The Kampala Metropolitan Area (KMA) is the fastest developing region in Uganda. Over recent years, this has placed exponential demand on the road sector, which consequently has contributed to rapid growth in motorized vehicles which, predisposes the region to a high risk of road traffic incidents (RTIs). A number of concerted road safety and post-crash management measures to respond to RTIs in the KMA in particular and Uganda as a whole have been undertaken. However, there is a need to greatly improve the measures by better identifying the factors influencing the exposure, vulnerability and emergency medical service (EMS) capacity for RTI victims. The present study seeks to investigate and reveal these factors.A Delphi technique employing a questionnaire and involving a multidisciplinary panel of experts was used in three rounds.The ten (10) most important factors affecting the exposure, vulnerability and EMS capacity for victims of RTIs in the KMA were identified. Socio-cultural, infrastructure and road safety aspects were the factors most identified as affecting the exposure and vulnerability. The absence of a national EMS policy and post-crash care system, as well as the fact that many victims lack health insurance, were noted to be the factors adversely affecting the EMS capacity.There exists is a real need to substantially reduce the burden of RTIs in KMA, with ultimate goal of saving lives that are being lost needlessly and reducing the impact of injuries and trauma and the economic losses associated with it. This study offers insights into the causes of RTIs and the most appropriate ways of responding to them especially with the establishment and empowerment of predefined and structured EMS systems. This crucial progress in the road sector has helped to spearhead the modest economic growth and development in Uganda. However, at the same time it has resulted, in an upsurge of road traffic incidents (RTIs) which contribute to mortality, injury, morbidity, trauma and disability [. RTIs also cost the governments, especially in the low and middle income countries (LMICs) such as Uganda, approximately 3% of their annual Gross Domestic Product (GDP) [In recent years, the Kampala Metropolitan Area (KMA) in particular and Uganda as a whole have been registering exponential progress in the road sector. Some roads have been fully or substantially completed; some are under construction and some are due for construction as soon as it becomes possible . This crsability –4. RTIs ct (GDP) .The KMA is the fastest developing region in Uganda. It has close proximity to Kampala, the capital city of Uganda, which is the political epicenter and economic hub accounting for 80% of all of Uganda’s industrial and commercial activities . Most ofAccording to the police records, the highest number of all the registered RTIs in Uganda happens in the KMA. For example, a total of 22,699, 22,461, 22,272, 19,870 and 18,368 RTIs happened in Uganda in 2009, 2010, 2011, 2012 and 2013 respectively. However, 12,099 (53%); 12,152 (54%); 12,136 (54%); ~9935 (50%) and 9651 (53%) respectively were registered in KMA [. At times, the views of an individual expert can be susceptible to biases so this is why the present study opted for a Delphi approach. Twenty two (22) distinguished experts were purposively contacted to participate in this Delphi study. This was after exploring their profiles and institutions of affiliation which are involved in road safety, EMS and injury prevention. It should however be noted that, no specific number of participants is recommended for Delphi surveys. Only 12 experts participated all the way up to the last Delphi round out of the 16 experts who initially participated in the first round. Their details are indicated in Table This study used a Delphi technique employing a questionnaire and involving a multi-disciplinary panel of experts in three rounds. The Delphi method uses a panel of experts to investigate a complex or imprecise issue using a series of structured statements , 12. At The selection criteria for the experts was as follows: (a) being recognized as an expert and being knowledgeable on the Delphi topic; (b) having accumulated a wealth of professional experience; (c) holding a key position that requires them to advise and/or oversee issues related to the Delphi topic; (d) being a researcher with recognized research and (e) being affiliated to a reputable institution. The experts selected were government bureaucrats; policy makers; traffic police commanders; academicians and researchers; consultants and emergency care specialists from public and private institutions working on road safety, injury prevention and EMS. A clear explanation about the study was made to them and if they consented , they were then requested to participate in not less than two Delphi rounds. In each round, the experts were provided with a questionnaire structured in three (3) parts, which solicited their feedback on E, V and C factors as per the study topic. Before distributing the questionnaires for each of the three rounds, all the reviewers carefully reviewed them and where necessary revised them.2 radius (970 sq. km2) in the central part of Uganda. It stretches from Kampala, the capital city of Uganda, to other areas of Mukono, Entebbe, Nansana, Kira and Wakiso [The KMA covers an area with an approximate 20 kmd Wakiso , 14. Simd Wakiso , 13–15.Round 1: Initially, 16 experts consented to receiving the open-ended questionnaire which requested their general opinions on the factors influencing the E, V and C for victims of RTIs in the KMA. The experts received the questionnaire in a hard and soft copy form. Answering the questionnaire covered a period between 2 weeks and one and half months. At the beginning, the questionnaire was pretested and reviewed by all the reviewers and where necessary adjusted before being distributed to the experts both in a soft and hard copy forms.Round 2: The experts’ feedback from round one was then reviewed, modified, aggregated and converted into another well-structured questionnaire which consisted of listing a wide range factors affecting the E, V and C for victims of RTIs in the KMA  listed needed to be rated much higher. They justified this on the fact that the Boda-bodas are increasingly being registered as the major cause of RTIs in the KMA. The 3 remaining experts never made any comment about the list.In this Delphi study, the factors that were identified as affecting the exposure and vulnerability of victims to RTIs in KMA were similar and multifactorial in nature. That’s because they were influenced by a number of different socio-cultural, infrastructure and road safety aspects. Those factors most affecting the EMS capacity were the absence of a national EMS policy and post-crash care system as well as the fact that many victims lack health insurance. Given that multidisciplinary experts with varied knowledge; work experience; recognized researches and extramural training were convened together for this study, the factors they identified offer another opportunity to further evaluate and revise the effectiveness of existing road safety measures. The findings also augment a prior advocacy that agitated for establishing a well-structured EMS system to cater for the ever increasing emergency demands being placed on health and medical units beyond even the KMA , 18, 19.In regard to the findings in this Delphi study; the factors related to driver indiscipline; driving under the influence of alcohol and drugs; failure to use adequate safety equipment  and excessive speeding were often induced by different road users’ cultures, behaviors and perceptions. Other factors were demographically attributed to age, peer influence and the economic status. Some of these factors were identified in other studies to contribute to the underlying causes of RTIs in LMICs including a systematic review study on the trend of RTIs in Kampala and Uganda at large –24. Simi2 (43%) of paved roads exist in the KMA out of 3000 km2 of total paved roads in Uganda [2 of road network but only 20% of it is in fair condition [The aforementioned road sector in Uganda has been progressing especially in the KMA with the benefits of the region having the most roads in fairly good condition. Approximately 1300 kmn Uganda , 13, 14.ondition .. This validates some of the E and V factors that were underscored to affect victims of RTIs in the KMA by the experts because their causes mostly emanate from road design and construction challenges. They include: lack of segregated lanes; inadequate road furniture; poorly planned-engineering; mixed traffic streams; poorly designed roads and the absence of traffic segregation facilities for non-motorized road users. These are similar with other findings in most of the LIMCs [Again, the majority of roads in the KMA lack necessary traffic signs and pedestrian facilities such as speed humps, warning signs, demarcated bus-stops, zebra crossing, footbridges and crosswalks as well as pedestrian reflectors. Yet these traffic signs and facilities are required for regulating the traffic flow and alerting road users about potential hazards along roads which ultimately help to reduce RTIs . This vahe LIMCs , 28, 29,he LIMCs , 31..It is pleasing to report that over the recent years, multisectoral road safety measures were instigated to respond to the heavy burden of RTIs. These included the deployment of more traffic and highway police along roads to police for road violations; efforts to increase public awareness and sensitization; greater coordination efforts and proactive road safety audits –10. They. However, much more is still needed to achieve effective implementation and enforcement of road safety in the KMA considering some factors which were noted in the Delphi surveys. These include: an inadequate driver training regime; ignoring use of protective equipment; drinking and driving; excessive speed; lack of driving permits; and the inadequate regulation of public passenger transport services. Most of these factors have been also highlighted by the World Health Organization, and they are also in line with the findings in another study [The above road safety measures are in-tandem with the national, regional and international road safety frameworks based on the Uganda National Road Safety Action Plan and United Nations General Assembly Action for the Road Safety Action 2010–2020 and are to be commended , 34. Hower study , 35.Based on RTI records all the road users  in the KMA are susceptible to being involved in RTIs –10. Some. Some of the reasons attributed to this include failure to wear and use protective safety and visibility gear and equipment (helmet and reflectors); failure of riders to comply with the traffic signals; riding at exorbitant speeds where it is unnecessary and dangerous. Researcher further indicates that the severity of injuries of the victims involved in Boda-boda crashes in Kampala city is greatly increased particularly by the failure of both motorcyclists and their passengers to wear protective gear [. It is therefore necessary to rank the unregulated rise of the Boda-bodas higher among the factors exposing victims to RTIs in KMA as some experts suggested.Of recent, the numbers of Boda-bodas have been exponentially rising to the point that it now predominates the public transport system of the KMA and Uganda , 38, 39.ive gear –39. It i. Two studies which assessed the pre-hospital care for victims of RTIs observed that it’s often left to police with