In 2007, the 5-year survival rate for children with acute leukemia in Baja California, Mexico was estimated at 10% (vs. 88% in the United States). In response, stakeholders at St. Jude Children’s Research Hospital, Rady Children’s Hospital San Diego, and the Hospital General de Tijuana (HGT) implemented a transcultural partnership to establish a pediatric oncology program. The aim was to improve clinical outcomes and overall survival for children in Baja California. An initial needs assessment evaluation was performed and a culturally sensitive, comprehensive, 5-year plan was designed and implemented. After six years, healthcare system accomplishments include the establishment of a fully functional pediatric oncology unit with 60 new healthcare providers (vs. five in 2007). Patient outcome improvements include a rise in 5-year survival for leukemia from 10 to 43%, a rise in new cases diagnosed per year from 21 to 70, a reduction in the treatment abandonment rate from 10% to 2%, and a 45% decrease in the infection rate. More than 600 patients have benefited from this program. Knowledge sharing has taken place between teams at the HGT and Rady Children’s Hospital San Diego. Further, one of the most significant outcomes is that the HGT has transitioned into a regional referral center and now mentors other hospitals in Mexico. Our results show that collaborative initiatives that implement long-term partnerships along the United States–Mexico border can effectively build local capacity and reduce the survival gap between children with cancer in the two nations. Long-term collaborative partnerships should be encouraged across other disciplines in medicine to further reduce health disparities across the United States–Mexico border. According to the World Bank, Mexico was the 11th most populated country in the world in 2011 with roughly 122,330,000 citizens, and spent $620 US per capita on healthcare [6.2% of its gross domestic product (GDP)], ranking 70th worldwide. Based on published data, Mexico’s health outcomes seem to underperform its healthcare expenditure rankings and GDP earnings, with some healthcare outcomes ranking low, such as infant mortality rate (97th), under-five mortality rate (87th), and access to improved sanitation facilities (104th)  is the third highest healthcare spender at $8,895 US per capita (17.9% of its GDP – the most of any country) , share a 24 km-long border. Close to 60 million people cross this border annually; therefore, it is the busiest land-border crossing in the world. Two of the largest hospitals that provide care to patients in these cities are Rady Children’s Hospital San Diego (RCHSD), the largest children’s hospital in California and the sixth largest children’s hospital in the US, and the Hospital General de Tijuana (HGT), the largest public hospital in northwestern Mexico. These two institutions are separated by only 43 kilometers – a short 30-minute drive – and although the international boundary is very distinct, this border region is culturally, linguistically, demographically, and economically blurred.With more than 160,000 new cases of childhood cancer diagnosed annually worldwide, the survival gap for children with cancer in high-income countries (HIC) and low- or middle-income countries (LMIC) is astounding , 3. AlthFive-year overall survival rates for children with cancer in HIC, like the US, are often 80–90% as compared to anywhere between 5 and 60% for children in an LMIC like Mexico –7. This Mortality due to cancer constitutes an increasingly large proportion of total childhood mortality in LMIC –10. MexiGiven the need for improved pediatric cancer care in the Mexican border region and the proximity to San Diego, leaders at RCHSD reached out to numerous hospitals in Tijuana to assess interest in engaging in a binational, collaborative partnership to establish a pediatric oncology unit in Tijuana and improve outcomes for children with cancer. Among the institutions contacted, the HGT responded and expressed its willingness. Subsequently in 2008, RCHSD, the St. Jude Children’s Research Hospital International Outreach Program (St. Jude IOP), and the HGT engaged in this long-term partnership to find a sustainable, local solution for the children with cancer of Baja California in need of life-saving oncology care. To the best of our knowledge, as of 2008, a transcultural partnership in pediatric oncology had not yet been established between institutions located in such close proximity of the same border.Physicians from RCHSD performed an initial site visit assessment at the HGT in May 2008. The St. Jude IOP had previously developed tools to aid in performing needs assessments . One of Infrastructure and clinical outcomes improvement by establishing a fully functional pediatric oncology unit within the HGT in a culturally sensitive manner and tailored to the local needs and healthcare system and developing a quality assurance plan.Capacity building by appointing a local program coordinator at the HGT, maintaining frequent communication between RCHSD and the HGT, and establishing and training a local, dedicated team of physicians, nurses, and ancillary staff to provide high-quality, specialized care.Ensuring the long-term financial sustainability and provision of medications, supplies, and equipment by facilitating the pediatric oncology unit’s national accreditation and identifying and supporting a local grassroots foundation affiliated with the HGT to build a fundraising program aimed at subsidizing the cost of expenses not covered by the public health system.A bilingual and bicultural pediatric hematologist/oncologist from RCHSD (PA) was designated to work with the leadership at the HGT and designed a 5-year action plan to facilitate the implementation of the new pediatric oncology program. PA worked in close collaboration with RCHSD and St Jude IOP leadership. In addition, she directly interacted with hospital leadership and key stakeholders at the HGT at all levels. PA monitored the progress by close collaboration and follow-up with all key stakeholders. Careful attention was made to the suggestions and guidelines previously published in the literature in regards to transcultural partnership implementation , 15–17 aBefore the partnership, it was not uncommon for the HGT to assign 10–20 pediatric patients to a single room on the pediatric ward. By August 2008, construction of a temporary pediatric oncology unit with five rooms was completed. In this temporary unit, cancer patients were able to receive care in an isolated environment. The current oncology unit in use today was constructed in 2011 and includes 10 isolated patient rooms, two intensive care rooms, and adequate bathroom facilities; an outpatient clinic was also completed with a procedure room, clinic rooms, an infusion center, and a school for the children.Table The creation of a start-up budget between St. Jude IOP, RCHSD and the HGT to provide initial funding.Assisting the HGT with its application for national accreditation from the Mexican Ministry of Health. Such accreditation ensured that the HGT would receive future funding from Seguro Popular.The close working relationship between key stakeholders at RCHSD and at the HGT to create a large-scale, feasible plan.The extra $1 million US provided by the Mexican federal government to enhance the infrastructure at the HGT.Four factors were essential to the infrastructure developments:The patient population tripled soon after the inception of the program. Leukemia, lymphoma, and brain tumors have constituted the most common cancers diagnosed in this population, and the disease breakdown seems to be a representative sample of the tumor burden in Mexico , 12 as wFigure Table The establishment and training of a multidisciplinary healthcare team is one of the most effective ways to achieve a high-quality pediatric cancer program where resources are constrained , 16, 22,Training for the physicians, nurses, and ancillary staff, including social workers, psychologists, and data managers, has been one of the pillars of this project. Training has taken place on-site and in other partner sites affiliated with the St. Jude IOP, such as Guatemala and Chile , 8. For One initial problem was the scarce number of pediatric oncologists trained to care for children with cancer. A “physician-extender” model was used as a solution, where a physician with training in one area pursues additional, specialized training to expand the care he or she can provide . Within Community outreach education and cancer workshops to educate local and regional healthcare providers and the general public about pediatric cancer have been one of the principal goals of the educational program. To date, nearly 2,500 community health care providers in Baja California have been reached by this initiative.Each of these training efforts has notably changed the skill level, dynamic, and culture of the multi-disciplinary team. Physicians are now well-trained to care for patients with cancer; nurses now feel respected as vital members of the team; and doctors and nurses now work together with other professionals and provide standard of care to their patients. A powerful change has taken place within a relatively short period of time.One of the priority action items since the planning stages of the program has been the facilitation of the national accreditation to ensure federal financing. None of the accomplishments related to infrastructure and clinical outcomes would have been possible without the constant funding provided by the Mexican national government through Seguro Popular. Seguro Popular provides a fixed amount of monies per patient per year based on the diagnosis. For example, for a patient with acute lymphoblastic leukemia, Seguro Popular disburses to accredited centers about $10,000 US annually. This fund covers for the majority of medications, including chemotherapy and antibiotics, supplies, and direct hospital costs. The local state government through its Ministry of Health supports the salary for personnel, equipment, and additional operational costs.This model has ensured a stable and predictable funding stream to provide comprehensive care for pediatric cancer patients, an essential element to the long-term success of any health system’s strengthening effort .Despite the immense financial contributions made by Seguro Popular, the funds have not been sufficient to meet the HGT’s needs. Therefore, local grassroots efforts have offered immense support to the patients and their families. Patronato Pro-Hospital de Tijuana – Patronato – is a local, apolitical organization founded in 2000 to support all patients at the HGT, which are often vulnerable. Given that the HGT is the largest public, community hospital in Northwestern Mexico, it serves as a safety net for the poorest in Baja California; as a result, nearly all families that seek care at the HGT live below the effective poverty line of $200 US per month. Among other services, Patronato provides food subsidies, funding for some medications not covered under Seguro Popular and lodging for families who reside outside Tijuana (about 35% of families). This strategy facilitates access to care and helps prevent abandonment of treatment. Thus, without Seguro Popular and the philanthropic efforts of Patronato, patients at the HGT could not have access to treatment and would more frequently be lost to treatment abandonment, since the majority of patients receiving care at the HGT cannot afford the high expenses associated to oncology care, including the cost of travel to the HGT, food, missing work for one or both parents to support their child, and many other expenses. Since the inception of the partnership program, cancer care has been provided free of all costs to all patients younger than 18 years of age receiving care at the HGT regardless of their income or socio-economic status. Moreover, Patronato has been the vehicle for the disbursement of funds