Violence at work is one of the major concerns in health care activities. The aim of this study was to identify the prevalence of physical and non-physical violence in a general health care facility in Italy and to assess the relationship between violence and psychosocial factors, thereby providing a basis for appropriate intervention.All health care workers from a public health care facility were invited to complete a questionnaire containing questions on workplace violence. Three questionnaire-based cross-sectional surveys were conducted. The response rate was 75 % in 2005, 71 % in 2007, and 94 % in 2009. The 2009 questionnaire contained the VIF (Violent Incident Form) for reporting violent incidents, the DCS (demand/control/support) model for job strain, the Colquitt 20 item questionnaire for perceived organizational justice, and the GHQ-12 General Health Questionnaire for the assessment of mental health.One out of ten workers reported physical assault, and one out of three exposure to non-physical violence in the workplace in the previous year. Nurses and physicians were the most exposed occupational categories, whereas the psychiatric and emergency departments were the services at greatest risk of violence. Workers exposed to non-physical violence were subject to high job strain, low support, low perceived organizational justice, and high psychological distress.Our study shows that health care workers in an Italian local health care facility are exposed to violence. Workplace violence was associated with high demand and psychological disorders, while job control, social support and organizational justice were protective factors. The problem of aggression towards health care staff is global and on the increase ,2. It isIt is difficult to analyze the literature on health care violence because of differences in definitions and methods . There aAnother issue which needs to be clarified is the relationship between violence and organizational justice, a psychosocial variable which has emerged in recent years as a determinant of workers’ health . A previThe Italian Ministry of Health recently issued a Recommendation specifically calling for the prevention of violence in health care facilities . HoweverThe purpose of this study is: (1) to evaluate the prevalence (one-year incidence) of physical and non-physical violence in an Italian local health care facility from 2005 to 2009; (2) to study the association between violence and psychosocial variables in order to promote the adoption of preventive measures. To overcome the aforementioned epidemiological problems we chose to administer questionnaires during periodical medical examinations at the workplace.District I of the Local Health Care Facility RMF (Civitavecchia) includes one hospital and some local health services. This study included all workers undergoing workplace medical examination who had been employed in that facility for at least one year (676 subjects). Periodical medical examination is compulsory in Italy for all employees exposed to occupational risks . The physician responsible for the medical surveillance of workers (NM) was not on the company staff, but was a university employee who had been working as a consultant for the facility since 1999 and had therefore gained the workers’ confidence. For many years the workers had been accustomed to completing questionnaires while waiting for medical examination so they were aware that the questionnaires were anonymous and that the results would be used in their interest. Most of the workers chose to complete the questionnaire, although participation was not obligatory. In order to avoid coercion, workers completed questionnaires in a separate room while waiting for medical examination; the occupational physician was unaware of the workers’ decision. In order to guarantee privacy and anonymity, demographics were limited to gender, age, job and department. The Ethics Committee of the Catholic University School of Medicine approved the study design.The present data consist of three cross-sectional surveys conducted in 2005, 2007 and 2009. We chose a two-year period for our surveys in order to avoid duplicate reporting. In the 2005 and 2007 surveys, workers were invited to report their experience of violence at the workplace over the previous 12-month period, making a distinction between physical and non-physical aggression. In addition to single-item questions on the occurrence of physical and non-physical violence, in 2009 the questionnaire included domains on mental health, job stress and organizational justice.Respondents were allocated to groups according to the department in which they were employed at that time.Physical aggression is defined as forceful, hostile or aggressive behavior which may or may not cause harm. A threat refers to the menace of causing harm. Verbal  aggression is defined as any annoying or unpleasant act  that creates a hostile work environment. Harassment is defined as behavior characterized by insistent requests, messages, phone calls or other unsolicited contact that may cause annoyance, worry or fear.The characteristics of incidents were studied using the Italian version of the VIF (Violent Incident Form), a validated questionnaire proposed by Arnetz for the registration of violent incidents in the health care workplace  and prevMental health was assessed by the 12-item version of the General Health Questionnaire (GHQ-12)  in its IJob stress was evaluated by Karasek’s demand/control/support model . The 17-The perceived level of justice at work was assessed by the Justice Measurement questionnaire  in its IAnalyses began with basic descriptive statistics on the sample and the consequences of reported events, and crude estimates of event rates. For each respective year, comparisons between groups were made by chi square and one-way ANOVA statistics.Logistic regression analysis was used to study the association between individual and occupational variables and the reporting of aggression in the entire period from 2005 to 2009.In the 2009 survey, the association of psychosocial variables with violence was also studied by logistic regression analysis. Univariate models included each job stress variable , organizational justice, and psychological distress. Significant associations were then studied using multivariate models adjusted for age, gender, job and department type. Odds ratios (OR) and 95 % confidence intervals (CI) were calculated.The statistical package PASW/SPSS 15.0 was used for the analysis.1,166 out of a total of 1,455 workers  took part in the survey. The average participation rate of 80.1 % ranged from a minimum of 71 % in 2007 to a maximum of 94 % in 2009. Table p = .685).Across the entire study period, a total of 107 workers 9.2 %) reported suffering a physical aggression in the twelve-month period preceding the survey; 101 reported suffering threats and 229 (19.6 %) reported being the victims of verbal aggression. In 2009, 25 workers (5.5 %) reported being the victims of harassing behavior . Females were the principal victims of harassment, but the difference in this case between males and females failed to reach significant levels Table . Gender Nurses and doctors were the professional groups most exposed to physical aggression and threats. A comparison with all other workers indicated that both nurses and physicians were at greater risk of physical and non-physical violence Table . HoweverResults showed that workers in psychiatric and emergency services are those at greatest risk of physical aggression, since about half of all violence of this kind is concentrated in these health care areas. Psychiatric service workers reported 40 episodes of physical violence . If the risk of a worker engaged in business services  is taken to be one, the risk of physical violence for employees in mental health services is twenty-two times higher  and the risk of being threatened as much as twenty-seven times higher (OR 27.8 95%CI 11.5-67.5). Twenty cases were reported  in the Accident and Emergency Department. Staff in accident and emergency departments were at a significantly higher risk of violence . The remaining episodes of violence were reported by workers in medical and surgical wards , in outpatients  and services . Workers in surgical and medical wards reported a higher risk of violence  than service workers  reported that they had been physically assaulted in the previous 12-month period, and 75 more workers reported experiencing at least one upsetting episode of physical aggression in the past; overall, 120 workers (26.5 %) reported at least one incident involving physical aggression during their professional lives  reported having been exposed to non-physical violence and described their experience. Patients , their relatives and friends  were responsible for more than half of these episodes; most of the remaining cases of violence were perpetrated by colleagues or superiors .The consequences of physical and non-physical violence included anger, disappointment, anxiety, distress and the intention to move to another place of work or to perform professional duties in a different way.The occurrence of workplace violence was severely under-reported to health or police authorities. Even though we asked for a description of the worst episode of violence experienced, only about half of these incidents had been reported either to a colleague or a friend. Only in exceptional cases was a report made to the Accident Department or the police Table .Logistic regression analysis Table  showed tA significant proportion of our sample reported experiences of workplace violence. We found that employees who experienced verbal violence in clinical settings had lower levels of perceived organizational justice and social support, higher levels of work-related stress and higher psychological problem scores than other HCWs. An important finding that emerged from this study is that isolated workers  are exposed to violence, and that employees who experience violence are psychologically distressed. They manifest high levels of job strain and perceive their health care facility to be unfair. We also observed an interesting association between lifetime exposure to internal non-physical violence and low job control. Perceived control is a measure of power in the organization and it is significant that verbal violence, which is an abuse of power, is exerted by colleagues on workers with less authority. The cross-sectional nature of our study prevents us from indicating a definite cause for the association between violence and psychosocial variables. However, the association of workplace violence with high demand and psychological disorders, and the protective role of job control, social support and organizational justice suggest that preventive programs should target these variables.The repercussions resulting from violence in the workplace are important as they can lead to a deterioration in staff health. A systematic review of studies on aggression showed that despite differences in countries, cultures, research designs and settings, the responses of health care workers to patient aggression are similar and include immediate responses such as frustration, fear, anger or anxiety ,43. ThesAs expected, nurses were the category most exposed to physical violence. Nurses are more likely to encounter aggressive behavior because of the amount of time they spend providing direct patient care. Studies show that the chances of suffering physical violence are 7.2 and 9.0 times greater for healthcare workers with moderate and high patient contact, respectively, than for those with little or no contact . In our Respondents from the psychiatric department experienced the highest overall level of patient-initiated aggression. One out of three workers reported being assaulted in the previous year, and