. performed experiments and analyzed the data, and N.V.C. and D.D. interpreted the results and wrote the paper.None declared.


The needs and concerns of patients with advanced breast cancer are changing at every phase of the care intervention. Management and coordination of hospital resources and services are also steadily evolving. The objective of the present expert report is to define a new oncology nursing role specialising in advanced breast cancer, to help guide patients throughout the whole healthcare itinerary.A group of eight experts in oncology nursing and medical oncology defined the content index of the curriculum document. A systematic review of bibliography was carried out, and the relevant contents were extracted. Based on these contents and the participants’ experience, recommendations were formulated and validated through a Delphi questionnaire and a participative meeting.The advanced breast cancer clinical nurse (ABCCN) should develop a clinical, psychosocial role focused on coordinating patients in the healthcare network. The nurse would be in charge of evaluating and supervising the care administered and the healthcare resources used. The ABCCN should be aware and participate in the protocols and available resources, be able to solve conflicts, deal with burn-out signs and have clinical, coaching and team-working abilities. The proposed curriculum provides a specific process for the care of patients, as well as an implementation process.The ABCCN’s role is crucial to assume the best care and the optimisation of available resources. This review and consensus document provides the required tools for the implementation in hospitals. Breast cancer is the most common tumour among women in developed countries , and appIn recent years, there has been much progress in therapeutic options in advanced breast cancer, which has increased the disease control and has significantly contributed to improving prognosis in a substantial proportion of patients. These patients require complex intervention and care, as well as good coordination of all specialists involved. These factors significantly influence on patients’ prognosis and quality of life , 5.NICE guidelines on the management of advanced breast cancer emphasise the need to assess the physical, psychological, social, spiritual and financial needs of patients at some key points in the course of the disease: diagnosis, start of treatment, end of treatment, relapses and end of life . GuideliThere is no current consensus document or curriculum in Spain that defines the professional profile, roles or activities of an advanced breast cancer clinical nurse (ABCCN). The purpose of this document is to review and establish a consensus on the activities to be performed by nursing professionals in an advanced breast cancer patients’ care consultation, as well as to turn nursing professionals into key members on multidisciplinary teams and providers of comprehensive support to patients, especially in terms of emotional considerations, health education and follow-up of toxicities. The ABCCN can help achieve better self-care among patients, greater treatment adherence and a decrease in oncological emergencies.Elaboración de Guías de Práctica Clínica en el Sistema Nacional de Salud. Manual metodológico), which forms part of the Quality Plan of the Spanish Ministry of Health [This document of recommendations was developed by a multidisciplinary team composed of eight experts in oncology nursing and medical oncology, following the Methodological Manual for the Preparation of Clinical Practice Guidelines in the Spanish National Health System , with three experts, and a recommendation-formulating group (RFG), composed of the members of the CC and five more experts were formed. All of them developed, in an initial face-to-face meeting in December 2014, a content index and a list of clinical questions to be addressed. Subsequently, a systematic literature search was conducted in three databases . A total of 236 publications were obtained. At the CC’s discretion, a total of 56 publications were prioritised. After reading them, a document answering each clinical question and including potential recommendations was prepared. Next, the recommendations were assessed individually by each RFG member, without any kind of communication or exchange of opinions. Both non-consensus recommendations and consensus recommendations liable to change at the CC’s discretion were debated during a structured participatory face-to-face meeting in July 2015. Recommendations that achieved unanimity (100 % agreement) or consensus (≥80 % agreement) were accepted as definitive. At the end of the process, a total of 147 recommendations (131 by unanimity and 16 by consensus) were validated. The most important recommendations were formally categorised with their level of evidence (LE) and degree of recommendation (DR), according to the modified version of the Scottish Intercollegiate Guidelines Network system [Median survival for advanced breast cancer is ~3 years. During the survival period, the entire set of therapeutic strategies––hormone therapy, chemotherapy, targeted therapies, radiotherapy and palliative care––is applied in different sequences or combinations .Given that throughout the course of the disease, there are constant variations in the type, dose and frequency of treatment, the clinical management of patients with advanced breast cancer should cover their needs at all points in the process, ensuring comprehensive quality care and being based, at all times, on clinical practice guidelines  . The ABCThe ESO–ESMO consensus on advanced breast cancer, developed by the European School of Oncology and the European Society for Medical Oncology, with the objective of improving health outcomes, recommends psychological care and a personalised approach to patients from the very moment they are diagnosed . Along tAs advanced breast cancer is a chronic disease, it is important to highlight the ABCCN’s role as a coach. Coaching tools improve adherence to treatment and control of adverse effects, as well as the patients’ health education assimilation . The ABCCN should apply communication