Interruption of transmission of the disease by early diagnosis and treatment is core to the control and eventual elimination of gHAT. Until recently, the format of available screening tests had restricted screening and diagnosis to central health facilities (passive screening). We describe a novel strategy that is contributing to elimination of gHAT in Uganda through expansion of passive screening to the entire population at risk.The incidence of In this strategy, patients who are clinically suspected of having gHAT at primary health facilities are screened using a rapid diagnostic test (RDT), followed by parasitological confirmation at strategically located microscopy centres. For patients who are positive with the RDT and negative by microscopy, blood samples undergo further testing using loop-mediated isothermal amplification (LAMP), a molecular test that detects parasite DNA. LAMP positive patients are considered strong suspects, and are re-evaluated by microscopy. Location and upgrading of facilities to perform microscopy and LAMP was informed by results of georeferencing and characterization of all public healthcare facilities in the 7 gHAT endemic districts in Uganda. Three facilities were upgraded to perform RDTs, microscopy and LAMP, 9 to perform RDTs and microscopy, and 200 to screen patients with RDTs. This reduced the distance that a sick person must travel to be screened for gHAT to a median distance of 2.5km compared to 23km previously. In this strategy, 9 gHAT cases were diagnosed in 2014, and 4 in 2015.This enhanced passive screening strategy for gHAT has enabled full coverage of the population at risk, and is being replicated in other gHAT endemic countries. The improvement in case detection is making elimination of the disease in Uganda an imminent possibility. Glossina spp). The disease is endemic in sub-Saharan Africa, within the limits of the geographic distribution of the tsetse fly. The disease is caused by protozoan parasites belonging to the species Trypanosoma brucei. Infection with T. b. gambiense causes a chronic disease (gambiense HAT or gHAT) and accounts for more than 95% of HAT cases reported annually [T. b. rhodesiense results in an acute form of HAT (rhodesiense HAT or rHAT). The two forms of disease are geographically separated, and Uganda is the only country that is endemic for both forms, albeit in geographically separate foci.Human African trypanosomiasis (HAT), also known as sleeping sickness, is a parasitic disease transmitted by the bite of an infected tsetse fly  in a roadmap for elimination as a public health problem by 2020 . This WHControl of gHAT primarily relies on identification and treatment of cases . This isThe potential for screening for gHAT in health facilities has been improved with the recent development of rapid diagnostic tests (RDTs) –13. The Confirmatory diagnosis of HAT has been improved following development of the Primo Star iLED fluorescence microscope (FM) by FIND and Carl Zeiss Microimaging . Unlike Diagnostic techniques for gHAT that are based on microscopy have imperfect sensitivity ,18. DeteIn Uganda, the number of gHAT cases has been declining, with 198 reported in 2008 and only 20 cases in 2012 . HoweverHere, we describe a programme that harnesses the recently developed technologies for screening and diagnosis of gHAT. This is deployed in the healthcare infrastructure in north-western Uganda to intensify control of the disease. We describe the approach used to identify and characterize health facilities in the region, selection of facilities and their upgrading, and how progress of the programme has been monitored.The first stage of the programme was to map the locations of all public and private not for profit  healthcare facilities in the gHAT endemic region of Uganda, and to characterise them. The process, completed in 2012, involved compiling a list of all facilities in the districts, then visiting and recording their locations using a hand-held GPS. A questionnaire , meetings with leaders at all levels, and radio broadcasts during the first year of the programme. Sensitisation focussed on informing the population of the symptoms of gHAT, availability of screening tests in local health facilities, and the process of diagnosis and referral.The diagnostic procedure for gHAT is initiated when a patient presenting at a health facility is found to have symptoms that are suggestive of gHAT . If symptoms that are also compatible with malaria are observed, then the patient is first tested with a malaria RDT, and if found to be either: negative for malaria, or positive for malaria but not responding to treatment after one week, then the patient is tested using the HAT RDT. If the symptoms are not consistent with malaria, the patient is tested with the HAT RDT. Patients found positive with the HAT RDT are considered as gHAT suspects, and are referred to the nearest facility equipped for parasitological confirmation, unless the HAT RDT is performed at such a facility, in which case no referral is necessary . PatientParasitological diagnosis entails performing a number of tests in the following sequence, until one of them is positive:If the subject shows typical cervical adenomegaly, a GP is taken and examined for the presence of motile parasites by bright field microscopy.○The mHCT test is performed using four capillary tubes .○A thick blood smear is made on a microscopy slide using 5μl of blood, stained with Acridine Orange (AO), and examined by LED FM as described elsewhere .○3 ml of blood are used to perform the red blood cell (RBC) lysis and concentration method, followed by staining with AO, and examination by LED FM, as described elsewhere .If no palpable lymph nodes are present, then 7ml of venous blood are collected and the following tests performed:When a patient is negative by microscopy, a minimum of 4ml blood is centrifuged and the buffy coat separated. The buffy coat is lysed with sodium dodecyl sulfate (SDS) solution, and in facilities without the capacity to perform LAMP, 100μl is dried on a filter paper and kept in an air-tight plastic envelope with a desiccant . SimilarIf the patient is at a facility that has the capacity to perform LAMP, a minimum of 4ml of blood is used to perform LAMP on fresh whole blood, and on fresh buffy coat that has been extracted by centrifugation followed by treatment with SDS solution. If any of the two samples is positive by LAMP, then the overall result is interpreted as positive. The results are communicated by SMS to the facility that performed the RDT, and when positive, the patient is requested to come back and parasitological testing is repeated. For all confirmed gHAT cases, the stage of disease is determined by performing a lumbar puncture and examination of cerebrospinal fluid by microscopy, then they are treated at one of the treatment facilities, in accordance with the national guidelines.Patients who are positive with the HAT RDT but negative by both microscopy and LAMP are followed up and tested every three months with the HAT RDTs until they become seronegative, or are confirmed as cases. If a patient is still positive by the HAT RDT during follow-up, then the procedures described above are repeated.Data on RDT usage, stock levels, number of positive patients and numbers referred, are recorded for each facility, then collated at the district level and transmitted to the central level by mobile phone. These data are subsequently collated and are analysed to assess progress and identify potential problems or unusual patterns in RDT usage, RDT positivity or HAT cases. Data are analysed monthly, and any remedial action found to be necessary is taken immediately.Access to screening facilities was analysed by calculating a raster surface of the Euclidean distance to all facilities. Adjusted estimates of the human population for 2015 from the WorldPop dataset  are overThe programme is responsive to the changing epidemiology and diagnostic needs in the region. The number of people found positive with HAT RDTs and their location, as well as the origin of gHAT cases identified in the 12 previous months were used to re-assess the number of health facilities included in the programme. The number of health facilities using HAT RDTs were reviewed in July 2014 and September 2015, in response to the evolving epidemiological situation of gHAT in Uganda, particularly in relation to the large numbers of refugees arriving from gHAT endemic areas of South Sudan .This project is carried out in conformity with the Helsinki Declaration. The project protocol was reviewed by Vector Control Division-Research Ethics Committee, Uganda Ministry of Health, and approved by the Uganda National Council for Science and Technology (registration number HS 1427). The project sites have the necessary facilities and trained staff to test patients and collect samples under GCLP conditions. Although the diagnostic methods in use  have been rigorously evaluated in multiple sites, patients are requested to give informed consent at the level of the microscopy or LAMP centre, as LAMP is still an investigational test.Two hundred and ten facilities were characterised, comprising 116 level II health centres , 78 level III health centres, 9 level IV health centres, 6 district hospitals and 1 regional referral hospital. Characterisation of facilities commenced in July 2011, and was completed in December 2011. These 210 and two others that were not characterised were equipped with HAT RDTs, with appropriate training in use of the RDTs and the diagnostic algorithm. Among these 212 facilities, 9 were also equipped to