Multiple guidelines exist for the follow-up of breast cancer, with no agreement on frequency or duration. The contribution of routine clinical examination for the detection of potentially treatable relapse, and the impact this has on survival, is unknown. In this study, we systematically review the literature to establish the proportion of potentially treatable locoregional relapses and new contralateral breast cancers detected by clinical examination, mammography and patient self-examination. We analyse whether method of detection of relapse influences outcome. The methods used were systematic review of the literature. MEDLINE, EMBASE, CancerLit, Web of Sciences and EBM reviews were the data sources for the systematic review. All studies with information on proportion of relapses detected by clinical examination, mammography and self-examination were included. A total of 30–40% of potentially treatable relapses are detected by patient self-examination. In studies published before 2000, 15% of such relapse is mammographically detected with 46% detected by routine clinical examination. In those published after 2000, 40% are mammographically detected with 15% detected on routine clinical examination. Patients with ipsilateral breast relapse detected clinically appear to do less well than those with relapse detected by self-examination or mammography. Routine clinical surveillance is responsible for detection of fewer potentially treatable relapses in more modern cohorts as experience with mammography increases. There is no evidence to suggest that clinical examination confers a survival advantage compared with other methods of detection. The data in this analysis suggest that a review of the guidelines on follow-up after breast cancer should be undertaken. The early detection of potentially treatable relapse remains a central purpose of follow-up after breast cancer . RegularAlthough studies suggest that mammography is useful for detecting metachronous contralateral disease and relapse in the conserved breast at an early and treatable stage . The valEarly detection of locoregional relapse has a beneficial effect on survival  after breast cancer. The impact on survival of method of detection is also explored.MEDLINE, EMBASE, CancerLit, Web of Sciences and EBM reviews were searched for relevant studies. The original search was conducted in January 2006 and all English language publications between 1966 and January 2006 were considered. Two groups of authors allowed access to further data. Analysis of this further data led to delay in publication of the review and also led to an original report in the literature. To ensure an up to date review and to allow inclusion of the original report in this review without risk of introducing selection bias, the complete search of the literature was repeated in May 2007. The search string used is reproduced as All abstracts were read and considered independently by DAM and KK to establish whether the full text article should be retrieved. Sources of disagreement at this stage resulted in the full text article being obtained. References of all full text articles obtained were also searched for further relevant studies.The study group comprised women with primary operable invasive breast cancer without metastatic disease out-with the breast and axilla at initial presentation.Data pertaining to isolated locoregional relapse only were presented, or such data were presented separately from distant relapse data. Locoregional relapse was defined as relapse within the ipsilateral breast or axilla or new contralateral disease. Supraclavicular lymphadenopathy was considered to be distant disease for the purpose of this analysis.Data for each site of relapse analysed are presented separately. There may be differences in the pattern of detection of each site of relapse , and this must be fully explored.The method of detection  of all types of relapse was included.Two separate analyses were conducted; first analysis was a comparison of methods used to detect relapse and a second analysis was the effect of method of detection on survival. Studies were included in a comparison of methods used to detect relapse if: The authors of studies which contained some relevant information were written to for extra data, and the study included if the author could provide sufficient data to meet the inclusion criteria above. The studies included in the analysis of methods of detection were included in the further analysis of survival if there was adequate data on survival included in the initial paper, or if the authors were able to supply outcome data after correspondence.Methodological quality was assessed independently by two authors (DAM and KK) by means of a pre-defined form. There are no accepted criteria for measuring methodological quality in prognostic studies and so this form was a modified version of the form created by When analysing survival, it is of particular concern if patients who are recognised as having relapse are not analysed. In retrospective analyses particularly, this may be because the patient has subsequently died and case notes have been destroyed. Therefore, when assessing the methodological quality in each study, we have included the percentage of patients with recognised relapse not included in the final analysis due to lack of information.vs interval clinic and whether detection was by patient, clinician or mammography in the first instance).Two authors, DAM and KK, extracted data from included studies independently. Data collected were year of publication and year of initial operation or referral, population size, age, primary therapy, study design, follow-up schedule including mammographic schedule, number of locoregional relapses and method of detection of locoregional relapse . For survival calculations, individual data were available for each patient allowing analysis of all individual patients.In all, 4061 titles were studied in MEDLINE, 4563 in EMBASE, 8906 in CancerLit and 3144 in Web of sciences. From all EBM reviews including the Cochrane database, three review articles were retrieved. From these titles, 188 abstracts were read and considered independently by DAM and KK. Nine review articles and four letters or editorials were also obtained from the 188 abstracts to examine the references of these articles for further relevant studies. In total, 68 full text articles were considered for inclusion.From the 68 full text articles considered, 11 studies met the primary inclusion criteria for our analysis of method of detection of locoregional relapse .A further 25 studies contained some data appropriate to our meta-analysis and the authors of these were written to. One was able to provide us with further information, including method of detection of local relapse and subsequent outcome for the complete study group and four additional patients, and has therefore been included in both analyses  recommend frequent visits for routine clinical examination and mammography for up to 10 years after treatment  in England and Wales recommend that follow-up should be limited to the first 2–3 years after treatment followed by discharge to general practice . NICE esBoth the ASCO and NICE guidelines have in common the fact that emphasis is placed on providing frequent clinical examination in the first 3–5 years after diagnosis. However, this approach is in disagreement with the findings in this review. There certainly is an increase in the hazard rate for relapse in the first 3 years after treatment , there iHowever, doubt remains over the value of the ASCO approach of providing regular clinical examination after breast-conservation surgery in the long term. Such examination is responsible for detection of only 13% of the relapses overall in the two most contemporary data sets analysed (This review indicates that in both the conserved breast and the contralateral breast, the contribution of mammography appears not only to be important, but in fact may be of increasing importance. While early studies such as those by This change in the impact of mammography is highlighted when comparing two cohorts treated by breast-conserving surgery at the same unit. The number of treatable relapses diagnosed by mammography in Edinburgh has increased from 31% among patients with relapse diagnosed between 1986 and 1998 . This fuInterestingly, the proportion of relapses detected by patients, particularly in the treated breast, has remained fairly constant at 30–40% throughout all the studies analysed here. This applies particularly to ipsilateral breast relapse and axillary relapse. It applies less to contralateral breast relapse, where mammography has a much larger impact, and this may reflect high pick up from mammography, less aggressive contralateral disease or simply a lack of patient awareness of the risk of contralateral breast relapse.There is great disparity between the findings of this analysis and the statements by NICE. NICE base their recommendations for follow-up on the findings of just one retrospective analysis (Much of the data in this review, particularly data relating to survival by method of detection of relapse, have come from unpublished data  has any Treatable relapse is not common, affecting only 1–1.5% of women per year (The need for clinical follow-up for the detection of relapse is uncertain. The majority of relapses are now detected by patients or mammography. Mammography in fact has a very high yield when conducted annually. There are few relapses detected by clinical examination and, certainly in the case of ipsilateral breast relapse, those which are diagnosed clinically may do less well.Isolated axillary relapse is very uncommon, and it may be that better patient education could increase the proportion of such relapse detected by the patient. While most women are well schooled in breast self-examination, it may be that the importance of axillary examination is less well appreciated.Future guidelines should take these facts into account, but should also try to address the additional needs of patients during follow-up for breast cancer. These include both detection of psychosocial problems and side effects of treatment which are central to maintaining patients well being.


