Sardina pilchardus, populations with the aim to examine whether this is affected by bathymetric positioning and the physiological state of the individuals. To do so, swimbladder size and shape were modeled in relation to catch depth and the size of various visceral compartments such as gonad, liver, fat and stomach. Swimbladder size was shown to be related to depth in a way that individuals with smaller swimbladders occurred at larger depths. Moreover, evidence is provided that the swimbladder in sardine might have a functional relationship both with the reproductive and the feeding state of individuals, since none of the fish with hydrated gonads and/or large stomachs displayed distended swimbladders.The present study assesses swimbladder dynamics in natural occurring sardine,  In most marine teleosts the swimbladder acts primarily as a hydrostatic organ, while in a few species it may also function as an organ for sound production  are physostomes and as such their swimbladder is not closed but connected both to the alimentary canal via a valved pneumatic duct and to the anus  onboard the RV “Noruega” . All samL (mm), and total weight, W (0.1 g), whilst maturity, fat index and stomach fullness were scored macroscopically as follows: hP was the prevalence of females with hydrated ovaries, i.e., females that were ready to spawn; fP was the prevalence of fish with well formed layers of fat surrounding the gut . Specifically, the ventral cross-sectional area of the swimbladder (xsaSB) was measured by spatially calibrating the image using the ruler and by drawing the perimeter of the swimbladder, pSB. Swimbladder shape was also studied by measuring circularity cSB: a value of 1.0 indicates a perfect circle whilst lower values indicate an increasingly elongated shape. In that respect cSB together with xsaSB served as indices of inflation  or deflation  of the swimbladder.The dimensional characteristics of the swimbladder were studied in more detail by processing the digital images using ImageJ . First, R served to validate the four-scale macroscopic assignments of swimbladder size. Variability in fP, sP, and hP, with macroscopic swimbladder size was tested using analysis of means (ANOM) while variability in HSI with macroscopic swimbladder size was tested using ANOVA. Variability in hP, was analysed using only the females while all other variables were analysed using both sexes. The relationship of swimbladder size (R) and shape (cSB) with haul depth was tested by means of generalized linear models, GLMs, using in both cases, sex as a covariate. Quantile and residual inspection plots revealed that a Gaussian model with an identity link was the most appropriate for the analysis of R data whilst cSB data were analyzed using Gaussian models with a logarithmic link.The allometric relationship between R, and circularity, cSB, increased significantly in all four size levels of the macroscopic scale .Swimbladder size was shown to be related with both the reproductive and the feeding state of the individuals. Specifically, hydrated females mainly possessed swimbladders of small or medium size while none of the females with distended swimbladder was hydrated . SimilarcSB and haul depth  the effect of hauling process including the rapid ascent of fish and (b) the effect of dissection on swimbladder size and shape. in situ values of swimbladder volume. In that respect, neither the sheer physical process of trawling and hauling nor the period that fish spend in the codend, are expected to cause major alterations in swimbladder volume. In addition, fishing duration was always quite small (∼20 mins) and the ascent duration lasts no longer than 10–15 min for the depths considered in this study, so the time between catching and bringing fish to the surface would not allow sardine swimbladder to physically respond to the pressure and temperature range of the haul. Moreover, in herring , the rate of gas loss by diffusion is low  and not with liver and fat which fluctuate at a rather seasonal scale . Indeed,On the other hand, the relationship between swimbladder size and reproductive state might be of more adoptive nature. Gonad size in sardine is known to undergo significant changes during the spawning cycle while a striking increase takes place at oocyte hydration, just previous to spawning . Even frAs for sex related differences, the results showed that the cross-sectional area and circularity of the swimbladder were not significantly different between males and females, and sex was not a significant explanatory variable in the model. For the Mediterranean sardine, the influence of sex on the swimbladder volume appeared as significant only for fish sampled at the beginning of the spawning season (October), because of the different degree of gonadal growth between males and females (ovaries more voluminous than testes), but not at other periods of the year . This stEngraulis japonicus (Sardinella longiceps on the south-west coast of India that the presence of bottom shoals can often be judged by the emergence of tiny bubbles from the sea-bottom that break-up at the water surface. The author suggests that these bubbles are released from the swimbladder which practically facilitates the fish to sink-down to the sea bed.Depth related changes in swimbladder size have already been described for herring  and are aponicus . Balan (E. japonicus; the authors further suggested that TS values would be elevated by 2 dB when fish migrate from 50 m deep during daylight to 20 m deep at night resulting in a 58% difference between daytime and nighttime biomass estimates. In that respect, our method may provide an easy means for measuring swimbladder size in parallel with body size measurements in acoustic surveys in order to make the appropriate calibrations in the analysis of backscaterring energy.The Atlantic sardine is a pelagic fish that performs extended diurnal vertical migrations . As acou


Introduction: Many studies have investigated the relationship between motivation and educational outcomes. The present study was conducted to determine whether the students’ motivation in Shiraz University of Medical Sciences (SUMS) decreases during educational years.Methods: 770 students in SUMS were selected by multi-stage stratified random sampling from each field and entrance year. The first questionnaire contained 57 questions on the effect of economic, social, educational, geographical and personality factors on the students’ motivation. The second one was based on 50 incomplete sentences. The validity and reliability of these questionnaires were approved by the experts and Cronbach's Alpha coefficients . In this cross-sectional study, ANOVA, t-test and Chi-square tests were applied for data analysis at the 0.05 significance level.Results: Six factors with the most effect on academic motivation were "family attitudes", "getting good jobs in future", "respect for themselves", " the ability to learn", "believing their role in victory and defeat" and "the tendency toward optimism about themselves". In addition, comparing professional doctorate and basic sciences’ results revealed no significant relationship between academic motivation and educational years . But comparing field by field showed that Dentistry and Hospital Management and Medical Information (HMMI) had a significant decrease in motivation score by increase in educational years .Conclusion: Achievement motivation level in SUMS students was higher than average and did not decrease during educational years. Also, the results showed that personal, social and educational related factors affected motivation level more than economic and environmental factors. Motivation is a complex part of human psychology and behavior that influences how individuals choose to invest their time, how much energy they exert in any given task, how long they persist in the task, etc -4.Some psychologists and theories such as Freud, Mcclelland and Mory viewed motivation as primary result of drives and needs and perceived it as intra-individual factors. They developed several biological and psychological needs for human. For example promotion is a social need and it means, overcoming barriers, achieving a high standard and competing with others . Human bAs mentioned, there are some intrinsic and extrinsic factors that can induce motivation. Although with each theory we try to define motivation and philosophy of motivation, the level of motivation is important for goal attainment. Pent Reach and Shraben believe that the level of motivation affects the achievement of goals and amount of affordance , 10.Different studies have shown that there are many stimulators to move the students forward, i.e. conducting behavior toward specific goals, increasing affordance, increasing activity level, hard working, functional improvement, positive emotion (hope and pride), self satisfaction, enjoyment from learning activity, family condition, gender of the students, number of family members, parents’ job, and economical status -17.Today, lack of interest in learning and motivation in students is important in difficulties for educational system that offer a low level of quality for learning. The amount of the students' motivation even interferes with social development . MckeachThe culture of students can affect achievement motivation, so research has found that European students like to be in the school because of art and sports activity; on the other hand, western students like to be in school because of its opportunity for social positions and improvements. Areepattamannil found that intrinsic and extrinsic motivation both could affect mathematic achievement among Indian immigrant adolescents in Canada, but there was no significant relationship between motivation and achievement among Indian adolescents in India, so this implies that context can increase or decrease the motivation . Also, mMotivation is recognized as an important factor in health science education because it helps the students achieve good academic performance, well-being and satisfaction, and also helps them to become good professionals. However, research that centers on motivation in the health science disciplines is scarce. In the health professions, the long-term goal of professional career practice is an important component of motivation, which is related more closely with future competencies to be used in regulated professional practice than with knowledge and skills to be acquired in the learning process during university study . WilliamThe study by Campos-Sanchez investigated the influence of different components of motivation  on learning human histology in health science curricula and their relationship with the final performance of the students in histology. Results showed that the overall motivational profile for learning histology differs among medical, dentistry and pharmacy students. This finding is potentially useful to foster their learning process, because if students are metacognitively aware of their motivation they will be better equipped to self-regulate their science-learning behavior in histology. This information could be useful for instructors and education policy makers to enhance curricula not only on the cognitive component of learning but also to integrate students' levels and types of motivation into the processes of planning, delivery and evaluation of medical education . Along wSince there are some concerns about motivational level in SUMS students, most faculty members in the talented students center believe that motivation decreases during education from the first entry level to the last year of education. Also, as evidence shows, there are many implicit and explicit factors