Knowledge regarding the best approaches to improving the quality of healthcare and their implementation is lacking in many resource-limited settings. The Medical Department of Kamuzu Central Hospital in Malawi set out to improve the quality of care provided to its patients and establish itself as a recognized centre in teaching, operations research and supervision of district hospitals. Efforts in the past to achieve these objectives were short-lived, and largely unsuccessful. Against this background, a situational analysis was performed to aid the Medical Department to define and prioritize its quality improvement activities.A mix of quantitative and qualitative methods was applied using checklists for observed practice, review of registers, key informant interviews and structured patient interviews. The mixed methods comprised triangulation by including the perspectives of the clients, healthcare providers from within and outside the department, and the field researcher’s perspectives by means of document review and participatory observation.Human resource shortages, staff attitudes and shortage of equipment were identified as major constraints to patient care, and the running of the Medical Department. Processes, including documentation in registers and files and communication within and across cadres of staff were also found to be insufficient and thus undermining the effort of staff and management in establishing a sustained high quality culture. Depending on their past experience and knowledge, the stakeholder interviewees revealed different perspectives and expectations of quality healthcare and the intended quality improvement process.Establishing a quality improvement process in resource-limited settings is an enormous task, considering the host of challenges that these facilities face. The steps towards changing the status quo for improved quality care require critical self-assessment, the willingness to change as well as determined commitment and contributions from clients, staff and management. The desire to improve on health systems and healthcare delivery is common in many low and middle income countries (LMIC). HoweverHealthcare in Malawi, as in other developing countries is hampered by chronic lack of resources, severe Prior to this study, the management and staff of the Medical Department, Kamuzu Central Hospital in Malawi, where this study was carried out, expressed the concern that their department was not performing up to the expectations of a leading referral hospital in terms of caring for referred patients, teaching of medical interns and clinical officers and conducting supervisory tasks at the district level.In the past, the Medical Department made several attempts to establish itself as a centre of excellence for tertiary care, for exaAgainst this background, a situational analysis to identify and understand the systems and the barriers to delivering sustainable high quality healthcare to its clients was performed at the Medical Department. The findings from this study will assist the Medical Department to prioritize potential solutions which will improve the processes required to provide high quality healthcare.The specific objectives were to assess1. the organization of patient flow and care within the department2. the stakeholder views and expectations of the quality of care in the Medical DepartmentThe Medical Department of the Kamuzu Central Hospital (KCH), is a tertiary referral hospital located in the Central Region of Malawi and serves a population of around 5 million. The hospital is under the direct administration of the Ministry of Health which provides the hospital’s budget. Even though the hospital generates some of its revenue through the paying services, during the time of the study it had no mandate to use the revenue, and instead was required to send such revenues to the Central Treasury of the Ministry of Health.The Medical Department has a bed capacity of 117 and the entire KCH has over 1000 beds in total. The department has four main sub units, namely the highly dependent unit (HDU), the male and female wards and the medical short stay (MSS) ward. Clinically, the department attends to a host of conditions and cases, both acute and chronic. Outpatient services are provided through two clinics: the main, non-paying OPD unit of the Medical Department (OPD II) and a fee for service paying clinic OPD I. Special clinics for hypertension, diabetes and HIV are run on a weekly basis. The department is also in charge of a small dialysis unit and the TB ward at a different campus, and is further obliged to perform supervisory visits in four districts of the Central Region of Malawi.A mixed method approach incorporThe quantitative aspect of the analysis consisted of conducting structured interviews with 100 outpatients as they exited from the consulting rooms in a convenience sampling approach. Participation in the survey was strictly voluntary. Patients, who were too ill to follow and answer the interview questions properly, were excluded. Only patients and not their families or legal representatives were interviewed.The exit interview sought to address research objective 1 by identifying:• the patient's perspective of the quality of healthcare delivery and• the patient’s satisfaction with services in the Medical DepartmentAJK 2008 Questionnaire. This validated questionnaire was developed for a quality improvement exercise in a hospital in Pakistan that has a setting similar to that of the KCH. In order to validate the questions before posing them to the study interviewees, the questionnaires for this study were first administered to some staff of the KCH.Guidelines were developed for the in-depth interviews, and a structured questionnaire was developed by the authors, adapting some of the quantitative elements from the Microsoft Excel and Epi-Info Statistical Programme (CDC Atlanta).All the questionnaires for both in-depth and structured interviews were originally designed in English. The structured outpatient questionnaire was subsequently translated into Chichewa  for clear communication with interviewees who could not speak or read English. Responses in Chichewa were then translated back into English through an interpreter. Quantitative data from the interviews were analyzed with The qualitative methods included participatory observation and in-depth interviews with key stakeholders. The data collection tools were developed in conjunction with partners in the Medical Department.staff, management, patient and affiliate  was used to document processes in the department. The principal researcher served as a participatory observer. By working in the field for a period of one month, she was able to observe firsthand the usual practices within the Medical Department.The study proposal was reviewed and approved by the research committee of the Institute of Public Health, Ruprecht-Karls University of Heidelberg, Germany and by the National Health Science Research Committee (NHSRC) of Malawi. No monetary or other forms of compensation were given to respondents. Permission was given for respondent views to be tape-recorded. All information received and reviewed was handled with the strictest confidentiality.The results reported below reflect the views of the different stakeholders interviewed.Out of the 100 sampled outpatients, 98 responded and only two declined. Unless stated otherwise, all analyses were performed on the results from 98 respondents. Overall satisfaction was very high among interviewees: 59% of the respondents rated their satisfaction level as 'very good’, 40% as 'good’ and only 1% as 'poor’.General satisfaction was further divided into three categories: Out of 95 responses, 45% liked the staff performance, 34% liked the patient focus in the hospital/Medical Department and 16% liked 'other things’.staff performance, patient focus and other areas were provided for respondents to identify what they thought were the major problematic areas or bottlenecks in the department. Out of the 82 respondents answering this question, 41% of them cited 'staff performance’ as the major problem/bottleneck, 27% suggested 'patient focus’ in this regard and 32% thought problems were due to 'other areas’ including 'shortage of drugs’ , 'long waiting times’ , 'whom-you-know service’ (queue jumping) and 'poor amenities in the department’. Table Three options: The responses by stakeholders from all categories were grouped into three main thematic areas of 'existing quality elements and models’ , 'challenges or problematic areas hindering good quality practices’ and 'recommendations for quality improvement’.Emerging themes from the in-depth interviews are summarized in Table The patients in this survey – both inpatients and outpatients - considered the quality of care in relation to how patients can receive better attention from care givers and be treated with respect as being very important. In their view, good quality included receiving both medical and non-medical care in a manner they perceive to be good.The staff respondents identified the lack of proper patient management as one of the Medical Department’s problems. Proper management here refers to care which is safe, effective, patient-centred, timely, efficient and equitable.Findings from the in-depth interviews related to staffing included most prominently the lack of staff, and at The medical staff in the Medical Department from January to December 2010 included two clinical officers (certified physician assistants), seven medical doctors , one nursing manager (matron), 24 nurse midwife technicians and six registered