The formation of the World Federation of Associations of Pediatric Surgery (WOFAPS) was an important unifying force in the emergence of pediatric surgery as a distinct specialty. Beginning with the formation of several national societies in the early ‘60s, an early, multinational effort was created. This was in large part fostered by the International Pediatric Association (IPA), which lent logistical support from the medical pediatric community to the pediatric surgeons. In 2001, the mission of the Federation was formalized to focus on the development and education of surgeons serving children, in all parts of the world. This was articulated in the famous Kyoto Declaration of Pediatric Surgery: “Every infant and child who suffers from an illness or disease has the right to be treated in an environment devoted to their care by a pediatric medical or surgical specialist”. This vision was unique at the time and foreshadowed the major increase in advocacy activity which has emerged in recent years. While the mission has evolved with time, the present organization continues to hold true to the guiding principles of the original founders and seeks to improve the quality of “Surgical Care for the child, no matter where they live”. Education and collaboration across borders underpins the organization’s endeavors. This article will present many historical details that have been drawn from lectures given by Professor Jose (Pepe) Boix-Ochoa over the years. The goal of these lectures, and this article, is to create awareness of both the challenges and successes incurred along the WOFAPS journey so that today’s pediatric surgeons can incorporate this knowledge of the “past to build the present to ensure the future” as articulated by Pepe.Today’s WOFAPS has much to be proud of and the achievements are the result of efforts by many prominent pediatric surgeons. The journey began in early 1950 and 60s. Although the development of pediatric surgery as a distinct specialty was slow in its acceptance, the concept gained awareness when surgeons caring for children in developed countries like England, US, Canada, France, Argentina, Brazil, Australia and Japan recognized the need for a national organization as a forum for advancing the quality of pediatric surgical care. These national associations fostered development through debate and discussion of individual experiences inclusive of successes and challenges with like-minded surgeons, dealing with the unique needs of the pediatric patient. Unfortunately, in the rest of the world, the surgical care of children was still under the helm of adult surgeons, who had varying types of relationships with the corresponding pediatric medical community within that region. There was no international pediatric surgical organization, and consequently no unifying voice to develop international and universal educational and scientific guidelines for the surgical care of children at this time.In 1963 at the Paris Congress of the French Association, Prof. Pellerin  proposed the creation of the International Union of Pediatric Surgeons (IUPS) to provide support for pediatric surgeons in developing countries and to provide an international unifying voice aimed at bridging gaps in training and the level of care in. In this proposal, the IUPS articulated the aim to: (a) keep each national society fully independent, (b) improve the relationship between all pediatric surgeons, and (c) provide information on the activities of its members at a world congress every 4 years. The historic document handwritten by Prof. Pellerin is impressive; the proposal was well received and was endorsed by the signatures of 24 pediatric surgeons from different nationalities who agreed to take this proposal to their Associations  with the already established International Pediatric Symposium (IPA) as it would create an opportunity to present the proposal to IPA attendees. Additionally, Lozoya gained support from Professor Robert Gross , who was influential in the newly formed American Pediatric Surgical Association (APSA). They recognized that the inclusion of such a large group of pediatric surgeons would create more awareness endorsing the value of an international organization. Dr. Gross shared in the enthusiasm for promoting the proposal and this was a turning point in the journey. The first World Symposium of Pediatric Surgery was held in 1968, in Mexico in conjunction with the International Pediatric Association’s symposium. This was a great success, but to build on the success of the first symposium, and to create a distinct entity for surgery, Lozaya and Pellerin made plans for the second WSPS which would follow the next IPA in 1971. The IPA was to be held in Vienna but Lozoya and Pellerin decided to host the WSPS in a separate city, Paris. This choice of venue was deliberate, recognizing that such destinations were more likely to increase attendance. Both the IPA and the WPSS were well attended demonstrating support for this type of international organization from the pediatric community.The next step in the journey was the transition of the symposium into a proper organization representing Pediatric Surgeons from around the world. This effort was led by Jimmy Lister , the BAPS’s general secretary (1970). Lister was a tireless organizer and a smart and flexible politician and used his influence to contact many pediatric surgeons around the world. It was implied that BAPS would lead the new organization, and further details would be discussed and developed by Lister, Beardmore (President of APSA), Professor Suruga (Japan) over the next year. The first discussion occurred in June 1972 on the sidelines at the Pan American Pediatric Surgery Congress in Tokyo. Two months later in August, this group of four met with Lozoya, Carvalho Pinto and the Presidents of South American Associations at the Pan-American Congress in Bogota. It was at this juncture that Pepe Boix-Ochoa became involved. The same year, Jimmy Lister brought a summary of these meetings to the BAPS’s Board of Governors at the Glasgow Congress and leadership of BAPS led by Nixon endorsed the proposal. Political ramifications were debated and resolved, and all associations present agreed to move forward.The final proposal was reviewed by Jimmy Lister, Prof. Lozoya, Prof. Suruga, and Harvey Beardmore in 1973 at Lister’s home in Sheffield. They spend 3 days together after the BAPS meeting in London drafting the Constitution and By-Laws in anticipation of review by the first WOFAPS Council at the next WSPS congress . It was at this meeting when the WSPS transitioned to WOFAPS.After all of the efforts, debate and discussion, a smooth transition would be expected, however, the provisional agreements allocating the past President and General Secretary of BAPS to assume these posts within the new WOFAPS was not well received by the larger membership. In Sao Paulo, 27 different national associations were in attendance; the debate was resolved by offering the Presidency role to Professor Jesus Lozoya, as one of the major promoters and founders of the initial concept. He declined because of his advanced age. Ultimately, Prof. Harvey Beardmore  who was the President of APSA was elected as WOFAPS President and Lozoya as Past-President Fig. ; this waThe next day, October 15, 1974, the first council meeting was held in Sao Paulo, Brazil. Fourteen of the 27 Associations represented became full members. Annual membership fees for associations were set at $100 US to entice associations to join. The Council discussed and unanimously approved a draft Constitution, the first Board of Governors and the announcement to all Societies—WHO, CIOMS, UNESCO and UNICEF—of the establishment of WOFAPS. The Constitution specified that membership to WOFAPS involved national associations and societies and not individual members. WOFAPS was established as an international body representing its various constituent associations and societies “organized exclusively for charitable, religious, educational and scientific purposes to improve the surgical care of children throughout the world”.The goal of membership and council in the early years was to develop strong relationships with founding organizations, national pediatric surgery organizations, in addition to honing the terms of the Constitution. Under the leadership of Beardmore and Lister, the Constitution was revised and finalized for formal approval of the council at the next meeting .To increase the visibility of the organization, the Executive Council decided to hold executive board meetings on the sidelines of other major congresses. The next executive WOFAPS meetings were held in Newcastle with BAPS in 1975, and in Boca Raton with APSA in 1976.The 2nd WOFAPS World meeting was held in Barcelona in 1977, in conjunction with the 4th IPA congress of the pediatric societies. It was a great success with over 800 participants and a large delegation from Communist countries and from Africa  in charge of organizing as the local host , WOFAPS began to identify and attempt to solve important problems related to surgically ill children.Harvey Beardmore presented his report on the contacts between developed and developing countries to ensure interchange of knowledge and helping young pediatric surgeons to train in major centers. Seventy worldwide societies (from both the developed and developing world) expressed interest but the lack of sponsors and financial support resulted in the idea remaining unfulfilled until the start of the WOFAPS Foundation some years later. The Executive Board began to develop with the formation of committees to deal with organizing the specialty.Prof. Marcel Bettex  was elected President and Pepe Boix-Ochoa was again re-elected as General Secretary. (A post he would hold for 35 years!!).In the ensuing years, under the leadership of Bettex, the organization matured, and underwent formal incorporation as a non-profit entity, in Switzerland. The following World Meeting was held in Santiago, Chile, in 1986, Jose Ricardo Piñeiro  became the new President in 1989, with Keith Ashcraft  and J. Pinus  as Vice Presidents. Istanbul was voted as the venue for the next Council Meeting in 1989.Keith Ashcraft was elected president at the Istanbul council meeting of 1989. He led WOFAPS to focus on the education of young surgeons from developing countries. He tirelessly worked with the Education Committee to support and assist young pediatric surgeons in visiting major Pediatric Surgical Centers around the world as observers. He travelled to many regional centers as an ambassador for WOFAPS and hosted many young surgeons for training in Kansas City.However, other major centers could not provide board and lodging, and candidates coming from developing countries had difficulty even arranging for transportation. The primary mechanism for overcoming these barriers was the direct support from the WOFAPS Executive, and their institutions, in hosting visiting surgeons. Dr Ashcraft also began the process of increasing communication with the membership societies, by sending out newsletters and briefings on the activities of the membership. The communication was helpful in increasing awareness, but the limiting factor continued to be the finances.A further change began with the election of Sid Cywes in 1996 as President in Melbourne, who combined the focus on education with advocacy for regions with minimal or limited infrastructure for pediatric surgery. He actively supported and assisted WOPSEC—World Organization of