The application of surface electromyography (sEMG) in neurology is sometimes limited by a scientific background in the use of sEMG. Students frequently use sEMG only when developing their graduate studies. To reduce these barriers, we promoted a free Winter School on sEMG to Latin American students. The school was a 3-day event with theoretical classes and computer programming in Matlab. Lectures were delivered in Portuguese and Spanish to 50 participants. All lectures were recorded and made available on YouTube®. After the School, participants completed a written exam to receive a certificate. The written exam revealed the average effectiveness of 71 ± 20% in the comprehension of topics addressed during the school. Participants rated the School as “excellent” and considered the event as having changed their thoughts about the use of sEMG. Limited mathematical skills or background were the main barriers identified to follow the lectures and to make use of sEMG. We conclude that the Winter School had a positive impact on participant's formation, especially by showing them the importance of continuous involvement with the concepts related to sEMG to become proficient in its use. From the participant's point of view, the activity was excellent and the follow up of the school on YouTube® suggests that combining face-to-face activities followed by the online availability of lectures is a valid strategy to reinforce the learning process and to reduce barriers in the use of sEMG. Whether similar results would be achieved for a paid registration event in an economically developing region, still requires further investigation. Latin America is one of the most unequal regions in the world based on the Gini Index . TherefoFor example, in Chile, which is considered an emergent economy, social inequality remains high, like in other Latin American countries, and education is considered a consumer good. It means that even public education has a high cost, which can be higher than the cost of studying at private institutions. It results in science being transformed to privilege people with better economic conditions and credit capacity, which ends up segregating the society . In BrazIn addition to the economic barriers, there are other barriers requiring attention. These include weak, or absence of a proper educational background to move forward in concepts related to higher education. One important topic of education and research widely used in the fields of physical education, physiotherapy, and engineering is surface electromyography (sEMG). However, many barriers are observed in the use of this tool, as we will further discuss in this article.sEMG encompasses the measurement of electrical signals involved in the muscle contraction and is quantified using surface electrodes, with applications in humans  and othehttp:www.robertomerletti.it and www.seniam.org, where a wide number of sources for historical and updated academic material are available to help elementary and advanced sEMG studies.For example, to promote better use of the sEMG in clinics, hospitals, and gymnasiums, knowledge of several basic concepts from anatomy, neurophysiology, and physics, among others, will be required. The user needs to properly locate the electrodes and be aware of particularities depending for example on the muscle evaluated , 18. SimThe real condition is that most health professionals from Latin America do not receive a background in mathematics sufficient enough to understand and use sEMG in their professions. Many students seek training in health courses just to get away from mathematical work. National scientific journals related to human movement sciences are available, and most of the papers published in these journals, addressing sEMG, are the result of laboratory research developed during master's and doctoral programs. These papers are accessible to students, but the use of scientific papers during the study of these topics needs to be strongly promoted. This establishes an important barrier to sEMG applications that have been considered when promoting regular congresses in the field, like the Brazilian Congress of Biomechanics, and the Congress of the Chilean Association for Human Movement Sciences. But this limitation is not observed only in economically developing countries (EDC).The evaluation of the knowledge from participants working in developed countries also suggested that neurology residents show a knowledge gap regarding the use of sEMG, resulting in up to a quarter of residents expressing a lack of confidence when using techniques like sEMG . FurtherThe knowledge about sEMG may also impact on aspects related to patient management. When considering the use of sEMG in a clinic or hospital, a patient's education about sEMG is also important. We consider that in some cases, not informing the patient or participant about what the examination is, and how it works, may increase stress and possibly change participants' behavior when realizing that many electrodes are going to be attached to their own body, and this misunderstanding may lead to limited clinical results. Among middle-aged patients undergoing sEMG examination, 52.1% of the patients either received no information about what sEMG is, or, the information provided was very poor or incorrect . On the Considering all these aspects, we promote educational activities that reduce the knowledge gap and barriers faced when using sEMG, observed among health professionals who want to or already do use of sEMG without proper training in basic concepts related to its use. In 2018 we organized the first Winter School on sEMG Digital Signal Processing for Latin American students. Here we describe this educational activity, and the impact it had as perceived by the participants. We also share our experience in the selection of the topics for lectures and the methodology for the development of the course. The barriers faced when using sEMG are also discussed.The Winter School lasted for 3 days during September 2018 and was held at the Universidade Federal do Pampa, a Brazilian public university established in a remote region of the Rio Grande do Sul state in Brazil. Registration was free of charge and we received 50 applications for registration. The event was advertised on social media and through email lists of different institutions. There was no limitation in the background level required or the purpose of the participants registering to the school, and the program was available to all participants before completing the free registration. We did not control registration according to the level of knowledge of the participants because it has been suggested that merging students with different levels of expertise may bring education advantages especially for those who are less experienced . Upon ren = 24, 49%) or graduate students , and the other 25% were young investigators with a master's or Ph.D. degree in human movement sciences or physiology, one post-doctoral fellow, and one high school student. We did not collect data regarding personal information like the age of the participants, but informally we can report that most of the participants were young with age ranging between 17 and 30 years. A higher number of female participants was noted, which may in part relate to the fact that most of the participants were from the physiotherapy field, which in Brazil usually has a higher percentage of female graduates.The 50 participants had different backgrounds  and came from cities from the south of Brazil (border with Argentina and Uruguay) to participate in the school that was conducted based on a group-learning methodology and thinking-based learning activities. The school was advertised to other countries from Latin America and we consider that the main limitation for attendance of participants from other countries was the high cost to travel and stay abroad. All the participants had a connection with academia being either undergraduate  to 10 , only 10.2% of the registered participants indicated a score higher than 5. The school's program was designed to include theoretical and practical activities in a friendly environment. We organized a single room meeting, with coffee and finger food; lectures were delivered using media projectors, whiteboards, and questions were allowed at any time. The organizers worked to have the entire class actively participate, and when the participants showed signals of tiredness or if they missed the concepts , a short break was proposed.The main goal of the school was to promote a solid basic background, and therefore, concepts related to muscle contraction, joint angles, and ground reaction forces were briefly addressed to ensure that all participants were familiarized with the origins of biological signals that were used for the examples. In this regard, differences between kinetic, kinematic, and sEMG signals were discussed, and sEMG generation and interpretation were often mentioned, commented on, and explained during the course. Topics were organized to promote a progressive level of complexity. The entire program was covered in 3 days within a total of approximately 20 h of activities. Topics were organized in three blocks:10%: the importance of the proper knowledge related to signal processing, its application in sEMG analysis, and where to find relevant material to study;10%: important aspects of data acquisition, mostly related to hardware characteristics;5%: examples of signal processing methods that are common among different techniques (like kinematics and kinetics) in human movements sciences;75%: data processing concepts: limits, derivation, integration, sums, complex numbers, functions, Euler identity, definitions and classification of signals, discrete acquisition, Nyquist theorem, aliasing, time domain and