Skin health has become a worldwide concern. Most of the studies investigated the effect of mobile phone radiation on DNA and animals, but a few studies were carried out about skin diseases in mobile phone and tablet users. Few systematic studies have examined the relationship between mobile phone exposure and skin diseases.  We evaluated the association between mobile phones and tablets and skin diseases. We checked databases including PubMed, Scopus, Springer, Cochrane, and Google Scholar from 1995 to 2013. The eligibility criteria were descriptive, and observational studies were in English and Persian language, and the subjects were of all ages and reported skin disease.  Most of the studies focused on signs and less on skin cancer. In total, 6 studies were included with 392119 participants with age over 25 years. In a nationwide cohort study in Denmark for BCC, the IRR (incidence rate ratios) estimates remained near unity among men and women. In the other studies, they reported an increase in temperature, hypersensitivity of warmth, facial dermatitis, angiosarcoma of the scalp, and burning sensations in the facial skin after mobile phone use on the exposed side and more within the auricle and behind/around the ear.  Overall evaluations showed that the level of evidence associated with the effects of radiation from the mobile phone and tablet on the skin is poor. This review shows a necessity for more studies in this area. Mobile phones and tablets have become the most effective communication tools especially in metropolitan cities . ExposurThe emitted radiation in mobile phone and tablet is electromagnetic ray in the microwave range 850–1800) [800 [1]. The skin receives much radiation in contact with mobile phone and tablet although many studies have been carried out on the effect of electromagnetic radiation on biologic system and intracranial tumors , 6, DiseAmong the factors that are related to skin diseases, less attention has been paid to environmental factors. Most studies have been done on these factors, in animals. The results indicate that exposure to radiation emitted by mobile phones caused skin changes in rats, as, increased thickness of surface layer, atrophy of epidermis, deep layer proliferation, vascular proliferation, impairment in collagen tissue and protein expression in human skin in proteomics approach.The lack of studies on the association between mobile phone use and risk of skin diseases prompted us to examine these associations in this systematic review.We reviewed PubMed, Scopus, Cochrane library, Google Scholar, and Springer 1995 to 2017. A range of mesh, key words, and their combinations were used, including skin disease, cell phone, smart phone, mobile phone, electrochemical magnetic field, skin cancer, skin carcinoma, and health effects. We also did not consider articles that merely assessed the physiologic effects and reviewed the bibliographies for additional publications. The language of publication was English and Persian.We included studies that had the following criteria: cross-sectional, cohort, and crossover studies to refer to the impact of mobile phone radiation on skin diseases. If the data were duplicated, the first published study was entered in the analysis. Studies retrieved from the databases that had the predetermined selection criteria were assessed by two of the authors independently. If the authors had disagreed, they resolved by discussion or in consultation with a third author.The exclusion criteria were included: nonrelevant articles on the type of study and subject of research, low-quality studies based on the CASP checklist, and studies that did not contain enough information. In the larger studies included in this survey were any conducted solely by telephone.The quality of the articles was evaluated based on the CASP scale by two researchers. This checklist contains 11 sections for cross-sectional studies and 12 sections for cohort studies.The information consisted of the name of the first author, where (country) the study was conducted, and the date of publication, sample size, and the method of data collection .The sample size in the 6 studies  was 392119, and the details of the articles are presented in In a nationwide cohort study, 355,701 mobile phone users in Denmark from 1987 to 2007 were followed up. After a period of at least 20 years, little evidence of skin cancer risk was observed among the mobile phone users .In a cross-sectional study that was conducted in 2008 on 2000 Swedish adolescence aged 15–19 years, the most participants assessed, they had skin complaints as rash and dermatitis .A cross-sectional study was initiated in 1995 including 11982 GSM and NMT users in Sweden and 2500 in Norway, the authors observed a low-risk warmth on the behind and around the ear [A cross-sectional study on 17,000 people in Norway and Sweden showed 31% mobile phone users in Norway, and 13% of those in Sweden had experienced at least one symptom that included the sensations of warmth on the ear and behind/around the ear, burning sensations in the facial skin. Most skin symptoms usually began during or after the call and lasted for up to 2 h but these results suggest an awareness of the symptoms, but not necessarily a serious health problem .A survey was conducted among a total of 330 medical students at the King Saud University. This study presents an overview about the impact of radiofrequency waves on the health of medical students in Saudi Arabia. The most of skin symptoms were reported including facial dermatitis .In this systematic review, we searched articles in databases. Abstracts and text of the articles were examined from various aspects. Eight articles were evaluated for quality, and then, six papers entered a systematic review.In the present study, the studied population was of both sexes with an average age of 35 years; therefore, this shows the importance of the issue. These persons have high performance in communities, so their illness increases the burden of the disease.All studies were cross-sectional or cohort, and there were different morbidity indexes between mobile radiation and skin diseases. The duration of exposure to mobile radiation was very different for skin signs; therefore, we did not have the possibility of meta-analyzing studies. Oftedal et al. in 1999, with a sample size of 17,000, reported the prevalence of skin problems caused by mobile use  However,We found that the use of mobile phones was associated with a mildly increased risk of skin problems. This is the first systematic review on the effects of mobile phone radiation on skin diseases.From 6 articles that enter to systematic review, two studies did not reveal a serious health problem , 13. In Previous studies have reported that collagen tissue increased in cells exposed to mobile radiation. Mobile phone radiation for one hour causes morphological changes and increased fibroblast activity of the skin. Another study also found that exposure to 900 MHz mobile phone radiation creates exocytosis in skin cells. Some studies have shown that the degree of destruction caused by mobile radiation is related to the duration of exposure to radiation . EpidemiIn patients with profuse sweating, it provides a predisposing condition, and the penetration of nickel to the skin increases the occurrence of contact dermatitis. Therefore, mobile phone dermatitis should be considered in the differential diagnosis of contact dermatitis. The patch test and dimethylglyoxime test may be helpful in establishing the diagnosis .In the study of Hardel et al. in 2011, he concluded that there is no relationship between the use of mobile phones and skin cancer [Overall evaluations showed that the effects of mobile phone radiation on skin diseases are weak and have no statistical significance. Some studies have shown weak impacts, and some studies have found that over ten years of mobile use have been effective, but mobile phones are still a new technology and little evidence about long-term side effects is available, as a result, prevention is the best approach. Epidemiological studies on this topic are limited, and its long-term effects have not been evaluated, and there is a gap in the assessment relationship between mobile phone radiation and skin diseases. People are worried about the health effects of mobile phones, especially since it is part of daily life. As a result, the implementation of standard policies and strategic planning for primary health care by government officials on this topic is necessary to reduce people's concerns in order to provide suitable solutions for high-risk people. These programs require extended studies on mobile phone technology and its impact on the safety of mobile users. Our study has limitations. First, only few studies on the study of mobile phone radiation and skin disease are available. Second, we did not have the ability to access the full text of some articles and low levels of evidence.


