This paper proposes a framework for an Air Quality Decision Support System (AQDSS), and as a proof of concept, develops an Internet of Things (IoT) application based on this framework. This application was assessed by means of a case study in the City of Madrid. We employed different sensors and combined outdoor and indoor data with spatiotemporal activity patterns to estimate the Personal Air Pollution Exposure (PAPE) of an individual. This pilot case study presents evidence that PAPE can be estimated by employing indoor air quality monitors and e-beacon technology that have not previously been used in similar studies and have the advantages of being low-cost and unobtrusive to the individual. In future work, our IoT application can be extended to include prediction models, enabling dynamic feedback about PAPE risks. Furthermore, PAPE data from this type of application could be useful for air quality policy development as well as in epidemiological studies that explore the effects of air pollution on certain diseases. Pollution and various forms of ecosystem contamination continue to be pressing issues across the globe . China’sEnvironmental sustainability now underpins the policy-building initiatives of government institutions and businesses alike. In developed countries such as those of the European Union (EU), air pollution damage, which brings about a direct threat to public health, is expected to rise in the next decade. This has compelled the EU governments to give priority to air pollution level reduction above any other climate change policy plans . In deveAir pollution from both outdoor and indoor sources constitutes the greatest environmental risk to human health around the globe . About sIn addition, people spend around 90% of their time indoors, and human exposure to indoor air pollutants may occasionally be more than 100 times higher than outdoor pollutant levels, according to the United States (US) Environmental Protection Agency (EPA). Indoor air pollution is equally detrimental, as statistics show that 4.3 million people per year die from exposure to household air pollution [Monitoring Personal Air Pollution Exposure (PAPE), which refers to the amount  and to develop an IoT application that measures PAPE based on this framework. The four sections of this paper are organized as follows. The first section provides a literature review of studies on key air pollutants, determination methods for air pollutants, and PAPE estimation techniques as well as the current opportunities and challenges in the field. The second part discusses the methodology, which includes the proposed framework and an IoT application that was tested by means of a case study. This is followed in the third part by the analysis and a discussion of the results of the case study. The fourth part presents conclusions that highlight the study’s important contributions and directions for future research.The key air pollutants that are currently being monitored by agencies such as the WHO, the EPA in the United States, and the European Environment Agency (EEA) in Europe, are particulate matter , CO, and VOC. Moreover, IoT-based indoor air monitoring devices such as Foobot and AirVisual are already commercially available on the market.As noted previously, there is a growing interest in measuring PAPE at the individual level. At present, there is a wide range of low-cost sensor technologies  that canThe different PAPE measurement techniques that have been developed in the last decade can be grouped into three categories. The first group is the traditional method in which pollution data are collected from fixed-site outdoor monitors and assigned to the home address of the individual through spatial interpolation techniques. Examples include Land Use Regression (LUR) , InverseIn summary, these methods are inadequate, as they do not address the issue of the individual’s spatio-temporal PAPE variability  and neglThe second group of techniques, which is built on the traditional method but addresses the issue of exposure variability, takes into account the activity patterns by tracking an individual’s location. It incorporates indoor pollution data based on the amount of time spent indoors. A commonly used indoor pollution measurement method is the indoor/outdoor ratio . Other tThe last group of techniques stems from the two previously discussed groups but further captures the issue of indoor pollution measurement accuracy and the spatio-temporal resolutions of data from fixed-site outdoor monitors. The periodic measurements by these fixed-site outdoor monitors by nature have low spatial resolution and do not address the issue of variability in pollution concentration . Since tPersonal exposure measurements can be performed directly and indirectly . PassiveOn the other hand, using a micro-environmental model is an indirect way of assessing personal exposure. In daily life, people move around and are exposed to various levels of pollutants in various locations. The term “micro-environment” is defined as a chunk of air space with a homogeneous pollutant concentration . Such a The key to measuring individual pollution exposure is to track an individual’s activities in both the space and time dimensions. GPS technology is the ideal technology, and it has been used successfully for this purpose. Some well-designed integrations of GPS devices and portable pollution monitors have been proposed by some studies ,55 to deTherefore, more extensive approaches have been developed such as the use of mobile sensors  to monitor PAPE indoors. Studies ,57 that Although continuous technological advancements have enabled researchers to propose solutions that provide measures of PAPE, the issue about the cost and scalability of such methods remains to be addressed. The most recent approach, as discussed in the third group of PAPE measurement techniques, employs mobile sensors that the individual carries around. Although these mobile sensors are able to provide better spatial resolution of pollution data, the willingness of individuals to carry these sensors is still a challenge, in addition to the cost and scalability issues of the method.The trade-off between cost and quality of pollution data continues to be a point of discussion among studies. The proposed PAPE measurement techniques that are currently available in the literature are limited to PAPE estimation alone and, therefore, fail to provide a more comprehensive view of the entire AQDSS. Thus, there is an opportunity to further explore the use of existing technologies to enable the development of a more comprehensive PAPE measurement technique that is able to provide a preventive, predictive, and personalized system.Within similar studies on the measurement of PAPE, there are some proposed conceptual frameworks ,36 and sAs pointed out previously, these government regulations play an important role, as they largely support and drive policies that enable the measurement and access to air quality data.The other two stakeholders are the individuals and the healthcare sector, which form the apex of the framework. They are supported by five layers of activities, as illustrated by the pillars on both sides. The first three on the left correspond to the analysis of past data to estimate PAPE and their related health impacts. The two pillars on the right represent future possibilities of forecasting PAPE and the associated health risks.Although the estimation of PAPE is fundamental to the entire AQDSS, its associations with forecasting and as a predictive health risk assessment system are noteworthy. Air quality forecasting techniques are already being explored in current research ,60 in enThis proposed framework can be adopted to aid in the development of an AQDSS and various IoT applications. For instance, consider a mobile application that allows an individual to select the best route to travel from home to work that minimizes the risk to pollution exposure. This could be achieved by employing different modeling techniques to continuously analyze real-time air quality data and forecast PAPE values for each of the possible routes to the destination. Actual PAPE data that are stored in the database can also be used for epidemiological studies and air quality policy development. This could be one of the applications of the proposed framework when all identified pillars are fully employed. In this paper, however, as a proof of concept, we focus mainly on PAPE measurement (pillar 2) in accordance with the system architecture that is illustrated on the base of the framework. In order to manage sensor data in an interoperable way, this implementation considers the Web Service Description Language provided by the Sensor Observation Service v2.1 (SOS) from the SOS-OGC consortium. This standard defines a Web service interface which allows observation queries, sensor metadata, as well as representations of observed features. Furthermore, this