time-series, frequency domain, Newton Prism experiment and frequency decomposition, Fourier series, harmonics, Fourier transform, spectrum, inverse Fourier, and signal filtering. We also focused on the interpretation of sEMG alterations and distortions, cross-talks, amplitude analysis, windowing functions, cancelation of signals, onset-offset analysis, frequency analysis, co-activation, synergy, and linear decomposition into basis functions. We also included some concepts of the Teager energy operator and prosthesis control, but these last topics were only briefly mentioned.The approach to these topics was always based on evidence from the literature. Basic topics related to the mathematics involved in sEMG processing and analyses were discussed based on scientific papers, and the explanation of concepts for signal processing and analysis was always followed up by a discussion of topics related to data processing and the interpretation of results from scientific papers, i.e., topics for non-engineers began with basic math and sinusoidal wave analysis. When a practical situation was needed to illustrate concepts, as well as to discuss how a decision on data analysis or processing affects the results of sEMG analysis, scientific articles were used, i.e., filter coefficients, signal decomposition, or alias signal . Papers considered for the examples were always related to the general study area of the participants such as those addressing gait biomechanics, jump landing, and for some cases, papers reporting the use of EMG associated with prosthesis control and biofeedback, especially to give a contextualized health scenario for non-engineers.The voluntary tutors to the school were one professor with a Ph.D. in human movement sciences, two Ph.D. students in biological sciences, and one MSc. in engineering, and a MSc. in kinesiology and clinical biomechanics. In addition to the handout and the introductory references already mentioned, the teaching activities were mostly based on the textbooks “Digital Signal Treatment” , “Discrehttp://youtube.com/neuromechTV). Slides used to explain the mathematical concepts and examples of data analyses were also uploaded to Researchgate as “Escola de Inverno: Fundamentos de processamento de sinais discretos em biomecânica.”An important concern when planning the school was the need for a follow up on the educational activities, and the importance of revisiting the concepts discussed during the lectures. This is why all the lectures were video recorded and uploaded with free access on YouTube®. Lectures are available for free in the non-monetized official channel of the Applied Neuromechanics Group, the NeuromechTV  to 10 . Participants graded the advertisement given to the school when registration was open as 9.83. The handout and reference list provided upon registration were considered pertinent, and about 50% of the participants said they read the material before the school started. The strategies employed to discuss the concepts on signal processing were graded as 9.33, and the performance of the tutors was graded as 8.83. The overall grade for the activities was 9.85, and the free registration was considered to be of 60% importance on a scale from 0 to 100, in which we asked whether participant registration was conditioned by the free registration.The written exam completed by participants after the school showed average effectiveness of 71 ± 20% (ranging from 40 to 100%) in properly answering the 15 questions related to the topics studied. We observed that better answers were found for questions addressing those topics in which more time was spent on during the lectures and for topics we highlighted as important during the lectures .The school had a significant number of undergraduate students from physical education and physiotherapy courses who participated, as we detailed in the previous section. As observed, when experiments and data processing and analysis using electrocorticography techniques were developed with undergraduate students, the enrollment in educational activities similar to that developed in our school may help increase their interest in following a postgraduate science program . FurtherWe do not believe that the different backgrounds of the participants limited the development of the activities in the school. Nevertheless, in schools aimed at more complex topics, or those prepared to solve particular problems, the heterogeneity of the participants may have different effects on the activity outcomes. We did not strictly control the methods of each activity, but in general, we conducted a team-based learning approach, which is also known to benefit learning in the laboratory environment . We alsoConsidering the topics addressed in the school, a good amount of time was spent on explaining filtering, especially because filtering is a fundamental step in the sEMG data analysis because of its susceptibility to low-frequency noise, baseline noise, and movement artifact noise , 27. FilThe activities developed in the school also considered concepts related to data acquisition. We aimed to provide basic concepts and straightforward recommendations on how a sEMG examination should be conducted. When it comes to professor basic knowledge of sEMG procedures is required, improving teaching practices as well, and we consider that a specific school for teachers would be a valuable activity for the future. The results from sEMG examination can be a good platform to promote learning sessions and tutorials on how muscles are controlled, to discuss concepts of supraspinal control, reflexes, movement production, and regulation . AlthougWe used a strategy of continuous online education by making all the lectures of the school permanently available online after the school was completed. Webinars and online classes are not a novelty these days, but most of the crash courses available are segmented for a very specialized audience, and sometimes assume that the viewers already have a good background. We believe that the recordings available online could promote additional learning when participants watch the classes again, also resulting in revalidation of the concepts, similar to what has been discussed when records of surgical procedures are integrated into patient care . FurtherFinally, the main barriers identified by the tutors and participants were mathematical skills or background, i.e., algebra, calculus, and mathematical logical thinking. Furthermore, in many cases, fear of the numbers and programming a computer, and the insecurities and anxiety about colleagues from developed countries—who might be better prepared—were other barriers identified among the participants in Latin America. However, important social barriers also exist in regions where investment in research is not aligned with the economical aims of institutions, thus negatively impacting science education. We therefore recommend the organization of basic science schools for health careers in Latin-America, and to frequently develop critical lectures to fill educational gaps, using theoretical frameworks similar to those of engineering and other sciences, but adding innovative learning strategies from modern pedagogy in health sciences, that considers the biological profile of the students and professionals of health and life sciences.The Winter School had a good impact on participant's formation and may have motivated other groups from Brazil to promote similar educational activities during 2019 as we observed schools in topics related to biomechanics and muscle function being promoted. From the participant's point of view, the activity was excellent, and the follow up of the school on the YouTube® channel, considering the social media engagement, suggests that combining face to face activities followed by online availability of lectures can be a valid strategy to sustain the interest of students on these topics.We recommended frequent organizations of basic science Schools in health careers in Latin-America at all levels i.e., bachelor, Master, PhD, and post-doc, as an initiative to fill educational gaps using theoretical frameworks similar to those that engineering and other sciences adopt, as innovative learning strategies for modern pedagogy in health sciences is advisable. Furthermore, we believe that providing schools that are conducted 100% online could significantly benefit a larger number of students and professionals.