Worldwide, there is a widespread and disturbing pattern of violence towards healthcare workers. However, violent occurrences in Israeli hospitals have often been unrecognized and underreported. Moreover, most studies have not sufficiently differentiated among the different types of violence.To examine the different types of violence experienced by nurses and physicians, the types of perpetrators and the specialty fields involved.A quantitative questionnaire was used to assess the incidence of a “basket” of violent behaviors, divided into eight types of violent manifestations. The study population consisted of 729 physicians and nurses in a variety of hospital divisions and departments  in a large general hospital. Six hundred seventy-eight of them responded to the survey for a response rate of 93%; about two thirds of respondents (446) were nurses and about one third (232) were physicians. The questionnaires were completed during staff meetings and through subsequent follow-up efforts.In the 6 months preceding the survey, the respondents experienced about 700 incidents of passive aggressive behavior, 680 of verbal violence and 81 of sexual harassment. Types of violence differed between patients and companions; for example, the latter exhibited more verbal, threatening and passive aggressive behaviors. Violence was reported in all departments (ranging from 52–96%), with the departments most exposed to violence being the emergency room and outpatient clinics. Nurses in the emergency room were 5.5 times at a higher risk of being exposed to violence than nurses in the internal medicine department. Nurses were exposed to violence almost twice as much as physicians. There was a positive association between the physician’s rank and his/her exposure to violence. A multiple regression model found that being older reduced the risk of being exposed to violence, for both physicians and nurses.These findings suggest that uniform definitions of a range of different violent behaviors and assessments of their prevalence are important to creating an improved discourse about hospital violence in both research and operational settings. The study findings could assist policy makers in the Israeli healthcare system in implementing interventions on a national level and can promote leaders’ commitment to violence prevention and management. This is an important contribution, as executive commitment is necessary and critical for the necessary organizational changes to occur. Aggression and violence in the workplace is an underreported, global problem that has been tolerated and largely ignored . In the The research literature offers many definitions for the terms violence and aggression. For the purposes of this paper violence is defined as a socially unacceptable behavior - aggressive and sometimes destructive - of an individual or group. Frustration, hostility and prejudice might serve as catalysts for violent behavior. Aggression can be an innate behavior or a response to frustration leading to self-assertion. Aggressive behavior can be destructive and aggressive or covert hostile behavior , 12.Although the above definition seems clear, there is no consensus in the literature as to which behaviors are defined as violent or aggressive behaviors, mainly with regard to violence in the workplace . Some reThe literature reports on diverse types of violence aimed at the medical staff in various countries. The published studies show that patients and those who accompany them demonstrate a variety of types of violence towards nurses, physicians and other healthcare workers. The prevalent types of violence are verbal violence, physical violence, annoyances and sexual harassment , 16. SomAs mentioned above, various healthcare professionals are subjected to violence to different extents. A considerable part of the studies published to date were conducted by nurses and published in various nursing journals. This suggests that nurses are on the front line more than physicians with regard to exposure to violence. The number of studies focusing on violence in ER suggests that it is more prevalent in the later than in other departments , 18. HowAccording to the literature review violence towards healthcare workers crosses borders and cultures, A study that reviewed the prevalence of violence by region found that rates of exposure vary by world region , with the highest rates of physical violence and sexual harassment being in the Anglo region and the highest rates of non-physical violence and bullying in the Middle East .A survey conducted in 65 departments of emergency medicine in the United States found that over a five-year period prior to the study, 3461 physical assaults had occurred in departments of emergency medicine, with guns or knives used in 20% of these incidents . In IranA study conducted in China, examining the extent of violence towards physicians and nurses in 12 hospitals found that some 50% of respondents reported that they had been exposed to some type of violence in the year prior to the study . A studyTo the best of our knowledge, in Israel, aside from studies limited to emergency rooms, the prevalence of all types of violence in general hospitals has not been measured to date. What is missing is not only an overall assessment of the extent of violence but an unpacking of this phenomenon into different types and their frequencies. While previous work may have differentiated between, for example and as above, violence and aggression, a more penetrating taxonomy is needed if we are to come to grips with the enactment of violence in different micro situations within hospitals. We aimed to fill this gap and provide a deeper understanding of violence in an Israeli hospital. In addition, it is important to compare between the prevalence of types of violence displayed towards physicians and nurses as well as their prevalence in various hospital departments.A.The types of violence - such as, verbal violence, verbal threats, destruction of property, minor physical violence, severe physical violence, use of a weapon or a sharp object and sexual harassment.B.The perpetrators of violence (patient/accompanying person)C.The professions (physicians/nurses)D.The hospital departments - .Therefore, this study examines the extent of violence along several dimensions:This study was conducted at a university-affiliated medical center with 700 beds, employing some 5000 workers that include approximately 700 physicians and 1000 nurses. The hospital is a tertiary university affiliated medical center that offers advanced services, as well as outpatient clinics in Jerusalem and the vicinity. Approximately 30,000 patients and visitors use the hospital’s services every day.The hospital is located in Jerusalem and treats patients from a variety of cultures and ethnic groups. The healthcare workers also come from a variety of cultures and customs. Notably, the study was conducted in 2011 and data collection took place in a relatively uneventful period in terms of the Israeli-Palestinian conflict.The data published in this paper are part of a larger study which included qualitative method. The qualitative component included focus groups and in depth interviews, which informed development of the quantitative questionnaire and provided deeper understanding of the causes and factors that lead to the formation of violence in general hospitals in Israel.The research population included all physicians and nurses from the departments of internal medicine, surgery, oncology, intensive care, ambulatory care and clinics, and the department of emergency medicine, who were asked to complete an anonymous questionnaire.With the aim of estimating the prevalence and identifying the types of violence demonstrated towards physicians and nurses, the behaviors studied were divided into eight different types.These types were defined on the basis of a literature review and focus groups with nurses and physicians.verbal violence - shouting, insults and curses;verbal threats, such as the threat of taking action against the healthcare worker after work;passive aggressive behavior - sharp looks, stern facial expressions, muttering;minor physical violence - shoving, blocking the way;destruction of property in protest - throwing a chair, breaking an instrument, tearing up a medical file;severe physical violence - punching, kicking, throwing objects;use of a firearm or a knife;sexual harassment.The resulting categories were:Respondents were asked to refer to the extent of their exposure to violence in the six-month period prior to the study from three aspects: type of violence, frequency of exposure, and the violence perpetrator - patient or person accompanying a patient.In order to compare the rate of exposure to violence between physicians and nurses, a new summary measure was formed, called “exposure to violence”., defined as being exposed to at least one incident in the past 6 months prior to completing the questionnaire. Also, the questionnaire included demographics such as age, gender, professional seniority, departmental seniority, job percentage and position.The passive- aggressive behavior category is sometimes excluded from studies of the prevalence of violence, in part because it is based on subjective perceptions. However, we found it to be a major theme in our focus groups, and a potential precursor of other types of violence. The unfolding of violent events in the hospital setting, which is bound up precisely with subjective perceptions, is described in a companion study .For purposes of validation, the questionnaire was given to three physicians and five nurses from a variety of fields and ethnic origins for their review. An interview was held with each of the reviewers concerning the clarity of the questionnaire and the suitability of its content for the domain that it aimed to examine. After corrections, the questionnaire was given to 11 key personnel from various sectors at the hospital for their comments.Based on an updated list of the physicians and nurses currently working in hospital departments obtained from the department secretariat, the researcher approached potential study participants. Medical as well as nursing managers were contacted in person and upon their advice; the researcher (first author) took part in staff meetings and presented the study’s purpose and procedure. Data collection was carried out in two stages: First, we asked doctors and nurses to fill out the questionnaires in pre-planned departmental meetings. In the second stage we contacted all those who did not participate in a staff meeting (according to the department’s personnel list)and asked them to fill in the questionnaire.To describe the association between qualitative variables and other sub-groups , a chi-squared test (×2) and fisher’s Exact test were used. An association between two dependent sequential variables was tested using the McNemar test.For quantitative variables, the relationship between subgroups was made using t-test for two independent groups and the Mann–Whitney test. Multivariate relationships between exposures to violence by patients or those accompanying them and all background variables  were tested through logistic regression.A total of 729 physicians and nurses were approached from the hospital departments, of which 678 participated in the study (a response rate of 93%). A description of the research sample is provided in Table As seen in Table Physicians and nurses were both exposed to violence at a considerable rate Table . One outFor example, during the previous 6 months, there were approximately 700 incidents of passive aggressive behavior, 680 incidents of verbal violence and 81 incidents of sexual harassment. These behaviors were demonstrated towards physicians and nurses both by patients and by people accompanying them. Companions demonstrated more verbal violence, verbal threats, passive aggressive behavior, minor physical violence and sexual harassment compared to patients who demonstrated more violence categorized as destruction of property, severe violence and use of a sharp object. As can be seen from Table b, df = 6, P = 0.002). A similar difference was also found among companions.A distribution of the prevalence of violent incidents perpetrated by patients and/or companions by profession