Dentists with a special interest hold enhanced skills enabling them to treat cases of intermediate complexity. The aim of this study was to explore primary dental care practitioners’ views of dentists with a special interest (DwSIs) in Endodontics in London, with reference to an educational and service initiative established by (the former) London Deanery in conjunction with the NHS.A cross-sectional postal survey of primary care dentists working across different models of care within London was conducted, with a target to achieve views of at least 5 % of London’s dentists. The questionnaire instrument was informed by qualitative research and the dental literature and piloted prior to distribution; data were analysed using SPSS v19 and STATA v12.0.n = 243) responded to the survey; 53 % were male. Just over one third  were aware of the DwSI service being provided. Most practitioners reported that having access to a DwSI in Endodontics would support the care of their patients , would carry out more endodontic treatment in the NHS primary dental care if adequately reimbursed , and had more time . Female respondents appeared to be less confident in doing endodontic treatment (p = 0.001). More recently qualified respondents reported greater need for training/support for performing more endodontic treatment in the NHS primary dental care (p = 0.001), were more dissatisfied with access to endodontic service in the NHS primary dental care (p = 0.007) and more interested to train as a DwSI in endodontics (p = 0.001) compared with respondents having a greater number of years of clinical experience since qualification.Six per cent of London’s primary care dentists (The findings lend support to the concept of developing dentists with enhanced skills as well as ensuring additional funding, time and support to facilitate more routine endodontics through the NHS primary care to meet patient needs. More recently qualified dentists working in London were more concerned regarding endodontic service access, expressed need for training/support for undertaking more endodontic treatment in the NHS primary dental care and a desire to train as a DwSI in endodontics. Primary dental care practitioners are the main providers of dentistry acting as ‘gatekeepers’ to specialist care within England –4; it isDentistry in England is provided through a blend of public (NHS) and private services . The majAll dentists nationally are trained to provide routine endodontics in line with General Dental Council (GDC) requirements for education , 9. EndoSpecialist services are limited. As of July 2014, there are over 40,000 dentists on the UK dental register which includes 263 specialists in endodontics, and although there are 310 in the over-arching specialty of restorative dentistry, many of the latter do not focus on endodontics or are on both registers [The emphasis nationally is on developing innovative models of care and local workforce education and training to meet local need , 16. Theet al. (2010) highlight the importance of carefully planning any shift to out-of-hospital services and understanding the effectiveness of any alternate care pathway on the local population to form an informed future action [to reduce unnecessary referrals to hospitals, reduce extraction rates and train GDPs to undertake complex endodontic procedures within the Primary Care sector” [The importance of providing advanced dental services was highlighted in a review of English NHS Dental Services in 2009 , with the action . In resp sector” .Out of the nine dentists (trainee DwSIs) successful in being selected across eight different London PCTs to undertake the training programme, eight completed the training, with one discontinuing after the mid-course evaluation. The host PCT of the trainee DwSI funded the service component of this scheme with the aim of developing their endodontic capacity in the short-term and building capacity for the future.It is important to establish the views of primary dental care practitioners on new initiatives as they are the ‘gatekeepers’ of patient access to DwSI and specialist services. The success of such a programme  depends on its utilisation by these professionals. Evaluation of new initiatives is important in shaping the delivery of health care through evidence .Assess primary dental care practitioners’ awareness of endodontic DwSI services in London.Assess acceptability of endodontic DwSI services to primary dental care practitioners.Assess perceived needs for and advantages/disadvantages of endodontic DwSI services.Measure the interest amongst primary dental care practitioners to provide endodontics and/or train as a DwSI.Determine the views on the most appropriate pathway of referring patients to DwSI services.The aim of the study was to explore primary dental care practitioners’ views of dentists with a special interest (DwSIs) in Endodontics in London, and how these views varied by sex, length of time since qualification, possession of postgraduate qualifications and awareness of the DwSI scheme. The objectives of this study were to:Since the conclusion of this research, the NHS has undergone radical reorganisation of administrative structures . The resA questionnaire instrument was derived through published literature and qualitative research, using Dillman's approach to surveys . The quaPresence of DwSI, or notPresence of dental teaching hospital/hospital providing specialist restorative dental services in the PCT area, or notLevels of routine NHS endodontic activity in primary dental care in the previous yearWhether the DwSI was accepting external referrals, and the nature of