almost three quarters of these workers had experienced physical violence during their working life. The A&E (accident and emergency) department also seemed to be a particular target for physical and verbal aggression. More than half of all the reported cases of physical and verbal violence had occurred in these high-risk departments. A high prevalence of violence in psychiatric settings has been observed in earlier studies  and confOur study has several limitations. Firstly, since our investigation was limited to a single health care district, we cannot extend our findings to all Italian health care services. However, our results are in agreement with the literature, and we have no evidence to suggest that the situation is different in other health care facilities.Secondly, the survey was a retrospective one, with the usual limitations of inaccurate recall of past events and of possible contamination by current events. However, the repeated measurement of aggression rates over time and their relative stability indicate that the phenomenon exists. The present study had a high participation rate compared to other similar studies on this topic, thereby increasing our confidence in the results.Thirdly, this study was limited to an exploration of abuse from a worker perspective; no attempt was made to validate the episodes reported. In fact, no objective criteria for misconduct were specified, and the findings presented here should be considered hypothetical. What workers perceived as misconduct may not constitute misconduct in an objectively ethical or legal sense. However, it is the perception of the event and not the event itself that may have the greatest impact on the individual . It has Fourthly, the present study relied on self-reported measurements, which could lead to problems associated with an inflation of the strength of relationships and with the common method variance. However, to minimize problems with self-reports we used well-known validated questionnaires that have shown good reliability. Moreover, although we attempted to exclude all possible confounders, we cannot rule out the existence of residual confounding.Our study has some strong points. The collection of data on the part of a physician who was not a direct employee of the health care facility, but who had a direct knowledge of workplaces and had had a long-lasting relationship with workers, increased the response rate and reduced the likelihood of inappropriate responses. Furthermore, this method could encourage workers to take part in prevention by suggesting possible remedies for workplace violence.We fully agree with the suggestion of the Italian Ministry of Health that an assessment of violence is necessary in all health care organizations. No paramount episode of violence had been reported to the occupational physician before workers began completing the questionnaires.In conclusion, our study corroborates previous reports of frequent physical and verbal aggression towards HCWs. In a standard public health service, nurses and doctors working in psychiatric services and accident and emergency departments are the most exposed to attacks. Abused workers suffer higher job stress, greater psychological distress, have a greater sense of injustice and lower social support than other workers. It is likely that a mutual increase occurs between workplace violence and psychosocial problems.Violence at work is a hidden phenomenon and in most Italian health care facilities there is no policy for prevention. Our study indicates that the problem exists and that prevention is essential.Most of the physical aggression and a significant proportion of the verbal aggression experienced by clinical staff are the result of patient interactions and generally regard clinical issues arising from patient care. Training workers in good working practices and alternative methods of resolving disputes is generally seen as the way to reduce the likelihood of this type of aggression , especiaOur experience indicates, however, that a significant proportion of the violence encountered in the clinical setting is perpetrated by other health care workers and it is this latter form of violence that is most closely linked to psychosocial variables. Traditional methods, such as the development of personal safety skills and de-escalation techniques, or institutional policies and environmental design may not be sufficient to prevent this kind of violent behavior. These should therefore be integrated with specific intervention targeted at root causes such as conflict in the workplace. The association of violence with psychosocial variables indicates the need for far-reaching changes in health care organization that should include decision-making procedures, work climate and support, and relations between workers. Counteracting violence requires strong commitment on the part of both workers and management.The authors declare that they have no competing interests.NM devised the study and collected and processed the data; TH revised the statistical analyses and helped to draft the manuscript. All authors read and approved the final manuscript.No funding was received by the first author for the study or preparation of the manuscript. Tarja Heponiemi was funded by the Academy of Finland (project no: 128002).The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/108/prepub


Myelopathy at the level of the atlas is rarely encountered by the practicing spine surgeon. Due to the region's unique anatomy, compression of the cord at this level is either caused by a large compressing lesion or an abnormally stenotic canal. We describe a rare instance of a congenitally stenotic canal due to a hypoplastic intact posterior arch of atlas, coexisting with an extremely rare ossified transverse ligament of the atlas. The coexistence of these two lesions has only been documented thrice before. We describe the clinical presentation, imaging findings, and favorable response to surgery. Hypoplastic intact posterior arches of the atlas and symptomatic calcification of the transverse atlantoid ligament are very rarely seen at the craniovertebral junction, Having only been reported 17 and 15 times, respectively, in the literature .We present a case of cervical myelopathy attributable to atlas posterior arch hypoplasia and an ossified transverse ligament, whose coexistence led to the slow development of cord compression and myelopathy. We present the radiologic appearance of these lesions and surgical management, to which the patient responded favorably. We also conducted a literature review and an attempt to explain why these may have coincided in our case.This is the fourth such case in the literature, with two being identical to ours having both lesions concurrent , 4, whilA 68-year-old Saudi female presented with progressive deterioration of her walking and gait balance for 5 months. She has long history of cervicalgia for several years. There was no history of head or neck trauma or rheumatological diseases. General physical examination was normal, without cervical spine tenderness or limitation of range of motion. Neurological examination revealed normal cognitive function and cranial nerves. She had significant quadriparesis, where she was not able to raise her arm above her shoulders level and was unable to stand. Her weakness was more marked on the right side that was associated with hypoesthesia of the upper extremities, hyperreflexia in all limbs, and positive Babinski's sign. Routine laboratory tests, including CBC, electrolytes, renal, and hepatic profiles, were within normal. Her cervical X-rays revealed multiple degenerative disk diseases without evidence of instability on dynamic views. Magnetic resonance imaging (MRI) of the cervical spine revealed severe canal stenosis at the level of the atlas with significant cord compression Figures . The posCervical canal stenosis is rarely encountered at the level of the atlas. This is due to the region's anatomy protective against compression, with the canal diameter at the retrodental level being between 17 to 25 mm while the spinal cord diameter at that level is 10–12 mm in diameter [Although the majority of anomalies at the level of atlas reported in the literature are defects of either arches of atlas , these rHypoplasia of an intact posterior arch of the atlas as a cause of symptoms has only been reported 16 times in the literature . Anomali Presentation is usually in middle age, with the exception of two cases of juvenile onset, both of who were Caucasian . The reaThis stressor may be in the form of trauma, or the gradual degenerative changes of age-related spondyloarthropathy . AlthougThe usual presentation is with myelopathy , and diaResponse in reported cases has been favorable to simple posterior decompression with a C-1 laminectomy. This is to address the canal stenosis, but since the anomaly is rarely the sole cause of the canal stenosis, the other stressors have to be addressed and if needed, surgically corrected . Calcification and ossification of the transverse atlantoid ligament is a disease suggested to be part of the spectrum of vertebral ligament ossification . A recenCauses of paravertebral ligament calcification are numerous and not different from those of ligament calcification elsewhere, these include insulin resistance, calcium pyrophosphate dihydrate deposition diseases, rheumatoid arthritis, advancing age, obesity, and perhaps a genetic predisposition . AnotherDiagnosis of TAL calcification is by CT, showing a calcified retro-odontoid mass following the contour of the TAL. MRI would be useful for CVJP as it better displays the noncalcified portions in addition to neural element compression. Contrast is usually unnecessary; it may reveal an inflammatory element, especially when associated with arthritides .The management of transverse ligament calcification should then be both targeted at the underlying cause of calcification , the calcified ligament itself if symptomatic, and its effect  if present .The natural history of this disease is similar to that of cervical spondylosis; it has been displayed in several instances that, with the continuous degenerative forces causing ligament injury, hypertrophy and ossification, these masses can attain considerable size thereby causing myelopathy . We beliWe cannot come up with a reason as to why this is the first and only encounter our institution would have with these entities and why this is the first case to be reported in the whole of the Middle East and North Africa region. This could either be due to a unique characteristic of our demographic or simply due to unfamiliarity to this disease from the part of clinician, radiologist, or pathologist . It has A newly emerging concept is to regard TAL ossification, AAOA, and AAI all as, perhaps, part of the craniovertebral junction's peculiar spondylotic process , 16. A rWe regret the fact that we only realized the full scope of this anomaly in retrospect, with the patient lost to follow up. With the many associations in the reviewed literature, we would have been more vigilant in searching for them in the patient herself and her family. We present a rare cause of myelopathy in our population, with none of the reported cases being in natives of the MENA region, despite the ubiquity of its risk factors. Studies are showing that ossification of the transverse ligament of atlas, if incidentally found, is not to be considered of no significance, but as a marker for local degenerative changes or systemic syndromes. Its presence should entail a thorough search for the growing list of reported associations. A thorough understanding of its significance, pathophysiology, and natural history will only be possible with more cases being reported and studied; this is only possible by increasing awareness among the medical community.