provided by the St. Jude IOP-RCHSD partnership to sponsor all training activities and salary supplementation for key personnel at the HGT.In addition, close relationships between leadership of the partnership program and Patronato have led to effective community advocacy contributions to strengthen relationships with local government leaders. This focus has been instrumental to the successful launching and sustainability of the program.Collaborative partnerships in pediatric oncology between institutions in HIC and LMIC may overcome health disparities by strengthening health systems and improving clinical outcomes for children with cancer. Innovative and dynamic collaborative models, where an academic pediatric oncology center in a HIC establishes a long-term partnership with an emerging center in a LMIC have been successful in improving survival rates for children with cancer . One of Numerous ethical principles have been at work throughout the successful St. Jude IOP-RCHSD-HGT collaborative initiative. In general, transcultural partnerships elicit several ethical issues that should be addressed prior to engaging in the relationship. They are not necessarily the classical principles of ethics such as beneficence, maleficence, justice, or autonomy, but center around an understanding of intercultural aspects and communications. There should be an understanding of the dynamics between each party with sensitivity to specific cultural norms and behaviors. There can be ethical conflicts that relate to relationships and trust. Is the trust based on signed agreements or does it depend on the relationship between the two parties? If the trust is based on relationship, when and how does the relationship begin and end?One also needs to be aware of the differences between autonomous decision making and paternalism. One partner should not expect to come in and direct decisions. Rather, all parties involved should guide each other and have a common motivation, similar perspectives, and unifying goals. Specific ethical issues will include potential sources of conflict such as emotions, assumptions and perceptions, values, needs and goals, lack of information or clarity, and individual styles of communication and behavior. To achieve a successful working relationship, stakeholders would benefit by separating any conflicts from concepts of right and wrong, and considering looking at or doing things in different ways that would be acceptable to all parties.Health disparities in pediatric oncology are well-documented, as are the epidemiology and burden associated with childhood cancer in developing countries , 13–15.In 2012, the Mexican census reported 32,972,300 children aged 0–18 years, comprising 37% of the total population . Of thosIn Mexico, cancer is the sixth leading cause of death in children 1–4 years old and the second leading cause of death in children 5–14 years old , 12. PriThe economic differences between the US and Mexico have contributed in part to some of the healthcare disparities that extend into the discipline of pediatric oncology. Before 2008, there was neither a pediatric oncology unit nor a pediatric oncologist in all of Baja California. Lack of pediatric cancer care is a problem that has extended beyond the San Diego–Tijuana border. In 2012, Mexico had 3.6 pediatric oncologists per million children under the age of 18 , as 44% The Mexican government acknowledged improvements needed to be made to its healthcare system, including improvements in pediatric cancer care; thus in 2006, the highly-acclaimed Seguro Popular legislation was passed. Seguro Popular is more properly known as the System of Social Protection for Health, and within it exists the Fund for Protection against Catastrophic Expenditures that specifically covers pediatric oncology medical care. The Fund for Protection against Catastrophic Expenditures was expanded in 2008 to include full payment for all types of childhood cancers , 12, 24.These initiatives targeted to Mexican children with cancer represent a major effort toward providing appropriate care for these traditionally underserved patients and represent a model for other LMIC across the world , 24, 30.Holism: One takes a holistic approach when one considers all systems components, processes, and relationships simultaneously. A successful transcultural partnership ultimately succeeds based on a true bilateral relationship, one where both institutions work through and improve the processes of the new oncology unit. Leaders at RCHSD took a holistic approach with the HGT by making at least weekly site visits from 2008 to 2010 and monthly visits afterward and by serving as accessible day-to-day mentors as problems arose.Context and collaboration: One considers the context when one considers global, national, regional, and local culture and politics. Collaboration takes place when long-term, equal, and respectful relationships are fostered between mentors and mentees, in all sectors and organizations involved. Since the inception of the program, one of the priorities has been to foster an equal, long-term relationship with the leadership at the HGT, the state government, and the healthcare team in Tijuana. This spirit of cultural and political sensitivity in relationships with Mexico’s Secretary of Health, the HGT leadership, local staff, and patients has been crucial to the success of various aspects of the program.Social mobilization: Social mobilization refers to efforts that advocate for social and political change to improve health systems and social determinants of health. In Tijuana, Patronato has played a major role, as the main advocate of the children, impacting the local community and society and leading to a successful development of the new HGT pediatric cancer program.Capacity enhancement: This occurs when individuals, communities, ministries of health, and other stakeholders in the health system become better able to provide for the various levels of healthcare and accept ownership for doing so. This is one of the greatest strengths of this particular partnership, as capacity enhancement has taken place at all levels, such that there now exists an independently operating pediatric cancer unit in Baja California for the first time. The Secretary of Health has become more engaged in supporting the development of pediatric cancer services in Mexico, and community pediatricians and primary care providers in Baja California are better able to diagnose cancer and refer patients promptly to the HGT.Equity: One strengthens health systems in an equitable way when one focuses on and empowers those who are marginalized. The very purpose of this transcultural collaboration is to reduce health disparities for children with cancer in the border region and to improve access to care and, ultimately, clinical outcomes. This mission continues to expand as the HGT has become a regional referral center and agent of healthcare change. The HGT recently has begun mentoring the Hospital General de La Paz, Baja California Sur, Mexico, as they seek to establish the first pediatric cancer unit in the state of Baja California Sur.Financial protection: Predictable funding streams dramatically affect the way an organization is able to operate and plan. The initial shared and realistic budget between St. Jude IOP, RCHSD, and the HGT was vital to the long-term planning, local sustainability, and success of the partnership. Specific training in budgeting and management RCHSD physician leaders had received prior to the partnership was invaluable. Predictable funding through Seguro Popular has been crucial to the success and sustainability achieved thus far.Evidence-informed action: This is when systems and processes are put in place to gather, analyze and apply local data, make decisions based on evidence, monitor programs, and strive for transparency. The HGT has implemented a new data management system that allows for analyses of data and helps with decision-making activities. Also, the transcultural partnership process was guided according to previously established best practices from earlier collaborative programs and the team at the HGT now has access to treatment protocols and therapy guidelines already developed at RCHSD and St. Jude IOP.In addition to recognizing cultural differences in the St. Jude IOP-RCHSD-HGT partnership, we employed several guiding Health Systems Strengthening principles as outlined by Swanson et al.  during tThe establishment of this partnership has faced some challenges, including cultural differences between the RCHSD and the HGT teams. Appointing a bilingual and bicultural physician from RCHSD (PA) to serve as the project medical director was the first step in overcoming those barriers. More effective communication in the language spoken at the partner site facilitated mutual understanding. The net result of this dynamic was that the HGT hospital administrators, physicians, nurses, and staff were empowered to take ownership of the evolving cancer program.A crucial element of the new unit that required creativity and commitment was the constant adaptation of the delivery of care by the HGT staff to the constantly changing amount of resources available to them; during these uncertain times, it was important to find ways to move forward and make improvement, and not wait for situations outside the hospital to change .Despite their commitment to the cause, individual healthcare workers still face their own limits while caring for children with complex, life-threatening treatment complications. These professionals often have a high work load, may receive lower salaries, and often feel undervalued. Employee motivation and morale can suffer as a result. One of the solutions has been the implementation of innovative incentive programs for nurses and allied staff to reward their efforts to provide excellent care.A limitation of the interpretation of our results is that we were not able to compare the survival rates at the HGT with other similar pediatric oncology units in Mexico in an individualized manner or to those obtained in well-established pediatric oncology centers such as Instituto Nacional de Pediatria, Hospital Infantil de Mexico, or Instituto Mexicano de Seguro Social, given the scarcity of published data in the field . In addiEngaging in this transcultural partnership has not only benefited cancer patients in Baja California. As stakeholders of the St. Jude IOP-RCHSD-HGT partnership learned a unique body of knowledge, such as techniques to reduce treatment abandonment rates in Tijuana, physicians in San Diego applied those principles to help with their patients with high risk for abandonment of therapy among their own underserved Hispanic population. Abandonment is not a problem frequently encountered by pediatric oncologists in the US, thus providers often lack the training to deal with families, especially large, involved Hispanic families, when this difficult situation arises. The team in San Diego has learned from the team in Tijuana to adequately address issues with these families in a culturally sensitive and tailored way; they are now cognizant of and respectful of their specific beliefs and Hispanic family values.In addition, when made aware of the realities faced in resource-restrained settings through the close working relationships with the pediatric cancer service in Tijuana, the team and leaders in San Diego have grown to better appreciate the precious and sometimes perceived as “unlimited” resources in the US. This realization has resulted in more cost-conscious medical care by the team at RCHSD.Despite all these improvements, 50% of the total expected number of new cases of pediatric cancer in Baja California are still not diagnosed or treated in the current pediatric cancer unit at the HGT. The distribution of the pediatric cancers currently treated at the HGT mimics the epidemiology of pediatric cancers in other areas of the world , 12, 19.Based on data obtained