Periodontal attachment loss in the maxillary anterior region can often lead to esthetic and functional clinical problems. Lifelong motivation is essential to the supportive therapy for these patients, and the maintenance of good esthetics, combined with conducive to maintaining long term dental and professional health. This paper aims to demonstrate an innovative treatment option for dealing with aesthetic challenges posed by a number of patients who have undergone initial cause related therapy for aggressive periodontitis. Awareness about various dental treatment modalities has increased among the patients now, as compared to what it was a decade ago.Oral esthetic and functional rehabilitation can be achieved by restoring teeth and soft tissue defects to an ideal natural form. Ideal gingival esthetics may not be achievable in a compromised case. Gingival replacement prosthesis has historically been used to replace lost tissue, when other methods such as surgery or regenerative procedures were considered unpredictable or impossible. It is very important to take care of function, comfort, phonetics, longevity and ease of maintenance, with preferably less cost. Materials used for replacing lost tissue architecture include pink auto cure and heat cure acrylics, porcelains, composite resins, as well as silicon based soft materials. GingivalThe following case reports describe a new technique for replacing the gingival tissue by an easier and quicker method, which is more economical for the patient. In all these cases, there was gingival recession following active periodontal treatment and the resolution of inflammation in periodontitis; the periodontal tissue was healthy, but with a reduced connective tissue attachment and alveolar bone height.A 25-year-old female patient presented to the Department of Periodontics, Manipal College of Dental Sciences, Mangalore, in August 2004, with a primary complaint of mobility of right lateral incisor (12) and spacing between right lateral and central incisor. On examination, the right lateral incisor showed grade II mobility, with probing depth of 7.0 mm. After thorough oral prophylaxis, flap surgery was done, resulting in gingival shrinkage and exposed roots. Postoperative checkup after three months showed that the disease was under control, with good oral hygiene maintenance, but the patient was still concerned about the spacing and mobility. As the prognosis for further periodontal treatment was poor, the patient was advised to go for extraction of the tooth and replacement with a removable or fixed prosthesis. Since the patient was not interested in extraction and wanted to retain the tooth, she was referred to the Department of Conservative Dentistry for further esthetic management [The topography of the soft tissue defect was evaluated.The color of the soft tissue was determined, to achieve the acceptable esthetics with tissue colored porcelain tints.Shade and contour of gingiva and teeth were confirmed by curing the composite resin material over the lost tissue portion, without application of etchant and bonding agent.Treatment was also planned to close the diastema and restore the exposed root surface using composite resin.The teeth were isolated, acid etched with 35% phosphoric acid  for 15 seconds and blot dried. Bonding agent  was applied and light cured, according to the manufacturer's instructions. Incremental composite resin  build up was done for the coronal tooth structure, to close the diastema. Ceramic tint powder  was taken in a well, to match the shade of the gingiva. One to two drops of dentin bonding agent was added to dissolve the ceramic tint in it. Composite resin material of selected shade was added to the mixture, till a thick paste consistency was achieved. The gingiva was built up to the proper contour, without any overhang of material. The material was then light cured. Finishing polishing was done using composite finishing and polishing system . A fiber composite splint was placed for two months, from canine to canine, for stabilizing the teeth to reduce the mobility [A 25-year-old female patient presented to Department of Conservative Dentistry and Endodontics, with a complaint of gap between her front teeth. The patient expressed her concern about her unesthetic appearance, because of the space between the central incisors. On examination of 11 and 21, the following were noted [Diastema of about 3.0 mm incisally and 4.0 mm gingivally.Gingival recession and root exposure on the labial surface of both 11 and 21.Abrasion of the labial surface of 11 and 21.On periodontal examination, there was no bleeding on probing and absence of periodontal pockets.Treatment was planned to close the diastema and to restore the soft tissue defect. Teeth and soft tissue defects were treated in a similar fashion, as described in Case 1. The ceramic tints chosen were Number 704 and 708, Vita GmbH and Co.KG Germany, in this case. Composite resin was blended with the root surfaces and care was taken not to impinge the soft tissue [A female patient, 24 years of age, had come to the Department of Conservative dentistry and Endodontics, with a primary complaint of spacing between her upper anterior teeth. Past dental history suggested aggressive periodontitis, for which flap surgery was performed in the Department of Periodontics six months back. The patient had been recalled after one, three and six months for review. After healing, gingival shrinkage and root exposure was noticed. The lower anterior teeth were splinted with composite fiber splint, as they were mobile. Once the disease was seen to be under control and the prognosis found to be satisfactory, the patient was referred for esthetic rehabilitation.Dental examination revealed diastema between her upper anterior teeth.Triangular space of approximately 2 mm was seen between 11 and 21Diastema of 2 mm was seen between 11 and 12Diastema of 1 mm was seen between 21 and 22The spacing was created due to pathological migration and papillary recession.Gingival recession was present.Recession of 1.5 mm from the cemento-dentinal junction on the labial aspect of 12Recession of 2.5 mm from the cemento-dentinal junction on the labial aspect of 11Recession of 1.0 mm from the cemento-dentinal junction on the labial aspect of 21The upper central incisors were slightly extruded because of the previous periodontal problem. No significant mobility was seen in the upper anterior teeth. The gingiva was healthy, with no bleeding and periodontal pockets on probing [The treatment plan consisted of creating acceptable esthetics by recontouring the incisal edges, closing the diastema using composite resin and reproducing the receded gingival architecture using pink composite resin. The resin was prepared by adding the ceramic tint powder , to match the shade of gingiva, to one to two drops of dentin bonding agent and mixing it with the composite resin material [An eighteen-year-old female patient came to the Department of Conservative Dentistry with a primary complaint of long front teeth. The patient had a history of undergoing flap surgery of her gums four months back. On examination, there was presence of gingival recession, along with pathological migration  of anterior teeth, leading to compromise in the esthetic appeal of the patient [Some of the young patients who have successfully completed treatment for aggressive periodontitis may have implications in terms of long term restorative maintenance. Restorations need to be carefully reviewed, maintained and replaced throughout the patient's life and the lifespan of some restorative options need to be carefully evaluated.There are various treatment options to meet these challenges. These include:Treatment with restorative camouflageTreatment with extraction and immediate fixed replacementTreatment with fixed appliance orthodonticsTreatment with gingival prosthesisTreatment with ceramic crownsTreatment with gingival resin from Ivoclar, Tragis to restore the gingivaThe innovative technique used here is a quicker (single sitting) and simpler one. No elaborate laboratory procedures are involved. The porcelain stains used in this technique, to get the shade of gingiva, readily dissolved in the dentin bonding agent, which shows that they must be chemically compatible with each other. The stains must have acted like mega fillers in the composite resin. They merged very well and this could be estimated by the high polishability of the restoration.The advantages of this technique are as follows:There is no composite resin impingement on to the soft tissue.Composite resin blends well with the root surface.Floss can be easily moved on and off the contact to maintain the oral hygieneThe ceramic tints which are used in this technique help to get the exact shade of lost gingival tissue, that may be difficult to achieve with composite stains.Though Ivoclar, Tragis resin material is available, the exact shade of gingiva may be achieved with this technique, at less cost.Fiber composite splint was used in Case 1, to reduce the mobility of the tooth. Since we closed the diastema in this case, we could apply the composite splints on the palatal surface, without compromising esthetic needs, thus improving their function.In all the cases, shade selection was done by curing the composite resin material directly on the tooth structure, without acid etching and application of the bonding agent. Once the shade and contour were confirmed, composite material was nicked off the tooth structure. The procedure was repeated till the proper shade and contour were achieved, without harming the tooth structure. Acid etchant and dentin bonding agent were applied prior to building up the tooth structure with composite resin, only for the final restoration. Further studies have to be done to find out the chemistry of the mixture (bonding agent with ceramic tints) and long term evaluation of the cases, to check the outcome of the treatment.For patients with periodontally compromised teeth, not willing for extraction, this technique is an option which is quicker, simple, more economical and facilitating conservation of the remaining natural tissues. Thorough clinical examination should be carried out and the patient should be fully involved in the decision making, during the treatment planning.