Purpose. To determine whether the rate of graft detachment in patients undergoing the DSAEK procedure is influenced by the time elapsed between donor death and tissue implantation. Methods. Data on procedure outcome and donor tissue for patients undergoing the DSAEK procedure were reviewed. Data on time elapsed between harvest, processing, storage, and implantation of the tissue, as well as donor tissue endothelial cell count were obtained from reports made available from the Eye Bank of Canada. The adverse outcome of interest was graft detachment. Results. 71 cases were reviewed, with 14% resulting in detachment. The following time periods were compared between detachment and nondetachment groups: donor death to enucleation; enucleation to processing; duration of storage at the Eye Bank to implantation. No statistically significant differences were found . Endothelial cell counts of donor tissue were compared between the two groups, and no statistically significant difference was found . Conclusion. The range of processing times and endothelial cell counts in donor tissue available from the Eye Bank did not predict a change in the rate of graft dislocation in one surgeon's practice. The Descemet's stripping automated endothelial keratoplasty (DSAEK) procedure is primarily used to treat corneal endothelial dystrophies , and morIn Ontario, procured donor tissue is sent to the Eye Bank of Canada before being shipped to the transplanting surgeons for implantation. A period of time, typically hours, passes between the death of the donor and enucleation of the eye, and between enucleation and processing. The tissue then spends a period of days in storage at the Eye Bank before implantation in the recipient eye. Currently all DSAEK donor tissue is prepared by individual surgeons in Ontario at the site and time of transplantation, as precut DSAEK tissue is not available.It is our hypothesis that a greater period of time spent in storage prior to processing results in a greater loss of tissue viability and concordantly leads to a higher rate of detachment. Additionally, it is hypothesized that a higher endothelial cell count indicates better tissue function and results in a lower detachment rate. The primary aim of our investigation is to determine whether these factors play a predictive role in tissue detachment in one surgeon's practice.Data on donor tissue and procedure outcome were collected through a retrospective chart review of all patients in one academic surgeon's practice at Hotel Dieu Hospital in Kingston, Ontario. The investigation included all of the senior author's DSAEK patients from April 1, 2007 until March 30, 2010. Ethics approval was obtained through the Department of Health Sciences Ethics Review Committee.All procedures were performed by one surgeon, the senior author. For all procedures the surgeon cut the donor tissue minutes prior to implantation in the patient. All tissue was cut using a Moria microkeratome, with a 300 micron head. No major problems occurred in preparing the tissue that might have contributed to DSAEK button detachment. All procedures were performed similarly, implanting the donor tissue using Goosey folding forceps. Four venting incisions were used in all patients, and interface fluid was drained via these incisions in all patients until no further fluid could be drained. All patients had a complete fill of air in their anterior chambers for 15 minutes after the drainage of fluid from the venting incisions, and about 50% of the air was removed just prior to concluding each case, to ensure no papillary block developed. All patients were kept in the recovery area, lying flat for 1 hour postoperatively. All patients were routine cases undergoing DSAEK for Fuchs' Endothelial Dystrophy or pseudophakic bullous keratopathy. None had complex anterior segments for any reason.Data on length of time between donor death and tissue procurement, procurement and processing, and time spent in storage were taken from the Eye Bank reports that accompany the donor tissue. Preoperative endothelial cell count of the donor tissue was also taken from this document. Clinic reports on followup were reviewed and any evidence of tissue detachment was recorded.A total of 71 procedures were performed during the period of study, with 10 resulting in postoperative tissue detachment. This corresponds to a detachment rate of 14%.Duration of time spent between enucleation, processing, and implantation, as well as endothelial cell count for the detachment and nondetachment groups are summarized in t-test. This showed no statistically significant difference between the two groups, with the P values reported in The time spent in each phase of processing was compared between the detachment and nondetachment group using a paired Student's t-test, again showing no statistically significant difference between the 2 groups.Endothelial cell counts of the two groups were similarly compared using a paired Student's As demonstrated by our results, there was no statistically significant difference in the storage and processing times between the detachment and nondetachment groups. This suggests that slight variations in donor tissue processing and storage times do not result in a higher incidence of DSAEK graft dislocation. This of course would apply only to this surgeon's practice, but may warrant further investigation. Also, it would only include intraoperatively prepared donor tissue and not precut tissue, prepared by the Eye Bank. However, Dapena et al. described success with a range of ages of precut tissue, suggesting that this result may apply to precut tissue as well . They diEndothelial cell count was also found not to be significantly different between the two groups, within the population of donor tissue available from the Eye Bank. Contrary to our initial expectation, the average cell count was actually slightly higher in the detachment group than in the nondetachment group, though this did not reach statistical significance.These findings must be considered in light of the limitations of our study. The main limitation to this study is its limited scope, including only the practice of one surgeon. Perhaps a greater sample size could have shown a statistically significant difference. Additionally, the lack of precut tissue in our evaluation must be considered.Neither length of processing time nor endothelial cell count appears to be significant predictors of graft dislocation in DSAEK procedures in one surgeon's practice. This suggests that in Kingston, all donor tissue from the Eye Bank being cut by the surgeon at the time of surgery has an equal chance of being successfully implanted, with the determinant of procedural success lying in the technique of the attending surgeon. A future direction for study could include various surgeons looking at their dislocation rates to see if this is the case in general, or that it was an isolated finding in one surgeon's practice.


Hemi-hydranencephaly is a very rare condition characterized by complete or almost near-complete unilateral absence of the cortical cortex, which is filled by a sac of cerebrospinal fluid. Prenatal vascular disruption with occlusion of the carotid artery territories ipsilateral to the damaged brain is the presumed pathogenesis.We have selected nine cases that fit the clinical and pathologic characteristics of hemi-hydranencephaly, demonstrating that destruction of one hemisphere may be not always associated with severe neurologic impairment and may allow an almost normal life. This disorder is an example of a possible prenatal re-organization in which the right and left cerebral hemispheres present functional potentiality to make up the damaged brain.The cases reported in the literature are discussed, including a patient previously reported and followed-up for 10 years. A review of the cases is performed with an evaluation of the most important aspect of this rare and mysterious disorder. Hemi-hydranencephaly (HHE) is a rare brain anomaly characterized by complete or near-complete unilateral absence of the cerebral cortex. The affected hemisphere is filled with cerebrospinal fluid (CSF) into membranous sacs, which also contains minimal residual neurons, glial tissue, and some blood vessels . UsuallyWe are not aware of patients affected by HHE before the case reported by Warkany  in his fHHE is a very rare disorder. HHE is much rarer than hydranencephaly, which has been reported with a prevalence of 0.2% at autopsy . The refHHE is thought to be due to the occlusion of a unilateral carotid artery causing ipsilateral absence of a hemisphere that will be filled by CSF. The meninges, basal ganglia, pons, medulla, cerebellum, and falx, all of which are supplied by the vertebrobasilar system, are not involved. The anomalous event should have occurred after neural migration and before synaptogenesis . During In cases of hydranencephaly, many predisposing factors have been reported ,9. In coin utero ipsilateral ligation of the carotid artery and jugular veins [Unilateral induced hydranencephaly has been demonstrated in monkeys after ar veins  and newbar veins . Recentlar veins -20.The formation of cavities resulting by a hypoxic-ischemia injury, as one of the possible causes of HHE, is a peculiar response to the developing fetal brain where the macrophage response to cell death is present and the neuroglial response is still developing . In patiWhy is such an impressive anatomic anomaly infrequently associated with severe mental retardation and/or language delay? First, independently of which hemisphere is affected, there are no differences with respect to clinical signs and outcomes.in utero, thus giving a clear picture of the functional potential of a single cerebral hemisphere. The results obtained from the literature show that relative preservation of cognitive performance suggests that a single cerebral cortical hemisphere connected to an apparently intact brainstem is sufficient for the development of higher cognitive function. According to the side affected, there is no outcome difference; a good or severe cognitive development may be possible whether or not the left or right hemisphere is involved. Good cognitive development has been reported [Most of the reported cases of HHE in the literature, including our patient, show that progressive learning is possible across many cognitive domains in patients with a single hemisphere. There have been many reports of cognitive performance outcomes in children who have undergone hemispherectomies for severe and intractable seizures . Pulsifereported ,11, in wreported , activatreported . The samTable He has mild impairment of right hand function, but is able to perform functionally significant bimanual tasks. The visual-evoked potentials are normal in both eyes and the visual acuity is 20/30 bilaterally with correction. The visual fields show partial right homonymous hemianopia.Based on the data of the cases of HHE reported in the literature, the family histories were negative and no similar cases were reported in the family members. Males were more frequently affected than females, with a male-to-female ratio of 5:3 (the gender was not reported in reference 5). The neonatal period was uneventful for all of the children, with the exception of the child reported by Greco et al. , who wasThe clinical signs presented by the affected patients were mainly neurologic . Ocular involvement was also reported. In one patient, HHE was associated with hydrocephaly  and in aLanguage delay has been reported in patients by Van Doornk , Greco eHemiparesis was reported on the right side in four patients ,5,9,10, The diagnosis of HHE was established based on the neurologic clinical signs of motor impairment and/or mental delay, and with the use of neuroradiologic techniques  there is no difference in the clinical impairment and outcome regardless of which hemisphere is affected; 2) the right and left hemispheres are almost equally affected; 3) there is a higher prevalence of males affected compared to females; 4) hemilateral motor function is always involved to different extents; 5) cognitive and language functions are very often preserved with good or partial good performances; 6) heterogeneity in the clinical presentation and outcome probably depends on the mechanism and timing of the injury.The Authors declare that the present work has not been published previously, that it is not under consideration for publication elsewhere, that its publication is approved by all authors, and has been approved by the responsible authorities where the work was carried out. The Authors have no financial disclosures or competing interest to declare concerning this manuscript.PP conceived the study, coordinated and wrote the article; FN, FG, ADP collected the data of the literature; MR, LP, RF, RR carried out the clinical diagnosis and followed up the patient. RR performed clinical and neuropsychological test evaluation. All authors read and approved the final manuscript.