from the HGT’s newly established institutional registry between 2008 and 2014, the number of new cases per year has risen from about 20 to about 70, which is the number of expected cases solely for the population of Tijuana. About 35% of patients treated at the HGT come from outside the city, so while access to care has increased for children with cancer in Tijuana and Baja California, there are still children both in the city of Tijuana and in the state who are not receiving the life-saving care they need.Looking to the future, efforts will concentrate around improving further the care, the infrastructure, and promoting awareness of pediatric cancer in Baja California. The community outreach programs will continue to train pediatricians, primary care providers, and health “promotores” throughout the state in order to prepare them to detect pediatric cancer earlier in communities state wide.Completing the HGT pediatric cancer unit’s transformation into a regional referral center that provides high-quality pediatric oncology care in Mexico and becoming a mentor for the Hospital General in La Paz, Baja California Sur and other hospitals in the region.Furthering innovations to retain the nursing staff and other healthcare workers and keep them motivated.Continuing to grow the “physician–extender” training and retention program, with the hope that palliative care and neurosurgery services can be added to those available to patients and their families at the HGT in the future.Initiatives going forward include:One of the critical factors for the long-term success of any collaborative transcultural program is to pursue healthy, long-term, and culturally sensitive relationships with government leaders and other stakeholders in the LMIC. Budgeting training and managerial skills are essential, as well as predictable and sustainable funding sources. Adherence to other Health Systems Strengthening principles enhances the likelihood of program success.One of the short-term goals of all transcultural partnerships in pediatric oncology should be to improve clinical outcomes for children in LMICs. The long-term goal of all collaborative partnerships should be to transform an emerging pediatric oncology unit into an independent, high-quality, referral center that can initiate other local and regional collaborations.There is a vast need for overcoming health disparities along the border region for both adults and children with various health conditions such as cardiac, infectious, metabolic, and surgical, among others; this represents a remarkable opportunity for improvement among clinicians, government officials, public health professionals, and other stakeholders on both sides of the border. The process that transcultural partnerships have developed to overcome health disparities is proven and could be applied to other disciplines of medicine.Even within the HGT, where pediatric cancer care has already experienced dramatic improvements and where other physicians and departments have witnessed the success of this program, there are several opportunities to establish similar collaborations. Next steps could include engagement of key stakeholders on both sides of the border with a willingness to overcome any cultural and system barriers.We invite pediatric cancer centers and academic institutions in LMIC and HIC to consider taking action regarding this ethical dilemma by initiating culturally sensitive, long-term collaborations with a sister organization in any discipline of medicine. We also encourage the enactment of policies that promote and facilitate such equitable, long-term transcultural partnerships.PA, SF, RR, DB, RCR, and WR made substantial contributions to the conception, design, interpretation, and/or analysis of the project and data, the drafting and revising of the manuscript for important intellectual content, and the final approval of the published article.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The main objective of this paper is to decompose the productivity growth of Egyptian cotton production. We employ the stochastic frontier approach and decompose the changes in total factor productivity (CTFP) growth into four components: technical progress (TP), changes in scale component (CSC), changes in allocative efficiency (CAE), and changes in technical efficiency (CTE). Considering a situation of scarce statistical information, we propose four alternative empirical models, with the purpose of looking for convergence in the results. The results provide evidence that in this production system total productivity does not increase, which is mainly due to the negative average contributions of CAE and TP. Policy implications are offered in light of the results. The agricultural sector is considered as one of the major sectors in Egypt’s economy, where its contribution to the country’s GDP is currently around 14% . First, The production of cotton has great importance in the Egyptian agricultural sector. First, because cotton production is a very intensive activity in the use of labor and it is carried out principally by small family exploitations. Additionally, it generates new opportunities of employment in the subsequent processes . Second, cotton production is important in Egypt because it helps to guarantee the food security for population . This coConsidering the importance of cotton production in Egypt, two issues are surprising. First, there are not empirical studies on this sector that analyze the evolution of total factor productivity (TFP) from its determinants. Second, a substantial decline was observed in cotton production (period 2004–2008), while the production of other agricultural products, such as sugarbeet, fruits, vegetables, rice and wheat, increased in Egypt in a remarkable way . In addiSome studies on cotton in Egypt, such as , enumeraIn view of the above considerations, the main objective of this study is to carry out a disaggregate analysis (by provinces) of TFP in Egyptian cotton production. In addition, it aims to analyze the evolution of TFP from its determinants (including the efficiency). On the basis of these results, this paper aims to provide evidence on the possible problems affecting the cotton production system in Egypt. One of the peculiarities of this study is the use of scarce data. To overcome this limitation, we propose four alternative empirical models to compare the results obtained. If the results obtained by the different models are similar, they can be considered to be more consistent and meaningful.To meet our objectives the rest of the paper is organized as follows. In the subsequent section we present a brief review of our methodology. Section three deals with the relationship between the statistical information available and the empirical models proposed. Section four presents the results. The final section presents the main conclusions and policy implications.Solow  proves tThere exist two main types of approaches that can be applied to estimate efficiency and decomposing productivity growth: data envelopment analysis (DEA) and stochastic frontier analysis (SFA) . In geneitQ is the production of the i-th firm  in the t-th time period ; f(·) is the production technology; itX is a vector of J input quantities of the i-th firm in the t-th time period; t is the time trend variable; α is a vector of unknown parameters to be estimated; itv is a vector of random variables which are assumed to be iid. itu, which is a vector of non-negative random variables assumed to account for technical inefficiency in production. There are several specifications that make the technical inefficiency term itu time-varying. In this paper we use the Error Components Model (ECM) specification proposed by  and changes in allocative efficiency ) Finally, policy makers should take into account that the behavior of productivity and its components is not homogeneous across provinces. Therefore, it seems reasonable to propose specific measures for each of them and to analyze the possibility of orientating production towards the provinces where productivity shows a relatively better behavior.


Allergic colitis is a clinical manifestation of food allergy during the first months of life. It is estimated that genetic factors play a role in the expression of this allergic disease. This case report described the clinical progress of infants who were cousins from two distinct family groups with allergic colitis. Five infants under six months of age and of both sexes were studied, with a diagnosis of allergic colitis characterized clinically and histologically by (1) rectal bleeding; (2) exclusion of infectious causes of colitis; (3) disappearance of symptoms after elimination of cow's milk and dairy products from the child's and/or the mother's diet. Patients were submitted to the following diagnostic investigation: complete blood count; stool culture; parasitologic examination of stools; rectoscopy or colonoscopy; and rectal biopsy. Patient age varied from 40 days to six months; three were males. All patients presented with complaints of intense colic and rectal bleeding. The colonoscopy showed presence of hyperemia of the mucosa with microerosions and spontaneous bleeding upon the procedure. Microscopy revealed the existence of colitis with eosinophilia >20 e/HPF. Patients were treated with a hypoallergenic formula and showed remission of symptoms. After one year of age, all were submitted to an oral challenge with a milk formula and presented food tolerance. Allergic colitis is a disease with evident genetic inheritance and a temporary character. The pathophysiological mechanism has still not been totally identified, but it is know that it involves the presence of CD8 lymphocytes, as well as TH-2 type lymphocytes and eosinophil infiltrate in all layers of the colonic mucosa. Additionally, circulating memory cells revealed by positive lymphocytic transformation tests suggest the involvement of T-cells in the pathogenesis of this entity, associated with secretion of tumor necrosis factor-alpha (TNF-α) by activated lymphocytes.Food allergy is an adverse reaction to food mediated by immune mechanisms, whether IgE or not. Allergic colitis is a type of allergy that belongs to the group of non-IgE mediated food hypersensitivity, also called food-induced proctocolitis. It is estimated that the prevalence of food allergy occurs in between 2.5 and 5% of the child population, and cow's milk affects two thirds of the cases, particularly in allergic proctocolitis, 50% of cases, even in those who are being breastfed.It is estimated that genetic factors exert a fundamental role in the expression of this allergic disease, since a high occurrence of atopy history in families of children with eosinophilic colitis has been describedIn this study, we report cases of allergic colitis in infants who are cousins belonging to two distinct family groups.Five infants younger than six months of age were studied, with a mean age of four months, three of them males, belonging to two distinct family groups  and 2, r, namely:The diagnosis of allergic colitis was characterized, clinically and histologically, as per the criteria set by Fiocchi et al.