Despite the growing interest by leaders, policy makers, and others, the terminology of health information technology as well as biomedical and health informatics is poorly understood and not even agreed upon by academics and professionals in the field.The paper, presented as a Debate to encourage further discussion and disagreement, provides definitions of the major terminology used in biomedical and health informatics and health information technology. For informatics, it focuses on the words that modify the term as well as individuals who practice the discipline. Other categories of related terms are covered as well, from the associated disciplines of computer science, information technolog and health information management to the major application categories of applications used. The discussion closes with a classification of individuals who work in the largest segment of the field, namely clinical informatics.The goal of presenting in Debate format is to provide a starting point for discussion to reach a documented consensus on the definition and use of these terms. We're still using paper. Nurses can't read the prescriptions that doctors have written out. Why wouldn't we want to put that on an electronic medical record that will reduce error rates, reduce our long-term costs of health care, and create jobs right now?"- US President Barack Obama, February 9, 2009American Recovery and Reinvestment Act (ARRA) of 2009, the federal economic stimulus package signed into law by President Barack Obama on February 17, 2009. The promise of HIT for improving quality and safety of health care while reducing costs has caught the eye of policy makers and other leaders in health care. I had the opportunity to be involved in commenting on some of the draft versions of the legislation, and it became apparent during this process that most people outside HIT do not understand our terminology. As such, this led to confusion that could have had dire consequences for language written into such prominent law, such as its funding of workforce initiatives not making the important distinction between informatics and information technology (IT). To that end, I submit this paper in this journal's Debate format, which will lay out my own definitions of the terms and provide a framework for others to embellish and/or disagree in follow-up writings. My goal is for our field to achieve clarity on what these terms mean to us and what we want to convey to others in using them.Health information technology (HIT) has achieved a new prominence in the United States (US) with its inclusion in the health information technology , I will define that term first. It is the term used to describe the application of computers and technology in health care settings. Sometimes the term information and communications technology (ICT) is used when the use of HIT has a strong networking or communications component.Since the ARRA legislation focused on informatics. This word has been around for several decades and its usage is not limited to biomedical and health disciplines. But certainly in the US, the most prominent usage of the word comes from the biomedical and health disciplines. My definition of informatics is the discipline focused on the acquisition, storage, and use of information in a specific setting or domain. To me, what distinguishes informatics from information science and computer science is its rooting in a domain. I also assert that informatics is more about information than technology, with the latter being a tool, albeit an important one, to make best use of information. The former School of Informatics at the State University of New York Buffalo defined informatics as the Venn diagram showing the intersection of people, information, and technology. Friedman has defined his "fundamental theorem" of informatics, which states that informatics is more about using technology to help people do cognitive tasks better than about building systems to mimic or replace human expertise ..biomedicCollen presented a history of its early usage in medicine, from its origination in Europe as somewhat synonymous to computer science to its more recent usage to imply computer science or IT applied to a specific domain . An earlMedical informatics generally refers to informatics applied in health care settings. Sometimes clinical informatics is used to describe this application as well. Other uses of informatics in biomedical and health-related areas include , dentistry , pathology (pathology informatics), etc.• The application of informatics focused on specific health care disciplines, such as nursing  to bedside and into widespread clinical practice [• research . This inpractice .Public health informatics – the application of informatics in areas of public health, including surveillance, reporting, and health promotion.• Health information management (HIM) is the discipline that has historically focused on the management of medical records. As the medical record has become electronic, this field has been in transition and increasingly overlaps with informatics. One major difference between HIM and informatics is the educational path of practitioners. HIM professionals have historically been educated at the associate or baccalaureate level whereas informaticians often come from clinical backgrounds, including those with doctoral degrees, such as M.D., Pharm. D., etc.computer science, which is often housed academically in engineering schools. However, IT professionals come from other backgrounds, including fields such as management information systems (MIS), whose programs are usually in business schools. Within IT and computer science are a heterogeneous array of people with varying skills, including developers, programmers, engineers, architects, and support personnel. Although focused on clinical research informatics, a forthcoming paper describes BMHI in the context of the Clinical and Translational Science Award (CTSA) program of the US National Institutes of Health (NIH), demonstrating how informatics is distinctly different from IT academically and operationally in the clinical and translational research setting [IT is the term generally used to describe computers and related technologies in operational settings. The academic discipline that underlies IT is  setting .electronic medical record (EMR) was most commonly used. However, this has mostly been supplanted by the term electronic health record (EHR), which implies a broader and more longitudinal collection of information about the patient. There is increasing interest in the personal health record (PHR), which usually refers to the patient-controlled aspect of the health record, which may or may not be tethered to one or more EHRs from health care delivery organizations. An integrated PHR is one in which the patient can interact with his or her own clinician securely to gain access to the working record of the clinician and hence become a integrated member of the care team by suggesting revisions to historical data and monitoring progress in concert with the clinician [Another source of diverse terminology concerns the health record of the individual. When these records were first computerized, the term linician .health information exchange (HIE), which is the exchange of health information for patient care across traditional business boundaries in health care. Even many health care organizations that have exemplary HIT systems have difficulty providing their patient information to other entities where the patient may receive care. An increasingly mobile population also needs to have "data following the patient." HIE is actually but one example of what is sometimes called secondary use or re-use of clinical data, where data from clinical settings is used for other applications, such as quality assurance, clinical research, and public health [There is also growing interest in c health . An impoc health .Regional Health Information Organization (RHIO), whose scope and size may vary widely. Another organization named in ARRA, which we will likely see help implement its EHR adoption goals, is the Regional Health Information Technology Extension Center, examples of which were recently described [HIE is generally administered by a escribed  and whosescribed .telemedicine, which refers to the delivery of health care when the participants are separate by time or distance, and telehealth, which has more of a focus on direct interaction with health on ICT. As with informatics, the "tele-" terms sometimes reflect medical specialties in which they are applied, e.g., teleradiology and telepathology. A somewhat related term is eHealth. An entire systematic review has been carried out around definitions of eHealth, which identified two broad themes  and six narrower ones  [Another broad setting of terms are the "tele-" terms. The two most widely used terms are ectives) .evidence-based medicine (EBM) is a part of BMHI, I and others [evidence-based practice (EBP), which advocates that health care decisions be made using the best available scientific evidence by those who receive care, informed by the knowledge of those who provide care, and within the context of available resources for that care [clinical epidemiology [comparative effectiveness research, which the legislation defines as "research to evaluate and compare clinical outcomes, effectiveness, risk, and benefits of two or more medical treatments and services that address a particular medical condition." The Academy Health Methods Council defines CER as "research studies that compare one or more diagnostic or treatment options to evaluate effectiveness, safety or outcomes" [Although not everyone would agree that d others  argue thd others . Some ushat care . EBM andemiology . A new tutcomes" .Another goal of ARRA (Section 3016) is to facilitate the adoption of HIT through the development of the HIT workforce, particularly in clinical settings, the most populous location of those who work in HIT. There are three broad categories of this workforce:1. IT professionals – those who install, maintain, and optimize the hardware and software. Recent research indicates that as health care organizations implement advanced HIT, up to 40,000 new jobs will be created [ created .2. HIM professionals – those who bring their knowledge and skills to bear on increasingly electronic medical records, especially in areas of documentation, coding, and legal and compliance issues. According to Bureau of Labor Statistics data, there are currently over 170,000 HIM professionals in the field, with need expected to grow to over 200,000 by 2016 [ by 2016 .3. Clinical informaticians – those who bring expertise at the intersection of health care and IT to assure successful adoption and use of HIT and the information within it. These individuals also optimize the use of information though leadership of clinical staff, organizing and structuring information for its direct and secondary use, and serving as a bridge between IT and clinical personnel. The number of informaticians needed is not known, but each of America's 6000 hospitals and a larger number of other health care settings will require their expertise to make the best clinical use of HIT, leading to estimates of 10,000 [f 10,000  to 13,00f 10,000  needed.Individuals from these categories will not only be needed in hospital and clinic settings, but also in a variety of other settings, such as for vendors who build and install HIT systems, public health agencies at the state and local levels, and health-promotion organizations. Clearly more research is needed to better understand the HIT workforce and its optimal organization and training.academic and those who are variably described as professional, applied, or operational [One of the challenge for informaticians is that they do not yet have a distinct professional identity. The heterogeneous nature of the field and those who work in it make such an identity difficult. I define the competencies of BMHI as emanating from three broad categories Figure . The intrational . These dThe ARRA legislation gives us a "stimulus" to better define the terminology related to BMHI and HIT. I am sure that not everyone will agree with how have I defined all the terms, which is why I have categorized this as a Debate paper, so others can weigh in and hopefully leave a documented paper trail to achieve consensus where possible. Let the debate begin!Defined in text.The author declares that they have no competing interests.The single author of the paper is solely responsible for it.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6947/9/24/prepub