standard defines a means to register new sensors and to remove existing ones. Also, it defines operations to insert new sensor observations. The feasibility was assessed through the developed case study.As indicated in the framework, the base shows the set of activities that are related to the gathering and management of all air quality and personal data. This groundwork is required for the entire system to function. There are five different sources of data. They are the (S1) outdoor pollution monitors, (S2) location tracking application, (S3) indoor pollution monitors, (S4) e-beacons, and (S5) meteorological monitors. S1 and S2 are intended for outdoor pollution modeling, and S3 and S4 are for indoor pollution modeling. We also consider meteorological data, as they are relevant for air quality prediction studies ,61.The data are extracted from the mentioned data sources and stored in a database management system. Data mining, numerical modeling, and geostatistics, as shown in the center of the framework are the key activities that support the entire system, as it is a continuous process to discover and analyze spatio-temporal data.There are essentially three elements to consider when measuring PAPE. They are (1) outdoor pollution, (2) indoor pollution, and (3) the individual’s location pattern. With respect to the outdoor pollution, the mobile-phone-based tracking app provides the time and location data of the individual in the outdoor environment. An outdoor pollution map is created by using potentially different strategies, such asNumerical-modeling-based dispersion models ,63,Big data, machine-learning-based models ,64,Geostatistic-based techniques, like Kriging ,66.Each of these techniques has its specific advantages and limitations, and its consideration in a specific application will support its choice. Actually, the latest family of methods has specific advantages, as it is suitable for working with the fixed network of pollution stations the city has implemented. Indeed, it also deals with the limitations of sparse data, as Data fusion can increase the reliability of data as well as it can contribute to dealing with local effects like street canyons, etc., by using the street granularity-based IoT air quality stations some cities are deploying, such as Airbox in Taipei  and ArraFor the duration of time that an individual is outdoors, the corresponding pollution data are estimated by superimposing the developed outdoor pollution map over the collected location pattern data.For the indoor pollution, the e-beacons indicate the period when the individual is indoors, and the indoor air quality monitors provide the corresponding air quality data, when available. Failing this, outdoor information will be used by default. The integration of personal mobiles and fixed e-beacons located in different indoor micro-environments enables the individual’s time-location information to be understood. The corresponding time-location knowledge combined with location-specific indoor air quality information collected from air monitoring devices can provide a detailed picture of personal exposure in the indoor environment.Both outdoor and indoor data are then integrated, and statistical modeling techniques are employed to either estimate or forecast the individual’s PAPE.In order to assess the feasibility of the proposed IoT application that measures PAPE and contributes to empowering users because of the relevant figures provided at the personal level, we conducted a case study to analyze significant functionalities.The study area was the City of Madrid, which is the capital of Spain, as well as its largest municipality. It was the first city in Spain to have air quality monitoring stations and has always been at the forefront of the fight against air pollution. In response to the most recent EU directive (Directive 2008/50/EC) regarding the establishment of limits to major air pollutants, the Madrid government has committed to maintaining acceptable pollution levels by continuous air quality monitoring.Ayuntamiento de Madrid [Agencia Estatal de Meteorologia [The Madrid air pollution monitoring network consists of 24 fixed-site outdoor monitors . The houe Madrid . Meteoroorologia .In this case study, S1, S2, S3, and S4 data sources were used and meteorological data were excluded see . We had For this particular case, Madrid does not yet implement the street-based pollution monitoring strategy, but based on similar studies ,44, the For the indoor pollution, Foobot indoor monitors were used. One of them was placed in the individual’s workplace, as this is where she spends most of her indoor time. The indoor pollution data were retrieved from Foobot’s API . The e-bAll of these data sources promote the scalability of the proposed IoT application, as most are publicly available without charge. The only costs incurred were for the indoor monitor and e-beacons. E-beacons, however, are low-cost, small enough to attach to any surface, and are finding an increasing number of location-based applications in various industries such as retail and transportation as well as in households . Hence, All data that were collected from the mentioned data sources were processed as indicated in the Data in Brief Collection documents that were submitted to the journal for this paper. The developed code can be also found in a public repository .The selection of the pollutants used for the PAPE estimation was based primarily on the data provided by the devices, which also agreed with the data on the most common air pollutants that have been widely studied previously ,24. TablExisting studies of PAPE essentially rely on modeling techniques in which data collected from fixed-site outdoor monitors are used to estimate pollution at specific geographic locations. To create an outdoor pollution map, there are several alternative methods. These include using micro meteorological numerical-based models  , or machOptimal Parameters and Model SelectionIn order to select the optimal parameters and the best modeling technique for each of the hourly outdoor pollution datasets, a 5-fold cross validation was performed to avoid overfitting. For each of the 24-hourly datasets and each of the three modeling techniques and all combinations of their respective parameters, the selection of optimal values was based on the root-mean-squared-error (RMSE) metric. The dataset was separated into two parts, training and testing, which were used to fit the model and calculate errors, respectively. The parameters and the model that provided the least RMSE were selected.For the Simple and Ordinary Kriging techniques, the weights Outdoor Pollution MapSimilar to , an hourThe selection of time frequency (hourly-based in this case) also impacts the accuracy, depending on how spiky the pollution looks. In Madrid, the pollution sources are strongly related to traffic and then variations are smooth . TherefoAll three methods estimate the value at a particular location by assigning a weight of the surrounding known values and calculating the weighted sum of the data. These techniques differ mainly in the calculation of the assigned weight a values . The adva values . We creaThe main data sources used to model the indoor pollution were the e-beacons and indoor monitor. The timestamps recorded from the e-beacons provide the time when the individual was detected indoors.In this study, we refer to “indoor” as the work location, since the indoor monitor was only present at the individual’s workplace. The “outdoor” environment, on the other hand, refers to any other location outside the workplace. To obtain the corresponding pollution values during these periods, each of these timestamps was matched to the closest timestamp logged from the Foobot device. As illustrated in Similarly, micro-environments  in the workplace could be replicated by deploying e-beacons and air monitoring devices in all available micro-environments.p.The PAPE Exposure(p) in period p inhaled by the individual was calculated by multiplying the pollution value SZ(p) by the respective minute ventilation (VE) value using Equation .