patient triageInner/outer London locationsType of service: salaried or general dental practiceThere are around four thousand practitioners across one thousand primary dental practices in London . A 5 % sRecruitment was conducted at practitioner level. The list of eligible practitioners and their postal addresses was obtained from the PCTs involved in the study and checked against internet sources. In accordance with the Dillman’s protocol for postal surveys , researcParticipant responses were entered onto a computer and analysed using the statistical package SPSS v19.0 and STATA version 12.0. Respondents were asked to rate whether or not they agreed with a series of statements regarding the provision of NHS and DwSIs in endodontics service and these statements were grouped into five different categories according to their relevance. The five categories were namely ‘Confidence to undertake endodontic treatment’, ‘Training/Support for undertaking more endodontic treatment in NHS primary dental care’, ‘Dissatisfaction with endodontic service access’, ‘Acceptability/Support for DwSI services’ and ‘Interest in training as an endodontic DwSI’. ‘Confidence to undertake endodontic treatment’ consisted of items exploring the confidence of respondents in carrying out endodontic treatment. ‘Training/Support for undertaking more endodontic treatment in NHS primary dental care’ consisted of statements which explored whether providing training or specialist support for respondents would result in them carrying out more endodontic treatment in primary dental care. The third category ‘Dissatisfaction with endodontic service access’ had items related to dissatisfaction with access to endodontic services in NHS primary dental care whereas ‘Acceptability/Support for DwSI services’ consisted of statements on acceptability and support for DwSI services in endodontics. And finally, ‘Interest in training as an endodontic DwSI’ outcome explored respondents’ desire to train as a DwSI in endodontics.t-test given differences in motivation and career expectations [Descriptive statistics were used to summarise the findings. The five different categories were compared by sex using independent samples ctations –35. Multctations .n = 16 years). Practices ranged from one to 10 surgeries in size, with the mode being two (31 %). Eighty percent of respondents worked in just one practice within the PCT, whereas the remainder covered two or three practices.Of the 799 dentists with valid addresses invited to take part in the survey, 243 (30 %) returned a completed questionnaire, representing almost six percent of primary care dentists in London. Ninety one questionnaires were returned by the postal service because the dentist address was not valid and ten questionnaires were returned by the participants who considered themselves ineligible. The response rate by PCT varied from 18 % to 47 %. Males constituted just over half (53 %) of the respondents. Five percent reported having a post-graduate qualification in endodontics. The clinical experience of the respondents ranged from one to 51 years (Meap = 0.001) and more supportive of the DwSI services as compared to male respondents (p = 0.047).Table p = 0.001) and those unaware of the DwSI service (p = 0.02); whereas confidence was higher in respondents having any post graduate qualification (p = 0.04), as might be expected. In relation to ‘training/support for undertaking more endodontic treatment in the NHS primary dental care’, female respondents (p = 0.04) and those with more years of experience post-qualification (p = 0.001) were less likely to undertake more endodontics treatment, even if they had more training or specialist support for endodontics. ‘Dissatisfaction with endodontic service access’, was more common in respondents’ who had qualified more recently compared with their those had qualified longer (p = 0.007). In relation to ‘Interest in training as an endodontic DwSI, respondents more recently qualified were significantly more interested in training as a DwSI in endodontics (p = 0.001). There was no difference across groups in relation to their ‘acceptability/support for DwSI services’.Multivariate regression analysis for five categories is presented in Table n = 90) of respondents were aware of the DwSI training scheme; however, there was a significant difference in the level of awareness between dentists in the PCTs which had a DwSI scheme compared with those where there was none, or the trainee was only accepting internal practice referrals . In PCTs that had DwSI schemes, 54 % (n = 59) of respondents had referred patients to the services, 82 % (n = 49) of which were to other dental practices. The most common reasons for non-referral (obtained through open questions) were ‘not being aware of the service’ and 'preferring to treat patients themselves'. Logistic regression analysis was carried out to test the effect of predictors on the referral of patients to DwSI service (Table p = 0.01) among the respondents who were not aware of the scheme. Of the respondents who had referred patients to a DwSI scheme, 55 % (n = 60) reported that the service was successful, and this was qualified with comments regarding the systems and outcomes as explained in the following section.Thirty seven percent (ce Table . Unsurprn = 215) reported that having access to the services of a DwSI in endodontics would support the care of their patients; 88 % (n = 210) felt that DwSIs should accept referrals from outside their practices and 82 % (n = 198) reported that they would feel comfortable in referring their patients to a DwSI for treatment. The perceived advantages