The introduction and wide acceptance of digital technology in medical imaging has resulted in an exponential increase in the amount of data produced by the radiology department. There is an insatiable need for storage space to archive this ever-growing volume of image data. Healthcare facilities should plan the type and size of the storage media that they needed, based not just on the volume of data but also on considerations such as the speed and ease of access, redundancy, security, costs, as well as the longevity of the archival technology. This article reviews the various digital storage media and compares their merits and demerits. Since the pioneering days of radiology, film-based radiography has been the principal mode of capturing, viewing, and storing radiological information. Though the radiographic film continues to be the most commonly used medium for storing imaging information, it has the disadvantages of being expensive; difficult to duplicate; and cumbersome to transport, store, and retrieve. There is also the possibility of data loss due to physical deterioration of the film over time.Over the last 25 years, imaging techniques such as CT scan and MRI, which are based on digital technology, have been introduced and have found widespread application in medical imaging. These studies allow physicians to examine the body in minute detail and enable rapid and accurate diagnosis of disease states. In contrast to conventional radiography, these techniques usually produce hundreds or even thousands of images per study. As the benefits of digital images have become apparent, imaging modalities that have traditionally been analog based have also begun evolving into digital systems. Computed radiography, digital fluoroscopy, digital mammography, and USG are examples of modalities that have benefited from the introduction of digitization into the imaging chain.These changes in radiology workflow in the recent years have resulted in a virtual explosion in the amount of image data produced by radiology departments . Though In addition to images from the radiology department, large quantities of data from the cardiology department or other imaging data such as clinical photographs and microscopic and endoscopic photographs also find their way into the image database. Thus, as hospitals move towards a filmless, paperless environment, there will be a never-ending demand for digital storage space.The introduction of picture archiving and communications systems (PACS) for archival, migration, and display of digital images has resulted in increased productivity by expediting image-based workflow. The data storage system is the heart of the PACS system and, most often, its costliest component. A reliabStorage can be classified as online, nearline, and offline. Online storage refers to data storage on magnetic discs and redundant array of inexpensive discs (RAID) systems. It provides access to the data in a few milliseconds. As this type of storage is expensive, images that do not require immediate access are stored in nearline storage. Devices such as magnetic tapes and optical jukeboxes are used for this form of storage. Offline storage media include magnetic tapes and optical discs that are stored elsewhere. This type of storage is typically used for long-term storage and for storing back-up data.The magnetic disc (hard disc drive) offers the fastest way to store and access large amounts of data. The data is physically stored by inducing magnetic moments on a ferromagnetic disc as it is spinning. The read–write head detects and modifies the data on the disc platter. The speed of rotation of the disc and the density of information on the disc head determine the physical performance of the disc.Redundant array of inexpensive discs (RAID) is a series of hard discs plugged together using shared logic to act like a single large disc. It aims to achieve a large data storage capacity with better input/output functionality, while minimizing cost and maximizing reliability by using redundancy of information. Data is subdivided into multiple consecutive segments that are distributed over several physical discs by a fast controller card. The data can be mapped using various patterns so as to achieve various levels of speed, capacity, and protection against data loss. RAID configurations that are commonly employed include RAID level 0, RAID level 1, and RAID level 5.RAID level 0 involves the spread of information onto all hard discs, without any redundancy. This architecture improves speed and makes use of the maximum capacity of the discs; however, a single disc failure may result in the loss of all data on the RAID.RAID level 1 creates an exact copy of the data on multiple discs. As all data is duplicated, the array continues to function as long as at least one disc is functioning. Though this architecture has the best reliability, the storage capacity of the array is limited to the size of one single disc within the array.RAID level 5 is an efficient balance of performance and reliability. It involves storage of ‘parity’ information on each disc that permits reconstruction of lost data. The information needed for reconstruction occupies less space than simple mirror imaging of the data. As the parity data occupies the size of one disc in the array, the total storage capacity of the array is reduced by one disc.Current PACS technology largely relies on RAID to provide large storage spaces and fast access times.Optical discs have been the medium of choice for archiving data for many years. A numberMagnetic tape provides the cheapest option for storing large amounts of data. It has higher readout speeds than optical and magneto-optical media. However, since data is read from the tape using sequential access (while data readout from magnetic discs is by random access), identification of individual scans and patients is typically much very slow. Of late, magnetic tapes are being used only as media for providing offline backup of data.The characteristics of these different storage media are compared in Traditional PACS archives have been based on a three-tier architecture, with fast, low-capacity storage for online storage; moderately fast, large-capacity storage for nearline storage; and a slower system with very large capacity for offline storage and backup. These systems had to rely on disproportionately large nearline storage, as magnetic discs had the highest cost per storage unit. Decreasing costs of magnetic disk storage have made the use of RAIDs increasingly popular. Most current storage systems employ a two-tier architecture: server-based storage to meet short-term needs for 6 months to 2 years and long-term archives for storage for longer periods and backup functions. A software application described as hierarchical storage management (HSM) automatically manages the migration of data between the online database and long-term storage.[Before planning a data archival system an in-depth analysis of the workflow of different imaging modalities in the department and the average amount of data produced per study needs to be performed. With continuing advances in imaging technology, the number of radiological investigations as well as the amount of data generated per imaging study are constantly on the rise. Provisions must be made for newer, more advanced, imaging equipment that may be added to the department in the future. With a lot more ‘-logies’ such as cardiology, gastroenterology, ophthalmology, and pathology adding to the image data that needs archiving, the storage requirements of these departments also needs to be considered during planning.The duration for which medical records and imaging data must be stored is dictated by hospital policies and local legal requirements. In general, 90% of all accessed data is less than a year old. Thus, it is wise to invest in at least a year's worth of online storage along with the PACS. Considering that the prices of magnetic disc-based storage will continue to fall, it may be prudent to keep adding additional storage space as the need arises. Longevity of the archiving technology should also be kept in mind. All storage devices are prone to failure over the long term. Current technology may become obsolete 5 years from now and it may be impossible to recover the archived data if the vendor no longer supports the equipment. Migration of data from one storage medium to another, with consequent PACS downtime, may be required when the next-generation archival media are implemented.As PACS technology continues to evolve, newer architectures and storage media are being experimented with, in the attempt to provide faster and more efficient and cost-effective archival systems. Most current storage media are connected directly to the PACS server (direct attached storage). This architecture imposes restrictions on the number of drives that can be attached to the server and thus limits the scalability of the archive. Newer architectures such as network attached storage (NAS) and storage area network (SAN) offer advantages in the form of upgradeability, connectivity, and security. Similarly, newer technologies such as Blu-ray disc technology and holographic data storage  are finding their way into the PACS environment. The latt


Health education practices are central to preventing heart disease. The great challenge remains how to promote the adoption of healthy behaviors that can reduce risk factors for heart disease. In São Paulo, Brazil, the Healthy Lifestyle Multiplier Students program is based on studies that train older students ("multipliers") as peer educators for younger students. These students influence each others' cultural development and psychosocial growth, encourage one another to diversify their social relationships, and transform teaching-learning experiences. This intervention focused on physical activity, healthy diet, and the health effects of cigarette and alcohol consumption. Lifestyle-associated health risks still greatly challenge health educators in Brazil. Although health education is a curricular requirement, information alone is not enough to modify habits, and Brazilian schools have lacked a creative approach to behavioral change.Our approach takes into account students' knowledge, health behaviors, and attitudes; in other words, we consider what the students know about health, what they should know about cardiovascular disease (CVD) prevention, what they should do to promote health, and how they should incorporate this understanding into their lives. Before the pedagogical intervention, we used questionnaires and written reports to identify the students' ideas and values related to the topics to evaluate their potential for learning and teaching. During training, the students developed teaching skills (based on the same content used for training teachers) for the interaction with their peers. We describe the experience of 80 students who worked with more than 1060 classmates from 4 public elementary schools in São Paulo, Brazil. We then discuss the methods we used to develop health education materials for schools so that other health professionals and interested laypeople can develop similar peer education programs , motor actions, and social relationships. We based the design of the course on the work of Paulo Freire . The pedhorizontal dialogue indicates Freire's rejection of hierarchic models of communication  in favor of a participatory process between equals. The communication process must respect the knowledge and culture of each social group involved. True dialogue, he suggests, is essential to social change and the transformation of individuals into agents of change.The multiplier students' peer activities are based on these principles and are conducted through horizontal dialogue, using appropriate language, approaches, and forms of communication. The concept of dialogue in education is central to Freire' s work. The term In this program, multiplier students are the agents of change. Sharing information about health benefits and risks associated with lifestyle is effective because of the influence that adolescents exert on their peers' attitudes and behaviors. The same influence or pressure of a