that can affect the students' motivation. Therefore, the center for talented students aimed to design the present study to measure the achievement motivation level in all schools of the university and survey the factors that can affect it. This study is a cross-sectional research conducted on undergraduate students (B.S. and M.D.) of ten schools in SUMS  in order to investigate their motivational level to study in their scientific field. The students were from different schools with various fields of study. They had entered university trough a national entrance exam held all over the country (Iran). Therefore, their selection was based on their scores in the entrance exam. Thirty percent of the students in SUMS were selected randomly by multi-stage stratified random sampling method. The research team selected the students randomly by systematic method from each science field and each entrance year in schools. Accordingly, 770 students entered the study. Based on the research objectives, two questionnaires were used in this survey. The first questionnaire was constructed by Hashemi in 1999 in Lamerd Azad University. Its validity and reliability have been confirmed in Iranian student population (%95 Cronbach's Alpha) . HoweverThe sample students were asked to fill out these questionnaires accompanied by some biographic information. Their answers were then analyzed in SPSS for windows, version 16.0  and Excel software. Some descriptive statistics are derived from the answers. And the results were compared in two genders, ten fields of study and among educational year using statistical tests such as Independent two samples t-test, ANOVA and Chi-square test . For the first questionnaire, the answers include five ordinal options which measure the effect of these factors on academic motivation. To detect the importance of each factor on the SUMS' student motivation, the percentage of the students who selected the option "High" or "Very high" in each question was considered as the importance index of that factor. The second questionnaire which is based on 50 incomplete sentences is a standard questionnaire used over the world to measure the academic motivation among the students. Its result was a score for each student which was calculated by comparing the answers to the standard question key. The total score of all questions was the final score for each person. It ranged from 0 to 44 for the students in our study. As a result, the total mean score was low compared to its maximum value (44 in our sample and 50 in standard one). In addition, no factor such as gender , marital status , field of study , educational year , and their high school final score  had a significant effect on motivation score in SUMS students. The only significant factor was the special seat that the government has considered for university entrance of the students from the family of war martyrs and those from deprived areas of the country . Therefore, students who have no special seat have more motivation score than those from war martyrs’ family significantly. Furthermore, the comparison of two general fields of study  showed that there was no significant difference between the mean score of the first and last year students . However, comparison with more details in eight fields showed different results. Dentistry and HMMI students revealed a significant decrease in motivation score during their education period according to the results of this study . The present study was conducted to determine the achievement motivation level of SUMS's students during their studies in the university. Accordingly, a random sample of 770 students from 8 different fields of study participated in this research. Two standard validated questionnaires  were used for this purpose. The results showed that achievement motivation scores from “Acheivement Motivation Scale” that are related to personal factors and self efficacy were higher than the average (>19) in these students and it is a valuable finding for university policy makers to use.Also, the six factors in questionnaire 1 as selected by 80% of the students were determined as the most effective factors on the level of the students' motivation. These 6 factors were related to personal and social groups. It is concluded that three important factors must be considered by university: 1) social, 2) personal, and 3) educational as other factors such as environmental, geographical and economic issues were of lower importance. As Boundra  and basic sciences, and first and last years of education. So this demographical condition could not affect achievement motivation. As mentioned, there was no significant difference between male and female participants in achievement motivation. Gang confirmed it in previous research. On the contrary, Darabi found that motivation is different between male and female students , 13. In Furthermore, some evidence on the comparison of motivation between the first and last educational years students (junior and senior) showed that academic motivation improved only for 34% of them during the first 4 years of education and the others remained fixed . Also, iThe findings of this study support those of the previous studies. For instance, intrinsic factors can improve the students’ attitudes more than extrinsic ones. So, authorities have to consider our findings in devising university entrance exam. However, if we fit the students with the field of the study and study major, we will gain more optimal educational results. Furthermore, since motivation scores were derived from the questionnaires in this study, the time in which the students were asked to answer the questions is very important. Feeling comfortable in non-stressful environments affects the answers and this can be mentioned as the limitation in this research.


As of November 2014, a PubMed search for “fetal alcohol” retrieved more than 14,500 articles. Alcohol consumption during pregnancy and its detrimental consequences on the developing brain raise major public health, social, and economic issues. However, the research on fetal alcohol spectrum disorders (FASD) in the real world is challenging, given that it is largely based on retrospective analysis. Therefore, establishing the relationship between brain damage and drinking habits proves particularly hard. One of the advantages of FASD studies carried out in the laboratory environment derives from the tight control of time, dose, and modality of alcohol exposure  give a substantial contribution to the genesis of the intellectual disability observed in FASD . We guesFinally, John Olney, in his opinion article , raises In conclusion, we wish to thank all the neuroscientists who gave their valuable contribution to this Research Topic. We are confident that their commitment to the experimental work on FASD will ultimately result in a great improvement of our ability to understand the intellectual disability.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Irrational use of medicines has been an issue concerned all over the world and the outlooks in developing countries are more severe. This study aimed to assess the different patterns of irrational use of medicines and its influential factors in China and Vietnam.A systematic review was performed on both published and grey literatures in English, Chinese and Vietnamese languages between 1993 and 2013 based on the WHO framework. Quality assessment was conducted on the basis of the Critical Appraisal Skills Programme. Key indicators were analyzed to compare the irrational use of medicines in two countries.A total of 67 published works about China and 29 about Vietnam were included, the majority of which were cross-sectional prescription studies in both China and Vietnam. Irrational use of medicines was found in both the countries but issues with polypharmacy as well as overuse of antibiotics were more severe in Vietnam while overuse of injections was unique to China. Various patterns of irrational use were also indicated between urban and rural areas, and among different levels of hospitals. Rarely does literature focus on the analysis of influential factors of irrational use of medicines. While lack of proper knowledge from both providers and patients were the most recognized influential factors in both countries, economic incentives from pharmaceutical companies in China, and weak control and regulation over prescriptions in Vietnam were the main factors attributed to this issue.Severe irrational use of medicines has been abundantly evidenced in both China and Vietnam, highlighting the importance of policy interventions on the issue. However, limited evidence on the appropriateness or its compliance (conformity) to guidelines of prescription has been found. In addition, convincing evidence on the underlying explanation of this issue is lacking, although economic incentives, health insurance coverage, and knowledge of service providers and users have been implied to be factors influencing irrational drug use. It is estimated that 60% of medicines in public health facilities and 70% of medicines in private facilities were prescribed and sold inappropriately in developing countries, which leads to the decrease in safety and quality of health care as well as enormous wastage of health resources .StatistiThe most common problems associated with irrational use of medicines include selection of medicines without consideration for cost-effectiveness and efficacy, inefficient procurement of unnecessarily expensive drugs, failure to prescribe medicines in accordance with standard treatment protocols, poor dispensing practices resulting in medication errors, improper patients adherence to dosing schedules and treatment regimens, and inappropriate self-medication –9. In deDespite expanding medicine expenditure in both China and Vietnam, irrational use of medicines has been a severe problem in both of the countries. It is estimated that about half of antibiotic prescriptions in China were medically unnecessary –17. In VSpecifically, the health care system in general and pharmaceuticals in particular in China and Vietnam are similar in the way that both nations adopted market mechanisms in their healthcare and pharmaceutical sectors .The commIn the meantime, China and Vietnam have their distinct characteristics in health systems and different implementation plans of healthcare reform. Since the 1950s, the public sector has been the dominant power of health care services in China. Government financial support had been the main source of compensation for public hospitals since hospital services were provided at their prime cost. Although government health expenditure grew 30 times its initial amount from 1980 to 2005, its proportion out of the total health expenditure declined from 36.2% to 17.9% . ProfitsAs Vietnam reformed its health system in the late 1980s by introducing market-oriented mechanisms, public hospitals were allowed to operate private pharmacies. Private pharmacies have become the dominant medicine supplier in the market, representing 60% of the market share on pharmaceutical sales ,32–34. HBoth Chinese and Vietnamese governments have taken actions to address the problems in the past decades. China launched a new health system reform in 2009 with the objective of equitable access to basic health care. Recently policies developed, such as the National Essential Medicines and Zero Mark-up for Drug Sale, are intended to improve the access, affordability, as well as the rational use of medicine. However, the original goals of the policies have not been achieved yet. By the same token, Vietnam is facing similar challenges in controlling irrational use of medicines. Despite the