–presence of rectal bleeding in an infant with adequate weight and height;–exclusion of infectious causes of colitis;–disappearance of symptoms after elimination of cow's milk and dairy products from the child's and/or mother's diet.Patients were submitted to the following diagnostic investigation: complete blood count; stool culture for investigation of enteropathogenic agents; stool parasitological examination of stools; rectoscopy or colonoscopy, and rectal biopsy.Hospital Israelita Albert Einstein (HIAE), in São Paulo.The endoscopic investigation was always performed by the same professional (AG) at the Endoscopy Service of .Evaluation of rectal mucosal morphology was performed as per the criteria of Diaz et al.Written consent was obtained from the parents for the tests.At the time of their first visit, all patients, despite the complaint of rectal bleeding, were in good clinical condition, hydrated, with no apparent condition of toxemia and presented without fever  and 4. NDue to severity of the clinical condition presented by the patients, associated with the endoscopic and anatomopathological findings that were extremely characteristic of allergic proctocolitis, it was decided to delay the challenge test due to the potential risk of intense rectal bleeding. Additionally, when submitted to a hypoallergenic diet based on extensively hydrolyzed protein formula or formula based on a mixture of amino acids, patients showed excellent clinical progress, with disappearance of rectal bleeding between 48 and 72 hours after the introduction of the hypoallergenic formula.. At the first timepoint, they were offered 20mL of dairy formula and were observed for 45 minutes. If there was no clinical manifestation suggestive of allergy, the offer of dairy formula ad libitum was authorized for family members as long as they maintained close observation as to the possibility of the appearance of long-term adverse reactions.All patients were submitted to the challenge test with a dairy formula at ages varying from 11 to 18 months. All of them showed tolerance to the dairy formula used. The test was performed under strict medical supervision, as per Nowak-Wegrzyn et al. criteriaAfter the triggering test with the dairy formula and the respective release for use of cow's milk and derivatives in the diet, patients were followed clinically for a period varying from 18 (minimum) to 33 (maximum) months, with an average of 26 months. During almost this entire period of follow-up, no patient presented with any clinical manifestations related to the colonic inflammatory process.Stool culture and parasitological examination were negative in all patients.. Rectal bleeding is the most frequent complaint, usually accompanied by intense irritability and discomfort during feeding. It has already been well established that the main allergen of the diet, during the first months of life, is cow's milk, followed by soy, but other foods may also set off food allergy, such as milk from other mammals, eggs, wheat, fish, seafood, nuts and almonds, peanuts, and coconut. When these known allergens are a part of the diet of the nursing mother, they may be transmitted through the human milk. For this reason, infants who receive exclusive natural breastfeeding and who present with a genetic predisposition towards allergies, may also show symptoms of allergic colitis, even if not in an exacerbated manner. Kilshaw and Cant demonstrated that the beta-lactoglobuline of cow's milk may be detected in samples of human milk between four and six hours after the mother has ingested cow's milk. It is important to point out that all of the five patients in this case report received natural breastfeeding during a period of their lives, and that four of them were still receiving exclusive natural breastfeeding when the signs of colitis appeared.Allergic colitis is the most common clinical manifestation of food allergy, especially related to cow's milk protein, among infants during their first semester of life,4,5. In this study it was possible to follow up the five patients, from the initial diagnosis until the time of success after the progression time, between the 11th and 18th months of life of the patients. Due to severity of the clinical condition shown by the patients, associated with the extremely characteristic endoscopic and anatomopathological findings of allergic proctocolitis, we decided to postpone the challenge test, due to the potential risk of intense rectal bleeding. Additionally, when the patients were submitted to a hypoallergenic diet based on extensively hydrolyzed protein formulas or a formula based on a mixture of amino acids, there was disappearance of the rectal bleeding within 48 and 72 hours after the introduction of the hypoallergenic formula.In the present study, it was possible to clearly demonstrate that this allergy manifestation is transitory, as has been stated by other authors. Particularly in the case of food allergy, some of the factors that play an important role in its activation have been described, such as maternal diet, infant's diet, prematurity, absence of exclusive natural breastfeeding, deficiency of secretory IgA, deficiency of the intestinal permeability barrier, etc. However, the occurrence of allergic colitis in family groups, such as was verified in the present study, seems to suggest strong evidence of familial genetic predisposition. Cases of allergic colitis have rarely been described among siblings or close relatives. The findings of this study confirm those of Nowak-Wegrzyn et al., who described a case of allergic colitis provoked by soy protein in a pair of twins, as well as those mentioned by Behjati et al., who described a clinical condition of allergic colitis in three brothers, within a group of 13 patients with histories of atopy in first-degree family members.Currently, it is generally recognized that there is a genetic predisposition towards allergy that acts in association with one or more triggering factorsAllergic proctocolitis manifests even in the presence of exclusive natural breastfeeding in which the predominant manifestation is the presence of hematochezia. Another characteristic is the eosinophil infiltration of the inflamed colonic mucosa, in which treatment should be made only by the use of hypoallergenic formulas with total exclusion of the protein aggressor until it can be present in the food diet. It is important to point out that in the present experience, tolerance to cow's milk protein occurred by the age of 18 months.


Southeast Asia has been the source of some recent encouraging developments on the health front, particularly in the area of tobacco control. In December 2012, the Philippines passed a landmark sin tax legislation that restructures the decade-old tax system for tobacco and alcohol products, updates the tax rates and indexes them for automatic increases, and earmarks its incremental proceeds for universal health financing. In August 2013, Malaysia proposed to exclude tobacco from the Trans-Pacific Partnership Agreement (TPPA), a bid to protect tobacco control measures from any state-to-state or investor–state challenge. Earlier in July 2012, it was reported that Health Ministers of the Association of Southeast Asian Nations (ASEAN) agreed to withdraw tobacco from the ASEAN Free Trade Agreement (AFTA). While their actual Joint Statement made no mention of trade, the language referring to tobacco control was clear .Of foremost interest in these developments is the increasing awareness of the linkages between public health regulation and economic policy. Health arguments are being advanced to affect economic policy, with the ultimate objective of reorienting incentives to improve health outcomes. Specifically, tax, trade and investment policies are being targeted. However, the likely impact on tobacco control may not be as straightforward.There are two ways in which trade and investment agreements can be bad for tobacco control. One, when trade liberalisation or the lowering of tariffs leads to more competition that results in cheaper products that can trigger more consumption. Two, when clauses like investor protection and intellectual property protection in these agreements place limits on a country’s capacity to regulate.In the case of ASEAN countries, a study by On the other hand, new generation free trade agreements (FTAs) contain investment chapters that provide very liberal protection to investments – including the ability to lodge claims against a country in international arbitration not governed by domestic law. The TPPA, of which Brunei, Singapore, Malaysia and Vietnam are a part, and where others like the Philippines intend to join, is a potential red flag as it could provide broader investor protection than is already contained in many current arrangements. That said, these countries already have existing agreements with countries where big tobacco corporations are based , so even sans the newer more ambitious FTAs, the potential risks already exist. Therefore, a specific carveout of tobacco from new agreements will have to consider existing ones as well.On the issue of foreign direct investment (FDI), most low- and middle-income countries are in the business of attracting FDI as a development strategy. To induce these FDIs, various incentives in the form of tax holidays, subsidies and privileges are provided. All this helps to lower production costs and ultimately product prices, and affect increases in demand. The Framework Convention on Tobacco Control (FCTC Article 5.3)  explicitTransnational tobacco companies have invested substantially in most Southeast Asian countries even before open trade, the objective being to establish strategic presence, a trend that continues even after the period of liberalisation . In certThe Philippine sin tax example provides interesting insights into the political dynamics of FDI. In the 1990s and 2000s, PMI was among the biggest supporters of sin tax reform. This support was part of the attempt to break the stranglehold of Fortune Tobacco, with the tax reform expected to introduce more competition by applying non-discriminatory rates between local and imported brands. In 2010, PMI and FTC created a joint venture, the Philip Morris Fortune Tobacco Corporation (PMFTC), which gave PMI a foothold in the local market. When the sin tax campaign was revived, PMI through PMFTC became the most rabid opposition. BAT, trying to enter the market, was the only industry player supportive of the reform. Clearly, for FDI market entry is primary, but once in, FDI will protect its business to the full extent.Taxation is considered the most effective tobacco control measure in terms of affecting prices and affordability, and in turn reducing consumption and the prevalence of smoking . HoweverFor sure, the tobacco industry remains a powerful political and economic actor in the region. The experience in the region shows not just the difficulty of instituting tobacco control measures, but also the complexity of issues implied in them. At the same time, the public health challenge of tobacco use is immense. One in five ASEAN citizens smoke; more than 500 Indonesian deaths daily are accounted for by smoking; tobacco-related healthcare costs can be as high as US$1.78 billion for Indonesia; and both youth smoking and youth intention to smoke are high .The complex linkage of public health and economic policy is evident in the way countries respond to communicable diseases, like MERS, SARS and HIV-AIDS, among others. Countries’ capacity to deal with these diseases is often linked to the impact on economic productivity, and health costs. In the context of freer mobility and greater regional connectivity, disease spread across borders and how it affects travel, tourism and the regional economy becomes an equally legitimate concern.To Unfortunately, the increased activism of ASEAN health officials on tobacco control is undermined by their lack of mandate on economic issues. Trade is the domain of economic ministers; hence, health ministers calling for the withdrawal of tobacco from AFTA is more a symbolic rather than a binding move. Moreover, there had been no discussion between the two sets of ministers to find ways to pursue it in the agenda.The vital role of ASEAN cannot be overemphasised. Its significance does not stop with the negotiation and signing of various trade and economic agreements, but extends to the need to ensure that other development goals are met. Better understanding of existing economic policy is needed to inform public health measures. More importantly, there is need to link and harmonise public health and economic objectives. For this, better coordination and cooperation among different policymakers and stakeholders are crucial.