of the victims, found that nurses are exposed to violence by patients to a significantly greater extent than physicians. In particular, patients and companions assaulted nurses twice as much as physicians. This difference was significant (Chi-square 20.909Table P = 0.0001) was found among different types of physicians; the more senior the physician, the less he/she is exposed to violence. Indeed, none of the interns escaped from being exposed to violence by patients or companions, as seen in Table When comparing among different types of nurses , no significant differences were found in the prevalence of violence toward them. However, a significant difference . As can be seen in Table These results were statistically significant. Namely, the less seniority one has, the more he/she is exposed to the types of violence mentioned. The rate of verbal violence demonstrated by companions of patients was high. The association between professional seniority and this type of violence, however, had borderline significance , while location of work was not found to affect exposure to violence for physicians.Nurses working in the ER were more exposed to violence than other nurses  were found to increase the risk of exposure to violence by patients, except in intensive care units.The other variables, such as having departmental procedures and regulations on coping with violence or participating in a violence prevention workshop, were not found to be risk factors.This study has gone into the basket of types of violence and measured the frequency of the types that occur in different departments in a major general hospital in Israel. Within this basket different types of violence are directed towards different types of staff by patients and companions. Thus, this study extends pervious knowledge of the phenomenon in a significant way.Previous studies found high levels of violence in Israeli ERs. This study is the first in Israel to examine the extent of violence perpetrated towards nurses and physicians in a general hospital, not only in ERs, and the study found that violence is a common occurrence in all of the departments studied. The rates of exposure to violence found in EDs in our study was similar to the rates of violence reported by Derazon et al., (1999) mentioned above, who found a high proportion of violence in the ED in a single Israeli hospital (74%). Our findings are also consistent with those of Landau and Bendalak (2010), who found that nurses experience the most violence, most of which is verbal and about 10% physical.the types of violence, physicians and nurses are exposed to various types of violence in the hospital’s various departments, as seen, for example in Table With regard to Passive aggressive behavior, heavily represented in our study, is often not included in studies of violence. It could be argued that this inflates the prevalence of violent events in our study. However, in a companion study , this tyIt should be emphasized that although sexual harassment is the least reported, it is a worrisome and troubling phenomenon. In such cases, nurses might experience a double threat: gender and professional.With regard to nurses and physician’ exposure to violence, as shown in the results, there is a difference between types of behavior directed towards nurses as opposed to physicians. This difference may be rooted in their gender and professional prestige. Perhaps patients and their companions allow themselves to behave more blatantly towards nurses than to physicians. Furthermore, passive aggressive behaviors require longer interactions to manifest themselves, and these are present in nurse-patient interactions as opposed to shorter patient- physician encounters. This exposure to violence seems to affect nurses’ daily practice, has an impact on stress and productivity, and also increases their intention to leave their job [heir job , 26.Our findings indicated that nurses are more exposed to verbal violence and to passive aggressive behavior than physicians as indicated in other studies as well , 28. ThiBoth nurses and physicians were more exposed to violence from companions than from patients. Companions may be acting out of a sense of responsibility or burden to protect the patient. These behaviors should be acknowledged and addressed by the staff and health system leaders to prevent miscommunication and harmful events.nurses themselves , no differences were found in the prevalence of violent incidents. This is probably due to the fact that in practice, all nurses work by the patient’s bedside, notwithstanding their academic certification. Patients and those accompanying them do not discern the hierarchy among nurses. This is different from the findings of previous studies, which showed that although both RNs and LPNs are frequently subjected to physical and non-physical forms of violence, LPNs are more exposed and at greater risk [When comparing among the ter risk , 30. Theprofessional seniority among physicians, only a few studies have been published by physicians or refer to a population of physicians, perhaps due to the lower prevalence of violence as shown in our study. The current study displays a significant association between professional seniority of physicians and certain types of violence. Namely, the more senior the physician the less he/she is exposed to passive aggressive behavior and sexual harassment. Notably, the current findings show that more companions than patients demonstrate verbal violence and passive aggressive behavior towards physicians.As for Similarly, an epidemiological study conducted in Japan found that 24% of physicians reported having been subjected to verbal violence and 5% reported physical violence. A significant association was found between age and verbal violence and between gender and physical violence. Physicians younger than 30 experienced more verbal violence and female physicians experienced more physical violence . WhetherRegarding hospital departments it must be emphasized that a significant difference was found between the extents of exposure to violence in the emergency room versus other departments. It is known that emergency staff is more subject to violence at rates sometimes exceeding 90% for verbal violence [violence . NotablyOther reasons for violent episodes in the emergency room’s are mentioned in the literature such as, crowding/workload, shortages of both nursing and medical staff, care of patients with dementia and emergency room procedures .Another conspicuous, albeit unsurprising finding is the low exposure to violence in the oncology departments. This finding might be linked to the nature of the relationship between nurse/physician and patients in the case of progressive life-threatening illnesses that require lengthy treatments. Another explanation for the low rate of violence in oncology departments is the comfortable physical conditions provided to the patients and families . These physical conditions are known as violence inhibitors .This study was performed as a case study in a single tertiary hospital, although it has implications for other Israeli hospitals and cross nationally as well.Violence has been treated too often as a monolithic concept. The variety of violent behaviors perpetrated by different actors and their frequencies in different departments that were uncovered by this paper must be taken into account in formulating policy interventions.a safe and healthy inter professional work environment should be created and sustained for RNs and all health care professionals” [The evidence from our research can refine this in terms of targeting the efforts.First and foremost, implementing interventions to increase the safety of the healthcare environment for both patients and employees should cover the entire healthcare system both in term of departments and personnel. True, nurses, especially in the ER, are at the front and it may necessitate aiming more training programs to prevent and manage crises in the hospital settings. But beyond this we have revealed that such interventions should prioritize young nurses. Yet, these programs as well as other safety measures which are designed to create a safe environment should be implemented and taught to all heath care workers. So when the American Nurse Association declared recently, “sionals” . The eviThere is a lack of research evidence for violence prevention program effectiveness . PerhapsFuture research should focus on refining content and methods of teaching all intervention programs to take account of the multi-dimensional nature of hospital violence revealed in this paper. No doubt, there is a need for a carefully planned program that would incorporate a multifaceted, multidisciplinary approach to violence reduction. Such a comprehensive approach should include unified guidelines for violence prevention, promotion of legislation, managerial support, and an effective reporting system. These measures which would include staff across all levels, continuous training programs as well as installation of security cameras, metal detectors, etc., should be instituted, , 35. In Perhaps, it might be possible to learn from the success of the oncology staff who has reported low exposure to violence. Thus, in an attempt to further develop and enhance the effectiveness of the training programs, each department’s unique characteristics could be addressed based on the added value of this study as a learning tool to achieve preventive measures.The authors of this article believe that management commitment is essential to enhance these recommendations. Managers need to understand that a change in policy can be implemented only when the manager becomes a service model, in which he or she serves the patients and companions and the hospitals’ employees.Moreover, violence as a social phenomenon encountered by hospital workers should be addressed at all operational and organizational levels of the hospital.Therefore, hospital management must clearly inform the workers and patients about the policy regarding violence, best practices and rules of behavior in the organization.Any violent event must enter a transparent reporting system as well as providing a progressive framework for lesson learning. In addition, violence prevention and management programs should be incorporated into standard organizational procedures such as worker evaluations, service promotion projects, etc.This study was performed in a single medical center; similar studies should be carried out in additional Israeli hospitals. They can build upon the concepts and measures developed as part of this study. The current study included only nurses and physicians. As violence in the health systems and its causes, involve the entire organization, the role and perceptions of other actors, such as administrators and security personnel, (not to mention patients and their companions), needs to be addressed. We do this is a companion study .The current study focused on extent of exposure per staff member. First, since all types of violence were weighted equally in our summary measure of exposure, the severity of violence is not brought to bear and this might skew some of our comparisons regarding levels of exposure among different groups, such as physicians and nurses. Second, as the number of patients to whom a staff member is exposed varies by department and profession, the data presented here do not provide an indication of the rate of violence per patient. That could be the subject of a complementary study.This study has shown that violence occurs in all hospital departments and that there is a difference in the degree of exposure to violence between physicians and nurses and between departments. The definition of the various types of violence is important to create a uniform discourse both at the research and at the organizational levels. Although this study was performed in a single large hospital, it provides important insights into a worrisome phenomenon both nationally and globally. An executive commitment is necessary and critical for a thorough organizational change to occur. The findings could enable policy makers in the Israeli healthcare system to formulate and implement interventions on a national level and to promote leaders’ commitment for violence prevention and management.