reported in free text responses to open questions were grouped into ‘better service’ or ‘quality treatment’ for the patients, ‘easy access’, and ‘an alternative option to extraction’ categories  respondents, in which long waiting lists for endodontic care were the major disadvantage (40 %), followed by lack of resources (16 %) and limited availability of the DwSIs (11 %), as illustrated by the following quotations:“Long waiting list and not enough dentists with DwSI training”as DwSI became overwhelmed)“Long waiting lists-gradually building up …” (Concerns about current DwSI capacity to respond to need were raised by 23 % (n = 84) of dentists agreeing as well as disagreeing with this statement and 31 % equivocal.There was a divergence of views on whether the DwSI service might result in loss of patients for general dental practitioners with almost one third supporting and one third opposed to this view and one third equivocal. Similarly, respondents’ views were divided on the issue of whether the DwSI service was needed if the hospitals increased their capacity with almost 35 % (n = 195) of the respondents’ stated 'direct referral to the DwSI' as being their preferred option  perceived them as clear, the remainder considered that it complicated the referral process  or set the bar for referral too high .There was a clear message regarding referral routes as 81 %  of the respondents reporting that practitioners would carry out more endodontic treatment in the NHS primary dental care if they were reimbursed adequately, or had more time . This was illustrated by the following quotations:"There needs to be better remuneration for RCTs  on the NHS”“PCT does not provide enough time-money to perform proper endodontic treatment on the NHS (Band 2 NHS)”There was a notably high level of dissatisfaction with the present provision of endodontic services in primary and secondary NHS services, with 93 % (n = 208) indicated that practitioners are often dissatisfied as a result of difficulties in accessing more specialised services, and 77 % (n = 182) felt that these difficulties were a cause for patient dissatisfaction.Access to more specialised endodontics was commonly reported as being a challenge; 88 % .Eighty three percent of the dentists referred patients to one or more hospitals in London with 24 % using three or more hospitals. Reasons for not using hospitals included ‘referrals getting rejected’ (15 %); and ‘performing RCT treatment in their own clinics’ (15 %), followed by ‘long waiting list’ (12 %). The main advantage of hospital services was perceived as the provision of high quality treatment to the patients (p = 0.001) in the mean number of years since qualification was found between respondents who were interested and not interested to train as a DwSIs in Endodontics (13.6 years (sd = 12.1) and 19.2 years (sd = 9.1) respectively).There was support for initiatives to develop DwSIs, with 73 % of the respondents expressing an interest in undertaking DwSI training in one or more branches of dentistry  of these primary dental care practitioners who responded to this question, estimated that they would refer an average of 24 patients per dentist (range 0-400) per year to DwSIs. Thus, when scaled up to cover the majority of London practitioners, this could translate in an estimated 83,520 cases annually for London  identified that they would reduce referral to hospitals if there were DwSIs available with an average of 18 referrals per dentist and a range of 1-200 patients.Only 29 % , particularly in endodontics (57 %); a higher than expected percentage of respondents reported having a postgraduate qualification in endodontics (5 %). Given the fact there was a considerable interest in becoming a DwSI, this could be an indication of this view; however, interestingly only around half (51 %) of the respondents felt that they enjoyed performing endodontic treatment, thus there was clearly a spread of perspectives amongst those who chose to respond. Although the views may not be representative of primary dental care in general, they represent an important contribution to the debate on dentists with enhanced skills.The survey suggested that female respondents were less confident and less likely to provide additional endodontic treatment with further training or specialist support. This approach of female respondents towards endodontic treatment was not affected by other variables such as having a post graduate qualification or number of years since qualification. Females were equally interested to gain enhanced skills training as a DwSI in endodontics as compared with male respondents.Similarly, respondents who had qualified longer ago reported being less likely to provide additional endodontic treatment with further training/specialist support, but also being less concerned about access to NHS endodontic services. This could be explained by older respondents considering themselves self-sufficient in delivering endodontic treatment and/or accessing endodontic services when required by their patients. In contrast, respondents who had qualified more recently expressed a desire for additional training/support in delivering more endodontic treatment in the NHS primary dental care. This could be attributed to the fact that graduates are now considered ‘safe beginners’  and recoGiven the higher level of interest in enhanced skills training to become a DwSI amongst more recently qualified respondents, it is possible that they might believe training as a DwSI in endodontics will help them in delivering endodontic treatment to patients, or they might perceive it as an opportunity for