From a public health perspective, substance abuse has long been a source of major concern, both for the individual's health and for wider society as a whole. The UK has the highest rates of recorded illegal drug misuse in the western world. In particular, it has comparatively high rates of heroin and crack cocaine use. Substances that are considered harmful are strictly regulated according to a classification system that takes into account the harms and risks of taking each drug (see the tables) ). The adverse effects of drug abuse can be thought of in three parts that together determine the overall harm in taking it: (1) the direct physical harm of the substance to the individual user, (2) the tendency of the drug to induce dependence, and (3) the effect of abuse of the drug on families, communities, and society ). In this report, we discuss published evidence relating to the harm of substance misuse and consider the neuropsychopharmacological mechanisms behind addiction in an attempt to gain an improved picture of the potential devastation that abuse of these substances may evoke. The physical harm caused by a drug needs to be considered in terms of its acute toxicity, as well as its likelihood to produce long-term health problems.Acute toxicity is the adverse effect produced by a drug following either a single exposure or multiple exposures under 24 hours apart. It is assessed by measuring the ratio of lethal dose to therapeutic dose. Research conducted on 20 human and nonhuman lethal doses of abused substances, which are distributed widely in Europe and North America, identified intravenous heroin to have the greatest direct physiological toxicity. Hallucinogens in general appeared to have the least . The cliAs well as acute physical harm, many drugs when used repeatedly over time have chronic physical consequences. The long-term health problem can either be directly related to the effect of the drug or due to the method of drug administration. Several drugs including marijuana are ingested by smoking and put abusers at increased risk of chronic cough, bronchitis, and lung and upper airway cancers. The long-term adverse effects of cigarette smoking are such that they reduce life expectancy by an average of ten years . Drugs t Long-term health problems also result from the psychoneurobiological impact of chronic use. Chronic marijuana abuse has been shown to result in depression, anxiety, and, in some individuals with a predisposing vulnerability, schizophreniform disorder . HalluciTo understand the nature of drug dependence it is first important to understand the concept of drug tolerance. Tolerance is commonly encountered with substance abuse and is described as a decrease in susceptibility to the effects of a given amount of drug as a result of previous exposure . This meDependence can be a physical or emotional adaptive state which results from the body's homeostatic response to repeated drug administration. Upon cessation of the drug, the homeostasis is lost and the dependence is unmasked, for example, cold turkey with heroin dependence . The cesReinforcers such as food and sex increase extracellular dopamine in the nucleus accumbens (NAcc) via the mesocorticolimbic pathway. This results in the sensation of reward. All known addictive drugs activate this pathway but at levels up to ten times greater than food . As a reAddiction comes about through an associative learning process characterized by compulsive drug taking, craving, and relapse , 21. Theμ opioid receptor on the GABA neurons, it inhibits them from firing thus removing the inhibition of the dopamine neurons. The result is an increase of dopamine release in the NAcc which is responsible for rewarding and reinforcing behaviour at that time . The LC contains noradrenergic nuclei that are implicated in attention and arousal as well as the “fight or flight” autonomic response. Tolerance and dependence arise through chronic activation of opiate receptors, which leads to homeostatic compensatory changes. Acutely, heroin inhibits firing of LC neurons. With chronic use, the LC neurons return to their normal firing rates. This results in increasing doses of heroin being required to achieve the desired effect , 30.Relapse is a very common problem during rehabilitation from opiate use , 32. AssWhilst not life threatening, the symptoms are extremely unpleasant, often being flu-like in nature. The severity of withdrawal depends primarily on the intensity of the initial drug effects as well as the dose administered and frequency of use. The general health and personality of the patient are also thought to play a part .Amphetamine is an indirect agonist of the catecholaminergic system. It causes release of catecholamines from the presynaptic endings as well as blocking the reuptake. It also inhibits monoamine oxidase activity and hence metabolism of catecholamines . These sAnother study which also used PET imaging showed evidence of drug cue-induced DA release in the amygdala and hippocampus. The preferential induction of DA release among cocaine users further suggested that these aspects of the limbic reward network might contribute to drug-seeking behavior .A recent study investigating changes in drug use severity and physical health-related quality of life among untreated stimulant users concluded that the severity of cocaine use is linked directly to physical health-related quality of life; strong evidence of the drugs long-term health implications . So far we have discussed the harm of addiction for the individual. However the implications of drug use extend far beyond the user, often damaging their relationships with their family, community, health workers, volunteers, and wider society . One of the biggest impacts abuse has is upon the children or dependants of the abuser. The Hidden Harm report by the Advisory Council on the Misuse of Drugs estimated that there were between 250,000 and 350,000 children of problem drug misusers in the UK . As withThe cost to the community and society of drug abuse is colossal. Drug abuse has a significant impact on healthcare services, public services, and criminal justice system. Drugs that lead to intense intoxication such as alcohol, amphetamines, cocaine, and heroin are associated with huge costs in terms of damage to the user or the general public and property and loss of economic output. A large part of the health care budget is spent on treating drug users . AlcoholDrug abuse has many damaging consequences not only for the individual, but also for the society as a whole. Underneath the pleura of social problems is a phenomenally complex mechanism involving tolerance, dependence, and addiction. Multiple brain areas are implicated in many functions such as reward, motivation, learning, inhibitory control, and executive function. Addictive drugs hijack the reward pathway that is intended for natural reinforcers and in doing so cause harm both acutely and chronically to individuals and society.


Clinical Significance. The use of a reversible treatment for reestablishment of the OVD in old complete dentures with a diagnostic occlusal acrylic splint allows for the reestablishment of the intermaxillary relationship, providing physiological conditions of masticatory performance associated with the recovery of facial esthetics in edentulous patients.The assessment and reestablishment of the occlusal vertical dimension (OVD) are considered important factors in the treatment of complete denture wearers. The long-time use of a complete denture can result in jaw displacement due to abrasion of the artificial teeth and residual ridge resorption, causing esthetic complications. Most patients with old dentures and incorrect OVD accept reestablishment of the OVD with new complete dentures, even if they were used to their old dentures. The present clinical report describes a method of gradual reestablishment of OVD using a diagnostic acrylic splint on artificial teeth in old complete dentures before the manufacture of new complete dentures.  The establishment of appropriate occlusal vertical dimension (OVD) is a fundamental factor in the manufacture of new complete dentures in harmony with the patient's masticatory system , 2. HoweThe decrease of the OVD can compromise the esthetic and cause morphologic changes in the complete denture wearers, such as hyperactivity or hypoactivity of the masticatory muscles, increase or decrease in masticatory force, temporomandibular disorders, decreased facial height as a result of mandibular ridge resorption and a downward and forward rotation of the mandible , 5, 6, aThe reestablishment of the OVD is considered one of the most challenging and complex procedures during oral rehabilitation of edentulous patients . It is rFor this reason, it is usually believed that changes in the OVD should be conservative and for a trial period, with an interim prosthesis if necessary , especiaThe present case report describes a method of gradual reestablishment of an appropriate OVD using a diagnostic acrylic splint on artificial teeth in an old complete denture before manufacture of a new complete denture.A 65-year-old woman came to the Araraquara Dental School, UNESP, Paulista State University, Araraquara, São Paulo, Brazil, for assessment and manufacture of a new complete denture. The complete dentures were fabricated 23 years ago and her principal complaint was poor esthetics and ear pain. Intraoral and extraoral examinations were performed that included supporting structures, oral hygiene, temporomandibular joints, and facial height and symmetry with the OVD, the physiologic rest position, esthetics, and phonetics.The initial examination revealed that the patient had been wearing a maxillary and a mandibular denture with excessive wear of the artificial teeth, causing decreased OVD and, consequently, an excessive freeway space, downward turn of the commissures, and overrotation and protrusion of the mandible with the dentures in position. In addition, the patient had been experiencing moderate pain in the temporomandibular joint.An occlusal vertical dimension assessment was performed, according to customary procedures at the department , as follAfter determining the OVD through the association of the metric, phonetic, and esthetic methods, the need of 14 mm for the reestablishment of the OVD was demonstrated in the current prostheses. Due to the clinical conditions and the needs of the patient, an oral rehabilitation was proposed in two stages, commencing with using occlusal acrylic splints on the old dentures, like a pretreatment of the OVD, before the manufacture of the new complete denture set.Three impressions with alginate  of the complete denture (1 maxillary denture and two mandibular dentures) were performed and poured with special plaster type IV . Next, two occlusal records with a wax roller were taken (one reestablishing the OVD with 7 mm and the other with 14 mm) for reestablishment of the OVD in two stages. All master casts were mounted in a semiadjustable articulator  for the manufacture of the occlusal acrylic splints. First, the maxillary master cast was mounted in the semiadjustable articulator and, after that, each mandibular master cast, with the respective record (7 mm and 14 mm), was mounted using the same maxillary master cast Figures .The first mandibular master cast was performed to determine an increase of 7 mm in the OVD. After waxing the maxillary cast , an autoThe maxillary occlusal splint was first positioned on the old maxillary denture, fixed with composite resin, and an intraoral occlusal adjustment was made to evaluate the patient's ability to tolerate this increase of 7 mm for a period of 30 days. After this period of adaptation, the mandibular occlusal acrylic splint was fixed in the old mandibular denture , an intrThe assessment and reestablishment of the OVD is considered an important factor in the treatment of complete dentures wearers . The decWhen controls and adjustments are not performed, changes of the OVD could interfere with the physiology of the masticatory system and the patient's ability to adapt , 18. MatAlthough it has been observed that complete denture wearers can tolerate an increase in OVD with new dentures , the conMost patients with old dentures and decrease in the OVD accept a gradual increase in the OVD, even if they are used to their old dentures . This coThe use of a diagnostic acrylic splint is a reversible therapy that could improve head and cervical spine postures and reestablish the OVD , 22, sloIn the present case report, a two-stage reestablishment of the OVD was performed due to the necessity to increase the OVD by 14 mm. This could allow for a reversible treatment if the patient does not adapt in the second increase phase. Therefore, a gradual reestablishment was necessary to evaluate the patient's ability to tolerate this increase, and it was demonstrated that this technique is an adequate alternative treatment.The use of diagnostic occlusal acrylic splints on old complete dentures with an altered OVD is an effective and reversible treatment, gradually allowing reestablishment in the OVD, verifying the patient's ability to tolerate the proposed increase before manufacturing a new complete denture set.