Rift Valley fever (RVF) is an emerging viral zoonosis that impacts human and animal health. It is transmitted from animals to humans directly through exposure to blood, body fluids, or tissues of infected animals or via mosquito bites. The disease is endemic to Africa but has recently spread to Saudi Arabia and Yemen. Our aim was to compare two major outbreaks of RVF in Saudi Arabia (2000) and Sudan (2007) from a One Health perspective.Using the terms ‘Saudi Arabia’, ‘Sudan’, and ‘RVF’, articles were identified by searching PubMed, Google Scholar, and web pages of international organizations as well as local sources in Saudi Arabia and Sudan.The outbreak in Saudi Arabia caused 883 human cases, with a case fatality rate of 14% and more than 40,000 dead sheep and goats. In Sudan, 698 human cases of RVF were recognized , but no records of affected animals were available. The ecology and environment of the affected areas were similar with irrigation canals and excessive rains providing an attractive habitat for mosquito vectors to multiply. The outbreaks resulted in livestock trade bans leading to a vast economic impact on the animal market in the two countries. The surveillance system in Sudan showed a lack of data management and communication between the regional and federal health authorities, while in Saudi Arabia which is the stronger economy, better capacity and contingency plans resulted in efficient countermeasures. Studies of the epidemiology and vectors were also performed in Saudi Arabia, while in Sudan these issues were only partly studied.We conclude that a One Health approach is the best option to mitigate outbreaks of RVF. Collaboration between veterinary, health, and environmental authorities both on national and regional levels is needed. Bunyaviridae family, genus Phlebovirus, which is endemic in many African countries, and also since 2000 in the Arabian Peninsula where Saudi Arabia and Yemen have been affected  is a transboundary zoonotic disease, transmitted to animals and humans via mosquito bites, but also directly through exposure to blood, body fluids, or tissues of infected animals . It is caffected . The RVFaffected . There iaffected –7. The iaffected –10.RVFV infection of livestock causes abortions and high perinatal mortality (>95%) in herds of sheep, goats, cattle, and camels. These animals are important not only for meat production but also for dairy production and trade. Outbreaks devastate the local economy, result in export embargoes, and contribute to poverty in many regions of the affected countries. Human infection may be severe and historically the disease has had a case fatality rate in humans of 1% , but in RVF is a transboundary disease, which has an impact on the important livestock trade between Sudan and Saudi Arabia, separated only by the Red Sea, where Sudan is the exporting and Saudi Arabia is the importing country. The close economic links, the geographical proximity of the two countries, and the two recent important outbreaks of RVF in Saudi Arabia 2000 and Sudan (2007) motivated us to investigate these outbreaks from a One Health perspective. Specifically, we investigated the reasons for, the consequences of, and countermeasures against the outbreaks. The study revealed similarities and discrepancies between the two countries regarding outbreak causes, consequences, epidemiology of the disease, and how the RVF outbreaks were tackled in terms of a One Health approach at the human–animal interface.www.ncbi.nlm.nih.gov/sites/entrez) and after reading their abstracts, 37 articles were found relevant and included in this review. The books, reports, and fact sheets that include information about the disease were searched through the following sources: World Health Organization (WHO) (www.who.int); World Organization of Animal Health (OIE) (www.oie.int); Food and Agriculture Organization of the United Nations (FAO) (www.fao.org); Saudi Arabia Ministry of Health, Google scholar; and United States Center for Emerging Issues (www.aphis.usda.gov).Using the terms ‘RVF’, ‘RVFV’, ‘Saudi Arabia’ and ‘Sudan’, 95 articles were identified by searching Medline through PubMed   31). In. In31). After the outbreak was declared in Saudi Arabia, control measurements were simultaneously implemented toward both humans and animals. Surveillance was urgently introduced to detect cases of RVF among ungulates and humans. Dead animals were disposed of in an appropriate manner , 22. A sAs soon as outbreak was announced, the governors of the affected states formed a committee to deal with the outbreak. The committee aimed to reflect a One Health strategy to tackle the disease outbreak. The committee was led by the general director of the government in the affected states and consisted of members from the ministry of Health, ministry of animal resources and a consortium of consultants, including community medicine, internal medicine, ophthalmology, nephrology, and pharmacology.For control of the RVF outbreak in Sudan, the committee aimed to target both human and animalhealth. To minimize the risk of transmission in slaughterhouses, strong precautions were applied . UnfortuAlthough Sudan aimed to implement a One Health strategy as mentioned above, it did not restrict the disease to the onset region in White Nile state. It spread to the states of Gazira, Sennar, and Kassala. The difference regarding the implementation of One Health in Sudan and Saudi Arabia is intriguing and possibly reflects the difference in resources.The RVF outbreaks were unexpected and caused great commotion in both Saudi Arabia and Sudan. No RVF outbreaks had been recognized for more than 30 years in Sudan and RVF had never been present in Saudi Arabia. The transmission to Saudi Arabia is suggested to be from Eastern Africa by importation of infected animals , similarIn Sudan, the outbreak was triggered by severe flooding  as a resDuring the outbreaks most efforts were directed toward acute control measures, but later, studies regarding vector competence of the RVFV were performed in Saudi Arabia . The resSaudi Arabia and Sudan are large countries with several neighboring countries. Shared borders might increase the risk of spreading RVF unless great care is taken regarding trade regulation of animals in the region. Application to regulations and guidelines from the World Trade Organization and OIE would reduce the danger of RVF being introduced to new unaffected countries. For both Saudi Arabia and Sudan, the surveillance system did not work properly to detect the virus in animals before it spread to humans, although it has been suggested that RVF is well established in animals before any disease outbreak in humans . In SaudThe outbreak in Saudi Arabia 2000 lasted for a longer time than in Sudan but with almost half the case fatality rate compared to Sudan. The stronger economy and the better capacity, contingency plans, and health care system in Saudi Arabia were probably the main factors for the lower fatality rate. One could suspect that there were more undiagnosed cases and late recognition of RVF cases in Sudan compared to Saudi Arabia, which could explain the higher case fatality rates associated with the human cases in Sudan. A similar experience of late diagnosis was seen in other RVF outbreaks, for example in Kenya in 1997–98 where 467 unexplained deaths occurred in humans before it was discovered that it was caused by RVF . In geneTo advocate for surveillance in RVF endemic regions among affected countries, we have to think seriously to compensate the communities that are exposed to RVF outbreaks to enable them to recover from their economic losses. After verification of RVF cases by veterinary authorities and community leaders, compensation could, for instance, be in the form of replacing dead or sick animals with new animals, and vaccination against all vaccine preventable diseases including RVF. Part of the support should also be directed toward improving the infrastructure of the veterinary facilities in the affected areas. This support could be offered by the government of the affected country if its economy allows that. In addition, the neighboring countries could also contribute because they are also in danger when the disease expands. Furthermore, regional and international organizations should contribute to such a compensation program. It would also be beneficial if regional funds were set aside to use for combating emerging infectious diseases including RVF. Altogether, such actions would encourage local communities and governments to notify authorities earlier about the circulation of RVF in their countries.In Sudan, livestock is one of the most important contributors to the national economy. It employs around 40% of the population and contributes to 25% of the gross domestic product (GDP) . Before Because animals, humans, and the environment are all involved in the infection cycle of RVFV, we expect that the budgets of ministries representing these interests are compiled together to prioritize control strategies against RVF. Such an initiative has not been visible in Saudi Arabia or Sudan.Human and animal health is a result of the sustainable relationship between humans, animals, and the environment. Therefore, it is important to tackle health problems in animals to protect human health. To prevent future RVF outbreaks, information based on virologic, epidemiologic, and demographic data; surveillance; and a better understanding of environmental factors and the ecology of RVFV are required to fine-tune existing approaches that could predict an outbreak. The impact of climate change on the spread and expansion of the disease needs to be studied in detail in order to adapt mitigation strategies. To achieve the goal of One Health, good collaboration between international organizations on a planning level as well as veterinary and health authorities on the executive level in each country is needed; this could reduce the occurrence of RVF in Sudan, Saudi Arabia, and other countries where the disease could emerge.