career progression. In any case, their interest to further enhance their skills could be harnessed in support of addressing the gap in provision of endodontic service in the NHS primary dental care. Moreover, respondents who had some post graduate qualification appeared to be confident in delivering endodontic treatment. Even if the respondents were not representative of all practitioners, this survey identified 138 London dentists interested in receiving enhanced skills training; this represents a great opportunity to build capacity and address the needs of patients identified in this survey.et al. (2010) involving minor oral surgery [The survey findings suggested that less than half of the respondents were aware of the scheme. This can be explained by the limited coverage of the educational and service initiative in the region, some PCTs having in-house services and the sampling frame for this survey purposively including both participating and non-participating PCTs. Whilst the findings suggest that awareness of the educational and service initiative was higher in participating PCTs, it was not universal as would be expected with a service that was restricted to participating boroughs (PCTs). This highlights the challenges of promoting new schemes and may also be a reflection of the high level of turnover of dental staff . The stu surgery , highligThe difficulties in accessing hospital endodontic services were highlighted by the findings of this study, together with the potential to reduce referrals and address the gap in service provision by a number of routes within a contemporary care pathway lending support for an established service, ideally in a phased manner with close monitoring and evaluation to ensure that patients are seen in the most appropriate setting. The cost-effectiveness of such schemes, has been suggested in previous studies which evaluated specialist services for Minor Oral Surgery provided in primary care, and reported the potential to reduce the secondary care costs –42; howeThe next clear message emerging from practitioners was the need for change to the present NHS system with regard to the provision of endodontic services; a number of issues raised by the respondents were supported by the wider literature and NHS data. First, practitioners (93 %) felt they were not reimbursed sufficiently for the provision of endodontic services in the NHS primary dental care . Second,The respondents to the survey demonstrated a clear view in favour of the initiative including agreement with the statement that DwSIs in endodontics would support the care of their patients, and support for increasing the number of DwSIs in endodontics. Similar positive views for the DwSIs have been expressed by practitioners across ‘Minor Oral Surgery’ and ‘Periodontics’ , 41, 46,et al. [The majority of respondents (82 %) stated that they would feel comfortable in referring their patients to a DwSI in Endodontics. One quarter of the respondents had referred over 800 patients to DwSI endodontic service. There was a strong feeling amongst respondents that DwSIs should accept referrals from outside their practices , and the majority favoured direct referrals to the service, despite there being a concern amongst a minority about losing patients to another dental practice. None-the-less it is clear that some dentists are adapting to new models of working across the health system with cross-referrals between practices. The findings from this, and previous studies , 46, undet al. , and Ricet al. , suggestet al. , 21. FurThere are several implications for policy and strategic action. First, as already highlighted , there aSecond, the single operating model of dental commissioning and contracting developing through NHS England provides an opportunity to develop skill-mix in the form of dentists with enhanced skills through managed clinical networks in a single operating framework. Innovations such as delivered by this scheme  should bThird, these findings suggest that there may be significant unmet need for endodontics within the population and this should be addressed in line with national recommendations for primary dental care redesign .Fourth, if schemes of this nature are commissioned in future, there should be adequate measures to ensure appropriate access through agreed criteria for referral so that the services do not become inundated, creating unacceptable waiting lists and dissatisfaction for patients and referring practitioners.Finally, if the initiative to develop ‘dentists with enhanced skills’ through the work of both dental faculties of the Royal College of Surgeons of England is successful, this will provide an effective means of formalising individuals with these skills within the professional hierarchy ; skills The findings of this survey highlight the need for developing an endodontic care pathway to meet patient needs through enhancing the delivery of care by existing primary care services, providing support for developing dentists with enhanced  skills in endodontics, with services available on direct referral from primary dental care. There was significantly greater interest amongst more recently qualified general practitioners in obtaining additional training and support for primary care provision and developing these skills, which could be harnessed to address the unmet need. The findings suggest there is strong support for this scheme to develop an ‘intermediate’ care level between the primary and secondary services, provided financial and organisational changes are incorporated in the commissioning of endodontics, through patient care pathway development.