Currently, use and disposal of plastic by consumers through waste management activities in Ghana not only creates environmental problems, but also reinforces the notion of a wasteful society. The magnitude of this problem has led to increasing pressure from the public for efficient and practical measures to solve the waste problem. This paper analyses the impact of plastic use and disposal in Ghana. It emphasizes the need for commitment to proper management of the impacts of plastic waste and effective environmental management in the country. Sustainable Solid Waste Management (SSWM) is a critical problem for developing countries with regards to climate change and greenhouse gas emission, and also the general wellbeing of the populace. Key themes of this paper are producer responsibility and management of products at end of life. The paper proposes two theatrical recovery models that can be used to address the issue of sachet waste in Ghana. The Limits to Growth, it has been broadly acknowledged that environmental sustainability cannot be achieved without altering the current system of mass consumption [Ever since the publication of sumption ,2,3. Prosumption . The choIn Ghana, rapid urbanization, lack of funding and economic decline in the 1970s through to the 1980s were cited as possible reasons for the poor sanitation of most towns and cities ,6. HowevTo investigate the actual situation of plastic waste management.To identify and propose a more sustainable plastic waste recovery strategy in Ghana.The paper seeks to propose theoretical scenarios for sachet water waste collections, the most prominent plastic waste in Ghana. The overall objectives of this paper have been grouped into two folds:The work focuses on outlining a theoretical recovery strategy to effectively manage the plastic waste  in the packaged water production industry from a sustainability perspective balancing economic, social and environmental objectives which are frequently in conflict. This is a descriptive-qualitative research utilizing literature on the theme of this paper and observation of best practices. The descriptive models are based on producer responsibility studies’ literature and practical activities of waste management in enterprises managing waste in most developed countries. The study was pursued both as a literature study and based on reports from the package water manufacturing industry and informal recovery/recycling businesses, as well as involving legislative and governmental institutions. Scientific papers served as a major source of data especially in conceptualising the theme of the topic.Over the last few decades, there has been a steady increase in the use of plastic products resulting in a proportionate rise in plastic waste in solid waste streams in large cities in sub-Sahara Africa ,10,11,12–0.035 kg/person/day, and plastics make up between 8% and 9% of the component materials in the waste stream [In 1979, the percentage was 1.4%, which rose to 4% in 1993, in 1996/1997 the proportion of plastic waste was 5% and by 1999/2000 its proportion increased to 8%. The per capita generation of plastic wastes stands at 0.016e stream . The continual increase of the share of plastic waste among solid waste is a result of the huge demand for plastic products in the country, propelling private enterprises to commit huge capital to the plastic industry. By 1996, there were about 20 plastic producing establishments in Ghana and by the turn of the century there were about 40 plastic manufacturing companies producing about 26,000 metric tons of assorted plastic products annually, with 90% of these companies in the Kumasi and Accra-Tema Metropolitan Areas. Additionally, over 10,000 metric tons of finished plastic products are imported annually into Ghana ,16. The packaged water industry is characterised by both small and medium to large scale industries that pack and machine-seal sachet water and also offer bottled water to consumers. Packaged water has become the preferred mode of drinking water both at home and in public. Bottled and sachet water is available in different sizes to satisfy different consumer needs. The bottles water sizes commonly available are 0.5 L, 0.75 L, 1 L and 1.5 L and for sachet water the available quantities are 500 mL and 200 mL sachets. However, the 500 mL sachet is most common on the market. This water is referred to as “pure water” by many of the locals. The sachet water industry in Ghana is a vibrant and highly profitable sector since there is always ready market demand for its products. The small scale sachet water companies usually produce between 15,000 sachets (500 bags) and 45,000 (1500 bags) sachets per day and have much smaller distribution coverage, more often distributing their products in and around the towns/communities where their factories are located. Usually each bag contains 30 sachets of 500 mL of water. The medium scale water companies have the technology, resources and adequate logistics support to produce both bottled and sachet water for more than one town and even may be able to cover a district. The large scale water companies produce both bottled and sachet water for sale nationwide, and most operate water packaging factories and depots in several towns and cities across Ghana. They usually produce and supply over 5000 bags of sachet water per day. There has been a proliferation of sachet water producing companies all across the country due to the relatively low start-up capital required. etc. poses many environmental threats. The sachets are made of non-biodegradable synthetic polyethylene (polythene) which does not decompose in the soil even after many years. The polythene even when subjected to burning produces major known and harmful greenhouse gases (GHGs) like carbon monoxide, nitrous oxide and carbon dioxide. Regardless of the accruing benefits like access to portable drinking water and employment generation through sachet water trade, due to sachet water production and consumption, the indiscriminate disposal of the waste in various undesired sites such as along the streets, gutters, motor parks, schools, markets, homes, and venues of social functions Itinerant waste buyers: these are waste collectors that are engaged in the collection and marketing of sorted dry recyclable materials. They collect the recyclable items from door to door, and this category of informal waste collectors are common is most parts of the world.Street waste picking: recyclables are recovered from mixed waste on the streets or from communal bins.Municipal waste collection crew: recyclables are recovered from vehicles transporting Municipal Solid Waste to the dump site.Waste picking from dumps: these are waste collectors that recover recyclables from dump sites before being covered.An informal waste recycling activity is a phenomenon in developing and least developed countries as a result of low economic development . There aIn Ghana, the informal collection and recycling sector is an important, but often unrecognised, part of the solid waste and resources management system, and it is estimated that about 20%–30% of recycling is achieved by way of informal recycling systems, reducing collection and disposal costs. They play a vital role in the value chain by reprocessing waste into secondary raw materials, providing a livelihood to a greater number of urban populations.Accra Plastic Waste Management Project by the private sector, mainly consisting of sachet water producers and sellers, as well as plastic manufacturers in December 2007. The major feature of the project was that, in addition to generating funds to manage the plastic waste in the capital, the project had the power to prosecute littering offenders according to the Accra Metropolitan Assembly’s by-laws, was able to recruit plastic waste guards as well as educate the general populace on the appropriate disposal of plastic waste. As the issues of plastic waste have gained much needed attention over the years, a task force was set up in the early 2000s with the agenda of turning plastic waste into a commodity for trade. The task force embarked on a series of campaigns to sell the idea of waste as a commodity to Ghanaians. The campaign caught on very well as Ghanaians enthusiastically started collecting plastic waste, especially sachet water waste for sale even though most of the collection was done by the informal sector and usually at the dumpsite or landfills. The task force however managed to promote the business by setting up plastic waste collection points mostly in the urban areas where individuals could send their plastic for sale. Some of the collectors of the plastic waste banded together to form the Plastic Waste Collectors Association of Ghana (PLWAG). The task force was gradually phased out due to financial reasons. As the task force was phased out, the government co threatened to ban plastic waste generating products which led to the birth of The threat by government to ban plastic production completely if carried out will increase the cost of production of packaged water and/or worsen the unemployment situation in the country. The national association of sachet water producers recognises the impact and environmental concerns of indiscriminate disposal of wastes from the consumption of their products. In this regard, there have been a number of programmes and efforts on their part to help curtail the sachet water waste threat in Ghana. Such programmes include the provision of bins in public places to facilitate the disposal of sachet wastes, assisting in the transfer of technology to members, facilitating training courses in bookkeeping and environmental education. There are also some NGOs like Trashy Bags which turns sachet and other plastic wastes into reusable shopping bags, fashion accessories, school supplies, and other products. The company employs about 60 Ghanaian workers to collect, clean and stitch plastic trash in the form of sachets that contain water and other beverages ,20,21,22The main aim of the strategy is to establish a community based approach to sachet waster waste management in which responsibilities are shared between households, the city authorities and producers of the sachet water. By encouraging producer responsibility and household participation, a greater portion of the sachet water waste, which usually ends up at dump sites, can be recovered efficiently and at low cost. The programme will seek to functionalize a multi-stakeholder return and/or buy back system that will facilitate the collection and return for recycling of sachet waste that normally finds its way into our environment. The concepts of the programme are discussed below.There are different ways of implementing a recovery system to achieve a desirable goal. The main goal is to increase collection and recycling of sachet waste of products at the end of life and also to encourage producers to be more environmentally responsible.It is a system where the consumers’ deposits will be refunded when handing in the used product. Here, the consumer receives a financial compensation when returning a discarded product which corresponds to a specified deposit paid when purchasing the product. Deposit-refund systems can be divided into natural and artificial systems. Natural systems are where the real value of the container induces the desire of producers to recover them. The refunds on such products have to be high enough to motivate consumers to return them after end of use, instead of keeping them for their own purposes or throwing them away. Deposit-refund systems are in many instances seen as the best solution when very high collection rates are desired. In Europe, for instance, many of the traditional deposit-refund systems for beer and soft drinks in refillable glass bottles are claimed, where they still exist, to lead to an almost 100% return rate.It is a system where the discarded products are collected in close proximity to consumers or households similar to the way the ordinary household waste is collected. The large-scale kerbside collection system is the German packaging collection is a great example of the potential of achieving high collection rates in this system. Consumers may drop off sachet waste at collection points that are convenient and of easy access to encourage maximum collection. It is a system where the consumer is expected to bring the discarded products to a container or something similar, which is placed at a shorter or longer distance from the home of the consumer. These