the help of community leaders, taxi drivers and lay people who are ill-equipped and untrained to deliver suitable emergency medical care [. Other studies noted that due to the absence of a pre-hospital emergency care system in Kampala, many patients arrive too late and those with serious injuries may die before they receive the emergency care they need. Others die immediately upon arrival to accident and emergency units due to poor emergency care they received before [.The absence of a national EMS policy and post-crash care system are compounded by other factors known to affect the EMS capacity. This problem has been identified before in various studies. One of the studies was concerned about the lack of a well-functioning pre-hospital emergency and trauma care system which can be widely accessible . Two stucal care , 18. Othd before , 41.. That would facilitate quick life-saving care and improve treatment which reduces and prevents life threatening injuries due to the potential effects of RTIs. The establishment of a well-planned and coordinated EMS system based on patient needs over time has been previously called for in different forums. As a result of this advocacy the Uganda National Ambulance Services (UNAS) [Ideally, a definitive and well-planned emergency care system needs to be urgently put in place. That should greatly help to significantly reduce deaths, injuries, morbidity and disability adjusted life years (DALYS) caused by RTIs . That wos (UNAS) , was est. However, this remains a challenge in many LMICs and Uganda is no exception, where the structured EMS systems are not yet in place. In a study on unintentional childhood injury in Kampala, it was found that only 3% of victims were treated on insurance [. Notwithstanding other factors, the findings of both studies could be attributed to the lack of a mandatory national health insurance policy in Uganda. Currently, fairly good EMSs in Kampala are privately offered, but at a premium. Free EMS is available in the government funded public health facilities. The poor and low-income earners involved in RTIs run the risk of not receiving quality EMS if they can’t easily access it. Therefore, since RTIs are unpredictable events, there’s a great need for Uganda to come-up with a mandatory national health insurance policy because it was identified in this study to be one of the main factors affecting the EMS capacity. A national health insurance system, if adopted, should also consider subsidizing the EMS to cater for all patients’ needs, especially for poor and low income earners.At times, depending on the injury severity, the emergency care for RTI victims can be complex requiring more resources and quick responses compared to those needed by other patients. It can thus, require and precipitate hurried and costly resource deployment . Howevernsurance . Similarnsurance . NotwithA noteworthy strength of this study is that it managed to convene multidisciplinary experts to deliberate on a common public health challenge affecting the KMA in particular and Uganda at large. Fortunately, 50% of the panelists were members of Uganda National Council of Road Safety. Therefore the factors that were listed to affect the E, V and C are dependable and oriented by the experts’ across multiple professions; educational levels; work experiences; research; and extramural training beyond the arena of road safety and EMS.On the other hand, the experts’ opinions should not be conclusive, and some caution is advisable while interpreting them based on two reasons. First, the definition of an expert is subjective and the criteria, which was used to select the experts, was to some degree influenced by references and networks. This might have accrued some degree of bias. Second, the Delphi method only explores areas of concern raised by the panel of experts, and so other important areas other than the main topic of discussion might have been overlooked.This study explored the factors affecting the E, V and C for victims of RTIs in KMA through the Delphi technique which involved a number of multidisciplinary experts on road safety, injury prevention and EMS. The socio-cultural, infrastructure and road safety aspects were identified as factors influencing the victims’ exposure and vulnerability to RTIs. The absence of a national EMS policy and post-crash care system, as well as the fact that many victims lack health insurance, were noted to be the factors adversely affecting the EMS capacity. Although a multiplicity of road safety measures are in place to reduce the burden of RTIs, there exists a real need to substantially reduce the burden of RTIs in the KMA, with ultimate goal of preventing needless deaths; reducing the impact of injuries and trauma and the economic losses associated with it. An urgent need is similarly required to establish and empower of predefined and structured EMS systems. This study offers some useful insights on the factors that were identified to affect the E, V and C for victims of RTIs in the KMA drawn from a panel of experts, and should guide any measures taken to respond to the burden of RTIs in the KMA and elsewhere in Uganda.


Social media is changing the way in which citizens and health professionals communicate. Previous studies have assessed the use of Health 2.0 by hospitals, showing clear evidence of growth in recent years. In order to understand if this happens in Spain, it is necessary to assess the performance of health care institutions on the Internet social media using quantitative indicators.The study aimed to analyze how hospitals in Spain perform on the Internet and social media networks by determining quantitative indicators in 3 different dimensions: presence, use, and impact and assess these indicators on the 3 most commonly used social media - Facebook, Twitter, YouTube. Further, we aimed to find out if there was a difference between private and public hospitals in their use of the aforementioned social networks.t student and Wilcoxon independence tests for the observed variables.The evolution of presence, use, and impact metrics is studied over the period 2011- 2015. The population studied accounts for all the hospitals listed in the National Hospitals Catalog (NHC). The percentage of hospitals having Facebook, Twitter, and YouTube profiles has been used to show the presence and evolution of hospitals on social media during this time. Usage was assessed by analyzing the content published on each social network. Impact evaluation was measured by analyzing the trend of subscribers for each social network. Statistical analysis was performed using a lognormal transformation and also using a nonparametric distribution, with the aim of comparing t student test at a CI of 95% show that the use of Twitter distribution is higher (P<.001) for private and public hospitals in Spain, whereas other variables show a nonsignificant different distribution.From the 787 hospitals identified, 69.9% (550/787) had an institutional webpage and 34.2% (269/787) had at least one profile in one of the social networks  in December 2015. Hospitals’ Internet presence has increased by more than 450.0% (787/172) and social media presence has increased ten times since 2011. Twitter is the preferred social network for public hospitals, whereas private hospitals showed better performance on Facebook and YouTube. The two-sided Wilcoxon test and The Internet presence of Spanish hospitals is high; however, their presence on the 3 main social networks is still not as high compared to that of hospitals in the United States and Western Europe. Public hospitals are found to be more active on Twitter, whereas private hospitals show better performance on Facebook and YouTube. This study suggests that hospitals, both public and private, should devote more effort to and be more aware of social media, with a clear strategy as to how they can foment new relationships with patients and citizens. The Spanish health care system is one of the best ranked in the world as far as patient safety , efficieInternet health-related queries rose from 2010 -9, and tThis scenario is defining a new paradigm in which health services’ consumers and procurers  share a new framework for information exchange . The unsHospitals cannot control the information in social media ; on the A longitudinal review of hospitals that have presence on 3 of the most popular social networks—Facebook, Twitter, and YouTube—was conducted. For each hospital, data about the use and user acceptation of the generated content was collected, as well as general information about the hospital .The studied cohort included all the hospitals listed in the “National Catalog of Public and Private Hospital Centers (NHC)” maintained by the Spanish Ministry of Health and Social Affairs . The ovet student test, and Wilcoxon test (CI of 95%) for each distribution. Statistical significance was considered for P values under .05. MATLAB statistics toolbox (version 2016R) was used to perform correlation, transformation, and independence tests [The study assessed 3 factors: presence, usage, and impact, similar to previous studies ,26. The ce tests .From a total of 787 hospitals identified in the NHC of the Ministry of Health and Social Affairs, 550 had an institutional webpage, and 269 of them had at least one profile in one of social networks considered in December 2015. Beyond new hospital openings and new profiles on social networks, variations in the number of hospitals  versus 29% (283) but also in the use of social media to disseminate information on their activities, which accounts for 33% (262) versus 60% (419). Focusing on the presence , Despite the fact that social media has a lower presence overall in public hospitals, there are more public than private hospitals using Twitter (44% vs 36%), whereas with Facebook and YouTube, it is the opposite (31% vs 36% and 24% vs 27%). With respect to YouTube, the presence percentage is similar for private and public hospitals.Data of the historical evolution of social media profiles disaggregated by social media type and public or private hospitals  confirmsWhere analysis of content generation by hospitals in social media  is conceThe evolution in the number of subscribers for the studied social networks for both private (dotted line) and public (continuous line) hospitals is exponentially increasing . All theAs opposed to our findings regarding Twitter, analysis of the evolution of Facebook profiles  comparedThe position and magnitude attributes of observed variables in , alpha=.05) and the lognormal approximation to a normal distribution .The Internet presence of Spanish hospitals is high ; nonetheless, the presence on the 3 main social networks is not as high  when compared with results of previous studies in the United States and Western Europe—which did not include Spain .Hospitals in Spain are adopting different types of social networks and using them to disseminate content. Considering all the hospitals with presence on social media, we find that Twitter had the most profiles, followed by Facebook and YouTube. The comparison of presence, use, and impact dimensions between public and private hospitals shows that private hospitals have a better performance and growth on Facebook and YouTube, whereas the growth on Twitter is similar for both public and private hospitals.Son Espases [Sant Joan de Deu are two hospitals that have proved that marketing campaigns can be very effective in increasing the presence of hospitals on social media. The case of Son