ND) in patients with ADHD and healthy controls (HCs). Twenty adult patients with ADHD and 20 HCs underwent ‐[18F]FMeNER‐D2 positron emission tomography (PET) and were genotyped on a MassARRAY MALDI‐TOF platform using the Sequenom iPLEX assay. Linear mixed models analyses revealed a genotype‐dependent difference in NET BPND between groups in the thalamus and cerebellum. In the thalamus, a functional promoter SNP (−3081 A/T) and a 5′‐untranslated region (5′UTR) SNP (−182 T/C), showed higher binding in ADHD patients compared to HCs depending on the major allele. Furthermore, we detected an effect of genotype in HCs, with major allele carriers having lower binding. In contrast, for two 3′UTR SNPs , ADHD subjects had lower binding in the cerebellum compared to HCs depending on the major allele. Additionally, symptoms of hyperactivity and impulsivity correlated with NET BPND in the cerebellum depending on genotype. Symptoms correlated positively with cerebellar NET BPND for the major allele, while symptoms correlated negatively to NET BPND in minor allele carriers. Our findings support the role of genetic influence of the NE system on NET binding to be pertubated in ADHD. Hum Brain Mapp 37:884–895, 2016. © 2015 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc.Attention deficit hyperactivity disorder (ADHD) is a heterogeneous disorder with a strong genetic component. The norepinephrine transporter (NET) is a key target for ADHD treatment and the NET gene has been of high interest as a possible modulator of ADHD pathophysiology. Therefore, we conducted an imaging genetics study to examine possible effects of single nucleotide polymorphisms (SNPs) within the NET gene on NET nondisplaceable binding potential (BP Attention deficit hyperactivity disorder (ADHD) is the most frequent neurodevelopmental disorder diagnosed in children. It is characterized by inattention, hyperactivity, and impulsiveness which frequently leads to severe social, academic, and vocational dysfunction FMeNER‐D2. Moreover, we hypothesized that the symptoms of hyperactivity and impulsivity would correlate to with NET BPND in areas related to motoric activity  whilst symptoms of inattention would correlate with NET BPND in the thalamus.Thus, the aim was to examine the relationship between the effects of SNPs in the NE system and the NET BPTwenty adult ADHD patients  and 20 HCs  were recruited through ADHD outpatient clinic at the Department of Psychiatry and Psychotherapy, Medical University of Vienna, and from the local community via advertisement as previously published elsewhere FMeNER‐D2, synthesized as previously described FMeNER‐D2 is currently the most suitable radioligand for in vivo NET quantification previously described FMeNER‐D2. Mean specific radioactivity of ‐[18F]FMeNER‐D2 was 537 ± 383 GBq/μmol (ADHD patients) and 473 ± 218 GBq/μmol (HC) . Brain radioactivity was measured in a series of six consecutive time frames lasting 10 min each in the interval of 120–180 min after tracer bolus application. Acquired data were reconstructed in volumes consisting of 35 transaxial sections (128 × 128 matrix) using an iterative filtered back projection algorithm (FORE‐ITER) with a spatial resolution of 4.36‐mm full‐width at half maximum 1 cm next to the center of the field of view. For coregistration, magnetic resonance (MR) images were acquired from all participants on a 3‐Tesla Philips scanner (Achieva) using a 3‐D T1 FFE‐weighted sequence, yielding 0.88‐mm slice thickness and in plane resolution of 0.8 × 0.8 mm FMeNER‐D2 inherent to the radioligand. NET BPND for each region was extracted from parametric maps from the Hammers Maximum Probability Atlas FMeNER‐D2. Our results showed significant differences in cerebellar and thalamic NET binding dependent on genotypes between patients with ADHD and HCs. These were largely due to the impact of NET gene polymorphisms on NET BPND in HCs which is not as pronounced in patients with ADHD. Strikingly, in patients with ADHD, a high correlation between specific behavioural symptoms, that is, hyperactivity/impulsivity, and NET BPND in the cerebellum was detected, an effect which was strongly moderated by genotype.Here, we report the influence of genetic variants within the NE system and its effect on in vivo NET binding using PET and the radioligand  deviate from in vitro experiments which found that the minor (T) allele resulted in decreased promoter activity and the major allele (A) in higher expression FMeNER‐D2 cortical areas cannot be properly assessed due to spill over from suspected bone uptake. Therefore, genetic influence in the neocortex could not be examined. Studying the cortex, specifically the frontal cortex due to its vast role in cognitive and behavioral control would be very intriguing to test whether and what effects polymorphisms in the NET gene would have on the binding. Another limitation is that we did not include the CAARS inconsistency index and, therefore, we could not assess whether there was any inconsistencies or irregularities in responses within subjects, nor could we analyze that in respect to our data.A limitation of this study is that with (The evidence presented in this article gives rise to a role for genetic influence of the NE