nurses. The support staff comprised 14 cleaners, three auxiliary nurses, three patient attendants and two clerks. There were also interns and students-on-rotation, who were assigned on duty, but their exact numbers were not known and varied frequently. Clinicians work in teams led by a senior clinician, and the teams alternate daily regarding the admission duty. Patients are followed by the same team from admission to discharge. Officially, three nurses are on day shifts and two are on night shifts in each of the three medical wards: 2A , 2B  and the Medical Short Stay (MSS) ward. All support staff are on day shifts only.Poor communication among staff and between staff and patients was reported in the interviews and observed to affect the quality of care in the Medical Department. Such comments included, 'illegible and or incomplete notes in patient files’, 'irregular staff attendance to handing over meetings’ and 'rare updates on the day-to-day management of the hospital from management to staff’  and 59% during the night shift (4 pm to 8 am). The Medical Department OPD II recorded a total of 1015 patients, with 437 males and 578 females in June 2010, which translates to an average daily attendance of 42 patients to the Medical Department during the study month. This data excludes visits on Sundays, since the unit is closed then.The OPD diagnosis record for June 2010 showed a large diversity, namely approximately 104 different conditions and cases  would suggest that staff workload is not a problem as strongly indicated by the interviewees. However, it must be stressed that being a teaching hospital, the mandate of the medical team is not only limited to caring for patients, but also to teaching, research and outreach support to the sub districts. It follows that the views of the stakeholder interviewees about inadequate staffing may be a valid point in spite of the data of staff-to-patient ratios in the June 2010 OPD records.Assuming the OPD data reported in this study is a true reflection of patient density at the Medical Department, then this observation may imply an inefficiency and underutilization, or misallocation or even absenteeism of the staff strength in the unit. On the Communication in healthcare is very crucial for the efficient management of patients. With the observed gaps in both verbal and written communication among staff, the Medical Department could adopt the SBAR (Situation-Background-Assessment-Recommendation) model to enhance communication among staff and to improve patient safety.This study equally confirms Øvretveit’s observation that manThe quality of healthcare is defined and influenced by people’s experiences, perceptions and expectations. While pResults, Section 4.1). However, relying on indicators like satisfaction alone does not prove that good quality of care exists[According to the definition of Peach the highe exists. It mighThis attitude can partially be explained by social desirability, i.e. whAlthough the study employed adequate measures to ensure that respondents could speak freely and sincerely during and after the interviews without being victimized by staff, it may be possible that some respondents were apprehensive about getting poorer care if they were forthcoming about any shortcomings in their own care at the Medical Department.Among the providers, quality of care was considered to be good in a hospital if the staff is satisfied with the work they do and patients appreciate the care they receive. Required here is a conducive environment where resources are available, staff work output is recognized through salary or incentives, and an end result of improved health for their patients (Additional fileIn order to reverse the process of staff becoming overwhelmed by their tasks, becoming complacent, demotivated and giving poor performance, it is essential to identify modifiable factors that are under the control of the Medical Department. It is worth noting that planning for quality improvement measures requires patient, staff and management involvement to establish where they stand on the quality ladder. All involved parties need to have achievable goals and define and implement appropriate processes for such. The willingness of staff members to engage in the change process must be recognized as being indispensable. Tasks for tertiary healthcare facilities in resource-limited settings, like the Medical Department of KCH in Malawi, are multiple and constitute a huge challenge for the staff. Quality improvement initiatives can serve as a tool for staff empowerment and better quality of patient care.The authors declare that they have no competing interests.All authors were involved in the conception and design of the study and have all approved the final version of the manuscript to be published. The corresponding author wrote the first draft, and all authors have been responsible for redrafting and revising the intellectual content of this article.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/14/1/prepubAppendices, Tables and figures.Click here for file


Crossing the Quality Chasm to find the few simple rules that might guide the local development of the 21st century health system. We have analyzed our health system's activities in the context of systems science as it seeks to create value  for its stakeholders. We have concluded that 5 rules are simultaneously necessary and sufficient for success: 1) The stakeholders agree on a set of mutual, measurable goals for the health system; 2) the extent to which the goals are being achieved is reported to the public; 3) resources are available to achieve the goals; 4) stakeholder incentives, imperatives, and sanctions are aligned with the agreed-on health system goals; and 5) leaders among all stakeholders endorse and promote the agreed-on health system goals.In 1991, Plsek sought to improve the quality of health care by challenging the readers of  Crossing the Quality Chasm, defined the ideal health system as one satisfying 6 attributes  and 10 operating rules (The 2001 Institute of Medicine (IOM) report, Care is based on continuous healing relationships.Care is customized according to patients' needs and values.The patient is the source of control.Knowledge is shared, and information flows freely.Decision-making is evidence-based.Safety is a system property.Transparency is necessary.Needs are anticipated.Waste is continuously decreased.Cooperation among clinicians is a priority., Plsek made a compelling argument that the solution to creating a health system that behaves as desired lies in perceiving it as a complex adaptive system governed by simple rules rather than as a complicated mechanical system controlled by myriad rules of governance  might bCommon pool resources (CPRs) are a particular form of complex adaptive systems. CPRs are characterized by the difficulty of excluding people from using them and the fact that use by 1 person or group means that fewer resources are available for use by others . ExampleWhereas the operating rules varied widely among the more than 5,000 CPRs identified by Ostrom (Both the boundaries of the CPR and the people or organizations who have rights to withdraw from the CPR are clearly defined.Appropriation rules (taking resources from the CPR) and provision rules (contributing to the maintenance of the CPR) are congruent with local conditions.Most people affected by the operating rules of the CPR can participate in modifying the operating rules.Monitors, who actively audit CPR conditions and behavior, are accountable to the appropriators (people who withdraw resources from the CPR) or are the appropriators.Appropriators who violate operating rules are likely to be sanctioned.Appropriators and their officials have rapid access to low-cost local arenas to resolve conflicts.The rights of appropriators to devise their own institutions are not challenged by external governmental authorities.An additional principle applies to large, complex CPRs: for CPRs that are part of larger systems, appropriation, provision, monitoring, enforcement, conflict resolution, and governance activities are organized in multiple layers of a nested enterprise .These general design principles suggest the specific rules that must be satisfied for health systems to create value. The current health system in the United States fails to satisfy several of these rules.Responding to the challenge Plsek put forth in the IOM report, we describe in this article the rules that we believe are necessary and sufficient to follow if health systems are to create value. Although we use examples from our integrated health system, HealthPartners, we believe that the rules apply to smaller units and to the US health system as a whole.www.healthpartners.com/public). The health system's mission and vision statements focus on optimizing health and creating value. In the past 10 years, HealthPartners has striven to create a system that satisfies the 6 attributes and 10 operating rules that Crossing the Quality Chasm used to define the ideal health system.HealthPartners, located in the upper Midwest and headquartered in Minneapolis, Minnesota, is an integrated health system that finances care, administers benefits, provides care in hospitals and multispecialty clinic systems, and contracts for care with a large care network , a "neutral ground" where competing organizations collaborate to create shared guidelines and care processes , and parRule 2:The extent to which the goals are being achieved is reported to the public.Ostrom observed that stakeholder access to monitoring data is critical to the success of CPRs . WithoutRule 3:Resources are available to achieve the goals.Demanding performance without providing the necessary resources will not create change. Money is just one of the resources required to implement systems that create value. Innovation in health systems requires the development of new products, procedures, devices, and systems that support the delivery of care. HealthPartners was an early adopter of the electronic health record, worksite health promotion, and e-visits. By collecting data on race, offering same-day mammography (women due for a mammogram are offered one during their office visit), and implementing a patient-recruiting system, HealthPartners has been able to reduce disparities in mammography screening among racial/ethnic minorities to a rate below the NCQA goal . In an eRule 4:Stakeholder incentives, imperatives, and sanctions are aligned with the agreed-on health system goals.Misaligned stakeholder incentives create goals for the stakeholders that are not consistent with a health system that focuses on creating value. HealthPartners has several initiatives under way to align incentives of all stakeholders with the Triple Aim. To align the incentives of employees and dependents with those of the employer and the health plan, HealthPartners implemented a program in which health promotion and health care are offered as a single benefits package designed to maintain and improve employee/dependent health and address employer cost concerns. Informed by evidence , this inTo align the incentives of clinicians, HealthPartners reports performance of medical groups ; in 1996Rule 5:Leaders of all stakeholders endorse, promote, and honor the agreed-on health system goals.When goals are not periodically revisited, reviewed, and defended, missions drift, and the goals of individual stakeholders can begin to dominate the agreed-upon system goals. Health systems are no exception. To maintain an organizational focus on the Triple Aim, HealthPartners prominently features its mission and vision throughout its facilities, in its strategic plan, and in all communications. HealthPartners requires all employees to commit to 6 promises to patients, families, and members . As HealHealthPartners executives lead and participate in community endeavors that promote social capital without regard to advancing the organization's market position. The chief executive officer leads a program to promote economic growth, job growth, and education reform to reduce regional health, education, and economic disparities . The chiThe simple rules we have identified are not much different from those identified in Grand Junction, Colorado ,22, or bWe have answered Plesk's challenge to identify the simple rules that govern the health system. Unless these rules are identified and addressed during the "plan" stage of a plan-do-study-act cycle, health systems may become lost in the forest of health care regulations and the opportunity to launch new initiatives. In a complex adaptive system, a single solution will fail unless all of the necessary rules for system functioning are satisfied.Crossing the Quality Chasm.The nation has progressed in increasing the value of health care. As early as 1993, teams that participated in the Institute for Healthcare Improvement Breakthrough Collaborative program had reduced patient waiting times by 50%, employee absenteeism by 25%, intensive care unit costs by 25%, and hospitalizations for congestive heart failure by 50% (Others may not agree with the rules as we state them. Their objections might range from minor quibbles to outright rejection. They may also identify more than 5 rules. Regardless, we believe that the most efficient way to create a health system that delivers value is to identify simple rules and use them to guide the attempts to provide value to health system stakeholders. To paraphrase Plsek , the goa


Craniofacial microsomia (CFM) is a congenital condition associated with orbital, mandibular, ear, nerve, and soft tissue anomalies. We present a standardized, two-dimensional, digital photographic protocol designed to capture the common craniofacial features associated with CFM. More n system ,4. CFM on system ,2. Phenon system -7. For tCFM has an estimated prevalence of 1:5,600 to 1:26,550 live births ,9 and rePhotographs can facilitate standardized phenotypic assessment of craniofacial morphology . SeveralIn this paper we present a standardized, two-dimensional, digital photographic protocol designed to capture the common craniofacial features associated with CFM.We developed a multicenter consortium entitled the "Facial Asymmetry Collaborative for Interdisciplinary Assessment and Learning (FACIAL)" to facilitate research on the etiology and clinical outcomes in CFM (NIDCR RC1 DE020270). Members of the craniofacial centers at four academic hospitals developed a digital photographic protocol to enable classification of the common craniofacial features coded in the phenotypic assessment tool for CFM (PAT-CFM), which iWe have included several recommendations for the imaging environment, and these are illustrated in Figure We recommend acquiring images in a space with minimum area dimensions of 3 meters by 1.2 meters (10 feet by 4 feet). Place the participant approximately 1 meter (3 feet) in front of the background. The camera should be 1.2 meters to 1.5 meters (4 to 5 feet) in front of the participant .To maximize patient safety, we recommend placing infants and toddlers between 5 months to 3 years of age who are able to sit with minimal support in a booster chair . To ensuWe have included several recommendations for preparing participants, and these are summarized in Table The hair should be pulled back to allow for an unobstructed view of the ears. A variety of items can be used to accomplish this, including: a wig cap, a hair tie, barrettes, bobby pins, self-adhesive tape, headband, and hair rubber bands . WheneveWhen possible, the participant should sit on a mobile chair or an exam stool so the photographer can rotate the participant to the correct positions required for image capture. While adults and older children are frequently comfortable and safe to sit on a seat with wheels, younger children might need to stand and rotate positions for photo acquisition. Infants and young children who cannot stand should sit on a parent's lap.This protocol includes images obtained while the participant has a neutral expression, as well as during facial animation. The rationale for the expression requested for each view is described in Table For neutral expressions, it is often sufficient to instruct subjects to relax their face. In addition to obvious signs of facial tension or emotional expressions, photographers should pay attention to the subject's mouth and eyes -22. The We developed this photographic protocol to capture the facial features commonly affected in CFM and to allow for the recording of these features using the OMENS rating system. These features are briefly described below, and summarized in Tables Malformations of the orbit in CFM commonly include small size, and inferior or superior displacement. These features are best illustrated on View A Figure  and 3 anMandibular asymmetry is a hallmark of CFM and is classically attributable to malformations of the ramus. Mandibular anomalies can be difficult to fully evaluate on two-dimensional images. Our protocol incorporates multiple views of the mandible to capture mandibular hypoplasia and resulting facial asymmetry , oblique (views B and D), and frontal view (view A) of the ear to allow for assessment of size, shape, and position. Views C and E allow for subsequent enlargement to create views O and P, respectively Figures  and 4.Facial palsies can involve any or all branches of the facial nerve and may be unilateral or bilateral. We propose a series of images  should taken with the participant in the Frankfort horizontal plane, which is achieved by ensuring the lower margins of the orbits are on the same level as the upper margins of the ear canals. This can be challenging for participants with microtia and/or orbital displacement. The goal is to obtain a full frontal view, in which the face is perpendicular to the camera. Participants should be optimally positioned on the horizontal and vertical axes to eliminate rotation from the midline . The griOblique views should be obtained in the Frankfort horizontal position, and the participant should face approximately 45 degrees away from the camera . The phoAs previously described, views M, N, O, and P Figure  can be gWe encourage photographers to preview images at the time of image acquisition to minimize the possibility of missing data during image acquisition. Reviewing images for key features Table  at the tIt may not be feasible to review all images at the time of image acquisition, particularly when photographing small children. In this case, photographers can acquire multiple images for each view to maximize the likelihood of obtaining adequate data coverage, and process the images later for subsequent evaluation.We have developed an image protocol designed to capture the common craniofacial anomalies associated with CFM. These images can be assessed individually, or they can be combined to create a composite sheet for each individual. In the PAT-CFM tool, we used the views described in this protocol to create a composite sheet that would enable efficient classification of the features included in the modified pictorial OMENS-plus classification system . We usedPhotographic records can serve as a powerful resource to capture and quantify craniofacial morphology. Acquiring