Pediatric Surgeons to Emerging Countries.Under the guidance of Prof. Cywes, the WOFAPS leadership increasing focused on assisting underdeveloped countries, particularly those in Africa, in providing medical volunteers, to advise and improve children surgical care, in addition to the counseling of traumatized patients following catastrophic events.He also organized and assisted with training programs for post-graduates from various African countries, and was instrumental in establishing the Pan African Pediatric Surgical Association. This evolved over the years 1991–93 and resulted in the first meeting in Nairobi, Kenya with Prof. Kyamby, appointed as the first President of PAPSA (1994).During this era, WOFAPS expanded its interaction with other major International Societies, Prof. J. Grosfeld was on the Board of Governors of the Society of Chirurgie International since 1985; at its major meeting of the International Surgical Week has always included Pediatric Surgery in all its scientific events.WOFAPS also maintained and deepened it’s relationship with the International Pediatric Association (IPA), serving as the voice for the surgical care of children with the medical pediatric Community. Initially, WOFAPS was acknowledged as a non-voting member of the Executive Council of the IPA in 1983. Pepe Boix-Ochoa served as the WOFAPS representative for the following 20 years; through his unrelenting efforts in 2001 at the IPA meeting in Beijing, China, constitutional changes were proposed that gave WOFAPS voting stature on the Standing Committee of the Executive Council of the IPA.The achievements of Prof. Cywe’s presidency culminated in 1998 with the South African Association of Pediatric Surgeons Congress, in Cape Town, which was combined with the Tenth WOFAPS Council. The depth of work being done by the WOFAPS Exco was reported at the Committee level, and by participating in the South African meeting, the bonds between the developed and developing countries were strengthened.Professor Jay L. Grosfeld  was elected the 9th President of WOFAPS, and Takeshi Miyano  was elected as Vice President at the Cape Town Council meeting.During his tenure Dr. Grosfeld was instrumental in developing the “Kyoto Declaration of Pediatric Surgery”, a milestone that outlined the guidelines for the establishment of educational requirements, and providing recommendations for the level of facilities and staffing required to care for ill and injured child and especially the newborn with congenital anomalies Fig. .The Declaration of Pediatric Surgery was voted and ratified at the 2001 meeting of WOFAPS held in Kyoto, Japan in conjunction with the Pacific Association of Pediatric Surgeons hosted by Prof. T. Miyano Fig. .Fig. 4SiThe event was attended by the then Crown Prince of Japan (the current Emperor) and Professor Takeshi Miyano of Tokyo was elected the 10th President of WOFAPS.At this time, 74 national organizations had joined the ranks of WOFAPS. A most important decision was taken by the Council in Kyoto: WOFAPS would organize the ‘World Congress of Pediatric Surgery’ to be held every 3 years, in association with the General Council meeting. The venues for the international meeting would be decided by the Association representatives in a secret ballot. The first bid for this first World Congress was won by the Croatian Pediatric Surgical Association.The Presidency under Prof. Miyano was a memorable one; with his hardworking and tireless spirit he dedicated all his strength and worldwide connections to popularize the Declaration of Kyoto and to prepare carefully with Ivan Fattorini and his enthusiastic team for the success of the first WOFAPS Congress in Zagreb. These efforts resulted in a superb congress with an excellent scientific program and extraordinary social program. The Council elected Prof. Arnie Coran  as President and Buenos Aires as the next venue.Prof. Coran’s goal was to consolidate WOFAPS and to establish a stable bureaucratic foundation for its activity. Under his guidance, the Constitution was amended, and WOFAPS was formally incorporated in Philadelphia, USA as a non-profit, tax-exempt organization, on January 18, 2007. In addition, with input from Prof. Prem Puri, and Prof. Jay Grosfeld, the WOFAPS Foundation was created, as a separate administrative entity, to carry out the charitable, educational, and scientific purposes of the Federation. Professor Grosfeld was elected the first President of the newly formed foundation. Under his guidance, a significant endowment was raised, primarily from the executive members.The World Congress of WOFAPS in 2007, organized by Prof. Juan Puigdeval from Buenos Aires held in conjunction with the umbrella Latin American organization—CIPESUR (Ciurgia Pediatrica del Cono Sur de America) and IPEG  was the largest meeting ever held by WOFAPS. This meeting was a transition in programming to a more complex and more diverse educational agenda, including simultaneous sessions for the first time. There were 1500 delegates of whom 240 were residents in training and 286 delegates from the IPEG joint Meeting. Seventy-three countries were represented, with 92 member associations, representing 98% of the Pediatric Surgical Associations from around the world.The 2007 WOFAPS Council Meeting was also notable for further refinements to the Constitution; most significantly, the composition of the Executive Committee was modified, with the addition of representatives of organizations from countries in the Middle East and Africa to assure better worldwide-representation. This composition has been maintained to the present time.The Council voted New Delhi as next World Congress venue and Prof. Prem Puri  as President and Richard Azizkhan  as President elect.An important practical step was the activation of the WOFAPS Foundation; Prof. Puri was able to negotiate generous funding from an Pharma Sponsor, which allowed WOFAPS to support 3–6 young pediatric surgeons each year to spend to spend three months as clinical observers in recognized and established pediatric surgical centers in various parts of the world  was confirmed as President and Prof. D. Gupta  as President elect. Finally, the end of an era had arrived. Pepe Boix Ochao stepped down as General Secretary and assumed the post of honorary Secretary. Prof Alistair Millar  was elected to take on this important task.In early 2011, Prof. Azizkhan convened a WOFAPS ExCo meeting in Paris where working Committees  were reorganized into a new structure with charters.Each of these committees was led by a member of the Executive Committee  with non-EC members playing important committee roles. This provided opportunities for individuals to become engaged with WOFAPS and for the ExCo. to identify potential future WOFAPS leaders.In particular, the Education Committee led by Prof. David Sigalet and Prof. Sameh Shehata successfully promoted numerous workshops and symposia throughout the world. They worked to encourage and promote mentor relationships between pediatric surgeons from different institutions and championed the availability of Execo members to serve as faculty for teaching and workshops in regional meetings.During this time, two important regional meetings occurred, which followed this paradigm. The first in Tuzla, Bosnia-Herzegovina in 2011, provided a much sought after teaching experience for surgeons in the region, recovering from conflict. The second was in Cartagena de las Indias, Columbia in 2012. These proved most successful were more than 30 world known pediatric surgeons attended—paying their own costs to attend and teach, as an act of solidarity with the young pediatric surgeons from the developing countries.Professor Azizkhan’s presidency culminated in the Congress in Berlin, October 2013, locally hosted by Prof. Jorg Fuchs. More than a thousand delegates from over 85 countries participated in this Congress. There were many highlights including eight pre-congress workshops, more than 80 invited speakers and chairpersons, four concurrent scientific sessions and the Boix-Ochoa lecture given by Prof. Alberto Peña.Further modernization and revisions to the Constitution were done by Prof. M. Hollwarth  and his supporting committee. Prof. Devendra Gupta  was elected as President and Prof. David Sigalet  selected as the president elect. Prof. Puri was reelected President of the WOFAPS Foundation, continuing the work of disbursing scholarships to young pediatric surgeons from LMICs. The organization pushed further into the modern era, with the appointment of Dr. Mahmoud Elfiky  as webmaster, and the institution of Web-based teaching and executive meetings.The ExCo continued the pattern of holding biannual regional WOFAPS Area meetings: during the years 2013–16, Executive meetings were held with regional association conferences in Lucknow, India; Sao Paulo, Brazil; Ljubljana, Slovenia; Antalya, Turkey and Fukuoka, Japan. There was a major shift in the administrative hub of WOFAPS, to Switzerland. The financial accounts and oversight were recognized as registered in Switzerland, effective 2013. This was a major accomplishment, made possible by the hard work of Alistair Millar, the new Secretary General.www.wofaps.org).The Education Committee continued its activity, largely led by Prof. Alp Numanglu, from Cape Town. His team developed and continues to host, a series of webinars covering the major topics in pediatric surgery, which are technically excellent, serving as examples of best practise for surgeons around the world. The use of the internet as a teaching platform continues to be an important platform for providing wide scale, low-cost access to high-quality educational materials, for the WOFAPS community  as President, and Prof Sameh Shehata  as President-Elect. Alistair Millar stepped down as treasurer, and Prof. Alp Numanglu  was elected as the new secretary-treasurer. Dr. Mahmoud El Fiki was re-elected as webmaster. Prague, Czech Republic was chosen as the venue for the 2022 meeting.The new executive team, led by Prof. Sigalet, held an initial ExCo meeting in Doha 2017 in April. A small working group, led by Prof. Shehata, and the secretary, Prof. Numanglu, developed the terms of reference for the Individual affiliate membership category. Dr. El Fiki continued to improve an update the website, including the ability for fees to be paid online. This has greatly improved the financial flexibility of the organization, and there are now over 200 individual affiliate members of WOFAPS (November 2019). Dr Cohen from Melbourne arranged for a 3 year grant from Karl Storz, supporting two fellowships per year, with a preference for candidates from Oceana.Under the leadership of Prof Sigalet, WOFAPS became a sponsoring member of two surgical consortiums, with similar goals. The Global Initiative for Children’s Surgery aims to provide a framework for developing infrastructure and human capital required to provide the appropriate surgical care for children, at the local, regional and national level. The G4 Alliance aims to develop the infrastructure for surgical care, for all ages, also at the various levels of local, district and reference center hospitals. These two efforts complement the WOFAPS mission, by helping to develop the surgical infrastructure within which pediatric surgeons can care for children, in emerging countries.The educational group continues to host on line Webinar activity, led by Prof. Numanaglu, and the website is developing the capacity to act as source of reference material, or links to other sites. As an