Classifying software defects according to any defined taxonomy is not straightforward. In order to be used for automatizing the classification of software defects, two sets of defect reports were collected from public issue tracking systems from two different real domains. Due to the lack of a domain expert, the collected defects were categorized by a set of annotators of unknown reliability according to their impact from IBM's orthogonal defect classification taxonomy. Both datasets are prepared to solve the defect classification problem by means of techniques of the learning from crowds paradigm .Two versions of both datasets are publicly shared. In the first version, the raw data is given: the text description of defects together with the category assigned by each annotator. In the second version, the text of each defect has been transformed to a descriptive vector using text-mining techniques. Specifications TableValue of the Data•A large set of software defect reports is collected (and processed) from public repositories and adapted for the task of defect classification.•Five labelers for each dataset give their annotations by means of the most convenient defect impact from the ODC taxonomy •As no ground truth is available, the evaluation of classification models learnt from this type of data is a challenge that has not been solved to date.•The processing and extraction of meaningful information from the text fields that may boost the performance of the learning algorithms may be improved.1In software engineering, having available the classification of the reported defects is useful, although this task is complex and time consuming. The datasets presented in this paper were prepared to learn to automatize the classification of software defects by means of the paradigm of (machine) learning from crowds. Thus, multiple annotators were asked to provide the most convenient category (label) for each defect report according to their subjective point of view. Note, therefore, that the labels provided by the annotators may be wrong. To enhance generalization, two datasets were prepared.https://www.bugzilla.org/) and collects support issues, feature requests and bug reports from the Compendium community. The collected dataset comprises 962 examples, all the entries available in the ITS in August 2014 (with the exception of some obvious spam). Only informative fields are taken into account: severity, summary and description. Severity is a 3-value variable , and both summary and description are text fields. Five annotators with experience in computer science were asked to annotate the examples according to the 13-category ODC standard The first dataset is composed of reports collected from the issue tracking system (ITS) of the Compendium project, a software tool for mapping information, ideas and arguments. An ITS is typically used by software projects for reporting and tracking defects as well as proposing new functionalities. An ITS organizes the information through tickets, which maintain data such as an identifier, summary, description, opening/closing/modification dates, etc. The ITS used by the Compendium project is implemented in Bugzilla (http://www.mozilla.org/), a popular open-source application which started back in the late 90 s with the Netscape browser. Nowadays, it is a suite of tools that includes the Firefox browser and the Thunderbird e-mail client. This second dataset, which contains 675 defects, was also labeled by 5 annotators. In this case, 10 different defect impacts appeared among the labels provided by the annotators: Installability, Integrity/Security, Maintenance, Migration, Reliability, Performance, Documentation, Requirements, Usability and Capability (the same 9 impacts annotated in the Compendium dataset and Maintenance). Note that there are 3 categories which were not used in any of the datasets: Serviceability, Standards and Accessibility.The second dataset has been collected from the Mozilla project  were separately presented to the different annotators. Each of them was asked to label all the reports of the given dataset. Note that no annotator had access to the labels provided by any other labeler. Moreover, annotators of both datasets are not the same.At the same time, the defects are originally described by the text reported by the user using two text fields: summary and description. Standard natural language processing techniques have been used to extract a relevant set of variables from the text fields and transform the original database into a dataset which can be handled by ML techniques. Specifically, the popular StringToWordVector filter implemented in Weka


With the recent success of oncolytic viruses in clinical trials, efforts toward improved monitoring of the viruses and their mechanism have intensified. Four main gene expression strategies have been employed to date including: analyzing overall gene expression in tumor cells, looking at gene expression of a few specific genes in the tumor cells, focusing on gene expression of specific transgenes introduced into the virus, and following gene expression of certain viral genes. Each strategy presents certain advantages and disadvantages over the others. Various methods to organize the dysregulated genes into clusters have provided a window into the mechanism of action for these viruses. Methodologically, the combined approach of looking at both overall gene expression, the tumor cells and gene expression of viral genes, enables researchers to assess correlation between the introduction of the virus and the changes in the tumor. This would seem to be the most productive approach for future studies, providing much information on mechanism and timing. VariousIn 2015, the Food and Drug Administration approved the first oncolytic virus based on the results of a phase 3 trial for melanoma  and how they are affected by treatment with the oncolytic parvovirus H-1 (H-1PV)  . They us (H-1PV) . They usThe human studies reviewed until this point compared between tumor cells and normal cells. A slightly different methodology was employed in a few studies in which gene expression was compared between susceptible and resistant cancer cells. For example, Carey et al. capitalized on the fact that vesicular stomatitis virus (VSV) replicates selectively in cancer cells that have defects in the interferon (IFN)-I pathway . They loTSP-1 was downregulated, and the other two, angiogenic factors CYR61 and Ang-2 were significantly upregulated when compared with controls. The advantage of this study over the previous one is that they were able to correlate the upregulation of CYR61 gene expression with the presence of the virus in the tumor tissue in vivo. CYR61 is a known protein that is involved in apoptosis, angiogenesis, the cell cycle, and extracellular matrix formation. By focusing on known genes but looking at the tumor cell expression in response to viral therapy and looking at the presence of the virus, researchers are able to better pinpoint the mechanisms at work when a virus infects a tumor cell.A second strategy currently employed to monitor the efficacy of oncolytic virotherapy is to monitor the expression of specific genes in the tumor cells. Interestingly, to the best of our knowledge, no such human studies have been published. However, a number of human cell-line studies have been done. For example, Tanaka et al. focused on the sterile alpha motif containing domain (SAMD9) gene in the human glioblastoma cell line called U251MG . They trStaphylococcus enterotoxin A (SEA) and that has improved tumor specificity due to regulating the expression of E1A and E1B genes  to stimulate the innate immune system and to activate adaptive immune cells in the tumor . They teFinally, Jiang et al. developed a recombinant adenovirus using SG502 and tumor necrosis factor (TNF), yielding SG502-TNF . They loIn vivo they showed that by day 30, none of the control mice survived, yet 3 animals injected with rVSV-F and 10 animals injected with rVSV-IL12, survived beyond day 30.Shin et al. investigated human squamous cell carcinoma cell lines, murine squamous cell carcinoma cell lines, as well as a murine model . They usin vivo), and in vitro studies with cell lines, but no human studies have been published to date to the best of our knowledge.In assessing the impact of oncolytic virotherapy, a fourth method is to look at the gene expression of the virus itself inside of the tumor cells over time. By marking the virus with GFP and measuring the viral gene expression over time within the tumor cells, there is a clear indicator of viral growth, followed by a decrease in viral presence in the tumor cell as the tumor cell is destroyed. This method has been demonstrated in a number of studies including: animal studies (in vivo). For example, Guse et al. used two different murine xenograft models, one for renal cancer and a second for ovarian adenocarcinoma  . They inSimilarly, Garcia et al. used three human mammary tumor cell lines along with a cell line for adenofibrosarcoma of canine origin, and infected them with CDV . They weIn critically assessing the advantages and limitations of each of the four strategies described earlier, various conclusions became clear. For example, when looking at overall gene expression changes of tumor cells, the advantages include that it generates the broadest view of what is happening inside the tumor cells after infection with the virus without the initial bias of inserting a gene and looking specifically at that gene. Of course, it is also provides a much wider scope which is more advantageous than looking at only one or two genes. The disadvantages of this method, on the other hand, is that they provide less specific information about specific pathways or mechanisms through which the tumor increases or decreases due to the wider lens used. In addition, this method provides no information on the viral gene expression or the correlation between the virus and the decrease in tumor size.Upon analyzing the second method, namely, gene expression of specific genes in the tumor cells, we saw various strengths and weaknesses as well. For example, this method could potentially provide more information on the mechanism for tumor shrinkage or growth. In addition, since the method is more specific it makes it slightly easier to execute. Furthermore, once the specific genes are chosen, it enables a more in depth analysis of how these genes are important and how gene expression changes in the tumor cells after viral infection can have an impact on the cells.On the other hand, looking at specific genes in the tumor cells might not reflect the overall tumor status since the broad picture of what is going on in the tumor cells is missing. Similar to the limitation of the first method, this method also does not provide any information on the viral gene expression or the correlation between the virus and the decrease in the tumor.The third method of looking at transgenes is advantageous because it is a relatively simple study to do, allowing for effective monitoring of a specific transgene, and it is not “shooting in the dark” and looking for a wide variety of genes. In this way, researchers can test how effective a specific transgene performs. However, disadvantages include that it lacks the broader perspective of a study looking at overall gene expression and does not provide any indication of how the expression of genes in the tumor cells change after viral infection.Monitoring viral gene expression is helpful in terms of providing information about how effectively the virus is infecting and replicating in the host cell, but provides no information about gene expression changes in the tumor cell or the mechanisms for tumor growth or shrinkage. Compared with analyzing marker peptides to monitor viral growth and replication, gene expression might not be as sensitive, but this requires further studies to confirm this finding.Overall, in terms of future directions, it would seem that combination studies are the optimal method for studying gene expression changes. They potentially allow both a broad picture of gene expression changes in tumor cells, and the ability to correlate the tumor shrinkage or growth with viral replication. Furthermore, much information about the precise mechanisms for how the virus attacks the tumor cells can be culled from this type of study. As more combination studies are performed, patterns in the clusters of genes involved will become apparent enabling researchers to pinpoint exactly how various viruses attack tumors and providing fruitful ideas for developing a new generation of recombinant viruses that are more effective.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication. AA drafted the article, reviewed the relevant literature, made substantial contributions to conception and design, interpreted the data and approved final version. JR drafted the article, reviewed the relevant literature, made substantial contributions to conception and design, interpreted the data, revised the article critically and approved final version. PZ made substantial contributions to conception and design, participated in revising it critically, interpreted the data, and approved final version. BG participated in revising it critically, interpreted the data, and approved final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The authors are all employees of Rapo Yerapeh Ltd.