group of friends that leads to the adoption of risk behaviors, such as smoking, can be directed to supporting resistance to peer pressure.We trained the teachers with the collaboration of graduate and postgraduate students from the cardiology department of São Paulo University Medical School. The training consisted of 4-hour modules every 2 months for 2 years, using expositive classes, lectures , and the younger students finished seventh grade.The interaction among multiplier students and their peers occurred at 1-hour weekly meetings during the intervention period. The study sample was representative of the lower middle-class population of urban São Paulo, having an ethnic background that is 57% white, 26% mulatto, 11% black, and 6% other. The population was 58% male.The learning content was arranged through concepts, skills, and attitudes — in other words, according to what the students know, should know, should know how to do, and should be . Before The goal of supervising the multiplier students was to enable them to support the dialogue with their peers on health and prevention of CVD, reflect on healthy lifestyles, teach them strategies that facilitate risk communication, strengthen their self-confidence so that they can resist peer pressure and marketing appeals, and develop leadership skills to support peers who choose healthy lifestyles.The multiplier students were trained using the following steps:The multiplier students were asked what they knew about the risks associated with inadequate physical activity, unhealthy diet, smoking, and alcohol consumption.Using the answers, the teachers compiled educational material that led smaller multiplier student groups to work through each of the themes.After working with the educational material, small groups of multiplier students planned interactions and activities to transmit the concepts to their peers, acquiring new and correcting erroneous concepts.The teachers encouraged the students to develop teaching methods  for working with the peer groups.The multiplier students constructed the pedagogical dynamics and presented them to the teachers, who then evaluated the content. Teachers corrected or commented on content only, preserving the proposed teaching methods.The teachers scheduled the activities of the multiplier students with their peers.The multiplier students led the activities with their peers.The groups were located in 4 similar public schools. The cultural differences among the adolescents in each group were worked out without treating a particular culture as dominant or normative. For instance, the multiplier students compiled their mothers' recipes into a cookbook to make the point that a healthy diet can be created from the foods of any cultural tradition. The book included recipes from African, American, Arabian, Italian, Japanese, and other cultures.Play (games and role-play) is essential to adolescent learning , and theDuring the training, the physical education teacher showed the multiplier group how to measure heart rate; this activity taught the group that the heartbeats of physically active people change more slowly than do those of inactive people. The group decided to demonstrate the heartbeat exercise by organizing a list of physical activities and inviting peers to participate .The multiplier students used illustration boards to show the younger students how to perform the activities. Their goal was to demonstrate that physical activity could be fun and make people feel good; students participated in running and ball-tossing, a 15-minute soccer game, other ball games, hula hoop, jumping jacks, and skipping rope, among other aerobic activities, to establish the association between pleasure and physical activities. After these activities, multiplier students led a classroom discussion about the activities.To control the content of the intervention, teachers observed the activities and evaluated them with the multiplier students. In evaluating the physical activity demonstration, the teachers noted the students' enthusiasm in associating enjoyable play with the benefits of physical activity.For the healthy diet theme, multiplier students chose a food demonstration in 4 phases. During the first phase, they talked about the benefits of a healthy diet. They displayed handmade posters throughout the school, calling attention to the colors of different foods and the importance of eating a variety of foods. In the second phase, they made posters with peers, using collage material from magazines, newspapers, and supermarket flyers, focusing on healthy and less healthy foods and daily activities. During this activity they talked with peers about lifestyles and habits. In the third phase, they provided foods for peers to taste as part of a hopscotch game with questions and answers . The gamThe peers made faces depending on the offered food, which entertained the students, and the participation achieved the intended goal of the content through simple and meaningful language. Teachers not engaged in the project reported that peers in the classroom talked about the taste of certain foods.Another resource the students used was an open-air market , which aTheater and music were important ways the multiplier students communicated information about smoking. Theater was the first form of communication the students used. This form allows the understanding that the meaningful and figurative aspects can only be taken together, a way of communication in which the healthy and unhealthy habits can talk with each other through music and dialogues between friends, cousins, and siblings. In the didactic activity, the following dialogue was used in the theatre:Hey, Joe, dude, did you see John's uncle went to the hospital? He couldn't breathe any more, the aunt said he had a heart attack. Dude, he smoked so much it was impossible to breathe near him!Yeah . . . and they say that when it is like that, we are passive smokers.For real, man?Yeah, there is a dude at school who said that cigarettes have more than 4000 toxic substances and that they spread in the smoke that enters the lungs and that burns at the tip of the cigarette, and if you are near it and breathe this smoke, we smoke too. And he's a great pal.Really, dude, seriously?This process aims to promote the cultural development and personal growth of the players through mastery and interactive use of theatrical language. The communication arises from the creativity and spontaneity of the interaction between individuals engaged in the dramatic solution of a health risk problem .The theatrical activities comprised dialogues, poems, and songs. The songs, with lyrics adapted from familiar melodies, gave students the opportunity to use humor to present the concept of the healthy habit. The amount of interaction and level of student response indicated that live theater is an effective means of stimulating both thought and discussion pertaining to the effects of risk behavior .During these activities, students sang "The Cigarette" to the melody of "Stupid Cupid" by Paul Anka, a song that became a hit in Brazil:"Oh, Oh, cigarette, please leave me alone.My heart can't take it anymoreI smoked till a while agoHey, hey, that's the endOh, cigarette, go far from me."Vygotsky says that the process of concept formation is rooted in the use of words because they acquire different meanings in each of the phases of human mental development and activity. Thus, by singing with their peers, students move through different stages of learning about the themes .Multiplier students chose a puppet theater  to teachAlcohol consumption was the most difficult topic for the students, many of whom have experienced, in their family or community, embarrassing situations caused by alcohol consumption. The use of the puppet theater allowed the students to develop a dialogue with the peers without embarrassment and, based on many individual reports, the audience participation attracted the attention of the entire school. The content of the puppet theater went beyond cardiovascular risks, including car accidents and fights caused by alcohol consumption.The multiplier students developed games for each of the 4 themes to encourage discussion among the peers. Four players competed by throwing dice to determine the number of spaces to advance on a board. Each space had a number corresponding to a card, on which was written a question about the theme. The questions covered all 4 themes . Players might be asked the following questions: Why is physical activity good for the heart? What do fats do to the heart? What does it mean to have foods of 5 different colors at one meal? Why does the health department warn against cigarette smoking? Do you know what the healthy habits for the heart are?Players who answered correctly advanced; players who answered incorrectly were penalized by backtracking 1 space. When a peer gave the wrong answer, the multiplier student asked whether anyone knew the right answer, and the one who did received a small reward. The multiplier students had decided on rewards such as apples and bookmarks (made by the students) with phrases that encouraged healthy habits. Key chains were offered to those who were penalized, so they would not forget the importance of treating the heart well .Multiplier students succeeded because they did not allow the teaching to interfere with the design of the game. For example, the game penalized players for incorrect answers as part of the fun of the game. Even when teachers admit that playing is learning, they tend to set limits on the untamable, spontaneous expression of the students  and to gThe multiplier students felt comfortable explaining each answer and even used some technical terms, showing their familiarity with the subject. Furthermore, they were not embarrassed to say, "I don't know the answer." When players asked the multiplier students a question designed to confuse them, they requested assistance from one of the teachers (during the activity) or the research team (during the training).During the playing of board games, we noticed that the students used our terminology in the questions. The games were as successful as the theatrical, musical, and food experimentation activities , but becWe succeeded in our intention to allow the multiplier students to determine how to transmit the concepts. We tried to avoid a "don't do it" message because many adolescents and their family members smoke or drink alcohol, and such a message would push them further from the dialogue. Furthermore, we did not want to repeat the messages of other people, the media, and laws. We avoided the concepts of "right" and "wrong," and instead used the word "healthier." The techniques used should encourage students to reflect on their own choices regarding physical activity, diet, smoking, and alcohol consumption. The students did not repeat the conventional warnings such as "don't do it,"  "don't eat it," "stop doing it for your own good," and "it is bad for your health," which was one of our goals. It was satisfying to the technical team and the teachers, who, during the training sessions of the multiplier students, many times had to counter media portrayals and common beliefs about health risk behaviors . When designing the educational activities used in this project, we looked mainly at activities that would empower students and their peers .Multiplier students at one school requested space for a Multiplier Students Corner at the science fair, so the whole school could be made aware of the program. They set up posters, which they and their peers had made, describing the program themes and the history of the program. This space promoted reflection on the themes by the school community and school visitors.The Healthy Lifestyle Multiplier Students program prompted the community to discuss themes that were absent from the school's formal curriculum. The proposed health education process was creative and motivational and encouraged the adolescents to learn about health while improving the quality of public education.We recommend that those who are interested in creating such programs gather the students, show them the content, allow them to determine the process, and follow the development of the process among peers. We encourage others to foster adolescents' capacity for leading the teaching-learning process. Edit 1 Supporting Video 1Part 1 Supporting Video 2Part 2 Supporting Video 3Part 3 Supporting Video 4Part 4 Supporting Video 5Part 5