systems include drop-off centres and recycling stations, among other things. The packaging waste collection as organized in Sweden is an example of a system that mainly relies on the consumers to bring the discarded products to containers, which are distributed in various parts of the cities. The collection results are fairly mixed but this system could be used to recover most of the sachet waste in Ghana.Extended producer responsibility is a strategy designed to promote the integration of environmental costs associated with goods throughout their life cycles into the market price of the products . There aLiability: refers to a responsibility for proven environmental damages caused by the product in question. The extent of the liability is determined by legislation and may embrace different parts of the life-cycle of the product, including usage and final disposal.Economic responsibility: means the producer will cover all or part of the costs for collection, recycling, or final disposal of the product manufactured. These costs could be paid directly by the producer or by way of a special fee.Physical responsibility: is used to characterize the systems where the producer is involved in the actual physical management of the products or the effects of the products.Informative responsibility: signifies several different possibilities to extend responsibility for the products by requiring producers to supply information on the environmental properties of the products manufactured.The concept was first formally introduced in Sweden by Thomas Lindquist in a 1990 report to the Swedish Ministry of the Environment . In thisThe producer recovery model as shown in Producers of sachet or bottled water can receive back plastic waste by providing incentives like discount coupons, the plastic waste they in turn return to plastic producers based on similar incentives or sell them to recycling companies for processing. Such a recovery system invokes a kind of extended producer responsibility. In Also, instead of the producers taking back the sachets from consumers themselves, they can partner with organised informal waste operators who will be tasked specifically to collect or recover the sachet waste before it ends up at landfill sites. They can invest in developing the needed skills and techniques among these informal operators.As shown in Consumers (including households and businesses) bring post-use plastic products to collection points or to waste collectors , who then transport it to processors or recycling firms. The collections can be coordinated by the authorities, producers or a body in charge of the program for maximum efficiency, and this can be done by integrating and improving on the already existing informal recovery systems. Each producer pays a financial contribution to the collection scheme. The amount paid, for instance, can depend on the amount of production of each producer. These payments are then disbursed by the authority in charge of the scheme to the actors in the collection process. The authority pays each collector based on a unit rate per weight that they handle, as already existing in the informal sector, or the collectors can sell their products to the recycling companies.Solid waste management is basically a welfare and development matter and it is commonly accepted that public participation is essential for its success. Stakeholder participation entails the involvement of all groups of people in the identification of their felt needs, mobilization of resources, and deciding on the direction and execution of programs and projects. It should take place at all levels of planning and management, including training, problem identification, implementation, monitoring and evaluation. Awareness, on the other hand, is the process of awakening and raising people’s sensitivity to concerns, in this case the plastic waste management problem in Ghana.Coordinating the preparation and distribution of information about the strategy and on how to innovatively manage plastic wastes in Ghana.Coordinating the preparation and presentation of weekly radio and TV programs on the environmental impacts of indiscriminate dumping and littering of the urban environment with plastic litter; Commissioning of the preparation and publication of bi-monthly feature articles in the print media on environmentally sound strategies of dealing with plastic wastes.Coordination of the holding of public meetings in all divisions to sensitize the people on the negative impacts of plastic waste management and the need to have then reused and recycled.Awareness should be created through formal and non-formal education with the assistance of both the print and electronic media. Environmental education with respect to plastic waste management, formal and non-formal, is vital to changing people’s attitudes to appreciating a clean and safe environment, and leads to their empowerment in enabling them to manage their wastes sustainably. It also creates responsibility among the different communities, increases environmental accountability and governance and encourages the rational use of environmental resources. There is need to create a mechanism for stakeholder participation and dialogue so as to empower and enable the public to participate in sound environmental practices. This may include:The ineffective tax levy systems, lack of incentives for the people of Ghana to separate waste, coupled with the overall negative attitude require that Ghana considers an approach that will involve all stakeholders in the plastic pollution problem. Policy approaches like product stewardship and extended producer responsibilities, if implemented right, can assist government in shifting responsibilities for the management of certain waste streams from the state to the producers, thereby reducing costs. Product stewardship is usually designed as a voluntary system that shares responsibility for the adverse environmental effects of products by all parties involved in the lifecycle whereas EPR focuses all the responsibility for waste management onto manufacturers ,27,28,29A community based approach to sachet waste management in which responsibilities are shared between households, city and municipal authorities and producers of the sachet water is needed. Through producer responsibilities and community participations, a greater portion of the sachet water waste, which usually ends up at dump sites and the environment, can be recovered efficiently and at low cost. The success of recycling not only depends on participation levels, efficiency of the equipment and infrastructure but on the quality of recovered waste. Therefore, it is necessary to recover recyclables at the early stage before they are mixed with other waste streams or end up at landfills. As steps are taken to establish a formal recovery sector, it is necessary to intensify efforts towards rebuilding the formal sector since the operating costs for collecting and recycling in the informal sector are much lower. However, there are serious threats to individual operators in recovery of the recyclable waste as their operations are not done under ideal conditions. Most informal waste sector workers (dump and street waste pickers) constitute the lowest level of society, even though their income and living conditions differ significantly according to their main activities, working conditions are unimaginable and include permanent exposure to dangerous, toxic and contagious substances. Therefore, the government should develop a management system which integrates the operations of the informal sector and also assists in improving their conditions. Creating a more positive public and political attitude towards waste pickers through civil society campaigns promotes informal sector integration.Since proper waste management is not the sole responsibility of the government, increasing the sense of responsibility of industries—like the packaged water industry—for their product impacts is necessary, such as where the packaged water producers finance a recovery programme. The packaged water industry, for example, can engage the informal waste sector to recover the waste from their products. The economic and environmental benefits of such cooperation are obvious. i.e., pre-treatment stage), new forms of recycling technologies such as chemical recycling, and the recyclability of end-products.Political will as well as attitude change is important in expanding the national recycling capacity. It is a matter of formulating national policies, respective laws and regulations for better collection and sorting of specific waste streams, limiting or banning landfilling of waste streams like plastic. Also, government should assist by removing obstacles to the entrepreneurial activities of both informal sector operators and organisations, which is an important factor in sustainable waste management. Alternatively, the government should promote research and development (R&D) focusing on present recycling technologies (


Oncogenes are the primary candidates for target-directed therapy, given that they are involved directly in the progression and resistance of tumors. However, the appearance of point mutations can hinder the treatment of patients with these new molecules, raising costs and the need to development new analogs that target the novel mutations. Based on an analysis of homologies, the present study discusses the possibility of predicting the failure of a protein as a pharmacological target, due to its similarities with retrovirus sequences, which have extremely high mutation rates. This analysis was based on the molecular evidence available in the literature, and widely-used and well-established PSI-BLAST, with two iterations and maximum of 500 aligned sequences. The possibility of predicting which newly-discovered genes involved in tumor progression would likely result in the failure of targeted therapy, using free, simple and automated bioinformatics tools, could provide substantial savings in the time and financial resources needed for long-term drug development. The resistance of cancers to chemotherapy may have a number of different determinants, which all lead to the same outcome—an increase in mortality rates. From the perspective of the development of new drugs, resistance may annul years of trials and the investment of millions of dollars. In some cases, the increase in patient survival may be well below expectations , and forTarget-directed therapy offers a new approach that has a direct inhibitive effect on the molecules involved in the development of the cancer and its resistance to drugs . The besThe exact effects of mutations on the therapeutic efficiency of the TKIs are determined by the type of mutation (missense or silent) and their position in the target molecule . A number of studies have identified critical point mutations in the kinase domain of the BCR-ABL protein . These mcompound mutations, i.e., multiple point mutations in the same allele, rather than multiple clones with different mutations  was aligned with those of viruses (tax ID:10239), with two iterations and a maximum of 500 aligned sequences. Artificial sequences and synthetic constructions were not considered for this analysis.Sequence similarity was analyzed using PSI-BLAST—the Position Iterated-Local Alignment Search Tool . The humStatistical significance was generated via PSI-BLAST. A maximum E-value of 0.001 was considered for this analysis. The lower the E-value, the higher the homology.in silico modeling. The latter is based on the identification of homologies between the target sequence and those known to occur in proteins which native structure were already elucidated , which are believed to represent the footprint of ancient germ-cell retroviral infections. They would then have been transmitted vertically from one host generation to the next , but mosRous sarcoma virus, the first oncovirus discovered (abl) of the mouse genome  can be measured as substitutions per nucleotide per cell infection (in viruses) and substitutions per nucleotide per replication cycle in eukaryotes. The size of the genome is also an important parameter here . A numbe11 Table , this riDespite this variation in mutation rates, functional versions of the same oncoprotein  can be found in normal . In this approach, nucleotide analogs are used to enhance the mutation rate of a virus  under high mutation rates, is actually being tested continuously, given that highly homologous sequences of the oncogenes are present in