There is a significant increase in survival for HIV-infected children who have early access to diagnosis and treatment. The goal of this multi-country review was to examine when and where HIV-exposed infants and children are being diagnosed, and whether the EID service is being maximally utilized to improve health outcomes for HIV-exposed children.In four countries across Africa and Asia existing documents and data were reviewed and key informant interviews were conducted. EID testing data was gathered from the central testing laboratories and was then complemented by health facility level data extraction which took place using a standardized and validated questionnaireIn the four countries reviewed from 2006 to 2009 EID sample volumes rose dramatically to an average of >100 samples per quarter in Cambodia and Senegal, >7,000 samples per quarter in Uganda, and >2,000 samples per quarter in Namibia. Geographic coverage of sites also rapidly expanded to 525 sites in Uganda, 205 in Namibia, 48 in Senegal, and 26 in Cambodia in 2009. However, only a small proportion of testing was done at lower-level health facilities: in Uganda Health Center IIs and IIIs comprised 47% of the EID collection sites, but only 11% of the total tests, and in Namibia 15% of EID sites collected >93% of all samples. In all countries except for Namibia, more than 50% of the EID testing was done after 2 months of age. Few sites had robust referral mechanisms between EID and ART. In a sub-sample of children, we noted significant attrition of infants along the continuum of care post testing. Only 22% , 37% (Uganda), and 38% (Cambodia) of infants testing positive by PCR were subsequently initiated onto treatment. In Namibia, which had almost universal EID coverage, more than 70% of PCR-positive infants initiated ART in 2008.While EID testing has expanded dramatically, a large proportion of PCR- positive infants are initiated on treatment. As EID services continue to scale-up, more programmatic attention and support is needed to retain HIV-exposed infants in care and ensure that those testing positive initiate treatment in a timely manner. Namibia's experience demonstrates that it is feasible for a rural, low-income country to achieve high national coverage of infant testing and treatment. HIV infection is having an increasing impact on the health of children, threatening to undermine hard-won gains in child survival in countries with high HIV prevalence. Based upon the most recent global estimates, 2.3 million children younger than 15 years of age are living with HIV .One contributing factor to low coverage of ART in infants is that diagnosing HIV in infants requires virologic testing, rather than simpler antibody-based rapid tests that are used in adults. Early infant diagnosis (EID) is done through polymerase chain reaction (PCR) testing of dried blood spots that are collected at peripheral sites and sent to central laboratories. WHO recommends that all infants born from mothers who tested positive during pregnancy should have a blood sample collected for EID testing at four to six weeks of age . This wiThough critically important for the survival of HIV positive infants and the Universal Access objectives of national programs, EID requires capacity, participation, coordination, and management of multiple health structures as well as significant logistical, financial and human investment. Due to increased investments by the global community and national governments the number of laboratories providing EID services to the national program increased dramatically in sub-Saharan Africa from 2005 to 2009. However there remain concerns regarding whether existing national programs are effective in identifying HIV-exposed and HIV-infected infants and children and linking them in a timely manner to required care and treatment. This comparative descriptive analysis across four countries in Africa and Asia reviews the early implementation of EID programs as they are in the process of scaling up, with a specific focus on examining when and where HIV-exposed infants and children are being diagnosed and initiated onto treatment.Four countries- Cambodia, Namibia, Senegal and Uganda - were selected to provide a broadly representative sample of HIV care in high and low HIV prevalence countries in Asia and sub-Saharan Africa. All four ministries of health were solicited and agreed to the review both for national program development and to contribute to the global evidence base. In each country under ministry leadership, a desk review of existing documents and data and key informant interviews with key program managers, laboratory staff, and implementing partners were undertaken. Following this, EID testing data was gathered from the central testing laboratories and then complemented by health facility level data extraction which took place using a standardized and validated questionnaire. The focus of the paper is on the EID laboratory testing data and health facility level data that was extracted, but information on how the desk reviews and key informant interviews were conducted is also included below as reference for others who may want to conduct a similar review.The desk review included only available nationally endorsed or commissioned documents, plans, and analyses of the data that were focused on EID, PMTCT, and paediatric care and treatment. Documents where EID, PMTCT, or paediatric HIV care and treatment were not a primary focus or which were not endorsed or commissioned by the respective Ministry of Health were excluded. The rationale for these criteria was that the objective was to conduct a focused review of national EID programs, rather than the activities of specific partners or broader child health services. Documents reviewed included national policy documents, national technical guidelines, relevant memos or circulars, national forms and data collection tools used for EID, national testing and procurement data, any existing documentation of the EID system, national scale up plans, and any analyses done to date of EID service. The documents were provided by the Ministry of Health in each country after a request from the UNICEF country offices. This information was reviewed in order to establish the history, policies and current status of the EID program at a macro level. The desk review began prior to the in-country visit and was supplemented by data made available in the first two days in country.Key informants were defined as persons actively involved in managing, supporting, or providing early infant diagnosis services. This included program managers in the ministries of health at national and district level, technicians in the reference laboratory, health care workers involved in EID and infant care at site level, and partners involved in EID at an implementation level. Feedback gathered included: (1) policy considerations for EID ; (2) management of EID ; and (3) EID program implementation The fact that early infant diagnosis is a reference test allows for a significant amount of data to be gathered centrally. The EID database at the central laboratory was thus the lynchpin of the review and was used to prepare analyses of testing volumes, age at testing over time, and turn-around time analyses. The available data was extracted from the central database which incorporated data from all laboratories performing EID in each of the four countries. PMTCT/MIS data was gathered at national and regional level.For the health facility level data extraction, 18 to 25 EID collection sites per country were selected based on health centre type, geography, partner participation and maturity of the EID service. EID collection sites reviewed contributed to variable proportions of total EID tests completed by the national program in the public sector ranging from 36% to 91%  IVs, 207 of the 955 HC IIIs, and 47 HC IIs. EID services were present at more than half of the ~900 PMTCT sites nationwide and at many more clinics than where paediatric ART was provided (234 sites). In Namibia, EID was available at 205 sites across all 13 provinces, including the large majority of the 35 ART sites and more than 200 PMTCT sites. In Cambodia, EID services were available at 26 sites across 16 of 23 provinces as well as in Phnom Penh and were available at the large majority of the 31 OI/ART Sites and slightly less than half of the 69 Referral Hospitals. In Senegal, EID services were offered at 48 sites across 12 of the 14 regions.While expanded geographical coverage across the four countries reviewed brought services closer to the patient, it did not always translate into significantly greater sample collection at lower-level facilities or more even geographical distribution of sample collection. In Uganda lower-level clinics (HC IIs and IIIs) comprised 47% of the EID collection sites nationally, but only 11% of the total testing volume Figure . Data frThe policies of all countries recommend testing beginning at six weeks or as soon as possible thereafter. In all countries the age of testing was recorded on the testing form, but only in Namibia, did the laboratory coding systematically record the reason for the testing to be either "from PMTCT" or "symptomatic", thus enabling an accurate determination to be made regarding what proportion of testing of infants known to be exposed perinatally was occurring in the context of PMTCT in the first two months of life. In this case of 11,720 total infants were coded as referred from PMTCT services and 1,314 because of having symptoms suggestive of HIV. The median age of testing among infants referred from PMTCT services was approximately 2 months over the life of the program, with a large proportion of these infants being tested well after two months of age. Although the specific reason behind referral for testing in the other three countries was not known, among all infants receiving EID, the proportion of tests that were done in their first two months was less than 50% in 2009 in each country, although this proportion had increased over time in all countries from 2007 to 2009  was analysed from collection at site to laboratory and averaged 1.38 days in Namibia, 5.25 days in Cambodia, and 12.6 days in Uganda over the life of the program, with wide variation between sites.  