AbstractEuglossaviridissima Friese is here reported for the first time in the Cape Region of the Baja California peninsula, Mexico, where no species of the group have been found previously. These records are presented, their biogeographical implications discussed, and some interpretations of the local factors that influence the bees is presented.Orchid bees are a conspicuous component of the neotropical bee fauna, with a few species reaching the northernmost natural distribution for the group in northwestern continental Mexico. Among them,  Euglossini are the only bees within the corbiculate clade  that are restricted to the neotropics , Mexico, is a biogeographic province with distinctive floristic and faunistic elements (PageBreak), favoring high rates of endemism in the region  were tested intending to collect male bees in those localities where activity of the orchid bees was thought to be more likely, that is, San Bartolo, Santiago, and Todos Santos. The baited traps consisted of 600 ml plastic bottles following protocols used in South America  came from Todos Santos; all were PageBreakcollected in August, a single female from San Bartolo collected in April, and two males from Santiago collected in October. Most of the specimens were caught in oases vegetation (96.7%). All the bees were captured while visiting flowers of Tecomastans. The male specimens of E.viridissima were not attracted to the traps baited with chemical attractants.In total, 33 specimens  of CIBNOR .Voucher specimens are deposited into in the entomological collection at the Euglossaviridissima as the first record of an orchid bee species on the Baja California peninsula has several implications. Biogeographically, E.viridissima has the northernmost natural distribution within Euglosines , it makes conceivable to think of possible euglossines-plant interactions, but also to find specific relationships with endemic orchid species. However, further research on these subjects is encouraged.It is possible that abiotic factors  have more of an effect on populations than food availability. We do not discard the possibility that natural enemies also play an important role on these boundaries (e.g. more humid places increase likelihood to fungus attacks on immature stages). The new finding of bundance . FurtherE.viridissima in the Cape Region of the Baja California peninsula represent an important piece of information regarding these bee’s distribution and likely dispersal or ecological capabilities. They also bring the opportunity to stress the need to sample the local bee faunas, in a time when pollinators are known to be declining in different parts of the world.Overall, the records of


Immunization for children against vaccine-preventable diseases is one of the most important health intervention method in the world, both in terms of its health impact and cost-effectiveness. Through EPI and various other programs such as the Decades of Vaccines, immunization has been improving the health of children around the world. However, this progress falls short of global immunization targets of the Global Vaccine Action Plan (GVAP). Furthermore, the African region still lags behind in immunization, and suffers from a high proportion of vaccine preventable diseases as a result. Reminders and recall for vaccination have been shown to improve health care-seeking behaviours, and have been recommended for application in routine and supplemental measles immunization activities. With mobile phones becoming more accessible in Africa, SMS vaccine reminder system has been proposed as a convenient and easily scalable way to inform caregivers of the disease and the importance of immunization, to address any concerns related to immunization safety, and to remind them of vaccination schedules and campaigns. There have been 6 published articles and 1 unpublished article on the effect of SMS reminder system for immunization in Africa. The studies done has shown that SMS vaccination reminder has led to improvements in vaccination uptakes in various metrics, whether is through the increase in vaccination coverage, decrease in dropout rates, increase in completion rate, or decrease in delay for vaccination. Immunization for children against vaccine-preventable diseases is one of the most important health intervention method in the world, both in terms of its health impact and cost-effectiveness. Proper immunization is not only important for the vaccinated individuals, but also for the general population . In 1974Despite 126 countries achieving the 90% vaccination coverage target for DTP, with high coverage achieved in the Americas, Europe, the Western Pacific, and the Eastern Mediterranean Ocean, the African region still lags behind in immunization, and suffers from a high proportion of vaccine preventable diseases as a result. About 1.5 million children around the world die each year from vaccine-preventable deaths, with Africa suffering the most . In 2016Reminders and recall for vaccination have been shown to improve health care-seeking behaviours, and have been recommended for application in routine and supplemental measles immunization activities . In CochMobile phones are becoming more accessible in Africa, as the costs of services are getting cheaper . OwnershOne of the biggest reasons for missed vaccination in children in Africa is the lack of communication between mothers and health workers, which could lead to a lack of knowledge on vaccination, or lack of proper service or vaccines on the day of vaccination . AnotherSMS can be used as a convenient and easily scalable way to inform caregivers of the disease and the importance of immunization, to address any concerns related to immunization safety, and to remind them of vaccination schedules and campaigns. Furthermore, SMS can be sent to inform mothers of any issues at the health facility, such as stock-outs and long waiting time, in order to inform mothers to visit a different health facility or come on another day. SMS reminders have the potential to help increase vaccination coverage, as well as to increase the public’s positive image of vaccination activity.Overall, more than 40 published studies in Cochrane review from different regions have proven the effectiveness of vaccine reminders. In Africa, SMS vaccine reminder system has been done in a small scale in a few countries. In Mozambique, about 35,000 children in the northern province of Nampula have been registered with the mVaccination pilot programme, launched in 2015 by GSK and Vodafone, with funding from GAVI and USAID. In December 2015, the service was expanded from17 to 76 healthcare facilities . In BeniAlthough there has been no full-scale implementation of SMS vaccine reminder system in Africa at a national level, many studies and small-scale interventions have been done in the African region in the past few years . This suThere have been 5 published articles and 2 unpublished article on the effect of SMS-reminder system for immunization in Africa. Of those, 2 are done in Kenya and 2 are done in Nigeria. All studies have been shown to either improve immunization coverage, or reduce dropout rates for vaccination. All but one article used randomized control trial as the type of the study, with one intervention evaluation study in Kenya. All but one article used the reminder for vaccination, with one study using the reminder for Vitamin A administration. The primary outcome measure used in most studies are either the completion rate of the whole vaccine set, or the completion rate for pentavalent vaccine 3rd dose or for DPT3, with one study using the decrease in dropout rates as the primary outcome measure. Although there are control results in all studies, only 3 studies contain baseline measure .While 3 studies only focus on SMS reminder system as a sole intervention, with no reminder system as the control, 4 studies added other forms of intervention alongside SMS reminder system, either together or as a combined intervention, or as another monitored intervention in itself. A study uses conditional cash transfer in addition to SMS reminder, alongside the normal SMS reminder . AnotherThe study in Kenya by Gibson et al., which uses conditional cash transfer in addition to SMS reminder intervention, shows that better immunization coverage can be achieved with additional cash incentives. This is however, only achieved with certain amount of money, as KSH 75 cash incentive + SMS intervention did not increase the coverage from the normal SMS intervention, but KSH 200 cash incentive + intervention increased the coverage by 4% from normal SMS intervention and by 8% from the control coverage. Another study that pairs SMS with additional intervention was done in Nigeria by Brown et al., with PHCIPT  paired with SMS reminder. The study however, found that the group using SMS alone actually had a slightly better routine immunization (RI) completion rate (98.6%) as compared to SMS+PHCIPT (97.3%), and a much better immunization rate than the group with PHCIPT alone (70%). In the 2016 study in Kenya by Haji et al, sticker reminder intervention was also tested, and found that it did not lead to a big decrease in dropout rate when compared to the control (16% dropout rate in sticker reminder and 17% in control). SMS reminder however, showed much higher decrease in dropout rate, from 17% in control to only 4% in SMS reminder intervention group .Of the 7 studies on SMS-reminder for vaccination, 3 studies disclosed the name of the software, while one study stated that it had used “Internet-based web-to-SMS”. Only one study used UNICEF’s open-sourced software called Rapid SMS, which was developed for sending automatic mass SMS messages. Of the studies that listed their SMS schedules, all but one study scheduled their SMS to remind the parents days before the vaccination date, and all but one sent multiple SMSs leading up to the date. Reminder/Recall