example, the ‘best’ of the recent webinars are available through the website at any time. This is an area of great interest to the organization; the plan is to develop this further, so that surgeons working in more isolated settings can turn to the Wofaps website as a source of trusted, evidence based reference materials. This was the topic of a meeting with the APSA leadership in Boston, April 2019, hosted by Prof. Ron Hirschl, and attended by Prof Sigalet, as well as representatives from BAPS, AAP, CIPESUR, EUPSA, and PAPS, as well as the online educational development team of APSA.The Exco continued the pattern of holding meetings in association with regional and national associations of Pediatric Surgery; joint meetings were held in Asuncion, Paraguay (October 2017), Bucharest Romania (June 2018), Addis Abba Ethiopia (with PAPSA), Croatia (October 2018) and Xian, China (April 2019). The last meeting was notable, as this was the first WOFAPS meeting held within China.Prof. Sigalet’s term ended with the 6th World Congress of Pediatric Surgery, held in Doha, Qatar, November 1–3, 2019, with Prof. Sigalet and Dr. Mansour Ali from Sidra Medicine the local organizing co-chairs, and Prof. Pippi Salle organized the urology component, with a pre-congress workshop given by the major leaders in pediatric urology. Over 800 delegates from 82 countries attended the Congress; notably more than 53% were from LMIC’s, which was appropriate since the theme was the optimization of care for major anomalies in an LMIC setting. Sidra Medicine  supported 100 young surgeons from LMI Countries to attend the meeting. In the Council meeting, Prof. Sameh Shehata  was confirmed as President, Prof. Alp Numanglu  as President Elect, and Prof. Udo Rolle  as Secretary-Treasurer. Antalya Turkey was chosen as the site of the 2025 meeting. Dr. Zoran Bahtijarevic was confirmed as the Chair of the foundation, and Dr. Mahmoud Elfrikey reappointed as webmaster.At this time, WOFAPS has expanded it’s reach to include a much broader range of activity, but the goal remains the same. The words of Prof. Jay Grosfeld are as relevant today, as they were when he used this paragraph to introduce the Kyoto Declaration for the Surgical Care of the Child in 2001: "The WOFAPS objectives are to improve and maintain the standards of pediatric surgery and promote and integrate these standards throughout the world. The WOFAPS serves as a center for cooperation and interchange of information among pediatric surgical associations, societies and organizations approved by the Federation. The Federation encourages and hopes to maintain high standards of care, ethical practice, education, training, and research in pediatric surgery and its allied sciences worldwide. Over the years, the WOFAPS has matured as an organization that represents the international body of pediatric surgeons. It is recognized as a formidable group that provides support to the goals and objectives of its member organizations, educational, scientific and clinical recommendations, and an international forum that allows exchange of ideas and exposure to contemporary techniques and methodologies at its world congresses."


People living with HIV and AIDS (PLWHA) experience stigma and discrimination throughout their life. The consequences of stigma and discrimination are severe when enacted by healthcare providers (HCPs), and result in a delay in or poor adherence to treatment. Studies have demonstrated the presence of stigmatising behaviours among HCPs, yet only a few have presented the impact of interventions on the knowledge and attitude of practising (clinicians and nurses) and future (students) HCPs.To evaluate knowledge, attitudes and infection risk perceptions related to HIV/AIDS among practising and future HCPs in central India. In addition, the impact of the ‘HIV-related stigma-reduction workshop’ using a pre-intervention and post-intervention study design was evaluated.The study was conducted in 2016 at two tertiary-care hospitals and three healthcare colleges in central India. Overall, 650 HCPs (75 clinicians and 211 nurses) and students ) voluntarily participated in the study.The educational intervention comprised of training in epidemiology, the transmission and treatment of the HIV infection, the rights of PLWHA, the duties of HCPs and the use of standard precautions.At pre-intervention, DMLT students had the lowest and clinicians the highest knowledge scores . The stigmatised attitude was reflected in all groups, the lowest among clinicians (21%) and the highest among DMLT students (34%). Improvement in the post-intervention knowledge scores was the highest in medical students (36%) and the lowest among clinicians (16%). The participants’ attitudes improved between 3% and 17% across all groups.Significant post-intervention improvements were seen in both knowledge and attitudes in all groups. Students had a higher tendency to improve than HCPs. Further long-term studies are needed to evaluate the sustainability of the improvements in knowledge and attitudes of the participants. A context-specific educational intervention was implemented to improve knowledge and attitudes of practicing and future HCPs towards people living with HIV and AIDS.The study was conducted at two hospitals and three educational institutes where the participants work and/or study. Thus, we may observe a social desirability bias, resulting in the underestimation of stigma and discrimination among the participants.The end goal of any educational intervention is to reduce stigmatising behaviours, but behaviour change is a long-term process that is complex to capture and quantify; thus, attitudes were captured as a proxy.The post-intervention questionnaire was completed immediately after the intervention due to feasibility reasons. Thus, we cannot claim the sustainability of the positive effect of the intervention.Additional follow-ups would provide stronger evidence of the long-term positive impact of the study on attitudes and knowledge.The HIV and AIDS epidemic is a global challenge. At the end of 2017, it was estimated that 36.9 million people were either infected by HIV or living with AIDS  globally. Of these, about 22 million people could access antiretroviral therapy (ART) and 940 000 people had died from HIV-related illnesses.HCPs are the core and integral part of the healthcare delivery system, and play a pivotal role in creating a positive environment for better health outcomes for PLWHA and preventing viral transmission.12In 2016, with a prevalence of 2.1 million PLWHA, India was ranked third in the world after South Africa and Nigeria.19 20Educational interventions intended to improve knowledge of HIV/AIDS are effective in reducing stigma among HCPs and improving healthcare delivery.To evaluate knowledge, attitudes and infection risk perceptions related to HIV/AIDS among HCPs and healthcare students in the Ujjain district of central India. Furthermore, to evaluate and compare the impact of the ‘HIV-related stigma-reduction workshop’ intervention on the participant groups using a pre-intervention and post-intervention study design.This intervention study was conducted between January 2016 and August 2016 at three colleges of healthcare courses and two tertiary-care hospitals in Ujjain district in Madhya Pradesh state in India. One of the hospitals is associated with a medical college, a nursing college and a Diploma in Medical and Laboratory Technology (DMLT) college and is referred to as the teaching hospital (TH). An ART centre with specialised healthcare facilities for the PLWHA is located at the TH. Another participating hospital is referred to as the non-teaching hospital (NTH). In this study, the students of Bachelor of Medicine, Bachelor of Surgery, are referred to as medical students.27There was no direct involvement of patients or the public in the present study.The participants were practising HCPs, that is, clinicians and nurses, and future HCPs, that is, students of medical, nursing and DMLT courses enrolled in respective institutes in Ujjain district of central India.All groups of the HCPs and students were invited to participate in the workshop through various means such as leaflets posted at the notice boards, announcements during lectures or meetings. The leaflets were written in Hindi and English to offer equal chances for all potential participants to learn about and attend the workshop to enhance their HIV/AIDS-related knowledge and ways to stay protected at the workplace. The workshops were conducted at respective colleges and hospitals to provide an equal opportunity to participate.Participation was voluntary, and the participant could leave the session at any time without experiencing any repercussions. The participants who could not attend or complete both the pre-workshop and post-workshop sessions were excluded from the analysis .The intervention was designed as an educational workshop that suited best the local context. All workshops were conducted by the same facilitators: a clinician and an officer-in-charge of the ART centre at the TH (BLB), and the team leader of hospital infection prevention and control team at the TH and the NTH (MS). In total, 13 workshops were conducted. Participants were divided into smaller groups as follows: clinicians (two groups), nurses (five groups), medical students (three groups), nursing students (two groups) and DMLT students (one group) to ensure that they feel comfortable in the learning environment.Kavach’) was discussed.Kavach’.The workshop was 2 hours long and divided into three sessions: the first session consisted of an animated video demonstrating the HIV infection epidemiology, the mechanism of viral transmission, diagnostic testing, treatment options, how the ART medicines work and ethical issues related to PLWHA and ART. This was followed by a second session that involved a PowerPoint presentation focusing on topics such as the rights of PLWHA, the duties of HCPs and predictable consequences due to presence of stigma and discrimination against PLWHA. The third session was more interactive and dynamic. Here, information about universal precautions and infection prevention and control measures was provided, describing the importance of the use of standard precautions, including hand hygiene in the daily work-routine. It was explained how and when to use gowns, gloves, face shields, masks and goggles, and the availability of postexposure prophylaxis in the study settings and the use of an in-house prepared alcohol-based hand rub . After receiving feedback, the questionnaires were modified and finalised, and brief educational intervention was designed considering the time constraints among the participants.The responses related to the knowledge and attitude questions were scored in the following manner: each correct response in the knowledge section received a score of one, and each incorrect response received a score of zero. Scores of each individual were converted to the percentage of correct responses. Like in previous publications in this field; the levels of knowledge were categorised into ‘low’ for the participants who scored ≤50%, ‘moderate’ for those who scored between 51% and 74%, and ‘high’ for those who scored ≥75%.30Responses to the questions related to participants’ attitude towards PLWHA were classified into three categories: positive (non-stigmatising), unsure and negative (stigmatising).32Scores of each individual were added and converted to the percentage of correct responses. Responses, where the