Espases hospital is very interesting. This hospital was inaugurated in 2011 with a massive marketing campaign carried out during its construction by a social media company. As a result, when this hospital was inaugurated and included on the NHC, the number of followers was significantly high, accounting for almost 32% (3521) of Twitter subscribers of public hospitals at that time. However, after the inauguration, Son Espases ’ activity on social media dropped, most probably because the social media company was no longer contracted. This abrupt change correlated with the large decrease in tweets produced at that time. From The evolution of the presence, use, and impact of Spanish hospitals on social media is of increasing importance lately. Although the presence of Spanish hospitals on social media is low when compared with other countries, results of the analysis on presence, use, and impact of hospitals profiles on social media show that usage is constantly increasing. Since 2011, the presence of private hospitals on the Internet has grown exponentially. Private hospitals have deeper penetration on Facebook and YouTube than public hospitals, especially in the case of YouTube, where the number of subscribers is three times that of public hospitals. These results contrast with the fact that Spanish citizens prefer public hospitals rather than private . Spanish Espases  and SantSimilarly, Facebook and YouTube are social platforms that allow hospitals and users to hold conversations (post and comments) in a very different way from Twitter. A previous study suggests that dialogue between hospitals and users (even patients) on these social networks may be a good source of information regarding service quality .If we look at 2015, only 30.5% (96/314) of public and 36.6% (173/473) of private hospitals are involved in at least one of the observed social networks. This shows that hospital management and marketing teams are not aware of the opportunity that social media provide as an effective communication channel. The ability to respond in real time to users and give information on special situations or health campaigns through social media provides a new method of collecting data and assessing the quality of service, which is faster than traditional phone and onsite surveys.t student test with a CI of 95% showed that Facebook friends, Twitter followers, and tweets and YouTube video replays reveal a statistically significant different behavior between private and public hospitals (P<.001), whereas YouTube videos and subscribers showed a different, nonsignificant behavior. These findings confirm the results of Griffis and colleagues [P<.001), whereas the other observed variables had a nonsignificant different behavior. The reason for this difference may be that for the second-stage analysis (nonparametric), raw data was used without performing any transformation, which may have led to bias in the data toward a certain direction. Nonetheless, the two-checked statistical significance of different behaviors in the use of Twitter for private and public hospitals confirms the hypothesis of our study.Statistical analysis of the variables of private and public hospitals observed in the study, including Facebook friends, Twitter followers, number of tweets and YouTube videos, subscribers, and replays was performed in two stages. In the first stage, due to the leptokurtic distribution of all the variables , a lognolleagues . In the This study focuses on analyzing the different trends and behaviors that public and private hospitals have in the use of social media, but the statistical tools used to pursue this analysis are a critical issue. This paper suggests using nonparametric techniques such as Wilcoxon test, used before in other scientific studies , which pThe research question analyzed in this study is relevant in the era of social communication. Hospitals should have a strong presence on social media just as other entities and corporations do, as they provide an extraordinary and innovative instantaneous communication channel that reaches a wide audience. Unlike traditional communication campaigns, social media allow the release of information in new media formats , adding formal and informal messages  in very short time periods. Another singular characteristic is that hospitals can instantly assess the impact that the message or communication campaign has regarding new subscribers, retweets, or likes. Our study confirms that the performance on Twitter is different between private and public hospitals , whereasWhen analyzing the performance of hospitals on social media, the risks as well as the ethical aspects of the use of social media in health care should also be considered. It is an important issue that is beyond the scope of our study. Scientific literature has addressed these issues in recent years , and sevOur findings are based on the entire population of public and private hospitals in Spain; nonetheless, even though the data collection method was based on previous publications, the authors cannot guarantee the location of all the webpages and social media profiles of the hospitals in the NHC. The fact that social media are constantly and rapidly changing affects the way data are collected and analyzed. Finally, some hospitals are outliers in the way that their performance shows a comparatively higher use and impact on social media than others, regardless of being public or private, and this could need further analysis, which is out of the scope of this study.Future work will tackle analysis of the subscribers’ public profile and each profile on each social media, and among them, which type of subscribers are more likely to interact with posted content  and which type of information has greater or lesser impact.The presence of Spanish hospitals on social media is constantly evolving, showing an incremental growth year by year; however, it is very low compared with hospitals in the United States and Western Europe. Public hospitals are more active on Twitter, whereas private hospitals have a better performance on Facebook and YouTube. The Spanish health care system needs to maintain a high-ranking position, and to do so, this study suggests that hospitals, both public and private, should devote more effort to and be more aware of social media. The study conclusion is that private hospitals and public hospitals show statistically significant different behaviors in their use of Twitter (number of tweets and number of followers).


We used tools to characterize the subjects and the Folkman and Lazarus Inventory of Coping Strategies.  the coping strategies most often used by family members were social support and problem solving. Mothers and fathers used more functional strategies . We found no significant differences between the strategies and other variables examined.  despite the suffering resulting from the illness of a dear one, family members make more use of functional strategies, allowing them to cope with adversities in a more well-adjusted way. Mental illness is currently a major topic worldwide, as it is increasingly found in the day-to-day life of the population. About 700 million people worldwide suffer some form of mental or neurological disorder. One out every four persons will develop some form of these disorders during his or her lifetime. It is unusual to find a family that does not have at least one member suffering from some form of mental disorders-We often find that not only the individual involved suffers losses resulting from this situation, but also their family members and society at large. The family experiences a sequence of stressors that interfere in family unity, such as the diagnosis of the disease itself, the adverse effects of medication, the individual's inability to perform daily tasks, possible changes in economic and social status, uncertainty as to whether there is a cure, and the possibility that the disease may become chronicStressors are coped with based on how significant they are for those involved. Coping means trying to overcome that which is causing stress, and may refocus the significance associated with the difficulties, guide the individual's life and keep him/her physically, psychologically and socially healthy-,--The literature mentions numerous studies on coping strategies for family members and caregivers of people with chronic diseases,,,Families are generally vulnerable and unprepared to cope with the entire process of the illness and treatmentThus the objectives of this study were to identify the coping strategies of the family members of patients with mental disorders hospitalized in a psychiatric hospital, and associate them with family member sociodemographic variables and patient clinical variables.A descriptive, exploratory cross-sectional study performed at a 250-bed psychiatric hospital in the interior of São Paulo working with SUS, healthcare plan and private patients, thus serving a heterogeneous group of people in terms of socioeconomic and cultural level. The study population was made up of the family members of patients hospitalized in said hospital due to mental disorders between October and December 2013. The inclusion criteria were: 18 years or older, be related to the hospitalized patient in some way, and have followed the patient before and during hospitalization. Where two or more family members qualified, we chose the one spending more time caring for the hospitalized patient (indicated by the family members themselves), resulting in a sample of 40 subjects. The size of the sample was limited by the time available for data collection (October 1 - December 31 2013), which in turn was a function of the human resources and time available for this study. Inventory of Coping Strategies (FLICS)Data collection used two tools: sociodemographic description of the family members and clinical status of the patient, and the Folkman and Lazarus The Folkman and Lazarus Inventory of Coping Strategies includes the thoughts and actions people used to handle the internal or external demands of a specific stressful event. It is a list of 66 items answered using a Likert-type scale, with four possible answers . This scale is not associated with a total score as a sum for assessment, as the items should be assessed using average scores within each factorThis tool was translated and validated for Brazilian Portuguese, demonstrating correspondence between the original English language version and the translated one, allowing it to be applied to other studies. In the original study, Cronbach's alpha ranged from 0.56 to 0.85 across the factors. The items that make up this tool are split into eight factors: comfort, distance, self-control, social support, acceptance of responsibilities, escape-avoidance, problem solving and positive reappraisal The elements of FLICS are split into two categories: (1) functional strategies, made up of self-control, social support, problem solving, positive reappraisal and acceptance of responsibilities, and (2) dysfunctional strategies, corresponding to confrontation, distancing and escape and avoidanceWe ran a pre-test with five subjects to test, adjust, fine-tune and measure duration of application of the proposed data collection tools, which did not result in any changes. Data was collected during verbal interviews conducted during visiting hours.Statistical Package for Social Science (SPSS) version 19 for Windows, IBM Company, Copyright 2010. For descriptive data analyses we used position measurements and variability for continuous variables, and simple frequency for the categorical variables. The data was processed and analyzed using To assess the coping strategies we calculated the mean, median and average deviation of the score obtained for each factor. Mean scores were calculated based on the number of items in each factor. The internal consistency of FLICS data was checked using Cronbach's alpha. To analyze the mean scores of the association between coping strategies and sociodemographic variables, we used Mann-Whitney's non-parametric test to compare the two groups, and the Kruskal-Wallis test and Dunn's post-hoc test to compare more than two groups. We used a significance level of 0.05.This study complies with Brazilian and international standards of ethics for research involving human beings, and received a favorable opinion from the local Ethics Committee . All of the patients signed the Free and Informed Consent Form.Of the 40 family members of patients with mental disorders, 20 were male and 20 female, with ages ranging from 18 to 67, with an average of 39 and SD of 14.7 years. Regarding the family relationship, seven (17.5%) were a parents (father or mother), 10 (25%) were the children, nine (22.5%) a sibling, and 14 (35.0%) were a nice/nephew, grandchild, in-law or cousin. 