Physiological whole saliva is a unique body fluid constantly washing the mucous membranes of the mouth, throat, and larynx. Saliva is a clear, slightly acidic mucinous-serous secretion, composed of various electrolytes, small organic substances, proteins, peptides, and polynucleotides. There are many ways to use saliva as a biological fluid (biofluid). The significant advantages of saliva as a unique diagnostic material are its availability and the noninvasive method of collection. The aim of this review is to emphasize the diagnostic value of saliva as a research material in the configuration of its structure and secretion disorders. The data were obtained using the MEDLINE (PubMed) search engine, as well as an additional manual search. The analysis covered 77 articles selected from a group of 1986 publications and initially qualified for devising. The results were evaluated and checked for the correctness of qualifying in accordance with inclusion and exclusion criteria. The diagnostic use of saliva has attracted the attention of many researchers due to its noninvasive nature and relative simplicity of collection. In addition, it should be noted that the determination of chemical and physical saliva parameters can be effectively performed in the patient's presence in the dental office. Physiological whole saliva (WS) is a unique body fluid constantly washing the mucous membranes of the mouth, throat, and larynx. Apart from the gums and the anterior part of the hard palate, the entire oral mucosa contains fine salivary glands from 200 to 400) which are responsible for the production of only 10% of the secretion. The large glands include 3 pairs of salivary glands, parotid, submandibular, and sublingual, which produce 90% of saliva [00 to 400Given the integrity of the hard and soft tissues of the oral cavity, this secretion is extremely important and constitutes a factor which is the most relevant to the maintenance of homeostasis in the mouth (due to the content of organic and inorganic components). It moisturizes oral tissues, allowing for articulation, digestion, and swallowing . The fluSaliva contains 99.5% water, 0.3% protein, and 0.2% inorganic and organic substances . The mosMucins (MUC) present in saliva protect the surface of oral mucous membranes from toxins and various types of irritants contained in stimulants or food. Recent studies also prove that these substances protect the mouth by various mechanisms influenced by unique polymer structures. First, mucins can interact with salivary proteins to change their location and retention and thus increase the protection of the mouth. In addition, MUC7 and MUC5B may interact with microorganisms in the oral cavity to facilitate their removal and/or reduce their pathogenicity . HoweverSaliva also plays a very important role in the inhibition and development of carious lesions of the teeth, improving remineralization of the tooth enamel and preventing demineralization . When th− anion activates α-amylase and F− has anticarious activity, whereas I− plays a role in defence mechanisms, mainly due to the presence of peroxidase in the system [Inorganic ingredients of saliva come mainly from blood. Their content in the secretion is not constant and they always appear in the ionized form. Cations such as Na+ and K+ are involved in the active transport of compounds through cell membranes, while Ca2+ and Mg2+ activate some enzymes. The Cle system .There are many ways to use saliva as a biological fluid (biofluid). The significant advantages of saliva as a unique diagnostic material are its availability and the noninvasive method of collection , 14. ColThe aim of this review is to emphasize the diagnostic value of saliva as a research material in the configuration of its structure and secretion disorders. This review summarizes the comprehensive literature search, which was conducted using databases, and presents the selected studies of the physical and chemical properties of saliva in the field of dental treatment in various physiological and pathological areas of human health.The selected literature covers the years 2000–2018. The data were obtained using the MEDLINE (PubMed) search engine, as well as an additional manual search. The results were evaluated and checked for the correctness of qualifying in accordance with inclusion and exclusion criteria . The anaThe analysis of blood, which is the most common preparation in clinical chemistry, aims to identify diseases and monitor the progress of treatment. However, medical personnel increasingly appreciate and use saliva as a diagnostic material. Saliva is a clinically informative biological fluid that can be used in innovative laboratory and clinical diagnostics, as well as in monitoring and treating patients with both oral and systemic diseases. The diagnostic use of saliva has attracted the attention of many researchers due to its noninvasive nature and relative simplicity of collection , 18.Saliva as a diagnostic material is easy to collect, transport, and store. However, it should be remembered that samples of this material ought always to be collected from patients at the same time, preferably between 9:00 and 11:00 am . A patient should not eat at least 90 minutes before the collection and stop taking medicines that affect salivary secretion 1 day before the procedure. Before sampling, the mouth should be rinsed with deionised water, and saliva should be collected for 10 minutes . There aDepending on the purpose of the material, glass or plastic containers are used, into which saliva can be drained, spat, or sucked. There are also absorption methods using commercially available kits, for example, Salivette. They include an absorbent cotton or synthetic cartridge, which the patient chews for a given period of time . BecauseSaliva diagnosis can be performed in the laboratory or directly in the dental office. Not only does the examination of the properties of this systemic secretion include the contained substances and chemical parameters, but also physical properties are increasingly explored .An adult person produces from 0.5 to 2 litres of saliva per day, but only 2–10% of the fluid is produced at night. During sleep, the rate of salivary secretion decreases to less than 0.25 ml/minute, while during chewing or speech these values oscillate around 10 ml/minute . The basIn their studies, Fallahi et al. proved the insufficiency of cohesion forces in situations where the lowest value of adhesion forces was caused by the reduction of salivation, showing that not only the quality but also the amount of saliva secreted in adults using mobile prosthetic restorations is important . The disAcmella oleracea) [In their studies conducted in patients with xerostomia, Davis et al. demonstrated an increase in salivary secretion after the use of a toothpick by 440% compared to the baseline, while the growth was by 628% in subjects using toothpicks containing additional spilanthol, which is a fatty acid amide of plant origin obtained from the electric daisy (leracea) .The analysis of saliva performed by Khanum et al. immediately before and after extracorporeal dialysis in patients with renal insufficiency and significant changes in the oral environment showed an immediate effect of the stimulation of salivary secretion after the procedure , which wVarious studies using physical stimuli were conducted in order to help people suffering from xerostomia. Aparna et al. observed that the production of saliva by the parotid glands increased in 76% of patients suffering from xerostomia after the use of percutaneous electrical stimulation (TENS currents) , 35.Xerostomia is also associated with the consumption of some drugs, for example, anticoagulants, antidepressants, antiretroviral, and nonsteroidal anti-inflammatory drugs, as evidenced by numerous reports . López-PHypersalivation is extremely troublesome for patients struggling with Parkinson's disease. Nowadays, three mechanisms leading to increased salivation have been identified in this disease: elevated salivary gland production, disturbances of salivary absorption in the bottom of the oral cavity, and disorders of oral saliva removal. In refractory schizophrenia, hypersalivation is most often caused by clozapine .Botulinum toxin is one of the most effective treatments for increased saliva secretion. In their studies, Mazlan et al. attempted to determine the most effective dose of this neurotoxin in reducing salivation in adult Asians suffering from neurological diseases. A prospective, randomized, double-blind controlled trial was conducted, which lasted for 24 weeks. The reduction in secretion was greater in the groups that received higher doses. The group taking 200 units showed the greatest decrease in salivation before week 24 and reported the most significant improvement –45. In cLaboratory tests focus not only on the determination of substances in saliva but also on the analysis of its parameters. The pH value is one of them.Saliva is a slightly acidic (pH 6-7) secretory fluid whose main ingredient is water (99%). Saliva collected without stimulants, such as food, is hypotonic, and after stimulation, it becomes isotonic compared to plasma . Saliva There was no relationship between the pH value and the age of patients; however, pH values differed in various areas of the oral cavity . The higThe use of various oral care products also has an influence on pH. A phase IV clinical trial with three age groups was designed in order to analyze the effect of two rinses on saliva pH and to correlate the outcomes with age, buffer capacity, and salivary flow rate in healthy volunteers. A sudden significant increase in saliva pH was observed immediately after rinsing, while after 15 minutes the value dropped to an almost stable level. A huge increase in saliva pH value after using commercial rinses proves that saliva is a dynamic system and that the body is able to react to the stimulus by changing the content of this fluid. The results of this study increase the importance of in vivo measurements and strengthen the concept of the protective action of saliva .The analysis of the latest literature reports led to the conclusion that the potentiometric method using pH meters is the most common laboratory technique for measuring saliva pH and that this parameter should be measured immediately after collecting the material . There aGiven the modern methods of testing secretions, such as saliva, we should mention the possibilities of measuring buffering capacity. Hydrogencarbonate ions (HCO3−) are the most important in maintaining the homeostasis, chemical stability, and buffer capacity of saliva. Their concentration increases with the volume of saliva, proportionally