missing data was higher than 50%, were excluded from the analysis. Risk perception questions were categorical and dichotomised according to the outcome of interest, for example, (a) I am willing or not willing to care for a patient or (b) I am at high risk or not at high risk of HIV exposure at the workplace.The data on demographic and basic HIV-related information was presented as mean and standard deviation (SD) for continuous variables and as percentages and frequencies for categorical variables. The knowledge, attitudes and work environment variables were presented as median with interquartile range (IQR). The difference between the pre-intervention and post-intervention scores were analysed using a Wilcoxon signed-rank test for continuous variables and McNemar’s test for categorical variables. The score difference was calculated by subtracting the pre-intervention (baseline) score from the post-intervention score and represents the percentage unit increase or decrease concerning the baseline score. As these scores were not normally distributed, a Kruskal-Wallis test was conducted to determine a statistically significant difference among the participant groups in pre-intervention and post-intervention scores as well as the difference of scores. Post-hoc Dunn’s tests were conducted to evaluate the relationship between the groups. The statistical significance was set at the level of p<0.05. The data were entered in Epi info software (V.3.1) and Microsoft Excel and statistical analysis was performed using the Statistical Package for the Social Sciences  and STATA V.15.0  software.In total, 920 people were invited to take part, and 746 (81%) voluntarily participated in the study. Of these, 650 (87%) attended all three sessions of the workshop and completed the questionnaire twice; 56% were students and 44% were practising HCPs. Thus, data from these 650 participants was included in the analysis .The mean age of the participants was 23 years, the majority were of the Hindu faith and 56% were males The pre-intervention knowledge score, presented as the percentage of correct responses, demonstrated the low overall level of knowledge, with the poorest in DMLT students (22%) and the highest among the clinicians 45%, . The posEvidences of a stigmatising attitudes were observed among all respondent groups. The lowest level of stigmatising attitudes at pre-intervention was found in the clinicians’ group, where 79% responded to the questions without stigma. On the other hand, in the DMLT students’ group, only 66% of responses presented a non-stigmatising attitude . At postThirty per cent of the medical students and 67% of the clinicians perceived themselves to be at high risk of HIV infection in their workplace at the pre-intervention stage. The willingness to care for PLWHA was relatively high at the pre-intervention stage, ranging from 72% among the nurses to 94% among the DMLT student group. The proportion of the participants who were willing to care for people living with hepatitis B was similar to those willing to care for PLWHA.After the workshop, the medical and nursing students reported a significant increase in their awareness of the risk of HIV infection compared to their statements at pre-intervention. There was a significant increase in the post-intervention willingness to care for PLWHA in the nursing group, and a non-significant decrease in the DMLT and nursing students’ group .The present study evaluated the effect of ‘HIV-related stigma-reduction workshops’ and showed that there was a significant improvement in HIV/AIDS-related knowledge in all groups who participated in the intervention, irrespective of their inadequate baseline knowledge. Our study highlighted the fact that stigmatising attitudes were widespread among practising HCPs and students of various healthcare courses. However, stigmatising attitudes and discrimination that led to an unwillingness to provide medical care to PLWHA were significantly reduced among the participants after the intervention. The student groups showed more receptiveness to improve their knowledge and attitudes towards PLWHA than the practising HCPs.Low knowledge levels can perpetuate myths and misunderstandings that extend to baseline beliefs and stigmatising attitudes. The present study showed that while the baseline HIV knowledge of both the practising HCPs and the healthcare students was inadequate, there was a significant knowledge improvement in all participant groups after the intervention. These findings are comparable with results from a cross-sectional survey conducted among practising HCPs and healthcare students in Uttarakhand, India.33In our study, the overall post-intervention knowledge scores significantly increased in all groups, and particularly so in the students’ groups. This was similar to the effect of educational interventions on HIV knowledge in two single-centre studies involving nursing students in Bengaluru and nurses in Delhi, India.We hypothesised that there would be a greater post-intervention increase in knowledge among the clinicians’ group than the other groups. However, the students’ groups showed significant knowledge gains and the clinicians showed the lowest increase. Theories suggest that knowledge is associated with baseline beliefs and attitudes, and depends on the readiness of the learners and their willingness to integrate the change into their behaviour.Stigmatising attitudes towards PLWHA can feed into a lack of desire or willingness to learn more about the disease. The present study confirmed our hypothesis that stigmatising attitudes are widespread among practising HCPs and healthcare students in the region. Our pre-intervention stigma levels were higher in healthcare students and lower in practising HCPs, which is consistent with a cross-sectional study of HCPs in Uttarakhand, India.Studies show that working on empathy-building techniques and including PLWHA testimonies in interventions can improve outcomes for HCPs and contribute to decreasing the stigma and discrimination towards PLWHA.Similar to the knowledge scores, the student groups showed larger improvements in their stigmatising attitudes than the working professionals. We must acknowledge, however, that although improvements in knowledge were seen in all groups, increased knowledge is not typically enough to affect changes in a person’s attitudes and the baseline beliefs that contribute to stigma and discrimination. These changes are the result of a complex interplay between knowledge, baseline beliefs and attitudes that affects the readiness of the learners and their willingness to integrate the change into their behaviour.10 34 35et al that showed a relatively high willingness of HCPs to care for PLWHA despite the presence of stigmatising attitudes.Another highlight of our study was the willingness to care for PLWHA shown by the majority of HCPs and students at the pre-intervention stage. Our findings are in line with a study conducted in India by Kermode Medical and nursing students significantly improved their perception of HIV/AIDS risk in the post-intervention test. The same receptiveness to learning that was shown by the student groups in our study is likely to be the reason their knowledge in this area also improved. It must be said, however, that educational interventions may have a limited effect on risk perception if appropriate personal protective materials are not available in the workplace. This points to the necessity to create structural and policy changes that contribute to a safer work environment in conjunction with educational interventions in order to both reduce perceived and actual workplace risk.Our study is based on the call for new research that promotes the development of knowledge-building and stigma-reduction interventions to target a broad range of HCPs that PLWHA will encounter in their healthcare journeys.The number and duration of educational sessions does not necessarily correspond to greater increases in knowledge, and shorter interventions may suffice to bring participants to an adequate level of knowledge.To the best of our knowledge, this is the first study that presents and compares pre- and post-intervention knowledge and stigma in terms of attitudes towards PLWHA, among various groups of practising and future HCPs. The context-specific low-cost educational intervention was feasible and appreciated by most of the HCPs during both the pilot testing and the real study. Our intervention is brief and requires relatively few resources and little time, which is important in settings where HCPs work. These features increase the generalisability and feasibility of adopting the intervention design and applying it in other similar settings where HCPs are burdened by a heavy workload.This study shows that an educational and skills-based intervention, even if only for 2 hours, can be effective in increasing knowledge and reducing stigmatised attitudes. Therefore, recurrent training and educational workshops might have a sustainable effect of improved knowledge and reduced stigmatised attitudes and behaviour towards PLWHA. Finally, the present study fills a knowledge gap by providing a better understanding of knowledge, attitudes and risk perceptions of various HCPs and healthcare students in India and globally.Like any study, this methodology must be seen in the context of its limitations. The major consideration of our study is that the post-intervention questionnaire was completed after a short break following the intervention. Thus, we could not validate whether the reduction in stigmatising beliefs was sustained over time. The end goal of the intervention was to reduce stigmatised behaviour. However, behaviour change is a long-term process and is complex to capture and quantify; thus, we were restricted to capturing attitudes as a proxy. Although the present one-time post-intervention data collection design presents a strong association between the intervention and the results, additional follow-ups, for example, at 4 weeks, 6 months and 1 year, would provide stronger evidence for the positive impact of the intervention on attitudes and knowledge than the current design.Given that the study was conducted in workplaces, the presence of social desirability bias in participants’ stigma-related responses cannot be ruled out. Therefore, it is possible that the rate of stigma presented in the study is underestimated. The voluntary participation, with an emphasis on increasing knowledge, and the anonymous questionnaire completion, might have motivated HCPs to participate in the study.Combating stigma is a key priority in achieving success in epidemic control and providing quality care to PLWHA. The findings from this study show that the HIV-related stigma-reduction workshops that are brief, feasible and relatively low-resource interventions, can successfully increase knowledge and reduce stigma in both HCPs and students. Considering the generalisability and feasibility of the intervention design, repetitive contextualised workshops with extended follow-ups are recommended to evaluate their impact and assure sustainable effect. We propose incorporating of more practical and integrated educational training in the teaching curricula of all healthcare courses. This will benefit the HCPs, PLWHA and the community. Moreover, in future studies, we recommend the inclusion of a qualitative component and behavioural assessment to understand participants’ attitudes and willingness to change stigmatising behaviour towards PLWHA.