Current trends in US population growth, age distribution, and disease dynamics foretell rises in the prevalence of chronic diseases and other chronic conditions. These trends include the rapidly growing population of older adults, the increasing life expectancy associated with advances in public health and clinical medicine, the persistently high prevalence of some risk factors, and the emerging high prevalence of multiple chronic conditions. Although preventing and mitigating the effect of chronic conditions requires sufficient measurement capacities, such measurement has been constrained by lack of consistency in definitions and diagnostic classification schemes and by heterogeneity in data systems and methods of data collection. We outline a conceptual model for improving understanding of and standardizing approaches to defining, identifying, and using information about chronic conditions in the United States. We illustrate this model’s operation by applying a standard classification scheme for chronic conditions to 5 national-level data systems. Thrall ; and a broad spectrum of behavioral health problems, some of which have traditionally not been classified as diseases –6.The nation is recognizing the emerging high prevalence of multiple chronic conditions (MCC) and related implications for prevention, treatment, public health programs, and planning –7. PeoplPreventing and mitigating the effect of any single chronic condition, or constellation of conditions, requires improved measurement. However, 2 major barriers exist. First is the lack of consistency in key definitions  and in diagnostic classification schemes  ,2,8. SecIn this article, we outline such a conceptual model for improving understanding of and helping to standardize approaches to defining, identifying, and using information about multiple chronic conditions in the US population. We first provide further context regarding the lack of consistency in past definitional approaches. We then describe the conceptual model, developed by an MCC working group within the HHS Office of the Assistant Secretary of Health (OASH), and detail the working group’s development of a list of selected chronic conditions. To demonstrate the opportunities and challenges associated with using this set of chronic conditions, we provide an overview of 5 data systems maintained by HHS that measure chronic conditions and illustrate the model’s operation by applying a standard classification scheme for MCC to the HHS data systems. We conclude by suggesting options for policy makers, public health officials, researchers, practitioners, health plans, and others to consider for improving the collection, analysis, and use of data on chronic conditions.Accurate case definitions are integral to public health surveillance efforts for monitoring population health and for conducting public health and clinical investigations . HoweverThe heterogeneity of these definitions stands in stark contrast to the process of measuring infectious conditions using established case definitions –19. As aThe classification schemes currently used for identifying chronic conditions vary in origin, scope, and composition ; the ChrTo standardize the analysis of health-related data sets for chronic conditions, we propose a conceptual model that involves a classification scheme consisting of 2 related dimensions: 1) identifying and specifying conditions of interest, and 2) understanding the structure of the data system of interest. The intersection of these 2 dimensions  allows for the production of chronic condition indicators for program, research, and policy purposes .The first dimension (identifying and specifying codes for conditions) creates a classification scheme of coding rules that enable a set of specific individual conditions to be identified in data records created in a given data system. This process initially requires the specification of criteria  for defining chronic conditions. These criteria may then be applied to sets of health conditions to select chronic conditions of interest. Finally, the set of chronic conditions of interest must be mapped to measures that use standard coding rules and algorithms that can be systematically applied across different data systems. The coding algorithms can be data system-specific, because they are a function of the type of data available .The second dimension (understanding data systems) is a hierarchical model that generically describes major components of data systems. The highest level is a data system, such as a surveillance system or family of related systems. Such systems, in turn, consist of component data sets that are discrete units that can be used for analysis. In the example of surveillance systems, a data set could be the data collected for 1 year. Then data sets can be deconstructed further into data elements — that is, the individual components that form a data set, typically representing an individual person or encounter  as the unit of analysis.The point at which the 2 dimensions intersect  results in the output of an indicator of the number of chronic conditions. This indicator allows researchers and others to examine variability in a variety of outcome, cost, and use measures, including mortality, associated costs, health care use, and other parameters.Another key issue involves the decision basis on what to include in sets of selected conditions. An example of the ramifications is that patterns of key indicators, such as MCC prevalence, services utilization, and cost indicators may vary directly as a function of the type and number of conditions. The optimal list should comprise a number of conditions sufficient to be practically useful but not overly inclusive.Chronic Care: Making the Case for Ongoing Care  — each of which was listed by at least 1 of these sources and the majority of which were drawn from at least 2 of the 3 sources — that represented a practical balance of the above criteria. Identifying a manageable number of conditions helps to ensure comparability across data systems that encompass a spectrum of populations and settings. In addition, these conditions can be identified using ICD codes and applied to various data systems  ,25; NatiThe OASH working group selected codes that could be used to link the OASH list of 20 selected chronic conditions to measures in the HHS data systems. Although the CCS codes used by the Medical Expenditure Panel Survey and National Inpatient Sample data systems are based on ICD, the ICD codes used by CMS in the Chronic Condition Data Warehouse do not completely correspond with those in the CCS. For this reason, the OASH working group identified ICD codes instead of CCS codes for the CMS Beneficiary Claims Data File. The complete list of CCS codes is maintained by the Agency for Healthcare Research and Quality .Three patterns describe the specificity of the mapping for the selected conditions. The first pattern is characterized by the presence of a measure for a condition in each data system. For example, a measure for hypertension is in all 5 data systems. For this pattern, the data elements reflect various sources: for example, in NHIS, respondents provide the self-reported diagnosis for each condition, whereas in NAMCS, data are collected for both the reason for the current visit and for a checklist of ever existing conditions. However, not all data systems measure all 20 conditions: NHIS measures 10, NAMCS measures 19, and CMS measures 15; both the Nationwide Inpatient Sample and the Medical Expenditure Panel Survey measure all 20.In the second pattern, although a 1-to-1 match was not found, related conditions could be mapped onto the same general condition described in the OASH list. For example, although NHIS does not have a specific question on chronic kidney disease, it does have questions on weak or failing kidneys, which could be mapped to chronic kidney disease.For the third pattern, data in a given system could not be mapped to the condition identified in the OASH list. For example, data on congestive heart failure, cardiac arrhythmias, hyperlipidemia, dementia, and depression are not collected by NHIS, although data on these conditions are collected by the other 4 data systems. Other conditions for which data are not available in NHIS include autism spectrum disorder, HIV, osteoporosis, schizophrenia, and substance use. For NAMCS, data are not available for chronic kidney disease; and for CMS, for autism spectrum disorder, hepatitis, HIV, schizophrenia, or substance abuse disorders. Although claims data may be available from CMS, they are not now available in the analytic data sets.As the prevalence of chronic conditions continues to increase in the US population, the United States will face even greater challenges in delivering care to people with MCC –35. AccuAs this article has shown, improvements in measurement require that we first improve methods for characterizing and monitoring chronic conditions, including achieving common agreement on the meaning of the terms “chronic condition” and “multiple.” Our review of existing definitions showed not only how existing definitions differ but how these differences affect research and practice, including difficulties in comparing results of studies and the prevalence of MCC across various data systems. Although some commentators have defined “multiple” as the presence of 2 or more conditions in an individual ,5, furthAlthough the absence of standard case definitions for chronic conditions poses major challenges for uses across data systems, existing definitions and classification schemes might be applied more easily across multiple population subgroups within a given data system. For example, noting in the early 1990s the inherent limitations of condition-specific approaches to classifying chronic conditions among children, commentators associated with a research consortium on chronic illness in childhood pointed to the need for a widely applicable, but modifiable, definition of chronic conditions for use in research, program development and delivery, and development of health care policies . This apOur conceptual model provides a framework for more consistently applying lists of selected conditions to multiple data systems. For the OASH list of selected chronic conditions, the model explicitly documented data elements that were used to identify the selected conditions and how the data were collected and coded. This conceptual model can be used to document coding decisions that are applied to additional data sets, an especially important need when multiple data systems are used to examine the burden of chronic conditions. Although this model may be useful for improving the consistency in research and programs that address MCC, other opportunities allow for refining sets of conditions. For example, a rigorous measure development process that applied decision rules to data from multiple systems on key parameters  could assist in refining sets of conditions for analysis. Additional analysis to determine the optimal number of conditions also could help in refining measures of the impact of chronic conditions in the US population.Although this article focused on consistency in defining and classifying chronic conditions, an important related issue is the coordination between essential actors involved in developing and using data, including coordination on methods for establishing classification schemes . Deciding on the number of chronic conditions to include in a given list and addressing implications for key parameters  require a combination of clinical acumen and expertise in use of surveillance data. Thus, the gaps identified in this article help to sharpen focus on the need for collaboration among different organizations, agencies, and institutions at different levels  that collect data and maintain data systems and that may benefit from using a common conceptual model and classification scheme. Beyond data managers, analysts, and researchers, other stakeholders need to engage in the process, including practitioners and policy makers, who can provide valuable input to guide analysis of the most pressing needs for data on chronic conditions.Researchers, practitioners, and policy makers can consider using the issues identified in this article as the basis for improving the collection, analysis, and use of data on chronic conditions in the United States. Foremost, the examination of different classification schemes and their application to multiple data systems suggest that the terms “chronic disease” and “chronic illness” might be supplanted by wider adoption of a functionally more accurate and inclusive term, such as “chronic conditions.” Greater consistency in and more complementary use of classification schemes for chronic conditions hold the promise for improving research and generating a stronger knowledge base for policy makers and program managers.