Namibia, with the shortest turnaround time, used only one EID testing laboratory, but invested in overnight transportation of all samples from 37 local collection laboratories. Uganda with the most testing laboratories actually had the longest sample transport time. TAT for processing within laboratories averaged 9 days in Namibia, 18 days in Cambodia, and 3.33 weeks in Uganda over the life of the program. In all countries health facility registers did not systematically document the date that the result arrived back at sites and therefore the total TAT from sample collection to result arrival at site could not be measured.There were two main models of service organization observed at facility level for exposed infant care and EID testing. The first is a centralized collection model where services such as MCH, OPD and ART identify exposed infants and refer infants to the site laboratory for EID sample collection. EID sample collection takes place in the site laboratory and the parents of the infants are either told to return to the service from where the infant was referred, or to the laboratory itself for test results. The second collection model that a number of higher volume countries or higher volume sites are implementing is the decentralization of EID sample collection beyond the site laboratory to multiple points within the health care facility such as the ANC, ART centre, OPD, and ward(s). In this model, samples are collected by nurses or doctors within each service. Infants have their EID samples collected, receive exposed infant care, and receive their results all at the same locationAcross the sites reviewed, few had robust referral mechanisms in place between testing and HIV care and treatment. In a sub-sample of children in Uganda, Senegal, and Cambodia for whom this data was available we noted significant attrition of infants along the continuum of care post testing. The most complete data and largest sample size was from Uganda Figure . OverallIn Namibia, we examined the extent to which PCR-positive infants who were enrolled in HIV care subsequently initiated ART and associated time delays. The proportion of HIV-positive infants initiating ART increased after the new guidelines and delays in time to initiation correspondingly decreased Figure , with moWe report a dramatic increase in EID testing volumes between 2006 and 2009 in four countries which represent a mix of high  and lower  HIV prevalence and diverse health system capacities. However, while the number of tests expanded rapidly, the public health impact was far from optimal. In 3 of the 4 countries only 22% to 38% of infants testing positive by PCR initiated ART. It is important to recognize that the data reviewed covered a period of time when international guidelines on when to start treatment in infants were changing and therefore not all infants were eligible for treatment at the time they tested PCR positive. However, even after guidelines had been changed, a substantial proportion of PCR-positive infants were still not being initiated on ART at the review sites. The exception to this was Namibia which has been able to achieve high population-based coverage of both infant testing and treatment. Namibia's success demonstrates that it is feasible for EID services to contribute to a large public health impact in a highly rural, low-income country. These observations underscore that it is critical to focus more attention on ensuring that all infants who test positive rapidly initiate ART.In order to increase EID testing coverage, many countries have prioritized decentralizing the service both geographically and through various levels of the health system. This review found that decentralization alone is not sufficient to greatly increase utilization of services at lower-level sites. To improve uptake of testing in the first two months of life, infant follow up must be underscored in PMTCT counselling. With high coverage rates in many countries for the first childhood vaccination, HIV programs have been working to strengthen the linkage between EPI (Expanded Programme on Immunizations) to enable earlier EID. However these efforts can only succeed when practical operational guidance on provider initiated counselling is coupled with measures such as coded documentation of mothers' HIV status on health cards to enable the identification of infants needing EID.Among infants with PCR-positive results, very high rates of loss to follow up occurred in the postnatal period. Many caregivers never received the EID results, and very few sites reviewed had robust mechanisms in place to follow up with infants whose parents or caregivers did not return for results. Standard operating procedures are needed by which sample collection and result return are closely linked to counselling, clinical care, and to follow up. It is critical for all sites to have a clear understanding of the EID sample and result flow, the patient flow, and who is responsible for key infant care tasks.In this regard, the reviews identified two broad types of approaches to organization of EID services, each of which potentially poses challenges for retaining infants. In Senegal and Cambodia, the site laboratory technicians manage the EID supplies, sample collection, record keeping, dispatch of samples, and receipt of results. Having skilled laboratory technicians can facilitate the transportation of samples and communication with referral laboratories, but not having clinical providers in charge of coordinating the service can result in challenges with regard to post-test counselling, exposed infant follow up, and returning the results to caregivers and service providers. On the other hand, the model utilized in Namibia and Uganda in which EID was offered in multiple clinical units within a site  requires significant site organization for consumables and registers. With multiple collection points the logistics of getting all samples to the referral laboratory and all results to their correct collection point is challenging.In light of these difficulties, a third approach to the organization of EID services may be useful in some contexts, which includes aspects of both the centralized and decentralized collection models. To address some of the problems noted in the review, Uganda implemented an EID strengthening pilot in which a single centralized care location is designated where exposed infants receive comprehensive longitudinal care  Sites pick the location of the EID care point themselves by deciding which unit they believe is best positioned, which may be ART, OPD, or MCH clinics - in most cases sites have chosen ART clinics. HIV-exposed infants presenting at other entry points are all referred to and managed by this one designated care point. A focal person is designated to be responsible for infant follow-up at the EID care point, and monitoring tools, job aids, and mentoring are provided for the care point and referring units. Uganda has subsequently reported strong improvements in the proportions of eligible infants receiving test results and initiating ART at sites that have implemented this approach , and basSystematic referral mechanisms are also needed to ensure PCR- positive infants are enrolled on ART. However, these were not present at most sites providing EID services. Indeed, despite the co-location of testing and HIV care and treatment in the same hospital (and sometimes the same unit), a high rate of attrition occurred between testing and enrolment in HIV treatment for those infants testing positive by PCR. The little data available indicates that, even for the small number of PCR-positive infants that were initiated on treatment, substantial delays were common between when caregivers received results and when infants were initiated on treatment, with many PCR-positive infants being enrolled in HIV care but never HIV treatment. Though the reasons for delays and loss-to-follow-up between enrolment in HIV care and enrolment on ART cannot be determined from the current analysis, possible contributing factors may be the requirement in some cases for several adherence counselling visits prior to ART initiation, the desire of clinicians to obtain a baseline CD4 prior to initiating ART, or the fact that some sites provide care for PCR-positive infants (mainly CPT and infant feeding support) but have to out-refer to other sites that offer ART. This data highlights the urgency of streamlining current processes for initiating ART in infants to avoid such delays which are resulting in increased mortality in these highly vulnerable children. Where feasible, decentralizing ART to lower-level clinics that also provide MCH and EID may also have potential to improve retention through enabling a "one stop shop" where HIV treatment can be initiated without referral to another site or hospital service.There are several limitations to the conclusions that can be drawn from this retrospective multi-country review. Firstly, the data was routine programmatic data and mostly cross-sectional. Estimating the proportion of infants who were lost-to-follow-up at different points of needed care in the postnatal period therefore required the linking of data from several different sources of routinely-collected data because sites and national programs do not follow HIV-exposed infants longitudinally. However significant efforts were made to eliminate repeat PCR documentation to ensure no infants are double counted. The possibility exists that some of the infants that were estimated as lost-to-follow-up received services, but that this was not recorded either because care occurred at other sites that were not covered by the review or because of the suboptimal quality of the routinely collected data at the sites that were reviewed. We also did not seek to collect data about care services provided to the HIV-positive mothers, such as whether they were enrolled or retained in HIV care and treatment services. Additionally, given the nature of the review, we could not determine what the reasons were why infants were lost-to-follow-up or if any specific approaches had been used successfully to improve the continuum of care. More in-depth prospective reviews would be helpful for programs to better understand these important issues, and the optimal approaches to reduce loss-to-follow-up and ensure timely ART initiation. Encouragingly, since the reviews the countries involved have continued to make improvements in their programs, including taking action to address the high rates of loss-to-follow-up.This review provides useful insights into the functioning of EID services in low resource settings and gives an indication of what changes are needed in order to achieve optimal impact of this intervention. While the volume of EID tests has expanded dramatically in these four countries, a large proportion of HIV-infected infants testing positive by PCR were not subsequently initiated on treatment. In order to improve retention and enable the achievement of high coverage of paediatric treatment it is critical for EID services to be fundamentally linked to PMTCT and MCH as well as to ART programs. Shifting focus from the laboratory aspects of EID alone to the full package of HIV-exposed infant care should enable EID services to have a much greater impact on child survival in the future.The authors declare that they have no competing interests.AC made substantial contributions to design of the review; the analysis and interpretation of data; and the drafting of the manuscript. ST made substantial contributions to design of the review; the acquisition, analysis and interpretation of data; and the drafting of the manuscript.RG made substantial contributions to design of the review; the analysis and interpretation of data; and revising the manuscript for important intellectual content. NH, SP, CK, and AW made substantial contributions to the design of the review and the acquisition, analysis, and interpretation of data. MB made substantial contribution to the analysis and interpretation of data and the drafting of the manuscript. CL and RE made substantial contributions to the design of the review and the analysis and interpretation of data. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/11/553/prepubEID Data Collector Tool. This is a copy of the questionnaire used for the site-level data extraction. It covers the EID continuum from early identification of the HIV exposed infant through to discharge of the HIV negative baby with a confirmed status or initiation on ART.Click here for file