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants.CD, AM, and MK: conceived the project; delivered lectures; analyzed data; wrote and approved the final version of the manuscript. FC: conceived the project; approved funding; delivered lectures; analyzed data; wrote and approved the final version of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Aedes species mosquito vectors, especially the day-biting Ae. Polynesiensis. The paper reminds us of the danger that tropical diseases can pose for troops sent into endemic areas and constant and careful surveillance that is required to prevent rapid resurgence of Aedes-transmitted LF in populations, where the LF elimination program has been successful.The deployment of United States (US) Armed Forces personnel into the central Pacific islands of Samoa and Tonga, which is highly-endemic for lymphatic filariasis (LF), resulted in thousands of cases of the acute form of this disease and greatly reduced their ability to carry out their mission. The major driving factor for the intensity of transmission was the aggressiveness and efficiency of the  Wuchereria bancrofti, Brugiamalayi and Brugia timori. The adult worms live within the lymphatics and the female worms liberate motile embryonic forms called microfilariae into the peripheral blood. In parts of the world where the LF vectors are Anopheline, Culex and Mansonia mosquitos that bite mostly at night, microfilariae numbers in the blood peak during the night . In the central Pacific, where the vectors are Aedes mosquitoes that bite mostly during the day, microfilariae numbers peak at midday . The global burden of LF is estimated to be around 70 million and its debilitating manifestations of lymphedema, elephantiasis and hydrocele disable around 36 million making it one of the leading causes of chronic disability [Lymphatic filariasis (LF) is a mosquito-transmitted parasitic disease caused by infection with the filarial worms, sability . There isability . This foIn 1997, the 50th World Health Assembly passed a resolution to eliminate LF as a public health problem and, in 1999, the Pacific Program for the Elimination of LF (PacELF) was established to eliminate the disease in the 22 LF-endemic countries in the Pacific region through a strategy of annual rounds of mass drug administration (MDA) . By MarcDuring WW2, LF was a major health issue for the US Armed Forces stationed in filarial-endemic areas of the South Pacific and this has been comprehensively reviewed by Coggeshall  and WartThe very sensitive and specific filarial antigen tests that are now regarded as the “gold standard” for LF infection  were notAn interesting observation is that psychological disturbances were common and recorded by several authors ,13,14. SNo specific treatment was available for LF at that time and the length of time it took for the signs and symptoms of LF to resolve after returning from and endemic area varied. For most cases, it was 20–30 months and for others it took 3 years ,15 and aAe. tongae and Ae. tabu [Aedes species breed prolifically in a wide range of places such as tree holes, leaf axils, water-filled tree stumps, coconut shells and crab holes on beaches, and very importantly, in artificial containers like buckets, cans, bottles and tires, which you would expect to be present in big numbers where troops congregate. [Ae. polynesiensis is a more efficient LF vector than anophelines, especially when the number of circulating microfilariae is low [The reason that Wartman and many of the other authors give, is that that the US Armed Forces personnel were in very close contact with infected local inhabitants in an area that was highly endemic for LF that was transmitted by a day-biting mosquito . In addiAe. tabu . In AmerAe. tabu . Aedes sgregate. . Researce is low . All theFirstly, it is a very good example of how deployments can unexpectedly expose a large number of armed forces personnel to a tropical disease or other infective agent that can have a serious effect on their ability to carry out their mission. Several authors cited above point out that little was known about LF, especially its acute form, and the possible threat to the US Armed Forces personnel prior to them being sent overseas. Tropical diseases can still pose a threat to modern day military forces deployed to areas, where they are endemic, and measures must be taken to mitigate the risk .Secondly, it reminds us of the importance of recognizing the acute form of LF and the need to be aware that it can occur in travelers, expatriate workers, defense force members and others who have a relatively short exposure especially where especially efficient vector mosquitoes are present .Aedes species are the vectors. As mentioned in the introduction, Tonga has achieved the LF elimination target [Ae. polynesiensis. Even when the LF prevalence is brought down to the elimination target there will need to be constant vigilance against resurgence, because unlike other mosquito species, Ae. polynesiensis also has the ability to efficiently transmit LF when population prevalence of the parasite is low and there is a small number of circulating microfilariae [Aedes is the vector [Thirdly, it has very important lessons for the LF elimination program in the parts of the Pacific, where n target . Samoa an target . That shfilariae ,23,24. Le vector . Will th


The increasingly digitized healthcare system requires new skills from all those involved. In order to impart these competencies, appropriate courses must be developed at educational institutions. In view of the rapid development of new aspects of digitization, this presents a challenge; suitable teaching formats must be developed successively. The establishment of cross-location teaching networks is one way to better meet training needs and to make the necessary spectrum of educational content available. As part of the Medical Informatics Initiative, the HiGHmed consortium is establishing such a teaching network, in the field of medical informatics, which covers many topics related to the digitization of the health care system. Various problem areas in the German education system were identified that hinder the development of the teaching network. These problem areas were prioritized firstly according to the urgency of the solution from the point of view of the HiGHmed consortium and secondly according to existing competencies in the participating societies. A workshop on the four most relevant topics was organized with experts from the German Society for Medical Informatics, Biometry and Epidemiology (GMDS), the Society for Medical Education (GMA) and the HiGHmed consortium. These are:recognition of exam results from teaching modules that are offered digitally and across locations, and their integration into existing curricula; recognition of digital, cross-location teaching in the teachers' teaching load; nationwide uniform competencies for teachers, in order to be able to conduct digital teaching effectively and with comparable quality; technical infrastructure to efficiently and securely communicate and manage the recognition of exam results between educational institutions.For all subject areas, existing preliminary work was identified on the basis of working questions, and short- and long-term needs for action were formulated. Finally, a need for the redesign of a technologically supported syntactic and semantic interoperability of learning performance recording was identified. Digitalization has a far-reaching impact on everyday life in almost all areas of society. The demands on students, teachers and university employees are subject to a fundamental change process , 2]. Ac. Ac2]. AThe establishment of cross-locational teaching networks promises to increase competence at distant institutions . Both thWhile cross-location teaching has great potential, the actual implementation poses challenges for both students and teachers. The many technical, didactic, organizational and legal challenges mean that participation in courses across locations is still rare. Even the content and forms of teaching are subject to digital transformation. For example, the digital delivery of teaching materials via online learning platforms is being expanded into web-based self-study units and fully digitalized online courses . The fleThe German Medical Informatics Initiative (MII) is currently researching and developing methods to share medical data from multiple locations for translational health research . As the The teaching modules within HiGHmeducation have been designed both for those interested in studying and for those already in employment. The modules are also open to all disciplines of the health care system, such as medical informatics, medicine, nursing and administration, since the requirements for digital skills are increasing in all occupational groups of the health care system. This interdisciplinary structure should also strengthen interprofessional learning and working. Each module represents a thematically complete course with a defined workload and is based on the didactic framework developed for HiGHmeducation . In order to assess whether the didactic methods successfully supported the teaching of each module’s learning objectives, a standardized evaluation is conducted at the end of each module using a German version of the Community of Inquiry questionnaire . The comThe work of HiGHmeducation, the teaching network, is hampered by various aspects, which are described below; possible solutions to these problems have been offered within other teaching networks; these include the MedizinDidaktikNetz (MDN) as a working group of the Medizinischen Fakultätentag (MFT), the Digitalization Committee of the Gesellschaft für Medizinische Ausbildung (GMA) and the Hochschulforum Digitalisierung (HFD) are active in these areas. For this current paper, this preparatory work by these other organization was utilized as a baseline of knowledge in the planned workshop groups. In particular, the aspects of the German education system, which are hampering HiGHmeducation and were therefore the focus of the planned workshop groups are (in no particular order):Recognition of exam results from other institutions into the curriculum at the home institution. High standards in teaching modules require a considerable investment of both time and effort on the part of the teacher in the development and implementation of the modules. In modern teaching it is important for teachers that this time spent be recognized so that it reflects in their teaching load. For this reason, it should be possible to credit digital teaching in the teaching load appropriately, such that it reflects in the compulsory teaching regulations of the German federal states.The transition from the complementary use of digital technologies in conventional courses to fully digital courses requires new skills on the part of teachers. There are numerous German-language materials for acquiring these skills, making it difficult to provide an overview. Teachers face a challenge in selecting relevant continuing education content.When developing a teaching network and cross-locational modules, scalability for larger