Because lymphatic filariasis (LF) elimination efforts are hampered by a dearth of economic information about the cost of mass drug administration (MDA) programs , a multicenter study was undertaken to determine the costs of MDA programs to interrupt transmission of infection with LF. Such results are particularly important because LF programs have the necessary diagnostic and treatment tools to eliminate the disease as a public health problem globally, and already by 2006, the Global Programme to Eliminate LF had initiated treatment programs covering over 400 million of the 1.3 billion people at risk.To obtain annual costs to carry out the MDA strategy, researchers from seven countries developed and followed a common cost analysis protocol designed to estimate 1) the total annual cost of the LF program, 2) the average cost per person treated, and 3) the relative contributions of the endemic countries and the external partners. Costs per person treated ranged from $0.06 to $2.23. Principal reasons for the variation were 1) the age (newness) of the MDA program, 2) the use of volunteers, and 3) the size of the population treated. Substantial contributions by governments were documented – generally 60%–90% of program operation costs, excluding costs of donated medications.MDA for LF elimination is comparatively inexpensive in relation to most other public health programs. Governments and communities make the predominant financial contributions to actual MDA implementation, not counting the cost of the drugs themselves. The results highlight the impact of the use of volunteers on program costs and provide specific cost data for 7 different countries that can be used as a basis both for modifying current programs and for developing new ones. Lymphatic filariasis (LF), commonly known as elephantiasis, is a profoundly disfiguring parasitic disease caused by thread-like nematode worms. This disease can often be disabling, thus reducing the potential productivity of the affected individuals. The WHO places the number of people at risk in 83 countries at 1.307 billion. This study was undertaken in seven countries—Burkina Faso, Ghana, Egypt, Tanzania, the Philippines, the Dominican Republic, and Haiti—using a common protocol to determine the costs of mass drug administration (MDA) programs to interrupt transmission of infection with LF, because there is lack of sufficient information about the costs of these programs. The results demonstrate that LF MDA is affordable and relatively inexpensive when compared to other public health programs. In the context of initiatives for integrating programs for the control and elimination of neglected tropical diseases, this study adds specifically to the relatively scarce body of information about the costs of MDA programs for LF. It also adds to the general knowledge about the application of methods that can be used to estimate the costs and cost-effectiveness of an integrated approach. Lymphatic filariasis (LF), commonly known as elephantiasis, is a profoundly disfiguring parasitic disease caused by thread-like nematode worms. The World Health Organization (WHO) places the number of people at risk in 83 countries at 1.307 billion.The 1997 World Health Assembly resolved to eliminate LF as a public health problem after LF had been identified as one of only a small number of diseases classified as potentially eradicable. Demonstrating that LF elimination is a cost-effective and affordable investment is essential for both Ministries of Health and potential donors as they choose among competing health needs. While several cost-effectiveness analyses have been conducted and one estimate for MDA in high prevalence areas gives a range of $4–8 per disability adjusted life year (DALY) averted, Cost analyses aggregated in this report are based on studies in Burkina Faso, the Dominican Republic, Egypt, Ghana, Haiti, the Philippines, and Tanzania. Detailed analyses from two of these countries have already been published elsewhere.Data collection and analysis were carried out by research teams in each of the participating countries. The cost analysis teams in Burkina Faso, Tanzania, and Ghana were part of the Ministry of Health. In Egypt the study was a joint effort between the Ministry of Health and Population and the Ain Shams University Research and Training Center on Vectors of Diseases. The Philippines' research team was based at the National Institutes of Health-Philippines. The Dominican Republic researchers at the Centro de Gerencia Social, Instituto Tecnologico de Santo Domingo worked with the Ministry of Health LF program. External consultants in Haiti worked with Ministry of Health LF program staff to collect and analyze cost study data.http://www.taskforce.org/lfsc/professionals.html) which served as the tool to identify, organize, analyze, summarize and present the cost data. The protocol and accompanying data collection instrument created a systematic process for data collection and analysis so that the cost estimates would be comparable across a variety of country settings, programmatic approaches and program sizes.Researchers from the participating countries collaborated with the Emory University LF Support Center in the development of a protocol  and financial costs . Economic costs are useful to evaluate the allocation of program resources and their opportunity costs, e.g., whether these resources could be used more productively elsewhere. Financial costs are helpful to program managers to measure actual program expenditures and assess affordability.The cost analysis identified both The protocol adopted a national program perspective because most resources dedicated to the LF MDAs were channeled through Ministry of Health (MOH) programs. Participants agreed to gather MDA costs, beginning with the year 2000, the first year of the LF global elimination effort. Costs were calculated in local currencies and converted to US dollars for the final analysis, based on average exchange values for the years being analyzed (base year 2002).Most of the countries were still in the early stages of expanding their MDAs when the cost analysis studies began. The exception was Egypt where the MDA targeted almost 90% of the population at risk the first year and 100% the second year studied.Project inputs defined in the protocol were: personnel, supplies and drugs (medications for the MDA and for treatment of adverse reactions), as well as capital and recurrent costs for equipment, transportation, and facilities. Each input was allocated to one or more categories of activities involved in accomplishing the MDA: training, mapping, mobilization and education, drug distribution, adverse reaction monitoring, surveillance/laboratory, and administration . CapitalStudy sites were chosen purposively to be representative of the LF- endemic regions in the countries . NationaTanzanian investigators studied four districts located on the eastern coast, Kilwa, Mafia, Mkuranga and Masasi for the years 2000–2003. Data collection for the first three years was retrospective.Data collected retrospectively in Burkina Faso documented the first two years of the MDA in the region of Gaoua in the first year and expansion into Tenkodogo in the second year.The Philippines team chose to study seven municipalities and one city in the province of Sorsogon. These were selected based on filariasis endemicity using microfilaria rates, accessibility and population size. Half had high microfilaria rates (MF), half were easily accessible, while one quarter had large populations. In each municipality, one sentinel barangay or village was selected based on high MF rates and one to three adjacent barangays were also studied.Cost data collection in Haiti was conducted in Leogane, where the first MDAs took place. Located 30 km west of Port-au-Prince in the south, Leogane is one of the highest risk areas in the country. Except for lower coverage in year-2 (2001) of the MDA program (because of side reactions that occurred after the first MDA) the program expanded not only in Leogane in 2002 but also to Milot, another high risk area just south of Cap Hatien in the north.Researchers in the Dominican Republic collected cost data for the first two MDA campaigns. These were launched in Barahona on the southwest coast of the country.The Ghana study costed three districts from the two epidemiological zones in the country, north and south. The districts were selected to reflect differing levels of program assistance. Builsa in the upper eastern region of the country received government support only, while Lawra in the upper west and Ahanta West on the west coast also received NGO support.The cost analysis in Egypt covered the eight governorates along the Nile affected by LF. Costs were obtained for one district in each governorate and applied to the rest of the affected areas in the governorate based upon information about numbers of persons at risk, participating government personnel and quantities of medication distributed.st week post-partum, the very sick, children under two years of age in countries where DEC plus albendazole is the MDA regimen, and children under 90 cm in height  where albendazole is administered with Mectizan.Data collection was both retrospective and prospective. The number of rounds of MDA costed per country ranged from one to four, with most countries costing two rounds. Countries developed national estimates for the program using data collected from a sampling of sites representative of the program . CoveragThe data were collected from national, regional and district levels of the health care system via pre-tested questionnaires and spreadsheets, sometimes with the assistance of other agencies such as Ministries of Agriculture and Information. As LF is but one of many population-based health programs, most inputs  were often shared by more than one program, and costs were apportioned accordingly. To capture the actual costs and percentage of the resources dedicated to LF, the teams reviewed program records and interviewed LF program administrators and personnel about allocations of personnel and resource time per year. Government tax fees such as customs tax on the drugs and the road tax were excluded.As indicated in Of the several trends that can be seen in Identification of resource allocation by activity and input is a useful and informative outcome of this study.The use of resources for different activities varied among countries, and Analysis of financial costs by input, particularly useful for projecting budgets and for gauging the need for additional program support, again gave results varying appreciatively by country . In all Economic costs, the drug donations can make up over 90% (range 9%–99%) of the costs. This was particularly true in countries like Burkina Faso and Tanzania where both drugs used in the MDA  were donated. When Financial costs are analyzed, however, it is clear that contributions from national governments represent a significant portion of the resources used to implement the MDAs . These relationships can be seen graphically in These cost analyses not only identified how program resources were allocated, but data also were used to identify sources and amounts of funding for 5 of the 7 study countries. Funding was categorized as coming from national governments , international organizations , pharmaceutical companies and local communities . As expeSensitivity analyses were conducted on the personnel input (data not shown) to gauge how much an increase in personnel costs would impact overall costs. Personnel was selected for sensitivity analysis because, with the exception of Egypt, this input represented the largest source of costs in the participating countries. Sensitivity analyses conducted on personnel input for Ghana and Burkina Faso demonstrated that increasing the proportion of personnel time dedicated to the LF MDA did not raise financial costs beyond the currently-calculated ranges, even under conditions where personnel time was doubled (Ghana - US$0.25 and Burkina - US$0.08) or tripled (Ghana - US$0.34 and Burkina - US$0.11). Additionally, a sensitivity analysis of personnel costs in the Philippines showed that personnel costs would remain well within the range of the current Financial costs (US$ 0.69) even if personnel time were doubled.There were three principal study