South Africa’s quadruple burden of disease, coupled with health system challenges and other factors, predicts a high burden of disability within the population. Human Resources for Health policy and planning need to take account of this challenge. Occupational therapists are part of the health rehabilitation team, and their supply and status in the workforce need to be better understood.The study was a retrospective record-based review of the Health Professions Council of South Africa database from 2002 to 2018. The data obtained from the Health Professions Council of South Africa was analysed for the following variables: geographical location, population groups, age, practice type and sex. Data was entered on a Microsoft Excel spreadsheet and analysed using the Statistical Package for the Social Sciences (SPSS version 22.0).In 2018, there were 5180 occupational therapists registered with the Health Professions Council of South Africa with a ratio of 0.9 occupational therapists per 10 000 population. There has been an average annual increase of 7.1% over the time period of 2002–2018. The majority of occupational therapists are located in the more densely populated and urbanised provinces, namely Gauteng, Western Cape and KwaZulu-Natal. Most of the registered occupational therapists are under the age of 40 years (67.7%). The majority (66%) are classified as white followed by those classified as black and coloured. Females make up 95% of the registered occupational therapists. Nationally, 74.8% of occupational therapists are deployed in the private sector catering for 16% of the population while approximately 25.2% are employed in the public sector catering for 84% of the population.Under-resourcing and disparities in the profile and distribution of occupational therapy human resources remain an abiding concern which negatively impacts on rehabilitation service provision and equitable health and rehabilitation outcomes. In South Africa, with a GINI coefficient of 0.63, inequity remains one of the defining features of the social, economic, political and health systems. The inequity at the level of health is stark when comparing the population dependent on the public sector (84%) and those with private medical insurance (16%), as well as differences between, and within, urban and rural public sector users. Health services play an important role in combating inequity, social injustice and the realisation of human rights. Human resources drive health system outcomes, and without an adequately staffed, competent, committed health workforce, the achievement of equitable health outcomes is compromised. The Sustainable Development Goals (SDGs) for 2030 cover a broad range of health challenges and emphasise the need to substantially increase health financing and the recruitment, development, training and retention of the health workforce.The importance of the health workforce as a building block of the World Health Organization (WHO) health system framework is well-acknowledged globally . The lacDespite these issues, human resources for the management of disability and rehabilitation services in South Africa (SA) lag behind the growing need for such services  which haThe implementation of primary health care (PHC) re-engineering provided an opportunity for reconfiguring rehabilitation services as an integral part of health services that are offered as close as possible to where people live and work –9. A serThe recently published Framework and Strategy for Disability and Rehabilitation 2015–2030 in SA , the most consistent account of global, regional and national epidemiological evidence for all diseases and injuries in the current period, shows that of the total number of years lived with disability (YLD) in the world, 74% is associated with health conditions for which rehabilitation will be beneficial. Additionally, 15% of the total number of YLD globally results from health conditions such as epilepsy, multiple sclerosis and cancer, which are associated with severe impairments . In Sout, the mosA proxy indicator for the level of provision of rehabilitation services suggests there is a scarcity of rehabilitation specialists and that the assessed demand for rehabilitation is much higher than services can provide  especialThe WFOT ratios are currently not achievable and therefore not appropriate for SA within the current growth pattern fiscal space. This calls for a different approach for course correction of current HRH planning and policies for rehabilitation services. There is a need to develop clear staffing norms (which may serve as benchmarks) that could help to ensure equity in HRH distribution for occupational therapists. Thus, specific staffing norms will lead to specific service targets for specific health outcome targets in rehabilitation. It is suggested that norms are developed in ranges (minimum-maximum as per various scenarios) that may provide some room for flexibility in the system.For HRH planning and estimation with regard to occupational therapy and other rehabilitation specialists, an estimated gap approach that considers needs may be better suited in the South African context . The disDespite the global evidence showing that workforce drives the performance of the health system , responsTo date, it is only new graduates from the SA educational pipeline that contribute almost exclusively to the current growth of occupational therapists. Though community service was introduced to improve access to healthcare, we are however failing to retain these graduates post-community service as the ASSAf consensus study 7] has shown. There are very few plans aimed at recruitment and retention of occupational therapists beyond community service to the public sector. The lack of posts in the public sector is one of the primary reasons for poor retention of community service therapists . Other p has showGlobally, occupational therapy has been a female-dominated profession. For example, in Canada, only 3% of all clinicians were estimated to be men . There iOur findings show a rapid decline in mid-level workers . This is a concern because of mid-level workers’ well-recognised potential to broaden access to services and improve the quality of care. The main contributing factor for this decline is that there are currently no education programmes for occupational therapy mid-level workers in South Africa; this has been the case for more than a decade. As part of South Africa’s transition to democracy, the education landscape was re-structured to create the National Qualifications Framework (NQF) which aims to improve quality assurance, facilitate access, allow mobility and support progression in education. Towards this end, a single integrated framework comprising qualification levels and types was created. Unfortunately, there was no 2-year diploma in the first version of the NQF, thus forcing the discontinuation of programmes for occupational therapy technicians. A later version of the Higher Education Qualifications Sub-Framework now includes a 2-year qualification level, making the education of occupational therapy technicians possible. However, to date, none of the higher education institutions has started OTT training programmes despite efforts from the Occupational Therapy Association of South Africa (OTASA) to encourage them to do so.It has been recognised that losing this cadre within the workforce is a problem. A survey at nine sites in South Africa found that disabled people living in sites with community rehabilitation workers had better access to healthcare services as well as health and education resources compared to those living in sites without this cadre of worker . A systeTask shifting to community health workers (CHWs) will be the key to improving access to rehabilitation services to a greater portion of the population. In 2012, the Department of Health trained a new cadre of CHWs in the field of rehabilitation in order to improve access to health services to persons with disabilities. As per a study conducted in 2015, it was stated that the new cadre of rehabilitation care workers (RCWs) will strengthen rehabilitation services in intermediate care and in the community, and they will assist in promoting the participation of clients in the community . In anotThere is an evident imbalance in terms of the inter-provincial, inter-sectoral and urban versus rural distribution of occupational therapists. The data produced for this study are reliant on the accuracy of the records produced by the HPCSA. The HPCSA does not account for the sector in which health professionals work, and thus, inequity in access between the public and private sectors remains unreported . FurtherThis research is timely as SA moves towards the implementation of the SDG with a particular focus on UHC under the umbrella of the NHI. HRH is a critical element to be considered in this context. Our findings show that over the 15 years studied, occupational therapists increased at a rate of 7.1%. Though this growth has exceeded that of the population, the density of occupational therapists to 10 000 population continues to be substantially lower than global recommendations. Therefore, it may take an unacceptably long time period to meet the demonstrated need which affirms the urgency to implement task-shifting to mid-level workers in order to meet the growing need for rehabilitation services. There is an urgent need to re-introduce OTT training.Though the composition of the population groups of occupational therapists is changing, the historical inequalities remain entrenched. This slow pace of transformation does not match the needs of the people serviced. It is acknowledged that occupational therapy service users will be best served when the profile of the profession mirrors that of the general population because of language, culture and other contextual factors. Furthermore, the imbalance in the urban versus rural distribution of occupational therapists is problematic because occupational therapy’s main concern is re-establishing people in work, leisure, learning, play, personal and community living which require service users to have ready access to services close by. Furthermore, people in low-resourced contexts, who can least afford having to travel to access services, are disproportionately having to do so. For these reasons, the distribution of occupational therapists requires attention. Addressing the sex imbalance might lead to a politically stronger and better-recognised profession. Additionally, the registration for the foreign qualified workforce could be streamlined and simplified.In a resource-deficit country like South Africa, there is a need for undertaking a granular HRH planning and forecasting exercise for rehabilitation services, focussing on more substantial elements such as disease burden, current fiscal space, and existing geo-spatial and social inequities to accessing rehabilitation services. Human resource strategies need to target the intractable health inequity generally with the aim to reduce the stark differences in the provision of health services and outcomes between the public and private sector. Limitations of this study include that the accuracy of HPCSA figures cannot be fully guaranteed. As such, there is much that this data cannot tell us—information which would influence demographic details such as where occupational therapists work and the sector of work. The existing data only described the current situation. Some of the key HRH aspects of the workforce are also unreported such as possible changes in the burden of disease, service delivery models, facility planning, facility workloads, skills mix, remuneration systems and health worker productivity, all of which are important in projecting future HRH needs and costs. The findings raise some concerning questions about the profession, specifically implications for access to rehabilitation services.