According to the Office for National Statistics, approximately a quarter of women giving birth in England and Wales are from minority ethnic groups. Previous work has indicated that these women have poorer pregnancy outcomes than White women and poorer experience of maternity care, sometimes encountering stereotyping and racism. The aims of this study were to examine service use and perceptions of care in ethnic minority women from different groups compared to White women.Secondary analysis of data from a survey of women in 2010 was undertaken. The questionnaire asked about women’s experience of care during pregnancy, labour and birth, and the postnatal period, as well as demographic factors. Ethnicity was grouped into eight categories: White, Mixed, Indian, Pakistani, Bangladeshi, Black Caribbean, Black African, and Other ethnicity.A total of 24,319 women completed the survey. Compared to White women, women from minority ethnic groups were more likely to be younger, multiparous and without a partner. They tended to access antenatal care later in pregnancy, have fewer antenatal checks, fewer ultrasound scans and less screening. They were less likely to receive pain relief in labour and, Black African women in particular, were more likely to deliver by emergency caesarean section. Postnatally, women from minority ethnic groups had longer lengths of hospital stay and were more likely to breastfeed but they had fewer home visits from midwives. Throughout their maternity care, women from minority ethnic groups were less likely to feel spoken to so they could understand, to be treated with kindness, to be sufficiently involved in decisions and to have confidence and trust in the staff.Women in all minority ethnic groups had a poorer experience of maternity services than White women. That this was still the case following publication of a number of national policy documents and local initiatives is a cause for concern. In 2010, 25.1% of women giving birth in England and Wales were born outside the UK[Ethnic group has been defined as “a collectivity within a larger population having real or putative common ancestry, memories of a shared past, and a cultural focus upon one or more symbolic elements which define the group’s identity…”. An ethnStudies in Europe and North America have indicated that, even in a developed country context, women from minority ethnic groups have poorer pregnancy outcomes than White women. The last two UK triennial enquiries into maternal deaths found that women from minority ethnic groups were at significantly greater risk,5. In paA study based on UK birth registrations (and thus country of birth rather than ethnicity) found that low birthweight (<2500 g) was most common in babies of women born in South Asia and that women born in the Caribbean and West Africa had a higher incidence of very low birthweight babies (<1500 g). LinkageIn a study comparing birthweight of first and second generation Asians in the UK, mean birthweight after adjustment was higher in babies of second generation women. This waOne likely pathway linking ethnicity and poor perinatal outcome is antenatal care. A rangeA population based survey in 2006 found that women from minority ethnic groups worried more about labour and delivery than White women did. In particular, although embarrassment was not a major concern, it featured more often as a significant issue for ethnic minority women than for White women.The importance of training of health care professionals in cultural sensitivity and the use of interpreters, advocates and link workers has long been emphasised in government reports,19. The There is evidence of a perception amongst some staff that if minority ethnic group women behaved more like White women, the health disadvantages of these groups would disappear. MidwiveWomen of all ethnicities born outside the UK may have particular difficulty with the transition to motherhood. The effects of being away from family and isolated in a foreign country, can lead to considerable unhappiness. Cultural differences may result in different expectations: whereas women in Northern Europe are encouraged to be up and active almost immediately following a normal birth, women from other groups may view the early postnatal period as a time for rest and seclusion, anticipating support from staff, friends and family and recognition of their changed status,27. The The aims of this study were to examine use of services and perceptions of maternity care among women who had recently given birth and who self-identified as coming from seven specific ethnic groups compared to women self-identifying as White. Lumping women from Black and Minority Ethnic groups together is recognised as of limited value in trying to understand differences in care associated with ethnicity, as is groupings like 'Black’ or 'Asian’. Thus, the opportunity to break down the groupings further was taken in order to better understand differences in care and perceptions of that care.Structured questionnaires and an information leaflet in 20 different languages were sent to more than 50,000 women aged 16 years and over living in England in 2010, excluding women whose baby had died. The questionnaire was coordinated by the Picker Institute on behalf of the Care Quality Commission and sent from 144 NHS trusts to investigate women’s experience of maternity care. Completion and return of the questionnaire was taken as consent. There was an option for women to complete the questionnaire by phone with an interpreter but this was rarely used. Women were asked about access, information, communication and choice regarding antenatal care, delivery mode and neonatal outcomes. Information regarding demographic characteristics, including age, partner status and parity were also collected. No data were collected on socioeconomic status as the focus was on patient experience.Based on the UK census question, respondents were asked to identify which group they belonged to from a list of 16 categories. In the analysis, ethnicity was grouped as: White , Mixed , Indian, Pakistani, Bangladeshi, Black Caribbean, Black African or Other ethnic group .The associations between women’s experience and ethnic group were investigated by logistic regression models. Multinomial logistic regression was used when the dependent variable (women’s experience) had more than two categories. Odds ratios and 95% confidence intervals were calculated by comparing each ethnic group to White (as a baseline group). The confounding factors age, parity and partner status were adjusted for in the models. Mode of delivery  was also adjusted for in the analyses of perception of care. Prematurity was also adjusted for in the analyses relating to intrapartum and postnatal care. We did not adjust for language spoken at home as this is a key component of ethnic identity.To minimise the non-response bias in the survey, the non-response weights were calculated based on the propensity modelling cell adjustment approach. Women wAll of the logistic regressions were calculated using survey commands in Stata to account for the non-response weights and the clusters at NHS trust level. Categorical variables were summarized as frequencies and percentages.Statistical analyses were carried out using STATA 11 software .A total of 24,319 women completed the survey, with a usable response rate of 52%. These were 84.8% White, 1.3% Mixed, 2.4% Indian, 2.5% Pakistani, 0.7% Bangladeshi, 0.7% Black Caribbean, 2.7% Black African, 5.0% Other ethnicity (excluding not known ethnicity)  survey data from 2007 and one Direct comparison of these more recent data with the 2007 survey is difficult due to differences in question design and the different grouping of ethnicity. Nevertheless, it appears that very little has changed, although with this more recent study we can better appreciate differences between Black African and Black Caribbean women and between Indian, Pakistani and Bangladeshi women. The direction and size of the disparity between women from ethnic minorities and White women is very similar to that reported in earlier studies.The attitudes of staff and the nature of interaction are a critical aspect of care for all women. HoweverLimitations of this study include the 52% response to the survey and that women who were less familiar with English would have been less likely to complete it. However, 3686 women from minority ethnic groups responded and the differential non-response was corrected for in the analysis. We had no information about duration of residence in the UK or about country of origin. A further limitation is the lack of any variable relating to SES. However, studies have shown that, although SES is associated with ethnicity, it does not explain differences in mortality. AnalysiThe strengths of this study are its size and more detailed breakdown by ethnic group. There were noticeable and significant differences between the different Asian groups, and between the two Black groups. For example, Pakistani women were significantly more likely to have poor experience of antenatal care, and Bangladeshi women of postnatal care, whereas Indian women were much more similar to White women in these respects. Similarly, Black African women were more likely to book late, have fewer ultrasound scans, an unplanned caesarean, be left alone and worried in labour and after the birth compared to Black Caribbean women. These differences may relate to recency of migration, availability of family and social support, differences in religious beliefs, cultural attitudes and expectations, and the extent of societal integration more broadly. It was interesting that women of Mixed ethnicity were not significantly different from White women in most of the outcomes investigated. The only exceptions to this were late booking, a less positive overall rating of labour and birth care and not seeing a midwife as much as wanted after hospital discharge.Postnatal differences tended to be in the other direction. For example, a length of stay of three days or more was more common in Asian and Black African women, possibly reflecting an increased need for care, as with the higher proportion of Black African women having a caesarean section. It may also reflect the expectation among Asian groups that the immediate postnatal period is a time for rest althoughThe greatest differences between minority ethnic group women and White women related to timing of the first contact with health professionals and booking for maternity care and being left alone in labour or after birth at a time when it worried them. Factors contributing to these differences have been explored elsewhere,16,42,43Implications for care are principally for health professionals to recognise the diversity within groups. For example, Asian and Black women vary in their cultural and religious beliefs, their economic and migration histories. This is reflected in the way care is accessed, preferences for traditional rather than medical models and the extent to which Western values are adopted. There may be too much of an expectation by health professionals that women and their families will adapt to the dominant culture, rather than the maternity service being responsive and sensitive to the needs of a multicultural population. It is disappointing that ethnic minority women’s experience of maternity care does not appear to have improved appreciably over the last decade, particularly as an increasing proportion of women using the maternity services were born outside the UK.Women in all minority ethnic groups had a poorer experience of maternity services than White women. That this was still the case following publication of a number of national policy documents and local initiatives to improve childbirth experiences and outcomes for ethnic minority women is a cause for concern. Previous research has demonstrated the importance of individualised care and the potential of advocates and link workers in improving the experience of care of minority ethnic groups. FurtherSES: Socioeconomic status; NHS: National Health Service; HCC: Health care commission; CQC: Care quality commission; IMD: Index of multiple deprivation; aOR: Adjusted odds ratio; HP: Health professional; MW: Midwife; AN: Antenatal; PN: Postnatal.The authors declare that they have no competing interests.JH conducted some of the analyses and drafted the manuscript. HG carried out the majority of the statistical analyses. MR oversaw the design, management and coordination of the study and helped to draft the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/13/196/prepub