the highly proliferative retroviruses which can successfully infect and transform normal cells . In thisAs discussed by Acanthamoeba polyphaga mimivirus).Recent studies have identified a number of molecules as candidates for the development of drugs . These iIRAK1 is involved in IL-1beta-induced NF-kappaB activation , and alsThe mutational status of a sequence is determined by its mutation and proliferation rates. But exactly which amino acid may be substituted in a given position (such as T315I in the case of BCR-ABL), and its importance for the outcome of a chemotherapy procedure, is related to selection of which particular mutation will confer advantage . Human oin vitro approach, As discussed above, samples obtained from patients can be used to identify the most frequent and relevant mutations, but the question remains as to whether it may be possible to identify relevant mutations in a specific target during the development of a new drug. Using an in vitro prediction of the identity of a mutation that likely confers resistance to a new drug without concomitant corroboration by clinical trials would be an economically attractive prospect, although the direct application of these results for drug development it would be an issue. However, the possibility of providing an inventory of potentially relevant point mutations, which could be investigated further through in silico studies, might represent a potentially economic strategy.The The interchange with evolutionary models has contributed to the understanding of cancer as a highly complex disease. In cancer research, the ongoing integration of molecular biology with disciplines such as theoretical ecology , mathemaSome proteins that possess less similarity with sequences resident in retroviruses and are relevant for tumor development, are those that act suppressing cancer, as p53 and pRB. These molecules appeared late in evolution to allow the establishment of the multicellular organisms . Those sMost of the targets for drug development are molecules involved in tumor progression, exactly because these sequences maintain their function under high mutation rates. The hypotheses presented here give rise to a challenge: identify a gene that promotes enough tumor progression to be considered a pharmacological target. At the same time, this sequence must be subjected to low mutations rate. The later feature may be reflected by its similarity with retroviral sequences.In the context of the present study, another consideration arises—if it is possible to identify a point mutation that potentially reduces the efficiency of a new drug prior to clinical trials, should this influence the decision to develop the drug further? In other words, should the development of the drug continue if it is known that it will fail in some degree due to the similarity of the target sequence with retroviral proteins?in vitro identification of the mutants that will be resistant to the first generation of a drug would contribute to the improvement of therapeutic strategies for non-responding patients. This would hopefully contribution to acceleration in the inevitable development of subsequent generations of the new drug.There are good reasons to proceed, however. In the specific case of the application of TK inhibitors to the treatment of leukemia and lung cancer treatment as examples, diseases that target sequences have viral homologous, one important reason is that most patients (70–80%) respond to targeted therapy. This represents some 246,000 leukemia patients and 1,277,500 lung cancer patients, worldwide, each year . In addiThe author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Genetics is the study of heredity, which means the study of genes and factors related to all aspects of genes. The scientific history of genetics began with the works of Gregor Mendel in the mid-19th century. Prior to Mendel, genetics was primarily theoretical whilst, after Mendel, the science of genetics was broadened to include experimental genetics. Developments in all fields of genetics and genetic technology in the first half of the 20th century provided a basis for the later developments. In the second half of the 20th century, the molecular background of genetics has become more understandable. Rapid technological advancements, followed by the completion of Human Genome Project, have contributed a great deal to the knowledge of genetic factors and their impact on human life and diseases. Currently, more than 1800 disease genes have been identified, more than 2000 genetic tests have become available, and in conjunction with this at least 350 biotechnology-based products have been released onto the market. Novel technologies, particularly next generation sequencing, have dramatically accelerated the pace of biological research, while at the same time increasing expectations. In this paper, a brief summary of genetic history with short explanations of most popular genetic techniques is given. Due to rapid advances in genomic technologies, genetics analyses have become essential in clinical practice and research. During the past decade, a great stride has been made to unravel underlying mechanisms of genetic-related disorders. Landmarks in genetic history are summarized in  On the Origin of Species by means of Natural Selection in 1859, Gregor Mendel introduced the fundamental laws of inheritance in 1865. This was crucial for understanding that “some characteristics of the organisms are inherited through genes.” Mendel's rules were improved by the experiments of Thomas Hunt Morgan in 1910 who discovered that genes were responsible for the appearance of a specific phenotype located on chromosomes. In 1911, the first genetic map was achieved by mapping the fruit fly genes. From the 1800s until the middle of the 1900s, it was not understood that the structure of hereditary genetic material was responsible for the inheritance of traits from one generation to the next. In 1953, Watson and Crick described the double-stranded, helical, complementary, and antiparallel model for DNA [Looking at the history in brief, genetics is the term introduced for the study of genes in organisms. Many early discoveries contributed as important milestones to evolve the study of genomes as it is applied today. One of the crucial steps that enabled visualizing intracellular structures was the invention of the single-lens optical microscope by Janssen in 1595 . A Swiss for DNA . They shThe first genetic analysis was performed in the field of cytogenetics. Although it was published that normal human chromosome number was 48, Tjio and Levan reported in 1956 that the correct number was 46 –9. AfterDespite the establishment of high-resolution techniques which enabled revealing many known or unknown genetic syndromes, several cases having submicroscopic aberrations that were not visible at resolution between 500 and 1000 bands remained undiagnosed. A new technique called fluorescence in situ hybridization (FISH) was developed in the field of molecular cytogenetics in 1982 . In thisBeing time-consuming and expensive to evaluate chromosomal rearrangements in the whole genome by FISH led to the development of new techniques such as array-based comparative genomic hybridization –35. CompArray-CGH failed to detect the recessive disease genes, mosaic aneuploidy, uniparental disomy (UPD), or heterochromatic rearrangements. Because of this disadvantage, it is thought to combine with SNP arrays to improve the resolution of array-CGH . These aLarger genomic changes such as deletions, duplications, and translocations can be detected by conventional karyotyping, FISH, or array-CGH methods but single nucleotide changes cannot be detected by these techniques. Molecular genetic techniques were rapidly developed after the establishment of polymerase chain reactions that enabled generating thousands to millions of copies of a particular DNA sequence . Mullis Taq DNA polymerase that was selected the first “Molecule of the Year” by Journal of Science was a major advantage in PCR technology . AutomatWith the advances in the field of molecular genetics, it became possible to launch the Human Genome Project to reveal the complete human genome. The programme was launched in the USA with an effort of the Department of Energy and the National Institutes of Health in collaboration involving 20 groups in 1990. The first draft of human genome was published in 2001 by The International Human Genome Sequencing Consortium . This fiIn addition to cost-effective advantages, sequencing the small part of the genome allows reducing the number of variations that in turn reduce the cost and time needed for data interpretation . Targete BCR/ABL  through the improvements of the molecular techniques [Approximately 10 years ago, karyotyping was the gold standard in patients with intellectual disability but array-CGH analysis has become the first line diagnostic test replacing karyotyping and FISH nowadays. As evident from this example, approaches to the genetic-related diseases could change in parallel with the advances in technology and science. “Philadelphia chromosome” is one of the oldest evolutionary examples of personalized medicine by revealing the etiological factor and the treatment options of a disease step by step by using the genetic analysis as the improvements in the genetic techniques were established. In 1960, a small chromosome called Philadelphia chromosome was identified to be the cause of the chronic myeloid leukaemia (CML). It was shown in 1973 by the chromosome banding technique that this chromosome was a result of a translocation between chromosomes 9 and 22 , 55. It chniques . The folchniques .Genetic test that will be used in the diagnosis should be chosen very carefully, which might not be the newest or the most sophisticated one. Sometimes only a karyotype could be enough to identify the genetic condition in the patient instead of more complicated array-CGH or NGS methods. As the technology in genetics rapidly evolves, new insights in terms of data interpretation and genetic counseling including pretest counseling, return of results, and posttest counseling need to be considered. Databases and consortium reports regarding the experiences of the clinicians and geneticists are crucial for integration of genomics into clinical practice.If the developments in genetics and computer technologies continue to progress at their current speed, history has shown us we can look forward to some amazing developments in human life in the very near future. Some realistic scenarios of human life in the future could even see us carrying identity cards, which include our genome characteristics, rather than the format we are currently using. Gene corrections, cloned individuals and organs, and even genetic-based techniques as a primary laboratory analysis in almost all human diseases for a clinician will no longer be a dream. We have come to the point nowadays where genetic testing is commercially available; the individual now has the possible means to access this delicate information named as direct to consumer (DTC) genetic testing. Contrary to the traditional hospital or physician based testing, accessing an individual's genetic information without medical or specialized interpretation has gradually been finding a place in our daily lives. Today, more than 25 companies, from all over the world, offer DTC service to the public. Serious concerns, however, regarding the use of this kind of service, have been raised in terms of misleading and incidental results derived from unproven or invalidated data. Moreover, there is also a significant risk for unauthorized use of sensitive genetic information by big business, particularly in the fields such as health insurance. On the other hand, DTC does provide early awareness of genetic diseases and thereby offers individuals the opportunity to play an active role in their own health care. The issue at stake here leads us to the same difficult medical ethics dilemma: patient autonomy and right to know one's genetic composition versus nonmaleficence.To conclude, in parallel with the rapid developments in the field of genetic technologies, ethical and legal issues regarding the implementation of those technologies need to be addressed. Because use of personal genetic information looks certain to directly impact our daily lives in the near future, protocols need to be discussed in detail, with guidelines provided and updated regularly as part of a regulated multidisciplinary approach.