limitations. First, investigators frequently encountered problems in estimating the proportion of time and money allocated specifically to the LF MDA programs. Staff had not previously tracked time apportioned to LF-specific activities, and since LF programs are small in relation to other MOH initiatives (consuming anywhere from 1% to 5% a year in most countries), recall was problematic at times. Similar situations were encountered with respect to other resources such as transportation, facilities and equipment dedicated to LF. Second, interpretations of the definitions of certain activity categories sometimes differed among researchers applying the cost analysis protocol and data collection instrument. At times questions arose about allocation to one or the other of categories mentioned. Third, while study teams attempted to identify the original source of funds, the original funder may not have been correctly identified in all cases, especially where money was channeled through one or more intermediary sources.Good cost analysis is essential to provide an evidence-based rationale for investing in LF elimination. The key target figure is the cost per person treated. Few results have been available to date, i.e., the number of years it had been running), 2) the use of volunteers, and 3) the size of the population treated.One of the most striking findings of the present studies is the variability in the Financial cost per person treated. Differences in programmatic structure can account for some of these differences because each country tailors the LF elimination strategy for a best fit to local conditions. But beyond the program-specific differences, the principal determinants underlying the variability appeared to be: 1) the newness of the country program  and at times provide their own transportation . However, while there is a strong relationship between the use of volunteers and lower cost per person treated, this does not suggest that any country choosing to use volunteers would see savings of 85%. Country-specific conditions that lead to the use of volunteers may also determine lower costs overall.et al.The use of volunteers leads to the question of how to accurately value the time volunteers ‘donated’ to each program. One traditional approach to valuing volunteer time is to apply the wage from the volunteer's normal paid employment and value their volunteer time accordingly. The problem with this, as pointed out by McFarland In the country programs included in this study, a diverse group of individuals, comprising students, teachers, farm laborers, and elderly retirees, served as volunteers. Owing to this fact and the economic conditions in the participating countries, applying traditional methodologies for costing volunteer time may not be appropriate. After several countries explored volunteer participation in MDAs and the earning capacity of volunteers in their regular pursuits, a decision was made by the investigators in all participating countries not to include these costs. Therefore, while the study included the per diem paid to volunteers during training, it did not account for the opportunity cost of the volunteer's time dedicated to the MDA itself. The evaluation of the community contribution from countries which used volunteers is very definitely underestimated.Program managers can control, to some extent, the use of volunteers and might explore this strategy in resource-constrained environments. Beyond the monetary savings, there is a benefit from connecting the program with volunteers who are opinion leaders from different community sectors. So while initially decisions to utilize volunteers might be financially based, countries ultimately can benefit not only from volunteers' labor but also from their connections to the communities in which they serve. However, program managers must bear in mind the competition for volunteers from other health programs which sometimes pay volunteers more for their efforts. The sensitivity analyses on personnel time devoted to the MDA point to the possibility that it may be worthwhile exploring opportunities to increase remuneration for volunteers. Indeed, both valuing and best utilizing volunteer time merit continued examination.The third principal source of variation in cost per person treated was the size of the population treated, an element that can be controlled by program managers during program expansion. When programs scale-up, the cost per person treated drops, primarily because most of the overhead costs are associated with start-up costs at the national and district levels. Once the system has been established, the majority of the new costs are in the new area (district or governorate) that is being covered. In Burkina Faso and Tanzania the Financial costs per person were halved as the MDA covered larger populations. Between 2001 and 2002 Program costs in Burkina declined 45% while the population treated increased by over 400%. The progression in Tanzania between 2000 and 2003 was similar, with the Financial cost per person treated decreasing by 47% while the treated population increased over 13-fold. Between 2000 and 2001, the number of persons treated in Egypt increased 29%, while the Financial cost per person treated decreased 27%.Such findings emphasize the need to keep current programs adequately funded so that these programs can expand and increase the number of persons treated and thereby capture the savings resulting from the economies of scale.Once the principal determinants of the cost per person treated are identified, they can be used to manage program costs either by making internal changes within a program, such as scaling-up and increasing efficiency, or by taking advantage of existing external resources, as through integration. LF elimination programs can be integrated into the existing health system, as in the Dominican Republic, or with other preventive chemotherapy programs. For the LF elimination program, costs per person treated are within the range of those estimated for other similar disease control and elimination programs; namely soil-transmitted helminths  by national governments , since Egypt has selected small MDA implementation units, i.e. the village level, and hence focused on monitoring potential ‘at-risk’ areas closely in a large number of implementation units.Tanzania's national program chose to invest heavily in social mobilization and education to assist the districts in raising awareness in the general population for current and future MDAs. The districts placed more emphasis on funding drug distribution and personnel training.The principal aim of this study was to provide critical information regarding the cost of implementing MDA for the prevention of lymphatic filariasis. The study demonstrates that the costs of MDA programs for LF elimination are comparable to those estimated for other similar disease control and elimination programs. While some programs had costs per person treated of over a dollar, it was quite straightforward to identify those factors most affecting program costs.Such findings can be used on a national scale for program planning, development and fundraising, and on a global scale for calculating current global costs, predicting scale-up costs and calculating savings from integration with other programs. These results also will form the basis for guiding cost-effectiveness and cost-benefit analyses, as more information on the effectiveness of MDAs in the study countries becomes available. Additionally, the analytic tool used in this study will be valuable for further studies of the LF elimination program including costing of LF disability alleviation activities and the process certifying LF elimination.A further finding of particular importance was documentation of the impact that the use of volunteers has on program costs. Further research on how best to utilize volunteerism for such public health programs could contribute appreciably to ensuring success of the MDA-based programs and to anchoring them in the communities they seek to protect.Finally, implementation of this study produced a number of ancillary program benefits. The process of defining and reviewing costs allowed for a review of operations at all levels  that was also frequently used to assess efficiency. The findings provide the opportunity for the development of cost-effective implementation models built on best practices from each country; hopefully, these can be adopted and adapted by new programs from the start, particularly in Africa where almost 30 more endemic countries still need to initiate LF elimination programs.


Dermatofibromas are common benign tumors in women, and breast cancer is the most common malignancy in women. The aim of this study is to determine if there is any relationship between the two conditions.Five patients with dermatofibromas and 10 control patients (two groups) had their skin biopsies measured for arsenic by inductively coupled mass spectrometry. Fifty randomly selected patients with breast cancer and 50 control patients were examined for the presence of dermatofibromas.The dermatofibromas were found to have an arsenic concentration of 0.171 micrograms/gram, compared with 0.06 and 0.07 micrograms/gram of the two control groups. Forty-three out of 50 patients with breast cancer had dermatofibromas and 32/50 patients with breast cancer had multiple dermatofibromas, compared to 10/50 control patients with dermatofibromas and only 1/50 with multiple dermatofibromas.Arsenic is important in the development of dermatofibromas and dermatofibromas represent a reservoir and important sign of chronic arsenic exposure. Dermatofibromas represent an important sign for women at risk for breast cancer, and arsenic may represent the cause of the majority of cases of breast cancer. Breast cancer is the most common malignancy and the second leading cause of cancer deaths in women. Its incidence has been steadily increasing over the last 50 years, with a small decline noted in the period 2000-2005, due to a reduction in hormone replacement therapy. NumerousDermatofibromas are common benign tumors which are more common in women. They usually develop in people in their 20's and 30's and are most common on the legs though any part of the body can be affected. Their cause is unknown though minor trauma may precipitate their development. A few cases have been associated with immune problems.[Five patients with clinical dermatofibromas were randomly selected for the study. There were four women and one man, and their ages ranged from 39 to 54. Three of the women had a history of breast cancer, and three of the patients had a history of squamous cell carcinoma of the skin. Informed consent was obtained from each patient prior to examination and biopsy. An excisional or deep shave biopsy was performed on each lesion. Each biopsy was bisected, with half sent for routine histopathologic exam and the other half evaluated for arsenic by inductively coupled mass spectrometry.