AbstractChrysomelidae, caught with Malaise traps during two years in four areas with different levels of conservation in the Araucaria Forest, Paraná, Brazil, determining if body size is a good predictor of abundance, and if body size could be used to indicate environmental quality. Body size was considered the total length of the specimen from the anterior region of head to the apex of abdomen/elytron. Measurements were taken for up to ten specimens of each species for each area and for all specimens of those species represented by fewer than ten individuals. The highest abundance and richness of Chrysomelidae were obtained in the lowest body size classes. This herbivorous group showed a trend toward a decrease in body size with increasing abundance, but body size was not a good predictor of its abundance. There was a trend toward a decrease in body size from the less to the most conserved areas; however, the definition of a pattern in successional areas not seems to be entirely clear.Body size is correlated with many species traits such as morphology, physiology, life history and abundance as well; it is one of the most discussed topics in macroecological studies. The aim of this paper was to analyze the body size distribution of  Potential ecological relationships between body size and structure of animal communities have been one of main focuses in ecological studies . Body siThe relationship between body size and abundance is an essential link between individual and population level traits and the structure and dynamics of ecological communities . AccordiControversy has arisen regarding how body size and abundance are related, and concerning the ecological and evolutionary implications of these relationships. In this way, an early step in elucidating the factors that structure animal assemblages may be to understand how the body sizes of their component species are distributed , 1997. HPageBreak would be benefited in initial stages of succession while the small and specialized ones would be benefited in final stages of succession. In this way changes in species body size over the succession could be another important indicator of environmental changes and quality.Another aspect about the body size that has been widely discussed is its use in the assessment of environmental quality. In general, richness and abundance are the variables most used to measure not only the diversity but also to assess the environmental quality of areas in different successional stages. Studies have shown that habitat type, management, succession and degradation level have a great influence on the body size of insects increasing or decreasing species body size along succession . AccordiChrysomelidae is one of the most diverse groups with more than 36,000 described species . This park is a conservation unit in the state of Paraná with an area of 3.122 ha, mainly covered by natural fields  (The data came from the project Vila Velha (PROVIVE), which was developed in the Parque Estadual of Vila Velha (y-woody)  associatAraucaria angustifolia (Bert.) O. Ktze (Araucariaceae), Ocotea porosa (Nees & C. Mart.) Barroso (Lauraceae) and some Myrtaceae. Plant succession is at an intermediate to advanced stage; d) Phase 3, primary forest changed by selective cutting. It is the best preserved of all, showing a very similar flora to Phase 2 area, but with higher density of araucarias, epiphytes and lianas.Of the five areas sampled during the PROVIVE project, the material from four areas was used in this study, one edge area and three with increasing conservation level. A brief description of these areas is as follows. More information could be found in Chrysomelidae assemblage is composed by species that fly PageBreakfrom ground to 2m high and, because of the sampling effort, it was assumed that this trap sampled all species that occur in each sampling area.In each sampling area, a Malaise trap was placed and the caught material removed weekly from September 1999 to August 2001. As Malaise is a selective trap collecting flying insects, in this study Coleoptera were mounted, labeled, and the chrysomelids identified to the lowest taxonomic level possible. The material is deposited in the Coleção de Entomologia Pe. J. S. Moure, Departamento de Zoologia, Universidade Federal do Paraná (DZUP).The Chrysomelidae species sampled in each area were measured. The size was considered the total length of the specimen from the anterior region of the head (excluding antennae) to the apex of the abdomen or elytra  and adjusted on a logarithmic scale, following Correlation analyses were performed between size classes and abundance and, between size classes and richness.Chrysomelidae. The dependent variable was the abundance of each species and the independent variable its average size. The slope obtained was visually compared to that proposed by A regression analysis was performed to determine the influence of body size on the abundance of Chrysomelidae community in each area, ANOVA (5% significance) was performed based on all measured values. This analysis was also used only for those species recorded in all areas. In addition, ANOVA was used to determine if the size of species varied in areas with different succession levels. For this, species that occurred at least in two areas and that had at least six specimens sampled were selected. Each species was analyzed separately, totaling 15 species that met these prerequisites.To examine if there were differences in body size of the The normality of data was previously tested by the Kolmogorov-Smirnov test and data were log transformed. The analyses were performed using the STATISTICA program 8.0 .PageBreakChrysomelidae species were sampled and, 1,217 specimens were measured  only when data from all areas are included  in chrysomelid body size in areas less conserved, Border and Phase 1 to Phase 2  the spectrum of body size measurements is very high comparing to the lowest rich area (Phase 3). Consequently, there is a high probability of increasing the body size in the richest area since increasing the spectrum usually increases the average. On the other hand, in Phase 2 where the PageBreaksecond richest value was found, the spectrum has no influence since it was found the smallest size. Furthermore, we could not methodologically limit the number of species to eliminate some possible spectrum effect because it would change the composition of the local fauna and, although it seems to have a gradient relating the number of species with body size, the higher number of species alone does not explain the size found.Many features of organisms are correlated with animal body size, but especially life history, ability of dispersion and efficiency, and feeding specialization are linked to succession, so that changes in body size during plant succession may be an important indicator of environmental changes . The Chr Phase 2 ; howeverIn the literature, there are different results, some of them show the same tendency as in this study, such as those of There are environmental changes that could favor different species at different stages of succession. In early succession, plants have few defenses, high growth rates and low proportion of carbon and nitrogen in their tissues . As largColeoptera predator group. They studied the Carabidae fauna of areas in regeneration after the closure of a fertilizer factory. According to them, before the factory closure, there were few herbivorous species, which were large and generalists, and thus prey for large Carabidae. With the factory closure, there was a reduction of local pollution, allowing a recovery of vegetation. Thus, with the increase in primary production, there was an increase in immigration of herbivores expanding the food availability for carabids. Furthermore, the authors suggested that habitat structure must have also influenced the Carabidae body size, interfering with foraging efficiency. Early stages of succession and more open areas favored large species which are more efficient at traveling over larger distances in a patchy environment compared to later stages with denser vegetation, where smaller and more agile species may be favored.Carabidae body size, and concluded that disturbed habitats support a smaller body size fauna. Carabidae species of small size in early stages and brachypterous species of larger size in later stages of succession. Carabidae, recorded that the intensification of agriculture has a greater impact on large-sized species, so that small species predominate in more disturbed areas.Other studies, however, have found opposite results. PageBreakChrysomelidae in the most conserved areas, at least for this data set.As these results conflict with those obtained here and mainly do not deal with herbivorous insects but predators, it appears that the efficiency-specialization hypothesis proposed by Chrysomelidae community where the edge area had the highest average body size, for three species that showed significant differences in body size among areas , the Border was the area where these species had the smallest body size. These species did not contribute to explaining the Chrysomelidae pattern, where it was not possible to know which species most influenced the pattern.Among the 15 species examined, only four showed significant variations in body size among the different areas, and consequently, it was not possible to establish a consistent pattern between body size and level of conservation when species were analyzed separately. However, interesting information was obtained. Unlike what was determined for the entire Chrysomelidae, an essentially phytophagous group, showed a trend toward a decrease in abundance with increasing body size, in a negative polygonal relation. Furthermore, a greater number of chrysomelid species collected by Malaise traps occurred in smaller body size classes; species ranged from 1.0 to 15.0 mm in length and most of them measured between 3.0 and 4.99 mm.The Chrysomelidae community determining the size of species populations.The results presented here seem to follow the pattern found for several animal groups, where body size is a poor predictor of abundance. Other factors such as availability of food, metabolic efficiency, host plant specificity and/or parts of the plant, predation, parasitism and climate should act more on the Chrysomelidae communities in areas with different levels of conservation. There was a trend toward a decrease in body size of the less to the most conserved areas. The Border area, which is an ecotone and more influenced by human activity, had larger chrysomelid body sizes. However, the definition of a pattern in successional areas did not seem to be entirely clear, due to significant increase in body size of a later succession stage in relation to one of the others areas in an intermediate successional stage. Nevertheless, the results suggest that degrading the habitats, the small and specialized species would be at risk of disappearing.It was demonstrated that there is a change in body size of Chrysomelidae community. It would explain the higher richness and abundance of this group into smaller size classes, but it should not be considered the only explanation. Other factors, such as those already mentioned could be interfering in the ecological processes that generate such patterns.The fractal characteristic of the environments, mainly the plants, may be one of the operating mechanisms in