perform microscopy, and a further 3 to also perform microscopy and LAMP . TechnicThe increase in number of screening facilities reduced the median straight line distance that the population at risk must travel for screening, from 23km to 2.5km, with 99% of the population within 9.6km of a facility that is equipped with RDTs . This reThe higher density of microscopy facilities that were established along the borders with the Democratic Republic of the Congo (DRC) and South Sudan reflects the historically larger number of cases in this area compared to the southern areas of Arua district, as well as in Adjumani and Amuru districts to the east of River Nile . The medst July 2014, 6,677 RDTs had been performed  (By 3107–0.73) . During The 13 HAT cases were spread across the project area, with one case originating from South Sudan . Of thesThe majority of the HAT RDTs were used in RDT facilities owing to their larger number. However, RDTs were used at a higher rate at facilities with LAMP and microscopy than by facilities with only RDTs, where they were used at a mean rate of 4.72 RDTs per month, compared to 10.7 and 6.2 RDTs per month in facilities with LAMP & microscopy and microscopy respectively .We have described the development and implementation of a new strategy for enhanced surveillance and diagnosis of gHAT. As elimination of gHAT as a public health problem in Uganda and elsewhere draws nearer, novel strategies are required to guarantee that the goal of elimination is achieved and sustained in an arena with limited financial resources. This has been made possible with the development of new diagnostic and screening technologies that, with modest capital investment, have opened up the potential of integrating gHAT surveillance and control into the state primary healthcare system.Although this strategy has resulted in an increased number of gHAT suspects identified by passive screening, the number of gHAT cases in Uganda has continued to decline, with just 9 cases in 2014 and 4 cases in 2015, a decrease from 20 that were diagnosed during 2013. In 2016, the number of gHAT cases in Uganda remained at four. This decline could be attributed to multiple factors, including change in land use or the large scale vector control activities in areas to the west of River Nile, which resulted in a drop in tsetse fly densities of 90% ,29. By iBy upgrading 12 facilities to perform confirmatory testing for gHAT, there has been a substantial reduction in the distance that is necessary to travel to get a diagnosis for gHAT. Previous studies of rHAT in Uganda have demonstrated that difficulties in accessing appropriate diagnostics can be a barrier to diagnosis –35 and tConfirmation of gHAT cases remains complex, and one of the challenges of this novel approach is ensuring that patients that are positive by an RDT at a facility without capacity for microscopy present themselves for confirmatory testing. In the new strategy, the patient is referred to another facility where, owing to the low prevalence and the resulting low positive predictive value of screening tests, the final outcome is often negative. To mitigate this, sensitisation was conducted at all levels, to change expectations among patients and health personnel, and to implement the new strategy to ensure that patients do complete their referral. Consequently, the proportion of RDT positive individuals tested by microscopy in our project was high (79.9%). During the course of the programme this has been complemented by the active follow-up of serological suspects at three month intervals until they become negative, and by active follow-up of those that did not present for parasitological confirmation by motorcycle teams.The diagnostic algorithm described here required training of staff at health facilities, many of whom were not familiar with HAT as a differential diagnosis. However, as the project area  is also endemic for malaria, staff at all facilities were already familiar with performing malaria RDTs, which are done in the same way as gHAT RDTs. In spite of familiarity with the RDT format, it was necessary to keep health staff sensitised to consider gHAT in their differential diagnosis , which iT.b. rhodesiense HAT is endemic in another region of Uganda, and there has not been any report of this form of the disease in the region described here. In the unlikely event that a T.b. rhodesiense HAT patient presented at any of the health facilities in the project area, he/she would likely be missed by the diagnostic work-flow described here, unless they presented with clinical signs that are strongly suggestive of HAT. In such situations they would undergo testing by microscopy, regardless of the result of the screening test.The new diagnostic algorithm described here is integrated in the primary health system in rural Uganda. Thus, HAT screening has become part of the routine activities in health centres in endemic areas. Implementation of the algorithm is also highly adaptable. It is used in private clinics that can refer RDT positive individuals to public facilities for confirmation. It can also be deployed in less or more facilities depending on the epidemiological circumstances. For example, the number of centres using HAT RDTs was increased in 2016 to respond the new challenge of refugees fleeing the armed conflict in South Sudan and seeking refuge in HAT endemic areas in northern Uganda . HAT RDTIn this project, LAMP is used as a ‘back-stop’ to the imperfect sensitivity of the microscopy algorithm. Data from a recent study in the DRC estimates the sensitivity of microscopy at 69.5% (95% CI = 63.0–75.3%)  and hencThe enhanced algorithm for passive screening and confirmatory diagnosis of gHAT described here can be deployed in gHAT foci in other countries that have under-utilised their public health infrastructure. The integrated nature of the strategy utilises existing health care infrastructure, and so has the appeal of minimising costs and management, by optimising deployment of resources and integrating HAT screening into routine healthcare activities. Studies would however be required to determine the costs and cost-effectiveness of implementing the strategy. In light of this, further work is being undertaken to estimate the total costs of this strategy and compare these costs to other algorithms for screening and diagnosis of gHAT.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S1 Fig(DOCX)Click here for additional data file.


The World Health Organization recommends inclusion of rotavirus vaccines in national immunization programs (NIPs) worldwide. Nordic countries are usually considered comparable in terms of demographics and health-care services and have comparable rotavirus disease burden. Nevertheless, the countries have reached different decisions regarding rotavirus vaccine: Norway and Finland have already introduced rotavirus vaccines into their NIPs and Sweden is currently changing its recommendation and vaccines will now be introduced on a national scale while Denmark has decided against it. This study focuses on the selection and interpretation of medical and epidemiological evidence used during the decision-making processes in Sweden, Norway, Finland, and Denmark. The so-called “severity criteria” is identified as one of the main reasons for the different policy decisions reached across the Nordic countries. Two oral, live, attenuated rotavirus vaccines, Rotarix™ (derived from a human G1P[8] rotavirus strain) and RotaTeq™ (a reassorted bovine–human rotavirus), are used internationally; and both vaccines are considered highly effective in preventing severe gastrointestinal disease , and as Globally, there are no uniform guidelines for decision-making processes or policies for introduction of new vaccines, although individual countries usually consider disease burden, health care and vaccine-related costs and safety and effectiveness of vaccine candidates . SurveilThe Nordic countries are usually considered similar and comparable in terms of demographics, disease burden and health-care systems with tax-based funding, publicly owned and operated hospitals, universal residence-based access, and comprehensive coverage .In addition, their setups for evidence assessment are similar, in that all countries establish working groups formalized and chaired by national public health institutions and with broad representation from medical and public health communities. These working groups formulate their interpretation of the evidence as well as recommendations for the policy makers. The final decision to introduce the vaccine is then taken by the national government. Nevertheless, the countries have reached different decisions in terms of introducing rotavirus vaccines. Norway and Finland have introduced rotavirus vaccines into their NIP , 10, whiPublic health policy decisions often involve assessment of scientific evidence. While policy processes are complicated and influenced by factors beyond scientific evidence , it is cThe study was initiated in Denmark, and to obtain information on the decision processes in three other Nordic countries, we contacted middle- and/or top-level leaders at the national public health institutions who contributed the evidence base for the policy processes in Denmark, Sweden, Norway, and Finland, respectively. The email contained a brief introduction to the study along with a semi-structured questionnaire intended to facilitate the presentation of the evidence considerations. Further the main email included an invitation to forward the questionnaire Table  to the pThe responses from each country