reaching a peak of 40–60 mmol/l, which clearly exceeds the concentration of this anion in the blood plasma . An incrThe main buffering systems are bicarbonates, phosphates, and proteins. Bicarbonates are secreted only by large salivary glands, and their concentration depends on the rate of secretion. The second buffering agent is phosphate, whose concentration decreases with the increasing secretion rate. Because, contrary to the level of phosphates, the concentration of bicarbonates grows with the rate of saliva secretion, they are responsible for about 50% of the resting saliva buffer capacity and about 80% of stimulated capacity. Proteins and free amino acids have little effect on the buffering capacity of saliva . Lactobacillus salivarius on the risk factors of caries. The participants were randomly divided into four groups and took L. salivarius WB21, L. salivarius TI 2711, Ovalgen® DC, or xylitol-containing tablets. They placed the pill on the tongue for a few minutes and allowed it to dissolve. The levels of streptococci and lactobacilli as well as the salivary flow, pH, and buffering capacity were evaluated before and after taking appropriate tablets. The level of streptococci was evaluated using Dentocult® SM Strip mutans, and the level of lactobacilli waas evaluated with Dentocult LB; the pH values were investigated using the CheckBuf test kit and the amount of salivary flow was assessed by a gum test. No significant differences were found between the groups in terms of the salivary flow and pH. The saliva buffering capacity increased significantly in the group of L. salivarius and Ovalgen® DC compared to the xylitol group [In their studies, Nishihara et al. evaluated the effect of lactic acid bacteriaol group . Streptococcus mutans and Lactobacillus spp., dental plaque, salivary flow, and buffer capacity of saliva before and during orthodontic treatment. The plaque index (PI) increased over time in each group, just like the saliva flow, and mainly in subjects treated with self-ligating brackets, suggesting a difference between these devices and conventional systems. The authors of the study call for periodic microbiological monitoring and the control of salivary parameters during orthodontic treatment [In his study, Mummolo et al. assessed the bacterial levels ofreatment .2. The final pH of the solution is then measured using a pH meterThe Ericsson method: it is certainly the most accurate of the three methods mentioned; however, it is also the most time-consuming. A saliva sample is collected from the patient and then transferred and processed in a medical laboratory. The results are then sent back to the dental practitioner for consideration. Precisely, 1 ml of freshly collected saliva should be transferred to 3 ml of HCl . To prevent the foaming of the solution, add one drop of 2-octanol and mix it for 20 minutes to remove COThe Dentobuff Strip System method: this method is much faster; a result can be obtained within a 5-minute period; however, this is neither as accurate nor as comprehensive as the aforementioned Ericsson method. Buffer capacity is determined based on the colour of the test strip 5 minutes after the application of a saliva drop onto the stripThe Saliva Check-Buffer method: it is decidedly the fastest of the three methods with results being available after only two minutes. Interestingly, it is also more precise than the Dentobuff Strip System due to it having more test areas. Buffering capacity is determined based on the colour of the test strip windows two minutes after the application of saliva is applied to the strip.Diagnosis of saliva buffer capacity can be carried out in the laboratory or, as it more often happens, in a dental office through direct diagnosis using special test kits. The saliva buffer capacity can be tested in three ways:Mucins are mainly responsible for the elasticity of saliva. They are compounds rich in proline, glycoproteins, and electrolytes, as well as water, and are considered protective agents of the oral mucosa. These substances are one of the most important proteins in the mouth. In nonstimulated saliva, they constitute 20–30% of the total amount of proteins. With their increasing amount, the density and viscosity of the secretion grow. The viscosity of saliva depends primarily on the MG1 glycoprotein , 61.No method has been introduced into general use which would allow for the unambiguous qualitative and quantitative diagnosis of saliva in terms of the biophysical properties mentioned above. From a technical point of view, a determination of the viscosity of saliva in a laboratory test does not cause major problems because viscosimeters are used for this evaluation. Different models of the tools are distinguished, capillary, rotational, with a falling ball, and comparative, allowing for the measurement of relative viscosity. Another approach to assess the biomechanical properties of saliva is to measure its elasticity .It is known that carious lesions in the teeth can in various ways affect the properties of saliva. Aminabadi et al. examined how the elimination of active tooth decays in people with more than five tooth caries surfaces influenced saliva parameters. The selected parameters were evaluated in the samples of unstimulated saliva. One month after the treatment of caries, during which all the affected surfaces were removed, saliva samples were collected and reanalyzed. The salivary viscosity significantly decreased, while the buffering capacity and saliva pH significantly increased. It should be concluded, therefore, that tooth caries can be prevented by improving the quality of saliva, including its physical parameters –65.3), and here the sample of saliva is placed.SALIMAT (Poland), which is a prototype device used to test the direct viscosity of saliva, consists of a digital calliper as a supporting structure and reader to examine saliva . This teThe determinations performed in saliva can be used to diagnose infectious diseases, autoaggressive diseases, and cancer, as well as endocrine and cardiac disorders. Saliva can also be applied as a material in the examination of drug levels or tests for the presence of narcotics. Cortisol is a hormone most commonly determined in saliva. The diagnosis and monitoring of the therapy are based on changes in the levels of concentrations of this hormone . CortisoBoth increased and decreased levels of cortisol have a negative impact on the body and produce various symptoms and consequences. Cortisol tests are closely related to oral health. Lopez-Jornet et al. demonstrated that patients with lichen planus located in the oral cavity suffered from sleep disturbances and had higher levels of cortisol and proteins compared to the control group of healthy patients .Cortisol determination is recommended if we suspect the excessive production or the lack of cortisol production by the adrenal cortex . The secretion of cortisol shows large daily changes; the highest values are observed early in the morning and the lowest ones around midnight. Thus, a single measurement of cortisol is of little importance—we should take samples in the morning and in the evening. Cortisol determination also plays an important role in certain stimulatory and suppressive tests that are used to examine the activity of the hypothalamic-pituitary-adrenal cortex axis .In order to test saliva, we should collect the fluid in special tubes and centrifuge it. The examination is performed in 7 saliva samples collected throughout the day at specific times. Seven determinations throughout the day allow for the accurate assessment of changes in cortisol levels during the day. The measurement of cortisol in saliva is a simple, convenient, and accurate technique with a potential value in monitoring patients with hypercortisolemia. This analysis shows the late-night changes in salivary cortisol. Cortisol, determined in salivary samples, can be a simple, convenient biomarker for diagnosing and assessing the response to treatment in patients with Cushing's disease , 71. EliLokhmatkina et al. and Trickett et al. focused on the measurement of cortisol in salivary samples obtained from women who were victims of domestic violence and sexual abuse. The authors claim that this measurement may allow for a better understanding of the pathophysiological mechanisms of mental disorders related to violence in women and inform researchers and practitioners about the possibility of using salivary cortisol as a biological marker of prognosis, diagnosis, and treatment in those who are victims of this abuse , 74.In their research, Peterson et al. confirmed the fact that the analysis of cortisol level can be used in psychiatric and psychological examinations. In the laboratory protocol, men were exposed to neutral stimuli causing negative and positive effects. The concentration of cortisol in saliva was measured during the whole laboratory procedure. The results of this study were consistent with the view that male sexual aggression is connected with physiological hyporeactivity and physiological profile associated with psychopathic behaviours and features . FeinberVreeburg et al. analyzed the level of cortisol in patients with various anxiety disorders. Three groups of patients were compared: control, without psychiatric disorders, and remitted, with no current anxiety disorder and with current anxiety disorder. Cortisol levels were measured in seven saliva samples. A slight but extremely significant difference was demonstrated in patients suffering from panic attacks with coexistent agoraphobia and depression .The level of cortisol also changes under the influence of various stressful situations and the preparation for such events. This was confirmed by Meunier et al. in a study that concerned, among others, the analysis of salivary cortisol levels before, during, and after a simulated task related to intense emotional arousal. Communication skills training has an effect on physiological arousal. After simulated training, the cortisol level significantly increased compared to the control group . Bedini Tecles et al. and Preuß et al. used biomarkers contained in saliva to determine the level of students' stress related to public speaking, as well as a written exam. They showed that the highest concentration of cortisol was observed 20 minutes after the end of the presentation, and it had no connection with the level of stress indicated by students in the surveys, gender, or the quality of the presentation. In the case of written exams, the level of cortisol was high already on the day before the exam and dropped immediately after its completion , 80.By means of serial cortisol measurements, we can also determine the adrenal