Neglected tropical diseases (NTDs) continue to adversely affect the lives of millions of people across the African continent. A roadmap published by the World Health Organization (WHO) in early 2012 lays out a vision for the control, elimination, and eradication of 17 NTDs www.unitingtocombatntds.org), which includes commitments for support from governments, foundations, and pharmaceutical companies, it is expected that much-needed impetus to address some of the current challenges will be provided. In addition, it has been suggested that the traditional approach to undertaking and supporting research in Africa requires a change of mind-set from both the scientists and funding organizations. This change of mind-set from the traditional approach should include a more integrated approach regarding funding organizations and the formation of sponsor-scientist partnerships Over the last decade or two, most of the global funding mechanisms have been directed at HIV/AIDS, malaria, and tuberculosis www.ntd-africa.net). EFINTD aims to strengthen research capacity in NTDs in Africa. This objective is accomplished by harnessing the skills of and empowering young African researchers who are based in their respective countries to perform research on various NTDs. The funding scheme supports recently qualified doctorate researchers with junior fellowships  and more advanced researchers with senior fellowships . Selection of fellows is based on peer review of a full grant application, followed by defence of the proposals at a grantees meeting convened by EFINTD. At the grantees meeting, part of the selection process is an interview conducted by eminent scientists in the field of NTDs and donor representatives. The duration of the fellowships, which also include a mentorship programme, is three years. The successful fellow would continue with normal duties such as clinical or teaching responsibilities for the duration of the fellowship. African host institutions must provide the basic infrastructure and support for the project, although no commitment is required for career support beyond the life of the fellowship. Career growth of the African scientists is supported by offering financial support for direct project expenses, such as personnel, equipment, consumables, as well as facilitating yearly meetings, workshops, discussion groups, networks, and local and regional African-led collaborations. A contribution to administrative costs payable to the host institution is limited to a maximum of 3,000 EUR.In 2008, five European foundations  driven by a common goal formed the EFINTD  of fellowship awards  have been dispensed. Twelve awards involve research into tool-ready diseases such as lymphatic filariasis, onchocerciasis, schistosomiasis, and soil-transmitted helminthiases. Seven awards focus on tool-deficient diseases such as Buruli ulcer and human African trypanosomiasis www.surveymonkey.com), an online survey and questionnaire tool, a survey was conducted among the recipients of the first two rounds (2008 and 2010) of the EFINTD fellowships  of these publications have been in open-source journals, reflecting the shared philosophy of the fellows to communicate their research results to the widest possible audience, which is especially relevant for African researchers and institutions with limited resources and, subsequently, paid journal subscriptions. More than half of the total outputs generated by the fellows were contributions at international conferences, either as oral or poster presentations, which is in-line with the desire of the fellows and sponsors to disseminate research outputs as quickly as they are generated.Since the first awards were made in 2008, several outputs have been generated by the fellows, as summarised in Although 19 fellowships were awarded, more than 60 additional students and personnel were employed on the various EFINTD-funded projects. These include 31 students (at MSc and PhD level) as well as 31 staff members who ranged from medical and veterinary doctors to laboratory technicians and human resource personnel. Eight fellows indicated that the fellowship programme impacted positively on their careers, either in the form of promotion or appointment to new positions.th Lindau Nobel Laureate Meeting in 2010, while three fellows attended the 61st Lindau Nobel Laureate Meeting in 2011. Seven of the fellows were also able to secure additional funds by using the EFINTD funding as leverage.The EFINTD funding also allowed for fellows to attend and present at project-topic-related workshops and courses at leading European institutions such as the Bernhard Nocht Institute for Tropical Medicine in Hamburg, the Institute of Tropical Medicine in Antwerp, the Swiss Tropical and Public Health Institute in Basel, the Karolinska Institute in Stockholm, the University of Copenhagen in Copenhagen, and the Royal Tropical Institute in Amsterdam. Visits to the United States (Harvard University and Louisiana State University), the Middle East , and other African countries were also undertaken. It was also possible to visit collaborators and other laboratories to learn/master new techniques. In addition, one fellow attended the 60Another important aspect of the programme has been the commitment of EFINTD to so-called “soft-skills” development. A weeklong summer school at the Royal Tropical Institute in Amsterdam attended by most of the fellows is testimonial of this commitment. The summer school included topics such as leadership, project management, financing NTD research, ethics and human subject research, epidemiology, evidence-based healthcare, as well as reporting and publishing results. In addition, several workshops are routinely held at the grantees meetings, dealing with issues such as prioritizing research activities for NTDs and networking research activities. The impact of such programmes goes beyond empowering the fellows, as they have indicated that the skills and knowledge they acquire are quickly transferred to their research groups, laboratories, institutes, and university departments.A question regarding the contribution of the programme to infrastructure (equipment and laboratory space) had an overwhelmingly positive response, with more than 75% of the fellows indicating that they had benefited in this respect. Although, in most instances, the contribution involved only small equipment  and computers (hardware and software), these resulted in a significant impact at the respective institutions by enhancing the capacity of the research groups. In two instances, additional grants were secured with the help of EFINTD that enabled the fellows to upgrade their facilities to regional reference laboratories based in Kenya and Malawi.Although the projects have not been running for an extensive period, influence on local policies is already evident. At a local government level, this ranges from assistance to local districts  to awareness and educational programmes in Nigeria for public health officials on the primary transmission of Lassa virus from the multimammate rat to humans. At a national level, scientists are also participating in training. Specifically this has been the case in Kenya where a study coordinator also trains programme implementers for the national Schistosomiasis Control Programme. The provision of maps describing the spatial distribution of schistosomiasis in Nigeria to national governmental departments and NGOs has impacted on policy and the national schistosomiasis control programme in this country. In addition, it has helped to accelerate and delineate areas for drug distribution and treatment. Geospatial and mapping support generated by fellows have also been provided to the NTD Control Programme in Nigeria.The EFINTD programme has brought together scientists from different scientific backgrounds with various skills and expertise to forge local collaborations. Subsequently, scientific capacity has been generated and is being harnessed in combating specific NTDs in African countries, where a dire need still exists. The importance of South–South networking in the improvement of scientific capacity in Africa was highlighted in a recent report by the Disease Reference Group on Helminth Infections A mentorship support programme is offered to the successful fellowship applicants. The mentorship programme allows fellows to select and establish links with leading African and European scientists, thereby enabling fellows to select their own mentor(s). Resources  are provided for the fellows to visit their mentors and vice versa. Several of the fellows responded positively with regard to their experiences in the mentorship programme, and one fellow stated “I have benefitted from it immensely.” This was especially the case in terms of advice and support received in managing current projects and providing ideas for future directions thereof as well as career advancement and growth towards becoming independent scientists. The programme was rated as enriching and unique, since it differs from the traditional model of mentoring in which a mentor is assigned to a fellow. This model has been widely adopted by other agencies and African universities, but with less positive results. What also makes the EFINTD mentorship programme special is that it has a built-in mechanism to follow up on both the mentor and mentee. In the end both parties are accountable firstly to themselves, to each other, and lastly to the foundations. The fellows were, however, quick to emphasize that the success of this relationship is dependent on the choice of mentor, his/her availability, and personality.The overall rating of the fellowship programme by the fellows was overwhelmingly positive . Their a“It is the personal-development aspect of the EFINTD postdoctoral programme that I like best.”“The fellowship is exceptional as it provide fellows with opportunities to study in-country while obtaining necessary technical assistance from anywhere in the world.”“…in terms of flexibility and access to funds as well as support, this grant is excellent.”The ratings indicated that in terms of flexibility in administration of and access to funds, this programme has been outstanding. The programme is seen as unique, as it provides opportunities for African researchers to perform research on NTDs in their respective home countries and institutions. Furthermore, it is now possible for African researchers to apply for and access European funds directly and not through a European partner. A revision of the budget limits was, however, suggested to accommodate student and infrastructure support as well as foreign currency fluctuations. More emphasis on “soft-skills” development, especially in terms of career development, should also be encouraged.The consensus among the 19 fellows is that the EFINTD fellowship programme is a prestigious postdoctoral programme that is highly competitive and has a transformational research agenda. Furthermore, the EFINTD programme has empowered the fellows and their home institutions to effectively undertake and contribute to research on NTDs, raised their individual profiles in the NTD arena, and created opportunities to establish long-lasting local and international partnerships. The success of the EFINTD fellowship programme in Africa can be attributed to the following aspects:Empowerment of African scientists to perform research in-country on African problemsDirect access to research fundsAn effective mentorship programme that allows for fellows to select their own mentorAccess to and creation of networking opportunitiesInvestment in “soft-skills” development by fundersClose contact between funders and fellows, facilitated by regular grantees meetings and workshopsIn turn the African scientists feel that the foundations have benefited from the in-depth perspectives brought by researchers who come from diverse cultures, backgrounds, and NTD challenges through their very close personal contacts