were compared with regards to similarities and differences in the production and use of evidence to support the decisions taken. All discrepant views are presented in the result section to reduce any bias due to interpretations of the responses.As a supplement to the information on vaccination policy provided in the questionnaire, a background literature on rotavirus vaccine policy in the four countries was retrieved from a PubMed search (using the keyword “rotavirus” combined with each of the four country names) and from the websites of national public health agencies of the countries.Sweden will introduce universal rotavirus vaccine into the NIP in 2019. Rotavirus vaccines have been available for purchase at private vaccination centers for several years prior to this decision, and one of the vaccines available on the market is subsidized by the Dental and Pharmaceutical Benefits Agency, TLV. Furthermore, the County councils in Sweden have the possibility to offer vaccination free of charge to the population of that county, even if the vaccine is not part of the NIP, and as of February 2018, eight of them have decided to do so.Decisions regarding inclusion of new vaccines in the Swedish NIP are taken by the Swedish government . To suppStudies had demonstrated that disease burden and costs were largely comparable to other European countries and very few rotavirus-associated deaths were registered. National rotavirus disease burden estimates were assessed to 1–3 deaths among children less than 5 years over a 5-year period or <0.1 per 100,000 child-years , 16. An In 2015, The Public Health Agency published a report on disease burden , expecteIn Norway, the decision to introduce a new vaccine into the NIP is taken by the Ministry of Health and Care Services, based on advice from the NIPH . Considerations of the rotavirus vaccine for introduction into the NIP were initiated already in 2006 when the first vaccine candidates were licensed in Europe. Evaluation of the vaccine was done by a working group chaired by the NIPH and including representatives from the NIPH as well as from the scientific community and health professionals (doctors and nurses). Among the evidence considered by the group were studies on disease burden .Prior to vaccine introduction, an estimated 900 children, or 3.6 per 1,000 children less than 5 years, were hospitalized each year with rotavirus gastroenteritis in Norway and the mortality, although not specifically registered, was estimated as two deaths in children under 5 years old over a 5-year period. This shows that rotavirus disease in Norway hardly meets the severity criteria for a disease to be prevented by vaccination.The NIPH included data from other high-income countries that had already introduced the vaccine and experienced important reductions in rotavirus incidence. Data from Mexico and Brazil pertaining to the risk of intussusception were cited to justify a favorable risk–benefit ratio. The NIPH found that the overall burden of disease, particularly the number of hospitalizations and outpatient visits, the safety of the vaccine, and the general acceptance and high coverage of the existing NIP were arguments to support the introduction of the vaccine. The working group included considerations about economic/social inequalities and health, such as whether children needing it most might not get a given vaccine if it is not free of charge. The conclusion of the majority of the working group was that the vaccine should be included in the NIP although one working group member, the representative of the national nurses’ association, assessed that the evidence for health as well as economic benefits from vaccination was insufficient.A full economic analysis was done by a separate working group . The vacThe National Council for Priority Setting in Health Care (which existed until the end of 2017) discussed the issue in June 2012 and decided, with a narrow majority, that though the vaccine was safe and effective and not very expensive, the disease was not considered serious enough to justify vaccination of all infants in Norway. However, in 2013, based on the existing evidence the Ministry of Health and Care Services took a political decision to introduce rotavirus vaccine in the NIP, with implementation from autumn 2014.In Denmark, the decision to introduce new vaccines into the NIP is taken by the Ministry of Health based on advice from the national vaccine advisory committee, which is a group of experts led by the Danish Health Authority with representatives from clinical, laboratory, and epidemiological services and health authorities. The criteria considered when deciding on the possible introduction of a new vaccine include disease burden, severity of the disease targeted by the vaccine, safety and effectiveness of the vaccine.In 2011, following the publication of two independent studies showing a considerable burden of rotavirus disease requiring hospitalization as well as requests from vaccine producers and clinical societies, the national vaccine advisory committee requested the Danish Health Authority to conduct a health technology assessment (HTA). The HTA included scientific evidence, health economic analyses, and qualitative research (focus group interviews with parents) and was published in 2012 . The ecoAccording to the Danish Health Authority, the purpose of Denmark’s childhood vaccination program is to protect children from diseases that can result in either death or long-term harm, using safe and effective vaccines. It is stated explicitly that Denmark should not implement vaccinations in the NIP merely because this is feasible but only when the disease has serious consequences for individuals and/or society—the so-called “severity criterion.” Rotavirus infection hardly ever results in death or long-term harm in countries such as Denmark with free and universal access to health care.The vaccine advisory committee and the Danish Health Authority decided not to recommend the introduction rotavirus vaccine in the NIP due to failure to fulfill the severity criterion .Finland was invited to participate in this study, but only epidemiological data were returned in reply to the questionnaire, and we sought additional information through publicly available information and articles from scientific journals.Finland was the first Nordic country and one of the first countries in Europe to include rotavirus vaccine in the NIP in 2009 . In FinlIn summary, this study illustrates how four countries with comparable public health-care systems and similar burden of rotavirus disease arrive at different decisions regarding potential introduction of rotavirus vaccine in the NIP. Differences in use of the evidence to inform the decision-making process seem to have played a role for the different conclusions reached. Most importantly, there are different conceptions of whether the consequences of disease for the individual and/or society as a whole are substantial enough to justify universal vaccination, exposing healthy children to an intervention, and whether it merits the added expenses on the national health-care budget.As far as this study shows, all countries include disease burden as a key criterion, but interpret it differently: Denmark considered the low mortality and benign course of most cases of the infection to be an argument against introduction, whereas Norway, Sweden, and Finland consider the number of cases and health-care visits to be an indicator of a considerable disease burden.Another main difference between the countries is seen in their health economic evaluations. CE analyses are always sensitive to model assumptions, to decisions about discounting and about whether to include costs and benefits outside the health-care sector, and analyses concerning vaccines perhaps even more so for several reasons. The possible adverse effects of vaccination usually occur shortly after vaccination, while the disease prevented by the vaccine might occur years ahead in the future, and hence benefits of vaccines are discounted more than its disadvantages. For childhood diseases, the models used in the economic evaluation in different countries may differ in regard to whether time spent by parents caring for the sick child, income lost to parents, and/or productivity losses in society are considered in the analyses. Herd immunity is also not consistently included in the analyses. Finally, quality of life measures typically included in economic evaluations have not been validated in children , 27. As Although initiatives have been launched to harmonize economic evaluation methodology and make the process more comparable and transparent  Figure , differeIn conclusion, decisions on whether to introduce a vaccine into a country’s NIP are not based solely on available scientific evidence including health economic assessment [9]. As this study has shown, the scientific evidence itself is also not used and interpreted consistently across countries. Consequently, even comparable countries with very similar infrastructure, public health-care systems, disease burden, and cost-assessments arrive at different decisions when they interpret the same international, scientific evidence in the context of their national priorities and traditions  and carry out economic evaluations using different models and specific national inputs .GS-M and TF conceptualized and designed the study and analyzed the data. GS-M wrote the first draft and TF revised all versions. AL and SS provided data and input to all versions of the manuscript.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.