reliable, high-resolution, and high-quality facial images requires standardized methods to optimize image acquisition.We developed this protocol with the multidisciplinary, multicenter FACIAL team and used an iterative process of testing to develop a stepwise procedure to allow for a person with limited photographic training to be able to acquire high quality, standardized images that capture the most common malformations associated with CFM. We designed a protocol that could be incorporated into low-resource settings using a digital camera with reasonable resolution. We also aimed to create a protocol that was not overly burdensome for the study participants and/or patients, and allows for subsequent classification of images outside of the clinical or research encounter.The data collected via this protocol allows for future assessment of images using the OMENS classification system, along with other classification systems. We also anticipate that the standardized protocol may enable clinicians and researchers to document and assess changes over time, either with growth and/or intervention. Though we anticipate that reliability of ratings on the photos compared to ratings by in-person physical examination will be high for many of the malformations assessed in this protocol, future reliability studies are needed.Not all participants will be able to comply with the instructions, particularly infants and young children, and this will result in missing data. This is likely also true for some features on direct physical examination, such as facial nerve exams in neonates. Future reliability studies that include large numbers of participants of all ages will be helpful to further assess the reliability of the protocol and completeness of data collection across age-groups.Our assessment of facial nerve function is relatively simple. It is a first step in indirect assessment of facial nerve palsies in CFM and can be complemented with a video or clinical examination. Though we anticipate the reliability of the entire protocol will be high for older, cooperative participants for the anatomical components of the face, it will be important to formally evaluate the reliability of this photographic protocol, particularly for the nerve function.As with any study protocol, it is up to the reader to determine the applicability of the aforementioned techniques to their specific research or clinical question. Though this protocol may be helpful to document the primary malformations associated with CFM and establish a pre-surgical baseline (i.e. grade 2 vs 3 microtia), the protocol needs to be further evaluated to determine its utility in assessment of treatment outcomes.As this participant is under the age of 18, written informed consent was obtained from the participant's parent for publication of this methodology and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.orbital anomalies in size and position, mandibular hypoplasia, ear malformations (microtia), facial nerve palsy, and facial soft tissue deficiency.CFM: craniofacial microsomia; FACIAL: Facial Asymmetry Collaborative for Interdisciplinary Assessment and Learning; OMENS: classification system for The authors declare that they have no competing interests. The authors of this work do not have any financial disclosures or commercial associations with any imaging device/company that might pose or create a conflict of interest with the information in this manuscript.CH, LS, and CB conceptualized the paper. All authors contributed to content of the manuscript and development of the protocol. CH, LS, ES, DV, AD, LP, KS, and CB drafted and edited the manuscript. All authors have read and approved the final manuscript.CH, LS, KS, CB and ES are affiliated with the Children's Craniofacial Center at Seattle Children's Hospital, Seattle, WA. CH is an Assistant Professor in the Department of Pediatrics at the University of Washington, Seattle, WA. CB is an Assistant Professor in the Department of Surgery, Division of Plastic Surgery at the University of Washington. KS is a Professor in the Department of Surgery, Division of Otolaryngology at the University of Washington. LP, AD, and DV are affiliated with the University of North Carolina's Craniofacial Center at the University of North Carolina School of Dentistry, Chapel Hill, NC. AD is a Professor of Otolaryngology, Head and Neck Surgery, and Director of University of North Carolina Craniofacial Center. LP is the Dental Director at the University of North Carolina Craniofacial Center, School of Dentistry and University of North Carolina at Chapel Hill. DV is an Adjunct Professor in the Department of Dental Ecology, School of Dentistry at the University of North Carolina at Chapel Hill.


All great ape species are endangered, and infectious diseases are thought to pose a particular threat to their survival. As great ape species vary substantially in social organisation and gregariousness, there are likely to be differences in susceptibility to disease types and spread. Understanding the relation between social variables and disease is therefore crucial for implementing effective conservation measures. Here, we simulate the transmission of a range of diseases in a population of orang-utans in Sabangau Forest  and a community of chimpanzees in Budongo Forest (Uganda), by systematically varying transmission likelihood and probability of subsequent recovery. Both species have fission-fusion social systems, but differ considerably in their level of gregariousness. We used long-term behavioural data to create networks of association patterns on which the spread of different diseases was simulated. We found that chimpanzees were generally far more susceptible to the spread of diseases than orang-utans. When simulating different diseases that varied widely in their probability of transmission and recovery, it was found that the chimpanzee community was widely and strongly affected, while in orang-utans even highly infectious diseases had limited spread. Furthermore, when comparing the observed association network with a mean-field network , we found no major difference in simulated disease spread, suggesting that patterns of social bonding in orang-utans are not an important determinant of susceptibility to disease. In chimpanzees, the predicted size of the epidemic was smaller on the actual association network than on the mean-field network, indicating that patterns of social bonding have important effects on susceptibility to disease. We conclude that social networks are a potentially powerful tool to model the risk of disease transmission in great apes, and that chimpanzees are particularly threatened by infectious disease outbreaks as a result of their social structure. Pan troglodytes spp.) field sites have been affected by lethal epidemics, some have suffered great losses due to diseases. Respiratory epidemics have affected a number of study sites Pongo spp.), although there are reports of disease transmission from humans. For example at Ketambe, Sumatra, an influenza type disease and conjunctivitis have been passed from human caretakers to rehabilitant orang-utans, with the former then passed on to two wild orang-utans Great apes are susceptible to a wide range of diseases, including Ebola Patterns of disease spread are influenced by a number of parameters, most importantly by the social organisation of a species and disease-specific parameters, such as transmission mode, infectiousness and time to recovery. For example, data from humans suggest that highly infectious diseases, such as Ebola, measles or influenza, have infectious periods lasting for 10 days, 6–7 days and 2–3 days respectively, while tuberculosis is less infectious but has a longer infectious period Syncerus caffer) Trichosurus vulpecula) Orcinus orca) So far, virtually no epidemiological models exist for great apes, although social network-based approaches of disease transmission have been used for African buffalo  to determine the susceptibility of the orang-utan and chimpanzee networks to the spread of diseases with differing infectiousness and probability of recovery, (ii) to compare the association network approach with the more traditional mean-field approach, to determine if the topology of the network impacted predicted disease spread, and (iii) to compare the results between the species to highlight the impact of gregariousness on the threat of disease.Permits and ethical approval for the field studies were obtained from the Indonesian Institute of Sciences and the Ministry of Research and Technology and the Uganda National Council for Science and Technology, the Ugandan Wildlife Authority and the National Forestry Authority.We constructed networks for both species using association data, i.e. presence in the same party, where a party was defined as all individuals within 50 m of each other. The orang-utan data were collected from 2003–2011 as part of the OuTrop multi-disciplinary research project in collaboration with CIMTROP, in the Natural Laboratory for the Study of Peat Swamp Forests (2°19′S 114°00′E). The population comprised 46 individuals: four adolescent females, 10 adult females, two adolescent males, 16 unflanged males and 14 flanged males. Nine of these orang-utans were never observed in association with other individuals and so were excluded from the analyses, as this study focuses on diseases that are transmitted through close proximity between individuals or through direct individual-to-individual contact. Data were collected during focal follows that lasted for as long as 10 consecutive days. Association data were