with the fellows. Therefore, they have been able to ensure that their investments are paying dividends and have a better appreciation of the magnitude of these diseases in an African context. Since this is a dynamic and developing programme, the fellows made several suggestions and recommendations for its future. These suggestions might also be of relevance to other funding agencies with tailor-made programmes for African researchers:Minimum duration of programme. The fellows recommended continuation and possible extension of the current programme. Currently both junior and senior fellowships have a three-year duration. However, recruitment and delivery of PhD students can be problematic within three years. Although it is possible for senior fellows nearing the end of their tenure to apply for second-phase funding, which provides an additional two years of funding, it would be more desirable to extend the duration of the senior fellowship from three to five years, with intermediate progress review after three years.Long-term support for fellows that excel during the initial two rounds of funding. This could involve either the implementation of a third funding phase (career development into research leader) or facilitating support from other funding agencies, such as the Bill and Melinda Gates Foundation, the Wellcome Trust, or the European Commission.Sustainable long-term South–South network development. Such initiatives are already being developed and include an EFINTD networking group within the GLOBE e-portal of Foundation Mérieux. Another initiative that is currently being explored is the formation of an academy or association of African NTD researchers that would allow recipients and donors to continue interacting beyond the life of individual projects.Capacity building in terms of postgraduate students (MSc and PhD). Student bursaries can be incorporated into the current fellowships to allow student training and provide access to some of the benefits of the fellowship programme. In addition, it is recommended to transfer the current postdoctoral programme to MSc and PhD level. Furthermore, it is suggested to promote such a programme, especially in non-English speaking countries and among women scientists, in order to increase the scientific capacity in Africa.Infrastructure development in terms of equipment grants. A major consideration should be to develop programmes that specifically target infrastructure upgrades in African institutions, and these should be separate from research project support. Such upgrades would allow for independent research and the improvement of the research environment, which should enable African researchers to become internationally more competitive and attract back to Africa the large pool of highly skilled African scientists residing in the diaspora.Continuation and expansion of “soft-skills” development to include topics such as career planning and development.Establish communication channels with other national stakeholders or decision makers in government departments through workshops, etc.Publication of outcomes and main research findings generated during the EFINTD programme. This could be in the form of annual publication reports, information bulletins, or establishment of a formal peer-reviewed journal under the EFINTD Initiative.Survey S1SurveyMonkey questionnaire.(DOCX)Click here for additional data file.Table S1Description of 2008 and 2010 EFINTD fellows that participated in the survey.(DOCX)Click here for additional data file.Table S2Description of peer-reviewed papers related to EFINTD projects published by 2008 and 2010 fellows.(DOCX)Click here for additional data file.


Objective: Describe an unusual presentation of compartment syndrome of the hand. Methods: An unusual and severe case of compartment syndrome of the hand occurred in a 68-year-old woman following an innocuous distal radius fracture and ulnar styloid avulsion fracture. Results: The patient required surgical decompression and amputation of the index, middle, ring, and little fingers. Conclusions: This article highlights the importance of clinical suspicion toward postinjury compartment syndrome even if a fracture is not adjacent to the compartment itself and no clear vascular disruption is present. Compartment syndrome is a well-described limb-threatening complication of the leg and forearm, but not as common in the hand. Limb vascularity is affected as the compartment pressure increases beyond the level required to achieve adequate perfusion. It results in ischemia and tissue necrosis, leading to neurologic deficit, muscle necrosis, ischemic contractures, infection, delayed healing of fractures, and possible amputation.A thorough history and clinical examination are at the basis for this grave diagnosis, but sometimes one is mislead by the apparently harmless type, severity, and site of injury.This article presents a case of compartment syndrome of the hand as a complication of an innocuous distal radius fracture and ulnar styloid avulsion fracture.A 68-year-old woman presented to the Emergency Department following a fall on the outstretched right arm. She had a background of known hypertension and hypercholesterolemia and her medications included alendronate, simvastatin, lisinopril, and aspirin. The patient was diagnosed radiologically with an extra-articular (Frykman II) displaced distal radius fracture and ulnar styloid avulsion fracture see .No neurovascular compromise was present at the time. The patient was placed in a dorsal slab without prior manipulation, elevated in a sling, given appropriate analgesia, and advised to return for follow-up to the fracture clinic.The following day she was seen again in the Emergency Department with increased pain in the right hand. No signs of compartment syndrome were thought to be present at the time and she was sent home with further analgesia and reassurance.The pain in her right hand worsened overnight and she presented again to the Emergency Department with paresthesia and decreased digital movement the following day.On physical examination, the dorsal slab was found to be tight distally and therefore was removed. The forearm muscles were soft and nontender. Marked swelling of the entire right hand and a blue blister in the little finger were observed see . Thenar The patient was diagnosed with compartment syndrome of the right hand secondary to distal radius and ulnar styloid fractures.– carpal tunnel incision with extension into forearm– dorsal incisions over second and fourth metacarpals with decompression deep to fascia– midlateral incisions—radial bands right index finger and ulnar bands right thumb, index, middle, and ring fingers.The patient's blister was de-roofed and a decompressive fasciotomy of the right hand see  was perfTetanus and 3-day antibiotic prophylaxes were given, and the hand was elevated in a Bradford sling. Two days postoperatively, a CT angiogram was performed showing normal calibre and opacification of the right upper limb arterial supply from axillary artery to the terminal digital arteries.Day 3 postoperatively, the patient was brought back to theatre for a second look at the fasciotomy wounds. Little and ring finger pulps had fixed staining and no capillary refill on pinprick. Also a small necrotic area in the little finger was noted. Middle and index fingers were fixed stained with poor capillary refill on pinprick. Carpal tunnel, forearm, and thenar eminence incisions were closed. The dorsum of hand was covered with 2 split skin grafts, and the finger incisions were left open.Three days later, signs of necrosis on tips of the thumb, index, middle, ring, and little fingers were observed.Four days later, it was decided to amputate middle, ring, and little digits through middle phalanx and index through the proximal interphalangeal joint because of established necrosis dorsally at distal interphalangeal joint level and volarly at proximal interphalangeal joint level.The patient will be followed up by orthopedic as well as plastic surgery teams and will be provided hand therapy to maximize hand function.,3Distal radial fractures are common. They account for approximately 15% of all adult fractures.2The incidence of hand compartment syndrome is an even rarer complication with fewer cases described in the literature. When it does occur it is generally associated with a range of more common injuries, including fractures, burns, crush injuries, arterial injuries, limb decompression injuries, and iatrogenic origin.4One study found that 13 of 17 cases of hand compartment syndrome reviewed were believed to be as a result of the administration  of intravenous or intra-arterial medications or narcotics.5Where fractures were thought to be the causative factor in the diagnosis of compartment syndrome of the hand, these were generally present in the small bones of the hand and associated with crush injuries.5In the few cases of associated ulnar or radial fractures, the type of injury was much more severe, including compression or traumatic crush injuries of the forearm.A case reported in the literature that did show noncrush fractures leading to the syndrome was due to bony displacement causing arterial rupture, with the latter appearing to be the primary causative pathology.Another aspect to be considered is the severity of the fracture itself. A study looking at compartment syndromes in children found that in the majority of cases, the fracture was so severe that the use of an external fixator was required.When the same study investigated the mechanism of trauma leading to compartment syndrome, it showed the majority of patients had been injured as pedestrians colliding with a vehicle. The fall onto the outstretched arm present in our case involved a significantly lower energy than this.7Importance should be given to the etiology, mechanism, severity, and concomitant injuries since these can all provide a clue on the diagnosis of compartment syndrome of the hand.All cases reported in the literature highlight the importance of early diagnosis of such a complication. But none provide evidence of the possibility of such a devastating complication following a nonadjacent, displaced, low energy fracture with absent concomitant injuries, requiring only simple splinting and analgesia. This is of importance because this type of fractures is common and is seen on a daily basis in the emergency department by nonhand specialists.Compartment syndrome should be prevented by avoiding an overly tight cast and by always maintaining a high index of suspicion, especially if the pain is not proportional to the type of injury or the patient seeks medical attention due to worsening pain or change in sensation or color. In the latter cases, the cast should be removed and the hand be examined. If compartment syndrome is diagnosed, early intervention is key for the survival of the digits.A further interesting point is the fact that despite decompressive treatment and radiological confirmation of vascular patency of the hand, the patient still ended up requiring amputation of the index, middle, ring, and little fingers secondary to necrosis. The need for amputation has been reported in other cases but in clear minority and mainly following intravenous infiltration of drugsThis article highlights the importance of clinical suspicion toward compartment syndrome postinjury even if a fracture is not adjacent to the compartment itself and no clear vascular disruption is present. As shown the sequelae of compartment syndrome can be disastrous to the patient, and given the high incidence of distal radius fractures, we believe this article is even more relevant, describing an initial injury that virtually all junior doctors will encounter during their early training.