24 (60%) of the participants had ten or more years of schooling, and half (50%) of the sample claimed to be Roman Catholic.Regarding patient clinical variables, the most frequent was bipolar affective disorder , followed by depression  and schizophrenia . Most (n=26 65.0%) have had the disease for over 10 years, many with recurring delirium  and hallucinations .The coping strategy most often used by family members was social support, and the least used was confrontation. Functional strategies were the ones used most often. The internal consistency of FLICS factors measured using Cronbach's alpha ranged from 0.44 to 0.79 .There was a significant association between family relationship and self-control strategies (p=0.037), social support (p=0.021) and positive reappraisal (p=0.037), indicating that parents (mother and father) use this strategy more often than children, siblings or other family members .Women tend to escape and avoidance and problem solving more than men. Family members earning between four and seven minimum salaries are more prone to using positive reappraisal. We did not find significant differences in coping strategies in terms of age, years of schooling or religion, but did find a trend towards a significant difference for the variable "has partner'. Family members reporting no partner are more likely to use escape and avoidance for coping with their problems, while those who claim to have a partner score more highly in problem solving.The only clinical variable with marginally significant results was the presence of psychotic symptoms, showing that problem solving tends to be more used by family members of patients who do not display psychotic symptoms .Family member coping strategies differ by disease type and duration. However, we found no significant differences between coping strategies and patient clinical variables . The results of this study show that the family members of people with mental disorders preferentially use social support, problem solving and positive reappraisal to care for their ill family member. Fathers and mothers mention using more self-control (p=0.037), positive reappraisal (p=0.037) and social support . These strategies are classified as functional and constitute positive ways of coping with problems,-) found that the search for social support is an important strategy for caring for a mentally ill family member. Family, friends, religions, doctor visits and other resources provided by the healthcare system and the community were the forms of social support most often used by the subjects,,According to the Lazarus and Folkman perspective of coping with stress, social support is based on the person's effort to seek support within his/her social, professional and emotional spheresEducating caregivers about social support was effective in reducing stress among those caring for patients with dementia, and family members participating in interventions to build this skill developed fewer symptoms of depression and were more satisfied with their life. I must grow as a person in light of such difficulties. I must look at the problem differently, from a more positive perspective. I am looking for something god about what I am experiencing. I always learn something from experience. People with higher incomes tend to use this strategy, which may be associated with increased years of schooling and the positive influence this has on coping with a stressful situationPositive reappraisal describes efforts to create significant meaning in the face of problems, in order to provide personal growthxperience13. PeAlthough we have been unable to establish a positive correlation with the variables investigated, problem solving is one of the three strategies most often used by the participants in this study. It involves changing a situation through detailed, critical analysis to get satisfactory outcomes for problem solving Self-control refers to the efforts made by a person to control his/her feelings or actions, in the face of stressful stimuliA study in Ireland to find ways of coping with a family member with a mental disorder showed that caregivers more often used social support and self-control, both variables associated with being male and youngerFunctional strategies may be hard for family members who are vulnerable and suffering to deploy, especially in the early stages following the diagnostic, as the family is still adjusting to change. Here support groups may be effective strategies to help family members through this process, making it easier for them to identify the problem, express their feelings and learn from others, and in these situations information and support are shared, hope is given and similar problems and difficulties are resolved. These groups also reduce social isolation, stigma and biasA study of caregivers of elderly patients with dementia highlighted functional strategies as addressable protection factors for reducing stress, after they received three-months training in psychosocial skills. This educational problem also helped caregivers seek more social support, further using problem solving -Psycho-educational training of the family members of patients with mental disorders have been shown in the literature to be effective ways to promote positive coping with the problems, in particular: group trainingSurvey participants who were the sons or daughters of people with mental disorders had higher scores in the escape and avoidance dysfunctional strategy. These results suggest that the sons and daughters of patients with mental disorders are aware that they can help care for their parent, but at the same time want to avoid the situation, in an attempt to make it go away. They are unable to overcome the suffering, thus taking on the role of caregiver. Another study found that distancing, escape and avoidance were strategies often used by younger family caregivers living with the mentally ill patient, fostering the continuation of fears, concerns and physical and psychological problemsIndividuals with fewer years of schooling often use dysfunctional strategies, as it is hard for them to find the source of the problems and options to solve or address itConfrontation is an aggressive manner chosen to change a situation, such as anger and inflexibilityIndividuals reporting that they have partners were more likely to use problem solving, and those without were more likely to use escape and avoidance. Ideally, a partner is associated with affection, daily living, the exchange of experiences and mutual support, which may explain the choice of functional strategy.The trend to using the functional strategy problem solving among family caregivers of patients who do not display psychotic manifestations may be the result of a more stable clinical situations, and the absence of aggression secondary to delirium and hallucinations. A study of family members of patients with psychotic disorders found that escape, distancing and rumination were often found strategies, all of which are related to the existence of psychological stress,When assessing reliability, Cronbach's alpha varied from 0.44 to 0.79, showing moderate reliability. There are numerous factors that can influence the reliability of a tool, such as number of items and size of sampleInventory of Coping Strategies, we had problems selecting the value to assign to the strategies. It is felt that people need more time to reflect on the items and decide which answer best represents their actions/feelings regarding the conflicts they experience.Furthermore, when applying the After the initial impact of discovering the disease, the family starts to adjust to the new reality. Each moment has meaning, a need, a feeling, ways of coping and specific support networks. Some feelings permeate everything, but their meaning and intensity vary depending on the phase of the adjustment processNurses and healthcare professionals must be in direct contact with the family universe to identify the complex and conflicting realities of these people. This requires planning so that they may provide care and support, including assessment and follow-up of the families involved to learn of their physical, emotional and social difficulties, as well as early perception and recognition of problems or suffering that could change the family dynamic and influence patient treatment. It is extremely important to expand studies focused on this theme, always looking to contribute with new perspectives of psychosocial care for the families, with frequent reflections on professional practices and new public policy guidelines, in particular in the areas of mental health and psychiatry.The coping strategies most often used by the family members of people with mental and psychiatric disorders are social support and problem solving. Parents use more functional strategies for caring with a child with a mental disorder.There are few studies to date, either in Brazil or abroad, on the experience of family members of people with mental or psychiatric disorders, and how they cope with the stressors, in particular using a specific theoretical reverence such as the Inventory of Coping Strategies. The results of this study are limited because it used a small, non-probabilistic sample, leading to a possible bias and being less representative of the population. We also highlight the fact that we did not look at other variables that may have interfered in the coping strategies and provide better subsidies for our results, such as the persons' personality, overload, social support and stress levels.However, the results obtained enable understanding how family members face the presence of mental disorder in a dear one, and allows nurses to reinforce the concept that the family is an important care group, thus expanding their scope of action, with interventions designed to manage caregiver overload so that he or she may be able to better deal with the patient's disease, and maintain his/her balance and positive outlook, ultimately impacting the care of the person with mental illness. Furthermore, it makes way for intervention studies to explain new scientific evidence for implementing effective psychoeducation programs for training in these functional skills.