numbers of participants must be taken into account from the very beginning. This includes participant interaction and examination practices. For this purpose, technical infrastructure must be developed that effectively supports the process in the environment of German universities.These aspects fall within three primary stakeholders “learners”, “teachers” and “educational institutions”. This is shown in figure 1 Due to the overarching relevance of the four identified problem areas, a workshop was organized, comprised of experts from three organizations – firstly, the work group “Technology-based Teaching and Learning in Medicine” from the German Society for Medical Informatics, Biometry and Epidemiology (GMDS); secondly, the committee “Digitalization” from the Society for Medical Education (GMA) and thirdly from the HiGHmed consortium. Prior to the beginning of the workshop, some representatives from the three organizations discussed their respective experiences with regard to cross-locational teaching. In the process, they identified key problem areas (as outlined above), specifically in the areas of teaching culture, strategic orientation, and organizational and legal structure. This list of problem areas was prioritized according to two factors: firstly, the urgency of the problems from the point of view of the HiGHmeducation consortium and secondly, according to the expertise provided by the aforementioned participating professional societies. The four most relevant topics were selected to be addressed in the workshop. The topics were then sent to the participants before the workshop, so that they could indicate their preferences, based on their experience and expertise. At the beginning of the workshop, the participants were divided into groups according to their preferences and the organizations involved. During the workshop, each group began by clarifying and elaborating upon the specifics of the defined problem area, as each area had only been briefly outlined in advance. Each member of these groups contributed their experiences of both the scope of the problem and potential solutions. The solutions from these discussions were then collected and amalgamated into the results; these are presented sequentially below.The teaching experience of the experts present at the workshop shows that the recognition of exam results from other universities is an important prerequisite for increasing participation in external modules. This is due both to the fact that the marks are presented with their certificates or diplomas and also the fact that there is less risk of delaying the completion of degrees. The difficulty lies in crossing the institutional boundary – students need to have their participation in external modules recognized at the institution in which they are enrolled.What functioning mechanisms already exist for the recognition of exams taken at other universities? How can examination achievements be transferred?Should there be restrictions on the proportion of digital forms of teaching?In principle, recognition can be granted by decisions on a case-by-case basis or by framework agreements. The former represents a precise, but also complex and time-consuming procedure in which each student submits an individual application for recognition of an examination to the respective home institution. The European Credit Transfer System (ECTS) is a helpful instrument for this procedure: in the grading scale recommended since 2009, the distribution of the grades of other students in the same cohort is provided as additional information to the grade in the local grading system . In order to avoid duplicating workload on case-by-case decision-making, inter-institutional framework agreements should be sought. One example of a framework agreement is the EU-funded Erasmus program. The basis for recognition between two universities here is named the Learning Agreement . AnotherAnother factor that can affect exam recognition is the coursework format – differences between the proportion of digital formats permitted at the home institution and at external module providers can prevent the recognition of exam results. Such restrictions on the proportion of permitted digital coursework are often stipulated in higher-level legal structures, such as examination regulations and state higher education laws. These restrictions unfortunately contradict the principle which is a key goal of teaching called Constructive Alignment; this principle encourages the orientation of the learning format towards learning goals. It is therefore recommended to adapt statutes in such a way that participation in digital teaching modules can be fully recognized.In the short term: Develop a catalogue of the modules offered within the teaching network including which modules are recognized at which institutions. Collecting the grading systems used at all the sites in the network and their lower pass marks (as the other metrics of the Bavarian Formula are standard across Germany). In the long term: Create a framework agreement for the recognition of examinations for all institutions within the teaching network, taking into account heterogeneous grading systems where applicable.The following steps should be taken for the recognition of teaching modules from consortium partners: In the short term: Develop tools, including standardized text and standardized decision-making support, for the digital formats permitted in examination regulations depending on learning goals. Baumgartner has made concrete suggestions as to which teaching arrangements should be chosen for which types of learning objectives  of of22] ofIn the development step, teachers should be able to use certain teaching-learning techniques such as social interaction, retrieval practice, distributed learning  or “workFor implementation, teachers should know which participants they need to involve in order to create a successful teaching-learning organization. They should also be able to use computer-mediated communication and instruments for “Classroom Orchestration” effectively. Finally, teachers should be aware of the possibilities for support through evaluation. This way, feedback can initiate a dialogue between those involved, which will constantly improve and update teaching. However, they should also be aware of the control and legitimation function of evaluations in order to be able to check whether all participants have performed their services to achieve the desired teaching quality.In the short term: Further best practice examples of approaches to the use of digital media should be collected centrally in teaching networks. The common European framework of reference for languages, the “DigCompEdu framework”  initiative can be used to digitalize and transmit the performance certificates. The support and use of digital certificates of achievement using existing standards such as OpenBadges is helpful to document exam performance [https://openbadges.org/get-started/]. The digitalization of these conventional processes should be the goal for the near future. Network)  users enNetwork)  or xAPI In the long-term: Digitalization of paper-based processes is a pragmatic but not sustainable solution. New processes should be defined and introduced that make the best possible use of the existing optimization potential through digitalization. At the MIT Media Lab, for example, so-called BlockCerts were designed on the basis of the Blockchain technology, which represent an open standard for creating, issuing, displaying and verifying certificates [ificates . The Bloificates . The impificates .The cooperation of the experts from the professional societies and the consortium resulted in a collection of existing solutions, possibilities for action and open questions in the four problem areas. While the outcomes arising from the workshop were discussed in the context of a purely digital teaching format as utilized in HiGHmeducation, the results can also be applied in blended learning arrangements. As strengthen by our experiences with the COVID-19 pandemic, it has been shown that even in a predominantly digital teaching format, in-person classes are still helpful to ensure commitment, practical relevance and a personal learning atmosphere. It is noticeable that all four topics from the workshop presuppose that competence-oriented learning objectives have been defined, which are not only used to develop courses, but also to design legal frameworks and to train teachers.In addition to the short- and long-term recommendations for action, we see an urgent need for harmonization in the digital representation of exam results in medical informatics. This harmonization, supplemented by syntactic standardization, could offer the possibility to automate the processing of learning objectives received from other institutions. While semantic frameworks in the form of catalogues of learning objectives are developed for specific subjects  and are Based on the results of the workshop, we consider a national action plan and a superordinate institution on the topic of digitalization in university teaching of medical informatics to be a necessary and meaningful intervention to bundle different activities in this area . This inWe thank all participants of the workshop (study group) for their active participation: Marianne Behrends, Christoph Bohne, Barbara Braun, Bas de Leng, Jasmin Decker, Thomas Deserno, Cornelia Fiessler, Peter Heuschmann, Ina Hoffmann, Thomas Koehler, Martin Lemos, Christoph Rensing, Eugenia Rinaldi, Bernd Romeike, Julian Varghese, Joana Warnecke. Special thanks to Alexander Whillier for editing the English article version.This work was supported by the Federal Ministry of Education and Research under grant number 01ZZ1802A.The authors declare that they have no competing interests.