challenges in irrational use of antibiotics and other prescribed medicines, there is a lack of effective control and regulation mechanisms for drug use and for prescribing, especially at district and commune levels . The VieThe purpose of this research is to assess the landscape of irrational use of medicines in each of the two countries. Specifically, it aims to (1) describe the situation of irrational use of medicines in each country and (2) examine and analyze influential factors.Irrational use of medicines has broad definition which may vary from place to place or from disease to disease. In order to facilitate further comparability with other studies and to make this review more structured, a conceptual framework was developed, according to the WHO’s Access to Medicine framework Fig. 1)  Fig. 1) To identify eligible studies on irrational use of medicines from 1993–2013 in Chinese, English and Vietnamese, major databases such as PubMed, EMBASE, PQDT, WOK, CBM, CNKI , Wangfang and Chongqing VIP database, were searched. A pilot search in PubMed had been conducted to ensure the comprehensiveness of key search terms. We used a mixture of free text and index terms to maximize retrieval of potentially relevant studies. Our PubMed key word search included  AND  AND  AND (China OR Chinese OR Vietnam).Since a database on Vietnamese literature was not available, a manual search was conducted  strictly based on the inclusion and exclusion criteria in Since studies of different designs were included in this review, the checklists from the Critical Appraisal Skills Programme (CASP) were adapted and developed to assess the quality of the studies. More specifically, the CASP checklists for qualitative research, case control and cohort studies were developed into a quality assessment rating system . With 10Three reviewers  rated the literature separately and the average score was calculated as the final score for the literature. Disagreement among raters was addressed through discussion until consensus on all scores was met.The conceptual framework  was alsoFindings presented in Polypharmacy is a severe issue in both China and Vietnam. Vietnam’s problem with polypharmacy is suggested to be more challenging, indicated by the number of medicines per prescription .The majoAntibiotics and injections are two important, but commonly overused and costly forms of drug therapy . AntibioOveruse of injections was only reported in China. Most studies indicated the percentage of injections prescribed per 100 encounters was between 21% and 60%. The median was 40.75%. Moreover, the median of rural areas was 43.00% while it was a bit lower in urban areas at 34.55%. The median was 34.6% for studies focused on tertiary and secondary hospitals—lower than that for primary healthcare facilities (40.88%).The median percentage of self-medication with antibiotics was 47.4% in China, indicating the high prevalence of self-medicated antibiotics. No eligible study reported this indicator in Vietnam, but patients in both the countries tend to take antibiotics incorrectly.Although only a few studies focused on assessing and analyzing influential factors of irrational use of medicines, many studies described or derived potential influential factors from their assessment on irrational use. As a results, limited evidence is available to assess the extent to which each factor or attributes to life year loss, or resources waste. However, nine influential factors summarized in the framework were mentioned in articles with different frequency, and similarities and differences of them can be found between China and Vietnam, which may be used as a suggestion for further analysis on influential factors of irrational use of medicines .In China, economic incentive from prescribing medicines has been regarded as a factor influencing irrational drug use by 30% of studies. A survey on the health providers found that over 70% of the providers regarded bonuses as an incentive given to doctors to prescribe more or expensive services . AnotherStudies in China and Vietnam shared the same view that the lack of knowledge, especially from the patients’ side, was one of the important influential factors for irrational use. In Vietnam, over four-fifths of service providers have a misperception that antibiotics were indicated for treatment of mild acute respiratory infections with fever . A studyLack of effective control and regulatory mechanisms for medicine use was mentioned by seven studies in Vietnam as an important factor of irrational use ,46. One In addition, pressure from heavy workloads and patient demands, and the insurance status of patients were factors concerned in China. Furthermore, issues related to inadequate human resources in health facilities and the lack of qualified medical staff were more prominent in Vietnam.A great challenge for the rational use of medicines in both countries is the management of excessive kinds of medicines and the abuse of antibiotics. The situation was more severe in Vietnam than in China. More specifically, people in Vietnam tended to use more kinds of medicines than the Chinese, and the percentage of overuse or misuse of antibiotics was higher. In China, however, polypharmacy and irrational use of antibiotics were found to be more severe in the rural areas than in the urban area, and in primary healthcare facilities than in tertiary or secondary hospitals. We cannot draw any conclusion for Vietnam on this issue, as the number of studies on this perspective is limited.China, compared with Vietnam, had better population coverage of health insurance and stricter regulations on price, prescription and licensing for health providers. However, the factors of the policy on mark-up rate allowing service providers to make profits, “fee-for-service” payment methods, and the non-cost based prices for health services have been repetitively suggested in many studies as the direct link of perverse economic incentives to over-prescription ,46,48. AIn the meantime, people in rural areas were less educated, generally speaking, than their counterparts in urban areas; thus, people with a relatively better knowledge base about medications were less likely to be living in rural settings. Furthermore, insurance service benefit packages in rural China were not as comprehensive as those in the urban area. The management of pharmacies and the surveillance of the quality of medicines were also weaker in rural areas. All these factors contributed to the vulnerability of rural populations to irrational use of medicines, so that polypharmacy and abuse of antibiotics were much more severe in rural areas, which was in accordance with our findings from key indicators. Another trend we found in China was that the issue of irrational use of medicines was worse in primary healthcare facilities than in tertiary or secondary hospitals. A reasonable explanation could be that primary healthcare facilities, which are relatively small in scale, rely more on the revenues from drug sale. The improved access to primary healthcare facilities, which introduced more competition among primary healthcare facilities, could also be a contributing factor. That is to say, it is much easier for patients to replace one primary healthcare facility with another health facility so that doctors in primary healthcare facilities are keener to satisfy patients by prescribing antibiotics or injections. However, further research on the comparison of irrational use of medicines between urban and rural area or primary and tertiary/ secondary hospitals is necessary since our deduction was based on limited number of research and may not be comprehensive.Vietnam, on the other hand, introduced its health system reform after its economic reform in 1986. Although the public health sector remains to play its important role for inpatient services, privatized pharmacy operated by hospital dominated the retail market of medicines. Meanwhile, Vietnam’s public health insurance scheme is yet to standardize as less than half of its people are covered. This might be one important reason why a high proportion of self-medication among residents was found in Vietnam ,34. PatiAlthough neither China nor Vietnam has been able to prevent irrational use of medicines, lessons and good practice can be learnt from each other, and for other developing countries with similar problems. As one of the most powerful tools recommended by WHO to improve the rational use of medicine , the EssPerverse economic incentives have negative effects on the rational use of medicine. For China, policies to remove mark-up, such as the Zero Mark-up Policy, and reform of income distribution systems, should be considered. The rational prescribing should be considered as one of the indicators for the assessment of physicians’ performance. Price control on retail pharmacies, regulation of marketing campaigns as well as prescription management in private pharmacies are recommended to be the priority in Vietnam , so as tHealth insurance is another key factor in improving the rational use of medicine. As a third payer, especially in China where wide population coverage has expanded its influence on hospitals, health insurance agencies should uphold accountability of quality control. Quality-oriented and prepayment mechanisms, among which rational use of medicines can be an important indicator, could build a new connection between payment and quality service outputs, which could promote the rational use of medicine as well.This review did not find enough evidence, especially quantitative evidence, to form a comparable analysis of the influential factors of irrational use. The same reason also made it impractical to assess whether unnecessary or expensive drugs were prescribed or whether the prescription was prescribed or taken in accordance with clinical guidelines. The clinical needs of patients are fundamental to the rational use of medicine; nonetheless, the cost to patients’ communities should be considered with the same level of criticality and urgency as the personal burden of disease. Thus, more research should be conducted.Another limitation might have been sample sizes, as the sample sizes of the studies reviewed herein were not balanced between the two countries, which may have introduced certain types of bias. The homogeneity of included studies was not as uniform as had been expected. In addition, convincing evidence on the explanation of this issue is absent, which adds difficulty for formulating evidence-based policy recommendation.Severe irrational use of medicines has been abundantly evidence in both China and Vietnam, thus highlighting the importance of policy interventions required to tackle this issue. Based on the evidence from available studies, polypharmacy, overuse and abuse of antibiotics should be the focus of the interventions. Some but not sufficient evidences clued that in China, irrational use of medicines was more concerning in rural area than urban area, and in primary healthcare facility than in secondary or tertiary hospital. However, further research should be taken to find more evidence for this preliminary deduction. Although strong evidence on the influential factors and their influential mechanism of irrational use is absent, lack of knowledge from patient and provider was recognized by many articles, thus highlights the importance of education on providers and patients in both countries. Economic incentives, health insurance status and the enforcement of policy should be regarded as potential influential factors and further research on their impact on irrational use should be conducted.S1 Checklist(DOC)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.