REM sleep duration and nocturnal oxygen saturation were significantly higher when compared to the group not using the SNORAP .Sleep physiology and sleep hygiene play significant roles in maintaining the daily lives of individuals given that sleep is an important physiological need to protect the functions of the human brain. Sleep disordered breathing (SDB) is an important disease that disturbs this need. Snoring and Obstructive Sleep Apnea Syndrome (OSAS) are clinical conditions that affect all body organs and systems that intermittently, repeatedly, with at least 10 s or more breathing stops that decrease throughout the night and disturb sleep integrity. The aim of this study was to produce a new device for the treatment of patients especially with position and rapid eye movement (REM)-dependent mild and moderate OSAS. For this purpose, the main components of the device (the microphone (snore sensor), the heart rate sensor, and the vibration motor, which we named SNORAP) were applied to five volunteer patients . After receiving the sound in real time with the microphone, the snoring sound was detected by using the Audio Fingerprint method with a success rate of 98.9%. According to the results obtained, the severity and the number of the snoring of the patients using SNORAP were found to be significantly lower than in the experimental conditions in the apnea hypopnea index (AHI), apnea index, hypopnea index, in supine position’s AHI, and REM position’s AHI before using SNORAP (Paired Sample Test,  Sleep physiology and sleep health play very important roles in maintaining the daily lives of individuals. Sleep is an important physiological need to protect the functions of the human brain. While sleeping is an activity that must be performed at night, the duration and depth of sleep, and the number of awakening episodes at night all directly affect sleep quality. High sleep quality leads to more accurate functioning of healthy individuals’ brains and a high quality of daytime activities.In general, ventilation decreases during sleep, fluctuates in the tidal volume and as periodic respiration starts, blood pressure and heart rate decrease . Two difThere are many biological, psychological, and social factors that disrupt sleep physiology. Respiration disorders while sleeping are a very important disease group that disrupts sleep physiology in the area of sleep medicine. In particular, Snoring and Sleep Apnea Syndrome is a serious threat to the health of people and society, and most individuals are not concerned with snoring during sleep. However, individuals with Sleep-Disordered Breathing cannot get enough oxygen during nighttime sleep, and vital organs such as the brain and heart are not sufficiently oxygenated. Snoring is a stage that occurs during sleep, usually due to the vibration of the tissues in the upper airway, generally on inspiration, more rarely on exhalation and sometimes in both phases of respiration ,7.Sleep Apnea Syndrome is a clinical condition that affects all body organs and systems that interfere with sleep quality throughout the night, with recurrent intervals during the night that last at least 10 s or more and continue with breathing stops and reductions. It is typed based on anatomical location: (a) Obstructive Type; (b) Central Type; and (c) Mixed Type; according to size of affected by disease: (a) Mild Degree; (b) Moderate Degree; and (c) Severe Degree; and according to sleeping periods and position it varies as: (a) REM Dependent; and (b) Position Dependent. REM sleep is a situation when all skeletal muscles in the body except the diaphragm incur atonia while active, and episodic REM occur at electroencephalography (EEG). Therefore it is referred to as paradoxical sleep. Skeletal muscles providing upper airway tone in patients with OSAS incur atonia more frequently; thus, snoring and apnea attacks increase.Polysomnography (PSG) is the gold standard method for the diagnosis of OSAS. The assessment of the sleep stages and respiratory events in sleep was performed as per the guidelines of the American Academy of Sleep Medicine. Apnea was determined as an oro-nasal airflow cut for at least 10 s. Hypopnea was defined as a 3% decrease in oxygen saturation with a reduction of at least 50% in oro-nasal airflow or accompanying arousal. Arousal was defined as waking up while sleeping or passing to a more superficial sleeping environment. Characteristic PSG findings of OSAS can be listed as follows: (a) an increase in the duration of superficial sleep, and a decrease in that of deep sleep and REM is observed; (b) The recurrence of apnea and hypopnea recur frequently; (c) Oxygen desaturations recur frequently (d) REM sleep increases the frequency and duration of apnea, and the degree and duration of oxygen desaturation. Supine sleeping position also makes contribution to this increase; (e) Paradoxal chest and abdominal movements are typically seen during apnea; (f) Heart rate usually slows down during apnea and accelerates after apnea; arrhythmias can be observed during this period; (g) Irregular snoring that frequently recurs and interrupted by apnea is heard in respiratory voice recording. The degree of disease is determined by AHI  value detected according to PSG result. If this index is greater than 5, sleep apnea syndrome can be a matter. But, the clinically important value is 15 and above. OSAS classification, based on the AHI values, are given in Among these disease groups, Continuous Positive Air Pressure (CPAP) therapy appears as the gold standard treatment method, especially in moderate and severe degree OSAS. However, both REM-dependent and position-dependent patients with simple snoring, moderate, and mild OSAS cannot be proposed with CPAP therapies and cannot be treated completely. However, every grade of the disease leads to different symptoms that are specific to the person.Daytime complaints of patients can be listed as “daytime sleepiness , attention and concentration disorders, daydreaming and headache in the morning, and psychological problems ”; and nighttime symptoms are “snoring, discomfort given to the bed partner and other members of the house due to snoring, chest pain, drowsiness feeling in sleep, poor sleep quality due to short vigilance, night headache”. All of these symptoms, unfortunately, remain in the patient group, listed in The purpose of this study was to develop a new device for the treatment of a special group of patients whose sleep and wakefulness health has been impaired by sleep disorder.Recently, studies to find audio fingerprints have become popular, with even large corporate institutions developing algorithms in this area. The most well-known audio fingerprinting algorithm is Shazam , which iSpectrograms, signal and image processing methods are often used in audio fingerprinting algorithms. An algorithm based on spectrogram extraction of general fingerprint based audio signal has been presented by Haitsma and Kalker . WavepriVarious studies have been carried out to measure sleep apnea diagnosis and sleep quality. In their study, Lazaro et al. used signal processing to predict sleep apnea and respiration rate , while NThe SNORAP device was designed to prevent snoring and apnea (stopping breath for at least 10 s in sleep), one of the most common and important causes of disturbance to an individuals’ sleep health. Our device operated as real time as a wearable device. As shown in Raspberry Pi is a mini-computer the size of a credit card. The technical specifications of the Raspberry Pi include: 1.2 GHz 4-core 64-bit quad-core ARMV8 processor, 1 GB RAM memory, Bluetooth 4.1, 40 GPIO, four USB 2 ports, full size HDMI port, CSI camera port for connecting the Raspberry Pi camera, DSI display port for connecting the Raspberry Pi touch screen display, micro SD socket. Grove is a shield card that allows Raspberry Pi to connect to Grove sensors. There are 15 Grove sensor connections on the card. A grove sensor card has 15 4-pin Grove sensor connections on it. Grove Pi + is fixed on Raspberry Pi without the need of any other connection. The communication between them is carried out over I2C interface. All Grove modules are connected to the Grove Pi + card via the universal 4-pin connector cable. Grove modules with analog or digital output, are connected to an ATmega 328 micro controller  on the grove Pi + card. The micro controller acts as an interpreter between Raspberry Pi and Grove sensors. It issues and receives commands and runs commands that are issued by the Raspberry Pi. The screen produced by the 7-inch Raspberry Pi official manufacturer uses the DSI connector on Raspberry Pi, and thus, it does not occupy the HDMI port and GPIO pins. Its features: RGB 800 × 480 resolution, 60 fps support, 24-bit color depth, touch support up to 10 points by means of FT5406 touch-operated controller, 70° visual angle .The heart rate sensor module can measure the variation in human blood movement in the veins thanks to optical technology. It has CMOS with high performance and low power consumption, using PAH8001El-2G  in the sensor measuring heart beat via a finger clip. Since the heart rate sensor chip should have a high processing speed for the algorithm of heart rate data, STM32  is integrated into this module. The heart rate sensor performance was calculated in real-time, and was found to have an average difference of 0.55 bpm compared to the PSG system. The microphone was used to receive and process voice in the environment, and the vibration motor sent a warning to the user to perceive touch. The vibration sensor is in the size of a coin with a DC motor. It will vibrate when its entrance is logic High, in other words, the vibration motor is activated when a snoring sound occurs. It produces a very low- decibel sound that will not awake the patient. The vibration sensor included in SNORAP can be set according to individual’s perception characteristics of tactile stimulus. Thus, patients who need more stimulation are sent stimuli by increasing the severity of the vibration. The snoring sound detection success was 98.9%. The 98.9% accuracy rate assigned for the SNORAP device, the study’s subject, corresponds to the snoring volume. Our device does not directly measure the duration or severity of apnea periods, but rather it indirectly reduces or eliminates OSA periods that occur after snoring periods.As shown in Particularly for patients with mild and moderate sleep apnea (position and REM dependent), the snoring and apnea prevention device is very well operated by the snoring intensity and frequency of the person. The intensity and frequency of the snoring voice also points to the apnea, which may actually occur, especially when the patient is in a supine position and in REM, increased snoring attacks are sensed and vibration stimuli are sent to the body. The person then changes position so that snoring is decreased and the apnea that may occur afterwards can be eliminated.SNORAP is a real-time-operating device, which can be used for about 10 h during the night, and is easily placed on the patient’s arm. The device is suitable for long-time use, and its lifelong use is recommended for patients. The electrical stimulus (delay time) issuing time of the device after