cortex response to CRF . Huhn etThe examination of salivary cortisol is also important in research into numerous disorders involving hygiene and quality of life. On the other hand, Lipschitz et al. proved that educational training on sleep hygiene caused a decrease in the cortisol levels in salivary samples in patients after cancer .Leptin is a substance that has been frequently tested and measured over the past few years. It is a protein secreted mainly by fat cells, and as a hormone it plays a role in the regulation of food intake and energy management. Gröschl et al. showed that leptin is also produced, stored, and secreted by the salivary glands, and its level increases with the flow of saliva .Similar conclusions were presented by Jayachandran et al. who proved that obese people had higher levels of leptin in saliva. Their research also demonstrated a close relationship between the level of leptin and the range of movement of the teeth supplied with orthodontic devices. Smaller dislocations were reported in obese subjects than in those with normal Body Mass Index (BMI) .Schapher et al. also demonstrated a higher level of leptin in all types of salivary gland neoplasms and thus indicated that it was a marker in the diagnosis of salivary gland tumours . HoweverThe studies conducted by Rodrigues et al. on the level of leptin in saliva and taste sensation demonstrated that this level was higher in a group of girls but only those with normal body weight and a reduced sense of sweet taste. In a group of boys who were more sensitive to the bitter taste, elevated levels of this hormone were reported. The authors also found a tendency to higher concentrations of this hormone in obese people .Amylase is another substance very often determined in saliva in the laboratory. It is a protein that in human saliva is responsible for the formation of the glycoprotein complex within the pellicle which is formed on the surface of the teeth immediately after cleaning. It has a high affinity for bacteria living in the mouth and is associated with them by adhering to the surfaces in the mouth . It alsoIn their studies focused on the diagnosis of saliva in physically active people, Rutherfurd-Markwick et al. showed that the resting activity of amylase was higher in a group of women than in men. However, in men, a relationship was observed between the secretion of amylase and cortisol .Among members of a Paralympic swimming team, Edmonds et al. reported an increase in the level of amylase during 14 weeks of preparation for international competitions, probably due to the impact of the parasympathetic system .Higher levels of mothers' amylase secretion after caesarean section and with direct intraoperative contact with the child were demonstrated, compared to a group of mothers who had contact with their babies only after the procedure .It was also shown that the consumption of coffee, albeit not being a stress factor, resulted in an amylase activity increase in saliva, without changes in the level of cortisol, which may suggest the activation of the sympathetic nervous system. As the level of amylase increases after drinking coffee without a simultaneous rise in cortisol, the authors of the abovementioned publication suspect that it may have antistress properties .Not only caffeine but also methamphetamine (METH) aroused the interest of researchers in terms of the influence on salivary amylase. Haile et al. assumed that METH must affect the concentration of amylase because it activates the sympathetic system by increasing the central and peripheral concentration of norepinephrine. It should be noted that it is a biomarker of the sympathetic system activation, which correlates with the level of norepinephrine in plasma. The researchers managed to show that METH increased the level of amylase and was dependent on age, BMI, and the amount of METH taken per kilogram of body weight. Thus, they demonstrated that the activity of amylase, which is a peripheral norepinephrine biomarker, is closely related to the subjective effects of METH .The results of amylase determination also revealed changes in the profile of salivary proteins in morbidly obese women who were qualified for bariatric surgery. Lower levels of amylase were noted in a group of obese women who underwent surgery; the activity of this protein was also lower than that in a group of obese patients .Lysozyme is an enzyme originating from the large salivary glands, gingival fluid, and digested leukocytes. Lysozyme is also known as muramidase or N-acetylmuramide glycanohydrolase, which is an antimicrobial enzyme produced by animals which forms part of the innate immune system. Lysozyme is a glycoside hydrolase that catalyses the hydrolysis of 1,4-beta-linkages between N-acetylmuramic acid and N-acetyl-D-glucosamine residues in peptidoglycan, which is the major component of Gram-positive bacterial cell walls. This hydrolysis in turn compromises the integrity of bacterial cell walls causing lysis of the bacteria. In humans, the lysozyme enzyme is encoded by the LYZ gene. Elevated salivary lysozyme levels, a biomarker for oral infection and hyperglycemia, have also shown a significant association with hypertension, an early stage of cardiovascular disease.Gillum et al. also demonstrated that overproduction of leukocytes in saliva is not necessary to increase the amount of lysozyme . Kim et  S. mutans and L. acidophilus [In research on new drugs aimed at inhibiting the growth of cariogenic colonies of bacteria living in the oral cavity, Tonguc-Altin et al. proved that, thanks to the appropriate carriers and in combination with lactoferrin, lysozyme can be used to reduce the amount ofdophilus .Studies showed that, in diabetes, which is caused by increased glucose (Glc) concentration, glycation of proteins, including lysozyme, leads to the formation of advanced glycation end products (AGEs), which in turn significantly increases the risk and pace of complications development. Mirmiranpour et al. demonstrated in their work the possibility of inhibiting glycation of lysozyme by L-lysine, which gives an opportunity to alleviate pathological changes in this disease .In a study on salivary defence proteins in women with or without human papilloma virus (HPV) infection, Haukioja et al. proved that the level of this protein was higher in patients with the chronic infection and that the HPV infection of the oral cavity might be associated with the elevated concentration of IgG and lysozyme .In their research, Ligtenberg et al. have demonstrated that physical effort also affects the flow of saliva and the secretion of proteins (including lysozyme), amylase, and 5B mucin. Exercises of moderate intensity increase the levels of proteins and lysozyme, as well as amylase and 5B mucin. The flow of saliva also improves. On the other hand, very strenuous effort leads to a reduction in the amount of proteins in the secretion .Chromogranin A is an acidic secretory protein that can be found in many types of neuroendocrine tissues. It is secreted by sympathetic nerves together with catecholamines and can be used as a marker for sympathetic nervous system activity , 104. ChIn their research, Yoto et al. investigated the antistress effectiveness of two kinds of green tea against a mental stress task load. A group of patients participating in the study drank warm water, green tea (Sagara), and shaded white tea. Saliva was collected before the fluid intake and after mental stress load tasks. Their studies showed that concentration of CgA in saliva increased after mental stress, but drinking green tea can inhibit the growth .In their studies, Matsumoto et al. examined the soothing effects of fragrance from yuzu. The salivary CgA was used as a stress marker showing the activity of a sympathetic nervous system. The study group was exclusively women. Participants were examined twice, firstly using the yuzu scent and secondly using unscented water as a control in the follicular phase. They proved that inhalations of the yuzu scent significantly decreased salivary CgA levels .α chain in its structure. The main physiological role of IgA is to participate in immune reactions within the mucous membranes. The amount of IgA synthesized in the human body throughout the day is greater than all other immunoglobulins combined. Although the concentration of this immunoglobulin in the blood plasma is small, the vast majority of it is secreted on the surface of mucous and serous membranes. There are two IgA subclasses, IgA1 and IgA2, which can be produced as monomeric or dimeric form. The secretory IgA (sIgA) is dimeric form of this immunoglobulin. sIgA can be found in mucous secretions, like saliva, tears, sweat, and so forth [Immunoglobulins A are an immunoglobulin class that is characterized by the presence of a heavy so forth . It is pso forth . The secso forth . Stress so forth .Research carried out by van Anders has shown that chewing gum significantly decreased saliva production time by 3–6 min, but it also leads to lowering the IgA level, in both men and women groups .Laurent et al. in their studies focused on understanding the effect of stress factors on secretion of sIgA in children and adolescents. In saliva samples obtained after exposure to a series of performance or interpersonal stressors in laboratory sessions, the levels of sIgA, cortisol, and alpha amylase were determined. Participants displayed SIgA reactivity to and recovery from acute stress. The relations of sIgA with cortisol and alpha amylase reflected different forms of cross-system linkage. Youth SIgA trajectories followed a normative pattern of reactivity and recovery around the stressors; however, these responses were blunted in young people with higher externalizing scores. In contrast to SIgA, neither cortisol nor sAA related significantly to behavioral problems .Even though saliva is not a popular body fluid, more and more dentists, internists, paediatricians, pharmacologists, clinical and forensic pathologists, endocrinologists, immunologists, psychologists, and dentists are discovering that the liquid is an easily available, noninvasive diagnostic tool. Newly emerging and fast-growing technologies, such as the latest point systems, RNA sequencing, and fluid biopsy, can provide new diagnostic solutions in the field of saliva diagnostics. These recent advances have broadly widened the possibilities of saliva testing in the oral cavity, making clinical salivary diagnosis a reality that can be very precise and useful in the assessment of oral health. In addition, it should be noted that the determination of chemical and physical saliva parameters can be effectively performed in the patient's presence in the dental office.