Erik von Elm and colleagues discuss plans to increase access and global reach of Cochrane Reviews through translations into other languages.Please see later in the article for the Editors' Summary Cochrane Reviews, systematic reviews prepared by The Cochrane Collaboration, aim to inform healthcare decision-making anywhere in the world by providing high-quality timely critical summaries of research evidence.th anniversary year, The Cochrane Collaboration is responding to the challenge to increase access and global reach through translations into other languages.All Cochrane Reviews are prepared and published in English, but during its 20Current projects to translate Cochrane content into Spanish and French are promising as usage statistics increase with greater provision of translated content. Enhanced ways to search and access Cochrane Reviews in different languages will improve the user experience and availability of content.New technologies, such as machine translation using learning systems, translation crowd-sourcing, and the use of a controlled language for the original English version have the potential to considerably improve possibilities to translate Cochrane content at large scale and in several languages.Cochrane Database of Systematic Reviews (CDSR). As one of the seven databases in The Cochrane Library (www.thecochranelibrary.com), it includes all completed Cochrane Reviews and Protocols outlining the methods of reviews in progress. Both Protocols and full versions of the Reviews follow rigorous methodology and are peer-reviewed. They differ from other (narrative) types of literature reviews that are common in the medical literature , Spanish (6%), and English (5%) La Biblioteca Cochrane Plus (www.bibliotecacochrane.com), the Spanish version of The Cochrane Library, has pioneered translation and has become the most comprehensive project to translate Cochrane content (www.summaries.cochrane.org) have shown this effect as well. The number of visitors to the French-language version of Cochrane Summaries per month has almost quintupled, from about 10,000 in September 2012 to 50,000 in May 2013. Over the same period, France moved from ranking eighth to second among the countries with the highest rates of access of Cochrane Summaries.It seems clear that translation is a crucial strategy to meeting that challenge and, in fact, The Cochrane Collaboration's principles include the explicit commitment to enable wide participation by reducing barriers to contributing, encouraging diversity, and promoting access to its outputs through wide dissemination to meet the needs of users worldwide  content . Since 2www.bibliotecacochrane.com) is the Spanish version of The Cochrane Library. Designed and promoted by the Iberoamerican Cochrane Centre in 1998, it has become a reference electronic resource for the dissemination of Cochrane Reviews in Spanish-speaking countries. Free access has been funded by the Spanish Ministry of Health with contributions from the Pan American Health Organisation (via BIREME provision) for Latin American users. Until 2010 it included the full text of each Cochrane Review translated and updated when necessary. In the last 3 years and to keep the project sustainable, only the abstract, plain language summary, and most relevant parts of each Review are translated with a link to the full English version provided. In August 2013, full or partial content of 5467 Cochrane Reviews was available in Spanish. The average number of inquiries from users was around 3.5 to 4 million per year over the past 5 years and in 2012, more than 4.5 million people consulted the Biblioteca Cochrane Plus. This electronic resource also includes other evidence-based materials originally published in Spanish. Moreover, the Iberoamerican Cochrane Centre has also translated other evidence-based content including podcasts, training materials and guidance documents, such as the Cochrane Handbook for Systematic Reviews of Interventions, and the Methodological Expectations of Cochrane Intervention Reviews (MECIR).La Biblioteca Cochrane Plus .Several other initiatives on a smaller scale than the Spanish and French translations have focused on the translation of selected abstracts and plain language summaries, often with non-professionals in mind as the primary audience. Such translations have been prepared or are planned in such diverse languages as Simplified and Traditional Chinese, Portuguese, Croatian, German, Japanese, Russian, Korean, and Indonesian . At various times, these summaries have been translated into Portuguese, Spanish, French, Thai, Russian, and Chinese. However, translation is usually not straightforward: in one institution in Thailand, a country with a strong tradition of bilingual medical training, users preferred the original English language product. In other countries, the accuracy of the translation was problematic, not because of poor translation, but because the words mean different things. For instance, work in China on translation in qualitative research showed that there are often phrases and words without any English equivalent or with more than one meaning Since 1994, the Effective Health Care Research Consortium (EHCRC) has been active in many countries in preparing Cochrane Reviews and disseminating their findings, often through their own bespoke summaries called Evidence Update (www.cdbph.org) and demands for other evidence products, such as Policy Briefs and Rapid Responses.Cameroon is – apart from Canada – the only other bilingual country with both French and English as official languages. However, French is the predominant language. The Centre for Development of Best Practices in Health (CDBPH) in collaboration with the Effective Health Care Research Consortium (EHCRC) is working on a 5-year project to enhance the uptake and use of up-to-date health research evidence primarily from the CDSR. Efforts to reach non-English-speaking health stakeholders in Cameroon were hampered by language barriers, notably in building capacity for conducting Cochrane Reviews, reading and applying the evidence, or communicating it to policy makers. Consequently, significant resources were diverted to providing translations of Cochrane Review abstracts and plain language summaries. A list of priority reviews on topics relevant to Cameroonian stakeholders and EHCRC targets was established. The quality of these translations was verified by the French Cochrane Centre and Cameroonian teams. The CDBPH also started producing bilingual evidence assessments – summaries of Cochrane Reviews adapted to the local context. These translations have led to a higher uptake of Cochrane products, with more downloads from the CDBPH website  is to serve a multilingual health care community. The Cochrane Branch collaborates with one medical education journal in each language region . New or updated Cochrane Reviews of interest to general or internal medicine practitioners are continuously selected and summarised. To put them in context, clinicians are invited to write short clinical scenarios and questions, which are then answered using the evidence from the Cochrane Review. In this way, limited resources of the Cochrane Branch can be used effectively in order to reach multiple audiences.Different methods have been used for translation projects , with noCDSR is compiled of text written by several thousand different authors, many of whom are non-native English speakers.Sustaining any translation effort depends on the extent to which certain technologies (such as machine translation) can support humans in the accurate translation of content from English into other languages. Relying exclusively on human translation is probably too variable and expensive. However, whether a translation technology performs well depends directly on the complexity of the language and the specificity of the terminology used. The language used in Cochrane Reviews is both specialised from a technical point of view  and diverse . Therefore, a first line of strategic development around translations is to develop a controlled language and then to use it as much as possible in order to standardise the text sources that are to be translated. The quality of machine translation improves significantly if the primary text uses terminology in an unambiguous and consistent way. A controlled language is defined as using a restricted vocabulary, streamlined grammar, and a defined set of stylistic rules Conceptually, the approach of moving to a controlled language is close to one already developed by the Cochrane Effective Practice and Organisation of Care (EPOC) Group, one of the 53 Cochrane Review Groups, which helps Review authors formulate clear and consistent statements about the effect of interventions The Spanish and French translation projects have to date been working with computer-aided translation (CAT) software such as Dejà Vu. This software has the capacity to learn and recognise language patterns, which helps the translators to be consistent and reduces the amount and cost of text to be translated . HoweverUsing Simplified English is increasingly recognised as an important strategy to facilitate translation in various fields. For instance, in aircraft manufacturing and maintenance, it was employed to render the technical documentation easier to use and thus safer, as well as more efficient. The French Cochrane Centre has formed a multidisciplinary research group (QUARTET M) with the Laboratoire d'Informatique pour la Mécanique et les Sciences de l'Ingénieur , one of the country's largest research groups working on language technologies, machine translation, and statistical language modelling, and with the Centre de Linguistique Inter-Langues, de Lexicologie, de Linguistique Anglaise et de Corpus  specialized in phraseological and terminological analysis, technical writing, and the development of writing aid tools for Scientific English. The main focus of the project is to train a machine translation system using large multilingual text sources and Cochrane Review abstracts already translated into several languages. First results from tests using a sample of 600 abstracts translated into French to train the memory of the software have been promising. Rather than focusing on the technical problems of automatic translation only, QUARTET M has included a novel approach to investigate whether the adoption of Simplified English and writing aid tools has the potential to increase translation productivity, inclusiveness, accessibility, readability, and user experience. Most importantly, it is assumed that it would increase the feasibility of machine translation with human validation considerably. Besides, the usage of Simplified English could improve identification of Cochrane content in Google searches and enhance the development of derivative products by facilitating automatic extraction of data.www.equator-network.org/). The amount and quality of the material available in different languages varies greatly and therefore limits its usability to improve machine translation. Research may help to identify what minimum size of corpora is required to achieve the desired level of quality.The performance of any software used for translation increases with the amount of suitable training text that is fed into it. A body of literature, glossaries of technical terms, or systematic domain terminologies already translated in several languages can be used to improve its performance in a certain area of content and