In recent years in the field of biomechanics, the intensive development of various experimental methods has been observed. The implementation of virtual studies that for a long time have been successfully used in technical sciences also represents a new trend in dental engineering. Among these methods, finite element analysis (FEA) deserves special attention. FEA is a method used to analyze stresses and strains in complex mechanical systems. It enables the mathematical conversion and analysis of mechanical properties of a geometric object. Since the mechanical properties of the human skeleton cannot be examined in vivo, a discipline in which FEA has found particular application is oral and maxillofacial surgery. In this review we summarize the application of FEA in particular oral and maxillofacial fields such as traumatology, orthognathic surgery, reconstructive surgery and implantology presented in the current literature. Based on the available literature, we discuss the methodology and results of research where FEA has been used to understand the pathomechanism of fractures, identify optimal osteosynthesis methods, plan reconstructive operations and design intraosseous implants or osteosynthesis elements. As well as indicating the benefits of FEA in mechanical parameter analysis, we also point out the assumptions and simplifications that are commonly used. The understanding of FEA’s opportunities and advantages as well as its limitations and main flaws is crucial to fully exploit its potential. Finite element analysis is an advanced numerical method for conducting computer-aided engineering. From a mathematical perspective it enables obtaining approximate solutions to the partial differential equations that constitute a mathematical model for a given process or status of a physical system. In terms of its practical application, FEA is commonly used by various researchers to analyze stresses and strains in complex mechanical systems . The impThe area of dentistry which has always been tightly associated with biomechanics is oral and maxillofacial surgery. The progress of each of its subfields, such as trauma surgery, orthognathic surgery, reconstructive surgery and implantology, is strictly connected with the understanding of the pathomechanism of fractures, the biological responses of bone to biomechanical changes and the behavior of osteosynthesis materials and intraosseous implants, in both healthy and pathological conditions.Oral and maxillofacial pathologies have always been present, and so has the need to search for their optimal treatment methods. In the field of maxillofacial reconstructive surgery, the glass eyes, metal noses and ivory teeth discovered on Egyptian mummies represent a good example. In the matter of handling facial trauma, methods of immobilizing broken bones have been a subject of interest for many surgeons. Hippocrates studied the intraoral fixation of a dislocated mandible by using a golden thread tied around the teeth adjacent to the fracture site. Over time, Ivy, Salicetti, Gilmer and Gunning searched for other techniques of maxillomandibular fixation in the design of different wires and splints , until bNowadays, owing to the advancement of computing, we lean towards virtual analysis and tools complying to our needs for testing the mechanical properties of facial hard and soft tissues, osteosynthesis materials, implant components and different biological and synthetic bone substitute biomaterials, regardless of their complexity, in a more accurate, repetitive, safe and cost-effective way . FEA corThe maxillofacial region contains many essential anatomical structures. Interventions in this area require precise, well-arranged cutting lines, maintaining or restoring the functionality of tissues and obtaining predictable long-term mechanical outcomes. FEA, as the methodology which allows us to conduct different biomechanical simulations in the complex maxillofacial anatomy, while remaining repeatable, timesaving and cost-effective at the same time, is a highly valuable research tool.In the current literature a lack of updated complex coverage of the discussed subject is noticeable. The purpose of this article is to present in a maximally comprehensive way the ways in which FEA has already contributed to research in the specific areas of oral and maxillofacial surgery such as trauma surgery, orthognathic surgery, reconstructive surgery and implantology and to outline EFA’s present limitations as well as its forthcoming possibilities. It organizes the information on FEA’s usability and promotes the wider implementation of numerical methods in oral and maxillofacial studies.Based on contemporary articles and reports printed in reputable journals the review of the literature available on the featured subject was undertaken. The research was conducted using PubMed, Medline, Google Scholar, and the available books and reports. The key words “finite element study”, “finite element analysis”, “finite element modeling”, “oral surgery”, “maxillofacial surgery”, “traumatology”, “orthognathic surgery”, “reconstructive surgery”, “implantology” and a combination of thereof were used to select the literature form the databases. Afterwards, given the large amount of information available on this topic, the authors divided the accessed papers into groups, assigning them to the principal fields of oral and maxillofacial surgery such as trauma surgery, orthognathic surgery, reconstructive surgery and implantology, selecting a representative sample for each group. In order to preserve clarity, they are discussed in sections corresponding to the categories indicated above.Investigating facial trauma’s consequences and etiology in vivo is practically impossible because of ethical reasons. The creation of a reliable physical test model which satisfactorily reproduces the complexity and mechanical parameters of facial tissues is not only challenging but also cost-intensive given its single-use predestination. The above enhances the competitiveness of the virtual analysis of stress distribution under external traumatic loads.In the field of trauma surgery, FEA can be used to identify the regions of the craniofacial skeleton that are particularly prone to fractures . It enabSo far, based on FEA, researchers have tested the influence of the presence of third molars on the weakness of the mandibular angle  Table 1Table 1. As well as exploring the mechanisms of different fractures, FEA also meets researchers’ needs in analyzing relatively rare and more complex facial traumas, for example, to elucidate the damage to a human mandible in response to a blast event  or to coThe understanding of the pathomechanism of fractures is extremely important. It may find applications not only in industry (during designing helmets and other protectors for the head and neck) ,21,22,23Sometimes, it can be troublesome not only to choose the fixation element but also to overcome the anatomical obstacles. Here, owing to its specific anatomy, a particularly challenging topic has always been condylar fracture osteosynthesis. Due to the demands of surgical access, the fixation element in this type of osteosynthesis should be exceptionally handy, easy to mount and durable in order to minimize the risk of consecutive intervention. Those considerations have been the object of numerous FEA studies ,29,30. SThe selection of appropriate bridging elements is also a key determinant of successful outcomes in all orthognathic surgeries. In bilateral sagittal split osteotomy (BSSO), FEA has been eagerly used to compare the stability of bridging the bony segments with various fixation systems ,37,38,39FEA reflecting a two-jaw osteotomy, a more complex surgery dedicated to patients with deformation of both the upper and lower jaws, was also conducted . For exaAnother orthognathic procedure performed frequently among patients with narrow maxillae is surgically assisted palatal expansion (SARPE). The distribution of tensions in maxillae that underwent SARPE was simulated by the finite element method and it was revealed that the steps in the zygomaticomaxillary buttress and the pterygomaxillary disjunction seem to be important to decrease the harmful dissipation of tensions during SARPE .In patients with large gnathic defects, even the preparation of a treatment protocol may be difficult and time-consuming. As a result, at many stages of treatment, its final effect may differ from the desired outcome. Therefore, Chabanas et al. proposed their own treatment protocol based on computer-assisted planning. The authors used FEA to simulate the facial consequences of scheduled orthognathic surgery . CevidanFEA can be also used for the reconstruction of jawbones after extensive resections, usually due to oncological indications. From the viewpoint of postoperative management, the crucial parameters of the removed bone segment include its size, shape and location. Filling a bone defect within the maxilla or mandible should result in the restoration of its integrity and characteristic curvatures, and should create favorable conditions for further rehabilitation of the stomatognathic system. Using digital techniques, researchers can compare the level of stress at the bone-graft interface, to identify the type of transplant which is most suitable in a given clinical condition , and to In reconstructive surgery, thorough and accurate preoperative planning with the involvement of the state-of-the-art virtual methods for modelling, simulation and analysis not only improves the outcome of the procedure and significantly shortens its duration, but also allows the operator to predict the behavior of the reconstructed region after exposure to various types of loads. Moreover, the standard elements for osteosynthesis available on the market may not provide an accurate reconstruction in more complex cases. In such cases, CT images from the patient may constitute the basis for an individual digital model of the reconstructed area, which is then used to design a tailor-made bridging element and to test its applicability by means of FEA . For exaWhen the correlation between bone structure and mechanical stresses was pointed out with the use of FEA, research on the influence of mechanical load on cell differentiation and tissue development flourished, especially in the field of skeletal tissue engineering scaffolds . The infThe correct assessment of bone conditions and ability to bear loads at implant anchoring sites is a determinant of successful outcome in implantoprosthetic treatment. An adequate balance between the implant, abutment and suprastructure can be obtained only under the ideal biomechanical conditions which directly influence remodeling of the bone. The appropriate height of the alveolar process can be maintained by the application of an optimally designed implant and a