(1)SZ were obtained. Then, based on these specific time and location data, the corresponding pollution values were taken from the previously interpolated outdoor pollution values.The adopted modeling technique based on geostatistics ,66 using such as , where S such as , in whicIt can be argued that some local effects like turbulence around buildings, roughness of constructions, and some other aspects impact the accuracy of the estimation. The techniques used in such dimensions can be those related to the integration of meteorological, chemical and transportation numerical modeling (WRF and CMAQ models), with the limitations of being able to precisely estimate the boundary conditions as well as to properly model the city configuration . When running with high spatial resolution, they produce good results, although the quality is slightly reduced and numerical stability becomes an issue . AnotherTo validate the fully aggregated indoor pollution values (SZ(p)) obtained from the indoor monitor and e-beacon devices, they were matched against the pollution data that were measured simultaneously during the study period using a portable air pollution monitoring tool- Atmotube  that wasVariance in measurements can be attributed to the differences in calibration and measurement methods that were used by these sensors see . HoweverFrom this analysis, the value of people being able to figure out the distribution of the total intensity of pollutants based on their activity becomes evident, as this method can make them aware of the real dimension of the problem and avoid classical myths, like the idea that most of the pollution is acquired outdoors see . While tSince information is the key aspect in having the opportunity to make proper decisions, the advantage of such an integrated framework that is able to integrate not only outdoor conditions but also indoor ones when available becomes more evident. This can also have an impact not only at the individual level by making everyone aware of their exposed pollution levels but at an aggregated level as well, because the public health dimension is impacted when buildings are seen as actionable regarding the indoor conditions. Therefore, KPIs can be adopted by considering the gradient between outdoor and indoor levels per area of occupancy of the buildings. By having systematic monitoring inside, the management dimension can be adopted.Similar to ,94, anotIn this example, the better individual route will is B, as it causes the least amount of PAPE at 0.769 Although most of the tools that give routing solutions for transportation problems are based on duration, some of them have the capability of filtering them out based on pollution exposure outdoors ,94. In tDue to the lack of publicly available air quality information for other indoor areas such as shops, buses, cars, metros, etc., outdoor pollution data from the fixed-site outdoors information must be used in such cases. If there are more available resources, additional monitoring IoT devices in other indoor areas will provide greater accuracy. In most cases, good results demand good inputs, and existing data are replaced whenever better data become available. Quality improvements can be expected from those actions. Smart city empowered data sharing platforms such as IOTA Tangle  would boAccuracy for outdoor pollution estimation is another known limitation, both because of the time frequency resolution of available data and because of the interpolation errors. It would be possible to implement Weather Research and Forecasting (WRF) models such as the CMAQ. This decision requires significant effort, not only because of using the appropriate Digital Elevation Model (DEM) required to represent the landscape and building configuration, which is a complex task, but because it requires the boundary conditions to be realistic. This means adopting pressure and wind speed conditions for all surfaces external to the volume of interest. These situations need to be updated regularly throughout the day, as environmental conditions change as well. Indeed, numerical stability conditions must be carefully managed in this case as well.For future applications, the best solution for environments will come from both the increasing deployment of dense  IoT-based air quality sensors and the prosperity of the data sharing platform, which can increase the available data and, consequently, will increase the accuracy.This paper (1) proposed a framework for an AQDSS and (2) developed an IoT application based on this framework. The feasibility of the IoT application in measuring PAPE was evaluated through a case study. In comparison to mobile sensors that were used in previous studies, this IoT application has higher scalability, because it involves minimal cost and intrusion to the individual. This pilot case study also presents evidence that PAPE can be estimated by employing indoor monitors and e-beacon technologies that have not been used previously in similar studies.Using our proposed framework as a general guideline, the IoT application that we developed can be further extended to include prediction models that will allow an individual to make smart decisions when it comes to PAPE risk. Furthermore, PAPE data obtained from the application can be used in air quality policy development as well as in epidemiological studies to explore the correlations of PAPE with certain diseases.We faced difficulties during the extraction and integration of data from multiple devices, which highlights the importance of choosing the right technologies to use when developing such IoT applications. There was an observed variance among the different devices, which can be attributed to device calibration and the measurement techniques used. Future research should, therefore, explore these issues and identify emerging technologies that permit seamless data integration and more accurate PAPE measurements.


Medical education is in state of flux in Iraq. What used to be the best physicians and surgeons in the Arab world have fallen down to much lower status due to deliberate neglect and punishment of the intellectuals and professionals by the previous authorities. Once again medical educators and health professional are gaining momentum, gathering national and international support, to enter the contemporary world of medical education employing an integrated curriculum, PBL and Problem Solving Methods, Skill labs, simulation and structuring etc. Much needs to be done to return to formal glory but Iraqis are a dynamic nation of determined, dedicated and committed people. It is up to the international community to join hands with the Medics International to expedite the process. One such effort was the medical education conference held on 15-16 September 2018 with large input from medical educationists from Pakistan. The ancient land of Mesopotamia located between the Tigris and the Euphrates, is aptly described as the cradle of civilisation. After all, the history here dates back to Adam and Noah, who are buried in Najaf. Prophet Ibrahim was born near the ancient Ur city; the capital of Sumerian empire, and where Prophet Dulkifal challenged the might of Nebuchadnezzar-2.Long before the appearance of Akkadians, Assyrians, Sumerian, Aryans, the Indus valley civilization and others, this land of the Prophets and Saints introduced the fundamentals of civilisation to mankind. Hammurabi (c1750BC) ruled here introducing his famous code still present on a lead embedded clay tablet in the Louver in Paris. The remains of the Babylonian hanging gardens sit as a mount beside the gaily painted and never inhabited fort built by a later day dictator.In September 2018, the University of Kerbala Medical School, engaged with Imamia Medics InternationalThe second instalment of that activity was held on 15-16 September 2018, which was an eye opener for many who travelled from various countries to participate. Earlier on, many top medical educators of Pakistan initiated a six month long exercise of bimonthly seminars and workshops in Lahore under the leadership of Professor Mulazim Hussain Bukhari from University of Lahore, Pakistan. They facilitated several workshops on the second day. The hosts had requested a series of workshops on contemporary topics as well as a seminar of plenary lectures by eminent teachers and scholars.Medical Education is enjoying an unprecedented popularity these days. More and more people are joining various certification courses to earn a diploma. Pakistan is mighty powerful in medical education. It started way back in late1970s and early 1980s when Professors Fazle Elahi and Naeem Jafry introduced the concept of medical education at the College of Physicians and Surgeons, Pakistan. SZ (the first author) was fortunate enough to attend the very first workshop facilitated by these great visionaries, where a WHO expert came to teach the Bloom’s Taxonomy and theories of teaching and learning. Prof Naeem Jafri used to say that a school teacher has to earn a diploma like BT or CT before joining the profession, while doctors have to do none. How true! Things have changed since.Over the years, Pakistan has progressed more than any regional country except Iran which has an extraordinary programme of medical education in Tehran, Shiraz, Mash’hed and elsewhere. A visit to the Shiraz Medical Education Department in 2015, confirmed the amazing progress they have made. It is a pity that Iran faces isolation; otherwise we could learn so much from their centres, as well as their fully functional Virtual University.September conference in Karbala coincided with the month of Muharram, so many participants gained not only knowledge but also spiritual satisfaction through pilgrimage to the shrines of Imam Ali, Imam Hussein o Hazrat