perceiving a snoring sound is approximately 3.4 s. The severity of the stimulus is adjusted depending on the perception threshold of the patient, to whom stimuli are issued by sending vibrations to the patient’s arm in three 3-s bursts with 1-s intervals. This process, which lasts for 11 s in total, disappears spontaneously when the snoring noise is removed. When snoring attacks occur again, the same function is once again activated.An audio fingerprint is a short summary of an audio file . RecentlAs shown in In this study, the Audio Fingerprint method was used for snoring sound detection. One of the factors that determines the usability of a recognition system is so that it can effectively compare an unknown audio track with millions of known audio tracks. The Audio Fingerprint extracts the summary of the audio content and stores it in the database. In addition, the fingerprinting system must also be efficient in terms of calculation. Efficiency has a critical effect on both the calculation of fingerprints of unknown voices and in real practice, and even more so in the search for the best match in a large fingerprint database. Calculation costs are related to fingerprint size, search algorithm complexity, and fingerprint extraction complexity. The general approach is to create an index structure to reduce the number of distance accounts that will be made when a query is given. Many indexing methods group similar classes, ignore some classes, and search for the rest of the classes. The duration of an audio data database should be as short as possible, especially for real-time applications where it is important that the duration of the call is short. It is expected that call duration will not increase too much if the number of audio fingerprints in the database increases too much. In our real-time system, it took 3.4 s for our system to find out if there was no snoring sound or other sounds.Audio fingerprint techniques aim to deliver successful results when content-based audio recognition is performed, even when audio signals are mildly or severely broken. In order for audio fingerprint to be successful, first, it is necessary to significantly reduce the size of the input audio signal. Second, resulting properties must be robust against possible degradation of the entrances. For example, if the songs playing on the radio are to be detected, the system must be robust against any non-linear distortions that most stations identify to the pre-broadcast signal. Third, the resulting features should be informative: for sound identification, different sound clips must be matched to distant features in some appropriate metrics. Finally, the calculation in the feature extraction process must be efficient .As shown in In the front processing section: first, the sound was converted into digital form and brought into a common, designated form. In the case of audio recording, the accepted rule is that human ears miss frequencies above 22,050 Hz. For this reason, there were 44,100 samples in the second as per the Nyquist-Shannon Sampling Theorem.As the samples were a kind of signal, the Fast Fourier Transform was repeatedly used in small time windows from the samples of the sound to form the sound spectrogram. Peak points were preferred in this study given the high possibility of peak protection in cases of audio distortion. As they were highly resistant to noise and signal distortion, they used spectrogram peaks as their fingerprints. Fingerprints were created using the frequency values and time differences of the peaks found.It is a slow process to find the right audio records and starting point by using the peak points directly as they do not have enough dependency. Instead, fingerprints were obtained by pairing the peaks in the constellation map in binary combinations. The anchor point was selected and each anchor point had a target region. Each anchor point was sequentially paired with the peak points remaining in the target region.As there may be similar peaks when peaks are found, we found the appropriate trace for that sound by combining the peaks with fingerprints by using a hash function. The summarization function took an integer as input and converted it to another integer as output. By looking at the peaks of the spectrograms and the time differences between peak frequency combinations, we could create a summation to distinguish sounds. This study was developed based on Shazam’s method , where tSome match-up was obtained with some audio tracks as a result of the search in the database. The distance account methods were used in order to express the matching amount with audio tracks. The audio tracks with the shortest distance are the most probable candidates. The audio features used in audio analysis can be basically divided into two groups: high-level features and low-level features . The higSNORAP is a wearable device designed for home use. The present study consists of two parts: The first stage was the design and construction of the SNORAP device, which lasted about 1 year. The second stage was an experimental process that was conducted within 2 months at a sleep disorders center, operated by a medical doctor who received education in sleep medicine, accredited according to international rules, and having received its ethical approvals. Collection of data from volunteer patients was done in real-time during their night sleeps. The SNORAP application has been used on diagnosed patients by means of PSG findings belonging to volunteers staying at the lab for the first night after 5 days. Thus, the situations of patient before and after the use of SNORAP have been easily compared. The data collection period for each volunteer is 7 days. The volunteers were examined by a medical doctor  and their one-night tests were conducted in company with sleep medicine technicians. Before doing this study, the volunteer patients were trained in sleep medicine and examined by a medical doctor; the recorded PSG results were analyzed by the same physician in charge of the laboratory, and the diagnosis of OSAS was made in compliance with American Academy of Sleep Medicine (AASM) criteria.The test protocol consisted of two steps. The first consisted of the PSG recording and diagnosis phase; the second consisted of the phases where PSG and SNORAP applications of diagnosed patients were performed together. SNORAP was easily compatible with the PSG sensors proposed by AASM. It was also observed that snoring attacks occurring during the night are detected by PSG sensors; in addition, the SNORAP device simultaneously and in real time detected the same snoring attacks. The decrease in and removal of snoring and apnea attacks when SNORAP perceives snoring and issues a tactile stimulus to the patient was clearly monitored with the PSG sensors recommended by AASM.The experimental procedure for the device was tested on a total of five volunteer patients with a respiration disorder during sleeping , and only five polysomnographies (standard method for determining sleep disturbances) were recorded by the five volunteers. PSG records were taken with the application of the prototype device shown in PSG included six channels of EEG, two channels of electrooculography (EOG), one channel of submental muscle electromyography (EMG), two channel of EMG placed on both anterior tibial muscles, one channel of oro-nasal airflow cannula, one channel of oro-nasal thermal sensor, inductive plethysmography to demonstrate the two-channel chest and abdominal breathing effort, a channel of “body position” sensor, a channel of finger probe and pulsoximeter to measure arterial oxyhemoglobin saturation (SpO2), and simultaneous video recording.p < 0.05) than when compared to the group not using SNORAP. A volunteer patient from study groups in Using the PSG, the number and severity of snoring for each patient were compared. Snoring severity and number of the group using SNORAP were found to be statistically lower  when compared to the group not using SNORAP. As seen in In the PSG analyses performed on each patient, the apnea-hypopnea index (AHI), apnea index, hypopnea index, AHI in REM and AHI in supine position were compared. As seen in As seen in p < 0.05) when compared to the group not using SNORAP.When the results of PSG were examined, REM sleep duration and nocturnal oxygen saturation were compared . Rear slTo improve the impaired sleeping health of people with mild and moderate SDB through the tactile stimulus system that we created, we first diagnosed the individual’s diseases as polysomnographical before setting up a five-person experimental group where the probable effects of the device (named as SNORAP) on the patients and the diseases detected. According to the obtained results, snoring severity and number of patients using SNORAP were found to be significantly lower than the experimental conditions before using SNORAP in the apnea-hypopnea index, apnea index, hypopnea index, supine position AHI and REM. The REM sleep duration of the group using SNORAP and nocturnal oxygen saturation were found to be significantly higher when compared with the group not using SNORAP.The snoring sensor, which was the most important part of our device, was developed with the right methods and easily perceived the snoring sound. If you are working with a high sensitivity to snoring, your contribution to the treatment of sleep related respiration disorders is high.In Ke et al. , computeIn their study, Baluja and Covell  used imaIn the work of Burges et al.  a percepIn our study, the distinguishing features of snoring sounds were detected by taking fingerprints, thus at good classification success was ensured even in noisy situations. A number of methods have been developed to detect the vocalization of the soft tissues of the upper airway during sleep. As shown in Snoring is an important complaint seen in 44% of the middle-aged male population and 28% of the female population. It is a social problem that causes shame in society, and even affects marriages. The volume of the snoring can vary between patients and between nights in the same patient; it can be continuous or intermittent. Simple snoring is a condition that does not lead to regular sleep breaks; however, if awakened by a bed-mate, it causes sleep disturbances and insufficient sleep. Sleep apnea syndrome is the most common symptom. In males with snoring, the risk of developing OSAS within 10 years has risen . In multIt is typical that snoring in OSAS patients is interrupted by frequent recurrent apneas. Patients often refuse to snore, although there is a common finding in almost all OSAS patients. Weight gain and alcohol intake are important predisposing factors . AHI is Characteristic findings of OSAS as polysomnographical are the increase in superficial sleep and deep sleep, and decrease in REM duration. REM sleep increases the frequency and duration of apnea and the degree and duration of oxygen desaturation. The SNORAP device is not designed to detect the REM phase of sleep. Moderate and mild OSAS-diagnosed patients , were detected in company with PSG in our laboratory. Our goal is not to determine the REM period via SNORAP. Rather, our aim was to observe polysomnographic changes that occurred, by