system, which is a system that sends a message after the schedule to remind and follow up the mother after the time was due, was only used in two studies. The study in Zimbabwe contained a phone call follow-up and the study in Senegal contained a household visit as a follow-up instead. The cost of the SMS message (per one benefactor) was only shown in 3 studies. The study in Zimbabwe showed the highest cost per benefactor of 0.99USD while the study in Nigeria showed the lowest cost of 0.09 USD .In the Zimbabwe study by Bangure et al., on top of the vaccination coverage, the association between receiving short message services and delay in receiving vaccinations was also measured. The study found that the SMS reminder intervention group were 75% less likely to delay in having their children immunized than the control group. This means that the age of the children in the non-intervention group will be older than the correct age of immunization, and they can be exposed to these vaccine preventable diseases. The study also asked participants about their willingness to accept the SMS system, and found that majority of the mothers hold positive attitude towards the SMS system . This reIn the Kenya study by Haji et al., the delay for vaccination was also found in the non-intervention and the sticker group, whereas the SMS intervention group showed no significant delay. Multivariate analysis was also done to find factors related to missed immunization. The study found that low maternal education (below secondary education) and long distance from health facility  increase the odds of missing vaccinations. On top of the dropout rates, Haji et al. also surveyed for the reasons for dropping out, and founded that 35% of the dropped vaccinations were due to vaccination taken at a different facility, while 30% were due to the caretaker and children being out of town. Forgetting the date were 15% of the cause of missed vaccination, which shows that a significant amount of people who dropped out of the vaccination program could potentially be saved by a vaccine reminder system .In the study in Nigeria by Eze et al., the cost effectiveness of SMS reminders was also calculated, with comparisons made with the use of Junior Community Health Extension Workers (CHEWs) for functional home visits. The results showed SMS reminder as being more cost-effective by 0.25 USD per child. In this study, the reasons for refusal to take part and register for SMS reminders was also surveyed. Result shows that self-confidence in not forgetting appointments  and the fear of giving out phone numbers  were the greatest barriers to uptake in this study .In the study in Burkina Faso by Schlumberger et al., the delay for vaccination study was also done, and has shown similar results to the study by Haji and Bangure, significantly more timely vaccinations in the intervention group. The study also attempted to find the reasons for delayed or missed vaccinations in both intervention and control groups. Using telephone call back, the study found that 19% of the phone numbers called were disabled or now being used by a new owner with no association to the mother or the child. Of the answered calls, the reasons for missing the vaccination were shown to be due mostly to: children attending another health center (66%), children travelling with parents (18%), and parents’ negligence (13%) .In the study in Senegal, the timeliness of the Vitamin supplement intake was also measured, and found that the average age of supplementation for children pre-intervention is much older than post-intervention with SMS reminders. The study also included an SMS stock reporting for Vitamin A supplements availability in health posts. The stock report helped ensure that 100% of health posts had stock of Vitamin A capsules throughout the intervention period, with all intervention districts succeeding in submitting at least 80% of their weekly stock reports. The comparison was not made however, with the stock availability before the intervention, since earlier, Vitamin A stocks were distributed only twice per year and was not routinely given out. Since the communities in the study has very low initial knowledge of Vitamin A supplementation, which led to low supplementation rate, a questionnaire was also utilized to find how the mothers learn about the Vitamin A supplementation. The questionnaire revealed that before the intervention, more than 80% of the sources of information came from communications by health workers and radio. However, after intervention, the two intervention districts showed that 78% and 76% of sources of supplementation for the mothers were phone call and SMS. Social mobilization or communications by health workers became a much smaller source of information (10-15%) for intervention districts, showing that one could get high supplementation coverage even with less use of human resources, and that SMS messages or phone calls can replace traditional communication method to a great effect .In the 2016 SIA, a research led by the Ministry of Health and in collaboration with Kenya Red Cross and US Centers for Disease Control, was done in Kenya’s Western region to explore the feasibility of using the mobile phones to improve immunization nationwide. The study sent multiple bulks of SMS reminder messages about the MR campaign  through the Safaricom and Airtel networks in selected counties .From the seven studies done on SMS vaccine reminders in Africa, all have shown marked improvements in the different metrics for vaccination, whether it is through the increase in vaccination coverage , decrease in dropout rates , increase in completion rate , or decrease in delay for vaccination .In terms of the cost effectiveness of SMS as vaccine reminder, Eze has shown the cost per children for using SMS reminder is much lower than home visit, a current method of vaccination reminders in many African countries. The biggest cost reduction that was made in that study were salaries of workers and logistics, both massive costs in the house-to-house campaigns . AlthougLiteracy was shown to be an issue in SMS reminder system in two studies, and must be addressed when SMS-reminder system is being planned for implementation. A few suggestions include keeping the message simple, using automatic voice messages or calls, or instructing the mothers to ask a literate community member to explain the message . AnotherOther than forgetfulness and negligence, the biggest factors to missing vaccination, as founded in the studies, were being in the middle of travel, changing health facility and getting off the investigator’s tracking system, and distance from health facility. One must look to design a system that addresses these identified challenges. One way to help remind mothers who are travelling, is to have a recall system that some of the studies used, in order to keep reminding the mother until she is available to take her child to be vaccinated. To combat changing of health facilities, one must design a system that covers all health facilities and connects their patients’ data together in one registration platform. The distance from health facility is an important issue and one that unfortunately cannot be solved simply through an improved SMS system only.In terms of the systems used, all studies used different software to create this SMS reminder platform for immunization. To create a sustainable and scalable system, one must look to develop the program from existing and accepted products. Rapid SMS, a software developed by UNICEF, is an example of a software that is flexible, and built as an open-sourced software. Rapid SMS and its successors, RapidPro and Textit, could become a more common foundation to build a system on in the future.Although the studies reviewed showed that SMS reminder system is undisputedly a highly qualified tool for increasing vaccination uptake, the system itself is not the sole factor to be considered when trying to improve vaccination status. Literacy, movements of the population, health facilities, and remoteness of the area all play a part to affect vaccination of the population. Policy efforts should be put to address these areas where technology can only play a minor role. However, as it stands, SMS reminder for vaccination has proven to be effective in multiple control trials and pilot studies done in Africa. Through this review, one can conclude that a full-scale implementation of this system should be the next step for African countries to fight the low vaccination coverage in this region.One of the biggest reasons for missed vaccination in children in Africa is the lack of communication between mothers and health workers, which could lead to a lack of knowledge on vaccination, missing the vaccination schedule, or lack of proper service or lack of vaccines on the day of vaccination;Mobile phones are becoming more accessible in Africa, as the costs of services are getting cheaper; ownership has been surging rapidly, with some countries achieving more than ten-fold increase in ownership from 2002 to 2014;Overall, more than 40 published studies in Cochrane review from different regions have proven the effectiveness of vaccine reminders, although no study has been done to review all the studies for SMS-based vaccine reminders in Africa.The study provides detail into the methods of 6 different studies in Africa which use SMS vaccine reminder system, and could aid any people who want to develop the system to understand;The study contains both unpublished articles, articles from grey literature, and reports that were not published, in order to provide a comprehensive view on the uses of this system;The study looks into the details of the SMS system, which could give a good starting point for any individuals, organizations, or companies that are looking to create an SMS vaccine reminder system.The authors declare no competing interests.