recorded using instantaneous sampling every five minutes. In total, 165,717 focal scans were recorded.The chimpanzee data were collected between August 2007 and July 2010 on 55 members of the Sonso community of Budongo Forest: 12 adolescent females, 24 adult females, eight adolescent males and 11 adult males. Data were collected during focal follows and association data recorded using scan samples every 15 minutes. In total, 34,143 focal scans were recorded.Weighted association networks were constructed from the association data, using Dyadic Association Indices (DAIs) as the weights of the edges:A is the total number of times that A was observed, either alone or with other independent individuals, B is the total number of times B was observed and AB is the total number of times that A and B were observed together. Association indices range from zero to one, with zero indicating that two individuals were never observed together and one indicating that they were always observed together.where We simulated the spread of disease using a susceptible-infected-recovered model. This involved allocating each individual in the network one of three states at all times: susceptible, infected or recovered. The simulation begins with the infection of one individual in the network, patient zero; this individual is selected at random. All other individuals start the simulation as susceptible. The spread of disease from patient zero to its contacts is assumed to be a function of the transmission coefficient β, representing the infectiousness of the disease, and the dyadic association index, representing the probability that a dyad will associate. At each time step, disease spreads from infected to susceptible individuals with a probability that is the product of these two variables. Once infected, individuals recover with a probability γ, the recovery coefficient, and do not return to susceptible status. It is important to note that conceptually, recovered individuals are equivalent to dead individuals. In all cases the individual is removed from the network and can no longer transmit disease. In terms of modelling subsequent disease spread it is consequently not important to distinguish the number of individuals that recover from the number that die and so here both states will be referred to as recovered.We ran all simulations using tnet We explored the effect of network topology on the spread of disease by comparing the size of the epidemics predicted on the association networks with the size of the epidemics predicted on mean-field networks, where individuals mix homogeneously. In the mean-field network, all individuals were connected to all others and each dyad associated with an association index that was equivalent to the mean of the association indices in the actual network. This ensured that the overall force of infection in the mean-field model was the same as that in the association network Simulating the spread of diseases with differing transmission coefficients and probabilities of recovery on the orang-utan association network indicated that disease does not spread extensively under any combination of these parameters . Even wiThe spread of disease across the mean-field network  was verySimulations on the chimpanzee network indicated a much higher degree of vulnerability to disease than predicted for the orang-utan . DiseaseComparing the spread of disease on the chimpanzee association network with that on the mean-field network produced very different results to those seen in the simulations for orang-utans. Regardless of parameter combinations, the final size of the epidemic on the mean-field network was higher than that on the association network . Only diThe spread of a range of diseases with differing infection and recovery parameters was simulated in a community of chimpanzees and a population of orang-utans, to assess the vulnerability of these species to epidemics. While disease was not predicted to spread rapidly or extensively through the orang-utan population, the chimpanzee community was predicted to be extremely vulnerable to disease. Furthermore, the topology of the association network was found to have an important effect on the predictions of disease spread for chimpanzees, but not for orang-utans. It is important to note that the simulations were based on association networks using data collected over nine years for the orang-utans and three years for the chimpanzees. Although this difference prevents any detailed quantitative comparisons being made between the two species, the markedly different overall patterns that emerged highlight differences in how disease is likely to spread in each species. Overall, our results are relevant for the planning of conservation initiatives and disease prevention measures. While disease risk should not be ignored for orang-utans, infectious diseases represent a particularly major threat for wild chimpanzees and effective measures to prevent disease from entering communities should therefore be implemented, especially in habituated populations.As with all modelling approaches, there are a number of simplifications/generalisations that needed to be made, which are important to discuss. The definition of social contact employed here may have important influences on the inferences that can be drawn. Both orang-utans and chimpanzees were said to be associating if they were within 50 metres of one another (a commonly used definition by field workers). Although for much of the measured association time individuals will in fact be in much closer proximity than the 50 metre cut-off distance, in reality many diseases require very close contact for transmission to take place The simulations used here were based on static association networks, as opposed to dynamic networks which include temporal changes in contact patterns The disease simulations described in this paper, using a range of transmission and recovery parameters, provide clear evidence of the impact that differences in gregariousness between the orang-utans and chimpanzees have on predicted vulnerability to disease spread. Even diseases with very high infectiousness and slow recovery did not infect more than five of the 37 orang-utans (14%). A highly infectious disease associated with low recovery is, however, clearly a worst-case scenario, although it should be emphasised that the loss of five individuals could have an important impact on the population. The chimpanzee network, by contrast, was highly susceptible to diseases with a broad range of transmission and recovery parameters, particularly those with medium to high transmission coefficients. At a number of study sites, respiratory epidemics have indeed been shown to affect the majority of chimpanzees The relative lack of disease spread predicted among orang-utans, particularly in comparison to the chimpanzee, suggests that orang-utans are unlikely to be regularly affected by infectious disease, as a result of their social system. Further studies should investigate the extent to which this finding applies to orang-utans in rehabilitation centres, which live at much higher densities than those in the wild Although models with the most realistic parameters should produce the most accurate predictions, it is often impossible or excessively time consuming (in terms of data collection) to obtain sufficiently detailed data. For these reasons, in network epidemiological models, mean-field networks are often used instead of actual association or interaction networks. Our results show that for orang-utans, the mean-field network produced similar results to those from the association network for almost all combinations of parameters tested. This indicates that the fine-grained structure of the orang-utan network has little impact on predicted transmission patterns, with the exception of diseases with long recovery times and high infectiousness. It seems likely that the low levels of association between orang-utans in the network limit the spread of disease, regardless of the exact topology of the network. Consequently, the predictions produced here are likely to be widely applicable to other populations of Bornean orang-utans, which are known to spend a comparable amount of time alone as the population studied here The results from the mean-field network for the chimpanzee provide support for the value of using an actual association network approach in disease simulations for this species, as the predicted final sizes of the epidemics on the mean-field network differed considerably from those on the association networks, in most cases being greater. It is likely that there is a threshold level of association above which it becomes useful to incorporate association data. Without data from a wider variety of social systems it is difficult to estimate where this threshold may lie; however, it is clear that for highly gregarious species such as chimpanzees, the inclusion of  association data can have important effects on predictions.The models presented here to assess disease spread dynamics can also be interpreted as models for the spread of social information and the evolution of culture The results of this study indicate that while orang-utans seem to be at low risk of suffering disease epidemics, for chimpanzees disease represents a major threat. Once a single chimpanzee is exposed to a contagious pathogen, our model predicts rapid and extensive spread within the community. This emphasises the importance of this issue for the future conservation of the chimpanzee, and highlights the value of modelling approaches to the study of wildlife diseases.