People with disabilities tend to have greater oral health problems compared to those without disabilities. This may be due to barriers they come across in accessing dental services.  The objective of this systematic review was to provide a critical digest of the scientific literature concerning barriers and facilitators of access to oral health services for people with disabilities.  The electronic databases PubMed, Scopus, Web of Science, Latin American and Caribbean Health Sciences Literature (LILACS), and Brazilian Library of Dentistry (BBO) were searched using keywords relevant to the subject. The search was not restricted to specific languages or years of publication; all relevant studies were translated and reviewed.  Sixteen studies including 14 articles, a doctoral thesis, and a monograph were selected, and their quality was analysed using the Downs and Black assessment tool. Barriers to dental services were divided into physical or nonphysical based on the dentist's perspective, as per the perception of parents/guardians or by the persons with disabilities. The barriers that emerged included the dentist's lack of preparation to assist people with disabilities, structural problems of access to dental offices, communication difficulties, and lack of awareness regarding the need for dental treatment for the disabled person.  It is concluded that people with disabilities continue to run into complex physical, behavioural, or multidimensional barriers in accessing dental services. Improved training of dentists for the care of this population is hereby emphasized. The legal framework enabling access to dental care for people with disabilities must also be respected in each country. The number of persons with disabilities worldwide is almost one billion . The affThis is partly due to the difficulties encountered in the care of the oral cavity, which include structural barriers and motor difficulties and those associated with communication with the caregiver regarding the need for oral health care , in addiWhen individuals with disabilities take initiative to access health services and gain access, they subsequently choose to continue care in services that have empathetic, compassionate, and responsible professionals . Yet, acKnowledge of the main barriers that hinder oral health care in people with disabilities needs to be discussed. Access to care is determined by the geographical location of the patients and services, the convenience and ability to organize services in order to accommodate the individual, their adaptability to the service provided, and the reciprocal acceptability of professionals and end users . Access Thus, universal access to health services comprise (i) a political aspect involving decision-making and agreement by the different levels of the government in a country, thereby prioritizing and programmatically arranging the services and the intervention devices in context; (ii) economic and social aspects that cover financing issues and mitigation or elimination of barriers encountered by the user; (iii) system organization starting from the user's entry into the service up till the resolution of their health problem; and (iv) technical-scientific training and cultural competence, through comprehensive actions and respect for individuals, understanding the health-disease transitions, beliefs, values, and traditions .Based on the above, the objective of this systematic review was to critically gather from the scientific literature the main barriers and facilitators of access to oral health services for people with disabilities.This systematic review was carried out according to the Cochrane Collaboration Guidelines Combined , 18, MetThe guiding question of the review was defined as follows: How do people with disabilities access oral health services?The keywords were selected based on the study question and study population.Online databases were consulted from August 24, 2018, to August 27, 2018, based on the date of online availability and included PubMed, Scopus, Web of Science, Latin American and Caribbean Health Sciences Literature (LILACS), and the Brazilian Library of Dentistry (BBO). In addition, the references cited in all the primary studies included were manually searched to add all the relevant publications that may not have been included in the main search. At this stage, the grey literature was also accessed through the ProQuest Dissertations and Theses Full-Text databases, CAPES Theses Periodicals, the Grey Literature Report, and Google Scholar. Abstracts from the annual conference of the International Association for Dental Research (IADR) and its regional divisions (1990–2018) were also searched.The search strategy was appropriately modified for each database; two reviewers (SVR and LCT) performed the search in order to identify eligible studies. Though observational studies  were included, editorial letters, historical reviews, in vitro studies, controlled trials, case reports, comments, and qualitative studies were excluded from the present study. No language or publication date restrictions were imposed; all relevant studies were translated and revised.After the exclusion of duplicates, using the ®Mendeley reference manager, studies were initially screened on the basis of titles and abstracts. Articles that appeared in more than one database were considered only once. The full-text versions of the articles were evaluated by a pair of reviewers (SVR and LCT) who determined study eligibility; disagreements were decided by a third reviewer (JSR). Each eligible article was assigned an identification code (first author/year) to facilitate its classification. Inter-rater reliability was calculated by Kappa statistic; a value of 0.87 was considered optimal. Relevant information on study design, participant characteristics, exposure, and outcomes was extracted through a customized pretested data extraction form .The quality of the articles was assessed by two independent reviewers (SVR and LCT) using the Downs and Black scale . This inFor each aspect of quality assessment, the risk of bias was scored according to an adapted version of the Cochrane Collaboration tool , which iKappa was also performed to measure inter-rater agreement and to analyse the risk of raters' classification bias. A Kappa value of 0.86 was attained, which is considered optimal as per the relevant literature.Data were analysed using the extracted information which included the study title, author, year, country, sample size, study design, study results , and source of the study population. Because of the heterogeneity of the studies, a meta-analysis was not performed. The target audience of the questionnaires were people with disabilities; however, the dentist was interviewed. Also, the diversity among the studies was due to the age or the age groups of the target population, the difference in the health systems in the countries studied, and differences in the type of disability.n = 7) [n = 4) [n = 6) [n = 1) [n = 1) [n = 22) [A total of 2,190 articles were derived from all the databases after removal of duplicates . Howevern = 7) –35; (ii) [n = 4) –39; (iii [n = 6) –45; (iv) [n = 1) ; (v) wer [n = 1) ; and (vi[n = 22) –69.Only two studies were derived from a secondary database , 74, andThe results of the bias risk assessment are shown in The barriers observed in this review were classified as physical or nonphysical or classified based on the perception of the person responsible for, or the caregiver of the disabled person involved in the study, and the perception of the dental surgeon attending to the disabled person. The results of the barriers detected are reported in Common barriers observed among the included articles comprised the cost of treatment , 82, 83,The types of disabilities addressed in the studies were rather broad and are shown in The dental procedures reported in the aforementioned studies also highlighted the treatment needs of the population. In people with disabilities, the simplest procedures can be difficult to perform due to problems associated with communication or physical constraints such as muscle stiffness, poor mouth opening, and resistance to treatment that often led to care under general anesthesia . Four ofAs this population needs specially organized health services and comprehensive preparation of professionals , it was The design of all included studies showed a cross-sectional framework allowing to simply estimate the prevalence of evaluated variables or at most their relationship. On the other hand, in addition to cross-sectional studies not being adequate to analyse causality, just association, another problem is the possibility of a low response rate of participants. Therefore, the researcher needs to make use of sample contact strategies such as telephone and mail communication. In the results of the studies included in this systematic review, the response rate of the questionnaires sent was reported in ten studies, not mentioning significant sample losses, suggesting that the response rate did not affect the results. For the others, for not having addressed this issue, it is unknown , 83, 86.Studies that were not found in their entirety and excluded from the final selection in this systematic review were mostly those reported during the period from the 1950s up to the 1980s. Not including these studies in the analysis of the results hampered the possibility of revealing old and persistent barriers to dental