Novel research training approaches are needed in global health, particularly in sub-Saharan African universities, to support strengthening of health systems and services. Blended learning (BL), combining face-to-face teaching with computer-based technologies, is also an accessible and flexible education method for teaching global health and related topics. When organised as inter-institutional collaboration, BL also has potential for sharing teaching resources. However, there is insufficient data on the costs of BL in higher education.Our goal was to evaluate the total provider costs of BL in teaching health research methods in a three-university collaboration.A retrospective evaluation was performed on a BL course on randomised controlled trials, which was led by Stellenbosch University (SU) in South Africa and joined by Swedish and Ugandan universities. For all three universities, the costs of the BL course were evaluated using activity-based costing with an ingredients approach. For SU, the costs of the same course delivered with a classroom learning (CL) approach were also estimated. The learning outcomes of both approaches were explored using course grades as an intermediate outcome measure.In this contextually bound pilot evaluation, BL had substantially higher costs than the traditional CL approach in South Africa, even when average per-site or per-student costs were considered. Staff costs were the major cost driver in both approaches, but total staff costs were three times higher for the BL course at SU. This implies that inter-institutional BL can be more time consuming, for example, due to use of new technologies. Explorative findings indicated that there was little difference in students’ learning outcomes.The total provider costs of the inter-institutional BL course were higher than the CL course at SU. Long-term economic evaluations of BL with societal perspective are warranted before conclusions on full costs and consequences of BL in teaching global health topics can be made. Global health needs strong health systems . To thisThe African Capacity Development on Health Systems and Services Research (ARCADE HSSR) project focused on building research capacity in African countries . The proReviews on BL , 13, 14 BL is increasingly popular , 23, butOne of the first courses delivered using BL approaches in ARCADE HSSR was a course on randomised controlled trials (RCTs). The course was taught using CL at SU from 2009 as part of the master of science in epidemiology programme . The shiThis retrospective economic evaluation was conducted to estimate the total provider costs of BL in teaching a course on RCTs as a three-university collaboration in the ARCADE HSSR framework. A cost description was performed for all three institutions – SU, KI, and MU. In addition, at SU, a CL course was included in the evaluation as an historical comparator. The learning outcomes of BL were also explored and compared to those of CL at SU, using course grades as an intermediate outcome measure. As both the BL and CL versions of the course had the same learning content and objectives, course grades were a good source of outcome data available for the retrospective evaluation. The students’ final grades on both the BL and CL courses were formed based on assignments (50%: three assignments in the CL course and four in the BL course) and a final exam (50%). The grading scale on the course was 0–100 and the pass mark was 50% (50), which is the standard on postgraduate-level courses.In terms of running the courses, the final year of running each course was evaluated . Both the CL and the BL courses had the same learning objectives, and the same themes were covered in teaching . Descriptive statistics on both courses are presented in www.moodle.org). SU used a classroom with videoconferencing equipment for teaching the course, and KI used a meeting room with similar functionality. Students from MU participated in the teaching sessions in a classroom using their own laptops, because of low student numbers and non-availability of videoconferencing equipment for such a small number of students. The course also required a bridge for videoconferencing to connect all sites and allow for interaction. The sites used Microsoft Lync software to connect through the bridge. The faculty used Camtasia software in 2013 to make videos of the teaching content, which were made available for students to watch online.The BL course included 16 hours less of scheduled CL time compared to the CL course at SU . The BL All costs were examined from the providers’ perspective, using activity-based costing. Using activity-based costing, all activities needed to produce the course were first specified, after which cost ingredients were categorised for each activity. An ingredients approach was used to collect data on resources used in order to identify all necessary inputs regardless of the funding source. This approach consisted of identifying and valuing all resources required to set up and run the BL and CL courses and calculating the total costs for both approaches. Resource use was tracked from the start of the project and course planning until the end of 2013. All inputs were tracked by and linked to the site that incurred the cost, even if the purchase or work input benefitted all sites to some extent. This illustrated the needs of institutions with different roles, KI having the overall managerial role of ARCADE HSSR, SU representing the course organiser, and MU having a smaller participant role in this BL activity.We conducted a document review to achieve an overview of activities related to BL in the ARCADE HSSR project, by examining the project's grant agreement . The actAn overview of the collection and valuation of inputs is presented in For participants who were identified by key informants for their time contribution to the project or courses, time input to meetings was not calculated separately to avoid double-counting, and only travel costs retrievable from the project expenses  were included as meeting-specific costs. Only hours used to participate in the meeting were included for those meeting participants that were not otherwise included in staff time. This time was valued based on professional positions. These participants contributed to the meeting content, but as none of the key informants had mentioned them as key for the project or courses, we considered the inclusion of full costs excessive.The cost of videoconferencing equipment was covered by approximating the cost of the spaces that had the necessary equipment, and this cost was included in the running cost of BL. SU had purchased the bridge for the videoconferencing system, which was included in the start-up costs of BL in ARCADE HSSR. As Microsoft Lync was not specifically purchased for the project, the initial once-off licence fee was not costed, but the yearly fee for three devices was included as an approximation of a recurring cost of using the program in running the course. Several other communication cooperation systems were tested in ARCADE HSSR  at the project level, thus the cost for 1 year's use of each of these programmes is included in the ARCADE HSSR start-up costs of the BL course. The BL start-up costs also included an once-off licence fee for the Camtasia software. Other purchases in ARCADE HSSR that participants considered necessary for starting up BL included two computers, two microphones, and a webcam, which were all purchased at KI. The annualisation and depreciation of these costs are discussed at the end of this section.The valuation of the inputs was done by expenditure reviews of project financial records. For those BL resources not included in project records and resources needed in the CL version of the course, national market prices were used to approximate costs. A common overhead is added to instances of outside purchasing of services from the university in the main study setting of South Africa. This figure, 10%, was used as the overhead cost on the final sum, to account for resources that serve several departments or programmes .Costs were collected in local currencies where this information was available (KI and part of SU costs). Costs from MU and part of the SU costs were collected from EU reporting, where all costs were presented in euros. All currencies were first converted to US dollars using the average exchange rate of the year when the cost had taken place . Costs wAll equipment costs were classified as capital costs, as the useful life of all the items was more than 1 year, and start-up costs were considered capital expenditure. Annualisation was undertaken by using 2013 interest rates for each country's 10-year government bonds as the discount rate –31 and 5Work related to BL in general, done as part of the ARCADE HSSR project, was vital for achieving the knowledge, acquiring the equipment, and formulating the materials needed to deliver the RCT course as BL. Thus, interviewees were also asked about inputs needed for planning of the ARCADE HSSR project as a whole and on general BL activities within the project, as well as what share of these inputs was relevant to the RCT course. The averages of these estimations were used to allocate part of the general project inputs to the RCT BL course. Key informant estimations were also used to allocate staff hours related to BL activities in the ARCADE HSSR project to start-up and operational needs. As start-up inputs will benefit BL activities at the institutions and the courses for many years, these costs were annualised, and the annual cost for 1 year was included in the final costs. As the BL course had been running for 3 years, one-third of the ARCADE HSSR project costs allocated to running the RCT course were included in the costs of running the 2013 RCT BL course.Three input categories were formed to present the collected data under both start-up and running costs. Planning and management included inputs related to the course and project planning and management; central activities, such as general ARCADE HSSR meetings; and coordination and administrative work. The ICT capacity category included all inputs needed for ICT capacity building and maintenance. The course development and delivery consisted of inputs needed for the course module review and development, as well as course delivery. Space costs included only teaching space costs, as meeting space costs were included in the meetings category.A one-way sensitivity analysis was conducted