Periodontal lesions are considered a major problem in the global burden of oral diseases due to their high frequency and negative impact on quality of life. Periodontal inflammation is accomplished by a breakdown of microcirculatory function. Early detection of gingival microvessel dysfunction helps diagnose and prevent the progression of initial periodontal pathology. Doppler flowmetry is a useful tool in the diagnosis, monitoring, prognosis and management of periodontal patients which allows access not only of gingival blood flow but also of pulpal microcirculation. Doppler flowmeters might help to realise the ultimate target of predictive, preventive and personalised periodontology tailored with respect to the particular patient. This article highlights the main working principles of laser Doppler flowmeters and the ultrasonic Doppler flowmeters. The advances in blood flow measurement by ultrasonic flowmetry are discussed. Periodontitis is a highly prevalent chronic inflammatory disorder with a negative impact on the quality of life affecting 30% to 40% of the population over 35 years old . It invoThe main causes of gingival inflammation are an ecological imbalance between the oral microbial biofilm and an impaired host inflammatory response -7. PerioToday various methods are available for the investigation of blood supply in clinics, some of which are excellent in determining the presence and severity of arterial and venous disorders. However, the main drawback of these methods is the lack of any information on microvascular status of the diseased areas. This is particularly true for skin circulation, which has a rather complex vascular network with nutritional and thermoregulatory vessels, arteriovenous shunts, etc. . For a lSince the invention of Doppler flowmeters, useful information relating to the function and viability of an organ became available to scientists and clinical practitioners. The Doppler flowmeters are non-invasive and relatively simple instruments that have found enormous applications in research as well in clinics. The detection of blood flow by Doppler flowmeters is based on a Doppler effect. The Doppler effect or Doppler shift, named after the physicist Christian Doppler who proposed it in 1842, is the shift in frequency and wavelength of waves which results from a source moving with respect to the medium, a receiver moving with respect to the medium or even a moving medium . It is pLaser Doppler flowmetry (LDF) or laser Doppler velocimetry has been extensively used in medical and dental research. LDF is a non-invasive technique widely used in haemodynamic research for assessing microvascular blood flow, in particular, to partially quantify blood flow in human tissues such as the skin . This meLDF was firstly demonstrated by Maiman . Then a The LDF evaluates blood flow in capillaries that are close to the skin surface and the flow in the underlying arterioles and venules involved in the regulation of skin temperature . It workLDF technique was first described in dental literature in 1986 by Gazelius et al. . Of impoThere are numerous applications of LDF in dental research as well as in dental practice, in particular, this method is used for the investigation of microcirculation and vitality of the dental pulp ,39, periLDF provides data on the blood flow of the marginal gingiva at different dental regions. However, there exists a difference in blood supply of marginal gingiva of the upper and lower jaws  as well Scattering of the surrounding tissue as well as morphological characteristics such as gingival thickness, in particular, periodontal biotypes, might influence LDF variability ,52. Age Marginal blood flow can also be affected by individual characteristics of the restorations or plaque accumulation index . Vag andGingival microcirculation exhibits a dramatic, dynamic change in response to the development and progression of gingivitis. However, studies indicate controversies in an existing relationship between plaque accumulation, gingival inflammation and tissue microcirculation. The growth of blood flow in an inflamed gingiva in comparison with a healthy gingiva was demonstrated in several animal ,59,60 anLDF is an unbiased non-invasive method of monitoring the response to periodontal therapy . It is aThe LDF method also proved that smoking alters gingival blood flow. In young people, a significant, immediate increase in gingival blood flow was observed during smoking that afterwards returned toward baseline within 10 min . It is sChanges in gingival blood flow after orthodontic force application were also studied by the LDF technique. It was estimated that this change correlated to the degree of force applied to displace the teeth, although individual responses to the same degree of force varied in dependence on the degree of tooth displacement  and the LDF is the objective method to assess pulpal blood flow, even though it is not commonly used in clinical settings due to its expense and the time involved. This technique has been successfully utilised for estimating pulpal vitality in adults and children, differential diagnosis of apical radiolucencies , examining the reactions to pharmacological agents or electrical and thermal stimulation and monitoring of pulpal responses to orthodontic procedures and traumatic injuries ,77.It was proven that LDF better indicates pulpal vitality than traditional vitality tests ,78-80. LMany studies showed that blood circulation and not innervation is the most accurate determinant in assessing pulp vitality, as it provides an objective differentiation between necrotic and vital pulp tissue ,83. It wThe method is considered to be highly efficient in assessing pulpal vitality in healthy and traumatised teeth. LDF proved to be the most effective and early indicator for revascularisation of the pulp (3 weeks) . YanpiseThe LDF test might be useful for showing signs of adverse outcomes in luxated teeth. It was suggested to use predictive modelling for identifying ‘at-risk’ teeth early after the trauma and initiation of their treatment in advance, reducing the risk of the tooth being lost because of pulpal necrosis and infection -89. BesiPulpal responses to orthodontic forces or orthopaedic forces created by rapid maxillary expansion have been investigated by LDF -95. McDo3. That is why it cannot analyse different variables, in particular, the flow in individual microvessels, the number of vessels with an active flow and changes in vessel diameter [The existing controversies might be on several limitations of the technique. A major LDF drawback is that it only detects movement of erythrocytes in a small volume of tissue that is about 1 mmdiameter . The othdiameter .The artefacts caused by tissue motion in relation to the probe might be another source of error during LDF measurements. To reduce sensitivity to movement, a stabilising stent needs to be fabricated individually for each patient. Also, an accurate signal acquisition requires a fixed and constant position, minimising involuntary patient movement. The acquisition time of 3 min is used most frequently, especially due to the indications of the manufacturer -103. ThiLDF could not be used through restorations to assess dental pulp blood flow. It is highly important that investigated teeth must be isolated in order to avoid laser light interacting with gingival blood flow. The assessments might be also susceptible to environmental and technique related factors . In thisAnother obvious obstacle for common use of this technology could be costs of commercially available equipment and computer technology storing and comparing the recorded data.The basic function of ultrasonic flow meters (UFM) is to emit ultrasound and to detect reflected ultrasound , which pUltrasound is sound with a frequency that is higher than 20 kHz. In medical imaging, utilised ultrasound frequencies mainly range between 1 and 40 MHz. The transmission through air of such high frequencies is impossible, but they can satisfactorily pass through solid or fluid materials .Every flowmeter has a probe consisting of piezoelectric crystal, which generates the ultrasound beam. A second crystal, slightly separated from the first one, detects the reflected ultrasound. It means that every ultrasonic transducer has a dual function as both transmitter and receiver of ultrasound. The probe is applied to the skin, and a specialised ultrasonic gel is used to conduct ultrasound. A signal produced by an ultrasonic transducer usually consists of a pulse of a few microseconds with a certain centre frequency. Part of this signal extends through the target tissue, part is reflected by macroscopic tissue structures, part is absorbed by tissue and part is scattered by structures in the tissue smaller than the acoustic wavelength . The ultThe UFM technique was originally proposed by Satomura, Matsubara and Yoshioka (in 1956) for the physical measurement of minor vibrations . In 1960The UFM technique in dentistry is a well established and commonly used diagnostic tool in Russia and some other countries. Many researchers proved its useful role in prevention and early treatment of periodontal lesions -113.Doppler ultrasonic flowmeter has the following advantages:•Evaluation of blood in a limited gingival area (diameter of transducer is 1.5 mm);•Metal constructions in the oral cavity are not limitations or contradictions for investigation of blood flow in the gingiva or tooth pulp;•Investigation of a pulp blood flow;•Possibility to detect blood flow in hard-to-access areas;•Minimal time from measurement to obtain the results;•Method is well tolerated by patients;•Investigation could be repeated any number of times that allows controlling microcirculation changes over time.There are several standardisation requirements for the UFM technique:1. Patient should be at rest; there should be lack of physical activity before investigation,2. During measurements, patient should be laying or sitting.3. There should be comfortable temperature in the room (20°C–22°C).4. It is forbidden to smoke or chew, in particular, a gum before measurements.5. Investigator should not be pressured on the transducer not getting spurious result.6. During measurements, the transducer should be placed at the same position.During ultrasonic blood flow investigation, the ultrasonic gel provides contact between the transducer and oral mucosa. A transducer 20–25 MHz is used to characterise periodontal blood flow. The ultrasound penetrates tissues at the depth of 0.8 сm. It is possible to control the position of transducer by sound and visual signals. It also helps to find and verify different types of blood vessels. For example, the arteries' pulsations are heard as continuously rising and falling, while the veins' sound is similar to that of the surf. The sound obtained from microcirculation is characterised as weak amplitude fluctuations on background of sea noise. The Doppler signal is processed in a computer and is displayed as pulse curves with colour spectrum called dopplerogramms Figure .Dopplerogramms help to visually determine the velocity of blood flow. It is known that the fastest erythrocytes are moving in the centre of the blood vessel. On a dopplerogramm, the fastest blood particles have a darker colour and could be seen at the rim of the curve in a distance from the baseline while the slowest ones are in the middle of the curve near the baseline. The programme also indicates the direction of blood flow: to transducer  or from transducer .Computer analysis of Doppler pulse curves provides information about the linear  and the volume velocity values of blood flow in the examined area. Qualitative and quantitative assessment of the blood flow is possible. The qualitative characteristic of the Doppler curve varies depending on the type and diameter of the vessel. Microcirculation (mixed blood flow) is characterised by pulse curves with colour spectrum with no sharp peaks Figure .UFM has several advantages in comparison with Doppler laser flowmetry :1. Audible and visual control of the position of transducer2. Ability to determine a type of a blood vessel  by analysing the blood flow curve3. Ability to analyse the distribution of the blood cells with different velocities in the investigating vessel4. Detection of the direction of the blood flowOverall, laser and ultrasonic flowmeters are valuable tools in periodontal diagnosis and management. They might be especially useful for the prediction and prevention of periodontal diseases as well as for the management of gingivitis and periodontitis. However, they provide different information about blood flow in the investigated areas. That is why they are recommended to be used in combination for the prediction and prevention of periodontal lesions to provide more detailed and accurate data.LDF: Laser Doppler flowmetry; UFM: Ultrasonic flowmetry.Both authors declare that they have no competing interests.LO conceived the concept and idea of this article, participated in the collection of references, formed the thought line and outline of this article, coordinated, guided, led and corresponded the writing and heavily revised the entire manuscript. AB participated in the collection of references, constructed Figures LO is a professor of dentistry, the President of the City Periodontal Center ‘PAKS’ , the Head of the Therapeutic Dentistry Department of the St. Petersburg State Medical University named after I.P. Pavlov, Vice-President of the St. Petersburg Dental Association, a member of the Scientific and Dissertation Council of the Pavlov Medical University, member of the Peter's Academy of Arts and Sciences, member of the National Academy of Esthetic Dentistry  and Vice-President of the Periodontology section of the Russian Dental Association. LO is a leading specialist in the field of periodontics, immunology and dental care as well as in undergraduate and postgraduate training of medical service providers in St. Petersburg and other regions of the Russian Federation. AB is the assistant of the Therapeutic Dentistry Department at the I.P. Pavlov Saint-Petersburg State Medical University; her PhD was supervised by Professor Liudmila Yu Orekhova; she focuses on the studies of oral conditions, in particular, periodontal lesions, and microcirculation disturbances in oral cavity.