Human fetal osteoblasts (hFOBs) and stem cells are some of them and they are known to be overtly responsive to nanoscale topographies – allowing us to investigate the hows and whys of the response in vitro. Information gathered from these in vitro studies could be used to control the cells, i.e. make the stem cells differentiate or retain their characteristics without the use of medium supplements. In this review, hFOB and stem cell responses to nanotopographies are summarized and discussed to shed some light on the influence of patterns on the reactions. Although both types of cells are responsive to nanoscale topographies, the responses are found to be unique to topographical dimension, shape, orientation and the types of cells used. This implies that cellular responses are influenced by multitude of factors and that if done right, cheaper self-assembled nanotopographies can be tailored to control the cells. A new self-assembly, powder-based technique is also included to provide an insight into the future of nanofabrication.To understand how cells respond to the nanoscale extracellular environment   Cells in living organisms are surrounded by and in contact with nanoscale topographic interfaces. These interfaces, commonly known as basement membranes, are composed of a complex mixture of pits, pores, protrusions, ridges and fibers, with sizes between 5 and 200 nm. Basementin vivo, the nature of their interactions was not physically observed until Harrison cultured embryonic cells on a spider web. He found that the cells followed the direction of the fibers, which indicates that cells will adjust themselves on the substratal structure.; Institute of Research Management & Monitoring (IPPP) [grant PG117-2014A]; and University Malaya Research Grant [grant RP040A-15HTM].No potential conflict of interest was reported by the authors.


Background. A formative assessment of the implementation of HIV testing and counseling (HTC) at school showed high acceptability and willingness to test among learners. However, the success of the proposed HTC depends on the support and acceptability of key stakeholders, including the parents. The aim of the study was to assess the opinions and acceptability of the implementation of HTC at school among parents of adolescents in high school. Methods. This was a cross-sectional household survey conducted with parents of adolescents attending high schools in educational districts in North West and Gauteng provinces, South Africa. Results. A total of 804 parents participated, and 548 (68.3%) were biological mothers, 85 (10.6%) were fathers, and the remaining were other relatives including grandmothers. Almost all  parents were in support of implementation and provision of HTC at school, 701 (87.7%) would allow their children to be tested at school, 365 (46%) felt that parental consent was not needed to test at school, and 39.4% preferred to receive the HIV test results with their children. Conclusion. Parents accept the roll-out of an HTC program at school and have a role to play in supporting children who test positive for HIV. A formative evaluation was conducted in 2013 to assess the opinions of high school learners about the implementation of HIV testing and counseling (HTC) in schools and showed high acceptability of HTC and willingness among learners to test at school [In May 2015, the Department of Basic Education released the Draft National Policy on HIV, STIs, and TB to guide comprehensive responses to HIV and TB, with prevention being one of the key themes of the policy. The policy proposes to provide, via mobile health units, counseling on sexual and reproductive health issues to all senior, further education and training (FET) phase, and intermediate learners, where required. This should include the provision of dual protection contraception, HTC, and screening for STIs. Under roles and responsibilities, the policy proposes that parents and communities will be required to participate in the school response to HIV and TB and the implementation of programs at the school level. Their support, resources, and capacity will be harnessed to play a supporting role and will be enhanced through guidance and training .The need to involve parents as part of the comprehensive strategy for improving adolescents' health and development and prevention of HIV/AIDS has been advocated in previous research , 5. ThisAs already mentioned, parents were identified as one of the key stakeholders in the implementation of the proposed HTC at school. There has not been any empirical data on the role of parents in school based HIV testing in South Africa and other sub-Saharan countries. HTC services in most countries in sub-Saharan Africa are offered in clinics, in hospitals, through a door-to-door approach, and through outreach campaigns. There are no government-driven school based HTC services as yet . The proThe formative study conducted by the investigators to assess the acceptability of HTC at school  was a fiOne of the arguments regarding the appropriateness of HTC at school is that learners who test positive might be discriminated against. Research has shown that negative attitudes towards HIV-positive people are barriers against the uptake of HIV prevention strategies , 11. In This was a cross-sectional study conducted from April to August 2014 among parents or guardians of children who were attending high schools. The current study is a follow-up of a formative assessment survey conducted to assess high school learners' acceptability of HTC at school. The original survey was conducted among 3978 students in grades 10–12, selected from 17 high schools in educational districts in North West and Gauteng provinces, South Africa [The current study was conducted among parents of learners attending the high schools, where the formative assessment of HTC was conducted (17 high schools). Of the 17 high schools included in the sample, nine were selected from two rural subdistricts in North West province and eight were selected from an urban district in Gauteng province. The school setting was selected as most appropriate to access parents whose children attended the same schools, where the previous formative assessment was conducted. The research team consisting of a research coordinator and research assistants visited the selected schools to explain the purpose of the study and the plan to use the learners to deliver the questionnaires to their parents. The sampling procedure was similar to that adopted for the study conducted with learners; the Life Orientation (LO) teacher facilitated the sampling and recruitment process. In all the schools, the LO periods on the school time table for grades 10–12 were randomly assigned to the research team to distribute the questionnaire to the students who volunteered to transport the questionnaire to parents. As stated, the assigning of LO periods was random and the selected classes were not necessarily the same as those selected for the study with learners because the current study did not attempt to pair parents to children but aimed to recruit parents from the same schools where the previous formative assessment was conducted.Students in the assigned LO classes were requested to deliver and return the survey package which consisted of an information leaflet, a structured questionnaire, and informed consent in a sealed envelope to one of their parents and then back to the school after the questionnaire had been completed and sealed in a second envelope . The information leaflet provided adequate instructions on how to complete the questionnaire and on the voluntary nature of the study. Parents were also informed that nonparticipation would not affect their child's learning negatively. They were also informed that if they agreed to participate, they should sign the consent form and complete the questionnaire and return it to the school within four days of receipt. Learners were informed that only one parent/guardian in the household should complete the survey. This instruction was necessary to ensure that if siblings from different classes received the survey package, they should inform their parent/s that only one questionnaire should be completed per household to avoid duplication, which would affect the reliability of the study findings. The LO teachers from the selected classes received the returned envelopes in a sealed box which were then collected by the research team. The LO teachers also reminded the students to return the questionnaires within the stipulated time of four days.A structured, self-administered questionnaire was used to obtain data from parents who were asked to supply sociodemographic information such as age, sex, marital status, educational level, employment, income, and family setup. Parents also provided information on the age, sex, and grade and their relationship with the child who delivered the questionnaire. To answer the questions on whether parents communicated with their children about sexuality, parents were asked to indicate whether they had ever had a discussion about sexual issues with their children and whether parent-child communication about sexuality was important and the common barriers to communication about sex and related topics with adolescent children. To assess the parents' HIV testing practices, uptake of HTC was measured by asking whether they had ever been tested for HIV, and for those who indicated that they had, they were asked about the place the HIV testing took place, the last time they had an HIV test, and the reasons for testing. To assess acceptability of HTC at schools, parents were asked whether providing HTC at school was a good idea and whether they would allow their children to be tested at school, should HTC be implemented. Lastly, their attitudes towards HIV-positive learners were assessed using six questions in the form of agree/disagree/not sure. We used a validated questionnaire used by the investigators to assess learner's acceptability of HTC in school . The queEthical approval was obtained from the Research and Ethics Committee of the University of Limpopo, Medunsa Campus (MREC/H/45/2014: IR).P values of <0.05 were considered to be statistically significant.Data analyses were performed with Stata version 13. Descriptive statistics were computed and frequency distributions were used to summarize sociodemographic data. To assess the attitudes towards HIV-positive learners, we assigned a score of 1 for every positive answer in the attitude towards HIV-positive learners section and 0 for negative answers. Attitude scores ranged from 0 to 6, and the mean score was determined, with scores below the mean being considered as a negative attitude, and scores equal to and