Hydrodiscectomy is a new technique used for percutaneous spinal discectomy that employs a high-intensity stream of water for herniated disc ablation and tissue aspiration. No previous clinical study has examined the effects of percutaneous hydrodiscectomy. The aim of this study is to evaluate the outcomes of hydrodiscectomy compared to open microdiscectomy regarding pain, function, satisfaction, complications and recurrence rates.In this randomized clinical trial, patients referred to our tertiary hospital for lumbar back pain were recruited and included in the study if they had disc protrusion or small herniation in only one level, without neurological deficits and with no resolution after six weeks of conservative treatment. One group underwent open microdiscectomy, and the other group underwent percutaneous microdiscectomy via hydrosurgery. Function was evaluated using the Oswestry Disability Index and pain was assessed using a visual analog scale. Evaluations were performed preoperatively, and then during the first week and at one, three, six and twelve months postoperatively. Personal satisfaction was verified. Clinicaltrials.gov: NCT01367860.p=0.138). The rates of infection, pain, recurrence and satisfaction were similar between the two groups.During the study period, 20 patients were included in each arm and 39 completed one-year of follow-up (one patient died of unrelated causes). Both groups exhibited equal improvement on the visual analog scale and Oswestry evaluations after treatment, without any significant differences. The improvement in the lumbar visual analog scale score was not significant in the hydrodiscectomy group (Percutaneous hydrodiscectomy was demonstrated to be as effective as open microdiscectomy for reducing pain. The rates of complications and recurrence of herniation were similar between groups. Patient satisfaction with the treatment was also similar between groups. Open surgical procedures to treat spinal herniations are associated with complications such as epidural hematoma, infection, residual instability, recurrence of disc herniation and post-laminectomy syndrome, which suggests a need to develop minimally invasive treatment techniques 3versus 72% to 90% for the microdiscectomy technique, depending on the evaluation method 12The reported success rate for percutaneous lumbar discectomy ranges from 29% to 96%, Hydrodiscectomy is a new technique introduced for percutaneous discectomy. It uses a focused, high-intensity stream of water for ablation, which aspirates the tissue at the same time. It resulted in a fast, precise procedure in a study using cadavers The objective of this study was to evaluate the results of hydrodiscectomy and compare them to the gold standard procedure, open microdiscectomy, regarding pain, function, satisfaction with the surgery and complications or recurrence. The hypothesis examined was that the new technique was as safe and effective as traditional percutaneous surgery.This was a randomized, controlled, single blind study undertaken in a university at a public hospital in Brazil, comprising a convenience sample of consecutive patients admitted between June 2011 and January 2012, with follow-up until January 2013. The study was approved by the local Ethics Committee and was registered in ClinicalTrials.gov under protocol NCT01367860. It complied with the Declaration of Helsinki (1983). All patients provided signed informed consent.Patients 18 to 76 years old who were referred to our tertiary hospital for the treatment of lumbar back pain were recruited. They were included in the study if they had the following: disc protrusion or small herniation at only one level, as demonstrated by magnetic resonance imaging (MRI); MRI findings compatible with the symptoms; no neurological deficits; and no resolution after six weeks of conservative treatment. The exclusion criteria were as follows: neurological changes observed during conservative treatment, pregnancy, a clinical status that was not adequate for surgical procedures and those who did not provide informed consent. After inclusion in the study, the patients were evaluated for pain and function and were then randomly allocated to one of two groups by block randomization; one group of patients received an open microdiscectomy and the other group underwent percutaneous microdiscectomy by hydrosurgery.Randomization was performed in the operating room (OR) with opaque, sealed envelopes that were previously prepared in blocks of four each. Once the patient was admitted and prepared for surgery, one researcher (IDR) evaluated the participant for function and pain as described below. This evaluator was unaware of the treatment to be conducted and the patient undergoing the evaluations was also blind to the procedure. Then, the chief nurse (not an author) opened one envelope and disclosed the procedure to the surgeon. One experienced spine surgeon (AFC) performed all of the procedures in this study, with the help of assistants. The patient was blinded to the type of surgery before the procedure, although he/she could later observe the scar, which was larger and more centrally located in individuals who underwent open surgery.Microdiscectomy was performed with the patient under general anesthesia in a knee-chest position with hip flexion and with the aid of magnifying glasses and fluoroscopy. We created a longitudinal central opening and performed dissection up to the lamina during the small laminectomy procedure, followed by a flavectomy, hemostasis, removal of roots and a discectomy.Hydrodiscectomy was performed with the patient under sedation, which allowed the surgeon to observe the movement of the legs during the procedure. The patient was placed lying in prone position and fluoroscopy was used to locate the desired level for the operation. Blocking was performed with lidocaine . A needle was inserted percutaneously and posterolaterally, via an extrapedicular approach, below the neural foramen in the center of the disc using the traditional approach for a discectomy. Front and profile fluoroscopy were used to confirm the desired position. A dilator was introduced into the disc, followed by placement of a cannula over the dilator and into the outer annulus. The cannula was then advanced into the inner annulus. The dilator and needle were removed and the device for hydrosurgery  was introduced via the cannula access. Manual light pistoning and rotation movements were performed for approximately three to five minutes. The disc material was removed by suction.All patients underwent the same physical therapy protocol in our hospital after surgery. The physical therapists were blinded to the surgical procedure and were informed only that the patient had undergone herniated disc ablation for the treatment of low back pain.Function was evaluated using the Oswestry Disability Index (ODI) Surgical failure was considered to have occurred when radiating pain that was equal to or more intense than that experienced preoperatively was present at 30 days post-operatively. In these cases, an MRI examination was performed to evaluate the patient to determine whether they had indications for surgical revision with microdiscectomy, allowing proper planning for the removal of herniated material.p<0.05. The statistical analysis was performed with the Statistical Package for Social Sciences (SPSS) software, version 19.0 for Windows.The statistical analysis was performed based on an intention to treat (ITT) method. Normality was examined using the Kolmogorov-Smirnov test, and if confirmed, data were analyzed with a t-test. All normally distributed continuous data were analyzed using unpaired t-tests and expressed as the means and standard deviations. Baseline categorical data were presented as proportions between groups and statistically tested with the chi-square test and, when necessary, with Fisher's exact test. Statistical significance was established at a value of During the study period, 40 patients were included in the study, 20 in each arm. Except for one patient in the hydrosurgery group who died from other causes in the sixth month after surgery, all patients completed one-year of follow up. The demographic and clinical baseline data are shown in p<0.001 for both scales) and significant differences were found for the VAS score for lumbar pain in patients who underwent open discectomy (p<0.001). The lumbar VAS score was not significantly improved (p=0.138) for the group of patients who underwent hydrodiscectomy.As shown in p>0.05), residual pain or recurrence (according to Fisher's exact test and the chi-squared test).In the open discectomy group, one case of superficial infection occurred, which was treated with antibiotics; three cases of residual pain were observed, in which a postoperative MRI investigation showed proper removal of the herniation but with residual epidural fibrosis (revision surgery was not indicated in these cases); and two cases of recurrence were observed, with revision indicated in both cases. In the group of patients who underwent hydrodiscectomy, one case of infection occurred, which was treated with antibiotics. In four patients, the pain did not improve after treatment, and these patients all underwent open microdiscectomy two months after the first procedure, with subsequent improvement of their pain. One patient in this group was HIV-positive and died six months after treatment due to pneumonia. No significant difference was observed between the groups regarding the frequency of infection (p=0.27).In the hydrosurgery group, 13 patients (68.5% of those who completed the follow-up) were satisfied with the treatment compared to 17 patients (85%) in the open discectomy group, resulting in no significant difference between the groups according to a chi-squared test (Several randomized controlled trials have compared percutaneous discectomy with microdiscectomy Some devices for percutaneous discectomy have been criticized because they cannot remove the posterior portion of the nuclear material of the herniated disc In our randomized clinical trial, significant improvements were observed in all outcome measures except the lumbar VAS score in the group of patients who underwent hydrodiscectomy. One possible explanation for this lack of significance, despite the trend toward improvement shown in In a randomized study similar to the present study, Chatterjee et al.Improvements in pain were observed in the patients treated in both groups and the use of percutaneous hydrodiscectomy was shown to be as effective as the conventional open discectomy procedure. The complication rates in both groups were similar and limited to cases of infection. The rates of recurrent herniation were also similar between the groups, as were the rates of satisfaction with the treatment.Cristante AF designed the study, collected and interpreted data, wrote the manuscript and approved the final version of the manuscript. Rocha ID and Marcon RM collected and interpreted the data, helped with manuscript writing and critical revision and approved the final version of the manuscript. de Barros TE designed the study, helped with data interpretation, critically revised the manuscript and approved the final version of the manuscript. All authors are accountable for all aspects of the work regarding the accuracy and integrity of the study data.