The use of complementary and alternative medicines including dietary supplements, herbals and special diets to prevent or treat disease continues to be popular. The following paper provides a description of an alternative dietary approach to the self-management and treatment of cancer, the Bill Henderson Protocol (BHP). This diet encourages daily intake of raw foods, a combination of cottage cheese and flaxseed oil and a number of supplements. Some foods and food groups are restricted . Early background theory that contributed to the protocol’s development is presented as is a summary of relevant evidence concerning the anti-cancer fighting properties of the individual components. Supplement intake is considered in relation to daily recommended intakes. Challenges and risks to protocol adherence are discussed. As with many complementary and alternative interventions, clear evidence of this dietary protocol’s safety and efficacy is lacking. Consumers of this protocol may require guidance on the ability of this protocol to meet their individual nutritional needs.  The supplement list is extensive; products containing beta glucan, barley grass, a multivitamin and mineral, and a nutrient combination of green tea, l-lysine, l-proline and vitamin C  (p. 39).There is also a potential link between sugar and cancer involving the effect of sugar on the immune system. It has been reported that the daily ingestion of 75–100 g of simple sugars, including glucose, sucrose, fructose and honey has been found to induce a fifty percent drop in the activity of white blood cells for two to five hours . The immAlcohol intake has been associated with an increased risk for certain cancers including breast, rectal and pancreatic cancers ,133,134.This paper has summarized the available evidence on the anti-cancer properties of the components of the Bill Henderson Protocol. Prospective longitudinal studies with intermittent measures are not available for testing the efficacy of the BHP. Some data exists on some of the individual components suggested as part of the protocol. The protocol was created by Bill Henderson, motivated by his own interest in curing cancer  (p. xiiiAs a large component of his six component diet, Bill Henderson suggests cottage cheese and flaxseed oil recommended by Dr. Johanna Budwig in the 1950s. While it is known that the essential fatty acids found in flaxseed oil, as well as methionine and cysteine, are important in human health, with modern advancements to our understanding in areas of human physiology, lipid metabolism and lipoproteins, Budwig’s fervent belief in these combined substances as cure for cancer appears overly simplistic. Although Budwig lived until 2003, and was actively lecturing until the late 1990s, there does not appear to have been any attempts to test her theories using modern technology or different source materials, such as fish oil. An additional constraint to the interpretation and understanding of Budwig’s work is that it was originally published in German. While English translations are available, they are primarily copies of lectures, letters and transcribed interviews. The foundations of her theory seem at times to be “lost in translation” making it difficult to review and evaluate her theories.The information available on the supplements that are a part of the BHP is limited. The use of a beta-glucan supplement as an immune stimulant does appear to be supported by scientific research, although there is still much to assess about the value of differing beta-glucan sources and concentrations ,57,58,60The combination of lysine, proline, ascorbic acid and green tea extract has been studied by The Dr. Rath Research Institute and based on their published work, has shown this nutrient mixture to be a promising anti-cancer proliferation agent ,93,94,95Adherence to the BHP comes with several challenges; the first being the high number of pills to swallow on a daily basis. If one strictly adheres to all the components of the protocol, a minimum of 46 pills and 6 tablespoons of flaxseed oil are required each day. For cancer patients with digestive difficulties, including nausea and/or obstructions, this may not be possible. A common side effect of consuming large amounts of oil is nausea and this may impede adherence in taking the full amount of flaxseed oil. Those people intolerant of dairy products may find the ingestion of cottage cheese challenging. If one is able to consume all the required components of the protocol, the doses of certain nutrients including vitamin A, C, B6, niacin, magnesium and manganese exceed the tolerable upper levels of intake. Depending on the individual, this may or may not produce side effects. The possibility of conventional drugs interacting with the protocol supplements may also be of concern. For example, those on anticoagulants may be at risk of agonistic effects from an increased intake of supplements such as vitamin E, ginger, Ginkgo biloba, ginseng and omega 3 fatty acids, which can interfere with the expected therapeutic effects  (pp. 269The dietary guidelines of the BHP are restrictive, eliminating some of the most common foods in the Western diet. For many, this drastic dietary change may be one of the greatest challenges to protocol compliance and there is conflicting data about the value of eliminating the restricted foods. The nutritional status of cancer patients may already be compromised by virtue of their disease symptoms and further dietary restrictions may have negative effects such as insufficient energy intake. Supplementation in excess of recommended dietary intakes may trigger adverse effects that are unexpected. Evaluation of the potential benefits of the BHP in comparison to its potential negative effects in this population needs to be undertaken. Moreover, potential protocol adherents are encouraged to forgo conventional treatment, albeit for a limited period of time, to try the BHP and delay or attenuate treatment with known benefits.The Bill Henderson protocol is a dietary approach for the treatment and management of cancer. Presently, the protocol as a whole has not been evaluated, although varying amounts of evidence exist for some of its components. While there is some historical suggestion of a scientific rationale for this protocol, its claims remain unproven. Certainly further study is needed. Future investigations should consider whether this protocol meets the nutritional requirements of consumers with cancer and if it has any impact on morbidity and mortality in this patient group. Information on dietary information needs to be made available to consumer groups so that they may make informed choices when undertaking such self-management regimens.