applying this vehicle, measuring snoring successfully, to the patient groups for whom we already know that attacks of snoring and apnea/hypopnea increase during the REM period. As seen in the findings of our study; although our device did not detect the REM period, it reduced the number and severity of snoring and subsequent apnea attacks. The supine position also contributes to the increase. Oxygen levels that fall overnight during recurrent episodes of apnea-hypopnea (which frequently divides severe snoring and snoring in the supine position), especially in REM sleep, can lead to heart related problems. Heart rate usually slows down during apnea and accelerates after apnea; therefore, arrhythmias can be seen . The SNOThe volume of snoring can vary across patients and across nights for the same patient; it can be continuous or discontinuous. According to acoustic analysis, it may be at a frequency of 200 Hz at the palate level, and of 1000 Hz at the tongue base . It is tAs a result of this study, snoring and sleep apnea syndrome were shown to cause harm to both general and sleep health. A group of diseases which can cause damage, but cannot be fully treated have been described, and a device called SNORAP was proposed for the improvement of these diseases. designed by prototyping all of these physiological mechanisms, and demonstrated in the following cases: (a) simple snoring; (b) OSAS with mild and moderate severity; (c) OSAS with REM Dependent Mild and Moderate Degree; (d) OSAS with Mild and Moderate degree; and (e) Patients who received CPAP therapy, but had position-dependent mild and moderate apnea attacks.Sleep, which accounts for a third of our lives, is a physiological need for our brain and body health. The deterioration of this need, that is, changes in sleeping patterns and duration, diminishes the quality of individual activities during the day. Therefore, the maintenance of sleep health or the correction of the disrupted sleep quality causes the individual and society to lead a higher quality of life.The most distinguished characteristics of our study, when compared to other studies, is the benefit to certain disease groups as shown by our experimental studies. The second important feature of our study is that snoring sensor has a high success rate. The third important feature of our study is that we are able to monitor heartbeat. Our device increases the intensity and number of vibrating stimuli when the pulse or heart rate drops below 40/min or exceeds 120/min. The fourth important feature of our study is that device is coin-sized, and a device of such size can easily be placed on one of the individual’s anatomical regions with a bandage so as to provide optimal comfort for individual. Our primary goal is to help a special group of patients who we have observed to not get very good help. It has been recommended that a tennis ball be stitched into their night clothes so that patients with the diagnosis of Position-Dependent Mild and Moderate Level OSAS/Snoring can avoid entering the supine position during their night sleep. Moreover, considering patented products with this aim in the world, there is a product designed with belts to hang on the lower back and whose usages are difficult . HoweverExperimental works on patients at the sleep and electrophysiology lab are still continuing. In order to develop SNORAP, we are trying to integrate an airflow sensor into the system. Thus, in case there is no airflow, SNORAP can recognize it and the patient is warned more effectively by more accurately identifying apnea attacks. At the same time, we want SNORAP to determine REM periods. That is why, our works on EEG are continuing. In particular, we want to ensure in future works that the SNORAP device can determine a PSG sensor’s mission in the home environment.


I am very happy to start the New Year with recent news of progress in the health personnel licensing examinations in Korea.First, smart device-based testing was used to administer the Korea emergency medical technician licensing examination on December 2, 2017 in 5 cities in Korea, as previously announced [2 , and it cost 13.8 million dollars. It can provide a working space for 120 persons at the same time, and it will provide test makers with a more comfortable environment in a dedicated place.Second, the test construction center of the Korea Health Personnel Licensing Examination Institute was officially opened in Chungju, Korea on June 28, 2017 . ConstruIn 2018, the institute plans the following new projects: preparing permanent test centers and launching a committee on computerized adaptive testing. Currently, we usually rent test space from high schools to administer paper-and-pencil tests. However, for computer-based testing or computerized adaptive testing to be sustainably implemented, permanent test centers are required in the central cities of each province. The present form of smart device-based testing can be deployed in any location because tablet PCs are easy to handle and move. However, to adopt computerized adaptive testing, the PCs must have a wired internet or intranet connection . WirelesFurthermore, a task force team for computerized adaptive testing was launched in late 2017. As part of the preparation to implement computerized testing, a number of research projects are now under way: first, psychometric considerations, item pool construction, and administrative and financial support for the adoption of computerized adaptive testing; second, test equating of different item sets to implement the test at multiple times. In Korea, where this kind of testing has not been introduced on any high-stakes examinations, such as licensing examinations, we should be aware of the need to persuade not only medical health students and faculty members, but also the general population and government representatives of the merit of computerized adaptive testing as a way to estimate examinees’ ability more efficiently. If we adopt this testing format, examinees will be able to take the tests throughout the year.Journal of Educational Evaluation for Health Professions. Last year, 9 of the articles published in the journal described research that had been supported by a research grant from the institute. I hope that more articles supported by grants from the institute will be published in the journal in 2018. I will provide support for the journal to publish continuously as a way of helping medical health educators adopt a variety of innovations related to evaluation. I am also confident that brilliant articles will be published in the journal, making it an essential source of information in the field of educational evaluation.I have encouraged staff members of the institute and recipients of support from the institute’s research fund to publish their research output in


Interdisciplinary tumor board decisions improve the quality of oncological therapies, while no such boards exist for end-of-life (EOL) decisions. The aim of this study was to assess the willingness of hemato-oncological and palliative care professionals to develop and participate in EOL boards. An aim of an EOL board would be to establish an interdisciplinary and comprehensive care for the remaining lifetime of patients suffering from advanced incurable diseases.Staff from the interdisciplinary teams of all hemato-oncological and palliative care wards in Vienna were invited to anonymously participate in an online survey.309 professionals responded. 91% respondents reported a need to establish an EOL board, 63% expressed their willingness to actively participate in an EOL board, and 25% were indecisive. Regarding patient presence, 50% voted for an EOL board in the presence of the patients, and 36% voted for an EOL board in the absence of the patients. 95% had the opinion that an EOL board could improve patient care in the last phase of life. 64% stated that the development of an EOL board would be worthwhile, while 28% did not see enough resources available at their institutions. Regarding the desired type of documentation, 61% voted for a centrally available EOL decision, and 31% supported an in-house-based documentation. 94% voted for the availability of an information folder about EOL care.The willingness of professionals to establish an EOL board was very high. Further steps should be taken to implement such boards to improve EOL care. The last phase of life and the fact of facing death affects every individual. Medical and therapeutic treatment options for this period are increasing; however, despite all advances, treatment options go hand in hand with the necessity to inform patients about their right to decide against treatments as well as with the task to establish shared decision-making. The possibility of high-quality, individualized end-of-life (EOL) care also includes the involvement of caregivers, family, friends, society, the health system, and politics. It is evident that early palliative care and general palliative care may improve quality of life, reduce depression, and prolong life –5. Regarwww.surveymonkey.com). Questions related to the following topics were raised:Which professional group the respondent belonged to,Their attitude towards establishing an EOL board,Their assessment of the need for an EOL board at their own workplace,Their perception of caring for patients with incurable diseases at their workplace,Their willingness to actively participate in an EOL board,Their attitude towards the methods of establishing an EOL board (in the presence of patients or in the absence of patients),The benefit of establishing an EOL board in the last phase of life,The possibility of practically implementing an EOL board at their workplace,Their desired type of documentation on an EOL board decision,Their attitude towards delivering an information folder about EOL care.Professional staff from the multidisciplinary teams of all hemato-oncological and palliative care departments in Vienna were recruited to participate in an online survey comprising 10 questions . The online survey took place from 1 March 2016 to 31 October 2016 in two runs sent out by email (March 2016 and July 2016). Before, the survey was sent to the medical as well as to the nursing management of the following institutions for approval: General Hospital Vienna, Hospital Barmherzige Brueder, Caritas Socialis Hospice Rennweg, Kaiser Franz Josef Hospital, Hospital Goettlicher Heiland, Hospital St. Elisabeth, St. Josef Hospital, Hanusch Hospital, Hospital Hietzing, Hospital Rudolfstiftung, Hospital Wilhelminenspital and SMZ Ost Hospital. The study was approved at all institutions. The survey was conducted in German.The data were analyzed using descriptive statistics.www.surveymonkey.com. Double responses were prevented by the online system. There were 309 people who participated in the survey. The results are presented in Fig. The survey was conducted anonymously. To ensure adequate data protection, it was not possible to identify the participants. In the questionnaire itself, no email addresses or names of people or institutions were requested. All responses were made anonymously via the questionnaire server The results of the study show that the willingness of multidisciplinary professionals working