Abbas and martyrs of Karbala. It was not only inspirational indeed motivational, to attend several workshops conducted by the facilitators. Details on some keynote presentations and workshop details are covered in An amazing plethora of information was disseminated during these two days. The inauguration attracted numerous Deans, Vice chancellors and top health officials from Baghdad, Mosul, Basra, Kufa, Qadisiyah, and Babylon universities. The discipline and etiquette observed during the function was exemplarily. The speeches were brief and to the point, and about 300 attendees engaged and fully engrossed.It is a mixture of private – public partnerships. Many Iraqi doctors prefer to work in the state owned hospitals but also run their private practices, which are often quite lucrative. However, it has to be said that the condition of the public hospitals is not much better than what we have in some cities in the subcontinent. One major flaw appeared to be the lack of medical defence for any mistake, complications or negligence. It has thus driven many a surgeon opt out of surgery, leaving many an un operated goitre hanging grotesquely from the necks and hernias waiting to end up in complications. A senior physician said that the fear of revenge has driven many surgeons out of the country. To a question he replied that in case of a dispute the tribal chiefs settle the issue through a mutually agreeable compensation. The amount could be phenomenal, as the chief has to cater to the needs of his clan.The Arab Board (arab-board.org) is the final certification body with its headquarters in Syria and regional offices in Jordan and Egypt. It covers nearly 20 countries. In a meeting with the high officials it was discussed that Pakistan and other nations could help in exchanging their faculties of master trainers, under graduate and postgraduate students and further training and transfer of technology. Even the Arab Board may be interested in inviting recognised examiners, as external examiners to assess the students and evaluate their programmes.Historically, Iraq being an important component of colonial Britain had access to the best educational programmes akin to India. So in 1927, the first medical school was established in Baghdad by the British authorities, with Harry Sanderson, a seasoned physician as its dean.This curriculum was designed in an era when the world faced, calamities caused by major killers like Plague, Small pox, Syphilis, TB, Typhoid, Typhus, Cholera, and so forth. So Carnegie foundation, hired Abraham Flexner a non-medical educationist, to organise the teaching and training of medical students to combat prevailing clinical conditions. He based his curriculum on Biosciences, with the sole objective of producing a multitasking doctor. Social sciences including ethics were regrettably left out; thereby creating a huge vacuum in the practical application of the third dimension of the triangle of medical education formed by knowledge skills and attitude. Only now medical ethics is beginning to gain its due place.Perhaps an answer could be to engage the ‘Hidden Curriculum’ more effectively to inculcate ethical practices in the lives of future students. Frederick Hafferty5Role modelling is an extremely potent component of hidden curriculum. ‘Role modelling takes place in different academic settings and is observed during formal, informal and hidden curriculum. Hidden curriculum operates and exerts its effects at the level of organizational system and practices. Hidden curriculum could be uncovered by the slangs used in the Institution e.g. using slang of business hub as if practice of medicine is a business’.6Flexner’s curriculum has prospered in Iraq as well as numerous other countries since 1920s. Baghdad medical college taught and produced crops after crops of competent physicians and surgeons for over 80 years. One met several surgeons and physicians in later part of 1960s in London, who dominated the scene in the NHS. They were competent, capable and highly motivated doctors. They were the best amongst the Arab physicians.Following Baghdad duly inspired by the Royal College of Surgeons of Edinburgh, Mosul, Basra, and Mustansirya Medical Colleges were established. The Kufa medical college came up in 1977,9Iraqi history is inundated with atrocities and calamities. So the Iraq-Iran conflict of 1980-88 imposed by previous regime on the Muslims of these countries destroyed all that Iraq possessed. Medical education was one of the casualties. 1990s saw huge economic sanctions, followed by the Bush-Blair war of 2003 that annihilated Iraq.Previous regime had already forbidden the physicians from traveling abroad or outsiders to travel in to impart education. So after the glorious days of 1960s to 80s, the health services, medical education, teaching and training etc. collapsed. It is sad to listen to the stories of many seniors who could not attain their goals in life and now hope to catch up through international collaboration; some of them are Deans of Medical Colleges.In 2016, there were 24 medical colleges in Iraq.The Kufa Medical College under the able leadership of Dean Mohammad Saeed Abdul Zahra is one of the pioneers of clinically integrated curriculum. Baghdad and Kerbala have followed suit. Dean Riyadh Zubaidi of Kerbala took a bold step followed on by the current dean Dr Mayali. Babylon initiated the integrated curriculum this year, as did Duhok. Wasit joined this illustrious club four years ago.The undergraduate programme is covered in six academic years. Following graduation and compulsory two years of rotational clerkship and a year of rural service, they can choose to specialise through the Iraqi or the Arab Board of certification. Usually the physicians require four years of training in medicine and five years in Surgery.rd dimension of medical education. There are several reasons for this. One of them being the unattractive incentives for the supervisors, who are otherwise quite busy in their private practices; an ageless dilemma in many other developing countries!. What is worse is that the tribal culture and lack off indemnity, drive many a surgical trainee away from the profession, as was stated by a senior surgeon, who has opted out of surgical work to become a medical educator already deficient in number of physicians nationally.It appears that each medical College chooses its own curriculum, instructional strategy and tools of assessment and evaluation. Furthermore, there is not enough or at least tailored or structured exposure of undergraduates to the clinical scenes. Postgraduates may be at the worst end. The training programme needs to improve, as postgraduates are skilled but not trained for attitude, communication skills, ethics and professionalism; essentially the 3Iraqi Medical Schools namely Baghdad, Hawler, Kerbala, Kufa, Mustansiriya, Thi-Qar and Wasit. Their deans, professors, and policy makers met with Professor Nigel Bax and Professor Deborah Bax from the University of Sheffield. They discussed undergraduate education and how it could be developed to help recently qualified medical graduates deliver safe and effective care for patients.11A wave of change is fast spreading elsewhere. In a subsequent meeting it was revealed that a national Board of Medical Education is already looking at various options to engage international academic institutions to bring Iraqi Medical education and health services compatible with international standards but duly emphasising on the fundamental target of meeting the local needs. Recently the British Council facilitated a meeting in Erbil, in which seven In several meetings held with the senior faculty, deans, health officials, executive of ministry of Higher Education and CEOS of various institutions, an urgent need was felt to assist in matters of both undergraduate and postgraduate education, curriculum development, teaching, training, assessment and evaluation. The proposal for the competent authority to consider are given in In addition major institutions in Pakistan like the Aga Khan University have already established contacts with the emerging institutions in Iraq. The College of Physicians and Surgeons Pakistan and established universities the Punjab, like University of Health Sciences (UHS) and the Dow University of Health Sciences (DUHS) amongst others could play a major role in the whole process of training the trainers, faculty enhancement programmes capacity building and transfer of technology. Besides, many institutions in Iraq are willing to invite surgeons and specialist to serve the patients. Many Indian hospitals are already engaged in providing first grade services in special fields like Cardiac and Orthopaedic surgery. There is ample opportunity for Pakistan to send its teams of health experts to do the same for which the good offices of Imamia Medics International can be used to establish collaboration and cooperation in different fields.