services. This resulted in compromising the analysis due to a possible change in the nature of barriers over a longer time interval –69.In the analysis of the study quality, the “report” item assessed whether the information provided by the study was sufficient for the reader to make an unbiased assessment of the conclusions derived from the study . ExaminiPhysical barriers reflect problems relating to accessibility that people with disabilities encounter to reach a dental care facility. Two articles reported physical barriers hindering access to care facilities, such as surgeries being performed on the upper floors of buildings that did not have elevators and not remembering that dental extraction is a common requirement among people with disabilities , 81. InaFamily involvement in access to care for people with disabilities is very essential, as family support and emotional bond play a fundamental role in their health. Expecting a child with disabilities can inflict emotional distress and guilt in parents, who are required to prepare appropriately and introject situations of difficulty that they may encounter, given the social, structural, and programmatic inequities that place a disabled person in a vulnerable situation . The famPeople with disabilities often have a number of associated health problems such that oral health care takes a back seat in the family . This baThe studies selected belonged to various parts of the world, with representation from the United States , 74, 77,Permanent health education allows professionals to refresh their knowledge and practices through latest evidence and the best treatment approach available, thereby enabling the enhancement of technical skills, scientific knowledge, and ethical development of the processes and also building relationships between the teams involved. The appropriate distribution of professionals and services to the proximity of the population in need, irrespective of their location with an aim to improve access to care and to enable continuing health education, is a complex task, as there is a noticeable concentration of specialized professionals in large centres . This imMost of the studies included in the review were centred primarily in countries such as Brazil, the United States, and Canada. Brazil has a universal Unified Health System (SUS) enshrined in its federal constitution of 1988. It is a free system accessible to all Brazilian citizens, including people with disabilities. It has doctrinal principles: universality, equity, and comprehensiveness , 95. PriIn the United States, the most frequent barrier was the lack of experience among dentists and the cost of treatment , 74, 77.The difficulty to provide dental care and the lack of trained professionals to care for people with disabilities has a direct influence on their oral health. The procedures that need to be performed are most often on patients requiring urgent care where they are already in pain, mandating tooth extraction due to decay or prophylaxis due to bacterial biofilm accumulation. Procedures such as restorations and preventive treatments can be performed in order to prevent tooth mutilation. The use of prostheses can also restore the well-being and quality of life of people with disabilities , 80–83.The compilation of the barriers observed was derived from studies using quantitative methods which in turn may be a limitation of this systematic review, considering that qualitative studies may approach barriers differently. For example, qualitative studies are ideally not limited to structured questions with closed options, and one's view of access to services can be further explored, thus opening horizons for another systematic review (metasynthesis) for qualitative studies. Another limitation to be considered was the inclusion of only cross-sectional studies. Finally, it is alarming that facilitators of access to dental services for people with disabilities have not been discussed or reported in these revised studies, which paves way for further studies in this field, aiming at solving the barriers that hinder access to dental services.People with disabilities continue to encounter various physical, structural, geographical, professional, or behavioural barriers that hinder their access to dental services. Furthermore, there is a need to improve the training rendered to dentists pertaining to care for this population in various national and regional contexts. It would be ideal to enforce and implement accessibility laws in every country. Therefore, a lot remains to be achieved by the society with regard to the facilitation of access to health care. Overcoming the barriers encountered by people with disabilities can thereby enable their much deserved and dignified access to oral health services.


Training based on clinical simulation is an effective method of teaching in nursing. Nevertheless, there is no clear evidence about if it is better to use high- or medium-fidelity simulation. The aim is to analyse if students are more satisfied when their clinical simulation practices are based on high-fidelity simulation (HFS) or medium-fidelity simulation (MFS). Students´ satisfaction was assessed using the Satisfaction Scale Questionnaire with High-Fidelity Clinical Simulation. The sample is composed of 393 students from two Spanish Universities. Satisfaction with simulation in nursing students is significantly greater in MFS than HFS. Simulation is beneficial for learning in all its forms, but for the acquisition of basic skills, and at a lower cost, MFS proves to be effective. However, high-fidelity is not always better than medium-fidelity as this depends on the student’s level of knowledge and clinical experience. The educational model of the European Higher Education Area recognises the fundamental role of professional competencies for student learning . In SpaiHowever, being competent in a specific area is complex because students must be able to integrate knowledge, skills, capabilities, attitudes and learning outcomes, all of which enable problem solving in various ‘real-life’ situations ,4,5. In Clinical simulation complements clinical rotations in real clinical contexts—in Spain, this usually begins in the second year—rather than acting as a substitute for them, as real experiences have certain nuances which are not reproducible in a simulated environment . NumerouConsidering this, training based on clinical simulation consists of replacing reality with a simulated scenario, that is as realistic as possible, in which students and professionals can learn communication skills, psychomotor skills and team-working skills . These sAccording to the specific technological complexity, the types of simulators are divided into three categories depending on ‘fidelity’  : low, meAlthough students do not always recognise what is best for them , anotherThere are previous studies that tried to compare the different types of simulation with respect to the satisfaction that students obtained with their learning, but they are not conclusive ,31. TherConsidering these points, the aim of this manuscript is to analyse if students are more satisfied when their clinical simulation practices are based on HFS than on MFS. Our research aims to contribute to this debate due to the different simulator costs (high-fidelity vs. medium-fidelity). If there are no significant differences in the learning process, this could mean relevant cost savings. This is why this research has made some methodological improvements in the sample , considering some weaknesses of the previous literature.The study was designed and carried out as a quasi-experimental investigation. Students from the second academic year who enrolled in the simulation subjects  in the Nursing degree at Nursing Schools from two Universities in Spain (one from the north—the University of Cantabria—and another one from the south—the University of Seville) were invited to participate in the study.n = 401, 210 students from the University of Cantabria and 191 students from the University of Seville, which meant 100% participation) was proposed since it is well defined, accessible and not too large for data collection. This data collection was performed in 2017. After reading the information related to the study, they voluntarily confirmed their availability and interest in participating, being informed that their participation would have no effect whatsoever on their grades. All students were approached, although some of them refused to participate in the simulation activity or to complete the questionnaire (3 of the University of Cantabria and 5 of the University of Seville). The final sample was composed of 393 students (207 students from the University of Cantabria and 186 students from the University of Seville). Students from the University of Cantabria participated in an HFS intervention, while those enrolled in the University of Seville took part in an MFS intervention. The curriculum in both schools follows the guidelines of national requirements.A total population study  for the reporting of this study .At the University of Cantabria (HFS), theoretical classes were taught at the beginning of the course, accompanied by theoretical support in order to review the most important points designed for the assessment and intervention of patients in a critical status. Four different scenarios—previously peer reviewed and validated—were used in this study. Each scenario explained the situation of the patient, whether in the ward, the emergency room, at their home, or in a geriatric hospital. In each scenario, there were 4 or 5 students who performed the simulation with a professional role, while the remaining observers (fifteen) followed the evolution in an adjacent room on a TV monitor. All the students intervened in at least one of the cases. This was the first time that they had done so with an HFS.To elaborate the verification list, we have considered the competencies which have been selected as being the most representative in the context of the management of the critical patient (patient-centred assessment airway): (A) ventilation, (B) circulation and (C) recognition of the critical event, application of basic or advanced vital support measures, re-assessment of the patient, knowledge regarding the administration of drugs, communication with the patient, where appropriate, and communication with the medical team. Previously, the professors had prepared the scenario, simulators, materials and necessary devices, as well as the patient’s clinical history.The training took place at a simulation scenario in two rooms that were prepared for this purpose. The necessary staff included one instructor/professor , a technician acting as an assistant within the room and a software technician. Simulation has been used as a learning method over fifty hours (twenty-five hours per academic year).