in hemato-oncologic and palliative care wards to establish an EOL board is very high. The main respondents were nursing staff and medical doctors. A high percentage of the interviewees were willing to actively participate in an EOL board. Despite the fact that daily medical work is often characterized by bureaucracy and a lack of resources, professionals are very willing to participate in an EOL board according to the results of the present study. The fact that 60% of the participants considered the current provision of care for patients suffering from advanced diseases to be insufficient is a clear argument for further steps towards establishing better EOL care. This underlines the fact that the EOL phase represents an important area in hemato-oncology, and that professionals aim to improve the care of their patients and are willing to spend resources for this purpose. Since dealing with EOL issues will continue to be a taboo subject, active education might be necessary. Handing over an information folder with material concerning the last phase of life and advance directives, financial and social aspects, home care, hospices, palliative care, and mobile care service was considered to be useful by a high percentage of respondents. Thus, the results of this study will serve as a practical, relevant basis to encourage the implementation of EOL boards. One of the core tasks of palliative care is the bundling of multidisciplinary expertise. This comprehensive care becomes eminently important in the last phase of life, where personal and spiritual needs as well as financial and psychosocial aspects are relevant . An EOL In addition, the use of an EOL information folder was favored by the participants. This folder could be created and handed out so that patients and their caregivers receive bundled information that they are often missing. Previous studies have shown that confronting patients with their prognosis does not affect the well-being of patients, and that the majority of patients wish to be informed . NeverthAnother aim of this study was to question the preference as to whether EOL boards should take place in the presence or absence of the patients. The results showed that half of the respondents favored the presence of the patients, while almost a quarter opposed the presence of the patients. Both variants could be tested in a pilot test.The limitations and strengths of the current study should be mentioned. A limitation of this study was that the exact number of professionals to whom the questionnaire was sent as well as the drop-out rate could not be detected. Therefore, the reasons why participants were unwilling to take part in the survey could not be determined. Hence, there was a possible selection bias towards participants who found the subject area of the survey important and tended towards positive answers. Thus, critical opinions could have been obscured. Furthermore, some professional groups in the multidisciplinary team were underrepresented, which, however, corresponds to everyday work at palliative care wards. The strengths of this study include the high response rate, which was achieved by using a web-based online questionnaire that took little time to complete. Thus, the response rate was satisfactory. Another strength was the novelty of the research question.The willingness to establish an EOL board was very high among hemato-oncological staff, with 91% of respondents supporting this idea. A high number of participants (94%) voted to hand out an information folder with material regarding the last phase of life. Data from the current study found that respondents saw a need to establish an EOL board, that they would be willing to spend resources on this topic, and that most would actively participate. Thus, the results of the current study should serve as a basis to underline the importance of establishing EOL boards. Referring to these study results and to the fact that tumor boards are already established at Austrian oncology centers, the establishment of EOL boards at comprehensive cancer centers could help to improve the care of patients suffering from advanced diseases.


Israeli policymakers have expressed serious concerns about being able to meet the growing demand for physician services. For this reason, the Israel Ministry of Health (MoH) undertook studies based on 2008 and then 2012 data to obtain an accurate assessment of the size, specialty mix, demographic and geographic composition of the physician workforce. This paper highlights the findings from these studies about the number and percentage of licensed physicians in Israel who were not available, were only partially available, or were about to leave the Israeli healthcare workforce.The two studies cross-linked administrative files of the entire physician population in Israel. The two sources were the MoH registry of licensed physicians, which contains demographic, medical education and specialty information, and the Israel Tax Authority income file on employment data. A third source, used only for the study of 2008 data, was the CBS Population Census Data 2008 which was based on a large representative sample of the population (14%), along with the updated Population Registry, which provided data on physicians whose occupation was in medical care as well as the number of work-hours. By linking the files we could also assess the population of licensed Israeli physicians living abroad.Only 74% of licensed physicians of all ages in 2012 were active in the Israeli workforce. Of physicians under the age of 70, 87% were living and working in Israel. Female physicians tended to retire from the workforce earlier than males and were more likely to work fewer hours during their working years. The rate of physicians who worked longer hours declined in both genders as age rose. About 10% of licensees had been living abroad for at least a year and the majority of these were older. Approximately 7% of licensed physicians, ages 30–44, were abroad and most are presumed to be doing additional clinical training or gaining research experience.In some specialty fields young physicians were not replacing retirees at a compensatory rate; anesthesiologists, a specialty in short supply in Israel were more likely to be living abroad than other specialists.Assessment of the medical workforce pool and personnel planning require not just the number of licensed physicians but also information about the employment mix of license holders and their level of professional activity in Israel.For planning future workforce needs, it is important to keep in mind that the average female vs. male physician has lower clinical productivity due to shorter hours and earlier retirement and that a group of young physicians will predictably be abroad at any point in time; however major “brain drain” is not evident. Furthermore, extrapolating from the findings in the current studies, we believe that a potential shortage of physicians within Israel can be mitigated by better administrative support of physicians, use of physician extenders, and careful attention to improving physician satisfaction in certain specialties. In order to ensure the appropriate and efficient delivery of quality health care in a country, an adequate supply of physicians is needed to match the demand for services. In recent decades policy-makers in many countries around the world, Israel among them, have raised concerns that a variety of social, demographic, technological and economic factors, will lead to insufficient physician supply in the coming years .As aptly stated in a working paper from the Organization for Economic Co- operation and Development (OECD) on health workforce planning, there is a "need to know first where we are, before we can know where we're heading: The first step of any good health workforce projection is good data about the current situation" .That was the goal of an Israeli study based on 2008 data . The stuIn Israel, physicians are licensed just once in their professional lifetimes, and past assessments of physician supply were primarily based on the Ministry of Health (MoH) registry of all licensed physicians. The physician registry, although updated according to the population registry for deaths, does not include employment status information. In the past a number of attempts were made by the MoH to acquire more complete and accurate information on employment status , 5. The In the present paper, the authors, who were part of the original team of the 2008 and 2012 studies, wish to highlight new findings from the 2012 administrative data  and the In the study based on the 2008 data, national administrative files were cross-linked to obtain figures on the active and inactive medical workforce and its demographic and geographic distributions. In 2012 the study was repeated using the same methodology. Both studies derived data from two sources in their respective years, and the study using 2008 data also drew on the most recent (2008) CBS Population Census, specifically its Socio-Economic File (SEF). The two sources included in both analyses were the MoH registry of licensed physicians, which contains demographic, medical education and specialty information, and the Israel Tax Authority income file. The CBS receives the tax authority income file annually and it includes employment data that meet the Statistics’ Ordinance requirements for privacy. The SEF Population Census (2008) along with the updated Population Registry, provided data on physicians working in Israel whose occupation was in medical care, as well as the number of work-hours based on a large representative sample of the population (14%). In this paper, the 2012 data are presented whenever available and the 2008 data are presented when no updated data is available. The source of the data for each table is presented with each table.By cross-linking the MoH physician registry and the updated Population Registry, data were also obtained on physicians who resided abroad (based upon the United Nations definition of permanent place of residence). These include anyone who left the borders of Israel for at least 12 months with only an allowance of visiting the homeland for not more than 90 days .Since the Tax Authority Income file used by the CBS includes only data on civilian workers, we excluded from the study physicians who are practicing in a medical capacity in the armed forces.The findings from the 2012 data pointed to a considerable gap between the numbers of licensed physicians listed in the MoH registry  and the number of physicians actually living and working in healthcare in Israel  according to the Tax Authority income file. The personal identity information did not permit data linkage for about 1% of the physicians in the MoH listings who were excluded from the study. About 10% of the licensed physician population was living abroad. Of the remaining 29,129 physicians living in Israel, almost 5000 fewer  were actively employed in Israel. Thus, of the total number of physicians registered with the MoH of all ages, only 74% were living and employed in Israel in 2012. The number of physicians under the age of 70 working in Israel in the health field in 2012 stood at 22,082. This was 87% of licensed