techniques, such as active listening and empathy, and promote patients’ active participation in their health process and autonomy  , 18, 19.The ESO–ESMO guidelines recommend that all patients with advanced breast cancer receive comprehensive, culturally sensitive, up-to-date and easy-to-understand information about their disease and its management (level of evidence IB) . PatientThe ABCCN can offer training related to the process of advanced breast cancer, not only to patients but also to other health professionals, covering those subjects that each professional requires at her/his care level . The ABCCN can also act as a mentor to students completing their internships in the Oncology unit, focusing on the global vision of the process of advanced breast cancer and recognising her/his role and how the care provided to patients should be . At the same time, she/he should participate in the process of training nursing residents, to ensure the consolidation of advanced practice in the care of patients with advanced breast cancer  , 21. OwiIn the course of the teaching and clinical work, the ABCCN should make use of resources that may serve as a vehicle for conveying accurate and comprehensible information to patients regarding their disease, treatment, adverse effects and sequelae . These resources may be presented on paper , involve telematics  or healthcare services  .Patients with advanced breast cancer require continuous care from different health professionals who meet their needs whenever they arise. Therefore, the role of the ABCCN as case manager has also been established . The expWhile no evidence was found with respect to how much experience is required to perform the role of ABCCN, the participating experts agreed a minimum of 2 years of continuous experience with oncology patients to be able to perform the role of ABCCN with certain minimum guarantees . Various publications were evaluated to find out the ideal training, and while some of them favour having a specific certification to practise this role, others believe that a degree in health science or simple experience is enough –27. To aThere is no oncology nursing specialty within the current panorama of qualified training in Spain. However, it is important to design a face-to-face or remote continuous education programme for ABCCN  that covers all considerations related to comprehensive care of patients, their physical and psychosocial considerations and those of their families  . The ABCAlso, from the expert panel, scientific societies are advised to drive the creation of accreditations to assess the nursing curriculum, taking into account matters such as training, teaching, research or care provided . The ABCCN also requires a broad knowledge of the treatment protocols for advanced breast cancer and the operations at the centre where she/he works, as well as being informed of research activities. The ABCCN should know about and participate on breast cancer committees, be familiar with the resources available to offer help to patients both inside and outside of the hospital and know about patient associations, support groups and different complementary therapies  .The Spanish Society of Oncology Nursing  has been aware of the need to promote the establishment of nursing competencies in cancer patients and research within this framework. In this regard, a specific competency framework for oncology nurses was established at the second SEEO conference in 2005 . The expTo effectively assume the role of ABCCN, certain specific skills should be acquired. The ABCCN establishes a relationship of confidence with their patients, thus facing the possibility of being emotionally affected by their patients’ situation. She/he should have emotional self-knowledge and recognise her/his emotions and how they can affect in a high-risk department . The ABCCN must always be conscious of her/his mood, as this could influence her/his behaviour . Also, the ABCCN should be capable of exercising self-control and self-motivation and of channelling her/his own emotions towards an objective, focusing on goals and trying to overcome obstacles . She/he should be capable of experiencing empathy, recognising the emotions of others, knowing how to interpret what is happening to patients, understanding them and performing an assertive analysis of specific situations . Finally, the ABCCN should be competent in social skills, valuing interpersonal relationships as essential to human well-being and having certain values, such as tolerance, communicative abilities and knowledge of how to persuade people, negotiate with them, calm them down and reconcile situations of conflict .The ABCCN interacts with a multidisciplinary team, patients and their families and caregivers, as well as with healthcare and social systems. To do this, she/he must possess conflict resolution skills. The ABCCN should approach the conflict by applying a set of rules, through basic consensus between the parties . When there is no clear consensus, the ABCCN needs skills and experience to help approach different positions . Problem resolution should be done through a participatory process in which all parties jointly determine what the problem is and come to a resolution . The ABCCN should be capable of negotiating and assessing whether a conflict is resolved and whether the parties involved are satisfied .Teamwork is crucial to approach cancer management with unified criteria . RegardiIt is necessary to establish a healthcare track for patients with advanced breast cancer, to keep them from not visiting the ABCCN owing to a lack of information . Initially, access of patients to the ABCCN should be convenient and hassle-free, through her/his own visit schedules. An initial visit is required when patients are diagnosed and referred from medical consultation, and successive appointments must then be scheduled, depending on the assessment and patients’ needs. The participating experts established recommendations and came to a consensus on a circuit for how to develop advanced breast cancer patients’ care, as described in Fig. Patients with advanced breast cancer may have many and varied needs throughout the