correctly modeled denture. Since FEA provides additional information about the distribution of stress at the surface of the implant and adjacent bone, it has become a basic instrument for designing intraosseous implants, and has found application in many previous implantoprosthetic studies ,54,55,56To satisfy the demand of implantologists, who frequently deal with the problem of insufficient amounts of bone for anchoring an intraosseous implant in patients with missing upper molars, digital models of the maxilla dedicated to stress and strain studies during the elevation of the maxillary sinus floor have been developed as well ,59. UsinThe domain of modernity is the fact that time has become a valuable product. Thus, experimental research that is detailed but not time-consuming, implementing predictable solutions which enable patients’ fast recovery, is typically praised. According to the reviewed literature, FEA is in this respect superior to most clinical and in vitro studies and has many advantages. It helps to formulate the right research question and design appropriate experiments. In complex systems where many variables need to be considered, it allows the manipulation of single parameters, making it possible to study the influence of each one, and provides almost instant insight into complex biomechanical intercourses which would be unable to obtain with any single clinical method. Exploiting the designed numerical model, the inflicted conditions can be freely modified and the study can be repeated as many times as desired. The patient is not exposed to potential risks associated with the application of novel materials or therapeutic procedures that have not been tested previously, and the need for animal experiments is eliminated. Surgeons have gained a tool to virtually perform osteotomies and bone relocations and to test the optimal positions, strains and stress of fixation materials in order to assess the best therapeutic materials and concepts. Scientists have obtained an instrument to optimize the design process in the product development cycle. The fact that virtual studies are associated with markedly lesser financial burden than conventional research is also worth emphasizing.The visual interface of FEA stress and strain distribution is clear and easy to understand. It has definitely improved communication and cooperation between scientists and clinicians, encouraging them to pursue further research.However, aside from its numerous advantages, FEA has its limitations too. It should be noted that the conditions of computerized studies are fully programmed by the researchers, and as such they will always pose a risk of bias. The most serious limitations of FEA are simplifications and assumptions. Early simulation models suffered from generalizations and a lack of geometric precision. Some more complex anatomical structures were commonly omitted at the bone modelling stage, which put the validity of the results into question. Another issue is the matter of reflecting not only the anatomy but also the morphology of tested tissues. In this area, simplifications were also commonly adopted. The authors of much research on FEA assumed that distinguishing between cortical and cancellous bone was irrelevant and considered the investigated bone, in general, as homogenous, isotropic and linearly elastic material ,35,38. AThe goal of future research should be to verify whether the assumptions mentioned above were not oversimplifications. To improve the quality of FEA-based research, particular attention should be paid to the stage of model creation . At presAlong with the rapid progress in the implementation and market release of new technologies, the availability and decreasing costs of adequate software and hardware suitable for virtual analyses allowing a novel approach to solving some previously problematic aspects can be seen. In the matter of the evaluation of material constants, their individual calculation based on CT dataset has gained more enthusiasts. In the presented literature, for the calculation of Young’s modulus, Szucs et al., Tamura et al. and Fuji et al. converted each pixel of the CT dataset from Grey to Hounsfield units and using equations dedicated to this subject, calculated Young’s modulus from the obtained bone density. This approach enables researchers to distinguish stronger and weaker structures of the maxillofacial skeleton and as a result to create more realistic models ,36,41. WTo conclude, the thorough review of the provided literature indicates that FEA is a powerful tool in addressing many biomechanical problems and will undoubtedly continue to be applied in oral and maxillofacial research. Special attention should be placed on its wider implementation in research and practice in order to reduce the risk of unnecessary failure, extend knowledge of oral and maxillofacial biomechanics, introduce enhanced osteosynthesis solutions, reconstruction scaffolds, biomaterials or implant components and select the most optimal treatment materials and approaches.


Stress echocardiography is a well-established diagnostic tool for suspected coronary artery disease (CAD). Cardiovascular risk factors are used in the assessment of the probability of CAD. The link between the outcome of stress echocardiography and patients’ variables including risk factors, current medication, and anthropometric variables has not been widely investigated.This study aimed to use machine learning to predict significant CAD defined by positive stress echocardiography results in patients with chest pain based on anthropometrics, cardiovascular risk factors, and medication as variables. This could allow clinical prioritization of patients with likely prediction of CAD, thus saving clinician time and improving outcomes.A machine learning framework was proposed to automate the prediction of stress echocardiography results. The framework consisted of four stages: feature extraction, preprocessing, feature selection, and classification stage. A mutual information–based feature selection method was used to investigate the amount of information that each feature carried to define the positive outcome of stress echocardiography. Two classification algorithms, support vector machine (SVM) and random forest classifiers, have been deployed. Data from 529 patients were used to train and validate the framework. Patient mean age was 61 (SD 12) years. The data consists of anthropological data and cardiovascular risk factors such as gender, age, weight, family history, diabetes, smoking history, hypertension, hypercholesterolemia, prior diagnosis of CAD, and prescribed medications at the time of the test. There were 82 positive  and 447 negative  stress echocardiography results. The framework was evaluated using the whole dataset including cases with prior diagnosis of CAD. Five-fold cross-validation was used to validate the performance of the framework. We also investigated the model in the subset of patients with no prior CAD.The feature selection methods showed that prior diagnosis of CAD, sex, and prescribed medications such as angiotensin-converting enzyme inhibitor/angiotensin receptor blocker were the features that shared the most information about the outcome of stress echocardiography. SVM classifiers showed the best trade-off between sensitivity and specificity and was achieved with three features. Using only these three features, we achieved an accuracy of 67.63% with sensitivity and specificity 72.87% and 66.67% respectively. However, for patients with no prior diagnosis of CAD, only two features (sex and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker use) were needed to achieve accuracy of 70.32% with sensitivity and specificity at 70.24%.This study shows that machine learning can predict the outcome of stress echocardiography based on only a few features: patient prior cardiac history, gender, and prescribed medication. Further research recruiting higher number of patients who underwent stress echocardiography could further improve the performance of the proposed algorithm with the potential of facilitating patient selection for early treatment/intervention avoiding unnecessary downstream testing. Cardiovascular disease (CVD) is the leading cause of death in Western societies . In the Diagnosing CAD early can save lives and reduce risk of myocardial infarction and stroke. Diagnostic procedures are typically performed in specialized cardiac centers to diagnose CAD and risk stratify patients using tests such as a stress echocardiogram. Stress echocardiography is a diagnostic tool to assess the functionality of the heart and blood delivery under stress, such as treadmill or bicycle exercise test or following administration of a drug such as dobutamine. Dobutamine is a pharmacological agent administered intravenously to increase the heart rate in a similar way that would occur during physical exercise. During dobutamine stress echocardiography, incremental doses of dobutamine in 3-minute stages are administered until the termination of the test criteria is achieved. The principle of stress echocardiography is to increase the myocardial oxygen uptake/demand; if the supply is insufficient due to blocked heart arteries, echocardiographic features of this mismatch can be detected by identifying regional wall motion abnormalities in the underperfused heart muscle region during the test. Echocardiographic images are acquired at rest, during the intermediate stage, peak stress, and in recovery. The classical criteria were used as a termination of the test . Positive or abnormal stress echocardiography is defined as developments of new regional wall motion abnormalities. Wall motion abnormalities were defined as hypokinesia if the wall thickness was maintained and the endocardial excursion was between 5 and 2 mm, akinesia if the wall thickness was reduced and the endocardial excursion was less than 2 mm, and dyskinesia if the wall thickness was reduced and the endocardial excursion was outward moving in systole. Dobutamine stress echocardiography has a sensitivity and specificity of 83% and 86%, respectively . A compuMachine learning is a term used to define computer algorithms that can be trained to learn the patterns in training data. These algorithms are then effectively able to make predictions on unseen data. The ability of machine learning techniques to learn from experience without any explicit guidelines for the program or following any predefined rules is making these techniques increasingly popular in many domains . MachineSeveral frameworks that employ machine learning for CAD prediction have been proposed . These tClinical data have been used to predict coronary events: Voss et al  used 10 Another study employed machine learning on clinical and laboratory data of 378,256 patients to predict the first CVD event . The datIn