more than the mean were considered as positive attitude. Univariate and multiple logistic regressions were performed to assess the association between the outcome variable  and independent variables like parental sociodemographic variables. The adjusted and unadjusted odds ratios (OR) were calculated and confidence intervals (CI) were set at 95%, and n = 548, 68.3%) of the parents were biological mothers, 301 (37.4%) had completed high school, and over half  were unemployed, and the main source of income for almost all  was the old age and child support grants. For those who were employed, slightly over a quarter  earned less than R2000.00 South African Rand per month, while only 60 (17.8%) earned above R5000.00 South African Rand. In terms of family composition, the majority  were single headed households.The sociodemographic characteristics of the parents are reported in n = 576, 72.5%) than males . The mean age of the adolescents was 17.1 years ; the majority  were aged between 16 and 18 years, with only 114 (14.5%) aged 15 years and younger. In terms of the level of education, the majority  were in the 10th grade, over a third  were in the 11th grade, and over a quarter  were in the 12th grade.The parents provided demographic data about the index adolescent (the learner who brought the survey home). There were more females  indicated that they had communicated with their children on sexual issues at some time, more than half  initiated the conversations to prepare their adolescent children for sexuality, and almost half  indicated that it was not easy to do so.n = 703, 87.9%) indicated that they had been tested for HIV, about two-thirds  accessed HTC in a clinic, over a third  were tested in the past three months, majority  tested to know their status, and 367 (46%) were of the opinion that it was not easy for adults to test for HIV. Of the 97 participants who had never been tested, almost half  indicated that they never thought about going for an HIV test, and 22 (22.9%) did not believe that they could be infected with HIV. Logistic regression showed no association between the sociodemographic variables and ever tested for HIV.n = 389, 48.9%) of the parents felt that it was not easy for learners to test for HIV in the current HTC services. To assess the acceptability of HTC at schools, parents were asked to indicate if the provision of HTC for learners at schools was a good idea, the vast majority  were in support of the provision of HTC at school, and 701 (87.7%) would let their children test at school should HTC be implemented. Regarding parental consent for HIV testing at school, almost half  of the parents felt that parental consent was not necessary for learners to be tested at school. They also indicated their preferences as to how the HIV test results should be handled after testing at school, with slightly less than half  indicating that the result should be given to the learner alone at school. Concerning disclosure of HIV status should a learner test positive, the majority  felt that children should disclose the status to parents , family structure , and issuing of HTC results . Parents who preferred that the HTC results should be given to the child with the parent present were four times more likely to suggest parental consent for HTC  than those who preferred that they be given to the child alone. Univariate analysis and logistic regression showed no association between acceptability of HTC and sociodemographic variables. However, logistic regression showed a significant association between need for parental consent and sociodemographic variables. Need for parental consent was associated with parental relationship with learner  of the parents had positive attitudes towards HIV-infected learners; they scored more than the mean score of 4.7. The majority  believed that HIV-positive learners should be allowed to attend school with HIV-negative learners, 771 (96.4%) indicated that they should be allowed to continue studying after testing HIV-positive, 734 (91.5%) said that HIV-positive learners could share a class with their children at school, and 746 (93.0%) said that they could be friends with their children.The attitudes of the parents towards learners who are HIV-positive were assessed using six questions, and the scores ranged from 0 to 6 . The results indicate that the majority  did not approve of an HIV-positive learner having a romantic relationship with their children. Less than half  had less favorable attitudes towards disclosure of HIV status  were biological parents, the majority (68.3%) were biological mothers. With regard to the family structure, we found that an equal proportion (41%) of households consisted of father and mother and mother alone, respectively, while 13.9% consisted of grandmothers, aunts, uncles, and older siblings. This suggests that the father is only present in 40% of the households. The family composition in the current study has implications for parent-child communication, since there is evidence that family structure is important in determining young people's sexual behavior . In the Open discussions between parents and children are crucial for the implementation of the proposed HTC in schools. We found that a high proportion (81.5%) of parents had discussed at least one sexual topic with children under their care at some time. This was despite the structure of the family not being ideal for positive parent-child communication . As mentVarious stakeholders, including learners, identified parental involvement as a key element for the successful implementation of HTC at school . HoweverMadiba and Mokgatle  found thOur data also indicate a high level (92.9%) of acceptability of the provision of HTC services for learners in high schools among parents. The high level of acceptability of HTC at school and the high uptake of counseling and testing among parents suggest that parents view HIV testing as important not only for themselves but also for their children. We found that the level of acceptability of the proposed HTC among parents was much higher than that found among the learners (92.9% versus 76.9%). The current study did not investigate why parents support the provision of HTC at school; however, learners supported HTC at school because it was appropriate and convenient and was intended solely for them , 7. The The issuing of HTC results after testing at school is one of the key issues that might warrant further investigation because 39% of the parents felt that the results should be given to the child in the presence of the parent. We found that preference for issuing HTC result was independently associated with the need for parental consent at multivariate analysis. Parents who preferred that the HTC results should be given to the child with the parent present were four times more likely to suggest parental consent for HTC than those who preferred that HTC results should be given to the child alone. The survey conducted with the learners reported similar findings, with the majority of the learners indicating that they would prefer to receive their HTC results in the presence of their parents . AlthougOne of the arguments regarding the appropriateness of HTC at school among key stakeholders was that children who test positive would be stigmatized. Learners shared this concern and were anxious that other students might witness their reaction to positive test results and subject them to stigma and discrimination , 7. GiveA key limitation of the study is information bias; because the questionnaire was self-administered at home, participants might have misunderstood some of the questions. We found that parents often misunderstood the question asking them about their age; instead of their own age, they provided the age of the child who delivered the questionnaire, hence the missing values for the age variable. We acknowledge that this might be the reason why age is not normally distributed in the sample. The study might also suffer from recall bias, social desirability recall, and self-report bias. However, some measures were taken to reduce recall by asking few questions that required recall. One other limitation of the study was a low response rate; 1200 questionnaires were distributed but only 805 were returned, with a response rate of 67%, but the investigators had no control over the delivering and completion of the questionnaire. The language (English) of the questionnaire might have influenced the low response rate as parents who are not well literate might have decided not to respond. The study design was cross-sectional and quantitative; as a result, the reasons for high acceptability of HTC at school could not be established. There is a need for additional mixed method studies to further explore this topic, especially because the sample size is small and cannot be generalized to all parents in Gauteng and North West provinces.The vast majority of parents were in support of the proposed implementation of HTC in high schools. The findings revealed that parents felt that they had a role to play in the implementation of HTC. They wanted to be involved by providing consent for their children to be tested at school, to be there when their child receives their HIV test results, and to support a child who tested positive for HIV. However, these views did not apply to all parents, as some felt that the child does not need parental consent to be tested at school and that the HIV test results should be provided to the child alone at school. Parents had not received any information and had not been consulted concerning the proposed roll-out of HTC in high schools, but the draft DBE Policy on HIV, STIs, and TB states that parents would be trained and guided to participate in the school response to HIV and play a supporting role to children.Open discussion between parents and children is a crucial consideration for the successful implementation of the proposed HTC in high schools. Our findings suggest that parent-child discussions on sexual topics take place when the parent deems them to be necessary; for example, they wanted to discuss the HIV test results with their children after being tested at school as a way of supporting the child, particularly after a positive test result. The findings of this study can inform the development of appropriate interventions that empower parents with adequate skills to initiate or improve discussions about HIV testing and other sexual matters with children, and this will be a key feature of their supportive role in the implementation of HTC in high schools. There should be provisions from the Departments of Health and Basic Education to create awareness and educational interventions for parents.