[4Two control groups were randomly selected for the first phase of the study. The first group consisted of five patients with no detectable blood arsenic, who underwent a deep skin biopsy. This included one squamous cell carcinoma, one cyst, one intradermal nevus, one dysplastic nevus and one plaque of lichen planus. The second group consisted of five patients with detectable blood arsenic (5 micrograms/liter-9 micrograms/liter) and included one keloid, one intradermal nevus, one basal cell carcinoma, one verruca vulgaris and one seborrheic keratosis. Fifty patients with breast cancer were randomly selected for the second phase of the study through radio and newspaper advertisements. Their ages ranged from 39 to 65, with a mean age of 46 years. Patients over the age of 70 were excluded from the study because dermatofibromas can regress with age; and, the changes in the skin with age, including laxity, hyper and hypopigmentation, solar damage and the development of keratosis, could make the evaluation and diagnosis of any lesion difficult and they lead to false negative results. A control group of 50 women ranging in age from 37 to 65, with a mean age of 55 years, without breast cancer, was randomly selected for this study.After receiving informed consent, the patients were questioned about their breast cancer, including the age at which it occurred, the type of tumor, family history and the presence of breast cancer (BRCA) genes. The patients then received a total body skin exam to identify any potential dermatofibromas and if any were found, they were questioned about their duration. The dermatofibromas were diagnosed clinically by a firm, movable, non painful dermal or elevated or flat papule, which had a dusky red or mottled pigmented appearance and a rim of hyperpigmentation and may present with a dimple on compression. No biopsies were performed.The five patients with dermatofibromas had their tumors confirmed by histopathology, and none of the patients had measurable blood arsenic at the time of their biopsies. Analysis of the tumors by inductively coupled mass spectrometry showed an arsenic level of 0.171 micrograms/gram. Due to the inclusion of some normal skin with the tumor, this value may actually be significantly higher. The control group with detectable blood arsenic showed 0.06 micrograms/gram of arsenic, and the control group without detectable blood arsenic showed 0.07 micrograms/gram of arsenic.Of the 50 patients with breast cancer, 43 had dermatofibromas and 32 had multiple dermatofibromas . When paOf the 50 patients without breast cancer, nine had a single dermatofibroma, and one had multiple dermatofibromas. Though measurements were not taken, they all appeared noticeably smaller than in the breast cancer group. Five of the patients without breast cancer and without dermatofibromas had positive family histories (mother and sister) of breast cancer, but none had BRCA genes. Though 10 of the 50 patients had dermatofibromas, a need for follow up for many years is still needed to see if they remain disease free and in the breast cancer free group.The cause of dermatofibromas has remained an enigma even though the lesions are thought to be quite common. Since the exact incidence of dermatofibromas has never been studied, it is impossible to tell if there is any correlation with the rise in breast cancer. However, our control group shows that the incidence is approximately 20%, and the incidence of multiple dermatofibromas is less than 2%. While the initiating factor in dermatofibromas is unknown, trauma or damage to the superficial dermis is strongly suspected, and this is supported by the report of multiple dermatofibromas in patients with HIV and systemic lupus erythematosus in which damage to the endothelial cells occurs. In the history of patients, many state that the lesions develop after a minor cut, insect bite or shaving injury.–8The high concentration of arsenic in the dermatofibromas in the absence of arsenic in the blood suggests that it is a dynamic process in which small amounts of arsenic are being trapped in the tumor and that it acts as a reservoir for arsenic. This is important because the dermatofibroma exhibits two important characteristics of acute and chronic arsenic toxicity. First, there are several cellular variants of dermatofibromas, but, in most, endothelial cells are present in large numbers, suggesting an endothelial origin to the tumor. Arsenic Arsenic is a highly toxic and carcinogenic metal, which people are exposed to naturally in the environment and as a pollutant from industrial processes and chemicals. It has been used extensively as a pesticide on crops, at homes and pressure-treated wood, especially in its highly toxic trivalent and pentavalent forms. Arsenic is easily absorbed by plants and leaches in the soil and it easily enters the human food supply through water, seafood and fruits and vegetables. It has a half life of only 6-12 hours in the blood and concentrates in the kidneys and urine, which makes the finding of high concentrations in the dermatofibromas even more significant. Its exact mode as a carcinogen is unclear, but it is known to displace phosphorous in adenosine triphosphate (ATP), affecting DNA synthesis. It inhibits DNA ligation and repair, and it interferes with DNA methyltranferase, resulting in inactivation of tumor suppressor genes through DNA hypermethylation.14Numerous studies have been done on breast cancer, in an attempt to link it to environmental agents, especially insecticides. These stThe finding of dermatofibromas, especially multiple dermatofibromas, in women with breast cancer provides an important and simple screening tool to identify women at risk, years before the clinical signs of the disease appear. The finding of arsenic in the dermatofibroma shows who is chronically exposed to this carcinogen and strongly suggests that arsenic maybe the cause of a majority of the cases of breast cancer. The finding that dermatofibromas may represent a reservoir for arsenic mandates that studies need to be done to see if other reservoirs may exist, especially in the breast, and to determine if these tumors may impede the rapid excretion of arsenic, making the body exposed to an inordinate amount of arsenic and increasing its carcinogenic potential. Since most arsenic enters the body through food, eliminating arsenic from water, fruits, vegetables  fish, poultry, etc. should enable physicians and the society to dramatically reduce the number of cases of breast cancer in 10-20 years.


Intriguing parallels between civil servant and nonhuman primate hierarchies suggest that highly stratified societies foster health inequalities. Determining how social differences translate into chronic disease remains a challenge, but neuroendocrine pathways appear to play a role.  Despite continued growth in the global economy, good health remains elusive for a large proportion of the world's population. Health inequalities between rich and poor countries are based on historical patterns of development and exploitation that leave millions of people starved of basic material and social amenities. In those rich countries where absolute poverty is largely absent, continuing health inequality is more difficult to understand. The discipline of biology has an important contribution to make in this regard. Studying the pathways responsible for translating social differences into biological differences and chronic disease is an intrinsically challenging pursuit. It is also an ethically compelling application of life science.One of the root observations leading to the work I will describe arose from the first Whitehall study, which analyzed cardiovascular disease among 17,530 civil servants working in London 30 years ago . The relThe then-novel technique of multivariate modeling shed light on some of the causes of the inverse social gradient in CHD in the first Whitehall study and helped to shape the future research agenda. When conventional coronary risk factors—such as smoking, serum cholesterol, and blood pressure—were controlled for one-third of the gradient was explained. Importantly, serum cholesterol levels were slightly higher in men in the higher employment grades . The disThe discovery of stepwise rather than threshold nature of these health inequalities captured funding interest on both sides of the Atlantic. A second large cohort of civil servants was set up so researchers could study inequalities in health functioning and morbidity as well as mortality and explore the psychosocial, behavioral, and biological pathways involved . The WhiWe observed many health disparities that are important from a public health perspective, meaning that they account for a substantial proportion of potentially preventable mortality and morbidity in the populations of rich countries as well as in the Whitehall II population. All-cause and cardiovascular mortality both follow inverse gradients, but cancer mortality does not. Incident type 2 diabetes and CHD follow inverse gradients. In terms of quality of life, there are social gradients in depression and physical functioning , which emphasize that clinical disease can be viewed as the tip of an iceberg of ill health. Positive health and well-being are not restricted to those at or near the top of the hierarchy, but the nearer an individual is to the top, the more likely he or she is to be in good health.A biological pointer to the pathways responsible for the inverse social gradient in CHD emerged from our attempt to improve on the explanation provided by conventional risk factors in the first Whitehall study. We showed that there was a steep inverse social gradient in a cluster of risk factors known as metabolic syndrome  4]. Met. Met4]. That behavior-related factors did not provide a full explanation for the social gradient in metabolic syndrome is consistent with the operation of direct psychosocial and neuroendocrine pathways linking lower social status to CHD risk. The hypotheses we are testing concern the biological response of the individual to the social environment, drawing an analogy between low social status and chronic low-level stress exposure ,6. “StreIn contrast to this social “embodiment” perspective, it has been argued that biological integrity, in the form of inherited advantage, is the real cause of social inequalities in health. Cognitive function is a high-level expression of this property, and analysis of the changes in test scores over the first ten years of life in a population-based study (the 1970 Birth Cohort) emphasizes the importance of environmental influences. Cognitive performance was first measured at 22 months of age. Children who ranked low at baseline rose through the ranks if their parents were affluent, and conversely, children who ranked high at baseline fell back if their parents were poor. By age seven, the two groups had crossed over in the rankings, whereas children who had both high initial test scores and high social class parents remained near the top of the ranking, and vice versa . These aThe integration of disciplines in our work is challenging in an academic world dominated by a fierce reductionism. There is, however, a noble pedigree to the perspective, reaching back to Claude Bernard, Walter Cannon, and others who laid the foundations of physiology and systems biology. Central concepts include autonomic and neuroendocrine regulation based on interlocking feedback mechanisms, stress reactivity in the guise of the fight-or-flight response, and the limits of stability in organ systems . More reA serendipitous connection with the work of Stanford neuroscientist Robert Sapolsky reinforced our motivation to pursue work on social status and metabolic syndrome. His studies of the olive baboon hierarchy in the Serengeti revealed remarkable parallels with our findings in London. Baboons live in a benign environment where food is plentiful, infant mortality is low, and predators are scarce. Social rank is a preoccupation among males. Just as in male civil servants, total and low-density lipoprotein (LDL) cholesterol in baboons differed little by rank, whereas HDL cholesterol was directly related to it . In addiEqually intriguingly, Sapolsky's group recently reviewed the primate literature on social rank differences in cortisol levels . They idSince our initial observation of the metabolic syndrome gradient, our work has explored a number of aspects of the direct psychosocial pathway to chronic disease. We showed that metabolic syndrome is linked to adrenocortical function and sympathoadrenal and cardiac autonomic activity . We founMortality among adults 45 years or over in Holland on 22 June 1996—the day the Dutch football team was eliminated from the European championship—was compared with the 5 days before and after the match and in the same period in 1995 and 1997. Coronary and stroke mortality was increased in men on the day of the match . No clear rise in mortality was observed for women . Among men, approximately 14 excess cardiovascular deaths occurred on the day of the match [Many questions remain. The quest for a universal stress biomarker, the Holy Grail of “stress biology,” may be a vain enterprise, but with respect to obesity, diabetes, and cardiovascular disease, metabolic syndrome proves to be a useful construct. Uncertainty remains over the extent to which direct autonomic and neuroendocrine pathways are important causes in comparison to behavior-mediated explanations. A model involving interaction between autonomic function and behavior may be closer to reality, as the work on sleep disturbance and appetite suggests .Separating out long-term causal sequences is difficult. Controlled stress experiments in the laboratory demonstrate the plausibility of mechanisms linking socioeconomic status to disease risk , but tra