®- Sarasota, FL, USA- and SimMan 3G®- Stavanger, Norway). Initially, on the first day of training in each group, a talk lasting approximately five minutes explained the aims and organisation of the virtual hospital, including specifics regarding the lockers for changing clothes and changing into a uniform. Thereafter, a specific scenario took place, previously explaining to the students and observers what they would find in each room. This meant that, in the event of a critical situation, the student could visualise a patient with an illness in a realistic work environment. The team of instructors, both within and outside the simulation room, were in continuous communication via the use of microphones and headsets and provided ongoing moment-by-moment information. Each situation was both audio- and video-recorded to enable, were it necessary, an analysis between the case instructor and the students. Lastly, the debriefing took place. This was what any simulation should include: all the skills can be worked on, such as team-work, decision-making, task management and other psychomotor skills [We used two types of computer-controlled high-fidelity mannequins  performed by the students. Theoretical classes were taught at the beginning of the academic year (six hours), accompanied by the corresponding theoretical support for the follow-up and review of the most important aspects designed for the assessment and intervention in a patient in a critical status with cardiorespiratory arrest. At the beginning of the course, and while the theoretical classes were being taught, MFS was performed. The scenarios and the verification lists were similar to those of the school in the north.®Anne SKillreporte™ Laerdal® mannequin) to perform the CPR manoeuvres on four practical cases using the simulation mannequins. This was performed in small groups of 10–15 students, taught in three teaching units at three different hospitals. Three teachers participated in the MFS practice. The ‘supposed’ patient was found in a supine position, on the floor, having suffered an apparent cardiorespiratory arrest. Each student had to perform a focused assessment of the person and perform CPR during three complete cycles (1 cycle: 30 compressions/2 ventilations), and in no case was the sequence corrected or interrupted until the resuscitator had finished their practice or the case. All the students simulated with the simulation mannequin with feedback, in order to quantify the quality of the external cardiac massage and the ventilations performed. This assessment was completed with the direct observation on behalf of the teacher, using a verification checklist proposed by the national CPR plan to assess the appropriate adherence to the recommendations given in the resuscitation guidelines.The cardiorespiratory resuscitation (CPR) manoeuvres were practised between April and May 2017. This was done by using visual feedback simulation  as well as the authorisation of the other participating centre (the University of Seville). The students were informed of the study and granted their consent. Confidentiality was ensured for all participants during the process. All data collection measures were kept in envelopes and the authors of the study had exclusive access to them.t and analysis of variance (ANOVA)). The significance level was set at p < 0.05.The statistical analysis was performed using the Statistical Package for the Social Sciences  for Windows, version 26.0. A bilateral contrast and a 95% level of confidence were adopted. A descriptive analysis was performed of all the variables gathered for each group. For this study, the means and standard deviations (SD) for each item were calculated as well as the bivariate correlations. Mean differences tests of the Satisfaction Scale Questionnaire items and domains were carried out to identify if the type of simulation affects satisfaction  and 186 from the University of Seville . This questionnaire has presented a positive factorial structure, a good predictive capacity and a high internal consistency .Descriptive statistics of each item of the SSHF are presented in t = 0.00, p < 0.05). The medium-fidelity group had higher scores in all the domains (except “Relationship between theory and practice”), and the differences are statistically significant. Furthermore, the highest value is achieved by both groups in the communication domain. In other words, they indicated that they are really satisfied with the improvement of their communication skills due to simulation practice.The descriptive statistics and the ANOVA test are presented in In contrast, the lowest score in the MFS group was obtained in the domain “relationship between theory and practice”; that is, how case simulations worked when they are related to the theory learned. Regarding the HFS group, the lowest level of satisfaction was in the facilities and equipment domain.Beginner nursing students’ satisfaction about simulation experiences presented high scores in both cases (MFS and HFS). Different authors have also reported high scores, supporting our findings regarding the students’ satisfaction with both simulation methods ,32,33,37In particular, our research goes further and analyses if there are differences in the level of satisfaction of beginner nursing students between the MFS group and the HFS group.At this point, our results present a statistically significant difference, with the MFS group achieving a higher score than the HFS group. They also expressed significantly greater self-confidence dimension. Our results agree with Wang et al.’s  findingsIt is possible that these results may be due to the fact that MFS ensures a greater satisfaction than HFS which is more complex for students, and therefore they prefer specific cases to real situations. The results seem to indicate that the group which received MFS was more satisfied with it. This could be due to their degree of satisfaction regarding their achievement being higher than in the cases presented with HFS when it comes to evaluating simpler competencies. The complexity of the cases and the technology itself are often a barrier to effective learning, as some studies indicate. In this sense, the literature suggests that simple scenarios, appropriate to the student’s degree of knowledge, which favour the acquisition of achievement as they advance in their training, seem more appropriate, provided they are the ones most adapted to the student’s level ,41,42. IBenner  differenSome authors ,33 also We believe the reason for these discrepancies may be due to the level of maturity of each student, whether he or she is a true novice or more experienced. Our results go along with Lubbers and Rossman’s evidence , since tThe limitations of this study should be acknowledged. Firstly, the study was carried out with students who had little previous clinical experience and the results cannot be extrapolated to students with more clinical experience. In addition, the research has been performed in two different settings so the differences found could also be affected by the particularities of each setting. In this regard, future research should control the particularities of the setting to isolate the effect of the different types of simulation as much as possible. Finally, further research that goes beyond the differences in the level of satisfaction and considers the learning process in a more complete way is encouraged.Nursing students involved in this research with no previous clinical experience who participated in an MFS showed a significantly higher level of satisfaction than those who enrolled in an HFS, although due to practice, both types of simulations enhanced student communication skills. The use of simulation, regardless of the degree of fidelity, is well-received by nursing students, who maintain high levels of satisfaction. It seems reasonable to recommend its use, in all degrees of fidelity , for the acquisition of competencies, since student satisfaction with their own performance is an element favouring their involvement in the learning process.