this pilot study, we aimed to investigate the performance of a machine learning algorithm in predicting the stress echocardiography outcome in patients investigated for suspected CAD. Unlike previous research, we are testing a sophisticated feature selection method to investigate the significance of cardiovascular risk factors, current medication, and anthropometric data in this prediction.The cohort of patients was derived from the Cardiology Department at Milton Keynes University Hospital in the United Kingdom. Anonymized clinical data had been extracted from patients’ electronic records, predominantly based on the very detailed stress echocardiography reports introduced prospectively by one author (AK), a senior cardiologist, at the time of the development of stress echocardiography services in the hospital. We included all patients (n=563) examined using dobutamine stress echocardiography between 2002 and 2004 with available data. However, we excluded 34 patients who had incomplete clinical data about their risk factors, leaving 529 for this study.This study used real patient data, which can raise some ethical concerns such as the patient’s permission to use their data and any confidential information that may exposed because of this research. This was resolved by having hospital staff, the direct clinical care provider, anonymize the records before they were sent for analysis. This study was registered by the institutional clinical governance department, Milton Keynes University Hospital .The collected data were used to predict the outcome of the stress test based on the patient’s clinical information. .Feature normalization is the second stage used for continuous features (age and weight), which are normalized using the following equation for normalizing continuous features: , where N is the number of bins [Two normalized features were then discretized using the equal width discretization method:  of bins . In thisEach feature value is assigned to a bin based on the range into which it falls. The reason for the discretization stage is that most of the machine learning algorithms perform better with discretized data . Due theFeature selection, the fourth stage in this framework, is a set of techniques used to measure the significance of each feature for predicting the class label (outcome of the stress test). In this study, the joint mutual information maximization (JMIM) filter feature selection method  is used F = {f1,f2,....fN} is a discrete variable and C = {c,c,....cN} is a class label; the probability density function is .The value of mutual information between any two variables can be calculated using entropy. It is the amount of uncertainty about a random variable. Suppose F and C is as follows:The mutual information equation between I is the joint mutual information between the candidate feature and the features already selected in the previous iteration. The method employs the forward greedy search algorithm, seen below the equation.The JMIM method employs the maximum of the minimum criterion. The feature selected by the JMIM method is the one that maximizes the goal function, shown below, where The method does not rank the features based on their individual discriminative power, it selects the features that provide the most information as a subgroup; the interaction information between the features is important in selecting the next significant feature. Therefore, if the list of submitted features is changed, the rank order may be different. The whole dataset was submitted to the JMIM method to identify the significant subset of features . Smialowski et al  reportedThe outcome of the stress test was predicted in the classification stage. Two alternative classifiers were tested at this stage: support vector machine (SVM)  and randThe data were randomly divided into 5 folds, with 4 of them used to train the classifier and 1 for testing, and then this process was repeated 4 more times, at each time 4 folds were used for training and 4 of the folds that had never been used for testing before was used to test the classifier. At each time, the accuracy, sensitivity, and specificity were calculated. The overall accuracy, sensitivity, and specificity are the average of the 5.To find the subset of features that produces the best prediction performance, the classifier is trained and tested after adding every feature according to its rank identified at the feature selection stage.The proposed framework was used to study the whole dataset including the risk factors and medications, and it was also used to study a subset of the dataset that excluded the cases with prior CAD to investigate the influence of this variable on the performance of the model. The prevalence of abnormal stress echocardiography was 15.5%. A total of 447 patients had negative stress echocardiography results (84.5%). There were fewer women than men within the positive group, and the opposite was true with the negative stress echocardiography results. Mean age was 62.92 (SD 10.56) years and 60.93 (SD 12) years in the positive and negative groups, respectively .The feature selection stage was used to rank the features  in the whole dataset, and the significant features for the whole dataset are depicted by The results showed that prior CAD has the strongest power to distinguish between positive and negative stress echocardiography results. Sex appeared second because most of the positive cases were male, and most of the negative were female. ACE-I/ARB use was the only applied medication among the five most significant features. On the other hand, age, family history, and diabetes appeared the least contributory features in this model.Feature selection has been also applied on the subdataset. The order of the features was slightly different as the prior CAD feature was excluded from the data. As mentioned earlier, two classification algorithms were used in this study: SVM and random forest. The results showed that the performances of the two classifiers were close to each other. However, the SVM slightly outperformed the random forest classifier. In this paper, only results produced by the SVM are presented.The experiment was repeated on data from patients with no known prior CAD. The performance of the classification stage is depicted in To test the robustness of the proposed framework, the experiment was repeated again and the model trained without sex features. The results showed that the best performance was achieved with the best four features : 72.87% and 60.23%, respectively. The accuracy decreased to 62.19%.Feature selection is used as part of the proposed framework; these techniques have the capability to investigate the multidimensional relation between features and class label. In previous research , classifThe results of the feature selection and classification stages showed that prior CAD is the most important risk factor for distinguishing between positive and negative cases. Sex, weight, and smoking status are among the group of most significant five features, and the only current medication that is within this group is ACE-I/ARB. Hypertension, diabetes, and positive family history are shown as the least significant features for the discrimination task. Only four features were needed to achieve the best performance , which means by knowing only this information about patients, the proposed framework is able to classify 72.87% of the positive cases and 66.67% of the negative cases correctly, outperforming the previous study . ACE-I/ATo study the robustness of the framework, performance was tested without any information about prior diagnosis of CAD. Once this was tested, the order of the feature changed; cholesterol and nitrate medication became among the most significant of the five features. The feature weight was less significant in this model. This change in the order of the features can be attributable to the information interaction between them.Because prior diagnosis of CAD is such a powerful predictor of a positive stress echocardiogram, the other features contribute so little information by comparison, and it is hard to see their value. However, once these patients are removed from the dataset, we can see the predictive power of the other features for patients with no previous history of CAD.Features like age, diabetes, and family history are shown to be less significant for discriminating between positive and negative cases. It also showed that information about medications added significant value and could enhance the discrimination power of the clinical data. It also showed that interaction between features is important and can affect the order of the selected subset. Moreover, increasing the granularity of the value of the risk factors may improve their discriminative power by using continuous instead of categorial variables.To our knowledge, this is the first study that has investigated applying machine learning techniques to a simple dataset of patient anthropometrics, cardiovascular risk factor profiles, and cardioactive medications to predict positive or abnormal stress echocardiography results. The study also investigated the performance of different machine learning techniques and employed a sophisticated feature selection method to study the significance of the clinical attributes. This method considers the interaction between clinical variables when analyzing their significance and the class label. The proposed framework outperforms the other tools that have been proposed in the literature  in prediIn this paper, we report preliminary results using only 529 patients. The data includes only anthropometric and clinical data that has been collected during the patient’s hospital visit. Including more data from patient medical records could enhance the generic behavior of any proposed model and improve the performance of the developed model. As we have a large dataset going back nearly 20 years, the model could be extended to predict mortality due to a cardiovascular event.Machine learning techniques can offer the very promising prospect of faster and more accurate diagnosis , prioritizing higher risk patients and increasing the capacity of clinicians. However, it is well known that most machine learning techniques are considered to be black boxes, where the model produces results that are difficult to interpret. Despite the black box nature of various machine learning approaches, feature selection techniques can improve understanding of the relationship between the diagnosis and clinical attributes. Data visualization methods can improve understanding of the produced model and interpretation of the output.None of the clinical information detailing the results of the positive stress test such as wall motion score index were included with the clinical data. Inclusion may further differentiate between high- and low-risk patients.