Dysregulation of Autonomic Nervous System (ANS) and central pain pathways in temporomandibular disorders (TMD) is a growing evidence. Authors include some forms of TMD among central sensitization syndromes (CSS), a group of pathologies characterized by central morphofunctional alterations. Central Sensitization Inventory (CSI) is useful for clinical diagnosis. Clinical examination and CSI cannot identify the central site(s) affected in these diseases. Ultralow frequency transcutaneous electrical nerve stimulation (ULFTENS) is extensively used in TMD and in dental clinical practice, because of its effects on descending pain modulation pathways. The Diagnostic Criteria for TMD (DC/TMD) are the most accurate tool for diagnosis and classification of TMD. However, it includes CSI to investigate central aspects of TMD. Preliminary data on sensory ULFTENS show it is a reliable tool for the study of central and autonomic pathways in TMD. An alternative classification based on the presence of Central Sensitization and on individual response to sensory ULFTENS is proposed. TMD may be classified into 4 groups: (a) TMD with Central Sensitization ULFTENS Responders; (b) TMD with Central Sensitization ULFTENS Nonresponders; (c) TMD without Central Sensitization ULFTENS Responders; (d) TMD without Central Sensitization ULFTENS Nonresponders. This pathogenic classification of TMD may help to differentiate therapy and aetiology. Chronic TMD is a frequent disorder in the general population. Its diagnosis is mainly clinical and the diagnostic criteria include signs of dysfunction of stomatognathic system and provoked and/or spontaneous pain of the joint and/or the stomatognathic muscles at rest or during function.Pain, in particular, is necessary for the diagnosis of TMD. To date, evidence is inconclusive regarding instrumental biomarkers of TMD based on the anatomic and functional analysis of the stomatognathic system , 2. For The international classification of headache (ICHD) and that of TMD (RDC/DC) consider the characteristics of pain in headache and TMD and have introduced criteria to differentiate between them , 8. HoweCentral Sensitization Syndromes (CSSs). CSSs are a group of disorders characterized by chronic nonneuropathic and nonnociceptive pain; the pain is not proportional to the type of injury/damage and it must be accompanied by the presence of neurophysiological/neuropathological phenomena . These disorders frequently lack histopathologic and/or instrumental evidence that can directly and proportionally explain the severity of pain and disability, and specific therapies are usually unsatisfactory in the short and long term [ong term , 16.The nosologic category of CSSs is recent, and the list of disorders is in progress. Although originally used to justify the “chronic pain,” the current definition also embraces functional and cognitive impairment, such as those observed, among others, in IBS, insomnia, restless leg syndrome, multiple chemical sensitivities, and disorders characterized by affective and emotional symptoms  . These sSome neurophysiological characteristics of the neurons affected by CS are the generation or increase in spontaneous firing activity, the lowering of the activation threshold for their physiological stimuli, the more intense and longer activation after a nociceptive stimulus, and the development of larger receptive fields .Due to the plastic properties of neurons, CS determines a change in the functional state of the CNS characterized by an increased release of excitatory transmitters and continuous activation of specific nervous pathways. Through functional changes that involve the amplification of the physiological transmission of impulses, any central neural structure can become the center of hyperexcitation and can trigger an altered response to afferences. Information exchanged among the CNS structures remains active after the termination of the peripheral phenomenon and can induce endocrine, motor, not physiologically oriented autonomic responses, and pain. Neurophysiological tests were conducted in the CSS to demonstrate the presence of secondary hyperalgesia and/or allodynia, which are considered markers of CS , 18–21.From a biological point of view, the psychological phenomena related to chronic pain have a counterpart in the dysregulation of cognitive, neuromuscular, autonomic systems, and the endogenous opioid system .Although common anatomic and functional patterns of CS among CSS are not yet clearly demonstrated , convincChronic TMDs are characterized by chronic pain, which is also a characteristic of CSSs. The probability that pain becomes chronic is significantly related to the presence of spontaneous or provoked pain on palpation at more than one site of the body, both in TMD and in other CSSs . In addiTMD should be considered a multisystem disorder with the involvement and dysregulation of the sensory-motor, psychic, self, inflammatory, and immune systems , confirmTMD patients, in fact, showed consistent functional/structural changes in the thalamus and the primary somatosensory cortex. Additionally, functional and structural changes were frequently reported in the prefrontal cortex and the basal ganglia in TMD, suggesting the role of cognitive modulation and reward processing in chronic orofacial pain . Some stTaken as a whole, these data suggest that TMD patients suffer of a dysfunction in the endogenous pain inhibition systems , 50 espeSometimes the Central Sensitization starts from a peripheral injury and/or dysfunction; frequently, this is the case of chronic TMD in which muscle, dental occlusion, or temporomandibular joint (TMJ) dysfunction can be considered the peripheral triggers; the deep tissues  are the most powerful in determining the sensitization –54 produIt is possible that the chronification process has an individual predisposition characterized by the inability to “extinguish” the memory circuits in the brain  triggered by the original injury .In this case, the circuit would be continuously triggered by trivial, not necessarily painful, stimuli. Only for the fact that the circuit is active every stimulus would reinforce the memory process and the sensitization itself. Chronic pain is therefore to be understood as a “brain disease” and not as a peripheral disorder  althoughThis aspect would explain in part the current difficulties in the interpretation of specific TMD literature that deals with the search for an objective peripheral cause. Once the CS has been established for the effect of the original peripheral cause, the latter loses its function and is no more automatically related to the disorder.From the clinical point of view, these observations could have an interesting implication on the diagnosis and, therefore, the therapy of TMD, configuring the possibility of a gradation of central involvement in TMD according to its chronicity and its comorbidity with other CSSs. Consequently, a modulation of intervention can be hypothesized that may range from a purely dental therapy , in case of little or no CS, to drugs or psychological/psychiatric therapies when CS is prevalent.Indirect evidence of the presence of CS in TMD subjects is given by the effectiveness of centrally acting drugs in a percentage of patients , 58. TheTENS is widely used as a therapy for the control of acute and chronic pain –73.It is likely that the uncertainties about its effectiveness are linked to different modality of study, administration, and application of the stimulus, especially in older works –77.The mechanism of action is probably the activation of the endogenous opioids system, and particularly the brainstem PAG-RVM circuit.Direct evidences by Sluka's group on animal have shown that TENS works on endogenous opioid and activates central inhibitory pathway –82. Thisµ receptor of endogenous opioids) and naltrindole (antagonist of δ receptors) in arthritic rats prevents the antihyperalgesia after both low frequency low amplitude and high frequency high amplitude tens show that the δ and µ receptors are the target of stimulation. Particularly, at spinal level low frequency low amplitude TENS works on µ receptors while high frequency high amplitude TENS works on δ receptors [µ receptor blockade with microinjection of naloxone reverses the low frequency low amplitude TENS effect on secondary hyperalgesia in rats. The RVM microinjection with naltrindole (δ receptor antagonist) did not affect secondary antihyperalgesia of low frequency low amplitude TENS, while it affected the antihyperalgesia due to high frequency high amplitude TENS [The location of the mechanism of action has been demonstrated by animal studies. Spinal administration of low dose of naloxone  and does not work on dlPAG  . Taken tThe PAG-RVM circuit is part of the descending pain modulation system and is crucial in determining the coupling between the afferent and efferent responses towards excitement or inhibition , 86–92. The PAG-RVM is interleaved with the systems that are responsible for stress response, sensory integration, hormonal and motor somatosensory, and visceral response to pain –98 and iAn alteration of this balance due to central or peripheral phenomena, such as an alteration in the occlusion –108, mayThe data suggest that an imbalance between the arousal system and that of the descending pain modulation may be present in the CSSs. TENS may recognize its diagnostic and therapeutic rationale into the interaction with the circuits discussed above.While the analgesic effect of TENS was thoroughly investigated, there are few works that dealt with its nonantalgic effects. A positive effect has been observed on sickness , on fatiTaken together, although scattered, these data seem to suggest that effects on autonomic  and cognitive system are associated with analgesic effect of TENS, indicating widespread central, antalgic, and nonantalgic effects of this technique that could have utility in the management of CSSs.A particular type of TENS has been used for a long time in dentistry for a variety of purposes, including treatment of pain in TMD patients, prosthetic rehabilitation, and diagnosis and treatment in orthodontics –125. It The analysis of the physical characteristics and neuromuscular effects of ULFTENS in dental practice is beyond the purpose of this article. Our hypothesis herein is the possibility that ULFTENS can be helpful in understanding the pathogenesis and helping differential diagnoses of TMD meant as a CSS. Classically, ULFTENS is delivered with amplitude that induces contraction of the elevator muscles, so that a little upwards movement of the jaw is obtained . The main purpose is to obtain reduction of pain and “relaxation” at rest of the stomatognathic muscles, especially the masseter, anterior digastric, and anterior and posterior temporalis muscles, in TMDs. The effect of stimulation is clinically assessed with the use of surface EMG of the cited muscles and with computed kinesiography of jaw movements to measure the amount of free space between the dental arches after ULFTENS, which allows for the comparison with the prestimulation condition –129. A cThis assumption has been used to suggest that the ULFTENS acts through a double effect on muscle relaxation, favoring the peripheral metabolic exchange of contracted muscles, and the PAG-RVM circuit of pain, inducing the release of endorphins. On the other hand it is possible that not all stimulated subjects undergo a reduction in muscles contraction and an increase of free space . In a loTaken together these data agree with those works previously cited on low frequency low amplitude TENS suggesting its central effect, probably located at brainstem level. This location of the mechanism of action of sensory ULFTENS allows hypothesizing its use to evaluate the Central Sensitization at brainstem level.Using this type of ULFTENS, it was possible to highlight the dysregulation of the ANS and of the pain modulation systems in TMD , suggestThe hypotheses on the mechanism of action