Due to the ageing population and improving diagnostics and treatments, the number of cancer patients and cancer survivors is increasing. Policymakers, patients and professionals advocate a transfer of (part of) cancer care from the hospital environment to the primary care setting, as this could stimulate personalized and integrated care, increase cost-effectiveness and would better meet the patients’ needs and expectations. The effects of structured active follow-up from primary care after cancer diagnosis have not been studied yet. Therefore the GRIP study aims to assess the effects of structured follow-up after a cancer diagnosis, by a primary care team including a general practitioner (GP) and a home care oncology nurse (HON), on satisfaction and healthcare utilization of patients treated with curative intent.We will conduct a multicentre, two-arm randomised controlled trial in The Netherlands. We plan to include 150 patients who will be treated with curative intent for either breast, lung, colorectal, gynaecologic cancer, or melanoma. Further inclusion criteria are: age 18 years and older, able to answer questionnaires in Dutch, GP agrees to participate and the possibility to include the patient before the start of treatment. All patients receive care as usual. The intervention arm will receive additional structured follow-up consisting of a GP consultation before onset of treatment to empower the patient for shared decision making with the specialist and a minimum of three contacts with the HON during and after treatment. Primary outcomes are: patient satisfaction with care at the level of specialist, GP and nurse and healthcare utilization. Secondary outcomes include: quality of life, employment status, patient empowerment, shared decision making, mental health and satisfaction with given information. Repeated questionnaires, filled in by the participants, will be assessed within the 1-year study period.This randomised controlled trial will evaluate the effects of structured follow-up after a cancer diagnosis by a primary care team including a GP and HON, for patients undergoing treatment with curative intent. Results from the present study may provide the evidence needed to optimally rearrange responsibilities in cancer care delivery and consequently improve cancer care and patient related outcomes.NTR5909.Trial number:  Due to the ageing population and improvements in diagnosis and treatment, the number of cancer patients and cancer survivors is increasing , 2. The In the near future, health care systems in several countries, such as The Netherlands, United Kingdom, Australia, USA and Canada, will face several challenges in fulfilling the needs and demands of this growing cancer patient population , 5. In aTraditionally, management of cancer is delivered by in-hospital specialists. In countries where the general practitioner (GP) is the gatekeeper in the care system, such as the Netherlands, the GP has a long-lasting personal relation with the patient, is up to date with the patients’ medical history and preferences, and is considered as a trusted health care advisor by most patients . These tAt the same time, Dutch health care reports indicate that in 2020 the workload for GPs regarding care for patients with cancer will increase by about 66% within the Netherlands . In ordeScarce evidence suggests favourable effects of increased involvement of primary care in shared decision making and guidance during treatment, starting from diagnosis –18. HoweThe randomised GRIP study primarily aims to evaluate the effects of structured follow-up from primary care on patient satisfaction and health care utilisation for cancer patients treated with curative intent. In addition, we assess the effects on quality of life, mental health, patient empowerment, shared decision making and employment status.GRIP is a multi-centre, two-armed randomised controlled trial in the Netherlands.We aim to include 150 newly diagnosed cancer patients who are to be treated with curative intent for one of the following types of cancer: breast cancer, colorectal cancer, all types of gynaecologic cancer, lung cancer, or melanoma. We primarily intended to include prostate cancer, but our study was incompatible with ongoing psycho-social research in this patient population in the participating hospitals.Newly diagnosed with one of the following types of cancer: breast cancer, colorectal cancer, all types of gynaecologic cancers, lung cancer or melanoma. Not being recurrent disease.Cancer therapy is initiated with curative intent (cancer staged I-III).Patient’s general practitioner agrees to participate in the GRIP-study.Patient is 18 years or older.Patients can be included before start of the cancer treatment.Sufficient mastery of the Dutch language or translator available during study.Patients are eligible for study participation, when they meet all of the following criteria:Major psychiatric disease or personality disorders.Unable to fill in questionnaires.A patient who meets any of the following criteria will be excluded from participation:Patients will be first screened for in- and exclusion criteria in the hospital by nurse (practitioners) or medical doctors and secondly by the researcher.To ensure reaching the required sample size of 150 patients, we involved all three major hospitals (one academic and two-non-academic) located in the greater urban region of Utrecht, the Netherlands, in the study. In addition, researchers will visit all sites biweekly to motivate the sites for inclusion of patients. All four GP cooperative care organisations in the region, together representing 300 GPs, and two home care organisations employing primary care oncology nurses, participate in the study. The GP cooperative care organisations inform their member GPs about the GRIP study, and the GPs can decline to collaborate by opt-out.Eligible patients will be recruited in the hospital by the treating physician or oncology nurse after the patient is informed of his/her cancer diagnosis. After verbal consent, the treating physician or oncology nurse informs the research team, who contacts the patient by phone the (working)day after diagnosis. Written informed consent is obtained from all participants by the researcher.The researcher will randomise the participants to intervention or usual care by using an computer operated electronic randomisation module, which is designed and maintained by the independent data management department of the UMC Utrecht. For randomisation, gender, date of birth, study number and site of inclusion of the patient need to be filled in on the website. Minimisation is applied to ensure balance between groups in treating hospital and cancer type. Due to the nature of the intervention, patients and health care providers are not blinded.A “Time Out consultation” with the GP between the moment of diagnosis and the final decision on treatment in secondary care.Follow-up care from primary care, delivered by a home care oncology nurse (HON) in cooperation with the GP during and after active treatment. Active treatment includes surgery, chemo- and radiotherapy.Patients in the intervention group are offered additional structured follow-up guidance from primary care, next to the usual secondary care, consisting of two components Fig. :A “Time All components of the intervention are developed in close cooperation with the Dutch patient organisation “NFK (Dutch Federation of Cancer Patient Associations)” and the participating GP and home care organisations using existing healthcare services provided by regional organisations. Health care partners from the regional care network were chosen as preferred providers.After informed consent and before the final treatment decision are made in the hospital, the patient will be invited for an appointment with his/her GP for a ‘Time Out consultation’ of 20 min. In preparation, the GP of a patient randomised to the intervention group is contacted by the researcher to be informed about the intervention procedure. The researcher shortly explains the content of the “Time Out consultation” to the GP, including the topics of discussion with the patient as described below and an instruction to consult the HON after the Time Out consultation. In addition, the GP will be explained to not follow this structure when consulting cancer patients randomised to the control arm of the GRIP study in order to reduce