to assess the role of possible uncertainties in the data. Staff costs were identified as the key driver of total cost and also as most subject to recall bias; thus the total cost of time inputs was varied by 20% up and down. As space costs vary considerably depending on location and limited data were available for evaluation of space costs with videoconferencing equipment, space costs were varied by 20% up and down. Meeting costs were very specific to the project under evaluation (e.g. the number of meetings needed and number of people travelling); thus they were varied on a larger scale, 50% up and down. Furthermore, as significant variation existed in estimations of what proportion of costs related to BL activities in ARCADE HSSR project should be allocated to the RCT BL course, this parameter was varied to represent the lowest and highest estimations.Thirteen master's students participated in the RCT course that was delivered as CL at SU in 2010 . AltogetExplorative findings on course grades suggest that there was little difference between the groups in learning outcomes. The mean final grade of students taking the BL and CL courses was 67.3 (SD 7.6) and 64.3 (SD 5.8), respectively.The economic costs of the RCT courses are presented as start-up and running costs and are summarised under three main activities . The totStaff costs were the major cost category within most activities and in total costs . For theIn the BL course's start-up costs, meetings were the most significant source of costs, representing 50% of the total start-up costs. The source of these costs was five international meetings that were relevant for starting up the BL activities within the project. Three of these were general ARCADE HSSR project meetings, where only part of the content was related to BL and therefore only part of the total meeting costs were allocated to BL, according to interviewee estimates (50% for one meeting and 25% for two meetings). One international meeting was solely focused on BL, and one focused directly on transforming the RCT course to BL.Of the start-up costs of the BL course, 13% were equipment and licence costs, whereas such costs were less than 1% of running costs. Teaching space costs represented 17 and 31% of running costs of the BL and CL courses, respectively. The average per-site cost of the RCT BL course was USD 22,700, for example decreasing the SU costs by 23% when compared to the site-specific cost.At SU, the costs of starting up and running the RCT course as BL were 115% higher than starting up and running the course as CL . Of the Varying the estimates of the allocation of ARCADE HSSR costs to the RCT BL course had the highest impact on total costs in the sensitivity analysis . AllocatOur research indicated that delivering the course as BL incurred more than double the costs that were estimated for the CL format of the course at the leading university, SU, which also had the highest number of participating students. However, costs remained higher even after evening out the costs of BL between participating universities and after considering the per-student costs. Staff costs seemed to drive the total cost for both approaches, similarly to other studies . No notaEven though the BL course included fewer classroom hours, the results show that staff hours for course development and delivery were significantly higher for the BL course than the CL course. This finding was also highlighted by lecturers involved in developing and delivering BL courses in the ARCADE projects . This reIn the present evaluation we were able to both compare costs and explore one outcome of BL and CL for only one institution. Furthermore, our comparator (CL) at one institution was an historical control. There is a need for rigorous evaluation studies, such as RCTs, with a comparable time frame and outcomes that have a broader spectrum of the hypothesised benefits of BL – expanding the coverage of teaching health systems research and enhancing student learning. Before these types of rigorous evaluations are available, no firm conclusions should be made on cost-effectiveness of BL compared to CL.The findings of this evaluation are very context-specific, presenting an example of the costs of applying BL as an inter-institutional collaboration between three sites. As this evaluation included only the providers’ perspective, no conclusions can be made on the full societal costs of BL, as for example students’ costs were not included. This evaluation included the first BL course offered in the ARCADE HSSR project, and even if the third year of running the course was looked at in terms of the running costs, the findings represent the transition phase from CL to BL. Interviewees often highlighted that setting up and running the more recent BL courses implemented within ARCADE HSSR has been easier. Nonetheless, the present evaluation provides a full cost description of offering a BL course, including all inputs needed to start-up and run the courses, and not just actual purchases by a specific project, and it can thus be used as preliminary data on provider cost structures related to the shift from CL to BL in teaching health research methods to masters-level students as an inter-institutional collaboration.This pilot-scale evaluation offers new insight into the total provider costs of BL as organised in an inter-institutional collaboration with a multicountry setting. Intuitively, such efforts could have a great advantage in global health education, in bringing lecturers and students together from different settings , thus poThis contextually bound pilot economic evaluation focused on costing an inter-institutional BL course on RCTs, a key skill in health systems and global health research. The evaluation demonstrated that BL had substantially higher costs than the traditional CL approach in South Africa. Despite these costs, BL, especially when implemented with the intention of sharing limited teaching resources between institutions and increasing accessibility of education, has the potential to support global health research capacity building in resource-constrained settings. Further work investigating the long-term costs of BL, including societal perspectives and analysis of consequences, as well as strategies for cost reduction are warranted to determine the true cost-effectiveness of BL compared to traditional teaching approaches. Further exploration of capacity building approaches in LMICs are also needed.


It is amazingthat the first systematic description of occupational physical or mental burnout wasprovided more than two centuries after the modern contextualization of work. It is even more astonishing that morethan 40 years have passed without any studies assessing the actual implications ofburnout syndrome on the work dynamics in healthcare and the outcomes on patient care.Despite a significant increase in the number of studies on this subject that have beenpublished in the last five years . Thus, beforeinterpreting the study results, we must emphasize that they refer to professionalswilling to complete the questionnaire in units that agreed to participate in the study.Thus, it is possible that a larger sample would lead to even more alarming results. Theauthors found a burnout prevalence of greater than 60%, when considering burnout as thepresence of at least one of the domains involved.In this edition of the  must beinterpreted in conjunction with the results of other international initiatives and withthe data on professional and personal satisfaction among intensivists published byNassar, also in Revista Brasileira de Terapia Intensiva. The Brazilian intensivist is young,often well paid, but subject to a high weekly workload. As with other doctors in otherparts of the world, emotional exhaustion is the most frequently reported component ofburnout syndrome. However, Brazilianintensivists seem to suffer from burnout more frequently than their Portuguesecolleagues.The results of Tironi There is, however, indirect evidence. Emergency physicians withburnout report providing sub-optimal care on a greater number of occasions. In an important study, Welp et al.demonstrated that emotional exhaustion in intensive care physicians and nursesnegatively influences interprofessional care provision and patient safety culture inintensive care units, thereby stressing the importance of performing surveillance,recognition, and treatment of burnout syndrome.We know little about the consequences of burnout. The direct relationship between burnoutand worse care performance, although plausible, has yet to be demonstrated in practice.Some data suggest that patient satisfaction is lower when the assistant physiciansuffers from burnout; however, the link between the presence of the syndrome and worseoutcomes still needs to be clearly demonstrated. In addition to the directconsequences to the care provided, the high prevalence of burnout in intensivists canlead to the migration of professionals from intensive care to other healthcare areas,especially in settings where many physicians work in other specialties concomitantly tointensive care medicine, as is the case of Brazil. In a questionnaire applied to healthcare professionals involvedin the care of cancer patients, where emotional exhaustion rates similar to those of thestudy by Tironi were obtained (53.3%versus 50.6%), approximately one-third of the respondents reportedan intention to seek a different job. It is unclear whether an association exists between burnout and atendency to change jobs among Brazilian intensivists, as reasonable levels ofsatisfaction with their professional choice were reported. The scenario, however, does not seem encouraging. Asreported by Tironi, the bureaucraticburden and the lack of time for addressing the emotional needs of the patient, alongwith the inevitability of facing family conflicts, are frequent complaints amongBrazilian intensivists. As the first complaint is unable to assess the value of thesecond and both are related to the third, a system is created in which the user, ratherthan being empowered, becomes adrift. It should be noted that I refer to the dysfunctional bureaucracy,as described by Merton, and not the development of essential care protocols aimed athelping the physician and improving outcomes. The next years will determine whether satisfaction ofBrazilian intensivists with their profession persists or if burnout will prevail.A shortage of intensive care physicians exists in Brazil and worldwide.