Although clinicians and scientists have made persistent effort to reduce the use of coercive measures such as mechanical restraint, seclusion, and forced medication, it is required in some situations and staff members are thus confronted with a clinical and ethical dilemma: Coercive measures can save lives  but can be linked with many negative consequences, ranging from a degradation of the therapeutic relationship to symptoms of posttraumatic stress disorder , 2. MoreStudies on the use of coercive measures indicate vast discrepancies between countries and institutions, therefore raising the question of factors influencing decision-making processes including legislative, institutional, and staff-related aspects –7. AuthoThe ratification of the UN Convention on the Rights of Persons with Disabilities (UN CRPD) has shed a new light on this matter and raised an important debate in the field of mental health . The ConThese ethical questions, along with the statements of the CRPD, urge psychiatric institutions to control their structures and treatment concepts in order to create the conditions needed to fulfill the afore-mentioned requirements –15.In Germany, the highest court of justice, the Federal Constitutional Court, stated on the case of a forensic patient in 2011 that compulsory treatment can only take place with the intention of restoring the patients’ capacity to consent and only if several requisites are fulfilled. These encompass the impaired capacity of the patient to consent to the treatment after different options have been presented and explained, the necessary character of treatment to avoid acute endangerment of the patient or others, and the use of compulsory treatment as a last resort after all other alternatives have been exhausted.These legally binding statements and the related discussions show that decision-making processes regarding the use of coercion need to be reviewed and revised accordingly. The interpretation of the preconditions for compulsory treatment, notably its “last resort” character, requires in-depth considerations.Two short clinical cases from an acute psychiatric ward aim to highlight some of the core aspects of exemplary decision-making processes and underline the structural factors that these should be based on.Two patients were taken to an acute ward at the Department of Psychiatry of the St-Hedwig Hospital  by police force in handcuffs on the same day within a 3-h period and were admitted to a general psychiatric ward on the legal basis of the Mental Health Law (Berliner PsychKG). Both patients were previously unknown to the police authority and the hospital staff and did not hold valid documents authorizing them. Their behavior attracted the attention of the police through imminent endangerment of others and “confusion.” To simplify the presentation of the different courses of treatment, we will refer to them as patients 1 and 2. All personal patient data have been modified to avoid their identification.Patient 1 (20–25 years old) presented with agitation. He was threatening, screaming, scratching, and spitting, and refused a conversation. He looked well-groomed . The team, consisting of two nurses, a resident and a consultant psychiatrist, had the impression that the aggression of patient 1 was somehow undirected, i.e., not directed against certain persons and irrespective of the context. The perceived subjective and clinical aspects led to the assumption that patient 1 could suffer from an acute and potentially first manifestation of a mental disorder. He expressly refused to undergo medical examination and all offered treatments. The team tried many times to establish contact with the patient by calmly addressing him or offering him to sit down and talk, to drink something, or to retreat in a quiet room and rest. All of these attempts to de-escalate the situation didn’t have any effect. The patient was still agitated, threw himself against the ward door, thus bruising himself, or screamed at the staff. The team members thoroughly discussed the next steps to solve the acute situation.The involved staff members agreed that, in this situation, the legal conditions allowing the use of compulsory treatment and mechanical restraint were fulfilled and that, most importantly, every alternative had been exhausted. The team thus decided that, in order to prevent further harm to himself and others, compulsory treatment was the only available possibility. Because of the acute and dangerous character of the situation, the patient was then, according to the Mental Health Law, mechanically restraint, a blood analysis and an ECG were performed, and he received an i.v. medication. Legal procedures regarding the pursuit of the involuntary hospitalization and compulsory treatments including external medical review and a decision by a judge were initiated. The results of the analysis showed that the symptoms of patient 1 were caused by a severe overdose of L-thyroxine and an electrolyte imbalance due to anorexia nervosa. After a few days of intensive care treatment, patient l switched to outpatient treatment on another ward.Patient 2 (40–45 years old) presented with severe agitation. He was threatening, screaming, scratching, and spitting, and refused a conversation. He thus showed a similar clinical picture as patient 1 but also appeared to experience auditory hallucinations and to actively talk to them. Patient 2 was in a state of poor hygiene. Taking into consideration his manner of response, one could assume that patient 2 has experienced psychiatric treatment in the past. When the nurse asked him if he had any experience with psychiatric medication, he yelled at her and clarified his wish to refuse haloperidol. He seemed to feel especially threatened by the police and the psychiatric staff, not only due to psychotic symptoms but also due to previous aversive experiences with psychiatric treatment. Once again, the staff members involved in the situation discussed the clinical case in a multiprofessional setting and weighed out every possible option. The team suspected that patient 2 suffered from an acute exacerbation of a disorder that persisted for a longer period of time or a psychotic relapse. In this case, the team decided that patient 2—due to his previous aversive experiences—would have extraordinarily suffered from compulsory treatment, which may exacerbate previous traumatic experiences. Also, he calmed down a bit when given a space to withdraw and did not immediately endanger himself or others; however, he remained tense for several days and threw objects whenever members of staff tried to engage him in a conversation or offered oral medication. When left alone, he did not appear aggressive or present improper handling, showed a regular food intake, and welcomed the possibility to smoke. Somewhat later, he was seeking a medical consultation and expressed the need for a low-dosage medication. To this day, 6 years later, he regularly receives outpatient care and short-term crisis intervention treatment on a psychiatric ward, although he has felt threatened and deprived of his identity by the state and the psychiatric system of another city for more than 25 years.These clinical cases elucidate the complexity of decision-making processes regarding the use of coercive measures such as mechanical restraint and forced medication. Both persons presented with impaired capacity to consent and acute endangerment of themselves or others. However, their situations differed with respect to their subjective reactions, previous experiences, and response to de-escalation. These factors played a central role in the evaluation of the possible alternatives and eventually in the whole decision-making process.Decision-making processes leading to involuntary admission often imply uncertainty and doubt among the clinicians in charge . In a quThis suggests that the conditions facilitating the exploration of alternatives to coercion need to be elucidated , 22. TheFurthermore, the two cases suggest that in situations in which patients harm themselves and others, it is essential to comprehend the motivation behind aggressive or self-harming behavior. Whereas professional members of staff predominantly view the psychopathology as the key factor in the development of aggression, patients mostly believe that environmental factors  play a crucial part . The intIn recent years, complex interventions for acute psychiatric settings have been increasingly recommended to achieve a reduction of coercive interventions, as described in the “Weddinger Model”—a recovery-oriented treatment concept that has been introduced in the Charité University Department of Psychiatry at the St. Hedwig Hospital in 2010 and which aims to promote team competence on multiple levels –27. WithIn conclusion, it should be noted that a reduction of coercion in psychiatric settings appears promising if legal procedures and oversight are combined with multiprofessional, patient-centred, and recovery-oriented clinical work relevant to the complexity of any acute crisis situation.LM, JM, AH, and AW conceived and wrote the paper.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.