to reduce the workload related to post-editing. For instance, international organisations, such as the World Health Organization or the European Medicines Agency, have large multilingual resources relevant to health care. Also, the CONSORT Statement and other reporting guidelines contain relevant methodological terminology and are available in several languages (www.epistemonikos.org), is based on crowd-sourcing. The project uses freely available software to translate medical texts, including Cochrane Review abstracts, into Spanish (among eight other languages). The translated texts are further reviewed by volunteering clinicians or senior students without formal training in translation, who receive continuous feedback from more experienced contributors . In terms of search, there is a need to distinguish between two different approaches for returning search results by language: the more simple is a search and browse function for various languages that only returns results for one language at a time; and the more complex  is a multilingual search engine, which returns results in multiple languages at the same time. Another important aspect to take into account is mobile access via applications (apps). The free iPad application for The Cochrane Library include providing free one-click access to all people in low- and middle-income countries included in the World Health Organization's Health InterNetwork Access to Research Initiative (HINARI) (www.thecochranelibrary.com/view/0/FreeAccess.html). Historically, public funds have sustained translation initiatives and, accordingly, access to the translated content exceeding the abstract and plain language summaries has been free to view in the respective countries. One example is La Biblioteca Cochrane Plus, which is free to view in Spain as well as in eligible HINARI countries in Latin America. All translated plain language summaries and abstracts in the CDSR are free to view anywhere. Over the coming months and years, The Cochrane Collaboration will be working with funders and its publisher to explore how to move to a publishing model that is based upon open access but also ensures its economic sustainability. Including translations in these discussions as well as establishing sound permanent alliances in different geographical regions will be crucial to developing sustainable translation projects.In 2013, The Cochrane Collaboration took the first step towards its vision of making all Cochrane Reviews open access: all Cochrane Reviews published from 1 February 2013 will be free to view 12 months after publication (green open access) or immediately if authors choose to pay a publication fee (gold open access). Other routes to promote access to th anniversary a high priority on its global reach and relevance by engaging in the production of content in as many languages as possible. The success of previous experience demonstrates that when texts in local languages are provided, usage increases substantially. At the same time, the potential to produce cost-effective translations of good quality using new technologies, crowd-sourcing, or a combination has never been greater. If this approach is accompanied by efforts aimed at simplifying and making the use of English in reviews more consistent, there is a real prospect that Cochrane Reviews can become a genuinely international resource. As a global network, The Cochrane Collaboration has a considerable technical capability and benefits from two decades of work experience in diverse settings and languages. The organization will need, however, to continue to build partnerships around complementary expertise and with funders to ensure that people can access the information they need for healthcare decisions in languages of their choosing.As the world's largest producer of systematic reviews, The Cochrane Collaboration sets at its 20Table S1Comparison of expert reviews, systematic reviews, and Cochrane Reviews.(DOCX)Click here for additional data file.


The estimated prevalence of irritable bowel syndrome (IBS) is 10%. Up to one third of patients develop chronic symptoms, which impact on everyday functioning and psychological wellbeing. Guidelines suggest an increased role for primary care in the management of patients with IBS, and referral for psychological interventions. Literature reports dissatisfaction and frustration experienced by both patients with IBS and healthcare professionals. The aim of this study was to explore the perspectives of general practitioners (GPs) in relation to the diagnosis and management of IBS and their views on the potential use of a risk assessment tool to aid management decisions for patients with IBS in primary care.This was a qualitative study using face-to-face semi-structured interviews with GPs in North West England. Interviews were fully transcribed and data analyzed using constant comparison across interviews. Tensions between GP accounts and the NICE guideline for the management of IBS were highlighted.GPs described IBS as a diagnosis of exclusion and the process as tentative and iterative, with delay in adding a Read code to the patient record until they were confident of the diagnosis. Whilst GPs accepted there was a link between IBS and psychological symptoms they suggested that the majority of patients could be managed within primary care without referral for psychological interventions, in conflict with the NICE guideline. They did not feel that a risk assessment tool for patients with IBS would be helpful.This study highlights the tensions between evidence recognizing the need to identify patients whose symptoms may become chronic and offer pro-active care, including referral for psychological therapies, and the perspectives of GPs managing patients in every-day clinical practice. The reluctance of GPs to refer patients for evidence-based psychological treatments may have implications for commissioning services and patient care. Irritable bowel syndrome (IBS) is the commonest of the functional gastrointestinal disorders , with anThe majority of patients with IBS are managed within primary care  and of tPatients with IBS disproportionately use primary and secondary care services, with sufferers consulting GPs more frequently than matched controls ,13. TherBijkerk et al. (2003) report that patients and GPs share similar views on aetiology and symptomology, but differ in treatment approaches found acceptable . Dixon-WThis qualitative study was nested in an NIHR  programme of work (RP-PG-0407-10136) in which one aim was to validate prospectively a risk assessment tool which was developed following an investigation of the predictors of persistent gastrointestinal symptoms amongst new presenters to primary care . The aimThe aim of the study presented here was to explore qualitatively how GPs currently diagnose and manage IBS, whether management described is consistent with the NICE guideline , and GP Face-to-face, in-depth, semi-structured interviews were conducted with GPs in Greater Manchester, England who were participating in a larger programme of work which aimed to validate prospectively a risk assessment tool for predicting chronicity in patients with IBS. Initially we approached all practices that had a Service Level Agreement with the Greater Manchester Comprehensive Local Research Network (CLRN). We then took a staged approach to roll the study out to general practices within Primary Care Organisations in Greater Manchester. The total number of practices recruited to the study was 58. At the time of recruitment practices were informed about both the Risk Assessment Study and the qualitative interview study. GPs were invited to contact us if they were interested in taking part in the qualitative study. The role of the practices was to recruit patients to the study, rather than use the predictive tool. Data were collected between March and December 2011.Purposive sampling was used to maximise the variation of the sample of GPs. GPs who were invited to participate in the main study were also invited to participate in this nested qualitative study and two GPs agreed. The remaining 17 GPs were recruited from the 58 practices who had agreed to recruit patients for the main study. We sampled practices according to location, and asked if one of the GPs would participate in the interview study. As recruitment continued, we tried to ensure a spread of participants across gender, ethnicities, age ranges and years of experience in practice. Recruitment was then continued until theme saturation was achieved.Interviews were conducted, with written consent, at GPs’ premises, by two of the authors (EFH and VH). Interviews lasted between 20 and 70 minutes (mean 42 minutes). The topic guide was developed from review of the existing literature and discussion within the research team. The topic guide, designed to be used flexibly, was modified in the light of emerging themes. The main areas explored were GPs’ views on the aetiology of IBS, how they make the diagnosis of IBS and explain this to patients, treatments offered to patients, and the potential usefulness of a tool to aid their management decisions. The risk assessment tool was described to GPs as a management device to help stratify patients into those who might become high consulters in the long term, and thus may aid future decisions about management of these patients.Interviews were fully transcribed. Data coding was by constant comparison across interviews , by indiNineteen interviews with GPs were conducted  reported that 19% of patients formally diagnosed with IBS had been given the diagnosis on their first visit, and 56% after a further 1–5 visits . This coGPs emphasized the importance of self-management in patients with IBS, and felt that offering advice and reassurance was important in the first instance. Dietary advice was emphasized by our respondents, but Bijkerk et al. (2003) reported that dietary advice was not appreciated by patients, who were likely to have already tried such measures before consulting .A strong physician-patient relationship and empowering explanations given by GPs are reported to be important to the successful management of IBS ,30. HoweOf those who consult their GP with a functional gastrointestinal disorder approximately 30% go on to develop chronic symptoms . RobinsoParallels can be drawn with the use of the PhQ-9 where GPs are less receptive of a tool than patients , and theAlthough the NICE guideline  clearly The study was approved by NRes Committee North West 5 – Haydock Park.REC Ref No: 09/H1010/38This study is part of a wider study to test the validity of a risk assessment questionnaire in patients with IBS.EFH participated in the study design, data collection and analysis, and contributed to writing the paper. VH participated in data collection and analysis, and contributed to writing the paper. SH contributed to data analysis and writing the paper. SJO’B contributed to data analysis and writing the paper. DGT contributed to data analysis and writing the paper. PB contributed to study design, participant recruitment and writing the paper. CCG designed the study, supervised data collection and analysis, and led writing the paper. All authors read and approved the final manuscript.CCG, DGT, EFH, SH and VH were supported by the University of Manchester, Faculty of Medical & Health Sciences and the Manchester Academic Health Science Centre (MAHSC) at the time of the study.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/14/92/prepub