The main sources of radiation exposure of all living organisms including humans are natural. In fact, radon and its decay products are the cause of 50% of the total dose that is derived from natural sources. Because of the significant health hazards of radon gas, its levels are widely monitored throughout the world. Accordingly, considerable researches have also been carried out in Iran.The aim of this research is a systematic review of the most recent studies associated with evaluation of radon gas levels in Iran. The main emphasis of this study was on public exposure to radon gas.The most important route of exposure to such radiation is indoor places. In this investigation measurement of radon in water resources, tap water, indoor places and exhalation of radon from building material, the major sources of indoor radon gas emission, were considered.Significantly high levels of radon gas were found mostly in water and residenvial buildings.It conclusion with regard to the study of building materials, granite stone and adobe coverings cannot be recommended for construction purposes. Natural radiation is"the main source of radiation in the surrounding environment. It is estimated that the contribution of natural sources of radiation exposure to humans is approximately 90% . AccordiRadon Radon-222), a trace element, is colorless, odorless and tasteless. It is a natural radioactive gas that is derived from uranium decay present in rocks and soil 22, a tra. The con Because of the significant health hazards associated with radon, its concentrations are widely monitored throughout the world. Considerable research has been carried out in Iran, mainly in the northern region, which has high background radioactivity. As reported by the United Nations Scientific Committee on Atomic Radiation the coastal city of Ramsar has been shown to have the highest levels of radioactivity when compared to other inhabited areas of the world . The stuThis paper presents a review of the studies that have been carried out on the measurement radon in water, indoor places and building materials used in Iran, all of which have a critical and important role in the exposure of the general population to radiation.Initially, an investigation of the available research regarding the measurement of radon was carried out through an online literature search using the Pub-Med, Science Direct, ISI Web of Knowledge Scopus, Medlib, SID, Iranian Research Institute for Information Science and Technology (IRANDOC) and IRANMEDEX databases. The keywords “radon, Iran ” or “radon measurement in Iran”, used in this search. All studies associated with the measurement of radon until August 2012, in both the English and Persian languages, were collected and investigated. The relevance of articles have been screened by two independent reviewer initially. In total number of 1455 investigated papers, 176 titles and abstracts were recognized as potentially appropriate. Papers which containeded other natural radioactivity were excluded. The main purpose of this study was on public exposure to radon gas. The most important route of exposure to such radiation is indoor places.In this investigation, the measurement of radon in water resources, tap water, indoor places, and exhalation of radon from building material, as the major sources of radon gas emission, was considered. The reviewe articles were included as potentially appropriate. The results of multiple publications were cosidered only once, and the newest reference of it is reported. All of papers were monitored for inclusion by two reviewers separately. Disagreement was resolved during disscusion. Due to inclusion and exclusion criterions,the full text of total 27 papers  were screened in this systematic review. All investigated articles in this review were cross-sectional studies. Accordingly, information on the methods measurement, sample size and sampling locations and the subsequent results of the selected studies are indicated in A review of researches involving the evaluation of radon levels in Iran indicated that of the studies measured radon in water resources, especially in areas with high radiation levels and dewellings.All investigate studies in this paper were description and outcome has not been reported as OR or RR. Therefore, the publication bias could not be prove or disprove by the Statistical and graphical methods.The general overview of research regarding measurement of radon levels in the water resources in Iran  showed tA review of households radon studies  also sho222 Ra present in this material was 1.605 ± 0. 055 kBq/m 3 , which is 4 times higher than the level recommended by the International commission on radiological protection (ICRP) (200 - 600 Bq/m 3). According to the conclusion drawn by this review, the levels of uranium and radium present in granite are high, and can thus significantly increase radon levels in areas where it has been used. Hence, the use of such stones in buildings can become health hazard necessitating the need for a solution (226 Ra and 232 Th cause emission of radon from granite stones (A review of radon activity in building materials, demonstrated that the use of local granite and stone in areas with high background radiation areas should not be recommended. Investigation of Iranian compressed granite depicted that the amount of solution . Furthere stones . Other ie stones . A studye stones . In anote stones . AccordiIt should be noted that the most studies in Iran are in high background radiation areas, which it could be lead to overestimation of results presentation. On the other the only published articles were examined in this study also the number of investigated studies were limited, probably many studies are published and it is so far a study was part of gray literature.In this paper, studies involving the evaluation of radon levels in Iran with an emphasis on public exposure rather than occupational were reviewed. Most of the reported was associated with measurement of radon in water supplies; especially in high background radiation areas, such as Ramsar, and also indoor places with health hazards. Consequently, the highest values of radon gas in the water resources were reported in the hot springs of Mahallat and a house in the Talesh Mahalleh area of Ramsar. Most of the studies have proposed methods to reduce radon levels in water supplies, prior to its consumption by humans. In many of the studies involving the measurement of radon in residential buildings, the calculated dose received by humans was higher than the recommended amount. As for studies involving assessment of radiation levels in buildings, construction materials such as granite stone and adobe are thus not recommended. However, it should be noted that the evaluation of radon levels carried out in Iran, took place in a period of less than one year, where seasonal changes were not reported.


The objective of this study was to describe aspects of case study herds investigated by the Department of Agriculture, Fisheries and Food (DAFF) in which animal welfare incidents occurred and to identify key performance indicators (KPIs) that can be monitored to enhance the Early Warning System (EWS). Despite an EWS being in place for a number of years, animal welfare incidents continue to occur. Questionnaires regarding welfare incidents were sent to Superintending Veterinary Inspectors (SVIs), resulting in 18 herds being chosen as case study herds, 12 of which had a clearly defined welfare incident date. For each study herd, data on six potential KPIs were extracted from DAFF databases. The KPIs for those herds with a clearly defined welfare incident date were studied for a consecutive four year window, with the fourth year being the 'incident year', when the welfare incident was disclosed. For study herds without a clearly defined welfare incident date, the KPIs were determined on a yearly basis between 2001 and 2009.We found that the late registration of calves, the use of on-farm burial as a method of carcase disposal, an increasing number of moves to knackeries over time and records of animals moved to 'herd unknown' were notable on the case farms.Four KPIs were prominent on the case study farms and warrant further investigation in control herds to determine their potential to provide a framework for refining current systems of early warning and prevention. The Early Warning System (EWS) was established in Ireland in 2004 when the Minister for Agriculture and Food accepted the recommendation of the Farm Animal Welfare Advisory Council (FAWAC) for the establishment of a collaborative, nationwide early warning/intervention system for farm animal welfare cases. The EWS currently involves a partnership between the Department of Agriculture, Fisheries and Food (DAFF), the Irish Farmers Association (IFA), the Irish Society for the Prevention of Cruelty to Animals (ISPCA) and the Health Service Executive (HSE), and aims to identify and address cases in which the welfare of farm animals is compromised. Its purpose is to provide a framework within which problems can be identified and resolved before they become critical or overwhelming.The assessment and monitoring of farm animal welfare are key objectives of the European Community's Action Plan on Animal Welfare 2008) . However008 . HowDespite this, farm animal welfare incidents remain an ongoing concern in Ireland. Although the EWS has been established for some years, no quantitative evaluation has yet been conducted to evaluate its effectiveness. An unpublished study was conducted by DAFF between September 2006 and March 2007, before the introduction of AFIT, to investigate animal welfare incidents in Ireland . It provided baseline data on the number and category of dead and moribund animals recorded in animal welfare incidents, the number of animals seized and disposed of and explored the human resource implications for DAFF. The study reported that a total of 494 animal welfare incidents were investigated by DVO staff between 1 September 2006 and 31 July 2007. In the study, in excess of 1,500 animals were found dead during on-farm investigations, 78 animals required euthanasia on farm and 619 had to be seized and disposed off. Seventeen percent of herd owners had animal identification problems. It highlighted the need for further research to better understand the aetiology of farm animal incidents, identify and understand risk factors associated with on-farm animal welfare incidents in Ireland and thereby provide opportunities to refine current systems of early warning and prevention.This study will form part of a broader study which will include comparisons with control herds and a separate study investigating the human factors that influence on-farm animal welfare incidents. The objectives of this current study are to describe aspects of case study herds investigated by DAFF in which animal welfare incidents occurred and to identify potential key performance indicators (KPIs) which will later be studied in control herds to see if future monitoring of these KPIs can enhance the EWS.In 2009, Senior Superintending Veterinary Inspectors (SSVI) and Superintending Veterinary Inspectors (SVI) from DAFF Divisional Veterinary Offices (DVOs) were sent screening questionnaires to identify herds in their region with reported farm animal welfare incidents. For the purpose of this research, a farm animal welfare incident was defined as 'any situation where a person in charge of cattle or sheep causes avoidable pain or suffering to those cattle or sheep, or fails to take steps to prevent avoidable pain or suffering to cattle or sheep under his or her care, or fails to respond expeditiously to cattle or sheep that are experiencing avoidable pain or suffering under his or her care'. A case study herd was defined as any herd where a farm animal welfare incident was reported. From this initial list of herds, subsequent selection of case study herds was undertaken by three of the authors, with consideration given to species , geographic spread, farm size, the welfare issue, and the likelihood of the herd keeper cooperating with an interview, to facilitate a later study to investigate if any life-events influenced management of the herd. As the majority of cases involved cattle, it was decided to limit the study to cattle.For each study herd, data were collected about the welfare incident, including the welfare issue, the animal species and the date/duration of the problem. General data about each farm were extracted from two DAFF national databases: the Animal Identification & Movement database (AIM) and the Animal Health Computer System (AHCS). AIM records the sex of the animal, date of birth, herd movements during its lifetime and the final status in Ireland e.g. disposal through a 'knackery' or by 'on-farm burial', slaughter in a 'factory' for an animal destined for the food chain, 'export centres' for animals that are exported to other countries and 'location unknown' for animals whose whereabouts cannot be satisfactorily explained. AHCS records information on the tuberculosis (TB) and brucellosis status of herds, the type of herd, the names and contact details of the herd keeper, the private veterinary practitioner and the attendant Veterinary Inspector (VI).The following data were collected from AIM and AHCS for each study herd:a. General data• the sex and age of the herd keeper,• the type of herd (dairy or beef),• other species kept on the holding (if any), and• the size of the