In recent years, the interstitial cells telocytes, formerly known as interstitial Cajal-like cells, have been described in almost all organs of the human body. Although telocytes were previously thought to be localized predominantly in the organs of the digestive system, as of 2018 they have also been described in the lymphoid tissue, skin, respiratory system, urinary system, meninges and the organs of the male and female genital tracts. Since the time of eminent German pathologist Rudolf Virchow, we have known that many pathological processes originate directly from cellular changes. Even though telocytes are not widely accepted by all scientists as an individual and morphologically and functionally distinct cell population, several articles regarding telocytes have already been published in such prestigious journals as Nature and Annals of the New York Academy of Sciences. The telocyte diversity extends beyond their morphology and functions, as they have a potential role in the etiopathogenesis of different diseases. The most commonly described telocyte-associated diseases (which may be best termed “telocytopathies” in the future) are summarized in this critical review. It is difficult to imagine that a single cell population could be involved in the pathogenesis of such a wide spectrum of pathological conditions as extragastrointestinal stromal tumors (“telocytomas”), liver fibrosis, preeclampsia during pregnancy, tubal infertility, heart failure and psoriasis. In any case, future functional studies of telocytes in vivo will help to understand the mechanism by which telocytes contribute to tissue homeostasis in health and disease. The human body consists of more than 200 morphologically and functionally different cells, although the exact number is still unclear. Additionally, most of these cells are found in different stages of their development . Since tWe hold the opinion that a similar principle also applies to a recently discovered cell population—telocytes, which have been continuously described in the pathogenesis of many different diseases over the last 10 years. Considering the extent of this publication activity, we are somewhat surprised that until now there has not been a proposal to introduce a new term referring to the group of diseases caused by the reduced number or impaired function of telocytes, for example, “telocytopathies”., eponymously termed interstitial cells of Cajal , the new term “interstitial Cajal-like cells” was proposed for this newly discovered population of pancreatic cells. This discovery is attributed to the team of cell biologists and pathologists from Romania led by Professor Laurentiu M. Popescu (1944–2015). Professor Popescu was considered one of the greatest Romanian cell biologists and is also renowned internationally. He was awarded multiple prestigious prizes for his scientific achievements and was selected as a president or a member of many international scientific organizations [as Nature [and Annals of the New York Academy of Sciences [In the first place, it is necessary to point out that telocytes were discovered in 2005, only 13 years ago, in the loose connective tissue of the pancreas . Becauseizations , where tizations . Oddly, izations  containiPopescu 144–2015. izations ,11,12, ss Nature  and AnnaSciences . This coThe current state of knowledge indicates that telocytes form three-dimensional networks in various organs. Telocytes are typically described as cells with small bodies and one to five very long cytoplasmic processes, whose width is under the resolution power of light microscopes , contrasIn recent years, telocytes have been described in almost all organs of the human body. Although telocytes were previously thought to be localized predominantly in the organs of the digestive system, as of 2018 they have also been described in the lymphoid tissue, skin, respiratory system, urinary system, meninges and the organs of the male and female genital tracts .The processes of telocytes engage in intercellular communication not only with other telocytes, but also with adjacent structures and cell populations such as blood vessels, nerve endings, smooth muscle cells and cells of glandular epithelia. This communication is enabled by homo- or heterocellular cell-to-cell junctions or by extracellular vesicles.Telocyte-produced extracellular vesicles play roles in the regulation of stem cell function, tissue regeneration, immunological surveillance and the maintenance of homeostatic processes.The morphological characteristics of telocytes have been thoroughly covered in a large number of original ,84,85,86Some researchers, like American neuroscientist Lawrence Edelstein, go even further to highlight the putative functions of this newly described cell population. Professor Edelstein compared the network comprising the processes of telocytes to a primitive cellular communication network, similar to the nervous system at the cellular level ,107.Telocytes were firstly linked to the interstitial/pacemaker cells of Cajal, whose detailed description served as the basis for the discovery of telocytes. The pacemaking, which controls the contractile activity of the gastrointestinal muscles, is the essence of their significant physiological role—the orchestration of the normal peristaltic activity of the digestive system . The entJournal of Cellular and Molecular Medicine, the academic journal established by the discoverer of telocytes, Professor Laurentiu Popescu. Taking this finding into consideration may diminish the credibility of the published results regarding the supposedly groundbreaking roles of telocytes in the etiopathogenesis of various diseases. We emphasize that we are in no way casting doubt on the importance of the results published in this journal. The diversity of telocytes extends beyond their morphology and functions, as they have a potential role in the etiopathogenesis of different diseases. The most commonly described telocyte-associated diseases (which may be best termed “telocytopathies” in the future) are summarized in In the recent literature, few human studies have investigated changes in the distribution and function of telocytes during different diseases; most studies of this kind have used animal models. Moreover, the causative relationship between a quantitative reduction of telocytes and disease development is disputable. It is important to consider that the modification of the cellular microenvironment of different organs during a disease can be the cause of telocyte loss, rather than the other way around.Resolving the status of telocytes as an individual cell population will be important for morphologists, who still hesitate to include telocytes in histology and cellular biology textbooks and to incorporate them into the histological nomenclature. Tissue engineers are also interested in the final answer regarding the role of telocytes as stem cell “nurses” and their importance in regenerative medicine. Telocytes as “nurse” cells were reported, for instance, in the intestinal epithelium  and with


Background: Non-invasive cardiac mapping—also known as Electrocardiographic imaging (ECGi)—is a novel, painless and relatively economic method to map the electrical activation and repolarization patterns of the heart, providing a valuable tool for early identification and diagnosis of conduction abnormalities and arrhythmias. Moreover, the ability to obtain information on cardiac electrical activity non-invasively using ECGi provides the potential for a priori information to guide invasive surgical procedures, improving success rates, and reducing procedure time.Previous studies have shown the influence of clinical variables, such as heart rate, heart size, endocardial wall, and body composition on surface electrocardiogram (ECG) measurements. The influence of clinical variables on the ECG variability has provided information on cardiovascular control and its abnormalities in various pathologies. However, the effects of such clinical variables on the Body Surface Potential (BSP) and ECGi maps have yet to be systematically investigated.Methods: In this study we investigated the effects of heart size, intracardiac thickness, and heart rate on BSP and ECGi maps using a previously-developed 3D electrophysiologically-detailed ventricles-torso model. The inverse solution was solved using the three different Tikhonov regularization methods.Results: Through comparison of multiple measures of error/accuracy on the ECGi reconstructions, our results showed that using different heart geometries to solve the forward and inverse problems produced a larger estimated focal excitation location. An increase of ~2 mm in the Euclidean distance error was observed for an increase in the heart size. However, the estimation of the location of focal activity was still able to be obtained. Similarly, a Euclidean distance increase was observed when the order of regularization was reduced.For the case of activation maps reconstructed at the same ectopic focus location but different heart rates, an increase in the errors and Euclidean distance was observed when the heart rate was increased.Conclusions: Non-invasive cardiac mapping can still provide useful information about cardiac activation patterns for the cases when a different geometry is used for the inverse problem compared to the one used for the forward solution; rapid pacing rates can induce order-dependent errors in the accuracy of reconstruction. Cardiovascular disease is a major contributor to reduced quality of life and mortality worldwide  is a novel, painless and (relatively) economic method to map the electrical activation and repolarization patterns of the heart . Ventricular activation was then combined with a heterogeneous torso model and the forward problem was solved to produce simulated BSP maps . The inverse solution, using multiple regularization approaches, was applied to the simulated BSP maps in order to produce ECGi epicardial potential reconstructions and compute activation patterns (section “Inverse Solution”). Multiple measures were used to quantify and compare results obtained under the different conditions .The x = Δy = Δz = 0.5 mm was used, which gave ~2 × 106 nodes in tissue, to facilitate high-throughput generation of multiple datasets for BSP and ECGi analysis. Measurements of the LV volume, LV wall thickness, and RV wall thickness from the developed geometries are given in Idealized human bi-ventricle geometries were constructed as structured