physicians of that age who were living in Israel.The percentages of licensed employed physicians aged 30–64, ranged from 92 to 94% and at age 65 the employment rate began, as expected, to decrease Table . The perTable The overall rates of employment by age of male and female physicians do not reflect or account for the differences in hours worked per week. These can be viewed in Tables The cumulative number of weekly hours worked was self-reported by physicians for all places of work. The average total number of weekly work-hours was 48.4 h. Most employers in Israel define a full-time position for physicians as between 42 and 45 weekly hours. For our purposes, we will refer to those who work 40 h or fewer as those who work “less than full-time”.Of the total population of working physicians in 2008, 59% were male and 41% were female. Almost twice as many women as men worked less than full-time 42% vs. 23%)  worked 20 h or less, and only 2% of those in each of the peak employment age categories  did so Table .The hourly work distribution by age and gender Table  indicateOne of the largest groups of physicians unavailable to medical practice in Israel is that of licensed doctors residing abroad. In 2012 there were 3275 physicians  who had been living abroad for at least a year. Forty-five percent of those physicians were between the ages of 45 and 64 and 37% were aged 65 and over. Of licensed physicians aged 45–64, 10.4% lived abroad and of licensed physicians aged 65 and over, 20% did so. Almost twice as many male as female physicians (65% vs. 35%) lived abroad in 2012. From among the total population of physicians who resided abroad, 65% had received their medical degree abroad.Ninety percent of those found to be living abroad in 2012 were there for at least 3 years and 82% were there for 5 years or more. An examination of the data by year in which the physicians were awarded his/her degree showed that as license-issue dates were earlier, the percent of physicians living abroad was higher  who lived abroad and were thus unavailable to the healthcare system in Israel is shown in Table The distribution of practicing specialists by age Table  providesThe low percentage (3%) of family specialists that reached retirement age, together with the high percentage (34%) of young family specialists, is a reflection of the relative newness of family medicine as a specialty in Israel (since 1971).Unlike many other western countries,In years prior to this study, various professional bodies addressed the significance of the lack of accurate, updated data on the number and characteristics of employed physicians –13 and iThe methodology upon which the current work was based , 7 took Studies have shown that female participation in the Israeli medical workforce has increased over time , 12–15, While the current study could not provide a precise number of work-hours per physician to convert to full-time equivalent (FTE) positions (one of the study’s limitations), the age-categorized data did demonstrate a lower work-hour contribution by female physicians. Data from other studies indicate that female physicians also practice at lower activity levels during childbearing age, have a higher tendency to work part time and see fewer patients per day. They also take more parental leave, are more likely to leave the practice of medicine during childbearing years and are more likely to retire early , 18, 19.Greater female workforce participation in Israel would mean fewer FTE positions to be contributed to the workforce , creatinThe contribution of women to the physician workforce however is not solely a function of hours and years worked, but also of the kind of care and time given to patients, and the quality and nature of the professional relationship . With thSince lifestyle issues regarding the balance between home and career are important in women’s deciding on amount of time to work in a week, choice of specialties etc., it is worthwhile to further study the use and effectiveness of incentives such as family-friendly working hours and training programs, childcare options and financial incentives when planning to attract female physicians to specific programs, specialties or geographic areas in Israel.In Israel, as in other countries, age plays a role in how many hours doctors work, as well as how any more years they will continue to contribute to the workforce. Overall, fewer younger physicians than older ones worked less than full-time, with the percentage of physicians who worked shorter hours rising with age. A similar trend in European countries was seen wherein weekly work-hours rise for physicians between ages 35–39 and 45–49 but fall from 50 to 54 onwards as physicians approach retirement age . AttemptThe percentage of younger physicians in the labor pool in Israel has decreased over the years while doctors approaching retirement both comprised a growing segment of the labor force, and worked fewer hours . In the The Horev committee reported on the aging of the medical specialist population based on data from the publication of the Health Information Department of the MoH . In 1990The group responsible for the largest gap between the numbers of licensed and practicing physicians in Israel was that of physicians residing abroad. The findings indicated that at any point in time, approximately 10% of registered physicians of all ages were unavailable to the Israeli labor pool for this reason. The data also showed that the majority of those who were abroad were not young, recent licensees pursuing time-limited, post-graduate training. From among the 3275 physicians who were living abroad in 2012, 82% of them had been there for at least 5 years, a further indication that they may not have been there only temporarily.The study could not provide information on whether the physicians residing abroad were actually employed, and if so, in what capacity, nor could it determine their reasons for moving abroad. However, the phenomenon of leaving the country, even if only for a period, in effect removed a portion of physicians from the employment pool in Israel. Seven percent of licensed younger physicians (aged 30–44) were abroad-- many perhaps pursuing advanced training with a plan to return to Israel upon completion. Other doctors will presumably take their places abroad as the former return. So, while it may be of benefit to the quality of the workforce to have its physicians pursue fellowships or sabbaticals abroad, for the purpose of workforce projection and planning, this absence needs to be taken into account.We further recommend obtaining more information on Israeli physicians residing abroad to determine whether and in what capacity they are employed as well as any potential for their re-entry into the Israeli medical workforce and under what conditions. In addition, since our study shows the percentage abroad at a point in time, we recommend following this statistic over time.Immigration out of a country may well be an indication of discontent, and could increase. Indeed, there is evidence of Israeli physicians’ lack of satisfaction, overload, burnout and consequent withdrawal from the profession , 15. As Reasons for abandoning the medical profession and doctors’ emigration are similar worldwide and include burnout, poor conditions in the country of origin including work conditions, attraction to other professions and the erosion of medical autonomy. For the most part, reasons for emigration and the abandonment of the field of medicine do not stem from doctors’ negative sentiments towards the profession itself, but from the conditions inherent in its practice . The VanWe recommend that healthcare systems’ thinking about how to cope with existing or impending shortages in the supply of physicians, include both efforts for reduction on the demand side, as well as changes on the supply side. Doctors need to be supported to best leverage their time so that their days are not organized around tasks related to documentation and clerical and administrative activities which should be handled more appropriately by others in the system. Added clerical support can also reduce “no-shows” through concentrated appointment confirmations, especially in practices with limited or no clerical help, again, freeing up physician time to see more patients.In a report of American experts independently addressing the question of how to meet the challenge of impending physician shortage, the most common thread running through their responses was that, to the greatest extent possible, other healthcare professionals should be working with physicians on multi-professional teams, with each member working "to the top of their license", and each member taking on tasks that match their professional competencies . A team-The team approach also incorporates the adoption of newer models of clinical care professionals which have been shown to be comparable to, or better than, physician-provided care on several process and outcome measures , 30. In Increasing the employment of such physician extenders in Israel, through both expanded training programs and broader acceptance and mobilization of these other professionals, could improve both access and quality of clinical care for patients. At the same time, it could free up physicians to do what only they are trained to do, and thus contribute to alleviating a potential physician shortage. Another specific recommendation that follows from the findings of the current research would be developing additional non-physician personnel such as clinical microbiology professionals and/or nurse anesthetists.In addition, policymakers should consider promoting the use in Israel of specific technological advances, such as telemedicine for monitoring conditions remotely. This could result in reductions in use of services including fewer unnecessary physician visits and hospitalizations, thus easing up the demands on physicians’ time and enhancing efficiency .The methodology of this study can serve as an important tool for policy planners to periodically provide up-to-date information on active healthcare workers and on those who are unavailable, either fully or partially, to the healthcare system, in the service of planning for a potential shortage . To thisAssessment of the medical workforce pool and personnel planning require not just the number of licensed physicians but also information about the employment mix of license holders and their level of professional activity in Israel.Although a significant percentage of licensed Israeli physicians are living abroad at any point in time, major “brain drain” is not evident. For planning the numbers of physicians needed for the workforce, it is important to keep in mind that the average female vs. male physician has lower clinical productivity due to shorter hours and earlier retirement and that a group of young physicians will predictably be abroad at any point in time. Furthermore, extrapolating from the findings in the current studies, we believe that a potential shortage of physicians within Israel can be mitigated by better administrative support of physicians, use of physician extenders, and careful attention to improving physician satisfaction in certain specialties.