holding, cattle numbers per hectare.b. Yearly livestock data• total number of cattle in herd on 1 January each year, with subsets based on class - cows, heifers, males,• the number of calves born during the course of each year, including their dates of birth and the dates that they were registered on the database by the herd keeper, and• the number of all animal exits recorded each year, including to knackeries, by on-farm burial, to market, to slaughter and unknown locations.The identity of each study herd was anonymised (designated A to R).Six potential KPIs were identified from the yearly livestock data, based on a previous DAFF unpublished welfare study , the experience of the authors and from discussions with VIs heavily involved in welfare cases. These included:• the number of cattle in the herd,• the number of cows that gave birth to a calf each year,• the number of late registrations (greater than 27 days after birth) in the herd,• the percentage of all cattle exits from the herd that were moved to a knackery,• the percentage of all cattle exits from the herd that were disposed of by on-farm burial, and• the percentage of animals recorded as being moved to 'herd unknown'For each study herd with a clearly defined welfare incident, a consecutive four year window ('the study period') was identified, with the fourth year being the 'incident year', when the welfare incident was disclosed. The three year retrospective period was selected based on the authors' experience of welfare cases, data trends and the experience of VIs considered experts in dealing with welfare cases. The number of cattle in the herd on 1 January each year, by animal class , was extracted from AIM. A female animal was considered a cow if 30 months of age or older, and a heifer otherwise. It was not possible to distinguish bulls from bullocks, so all male animals were referred to as males.For each year of the study period, we then calculated:• the number of late calf registrations (greater than 27 days after birth),• the percentage of cattle exits separately attributed to (a) movement to a knackery, (b) disposal through on-farm burial, or (c) moved to a herd described as 'herd unknown', and• the number of cows that gave birth to a calf each year .For study herds without a clearly defined welfare incident (long-term welfare incidents), each of the above-mentioned calculations was determined on a yearly basis between 2001 and 2009.Data were managed using Microsoft Excel .Twenty-one replies to the screening questionnaire were received from 15 DVOs (a response rate of 53.5%).Eighteen case herds were enrolled, including 12 single farms and three sets of two associated farms i.e. herds H and I, K and L, Q and R  were recorded during the incident and/or three preceding years Figure . BetweenIn the 12 case herds with defined animal welfare incidents, the percentage change in the total number of cattle between year x and year x-3 is presented in Table The number of cows in each herd with a defined animal welfare incident was calculated for consecutive time periods: the incident year and each of the three preceding years. The percentage of available cows that gave birth to a calf that was subsequently registered was determined for this time period Table . No pattThe objectives of this current study were to characterize the types of farms investigated by DAFF for animal welfare incidents, using a case study approach and secondly to use these data to enhance EWS. The EWS is a partnership between interested parties who wish to identify ways in which farm animal welfare can be further improved and to identify and resolve animal welfare problems before they become overpowering. It is hoped that by better understanding these case farms we will develop a better understanding as to why, despite the EWS already being in existence, welfare problems still occur on some Irish farms. By studying KPIs we hope to be able to ascertain ways in which to enhance the EWS to make it more effective. This study will form part of a broader study which will include comparisons with control herds and a study of the human factors that influence farm animal welfare incidents.The welfare of farm animals is well provided for under Irish legislation and on-farm welfare incidents are not common. Traditionally, in Ireland, there has been a perception that welfare problems arise more commonly on farms run by older bachelors living in rural areas, where there is a lack of family support and poor access to health and social facilities. However, in this study the herd keepers ranged in age from young to old (31 to 84 years) and in sex . It is likely therefore that where welfare problems arise, that the underlying cause is not a singular trigger, but may possibly relate to sociological, health, psychological, economic and other circumstances. In five of the case herds the responding SVI/VI believed that problems started to occur after the death of a parent. At the time of the incident two herd keepers were suffering from ill health, one of whom also had reported problems related to alcohol, and another who was reported to be suffering from depression  on all calf registrations in Ireland in 2010 (including these case herds) showed that 2.22% of all 116,815 Irish herd keepers registered calves in excess of the 27 day limit. This figure is similar to the 2.26% of Irish farmers who despite being entitled to receive payments of greater than €100 from the Single Farm Payment Scheme did not apply for these payments , possibly indicating problems with completing the paperwork involved. In this study the majority of those herds with a defined animal welfare incident date registered calves late in the incident year and in the years leading up to the incident  buried animals on farm during the study period  is handled and/or temporarily stored for the purpose of further transportation to its final destination. Between 2002 and 2009 the total number of cattle on-farm deaths in Ireland ranged from 192,437 to 234,088, which equates to 9.1% to 10.9% of the total number of cattle disposals, with a peak in 2008 at 12.1% and a low in 2003 of 8.6% . For the 12 case herds with a defined animal welfare incident date, the number of animals disposed of at knackeries in relation to all exits from the farm increased annually during the study period, from a median of 5.1% three years prior to the incident, 14.6% two years prior to the incident, 16.8% in the year prior to the incident and 21.8% in the year that the incident occurred , there were 117,287 herds in Ireland. The average age of farmers was 55.8 years . We wereSocio-economic factors are likely to play a key role in animal welfare incidents e.g. family support; changes in personal circumstances etc., as welfare problems are not always due to intentional neglect or cruelty by herd keepers. A study by Sanne et al.  identifiThere are limitations with this study, including the small number of case study herds. The data for KPIs were all taken from national databases, which rely on herd keepers providing the correct information. There is a potential for bias in the case studies chosen as they were nominated by SVIs and not selected randomly. In addition, this study did not evaluate other factors such rural isolation, availability of family and community support, accessibility of health care and off-farm employment, which may also be important key indicators. This will be addressed in further studies, as will comparisons with control herds.This study was carried out to describe aspects of case study herds investigated by DAFF in which animal welfare incidents occurred and to identify key performance indicators (KPIs) that can be monitored to enhance the EWS. Six KPIs were identified, four of which could be used to enhance the early warning system already in place in Ireland, i.e. late registrations of calves, an increase in the use of on-farm burial as a method of carcase disposal, an increase in the number of carcases sent to knackeries and animals missing from the herd profile that cannot be accounted for. Further investigation by studying these KPIs in control herds is warranted to determine their potential to provide a framework for refining current systems of early warning and prevention.The authors declare that they have no competing interests.PK provided overall leadership to the study, and conducted the data collection and analysis. All authors contributed to the study design and participated in writing the paper. All authors have read and approved the final manuscript.


Objective. To describe our technique of performing tonsillotomy that increases visibility by providing a better view of the tonsils and related structures through the use of a 30-degree scope. Method. Patients had tonsillotomy with microdebrider with the aid of a 30-degree endoscope for both visualization and on-screen projection and magnification. Result. The endoscope-assisted technique provides a more detailed exposure of pharyngeal structures and their relationships with the tonsils. It is easier to clearly visualize the upper and lower poles. The magnification with the endoscope makes it easier to appreciate anatomic details and identify/deal selectively with minute bleeding points. Conclusion. The use of 30-degree endoscope in tonsillotomy provides better visualization of the upper and lower tonsil poles and may make the procedure easier for the surgeon and safer for the patient. Tonsillotomy was initially practiced in the 19th century and has been revived in the early 1990s , 3. The Increasingly, tonsillotomy  is being recommended over tonsillectomy in children < 4 years with tonsil hyperplasia or obstructive sleep apnoea, those with body weight < 15 kg and those with increased risk of bleeding, but technical difficulties with access, clear anatomical exposure, and visibility still remains, and it could often be quite problematic to visualize the tonsillar poles .Vascular supply to the tonsils come mainly from the poles, and poor visibility in these areas could hamper the use of diathermy with precision during haemostasis.In undertaking the endoscope-assisted technique, patient is placed on the supine position and the oral cavity splinted open with a Boyle-Davies gag as in standard tonsillectomy. The uvula is retracted anteriorly by means of a stitch on a clip. Dry gauze packing is applied to the inferior aspect of the oropharynx to limit blood flow towards the supraglottis.A 30-degree endoscope is introduced through the oral cavity, followed by a quick general inspection of the oropharynx and nasopharynx including the tonsils, adenoids, choanal aperture, and surrounding structures . The tonsils, tonsillar pillars, adenoids, choanae, and eustachian tubes are identified and inspected for any abnormality. The tonsils are then gently shaved down with a microdebrider. The aim is to shave off 90% of the tonsillar tissue without dissecting the tonsillar capsule from the adjacent muscles. Slight oozing of blood from the surface of the shaved tonsils is expected, and this can be controlled by applying adrenaline-soaked swab for a few minutes. The swab is then removed and the entire surface of the tonsil fossa including the upper and lower poles are examined for bleeding points using the endoscope, which in addition to making otherwise “blind spot” corners clearly visible also magnifies them .The tonsil tissue itself is not very pain sensitive , and as Performing tonsillotomy with minimal visibility of the upper poles (as is the case with tonsillotomy without scope assistance) is arguably the reason for various degree of breaching of the capsule, cutting into adjacent muscles and injuries to the palatal pillars; these inaccuracies explains the reason for presence of posttonsillotomy pain and increased risk of bleeding.Not infrequently, the introduction of the endoscope reveals incidental findings of adenoid hypertrophy, and at the same instance, clearly shows the surgeon whether or not there is any submucous cleft palate that would contraindicate shaving the adenoids. Endoscopic adenoidectomy with necessary haemostasis under endoscopic guidance, as opposed to blind curettage of adenoid tissue, can then be carried out if indicated (endoscopic adenotonsillectomy). Most so-called adenoid regrowths after adenoidectomy are now known to be caused by inadequate removal of the adenoid tissues occasioned by fear of damage to surrounding structures during a blind curettage technique: these can all be avoided by direct visualisation “of what you are doing” using a 30 degree endoscope.In our centre, the microdebrider is preferred to electrosurgical dissection as the heat generated from electrosurgical devices may be as high as 400°C, which can create a significant sphere of injury to the surrounding musculature of the tonsillar fossa . This, iEntire procedure is brief and, depending on the experience of the surgeon, could last between 5 and 15 minutes.Pain is very minimal and patient is able to feed orally straightaway and could be discharged same day.Tonsillotomy is an established method for reducing postoperative pain and bleeding, but still faced with challenges of visibility.Visibility provided by the use of endoscope-assisted technique improves ease and operative precision.Operative precision is vital in preserving the tonsil capsule, adjacent pharyngeal musculature, and the nerve endings.Pharyngeal musculature, and nerve endings, when preserved, significantly reduce or eliminates postoperative pain and bleeding.