process. It is, therefore, necessary to establish the circumstances that call for intervention by an ABCCN. Diagnosis requires an initial intervention for assessment and a first contact to evaluate therapies, symptoms, adverse effects, anxiety and pain control . Also, the ABCCN should facilitate contact with other professionals, either at the level of hospital care  or at the level of primary care, liaison nurses, palliative home care, social workers, etc. .Reducing the impact of hospital fragmentation caused by the application of the therapeutic plan, and offering a coherent and simple environment for patients.Eliminating the gaps that may arise in a multidisciplinary care system.Improving the patient experience by eliminating or reducing negative situations that could be prevented or mitigated.Promoting patient empowerment throughout the healthcare process, especially in stages of greater vulnerability such as diagnosis, recurrence and treatments .Key nurses or liaison nurses, who are focused on cancer either in general or on particular types, are relatively new in the Spanish healthcare system. Therefore, there is insufficient experience on which criteria should be evaluated when implementing this type of role, although the literature points to an achievement of greater effectiveness and efficiency in patient care . The expThe first step in the implementation process on which the authors of this document have come to a consensus Fig.  is the eFor the designation of the ABCCN, it is advisable to have a description of the position, based on the professional profile, competencies and skills , in addition to a specific methodology for assessing competencies  .It is appropriate to be careful with the method of initiation at the institution. Introducing the ABCCN to other healthcare professionals may be a novel event, especially at centres that do not have similar previous experience in other areas, and it should ideally be done by managers or corresponding authorities, through a formal introduction to all the departments and units involved in the field of action of the ABCCN . At the same time, the start of this new role and its objectives, responsibilities and location should be communicated by the usual means  . It would be beneficial to have previously worked with the multidisciplinary team, introducing the ABCCN and agreeing upon their objectives and roles . Also, it is advisable to agree with this team upon a gradual introduction that allows for effective learning .Recording the activity of the ABCCN is also considered to be important, and the expert panel agreed that this should be included in the institution’s usual schedules  . At the same time, it is also advisable to define some ABCCN activity indicators , although there are other activities associated with this role that require time but are difficult to quantify, such as case management . Some examples of healthcare activity indicators could be: attributable periods of time in the healthcare process, number of emergencies owing to treatment toxicity, number of central catheters in treatments that carry a risk of chemical phlebitis, adherence to oral treatments and referrals through screening to nutrition, psycho-oncology or oncogeriatrics departments, etc.The care of cancer patients has undergone substantial changes in recent years. Their physical and psychological needs should be handled appropriately through continuously provided care, and their demands should be met in all phases of the disease. In the case of ABC, there is a wide range of therapeutic options, support measures, required resources as well as a considerable number of specialists who are involved in the management. This contributes to the complex nature of these patients’ follow-up.The SEOM Handbook on Continuous Oncology Care recommends coordinating and optimising all available healthcare and social resources, fostering the integration of all healthcare levels and building comprehensive oncology care, with the aim of improving patient’s quality of life . The ESMKey nurses in cancer are referred to by many names, depending on the country in which they practise nursing and the roles they perform: Healthcare Coordinators, Patient Navigators, Health Coaches, Care Managers, Nursing Case Managers, Oncology Nursing Navigators, Oncology Patient Navigators and Key Oncology Nurses are just some of these names , 34. ThiThe roles of nurses specialised in oncology should include assessment of individual patient needs, education, coordination, communication and support provided to patients, implementation of effective transitions in the course of the disease and evaluation of the consequences for patients, families and the organisation . The cliThis document establishes several requirements in terms of training and personal skills for the ABCCN and recommends the provision of specific continuing education in lines of treatment, healthcare protocols, adverse effects, pain management, palliative care, care for terminally ill patients, communication, counselling and clinical research skills.Following the course set in 2005 by the SEEO at its second conference , where aIn summary, this consensus document will be a useful tool to improve the care and quality of life of patients with advanced breast cancer throughout the entire care process. It presents expert agreements and recommendations on the care provided by specialised nurses to patients with advanced breast cancer. It also establishes the profile and roles of the ABCCN, the healthcare process in which she/he participates and the resources required to perform her/his activity.The present manuscript provides an implementation algorithm that can be useful for those centres without previous experience in creating specialised nursing roles or with difficulties in implementing such positions as an ABCCN. Finally, it recommends evaluating the need for reducing the impact of fragmentation of services, offering patients a simpler and more coherent environment, eliminating the gaps that may arise in multidisciplinary care, improving the patient experience and promoting patient empowerment throughout the healthcare process before starting implementation.