of ULFTENS are summarized in In the “normal” condition collaboration exists for the control of arousal between cortical and subcortical centers. Information transmitted through sensory ULFTENS reaches the nuclear trigeminal sensory complex and through the latter is projected to subcortical areas that control arousal . Acute stress and pain lead to increased arousal  followed by the temporary activation of peripheral responses mediated by the ANS as well as the inflammatory, immune, hormonal, and neuromuscular systems , 142.It is likely that such action takes place by the “inhibition of the inhibition” of the “activation system” according to the hypothesis of Thayer , 144.In these conditions, the ULFTENS would act through the balance of subcortical arousal circuit by enhancing the inhibition through the endorphin system and, thus, reducing the cortical activation induced by stress or pain. The action on peripheral targets will vary, since the paths that lead to the peripheral response are themselves varied and dependent on individuals. For this reason, it will be possible to obtain different combinations of peripheral effects to observe the reduction of muscle tone and the change of the neutral position of the jaw, the reduction of pain, the variation of the dynamics of the pupil, the increase of the heart rate variability, the reduction of the oxidizing molecules and antioxidant barrier in saliva and serum, or the changes in cognitive-emotional test in which.In cases where the arousal system was not in suitable conditions to bear an additional stress , the stimulation with ULFTENS may not have the above-mentioned “inhibitory” effect. Peripherals answers cannot be, therefore, those expected and they can show an opposite behavior, for example, an increase in muscle tone, a reduction of the free space, an increase of salivary and blood levels of oxidants and a decrease in antioxidant barrier, a reduction of heart rate variability, and a paradoxical response of the pupil.By acting at the level of PAG-RVM component of the arousal control system, the ULFTENS would show the inability of this system to trigger the action of inhibition of endorphin circuitry if CS is present. The effects of sensory ULFTENS, both neuromuscular and not, are determined by the functional state of the general arousal system and by the subcortical system's ability to activate the appropriate stimulus-response coupling sequences.In particular, this hypothesis is different from that traditionally suggested for the mechanism of action of ULFTENS, because it does not consider its effect on the muscles tone and on the dynamic pattern of jaw movements (free way space after sensory ULFTENS) as the response of the peripheral neuromuscular system or its inherent proprioceptive properties. Indeed, we hypothesize that all the ULFTENS effects are linked to the central anatomofunctional substrate of the arousal balancer, affected by the state of “normalcy” or “CS.” Consequently, sensory ULFTENS can highlight, through objective data  and/or clinical techniques , not neuromuscular and those neuromuscular indirect effects studied by surface EMG/KIN that can contribute to accounting for the location of Central Sensitization.The TMD therapy is based on a “ex juvantibus” principle. Typically, the therapy starts with hygienic recommendations, self-administered jaw exercises, and physiotherapy and progressively adds more specific drugs or dental interventions against the supposed cause of peripheral or central pain, up to the surgery on joint or orthodontics . At presAt the other end of the range there are chronic forms characterized by CS, no more necessarily linked to a peripheral trigger in the temporomandibular district, which frequently represent a diagnostic and therapeutic challenge. Between the two forms, there are probably mixed disorders in which, from time to time, the central or the peripheral component could prevail, but both are active and mutually influent. Although not yet fully elucidated, it is likely that CS has a key role in the mechanism that leads to chronicity. Furthermore, as previously argued, the pain in other locations than TMJ area or the presence of other forms of CSSs is induced to classify the TMD as a disorder characterized by CS.The flowchart in The first step after the clinical evaluation is the administration of the CSI, which has proved sufficiently sensitive and specific to discriminate the syndromes characterized by CS. The cut-off score of the questionnaire is 40. Subjects with a score above 40 have a high probability of belonging to the group of the CSSs. The CSI does not allow the specific localization of CS. In this sense, the CSI is generic. On the other hand, sensory ULFTENS identifies responders and nonresponders to stimulation. The clinical parameters that can be evaluated by sensory ULFTENS include the resting tone of the muscles and the amount of interocclusal free space. The first must be reduced and the second increased after ULFTENS: in this case, subjects are considered responders.This criterion is probably insufficient because it only refers to a part of the activation of the PAG-RVM system and its quantification is not universally considered as reliable and specific for TMD. However, the information obtained indicates the response of the PAG-RVM circuit to the stimulation of the temporomandibular district.Future work could improve this decision-making process by introducing additional, more appropriate tests to assess the autonomous response after sensory ULFTENS, for example, HRV, with or without cognitive/emotional tests.Depending on the answer to the CSI and sensory ULFTENS, four diagnostic categories of TMD can be hypothesized.1) TMD Subjects Characterized by Central Sensitization (TMD CSS) without Impairment of the PAG-RVM-Spinal Pathway. These subjects are sensory ULFTENS responders, and their PAG-RVM-Spinal pathway responds to stimulation by activating the way of endogenous opioids, as expected from the hypothesis. According to this hypothesis, the CS is placed in areas overlying the brainstem, probably in cortical or subcortical structures responsible for the processing of pain and its cognitive and affective/emotional component. From a therapeutic point of view, it is likely that this group of people does not directly benefit of a dental approach. The most appropriate therapies should target the structures above the brainstem .(2) TMD CSS with Impairment of PAG-RVM-Spinal Pathway. These subjects are sensory ULFTENS nonresponders; that is, the sensory ULFTENS does not evoke the expected response on behalf of the PAG-RVM-Spinal pathway that activates the endogenous opioid mechanism. Frequently, in sensory ULFTENS nonresponders a paradoxical response is triggered, with an increase in muscular electrical activity and a reduction or even absence of the free space. Sensory ULFTENS is not able to activate the inhibitory component of the PAG-RVM-Spinal pathway because of the prevailing excitatory response of the system. In this case, it is possible to suggest that CS is located at the level of the PAG-RVM-Spinal pathway. Therefore, this system should be the target of therapy. Appropriate therapies  should be able to reverse the impairment of the system.(3) TMD without Central Sensitization (TMD noCSS) and without Extrastomatognathic Unbalance. This is the classic case of acute TMD of dental interest, where the occlusal component, muscle, fascia, and joints of the stomatognathic system are cause of the problem, and there is no clinical evidence of CS. These subjects are sensory ULFTENS responders. From this basis, it can be argued that in chronic TMD an alteration in the trigeminal system afferents is present. It has been shown that the construction of reversible occlusion (bite) that maintains the spatial characteristics of the mandibular-cranial balance obtained under motor ULFTENS stimulation can significantly improve symptoms in a sample of acute TMD subjects [(subjects . At pres4) TMD noCSS with Extrastomatognathic Unbalance. Also in this case, there is no evidence of CS, but the subjects are sensory ULFTENS nonresponders. It is possible that alterations in extra trigeminal districts in these subjects can influence the response to sensory ULFTENS of the fifth and seventh pairs of cranial nerves. In fact, afferents from extra trigeminal districts converge at the level of the caudal part of the spinal trigeminal nucleus, where they can contribute to the phenomenon of referred pain to the trigeminal area. Therefore, myofascial and articular disorders of extrastomatognathic districts may affect the trigeminal territory. Nonresponsiveness to sensory ULFTENS can depend on the anatomofunctional localization of the unbalance, namely, in districts not affected by sensory ULFTENS stimulation or, alternatively, because PAG-RVM system is working to reduce the inputs coming from extrastomatognathic system and could be no more engaged by sensory ULFTENS. In these subjects, it is possible to suggest a “postural” or physiotherapy approach aimed at rebalancing the extrastomatognathic structures responsible for symptoms referred to the trigeminal territory.(The proposed model of sensory ULFTENS as a as PAG-RVM system provocation technique and as a diagnostic tool for different types of TMD is, at present, only hypothetical. Further studies are needed to shed light on this topic, particularly studies of neuroimaging or animal studies exploring the anatomofunctional sites that interplay in different types or stages of TMD.Another limitation of the present study is inherent to the current idea of CSSs. In fact, a unique physiopathogenic pattern grouping all syndromes included in this classification into one entity has not yet been demonstrated. The term CS is too general, including any plastic or functional phenomenon that can involve any nervous structure, area, or CNS nucleus. It can also be attributed to multiple structures simultaneously.Future works are also needed to associate specific tests with specific CSSs. In our case, we have hypothesized that sensory ULFTENS could act on one possible site of CS, the PAG-RVM system, which has a crucial role in the descending modulation of pain, hyperalgesia, and allodynia. In this our hypothesis is completely missing an essential step, which is to test the effect of sensory ULFTENS on allodynia and hyperalgesia in individuals belonging to the four diagnostic and therapeutic categories suggested.TMD has to be considered a group of etiologically or, at least, pathogenetically different disorders. Without classifications that include these differences, the therapies are “casual” and not “causal.” In our work we do not want to support one or another therapy; we only hypothesized that the current therapies could be grouped in different way according to the proposed pathogenic-based classification. We proposed any “not already used” therapy. All the cited therapies have their “scientific” bibliography; all the TMD therapies, of course, are debated.Future work should focus on this objective to assess whether individuals belonging to the four categories are different in terms of pain, hyperalgesia, and allodynia, and if sensory ULFTENS helps in differential diagnosis and, therefore, in the choice of the appropriate therapy.Chronic TMD are a challenge for dentistry. The traditional clinical and research approach based on the injury and dysfunction of the stomatognathic system is no longer suitable to provide a convincing pathogenetic theory that could satisfactorily guide therapy. Thus, it seems useful to change perspective towards an interesting new possibility, represented by the study of chronic pain as a “central disorder,” originating from maladaptive learning and plasticity secondary to a peripheral dysfunction, the so called CS -, but quickly living its own independent life. Further clinical and basic research are needed to better understand the degree and type of involvement of anatomofunctional CNS sites in chronic TMD.