contamination.The Time Out consultation aims to facilitate continuity of primary care, to support the patient in a time of uncertainty, and to explore personal perspectives and preferences of the patients which may affect treatment choice to support shared decision making in secondary care.During this consultation the GP addresses a number of issues preparing for active participation of the patient: reflection on the diagnosis and prognosis, psychosocial consequences, awareness that a choice of treatment exists and the recommendation to use the ‘three questions’ model in the consultation with the specialist on treatment decisions . These tAfter the Time Out consultation and the final treatment decision in secondary care, the Homecare Oncology Nurse (HON) will be contacted by the GP to schedule a visit at the patients’ home. During this visit the HON explains his/her role and makes a personal support plan together with the patient. In this plan, the patient’s situation is mapped on four domains: living conditions, physical, psychosocial and existential domain. If one of the domains requires active support, the HON discusses the required actions with the patient and with the GP.The number, type and duration of contact moments with the HON is patient driven, with a minimum number of three contacts during the primary treatment phase, including the first home visit, and two contacts within 3 months after active treatment has ended. The content of contacts is based on the Dutch Distress Thermometer, which contains several items of the four domains on which patients are asked to rank their level of distress . ThroughAll the participating HONs are registered nurses with a specialised training in oncology and have more than 2 years of clinical experience. In addition, the GRIP study team provides a 4-h training regarding supportive care, recognizing alarm-symptoms and the details of the GRIP intervention in order to be able to comply optimally with the intervention procedures. This includes close collaboration with the GP, the minimal content and frequency of consultations and the registrations required for the GRIP study. Expectations of all actors are displayed in Table Participating GPs receive basic information on the GRIP study by their GP cooperatives organisations at the start of the study. The GPs of patients who are randomised to the intervention group are notified by phone after the patient provides informed consent for participation. During this telephone contact, the researcher provides the necessary instruction to perform a Time Out consultation. In addition, information is given by e-mail and through a website which describes the steps GPs are expected to take. This website also provides the information required for optimal guidance from primary care and collaboration with HON and secondary care providers.Patients in the control group receive care as usual during the cancer journey. Hence for this group of participants, follow up guidance after diagnosis takes place in secondary care and guidance from primary care is not structured. Details of usual care depend on disease, patients- and caretaker characteristics, patients’ preferences and varying hospital protocols. In general, the phases of usual care can be described as: diagnosis, choice of treatment, delivery of treatment and follow-up care in hospital. Treatment options are discussed in a multidisciplinary team and generally follow national guidelines. Cancer care in the hospital is commonly delivered by a team consisting of a nurse  and a medical doctor specialised in oncology. In general, the GP is informed about the diagnosis by phone or by mail through Electronic Data Interchange after the multidisciplinary team reached consensus on the treatment.The primary outcomes are patient satisfaction with care and health care utilization. Secondary outcomes are health related quality of life, employment, patient empowerment, shared decision making, mental health and satisfaction with information.To determine the primary outcome parameters the following validated questionnaires will be used: European Organisation for Research and Treatment of Cancer Satisfaction with care questionnaire (EORTC-IN-PATSAT32) , a NumerThe secondary outcomes are measured by eight questionnaires. Health related Quality of Life is assessed by the European Organisation Research and Treatment of Cancer-Quality of Life-C30 questionnaire (EORTC-QoL-C30), which incorporates functional scales , one quality of life scale and symptom scales (including fatigue and pain) .Employment is measured by the Productivity Cost Questionnaire of the institute for Medical Technology Assessment (iMTA PCQ), which contains 12 items . PatientData will be collected at baseline (T0), after 2 weeks (T1) and every 3 months , up to 12 months after the diagnosis (T5)  and treating hospital and cancer type. Mixed linear regression modelling adjusted for baseline variables as fixed factors (if measured at baseline) and stratification factors  will be used to compare outcomes on repeated follow-up measurements T3 and T5. In these longitudinal analyses, the statistic model accounts for missing data based on the observed data . DiffereWe assumed a medium effect size (0.5) to be a clinically relevant difference in patients’ satisfaction between the two study groups. Using a power of 0.8 and an alpha less than 0.05, at least 64 patients per study group are required. Accounting for an estimated dropout of 15%, 75 participants in each group are needed.The aim of the GRIP study is to assess the effects of structured follow-up from primary care after the diagnosis of cancer on satisfaction and healthcare utilization of patients treated with curative intent. To optimise personalised cancer care for a growing patient population and for effective implementation of structured follow-up from primary care, policymakers and professionals need more information on the effects of structured and continuous primary care involvement in the cancer continuum. The GRIP study will provide evidence on the effects on patient satisfaction and healthcare utilization and secondary outcomes. In this pragmatic study, patients with multiple cancer types will be included aiming at high generalizability of the results. It will be explored whether there are subgroups of patients for whom this structured primary care works best.In this protocol some choices were made, that need clarification. First, we chose to assess the addition of structured follow-up from primary care by a GP and HON to care as usual instead of substitution of the supportive care provided in hospitals. This choice was made because we believe it is not feasible nor desirable to completely replace supportive care provided from secondary care by that from the primary care team. In addition, we aim to test the assumption that additional care from primary care will lead to a shift of the utilised care from the secondary to the primary care setting.Second, patient satisfaction and healthcare utilisation are chosen as primary outcomes, since these factors are considered most relevant from the perspective of patient and society. Third, for the secondary outcome ‘patient empowerment’, so far, no uniform definition and no unique measurement tools exist. Therefore, we chose to use two validated questionnaires  to estimate the effect of our intervention on patient empowerment. Although in previous intervention studies during cancer treatment comparable numbers of questionnaires were acceptable, the use of several questionnaires might induce loss to follow-up.Last, we had to choose between random assignment at the patient or the caregiver level. We chose to randomise on patient level, using type of cancer and hospital for weighed randomisation, to ensure optimal comparison of study arms. To minimize the chance of contamination, GPs are only personally informed about the study details after one of their patients is randomised to the intervention. Given the low incidence of cancer in general practice , we accepted the low chance of contamination resulting from the situation were one GP will first have a patient who is randomised to the intervention arm, followed by a patient randomised to the control arm.The recruitment of participants started in April 2015. Patient inclusion will be completed in the first half of 2017. Patient follow-up is completed 1 year after the last patient will have been included.