The WHO Melbourne declaration set forth the target that by 2020 all countries obtain 100% of blood supply from unpaid voluntary donors. To ensure that the supply of blood is safe, health services impose a wide range of restrictions on the individuals who can donate. With the recent announcement by the Irish Blood Transfusion Service to relax restrictions on formerly UK-based blood donors, is it time to rethink the restriction on individuals who are still unable to donate?When donating blood in the UK, the health screening includes a question on whether the individual has had a blood or blood product donation. This question exists, among other reasons, because of safety concerns surrounding the bovine spongiform encephalopathy/variant Creutzfeldt-Jakob disease (BSE/vCJD) outbreak of the early to mid 1990s. BSE, colloquially referred to as mad cow disease, is a neurodegenerative disorder affecting bovine livestock caused by the recycled use of animal remains in livestock feed. The causative agents are misfolded prion proteins, which are transferred in the consumption of infected tissues. The widespread transmission of the disease in cattle, and subsequent human consumption of infected beef resulted in the contraction of a variant of the human disorder, Creutzfeldt-Jakob disease (vCJD). This fatal disorder, in its spontaneous form, was typically observed in people older than 60 years, at a very small incidence. vCJD affects various aspects of neurological function, including memory, location, and sight, always resulting in death. The variant form of the disorder has, to date, resulted in approximately 178 deaths. To curb the disease, the UK Government culled and destroyed more than 4 million cows. Internationally, UK bovine products were banned from export to most countries for at least a decade.Alongside the immediate problem of animal to human transmission were the potential long-term concerns of human to human transmission. Iatrogenic transmission occurring from the reuse of medical equipment used on individuals with CJD was a concern and was curtailed by more rigorous sterilisations and usage guidelines. Although vCJD cases resulting from organ transplantation had arisen, zero cases from blood transfusion had been reported in humans. Concerns over the long-term incubation period of the disease led to estimates of a potentially huge latent pool of future sufferers. By 2000, a number of animal studies had shown that the prion proteins responsible for CJD, if found in blood used for transfusion, were able to directly transfer the disorder between individuals. The combination of these pieces of information began to shift members of public health advisory groups towards increased stringent regulations. Subsequently, Switzerland issued a ban on blood donors who had spent more than 6 months in Britain during the original outbreak. This ban was also implemented in New Zealand and was followed shortly thereafter by bans in a a large number of countries. By 2004, the number of cases of vCJD caused by consumption of infected beef decreased significantly to controlled levels. However, 2004 also saw the emergence of a small number of individuals developing vCJD after having received blood transfusions from as-yet-undiagnosed individuals with vCJD. This resulted in a second national alert that, combined with research predicting large numbers of individuals who had potentially been infected after blood transfusion, prompted the then UK and Irish Governments to enforce guidelines that are still in place today. These guidelines included use of leucodepletion to remove white blood cells from blood products and, most importantly, the restriction of blood donation by individuals who had received transfusions from the 1980s onwards. These guidelines were further influenced by the potential for outbreak of other bloodborne diseases such as HIV and hepatitis B virus.To date, four individuals who, having received blood transfusions from people who subsequently died of vCJD, died themselves from vCJD. Although any deaths are cause for concern, the relatively low incidence of transfusion-related death indicates that the actual risk to the public is low. Indeed, news announced last month by the Irish Blood Transfusion service (IBTS) indicated their intention to reverse their ban on UK blood donations. Introduced in 2004, the ban prevented individuals who had lived in the UK between 1980 and 1996 from donating blood. Director of the IBTS, Stephen Field, pointed out the massive discrepancy between the predicted number of transfusion-related cases and actual cases. Alongside this, he pointed out that the four known cases had occurred before the implementation of the leucodepletion preventative measure, further confirming the low current risk of transmission. This change in policy is a significant step towards the reassessment of the guidelines in other countries. The immediate hopes of the referral will be to reclaim some of the 10 000 lost donors excluded over the period of the ban in Ireland alone. This situation is similar to the changes in regulation of donation from men who have sex with men (MSM) as a concern over potential sexually transmitted disease (STI) transmissions. In most countries, MSM can now donate, although they must undergo strict lifestyle questioning and often deferral periods before blood product use. The major difference between restrictions on MSM and the vCJD restrictions being the presence of reliable blood tests for many of the concerning viral pathogens which cause STIs not currently available for prions.For many, vCJD is an emotional and controversial issue. At the time of the initial UK BSE outbreak, government officials were, at best, slow and, at worst, negligent in their actions to tackle the effects on humans. Famously, the agriculture minister, John Gummer sought to quell concern by publicly encouraging his infant daughter to eat a beef burger, only for the government to recognise the danger posed and initiate the mass cull of cows 6 years later. By this time, millions had been further exposed, justifiably causing an evaporation of reassurance in the government and, by association, the scientific community to protect the public. Nearly 30 years on there is still some push back in relaxing safeguards associated with vCJD. In addition, the current blood contamination inquiry looking at the potential infection of 30 000 individuals during the 1970s and 1980s is creating further controversy around the safety of blood products in the NHS. These issues suggest that, moving forward, the issue must be addressed with cautious revaluation.Donating blood is a hugely rewarding experience and, in an ideal situation, should be available to as much of the population as possible. Combined with the WHO declaration on blood donation, many countries are in the midst of a difficult situation to reach voluntary donor targets. It is a sad irony that the individuals who might have benefitted the most from blood donation, who are often the most eager to reciprocate, are still unable in the UK. Further research into treatments for vCJD are essential. The lack of a reliable blood test is crippling, and second only to the lack of a treatment in the importance of issues surrounding this disease. Journals such as ours focus on encouraging and nurturing the dissemination of information with the hope that this knowledge gap can be bridged. The balance of public safety with the loss of benefits to a society can be a difficult balancing act. However, it is essential that authorities constantly seek to ensure they are using the most up to date data available and are quick to act as the risk:benefit balance of a disease evolves.EClinicalMedicine