Emergency medicine (EM) has always been on the frontlines of healthcare in the United States. I experienced this reality first hand as a young general medical officer assigned to an emergency department (ED) in a small naval hospital in the 1980s. For decades the ED has been the only site where patients could not be legally denied care. Despite increased insurance coverage for millions of Americans as a result of the Affordable Care Act, ED directors report an increase in patient volumes in a recent survey. It is probably no accident EM was one of just five specialties to implement and report on Milestones during the 2013–2014 academic year. And it is also no surprise EM will publish the first validity study on Milestones.In this context the emergency medicine (EM) residency community has embraced the challenge to transform training for the 21The NAS was part of the educational community’s response to improve graduate medical education (GME).One reason for this struggle is the lack of shared mental models, or frame of reference, regarding the competencies among programs and clinical faculty. There were several reasons for this struggle. First, the ACGME/ABMS general competencies were defined in conceptual terms that were often hard to translate into practice. Second, some of the competencies, especially practice-based learning and improvement and systems-based practice, were new concepts altogether. Third, work-based assessment methods were either unavailable or not well aligned with the purpose and goals of the competencies.The Milestones were developed collaboratively by each specialty to create the core blueprint, or roadmap, of the discipline in narrative, developmental language. In other words, they have helped to describe the competencies in more understandable language. The Milestones serve as a framework to inform and guide curriculum, choice of assessment methods and instruments, and assessment judgments by the clinical competency committee.There are two important caveats. First, milestones do not define the totality of any discipline, including EM. Milestones are key elements of a larger “whole” of clinical competence. Second, substantial professional judgment, on the part of the faculty, is critical in the overall assessment of readiness for clinical practice. Informed judgment, based on multiple assessments through various forms of observation, is a cornerstone of a competency-based system.EM was one of the early adopters in the NAS, being just one of five specialties to report both mid-year and end-year Milestones data in the 2013–14 academic year. Several aspects of the EM approach to developing and implementing the Milestones are noteworthy. First, the Milestones are grounded in the “Model of the Clinical Practice of EM” (EM Model). The EM Model consists of three core components: 1) individual conditions; 2) physician tasks; and 3) acuity levels. The knowledge, skills and attitudes comprising the current EM Model were informed by a national survey of 9,740 physicians in 2007 regarding EM practice.7The EM approach to Milestone development appears to have had an important impact. The initial validity study of the EM Milestones reported in year one shows very promising results. Factor analysis of the national Milestones data revealed a three-factor structure concordant with the three component EM Model of practice.The NAS is built on a foundational principle of continuous quality improvement. In the United States and most of the world, education and healthcare systems are experiencing significant change and disruption. We must continue to move away from a “static/stable” view of education and clinical care to one that is dynamic and constantly evolving. There are several implications for GME. First, changes in educational programs must become better integrated with the changes occurring in healthcare delivery and systems. Care of patients and populations is a dynamic, integrated process. As the frontline specialty of the healthcare system experiencing this disruption, EM is well positioned to lead and inform educational redesign. Second, work-based assessments will continue to grow in importance and prominence. One example of a useful technique in EM is end-of-shift encounter cards.Third, the current Milestones are truly version 1.0; as in all continuous quality improvement processes some amount of change and revision will be needed. The processes used by the EM community to create version 1.0 will be invaluable to the larger educational community and capturing the detail behind these processes will be important. Finally, we want to ensure the Milestones do not create overly reductionistic assessments and curricula. Residency education will be most effective when the output is a whole physician who effectively integrates all competencies, however defined, into his or her practice. For example the EM community has developed entrustable professional activities (EPAs) to further help operationalize the competencies and milestones.In conclusion, here is a request to the EM community: The ACGME, the ABEM and the dozens of talented EM faculty who volunteered their time, expertise, and wisdom to advance the Milestones, need and welcome constructive feedback to continually improve the NAS and Milestones. Milestones are tools to facilitate and promote innovation and continuous improvement in GME in the Unites States, but they are not yet fully realized and will require changes and adjustments. We are entering a period of transformation that requires collectivism among all the key stakeholders and that can feel, like any change, uncomfortable. Only by working together through dialogue and across organizations can the full potential of outcomes-based medical education be realized. The EM educational community has clearly taken up this charge.


We also explore the role of dysbiosis, a perturbation within the fragile ecosystem of the microbiome, and its role in the origin of select pathologic states, specifically, obesity and necrotizing enterocolitis (NEC) in preterm infants. We discuss the evidence supporting enteral pre- and pro-biotic supplementation of commensal organisms such as Bifidobacterium and Lactobacillus in the neonatal period, and their role in the prevention and amelioration of NEC in premature infants. Finally, we review directions to consider for further research to promote human health within this field.The field of genomics has expanded into subspecialties such as metagenomics over the course of the last decade and a half. The development of massively parallel sequencing capabilities has allowed for increasingly detailed study of the genome of the human microbiome, the microbial super organ that resides symbiotically within the mucosal tissues and integumentary system of the human host. The gut microbiome, and particularly the study of its origins in neonates, has become subtopics of great interest within the field of genomics. This brief review seeks to summarize recent literature regarding the origins and establishment of the neonatal gut microbiome, beginning  The evolution of the field of genomics, spurred largely by the Human Genome Project, has given rise to metagenomics, or “the application of modern genomics techniques to the study of communities of microbial organisms directly in their natural environments” . This buin utero and across the lifespan, its effect on promotion of health, and its role in the development of disease.The human microbiome is a microbial community best described as “the sum of all microbial life living in or on the human body” . It is aThe purpose of this brief review is to introduce the reader to the concept of the human microbiome and to summarize recent literature specifically regarding the neonatal gut microbiome, from its establishment at birth through its evolution during early infancy. We review differences in microbial colonization and immune function of the intestinal tract in healthy full-term newborns compared with their preterm very low birth weight (VLBW) (birth weight <1500 g) counterparts and the implications for development of disease when the microbiome is disrupted (dysbiosis). Finally, we describe the role of probiotic use as a potential factor involved in governing development of a “healthy” gut microbiota and discuss areas of further research warranted to deepen our understanding of this complex ecosystem and its role in human health and disease.in utero environment was largely sterile and that a fetus was not colonized with bacteria until the time of birth. Recent studies suggest the presence of a microbiome within the placenta as well as fetal meconium, suggesting that the colonization process begins well before delivery. Aagaard et al. have recently characterized a placental microbiome profile, composed of non-pathogenic commensal microbiota from the Firmicutes, Tenericutes, Proteobacteria, Bacteroidetes, and Fusobacteria phyla which, interestingly, shares some similarities with the human oral microbiome . , 6. in ucrobiome , 8. Thiscrobiome . Ardisoncrobiome .As such, the gastrointestinal (GI) tract has the greatest diversity and abundance of microbes and evidence is mounting that it becomes colonized antenatally. Approximately 100 trillion organisms – which is 10 times the total number of cells in the human body – typically comprise the gut microbiota and the majority of these populate the distal ileum and colon. More than 99% of the gut microbiota is anaerobes , 11. IntIt is easy to conceptualize then that the collective genome of the intestinal microbiota is >100 times the number of genes in the human genome; as such, there are a significant potential number of commensal antigens for the host immune system to encounter and to respond. This exceeds the number of self and pathogen-based antigens a human will encounter in their lifetime .Lactobacillus and Prevotella species. Infants born via Cesarean delivery are colonized by epidermal rather than vaginal species, such as Clostridium, Staphylococcus, Propionobacterium, and Corynebacterium and they have a deficiency of anaerobes with lower numbers of Bacteroides and Bifidobacterium when compared to vaginally born infants  from their mother’s milk that will affect the milieu within which their own microbiota will develop . Oligosaacterium , 30, 31.acterium . Other cacterium .Staphylococcus, Streptococcus, Bifidobacterium, and Lactobacillus  , 55. Thiysbiosis , 56, 57.Even after the microbiome is well established in healthy infants, dysbiosis, or shifts in microbial composition or diversity, can occur in the setting of dietary changes, antibiotic exposure, or infection. Dysbiotic conditions can favor invasion and growth of pathogenic species and can disrupt the finely tuned regulatory circuits of the immune system that maintain a system of pro- and anti-inflammatory checks and balances. The neonatal microbiome, in healthy full-term infants and especially in preterm infants given its dynamic nature, is fragile and impressionable. As such, the microbiome is extremely susceptible to external influences that can dramatically affect the short- and long-term health of the host. The development of NEC in the preterm population is a multifactorial, devastating, and as yet poorly understood disease process. A link between NEC and a microbial etiology has been recognized for decades and has been corroborated by outbreaks in NICUs, the presence of pneumatosis intestinalis as a likely byproduct of bacterial fermentation, and the often concomitant presence of bacteremia . As suchGiven the relative instability and impressionability of the developing gut microbiome in early life, coupled with its purported disease prediction, detection, and treatment benefits, it seems logical to explore avenues within which evolution and maintenance of a healthy gut milieu can be promoted. One such intervention that has gained overwhelming popularity over the last two decades, but that remains a controversial topic, is the use of pre- and pro-biotics. Given that an infant’s health and well-being are tightly linked to the development of the intestine and its digestive and immune capacities, it would seem logical that manipulation of the microbiota with the use of pre- and/or pro-biotic nutritional supplementation at an early stage could have a high and long-lasting impact .Bifidobacterium/Lactobacillus) in the colon of mammals” . Probiotic supplementation in the preterm neonatal population is purported to promote acquisition of normal commensal gut flora in these compromised hosts and to confer a protective effect against dysbiotic conditions such as NEC.Lactobacillus and Bifidobacterium. Probiotic preparations that recently have been studied in the neonatal population are summarized in Table Saccharomyces) is used as a probiotic. This diversity in design and execution of clinical studies of probiotics in neonates is also evident in the recent meta-analyses by Deshpande et al., and Wang et al., a systematic review by Mihatsch et al. and a 2014 Cochrane review  for 7 days and found that the synbiotic produced rapid colonization of the infant GI tract (within 3 days of administration) and infants remained colonized, at decreasing rates, for several months after therapy was stopped (L. plantarum for differing periods of time. L. plantarum levels were monitored over time using qPCR. They noted a discrepancy between the daily intake of Lactobacillus (2 × 1011 cells/dose) and levels detected in feces (104 cells/g), but noted that they were unable to account for the distribution or fate of bacteria within the GI tract following ingestion. Interestingly, they noted that following cessation of probiotic therapy, detection decreased to pre-intervention levels, suggesting that there is the possibility that certain