Although child sexual abuse (CSA) is recognized as a serious violation of human well-being and of the law, no community has yet developed mechanisms that ensure that none of their youth will be sexually abused. CSA is, sadly, an international problem of great magnitude that can affect children of all ages, sexes, races, ethnicities, and socioeconomic classes. Upon invitation, this current publication aims at providing a brief overview of a few lessons we have learned from CSA scholarly research as to heighten awareness of mental health professionals on this utmost important and widespread social problem. This overview will focus on the prevalence of CSA, the associated mental health outcomes, and the preventive strategies to prevent CSA from happening in the first place. Centre for Child Protection, headed by the Institute of Psychology at the Pontifical Gregorian University and scholars of the University of Ulm, to a group of religious leaders responding to the sexual abuse of minors around the world, including Argentina, Ecuador, Germany, Ghana, India, Indonesia, Italy and Kenya. Upon invitation, this current publication is a unique opportunity to highlight a few of the main lessons we have learned from the scholarly literature on CSA, with a focus on its prevalence, mental health outcomes and preventive strategies.Although only recently acknowledged as a concerning social problem, child sexual abuse (CSA) is, in our day, at the forefront of worldwide social policies and practices. Four decades of research has certainly contributed to better our knowledge on the experiences of victims of CSA. With more than 20,000 research papers on CSA listed under the most renowned research databases, child and adolescent mental health practitioners, researchers and decision-makers may find it challenging to keep up with this rapidly increasing literature. In response to this need, the aim of the current paper is to provide a brief overview on CSA to heighten awareness of practitioners on this utmost important and widespread social problem. The content of this paper was first presented at the annual symposium of the Until recently, there was much disagreement as to what should be included in the definition of CSA . In someIn that vein, the exact extent of the problem of CSA is difficult to approximate given the lack of consensus on the definition used in research inquiries, as well as the differences in the data collection systems across areas . For exaNational Survey of Child and Adolescent Well-Being, that workers were less likely to substantiate cases involving male victims [This discrepancy can be explained by the different steps that CSA cases go through before they are substantiated, and thus counted in official-report inquiries. First, victims of CSA or their confidants have to disclose their suspicions to the authorities. Many reports of child abuse are never passed on. In fact, the majority of studies highlight the fact that many victims continue to be unrecognized . A revie victims . As impr victims . ConsideIn terms of risk factors, being female is considered a major risk factor for CSA as girls are about two times more likely to be victims than males ,17. SeveSeveral models have been developed in an attempt to explain the adverse negative impact of CSA . Among tSeveral reviews and meta-analyses published in the 90s and early years of 2000 suggested that a wide range of psychological and behavioral disturbances were associated with the experience of CSA, which led experts in the field to conclude that CSA was a substantial risk factor in the development of a host of negative consequences in both childhood, adolescence and adulthood -41. MoreAmong the wealth of psychopathologies that have been studied among CSA victims, post-traumatic stress and dissociation symptoms have received great attention. Overall, victims have been shown to present significantly more of these symptoms than non-abused children, or than victims of other forms of trauma. In one of our studies that compared 67 sexually abused school-aged girls with a matched group, CSA was found to significantly increase the odds of presenting with a clinical level of dissociation and PTSD symptoms, respectively, by eightfold and fourfold . These rAside from post-traumatic stress and dissociation symptoms, a significant number of other mental health and behavioral disturbances have been linked to CSA. High levels of mood disorders, such as major depressive episodes, are found in cohorts of children and teenagers who have been sexually abused ,57. SexuThe mental health outcomes of CSA victims are likely to continue into adulthood as the link of CSA to lifetime psychopathology has been demonstrated -72. EvenIndeed, despite overwhelming evidence of deleterious outcomes of CSA, it is commonly agreed that the impact of CSA is highly variable and that a significant portion of victims do not exhibit clinical levels of symptoms . Some auThree promising lines of research have recently emerged that shed new light on the relationships between CSA and psychopathology. First, results from the growing field of polyvictimization, which is the study of the impact of multiple types of victimization , call for a de-compartmentalization of violence research by pointing out that cumulative experiences of victimizations are more detrimental to the child’s well-being than are any single experiences, including those of a sexual nature . This suIn light of the high prevalence of CSA and the wealth of deleterious outcomes associated with this abusive experience, it stands to reason that research attention must turn toward preventing CSA. Two widespread forms of sexual assault prevention efforts have been extensively studied and disseminated, namely, offender “management” and educational programs delivered, for the most part, in school settings. Offender management is the approach that aims to control known offenders, for example, registries, background employment checks, longer prison sentences and various intervention programs. It is a tertiary prevention initiative that acts mostly in the individual sphere and, as such, presents certain inherent limitations in regards to preventing CSA from happening in the first place . Indeed,The second most frequent approach, primary prevention, involves universal educational programs generally delivered in schools and aimed at potential victims. In the majority of cases, these universal programs also intervene in the individual preventive sphere and more infrequently in the family or societal sphere. Regarding children attending elementary school, meta-analyses by Zwi and colleagues , coverinThe advantages of the universal approach are numerous: these programs can be offered at low cost, they are fairly easy to implement widely, and they allow to reach a maximum number of children while avoiding the stigmatization of a particular population. Yet, this approach has also been criticized since it places the responsibility of prevention in the hands of children. Consequently, this approach should not be considered as the only answer to a social problem as complex as CSA. A multi-factorial approach may indeed constitute a more promising solution to solve the problem of sexual abuse. A multi-factorial conceptualization of sexual assault suggests that only the development of global preventive approaches, targeting personal, family as well as societal norms that influence the risk of assault, may substantially reduce incidence and prevalence rates ,120. ThoThe sexual abuse of children is a form of maltreatment that provokes reactions of indignation and incomprehensibility in all cultures. Yet, CSA is, unfortunately, a widespread problem that affects more than 1 out of 5 women and one out of 10 men worldwide. This alarming rate clearly calls for extensive and powerful policy and practice efforts. While the effects of CSA may not always be initially visible, survivors of CSA still carry the threat to their well-being. The traumatic experience of CSA is one major risk factor in the development of mental health problems affecting both the current and future well-being of victims. Considering that many victims continue to be undetected, the roots of these mental health problems may also be unrecognized. In an effort to provide effective services to all victims, we should prioritize the development of strategies to address the barriers to disclosure and reporting. Although the taboo of CSA might not be as prominent as a few decades ago when CSA was rarely spoken of, veiled issues may still prevent victims from reaching out to authorities to reveal the abuse they suffer. To effectively prevent CSA, global preventive approaches, targeting personal, family and societal conditions, need to be explored and validated so to protect the next generations of children and youth from sexual victimization.The authors declare that they have no competing interests.The project was initiated by Prof. Dr. Collin-Vézina who wrote the sections on prevalence and mental health outcomes of CSA. Prof. Dr. Daigneault and Prof. Dr. Hébert led the writing on CSA prevention strategies. All authors read and approved the final manuscript.Prof. Dr. Delphine Collin-Vézina is the Tier II Canada Research Chair in Child Welfare. She is a clinical psychologist by profession and a researcher in the area of child sexual abuse. She is an Associate Professor at the McGill University School of Social Work (Canada). Her proposed research program aims at promoting societal recognition of sexual abuse, and at implementing and evaluating promising practices to help victims of abuse heal from their trauma.Prof. Dr. Isabelle Daigneault is a clinical psychologist and an Associate Professor in the Department of Psychology at the Université de Montréal (Canada). She has a particular interest in the areas of resilience and mental health of young sexual assault victims, as well as in the processes influencing the life trajectories of young victims. Her projects also relate to the efficacy of treatments offered to victims and sexual assault prevention programs.Prof. Dr. Martine Hébert has training in child development and child clinical psychology. She is Full Professor at the Department of Sexology at the Université du Québec à Montréal (Canada) and director of the Research Team on interpersonal trauma. Her research interests focus on the diversity of profiles in sexually abused victims and factors related to resilience trajectories. Current projects also center on the evaluation of prevention and intervention programs.