Pakistan has one of the highest prevalences of child malnutrition as compared to other developing countries. This narrative review was accomplished to examine the published empirical literature on children’s nutritional status in Pakistan. The objectives of this review were to know about the methodological approaches used in previous studies, to assess the overall situation of childhood malnutrition, and to identify the areas that have not yet been studied. This study was carried out to collect and synthesize the relevant data from previously published papers through different scholarly database search engines. The most relevant and current published papers between 2000–2016 were included in this study. The research papers that contain the data related to child malnutrition in Pakistan were assessed. A total of 28 articles was reviewed and almost similar methodologies were used in all of them. Most of the researchers conducted the cross sectional quantitative and descriptive studies, through structured interviews for identifying the causes of child malnutrition. Only one study used the mix method technique for acquiring data from the respondents. For the assessment of malnutrition among children, out of 28 papers, 20 used the World Health Organization (WHO) weight for age, age for height, and height for weight Z-score method. Early marriages, large family size, high fertility rates with a lack of birth spacing, low income, the lack of breast feeding, and exclusive breastfeeding were found to be the themes that repeatedly emerged in the reviewed literature. There is a dire need of qualitative and mixed method researches to understand and have an insight into the underlying factors of child malnutrition in Pakistan. There are 165 million malnourished children under five years around the globe ,3. ChildIt has been estimated that 170 million (30%) of children under the age of five in the world are moderately or severely stunted, and 110 million (19%) are moderately or severely underweight . AccordiDespite economic and social development, childhood malnutrition still remains a major public health and social problem in less developed countries ,14,15. T(i)to identify about the range of methodologies and methods to access the children malnutrition;(ii)to highlight the emerging themes to address the children malnutrition; (iii)to identify the geographical areas that are neglected in this research in Pakistan; and(iv)to provide recommendations for future work.Malnutrition is the underlying cause of child morbidity and mortality in Pakistan. It has not been the priority issue of government of Pakistan to overcome the malnutrition in children. The aim of this narrative review is to collate and synthesize the published data to understand the problem as a whole. The dearth of studies on child malnutrition in Pakistan has evoked the researcher to search for and review the existing relevant literature. The specific objectives of this review article were:Malnutrition is widely known as under-nutrition until and unless it is not specified . MalnutrAs the topic is public health and anthropological relevance, various databases were utilized, including PubMed, Medline, NCBI, CINAHL, Scopus, and social science citation index. A number of keywords and combination of keywords were used to locate the relevant literature, such as “child malnutrition in Pakistan”, “child undernutrition in Pakistan”, “nutritional status of children in Pakistan”, “child health and nutritional status in Pakistan”, and “child health situation in Pakistan”. Furthermore, the list of references of relevant papers was also reviewed to access for more relevant literature on child malnutrition. The most relevant and current published papers in between 2000–2016 were included in this methodological review article. The research papers that contain the data related to Pakistan were assessed. The review papers, case studies, and letters to the editors were not entertained in this study. At the first stage, through different keywords, 178 papers were searched through different search engines using medical subject heading. At the second stage, titles and abstracts were screened for inclusion in the current study, and duplicate and irrelevant papers  were discarded. At the third stage, 69 papers were selected to review the title of the papers. At the fourth stage, the whole abstracts of the selected papers were reviewed and screened, and at the fifth stage, the decision was made to either include or exclude to review the whole article on the basis of full text papers. At the final stage, 28 papers were considered relevant and included for accomplishing this study. Narrative review is a method used to describe trends in the research field by calculating how many studies have used certain research methodologies, where they were carried out and what are the associated factors with problem under investigation. In a narrative review, the statistical analysis is not possible because the previously published studies were diverse in their objectives and questions. Narrative reviews do connect information into themes. The meta-analysis is only suitable for statistical analysis. Meta-analysis can only be undertaken when studies address the same question and administer the intervention in a similar manner or measure the same outcomes . There wIt was observed that in four papers , body maIn 12 papers, the target population of the children was school-age (more than five years), and 15 papers focused on less than five years’ children in the assessment of malnutrition. Different national and international reports have warned that first 1000 days are the window of the opportunity to strengthen the nutritional status of the children ,27,28,29Different other cross-sectional research and regional studies presented varied results in term of stunting, wasting, and underweight according to their methodology and geographical area. The prevalence of child malnutrition according to the studies under reviewed is discussed in Different studies have highlighted that the severity of malnutrition occurs in a particular age group of children. Laghari  and Gul There is rural and urban disparity in the prevalence of child malnutrition across the world. Mushtaq pointed out that in rural areas the prevalence of child malnutrition was higher compared to urban areas . The burGender is an important indicator of child malnutrition. Khattak found there was no significant difference in stunting and wasting in male and female children . Many otAccording to the latest national survey, 31.5% children were stunned, 45% were underweight, and 10.5% were wasted . SimilarMost of the researchers highlighted that socioeconomic, demographic, and lifestyle factors are responsible of malnutrition in children. Associated factors with child malnutrition according to the studies under review are briefly explained in Ansari  pointed Different national and international reports have warned that the first 1000 days are the window of the opportunity to strengthen the nutritional status of children ,59,60. DThere is dearth of qualitative and mixed-method studies on the causes of child malnutrition in Pakistan. In terms of geographical area covered, most of the studies were conducted in the provinces of Punjab, Sindh, and Khyber Pakhtunkhwa, whereas Baluchistan, Azad Kashmir, Gilgit Baltistan, and Federally Administrated Tribal Areas (FATA) were largely neglected by researchers. The prevalence of all types of malnutrition in Pakistan was found to be higher than the global threshold value. It was found that malnutrition starts at an early age and remains persistent at later stages. Most of the researchers employed the anthropometry technique i.e., wasting (weight-for-height), stunting (height-forage), and underweight (weight-for-age) by the NCHS/WHO for assessment of child nutritional status. The most vulnerable age group of children (6–23 months) was entirely neglected to exclusively study infant and young child feeding practices. It was clearly evident that higher intensity of child malnutrition prevails in the rural areas of Pakistan. Early marriages, large family size, high fertility rates with a lack of birth spacing, low income, and the lack of breastfeeding and exclusive breastfeeding were found to be major determinants of child malnutrition. This is the first study to review the range of methodologies and identify the neglected geographical areas and widely used methods of previously published papers assessing child malnutrition in Pakistan. This research will be helpful for further researchers to design their methodology and target population before conducting their research. This study highlighted methodological gaps: preferred techniques for assessing the child malnutrition, varied study designs, and tagged the geographical areas with human development index rating. However, there are some limitations in this study because the previously published papers were published in different time spans, varied types of populations were under-studied, the varied age groups of the children, the small sample sizes, and different natures of the studies. One-fourth of the studies reviewed in this research had sample sizes of less than 200, and it is very difficult to generalize the result of these small-scale studies. The studies reviewed in this research had the three types of the population groups i.e., community-based, hospital-based, and school-based studies. There was much variation in results of all three types of population, and it was difficult to draw conclusion about the causes of child malnutrition. Therefore, it is suggested that the future studies must be clear in the methodological stage for the selection of the homogeneous studies in term of target population, type and nature of the study, and sample size for better understanding the problem under investigation. There is a need for more research with a more homogeneous approach to know the current real situation of child malnutrition in a socio-cultural and demographic context.It is suggested that further studies should focus on the causes of malnutrition in the infancy stage to strengthen the nutritional status of children and that the neglected areas should also be studied to highlight this problem. The major causes of child malnutrition are also associated with the mother’s reproductive health care behavior, maternal diet, and autonomy. It is therefore suggested that further research also study the maternal factor while exploring the causes of child malnutrition. There is also a need to know about the diet and type of food that mothers prefer to give their children while exploring the causes of child malnutrition. Therefore, it is also suggested that the dietary diversity (DD) recall method should also be utilized to know about the preferred food that mothers give to their children. The component of micronutrients deficiency was entirely omitted under discussion of the previously published research. It is recommended that the micronutrient assessment should be a component of future research for a better understanding of the type of malnutrition. There is also the dire need of qualitative and mixed-method research to understand and highlight the cultural and lifestyle factors that cause child malnutrition in Pakistan.