Motor learning has been found to occur in the rehabilitation of individuals with Parkinson's disease (PD). Through repetitive structured practice of motor tasks, individuals show improved performance, confirming that motor learning has probably taken place. Although a number of studies have been completed evaluating motor learning in people with PD, the sample sizes were small and the improvements were variable. The purpose of this meta-analysis was to determine the ability of people with PD to learn motor tasks. Studies which measured movement time in upper extremity reaching tasks and met the inclusion criteria were included in the analysis. Results of the meta-analysis indicated that people with PD and neurologically healthy controls both demonstrated motor learning, characterized by a decrease in movement time during upper extremity movements. Movement time improvements were greater in the control group than in individuals with PD. These results support the findings that the practice of upper extremity reaching tasks is beneficial in reducing movement time in persons with PD and has important implications for rehabilitation. Motor learning is defined as a relatively permanent change in the ability to move associated with either practice or experience . In neurParkinson's disease (PD) is a neurodegenerative disorder affecting basal ganglia functioning, characterized by four cardinal signs; bradykinesia (slowness of movement), rigidity (stiffness), resting tremor, and postural instability. Bradykinesia is an inherent component of PD and affects both movement initiation and execution , 5. MotoAcquisition and retention of movement skills are important to researchers and clinicians who are involved in rehabilitation of individuals with PD , 6–8. NiAlthough a number of studies have examined acquisition and retention of tasks in PD, the sample sizes have been small and heterogeneous, and the experimental tasks and outcomes used have varied widely. For example, kinematic variables, including distance , speed , and acceleration, have been used to measure motor learning both in the upper and the lower extremities in individuals with PD , 10. OthRegardless of the design features of each study, practice of the experimental task is integral to any of the research paradigms. While some researchers have suggested that people with PD do improve with practice, but not to the same level or as well as do control subjects –15, othe Given the apparent heterogeneity of methodologies and participant samples, it is not surprising that there is disagreement on the extent and duration of skill acquisition in persons with PD. Such disagreement makes it difficult to draw firm conclusions and provide therapeutic recommendations to clinicians. To date, there have been systematic reviews, but no meta-analyses pooling or combining the existing data on acquisition and retention of skills in individuals with PD that may provide insight into the consistent effects of motor task practice. By focusing only on upper extremity and on movement time during practice of upper extremity reaching tasks, we were able to find a sufficient body of literature to analyze using a meta-analysis paradigm. The purpose of this study, therefore, was to determine how practicing a simple upper extremity motor task affects movement time for the task in people with PD.The electronic databases used to find research that evaluated upper extremity motor learning in people with PD were CINAHL, EMBASE, PubMED, MEDLINE, PEDro, Proquest, PsycINFO, the Cochrane Database of Systematic Reviews, and Scopus. The comprehensive search used terms within the following categories: motor learning, Parkinson's disease, upper extremity, and time/speed/rate. The specific terms within categories are listed in The first four authors worked in pairs. Each pair was randomly assigned to search a set of databases and to select articles for screening. This initial search strategy resulted in 127 articles.Once the set of 127 articles was retrieved, the first four authors evaluated them. The title, abstract, and full content of all articles were screened against the inclusion criteria, with each article appraised by two of the first four authors. Based on the criteria, articles for inclusion in the meta-analysis were chosen. Where there was disagreement between members of the pair of reviewers, the fifth and sixth authors (S. J. Spaulding and M. E. Jenkins) were consulted, and a consensus was reached. Inclusion criteria were as follows: articles that were published between the beginning of included databases up to September 2010, articles published in English, studies that examined upper extremity motor learning in individuals with PD, studies that included means and standard deviation or standard error, studies that evaluated motor learning with time as an outcome measure, and studies that had a control group.Following the methodologies used by Siegert et al. , articleThe authors then examined the experimental design of these 30 articles to determine research that provided pre/postmeasurements of movement time prior to and following an intervention designed to elicit motor learning. The final group of articles included five publications published between 1998 and 2009. Within those articles, there were seven independent studies.The first four authors working in pairs extracted the data from the seven independent studies. The following information was obtained for both experimental and control groups in all studies: sample size, pretraining mean, pretraining standard deviation or standard error, posttraining mean, and posttraining standard deviation. All time point values were documented immediately following the intervention and late (in terms of time after practice) as defined by each individual study. Data were extracted from text or figures, depending on how each article presented the data. If the resultant data were presented in a figure, each author, in the original pair of authors, extracted values, thus two measures were taken from the figure. The final value used was an average of the two authors' extracted numbers. Three studies reported both immediate and follow-up scores. When more than one follow-up period was measured, the authors chose to use the longest interval between training and followup. For the purposes of this meta-analysis, this period was termed late after training. Platz et al.  and Marig, a measure of the standardized mean difference, was determined for the pre/postscores in each of the control group and the group of individuals with PD. Hedge's g accounts for the overestimation of the population-standardized differences [A meta-analysis was conducted using the program Comprehensive Meta-Analysis (CMA) . Hedge'sferences .Because it could not be assumed that the people in the studies were highly homogeneous in their characteristics, a random effects model was used and provided a conservative estimate of the differences between the groups in the individual studies .A total of 58 individuals with PD and 56 participants without PD were included from the seven studies. Descriptive statistics of all the subjects are included in g with a 95% confidence interval (CI) for each of the included studies is summarized in Hedge's As seen in the forest plot representing the results for the control group , the poiAlthough many studies have reported that motor learning occurs in individuals with PD, not all studies have reported improvements . Among sThe results of the meta-analysis suggest that motor learning in upper extremity function occurs in both neurologically healthy controls and individuals with PD through practice of upper extremity reaching tasks designed to reduce movement time. This effect is present immediately after the training period but also is sustained after a period of time although the late effects are somewhat diminished. The control participants have a mild to moderate increased effect based on their mean effect sizes compared to people with PD. However, the substantial overlap of confidence intervals would suggest that both groups benefit from the practice in which they participate.Overall, these results are consistent with previous work in small studies that demonstrate skill acquisition and retention in people with PD in a variety of motor tasks. Such studies have demonstrated acquisition and retention of motor skills in varied upper extremity tasks not included in this meta-analysis such as serial reaction time tasks –27 and oIn addition, motor learning effect, demonstrated by improvement in movement time, was smaller among individuals with PD. This is not particularly surprising, given the role of the basal ganglia in both acquisition of motor task skill and in consolidation of automatic movements , 3, 31. A number of differences were identified in the experimental methodologies of the studies from which data were extracted to conduct this meta-analysis. There was variability among the duration and frequency of practice as well as the types of tasks. These differences preclude the authors from determining that there is one type of practice that was more effective to improve upper extremity performance. However, one can conclude that practice in general is beneficial and the manipulation of practice parameters is worthy of further study. Interestingly, even in the studies in which the individuals were off dopamine replacement medication , 18, theA limitation of the present meta-analysis is the small number of studies that the authors were able to include, but to the best of our knowledge, all of the available studies of simple reaching tasks reporting movement time as an outcome were incorporated. There are more studies evaluating practice, but they were heterogeneous in their tasks or in their outcome measures; therefore, they did not meet our inclusion criteria, and the data could not be included in this meta-analysis. Additionally, the sample sizes of the included studies were small, affecting the generalizability of this meta-analysis .Current literature in this area typically examines one single task or movement. Future research might best examine the generalizability of the effects of practice to other tasks and areas of rehabilitation. Conclusions from a broader range of tasks could lead to the use of programs that are directly related to movements needed for daily functioning. Finally, future motor skill acquisition research should further examine the effects of varied practice parameters in more diverse samples of persons with PD.Results from this pooling of data from various studies provide evidence that upper extremity movement time can be improved through the use of practice of reaching tasks in persons with PD, albeit potentially to a lesser extent than is shown in individuals with no neurological problems. The collective interpretation of this meta-analysis indicates that practice of relevant motor tasks targeted at maximizing acquisition and retention improved movement speed.