finite difference grids, wherein the left and right ventricles  were modeled as thick- and thin-walled truncated ellipsoids, respectively. A control  geometry was constructed in order to have physiologically-accurate ventricular wall thicknesses , d is the normalized transmural depth (varying from 0 at the endocardium to 1 at the epicardium), and n determines the transmural variation in helix angle . For all simulations in this study, R was set to 60°, giving a transmural rotation in helix angle of 120°, similar to that observed in existing human ventricular datasets  axis  of human ventricular myocytes, the 2006 version of the Ten Tusscher et al. model was used , and zBase and zApex are the values of the z coordinate at the apex and base, respectively. No electrophysiological differences were incorporated between the LV and RV  was solved numerically using a finite-difference PDE solver based on the explicit forward Euler method, using an operator splitting technique and an adaptive time step with minimum and maximum time steps of Δtmin = 0.02 ms and Δtmax = 0.2 ms, respectively  in quick succession along the endocardial wall :An inverse solution was developed, extending previously published preliminary work , First , and Second  order Tikhonov were used to regularize the solution. The GSVD technique was used to solve Equation (6) in each case.where  Hansen, , and R iAs an ill-posed problem, noisy signals can have an important effect on the reconstructed maps. Whereas it is common in modeling studies of ECGi to include additional white noise, this was not performed in this study for the bulk of our analysis. Please see “Discussion: Limitations” for further details on the inclusion of noise and its impact.Voltage root mean squared (RMS):Relative RMS error (rRMSe):Pearson correlation coefficient (PCC):Epicardial potentials were reconstructed from the BSP obtained at each instant of time for each geometry and activation case. Activation maps were calculated by computing maximal negative slope at each node at each time step , ∅ is the potential reconstructed or measured and ∅′ is the original simulated potential, while where r is the center of activation of the reconstructed potential in the 3D Euclidean space and r′ is the center of activation of the original simulated data. The Euclidean distance was calculated for all the ectopic cases and a median value is reported in this study.To investigate the focus location accuracy of the inverse solutions, the Euclidean distance (ED) was calculated at the center of the earliest activation: The impact of using only an initial patient anatomical reconstruction when performing ECGi, which doesn't capture any structural remodeling which may have occurred between the time of the scan and any present measurements, was investigated: Ectopic ventricular activation was simulated on all three geometries  and used to solve the forward problem and produce BSP maps; the ECGi reconstruction was performed using only the control geometry, representing the initial patient scan. Quantification of errors and correlations were performed by comparing the reconstruction with the control geometry activation for each matched ectopic location, such that geometrical differences don't have to be accounted for.Kr and IKs was employed to sustain the most rapid excitation rate (BCL = 150 ms). All other data were produced using the control AP models.The effect of heart rate on the epicardial reconstructions obtained using the three Tikhonov regularization methods was assessed for focal excitations using the control geometry paced at basic cycle lengths (BCL) of 1,000, 750, 500, 300, and 150 ms . Shortening of the AP  induced in silico framework . Then, the potential errors induced by using out-of-date and inaccurate cardiac anatomical reconstructions when performing ECGi was assessed . Finally, we investigated the effect of heart rate on the accuracy of reconstructed activation patterns using the different regularization approaches (section “Effects of Heart Rate on Non-invasive Cardiac Maps”).First, the impact of the different geometries  on simulated BSP under control pacing conditions were compared to illustrate recapitulation of activation pattern and ECG differences observed under these conditions in the The effects of the different geometries on the BSP were quantified by comparing the thick-walled and dilated geometries vs. the control during ventricular activation . Small dData are illustrated for a single ectopic site only RV-LAT— and summThe calculated ED, measuring the error in correlation between real and identified focus location, varied for each geometry using the three Tikhonov methods . SmallerThe ED was calculated and compared for each different heart rate and Tikhonov method . The SecThe reconstructed activation patterns were compared across the different pacing rates; illustrative data for the LV-LAT site are shown in in silico approach to evaluate the impact of different ventricular anatomical morphologies and heart rate on the accuracy of epicardial reconstructions attained through the application of the inverse solution to the BSP. We have demonstrated that the different cardiac anatomical states resulted in small but measurable differences in the BSP  whereas the First and Second order do account for this interaction and result in smoothed signals . Spatial heterogeneities in voltage will therefore be smoothed using First and Second order but not Zero. Following that this approach distinction correlates with whether or not the reconstruction exhibits rate-dependence, we propose that spatial gradients observed at rapid rates, not present at slower pacing rates, may account for this observation.In a previous preliminary study in the atria (Alday et al., The RMS and PCC of First and Second order reconstructions associated with both the pacing rates using the short AP model were comparable to the slow pacing rate using the control AP model, and differed from the rapid pacing rates . In partThese types of studies are key to fully translate ECGi technology into clinical settings. However, they are difficult or impossible to perform in control and experimental settings, and the accuracy of the forward and inverse solution is still under study (Bear et al., Another limitation is the idealized ventricular models used, which lacked the complex anatomy and microstructure of the real human ventricles (Stephenson et al., Due to both the BSP and inverse solution being computed using simulations, it is important to ensure that “inverse crime,” where the inverse method exactly inverts the forward method, is avoided. We ensure that this is the case through the use of Salu's method for the forward problem and Barr's for the inverse solution; thus, whereas the forward problem is solved by computing the electric field which arises as a result of currents in the cardiac tissue, the inverse solution uses an equivalent potential distribution on a closed surface. These independent methods, utilizing two different matrices, ensure that it is not possible for the inverse solution to exactly invert the forward solution.Only ventricular activation was considered for comparison between different rates and geometries, disregarding potential analysis of the repolarization patterns, which may themselves provide substantial diagnostic information. Future investigation of the effects of anatomical reconstruction inaccuracies and heart rate on the reconstruction of repolarization patterns may therefore provide valuable information. However, the present study was focused on identifying the location of ectopic pacing sites, relevant in particular for guiding ablation therapy, and therefore requires only activation patterns to be reconstructed.in silico experiments of the present study. Whereas the geometry of the heart was considered, this was not combined with analysis of its location, its mechanical movement, or electrode location errors, all of which have been previously shown to be important factors influencing the accuracy of the reconstruction (Swenson et al., There are multiple further factors which will be relevant for clinical studies but not accounted for in the idealized and controlled In addition, the inverse problem of electrocardiography is an ill-posed problem and therefore noisy signals can have an important effect of the reconstructed maps. Whereas, the simulated data in this study and used for our analyses did not include noise, we performed further simulations in which white noise was included. These data demonstrated that noise increased ED and decreased correlation, but the differences between conditions were maintained, indicating that whereas noise has an important impact on the activation maps and ED, our observations about different geometries and pacing rate are maintained (Section S3 in The systematic analysis revealed that the effect of size, thickness, and heart rate can manifest in the BSP and ECGi in different ways, with varying sensitivities and success rates in inferring the clinical variables from non-invasive information. We observed a rate dependence in the ability of different Tikhonov regularization methods to successfully reproduce cardiac electrical activity. Our results show that the ECGi approach gives the most accurate results when used with geometries depicting the current state of the patient's heart, but if a single image of the patient's heart is obtained, for example at the start of treatment, the ECGi approach still gives useful and reasonably accurate information relating to underlying electrophysiological abnormalities. In addition, clinical variables such as heart rate need to be accounted for when solving the inverse solution, in particular due to the increase in errors observed at rapid pacing rates.EP conceived the study. EP and MC designed the study. DW developed, applied, and analyzed data associated with the bi-ventricle cardiac excitation model. EP developed, applied, and analyzed data associated with the forward problem, inverse solution, ECG, and error analysis. EP and all other authors interpreted the data. EP and DW prepared the figures. EP and MC prepared, and all authors edited, the drafts of the manuscript. All authors approve the final version of the manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of the work are appropriately investigated and resolved.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 reviewer JT declared a past collaboration with one of the authors EP to the handling editor.