probiotics may not persist permanently  as one important mediator of epithelial cell barrier integrity  to healthy adult mice induces marked changes in cellular adaptive immune responses in a strain-specific manner  and bacteremia (n = 8) potentially associated with probiotic administration and noted that controlled trials did not routinely monitor for infection of test subjects receiving probiotic therapy } of NEC in the probiotic group. They quoted a number needed to treat (NNT) with probiotics to prevent one case of NEC of 25 , effective June 2008, which require that dietary supplements are manufactured consistently as to their identity, purity, strength, and composition. This is to ensure that consumers  will have access to dietary supplements that meet quality standards that are free from contamination and are accurately labeled. The rule addresses the quality of manufacturing processes for dietary supplements and the accurate listing of supplement ingredients. However, this rule is currently not enforceable to the stringent standards of prescription medications, and is dependent on the manufacturer. The fact remains that there are already NICUs around the world that are/have been using probiotics to decrease rates of NEC, with published evidence-based guidelines (Chan et al. recently called “for more stringent regulations to hold the manufacturers of probiotics to safety standards similar to those with prescription medications so that well-designed observational studies to rigorously evaluate the safety of various strains and regimens can be conducted” . In USA,idelines , even asAs research surrounding the human microbiome continues to expand, we gather more information about its development and function that may ultimately assist us in a better understanding of lifelong disease processes. Because the genesis of the human microbiome is primarily influenced by factors external to the host, rather than intrinsic genetic factors, an understanding of these factors and how they can be manipulated could impact the balance between health and disease beginning at or even before birth. In time, we may be able to harness the power of this knowledge to guide newborn delivery decision making, and to target use of pre- and pro-biotic species to promote an as yet to be elucidated “healthy” gut milieu. These potential interventions could ultimately allow for prevention of and/or intervention against infectious and immune-mediated disease beginning as early as the neonatal period.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Introduction. Illness anxiety disorder (IAD) entails a preoccupation with having a serious, undiagnosed illness in which somatic symptoms are, if present, mild in intensity . Case Report. This is a case of seventy-three-year-old Saudi man who started visiting the primary health care center around twenty-five years ago. With concerns of having cancer, the patient continuously visited the hospital, costing over $170,000. Throughout this period, the patient has been exposed to extensive unnecessary imaging studies and laboratory tests that have effects on his life in all aspects with such concerns. Five years ago, a family doctor has put an end to that by directing the patient to the right path. The doctor made several actions; most importantly, he directed the patient to a cognitive behavioral therapy which significantly improved a range of hypochondriacal beliefs and attitudes. This patient's case demonstrates the fundamental importance of a proper health system that limits such patients from abusing the health system and depleting the medical resources. Moreover, this case emphasizes the important role of the family physician who can be the first physician to encounter such patients. Thus, proper understanding of the nature of such disorder is a key element for better diagnosis and management.  Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5), categorizes a group of disorders as somatic symptom disorders and other related disorders which were previously known as somatoform disorders in the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) [The American Psychiatric Association in theM-IV-TR) , 2. ThisM-IV-TR) . The excM-IV-TR) . Diagnostion DSM-, categorM-IV-TR) . DSM-5 eM-IV-TR) . Since pM-IV-TR) . This wiM-IV-TR) .We present a case of a seventy-three-year-old Saudi man who has started visiting the primary health care center in our institution twenty-five years ago. He has been concerned with having a cancer that would give him only few days to live. At the beginning, the patient was evaluated medically through detailed history and documentation of his symptoms and then a management plan was created accordingly to exclude cancer. Full history, physical examinations, and radiological and pathological investigations were ordered and the results were all negative for cancer. The physician explained the results of the investigations to the patient but he refused them and continued to insist that he had cancer regardless of the results. The patient was then referred to Psychiatry Department to be evaluated but he could not realize that his symptoms might be of a nonorganic cause, either psychological or mental.The patient continued to visit the general hospital, emergency department, and the primary health care in the institution and was still occupied with the idea of cancer presence. Although the patient was seen by many physicians, the patient was always not satisfied with their conclusions. Eventually a physician reported the case to the department of medical eligibility addressing the issue of continuous primary health care center visits with very variable symptoms, nonconclusive diagnosis, and an unconvinced patient. The department of medical eligibility in the hospital administration took a decision to temporarily limit the patient's file to the psychiatry department to drive the patient to visit the psychiatrist to be evaluated psychologically in order to make his file eligible again. The patient was unhappy at the beginning but he had to visit the psychiatrist. So, an appointment with the psychiatrist was booked and a full psychological and social evaluation was performed by taking a thorough history from the patient. This revealed that the patient fit the criteria of the illness anxiety disorder in which he had a minimum of six months of a persistent belief of having a serious disease which he specifically named. Moreover, this persistent occupation with this belief was disabling and limiting him from having a normal life and thought that his days were counted in this life. Also, a persistent refusal of any medical advice or explanation for his symptoms and fears was neither related to schizophrenia nor related to mood disorders.A diagnosis of illness anxiety disorder was made despite the patient's strong refusal. The family and social history evaluation also revealed a very low socioeconomic status and similar conditions in the family. Interestingly, two of the patient's daughters had similar reported conditions which could raise the suspicion of the possible genetic predisposition that could be triggered by shared environmental factors between him and his daughters. Following this extensive detailed history and evaluation, the treating psychiatrist contacted the department of medical eligibility to make the patient's file eligible again as promised by them with an unlimited eligibility to all specialties and primary care center. For the past twenty-five years of continuous hospital visiting, he has had almost weekly and even daily visits to the primary care. The patient kept complaining of variable symptoms every week and specifically asking for certain lab tests and radiological studies. Also, he successfully convinced some physicians to order a biopsy for him.It is reported that physicians in the primary health care center used different techniques of counseling and they applied the biopsychosocial model to overcome the patient's fears but often failed to reach an achievement as the patient continued to complain of different symptoms and became a burden on the physician's clinic time and the hospital resources. It is also reported that the patient was extremely difficult to handle and convince. In the absence of institution guidelines to deal with such cases, all physicians tended to yield to the patient's persistent complaints and accepted his demands and fulfilled his desires by requesting whatever investigations the patient asked for. Over the years, the patient's investigations have cost approximately $178200 due to the system negligence to such cases. The patient's most requested investigations were mainly invasive radiological studies specifically abdomen and pelvis CT (18 times) and wide range of other invasive and noninvasive studies like chest CT (11 times), brain CT (7 times), chest MRI (4 times), lumbar spine MRI (6 times), and other studies. It is important here to put emphasis on the potential harms of radiation from radiological studies that are frequently requested by the patient in the absence of clear guidelines to be followed by practitioners for that group of patients. In addition, the patient asked for a variety of lab tests including renal profile, parathyroid hormone, complete blood count, estimated glomerular filtration rate, coronary risk profile, 25-hydroxy vitamin D, thyroid stimulating hormone, prostate specific antigen, free T4 level, and other very wide range of lab tests. Moreover, the patient underwent several biopsies like renal biopsy, prostate biopsy, gastric biopsy, and other different types of biopsies.The patient was abusing the system in which resources and time were wasted. The patient kept overstepping each barrier by the hospital's staff to minimize his burden on the hospital by manipulating staff and deceiving and misleading them by giving incorrect information. Also, he was targeting junior practitioners and disturbing them and even threatened to sue the administration if restricted from health care. Five years ago, an experienced board-certified family physician was shocked when he looked at the patient's file and decided to put an effort to solve this problem by taking some actions. First action considered, after getting the approval from the family medicine department, was to limit the patient's primary care visits to only one clinic and to refer him to the supervising physician himself. Then, building strong and effective patient rapport based on trust and honesty was initiated. After negotiations, the patient agreed to enroll in cognitive behavioral therapy (CBT) for six sessions ninety minutes each. The patient was advised to have a scheduled sleeping time, ensure healthy eating habits with regular physical exercise, be involved in social activities, stay away from stressors like searching web for symptoms, and avoid TV health shows and health magazines during active cycles of disorder. After that, there was an agreement with the patient not to disturb the clinic and he would get to see the physician regularly for checkups every three months.After five years of implementing the new rules, the patient is still visiting the clinic for regular follow-up and sometimes he breaks the rules and comes regularly to the clinic especially in active cycles of the disorder. On following the patient's condition in the last five years, it is noticed that there is a dramatic decrease in the total financial cost due to the relative decreasing number of visits, less time spent on arguing with the patient, and the filtration of his requests. Moreover, there is a remarkable improvement in the patient's condition because of CBT and relative compliance to health advice. We think that this rare case of extremely persisting illness anxiety is worth reporting because the patient managed somehow to escape attention and made a huge financial burden on hospital resources in the absence of clear guidelines in such conditions. Also, this case provides useful insight for future guidelines development.Because they consider themselves medically ill, individuals with IAD are usually encountered in medical rather than in mental health setting. Moreover, they show elevated rates of medical utilization by consulting multiple physicians for the same complaint and obtaining repeatedly negative diagnostic test results . They doPhysicians in the medical setting mostly fail to early recognize and deal with such situations leading to excessive use of unnecessary diagnostic tests and imaging studies . It was Another important aspect of this problem is the potential harms that can happen to the patients by exposing themselves to unnecessary, extensive, and invasive imaging studies which increase their risk of adverse health events . As for After over twenty-five years of seeking medical attention, a family doctor has put an end to this by directing the patient to the right path. The doctor took several actions like directing the patient to a cognitive behavioral therapy for six sessions ninety minutes each. The six sessions directed towards the cognitive and perceptual mechanisms thought to underlie the disorder appear to significantly improve a range of hypochondriacal symptoms, beliefs, and attitudes . FurtherIn general, this case report shows the full course of an IAD patient. It shows how the symptoms started and the huge burden of it on the patient himself, his family, medical practitioners, and the hospital. Moreover, it shows the course of the treatment and how it has helped the patient to improve significantly, although there are still active cycles of the disorder, which can be reduced by applying further booster CBT sessions. Finally, this case report fails to specifically mention the frequency of the active cycles and the severity of them.