Over the past decade, there have been massive developments in both Web-based and mobile phone technologies. Mobile phones are well accepted by students, trainees, and doctors. A review of the current literature has identified the following specialties that have used mobile phones in education: pediatrics, ophthalmology, nephrology, plastic surgery, orthopedics, pharmacology, and urology. However, to date, there are no published papers examining the application of the latest mobile phone technologies for psychiatry education internationally.The main objectives of this study are (1) to determine the feasibility and receptiveness of a locally-developed psychiatry mobile phone app and user perspectives  towards it, and (2) to determine the receptiveness of a locally-developed app for psychiatry education internationally.A Web-based app that contained textbook contents, videos, and quizzes was developed using HTML5 technologies in 2012. Native apps were subsequently developed in 2013. Information about the apps was disseminated locally to Singaporean medical students, but the respective native apps were made available on the app stores. A user perspective survey was conducted locally to determine student’s perception of the app.24=12.9, P=.0012).From the inception of the app until the time of preparation of this manuscript, there have been a cumulative total of 28,500 unique visits of the responsive HTML5 Web-based mobile phone app. There have been a cumulative total of 2200 downloads of the Mastering Psychiatry app from the Apple app store and 7000 downloads of the same app from the Android app store. The initial user perspective survey conducted locally highlighted that approximately a total of 95.2% (177/186) of students felt that having a psychiatry mobile phone app was deemed to be useful. Further chi-squared analysis demonstrated that there was a significant difference between males and females in their perception of having textbook contents in the mobile phone app (χTo the best of our knowledge, this is the first study to demonstrate the feasibility and global acceptance of a local, self-designed educational app for psychiatry education. Whilst the current research has managed to demonstrate the feasibility and acceptance of such an app, future studies would be warranted to look, in-depth, into whether there are cultural differences in terms of perceptions towards having such an app in psychiatry and what contents different cultures and cohorts of students might want within an app. Over the past decade, there have been massive developments in both Web-based and mobile phone technologies. It was perhaps the release of Apple’s iPhone in 2007 and the launch of the Apple App store in July, 2008 that was pivotal in causing a huge change in the way the world uses mobile phone devices. Mobile phones with app capabilities are considered to be a new generation of mobile technology, that are equipped with immense computing capabilities allowing individuals to have constant access to the internet and make use of various apps .Previous studies have looked into medical students and trainee’s ownership and perspectives towards mobile phone usage. In 2012, a questionnaire-based survey was distributed amongst the interns in the Republic of Ireland . PreviouA review of the current published literature on several databases has identified the following specialties to be using mobile phone technologies in education: pediatrics, ophthalmology, nephrology, plastic surgery, orthopedics, pharmacology, and urology. For example, in pediatrics, a mobile phone neonatal intubation app was deployed to enhance overall intubation skills . In ophtWe hope to make use of the latest Web-based and mobile phone technologies in implementing both a Web- as well as a native mobile phone-based psychiatry textbook companion for undergraduate students in psychiatry, as a means of overcoming the limitations in the current literature. In addition, we hope to be able to determine local and international users' receptiveness towards such an innovative methodology of acquiring psychiatry knowledge.The main objectives of this study are (1) to determine the feasibility and receptiveness of a locally-developed psychiatry mobile phone app and user perspectives  towards it, and (2) to determine the receptiveness of a locally-developed app for psychiatry education internationally.A newly written textbook (jointly written by the authors MWBZ and RCMH of this study) that integrated both local (Singapore) and United Kingdom clinical guideline was initially crafted in 2011. The core textbook contents are comprised of chapters, which include subjects in the areas of psychopathology, clinical interview, formulation and management, schizophrenia and psychotic disorders, mood disorders, anxiety disorders, personality disorders, substance misuse and dependence disorders, eating disorders, psychiatric emergencies, psychotherapies, sleep disorders, psychosexual disorders, somatoform and dissociative disorders, consultation liaison psychiatry, old age psychiatry, child and adolescent psychiatry, and forensic psychiatry and psychiatry ethics. As the book was self-published by the authors of this study, the copyrights of the chapters belonged to the authors and hence no permissions were required to reproduce the materials in the mobile phone app. In addition, the authors filmed videos demonstrating assessment methodologies for the various psychiatric disorders locally in Singapore .VideosPsychosis: history takingDepression: history takingAnxiety: history takingExplanation of antidepressantsExplanation of cognitive behavioral therapyAssessment of borderline personality disorderSuicide risk assessmentExplanation of electro-convulsive therapy treatmentFrontal lobe examinationMini mental state examinationExplanation of lithium therapyExplanation of neuroleptic malignant syndromeViolence risk assessmentExplanation of dementia medicationsSleep disorder assessmentThe core textbook materials, as well as the videos, were then integrated into a Web-based mobile phone app. The Web-based mobile phone app was programmed using an online app builder and a blogging website using both HTML5 and Java-script coding. Videos were stored online on a video-hosting website (Vimeo) , and embIn 2013, the authors MWBZ and RCMH were offered an educational grant for the development of a native Apple- and Android-based mobile phone app. The English language version of the Apple IOS and Android Play apps were made available for free on the app stores in late 2013. Given that the apps were made available for free downloads, no proceeds arose from their downloads.Information about the app was disseminated via printed materials locally in Singapore, as well as by means of a short demonstration to undergraduate students at the National University of Singapore, Yong Loo Lin School of Medicine on the first day of their clinical psychiatry posting. With ethics approval from the National University of Singapore, a user perspective survey was administered to students immediately after the end of their posting test to determine user’s perspectives towards the usefulness of such an app.The Web-based mobile phone app, Mastering Psychiatry , was lauWith regards to the utilization of the native apps, there have been a cumulative total of 2200 and 7000 downloads of the Mastering Psychiatry app from the Apple and Android app store, respectively . To our A cumulative total of 185 students voluntarily participated in the user perspective survey. The mean age for males was 22.3 years (SD 0.8) and that for females was 22.0 years (SD 0.4). The majority of the students  used an Apple IOS device, whereas 21.6% (49/227) of the students used an Android device. The majority of the students  had between 1-5 medical apps in their mobile phones. The medical apps they had previously downloaded were mainly used for educational purposes as well as for use in the clinics and wards. In terms of student’s perception about the utility of the app, a total of 95.2% (177/186) of the students indicated that having a psychiatry mobile phone app would be useful. The majority of the students wanted the app to contain textbook content and clinical videos and found these features particularly useful. Students perceived that an event management system within the app would be helpful for coordinating the tutorials. A total of 57.1% (105/184) of the students agreed that the app for psychiatry was helpful, and 71.4% (132/185) of the students agreed that a mobile phone app would be a good companion to a traditional textbook.24=12.857, P=.0012). There were no demonstrated significant differences between the genders in terms of their perception of having an app in mastering psychiatry, having clinical videos in the apps, having revision lecture videos in the apps, having text messaging notification services in the app, and in terms of the usefulness of the app, and whether the app was a good companion to a book. Further chi-squared analysis demonstrated that there was a significant difference between males and females in their perception of having textbook contents in the app . Thematic analysis was conducted and qualitative feedbacks are summarized in To the best of our knowledge, this study is one of the first to demonstrate the success of the implementation of mobile phone technologies for educational needs in psychiatry. The initial findings demonstrate the feasibility and acceptance of mobile phone apps for psychiatry in Singapore, as well as the feasibility and acceptance of psychiatry-focused apps globally. Our initial findings show that Asian students are amenable to using an online portal for their educational needs in psychiatry. In addition, a significant group of Asian students are amenable to trying newer modalities of technology, such as mobile phone technologies, to help them fulfill their mobile educational needs. The user perspective survey results show that a high proportion of students would like an educational psychiatry app to contain textbook-based content, clinical OSCE videos, and an event notification service. A high proportion of students concurred with the perception that a mobile phone app would be helpful in psychiatric education and that a mobile device could be a viable alternative to a traditional textbook. We postulate that the gender differences identified with regards to having textbook content in apps might be due to differences in learning methods between the genders. Of importance, no significance differences were found between the genders in the other domains, highlighting that the other materials included appealed to both genders and did help them with mastering a specialized topic matter.The usefulness of mobile phone apps for education has been supported by prior research. Tripathi et al  conducteAnother recent study published in 2014 by Heeyoung Han et al  examinedPerhaps the closest correlation with our current study is by Waldmann and Weckbecker . They deThe main strength of the current study is the demonstration of the feasibility of implementation of a mobile phone app for psychiatry both locally and internationally. The current study has also managed to demonstrate that local Singaporean students perceive mobile phone apps in psychiatry positively. This study also consistent with some of the findings of other studies with regards to the usage of apps for education.There are several limitations to the current study. We acknowledge that while there is a good number of viewership of our Web-based app, we do not have the absolute number of individual users who have downloaded the app, as we are limited by the database being able to only track individual unique access. This information, in conjunction with the platform that users view the app, is crucial in terms of designing future educational apps, as well as planning future studies. In addition, our perspective survey has only been administered to a local cohort of students and might not be entirely representative of the views of the global audience. To mitigate this limitation, we would need to find liked-minded individuals from organizations overseas to collaborate and perform a comparative study with regards to user perception of our educational app.This study is one of the first to demonstrate the feasibility and the global acceptance of a local, self-designed educational app for psychiatry education. Whilst the current research has managed to demonstrate the feasibility and acceptance of such an app, future studies are warranted to look in-depth into whether there are cultural differences in terms of perceptions towards having such an app in psychiatry and what contents different cultures and cohorts of students might want within an app.