The re-conceptualization of knowledge translation (KT) in Kitson and colleagues’ manuscript "Using Complexity and Network Concepts to Inform Healthcare Knowledge Translation" is an advancement in how one can incorporate implementation into the KT process. Kitson notes that "the challenge is to explain how it might help in the healthcare policy, practice, and research communities." We propose that these concepts are well presented when considering highly-partnered research that includes all sectors. In this manuscript we provide an example of highly-partnered KT effort framed within the KT Complexity Network Theory. This effort is described by identifying the activities and sectors involved. First, some may consider the implementation of an innovation to be synonymous with KT. In this manuscript, how these processes differ is clearly demonstrated. Figure 3 of the Kitson manuscript provides a clear depiction of the processes involved in KT (including implementation) as well as the five sectors that can independently or jointly influence KT. These sectors - community, health [systems], government, education, and research - encompass the primary sources of influence. Second, this manuscript posits that KT is neither linear nor cyclical, as is frequently depicted. Rather how KT occurs is dependent upon the interaction of the KT processes and five sectors. Kitson describes the processes of KT as problem identification, knowledge synthesis, implementation, evaluation, and knowledge creation. Third, the induction of complexity theory into KT supports the proposition that outcomes of KT processes are often “unpredictable, non-linear, and emergent.” For those of us deeply involved in KT activities as well as its study, this is quite reassuring.The re-conceptualization of knowledge translation (KT) in Kitson and colleagues’ manuscriptKitson notes that “the challenge is to explain how it might help in the healthcare policy, practice, and research communities.” These concepts were very useful to us, as they capture the unpredictable and constantly evolving nature of KT and research that is highly-partnered between the sectors described by Kitson. The purpose of this commentary is to provide an example of an ongoing highly-partnered KT effort framed within the KT Complexity Network Theory and describe how the KT model can be used to elucidate factors that impact the KT effort.problem identified is military Veteran suicide and the need to identify those at highest risk for suicide to improve suicide prevention efforts. To address this problem VA created a predictive model of suicide risk using existing electronic medical record data,3 a dashboard to inform providers of high risk Veterans, and a suicide prevention clinical initiative  using this information. Information was synthesized into initiative resources that include: educational handouts, video examples, medical record note templates, scripts to use when discussing suicide prevention with Veterans, and other tools. The implementation included policy memos that encompass the national VA healthcare system, identification of a coordinator at each of the 140 VA healthcare systems, web-based training, educational and support materials, and technical assistance. For sites having difficulty fully implementing the program external implementation facilitation5 is provided. The evaluation includes three components: the evaluation of patient outcomes and effectiveness of the suicide prevention clinical intervention, evaluation of program implementation and use of implementation facilitation, and an iterative adaptation of the dashboard and other tools based on feedback from community and healthcare stakeholders.This example is taken from activities conducted within the United States Department of Veterans Affairs (VA). Of note, this example is work that is actively under way and subject to further changes in the months and years to come, as expected according to the KT model. Applying the KT model during the course of a project or study allows participants to use the model to understand and address challenges that emerge from different sectors during the course of the knowledge transfer. The the Community: Veterans, family members, and other community stakeholders; the Health System: the United States Department of Veterans Affairs Veteran Healthcare Administration; Education: a clinical implementation team that focuses on educating providers, facility coordinators, and other stakeholders; Government: leadership of VA; and Research: an arm of VA that supports the evaluation described above. In this case, there is an overlap between the health system and the government, as the VA is a government agency with the mission of providing care to the nation’s military Veterans. This is likely similar to other government funded healthcare systems across the world. It is also likely different from other healthcare organizations that may be impacted by the government, but are not funded by the government, as is common in the United States. This research was supported through a Learning Healthcare Initiative randomized program evaluation that required early interactions between the research team, education specialists, the healthcare partner, and community stakeholders (See The five sectors (or stakeholders) include ders See .health system and government) to partner with research colleagues to evaluate healthcare initiatives. This allows the health system to learn and improve, while at the same time advancing research on such KT activities. This works with this energy, as opposed to researcher initiated projects that are well-designed ways to test research questions, but might not fit the current healthcare and government priorities. Given that another mission of the VA is to provide education, there are built in collaborators with whom to help develop educational materials to support health system and government in KT activities. Finally, a core value of VA is to include the Veteran voice and most initiatives strive to include community stakeholders to inform their work.At the conclusion of their article, Kitson et al ask readers to consider how to facilitate networks and support nodes to flourish across complex adaptive systems and how to recognize and use the energy within systems rather than fight it. We believe that the VA’s new Learning Healthcare Initiative funding does just this by providing a way for operational offices  would receive facilitation in a stepped wedge design. This resulted in only seven units to be randomized, which rendered randomization inappropriate. Therefore, the research team used information about the facilities and regions to assign each to a start time for facilitation. The facilities within the region that needed assistance changed over the course of initial KT. Because this was a highly-partnered research initiative the research team adapted their model to include those sites of highest need of assistance and, fortunately, the changes would not have resulted in a change of order.Healthcare facilities initially targeted for implementation facilitation assistance were identified during the planning stage as those in need of additional support to successfully implement the initiative. To enhance efficiency of the facilitation team and control for regional characteristics, research sector to incorporate these critical aspects of knowledge transfer in the evaluation of the implementation. In addition, not all processes are distinct. For example, products developed in our knowledge synthesis process were used in implementation. We suspect that this would be true of most KT efforts. Kitson also challenges those applying the KT Model to determine how they would know that they “know you have all the key stakeholders around the table at the same stage?” In our experience this did not occur. Rather, stakeholders vary in their presence and role across the course of the KT effort. This dynamic and changing stakeholder presence is one challenge that the KT model helps us better understand. Finally, while VA is making purposeful steps to advance partnered research, not all KT efforts need to be partnered to lead to positive outcomes and even partnered research can lack benefit to the organization in which it occurs. Again, this further enforces the need for partnered research activities to be comprehensively documented and their outcomes, beneficial or not, reported to all stakeholders as well as the broader KT community.While the application of the KT model has allowed us to better understand the “chaos” that is occurring during this highly-partnered effort and channel the emerging energy, there are limitations to the application of the model. Detailing the processes and contexts in which knowledge transfer plays out well or fails to do so is not incorporated into the KT model. Thus, this is left to the This highly-partnered knowledge transfer effort is currently in its early stages and we anticipate that the five sectors will continue to influence the processes that occur. While this may be challenging to those trained in traditional research methodology, as noted by Kitson, engagement of the sectors is vital for connections to take place. This is the challenge and the gift for those of us engaged in the study and conduct of highly-partnered KT.This article was supported by the Team Based Behavioral Health Quality Enhancement Research Initiative (QUERI) grant (QUE 15-289) and the Risk Stratified Enhancements to Clinical Care: Targeting Care for Patients Identified Through Predictive Modeling as Being at High Risk for Suicide, with the Office of Mental Health Operations grant (SDR 16-195) through the US Department of Veteran Affairs.Not applicable.The views expressed in this paper are those of the authors and do not necessarily reflect the position or policy of the United States Department of Veterans Affairs (VA), Veterans Health Administration (VHA), or the United States Government.JEK and SJL were responsible for the conception of the commentary and drafted the article. AEE provided critical revision of the article. All authors provided final approval of the version to be published.1QUERI for Team-Based Behavioral Healthcare, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA. 2VISN 16 South Central Mental Illness Research Education and Clinical Center (MIRECC), Central Arkansas VA Health Care System, Little Rock, AR, USA. 3Office of Mental Health and Suicide Prevention, Department of Veterans Affairs, Gainesville, FL, USA.