Chenopodium quinoa Willd.) was first domesticated in Andean countries over 7000 years ago. Following the Spanish conquest, quinoa was rejected as “Indian food.” After centuries of neglect, the potential of quinoa was rediscovered during the second half of the 20th century. Since then, the number of countries importing quinoa increased, with new producers appearing on the map and quinoa now being cultivated in areas outside the Andean countries. The geographical increase in distribution of quinoa has highlighted the difficulty of access to quality seed, which is a key factor for testing the crop outside the Andes. In this context, research partnerships have helped promote the exchange of quinoa germplasm and have allowed trials to be undertaken in non-traditional areas of cultivation. The number of countries growing the crop has increased rapidly from eight in 1980, to 40 in 2010, and to 75 in 2014. A further 20 countries have sown quinoa for the first time in 2015. In this paper, we analyze this trend and discuss the limits of quinoa’s expansion. As commercial production of quinoa is expected to develop, changes in international regulatory frameworks on genetic resources are needed in order to facilitate plant breeding for the most adaptive varieties for each region.Quinoa ( Chenopodium quinoa Willd.), is an annual species that originates from South America. Its domestication is thought to have begun in Andean region around 7000 years ago. Generations of farmers have been involved in quinoa selection, which explains the high levels of genetic diversity found today.Quinoa  and is tolerant to frost, drought, and salinity , 2015. Q•Highlands in Peru and Bolivia;•Inter-Andean valleys in Colombia, Ecuador, and Peru;•Salares in Bolivia, Chile, and Argentina;•Yungas in Bolivia;•Sea level in Chile.Research partnerships have often facilitated the exchange of germplasm and have had a powerful impact on this development by strengthened collaborations . HoweverToday, quinoa is still considered a minor crop for global food and agriculture and often classified as a Neglected and Underutilized Species (NUS) with a high potential of development. However, its current distribution is now changing due to changes in consumption patterns. In this article, we analyze this trend, and present a case for the increase in production of quinoa around the world.A survey was conducted of resource persons who have been involved in quinoa research over the global level during the last 30 years. The survey identified those countries involved in quinoa research and cultivation. In addition, an analysis was conducted on the issues of access to quality seed of quinoa.Quinoa project reports were studied to complement the information obtained through surveys. The genotypes used were described, together with their agromorphological characteristics and their origin was determined. The data generated was used to identify the key elements in the expansion of quinoa’s cultivation.From at least 7000 years ago until the beginning of the 1980s, quinoa has only been connected to the Andes. However, when researchers in other countries understood the potential and benefits of quinoa, experimentation has not stopped growing. Studies have been performed in an increasing number of countries. The number of countries growing quinoa has risen rapidly from 8 in 1980 to 75 in 2014, with a further 20 countries which sowed quinoa for the first time in 2015 .The first known experiment conducted outside the Andes took place in 1935 in Kenya  using th1 program “Quinoa – a multiple crop for EC’s Agriculture diversification, 1993–1997,” coordinated by University of Cambridge, UK, and the Food and Agriculture COST Action 814 on “Crop Adaptation to Cool and Wet Climates, 1991–1996,” coordinated by the Ministry of Agriculture, Belgium. Through international cooperation initiatives for promoting quinoa, field trials were set up in other countries such as Sweden, Poland, Czech Republic, Austria, Germany, Italy, and Greece.The project “American and European Test of Quinoa”  overseenFigure 1).The General Assembly of the United Nations declared 2013 as the International Year of Quinoa (IYQ). Quinoa was afforded a high profile as a crop with the potential to grow in importance in world agriculture . The rapThe main quinoa producers in the world, however, are still Bolivia and Peru. In 2013, the area under quinoa cultivation in Bolivia was 75000 ha and in Peru 45000 ha. These two countries produce more than 80% of quinoa in the world, followed by Ecuador, USA, China, Chile, Argentina, France, and Canada, which together represent 15–20% of the world production . The areThe activities carried out due to the IYQ have directly contributed to awareness raising for quinoa cultivation. FAO is actively involved in testing quinoa in 27 countries outside the Andean region, with the aim to promoting food security, due to the nutritional qualities of quinoa and its resistance to abiotic stresses. During 2013–2015, evaluation of quinoa varieties were conducted in:•Central and Southern Asia ;•Western Asia and North Africa ;•Africa .Size, shape, and compactness of the inflorescence are considered to be important for the rate of maturation. A large open inflorescence will dry quicker after rain and morning dew than a small, compact one, but it may also be prone to seed loss, as quinoa is relatively little domesticated, with few, modern varieties available .The breeding of quinoa, especially Europe and North America, concentrated on gains in time to maturity (around 150 days), high yield and uniformity . AnotherToday quinoa is presently cultivated or tested in 95 countries of the world . This glConsidering the evolution of global regulations on seeds, two periods must be distinguished for their importance on biodiversity sovereignty: the signing of the Convention of Biological Biodiversity  marks a particularly break and contrasts the before and the after for plant genetic resources’ access and sharing. The CBD stipulates national sovereignty over biodiversity and obliges parties to form bilateral agreements for accessing their genetic resources . In ordeQuinoa, unfortunately, is not one of the species pertaining to Annex 1 of the Treaty, which is a list of those species included the MLS of exchanges. The Declaration of Cordoba (2012) from the International Seminar “Crops for the XXI Century,” the first international event celebrating the UN IYQ 2013, proposed the addition of minor crops to be included in the Annex I to the Treaty. To date, however, there has been no consensus reached.The different regulations on plant genetic resources are usually applied at different levels  and for different purposes . For quinoa, however, there is no single existing legal framework providing a comprehensive coverage of all the issues related to the genetic resources and their sustainable management . The CBDex situ collections of quinoa accessions, which are now distributed without legal necessity of prior agreement from Andeans countries . Only 25% of genetic material exchanges correspond to individual exchanges, while 75% of the material has been exchanged among research networks. Considering personal links into existing partnerships, more than 85% of the respondents of the survey declared not signing MTAs.Exchange of quinoa germplasm has been undertaken both formally via legal provisions , or informally via research networks . The FAO Regional Office for Near East in Cairo, Egypt, assisted in distributing quinoa accessions among National Research Institutions from eight countries  to conduct an evaluation of these genotypes in semi-arid and arid conditions. This example of seed flow demonstrates the importance of research networks in distributing quinoa seed at the global level. It also has limitations because of change of codes (unique identifier assigned to the accession in a genebank) from one genebank to another, and from Andean countries to other countries. Avoiding code change is one main challenge for data and germplasm sharing with transparency, but sometimes code change serves as a form of protection for plant breeders to mask the origin of the material they are developing.The current situation provides a specific legal framework for access and exchange of genetic resources that have a strong impact on use and innovation. The Nagoya Protocol on Access and Benefit-sharing was adopted in Japan in 2010, entering in force in 2014 (70 Ratifications and 92 Signatures). It provides an international agreement, which aims at sharing the benefits from the utilization of genetic resources in a fair and equitable way, and contributing to the conservation of biological diversity and the sustainable use of its components. Considering the limits of the CBD for innovation in plant breeding, the Nagoya Protocol provides a new pathway for enhancing legal transparency on procedures for access and benefit-sharing, and for monitoring the utilization of genetic resources. Andean countries need to be active in this international agenda if they want to protect their interests on quinoa. Solutions need to be developed to better harmonize the different existing legal frameworks and to create new complementary ones. The rapid spread of quinoa at the global level provides an opportunity to consider more in depth the implications on seed exchange of the current regulatory instruments for genetic resources, so that they can be improved and implemented. In addition, it also offers an opportunity for plant breeders to reconsider models of varietal innovations in plant breeding to manage genetic resources for recombination without registration of intellectual property rights (IPR) for new varieties. In addition, adaptation of varieties to global climate changes needs to cope with an increasing unpredictability. Genetic structure of future varieties must be able to evolve to face those changes . LandracIntellectual Property Rights should be addressed, recognizing the work of the Andean people in the selection and conservation of local quinoa landraces , and maiFigure 2) in this manuscript.DB made the survey and networks analysis on quinoa global expansion and has written the first draft of the manuscript for revision by the co-authors. He is currently developing a Global Collaborative Network on Quinoa. S-EJ participated in many introduction of quinoa around the world. He shared his experience to integrate his global view on quinoa expansion to increase the quality of the mini-review. AV participated in various national projects on quinoa trials in the Near East and North Africa during his studies. He mapped the seed exchanges with the example of (The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer EL and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.