This case report discusses the diagnosis and management of a 67-year-old male presenting with a spontaneous transdiaphragmatic intercostal hernia with contralateral intercostal hernia. The patient had a history of chronic obstructive pulmonary disease (COPD) exacerbations requiring multiple prolonged courses of steroids. The patient was ultimately diagnosed with computed tomography (CT) and underwent surgical repair via thoracotomy with primary repair of the diaphragmatic defect. The patient's postoperative course was uncomplicated. A review of the literature since the first similar case in 1977 recognizes the propensity of this injury to be found in patients with COPD and chronic steroid usage, as well as its diagnosis and management. The case reviewed is the second documented case of a concurrent abdominal wall herniation and the first one with a contralateral injury. It is important for clinicians to be aware of this pathology when evaluating patients with COPD and chronic steroid usage.  The authors report a rare case of combined cough-induced transdiaphragmatic and abdominal intercostal hernia with associated rib fractures, visceral herniation, and contralateral abdominal intercostal hernia, as well as the management of this condition, and a review of the literature to date. These findings are typically the result of blunt trauma; it has been rarely appreciated in the literature in atraumatic patients following episodes of severe coughing or exertion, as is the case in this report .A 67-year-old male was referred to the authors after undergoing chest X-ray (CXR) with evidence of left-sided rib fracture and pleural effusion on 27 January 2015. The patient had developed an intractable cough in December and was started on prednisone and antibiotics by a pulmonologist. The patient was admitted with COPD exacerbations twice in January for intravenous steroid and antibiotic therapy. Following the second time of hospitalization, the patient had some improvement and was discharged on a steroid taper.Three days following discharge, CXR and dedicated left-sided rib films showed a displaced left 8th rib fracture and left-sided effusion. Physical examination was notable for a 10 × 15 cm mass of the left chest flank associated with ecchymosis. The patient was also seen to have paradoxical motion of this mass with respiration. When lying in the right lateral decubitus position, there was note of concavity at the left 8th rib space. The patient denied respiratory distress but did exhibit decreased breath sounds on the left side. A CT was obtained with evidence of rupture of the left hemidiaphragm measuring 11.4 cm with herniation of omentum, splenic flexure, stomach, and anterior spleen into the chest cavity. There was displacement of bilateral 7th and 8th ribs with a left-sided 8th rib fracture and herniation of the abdominal contents through the intercostal space Figures . This heGiven the complex nature of the injury, surgical repair of the diaphragm and hernia was required. The patient underwent a left posterolateral thoracotomy; the incision was made over the defect in the chest wall. Omentum, transverse colon, and stomach were encountered in the extrathoracic hernia sac. These structures were mobilized into the peritoneum; there was no evidence of ischemia and therefore no resection was required; the hernia sac was excised. The diaphragmatic rupture was repaired with 2-0 pledgeted prolene. Immediately following the repair, the patient had a severe coughing episode intraoperatively resulting in tearing of the medial portion of the repair. Because there was not enough healthy diaphragm to repair the new defect primarily, a dual mesh Gore-Tex patch and 2-0 pledgeted prolene were used to close the defect. The left lower lobe was then reinflated and the intercostal defect was repaired with heavy vicryl figure-of-eight pericostal sutures. Two chest tubes were left in place.The patient recovered without further incident; a steroid taper and antibiotics were continued upon discharge. The authors have no plans for repair of the right-sided defect as it is asymptomatic and without herniation of bowel. The patient has been seen in follow-up through December of 2016, nearly two years after initial presentation. At that time, the patient had no evidence of recurrence and was exercising regularly without exertional dyspnea or chest pain.An injury in which the abdominal viscera herniate through the diaphragm into the thoracic cavity and through the chest wall is known as a transdiaphragmatic intercostal hernia (TDIH). This requires two distinct defects and is often associated with rib fractures at the intercostal hernia , 2. TDIHOne of the mechanisms behind rib fractures associated with violent coughing is postulated to be similar to a stress fracture in that the force applied from the cough exceeds the elasticity of the bone. Another thought is that the fracture is associated with the opposing forces of the intercostal, diaphragmatic, abdominal, and serratus muscles on the rib . This exTDIH is typically noted initially on CXR; ultrasonography, magnetic resonance imaging (MRI), and direct visualization have also been used to make the diagnosis. The best modality, however, appears to be CT , 9. TDIHIt has been postulated that, given the high incidence of COPD in these patients, they are often on long term or frequent doses of steroids, as was the patient presented. Concomitant use of steroids was also documented by Rogers et al.  and KallA review of the literature revealed a total of 14 cases of TDIH, the oldest dating back to 1977. These cases as well as the one presented are reviewed in Based on the literature review, it seems that the most common symptoms associated with spontaneous TDIH are pain, protrusion/swelling, and ecchymosis. An important aspect in the physical exam is that when the patient lies in the lateral decubitus position on the side contralateral to the injury, there is a concave defect noted at the hernia site, often with paradoxical motion . This paDefinitive management of a TDIH is primarily surgical. In the authors' review, all cases required surgical repair except for one which is pending optimization, though definitive management is planned. Repair typically consists of a thoracotomy over the defect; however, an abdominal approach has been utilized in two of the cases, and a thoracoabdominal approach has been utilized in three cases. The hernia defect is reduced with excision of the hernia sac and repair of the diaphragmatic defect. This can be done primarily or with mesh, as in the case presented. Finally, the intercostal defect is reapproximated and the incision was closed. Evidence of ischemia or necrosis mandates excision of that portion of bowel. Chest tube drainage of the thorax is also employed , 9, 12.Spontaneous TDIH is a rare complication of sudden changes in diaphragmatic-peritoneal pressure gradient. There are currently 15 cases reported in literature, this case being the second with a combined thoracic and abdominal component and the first with a contralateral injury as well. This injury can quickly progress given the nature of the constant force of the diaphragmatic, intercostal, and abdominal muscles, which can lead to strangulation. It is important for clinicians to have a high index of suspicion for this etiology, particularly in patients presenting with ecchymosis and a painful bulge in their chest following severe coughing or straining. Patients with suspicion for this pathology should undergo CT for diagnosis and should be definitively managed with surgical repair.