We conducted a choice experiment to estimate citizens' willingness to pay (WTP) for AgGR conservation programmes in Finland, and used a latent class model to identify heterogeneity in preferences among respondent groups. The findings indicate that citizens have a high interest in the conservation of native breeds and varieties, but also reveal the presence of preference heterogeneity. Five respondent groups could be identified based on latent class modeling: one implying lexicographic preferences, two with reasoned choices, one indicating uncertain support and one with a preference for the current status of conservation. The results emphasize the importance of in situ conservation of native cattle breeds and plant varieties in developing conservation policies.Evaluation of conservation policies for agricultural genetic resources (AgGR) requires information on the use and non-use values of plant varieties and animal breeds, as well as on the preferences for  The intensification of agriculture has led to marked changes in the utilization of agricultural genetic resources (AgGR), and many previously common cultivated plant varieties as well as native animal breeds that are of interest in terms of food and agricultural production have become rare or even endangered  and the Global Plan of Action for Animal Genetic Resources FAO, . Nationain situ  and ex situ , and both plant genetic resources (PGR) and animal genetic resources (AnGR).To evaluate conservation policies, there is a need for monetary benefit estimates that encompass both use and non-use values associated with genetic resources. Use values refer to the benefits obtained from current and future use of genetic resources in production and breeding, while non-use values are generated from the knowledge that genetic resources, e.g., certain breeds, exist and are saved for future generations. Stated preference methods, such as the discrete choice experiment (CE) method, are capable of estimating both use and non-use values in monetary terms. A choice experiment is a survey-based method whereby respondents are asked to choose between two or more discrete alternatives that are described with attributes. By varying attribute levels and including a price variable as one of the attributes, respondents' willingness to pay (WTP) for a policy alternative or attribute level is indirectly revealed based on the choices they make  of the alternative programmes were illustrated to the respondents using a table.Table After introducing the attributes, the respondents were presented with six choice tasks. Each choice task included three alternatives: the status quo alternative, described as maintaining the current situation, and two policy alternatives describing an improved level of conservation compared to the current level. Each alternative was described with five conservation attributes, their levels and the cost attribute. The status quo alternative was uniform across choice tasks. An example of a choice task is shown in Table We employed an efficient experimental design to allocate the attribute levels to the choice tasks in the choice experiment survey. Efficient designs aim to generate parameter estimates with standard errors that are as low as possible, and thus produce the maximum information from each choice situation   were included for all alternatives in order to allow systematic choice tendencies not explained with the parameters describing the attributes.Heterogeneity was statistically included in the latent class model by simultaneously dividing individuals into behavioral groups or latent segments, and estimating a choice model for each of these classes. The estimation was carried out by assuming first one class, then two classes, three classes and so forth. In each step, the explanatory power of the model was assessed to decide on the optimal number of classes. For this purpose, we used the Bayesian information criterion (BIC) and Akaike information criterion (AIC), which are log-likelihood scores with correction factors for the number of observations and the number of parameters. The latent class model also enables the calculation of the WTP for the attributes for each citizen segment.a posteriori of the actual estimation of the latent class model in order to describe the heterogeneous citizen segments. Thus, the segments were formed solely based on the conservation program choices. The membership in the most probable segment was regressed using a logistic regression to characterize each class compared to the rest of the respondents. The explanatory variables for the class memberships included respondents' socioeconomic characteristics, perceived values and responsibilities, use of provided information, response certainty and self-reported perception of the carefulness of completing the survey. The independent variables in the logistic regression models and their descriptive statistics are presented in Table The relationship between the individual characteristics and the latent classes was examined In 24% of the choice sets, the respondents chose the status quo option, i.e., the current state without any additional program to conserve AgGR. The probability of choosing one of the two alternative conservation programs varied between 46% for the lowest cost level of €5 and 28% for the highest cost level of €300.Table The alternative specific constants (ASC) capture the tendency to choose one of the alternatives which is not explained by the attributes. The negative ASC1 (SQ) coefficient showed the reluctance to choose the status quo alternative regardless of the attribute levels in the policy alternatives. Furthermore, the ASC2 and ASC3 coefficients differed unexpectedly in sign and significance. The positive coefficient for ASC2 and negative for ASC3 indicated that the conservation programme that was presented first received more support. This was surprising, as the programmes were not presented in a specific order in the survey. The model predicted 48% of the choices right, clearly exceeding the probability of correct random choices of 33%, leading to a relatively weak goodness of fit.The homogeneity of preferences was tested in the estimation of the latent class models. Based on the AIC and BIC, the estimation process showed that a model of five citizen clusters provided the best fit of the data. Table The latent class model showed that although preferences for some attributes, such as conserving goat and chicken breeds in gene banks and cattle breeds on farms, did not differ significantly between clusters, there was significant heterogeneity in preferences for most of the attributes. The first class, named as “conservationists,” comprised 27% of the respondents. They did not take the personal cost of the conservation programme into account in their decision process, as the coefficient of the cost variable was not significant. Instead, almost all the conservation attributes had significant and positive signs. Contrary to other clusters, most plant-related attributes were significant for conservationists. They also valued the conservation of ornamental plants. Table The second cluster, covering 26% of the respondents, was named as “bid-sensitive animal conservers.” This group had a higher tendency to choose the improvement programmes compared to the status quo. The coefficient of the bid was significant and the second smallest of all clusters. In this cluster, the emphasis of preferences was on the conservation of animal breeds. The conservation of plant varieties in gene banks was even valued negatively. These respondents perceived more often than average that citizens and consumers should be responsible for the conservation of genetic resources. They also had positive agri-environmental attitudes. Furthermore, the respondents in this cluster used more than the average time to familiarize themselves with the information available in the survey concerning PGR, and they were slightly younger than the average respondent.A confusing aspect in the third cluster was the large difference between the ASC for the two conservation programmes. This group, comprising 17% of the respondents, had a considerably greater tendency to choose conservation programme A rather than B or the status quo, although this could not be explained by the experimental design and attribute levels. The bid variable followed expectations, but for the other attributes, only plants on farms and the class-independent variables were significant. The logistic regression revealed that members of this cluster were older and had a lower income, and they emphasized the responsibility of citizens in conservation. Geographically, this cluster had more members who lived in Eastern Finland. The respondents in this group were relatively uncertain of their preferences, used the additional information less, and responded, according to their self-evaluation, less carefully than other respondents. As there were random tendencies in their support for a programme (ASC), but they still preferred an increase in several conservation attributes, they were named as “uncertain supporters.”The fourth class, with 17% of respondents, clearly preferred the status quo option, as the ASC for the programme options were negative. The coefficient of the bid variable was not significant. Among these “status quo preferers,” the choice was consistent with their negative attitudes, as the relative importance of AgGR was low, as well as the perceived existence and use values. Citizens and consumers were less frequently seen as those responsible for conservation; instead, it was perceived as a responsibility of the farmers. This class was characterized by an older age, lower educational level and growing up on a farm.ex situ conservation of Finnhorse positively affected their choices. In this class, the conservation of genetic resources was not seen as a responsibility of citizens or consumers. The logit model for this group showed that they evaluated themselves as careful respondents but felt somewhat uncertain of their choices. They were younger than average and less familiar with products from traditional breeds and varieties.The fifth class of respondents (13%), named as “bid sensitives,” were the most sensitive to the cost of the programme of all groups. Nevertheless, the ASC revealed that they were interested in conservation, and almost all conservation attributes had significant coefficients. Among these respondents, particularly the WTP for different attributes was calculated based on the conditional logit model and the latent class model for those classes for which the cost coefficient was significant Table . WTPs baThe results of a choice experiment concerning agricultural genetic resource policies showed that citizens are interested in the conservation of native breeds and varieties in agriculture. However, there was considerable variation in preferences between citizen segments. Of the five identified groups, two groups covering over half of the respondents had a high interest in the conservation of native breeds and varieties. Respondents in one of the segments clearly preferred the current state of conservation to additional conservation efforts, while one group had a favorable attitude toward conservation if the expenses were on a low level, and respondents in one segment were supportive but wavering in their preferences. The respondent groups were identified based on their preferences for conservation, and they also differed with respect to the use of additional information, their response carefulness and the certainty of the stated WTP.Similar to previous studies of consumer preferences on biodiversity  for the conservation of genetic resources (McNeely, In this study, the conservation policies were based on equal participation of all citizens, as the policy was financed with taxes. An alternative approach would be to apply market-based incentives, e.g., McNeely, . PES wouThe Guest Associate Juha Kantanen declares that, despite being affiliated to the same institution as the authors, the review process was handled objectively and no conflict of interest exists. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.