system and alterations in NE signalling as a part of the pathophysiology contributing to ADHD and thus strengthening the hypothesis of imbalances in NE system in the neurobiological mechanism of ADHD. However, we did not detect any differences in the midbrain and the putamen. We can only hypothesize about the possible reasons for these distinct effects. Our results may suggest that the NET genotype effects modulate the NET availability in a region specific manner. Conversely, we cannot exclude other possibilities, such as other influential genetic or nongenetic factors that interact with these regions. In addition, we did not detect any association of any SNP to ADHD, which is probably due to insufficient power of this sample to assess these subtle effects. Due to the heterogeneous nature of ADHD further research requires larger samples for the validation and for the establishment of potential endophenotypes in ADHD. Replication in vivo and in vitro studies is needed to establish if NET genotypic influence could serve as an endophenotype for NE neurotransmission. Moreover, SNPs within the NET may also be very important in relation to the dopaminergic system. The NET is also responsible for reuptake of dopamine in cortical regions [Morón et al., ND in patients with ADHD compared to HCs, depending on their genotype. We find genotypic difference in the thalamus between major and minor alleles for a functional promoter SNP in HCs only. The inverse effect of genotype which was detected in the cerebellum indicates genetic influence of NET on the binding in the cerebellum to differ between groups of ADHD subjects and HCs. The results are compatible with the theory that NE follows an inverted‐U‐shaped curve. Its effect on differential association of behavioral scales with binding further demonstrates a functional and neuropsychological activity to be imbalanced in ADHD.To conclude, this is the first imaging genetic study showing significant differences in NET BP


GWAS) linking 145 genomic loci to traits affecting the formation of red and white cells and platelets in European and other ancestries. We present strategies to address the main challenges in GWAS discoveries, particularly to find functional and regulatory effects of genetic variants, and to identify genes through which these genetic variants affect haematological phenotypes. We argue that studies of haematological trait variation provide an ideal paradigm for understanding the function of GWAS‐associated variants owing to the accessible nature of cells, simple cellular phenotype and focused efforts to characterize the genetic and epigenetic factors influencing the regulatory landscape in highly pure mature cell populations.Haematopoiesis, or the process of formation of mature blood cells from committed progenitors, represents an accessible and well‐studied paradigm of cell differentiation and lineage specification. Genetic association studies provide a powerful approach to discover new genes, biological pathways and mechanisms underlying haematopoietic development. Here, we highlight recent findings of genomewide association studies ( Haematopoiesis is the process whereby self‐renewing haematopoietic stem cells (HSC) in the bone marrow differentiate to lineage‐committed erythroid, myeloid and lymphoid progenitor cells Measurements of full blood counts (FBC), obtained through automated haematology analysers, including the size, physical characteristics or number of blood cells, have medical importance. Deviation from normal parameter ranges can be diagnostic for human diseases, indicating the presence of infection, anaemia, thrombotic diseases or haematological disorders Genomewide association studies (GWAS) assess the statistical association of genetic variants with a given disease or trait of interest. GWAS in the last decade has successfully discovered thousands of genetic variants, mostly single nucleotide polymorphisms (SNPs), associated with the many common human diseases and traits Developing and implementing approaches to aid the interpretation of causal SNPs, and assigning a functional mechanism for how each variant alters a phenotype or disease state, represent an important present challenge to the field. Demonstrating potential functionality to trait‐associated variants is a necessary condition for definitive assignment of causality. Therefore, to reflect the difficulty in identifying causal variants, we refer to putative causal candidates as functional variants for the rest of this review.Here, we highlight recent breakthroughs in understanding the genetic factors determining blood cell formation. We discuss strategies and challenges in prioritizing most likely affected genes and functional genetic variants. Finally, we discuss future opportunities in association studies involving blood traits.ad hoc statistical approaches for instance multivariate modelling Here, we have surveyed the findings of 24 published GWAS studies in European (EUR) HK1, G6PD), sickle cell disease , thrombocytopenia (MPL), leukaemia (PTPN11) and bone marrow failure (TERT). Furthermore, genes in nearby regions are enriched for relevant Gene Ontology biological processes such as haematopoiesis , immune system development  and oxygen transport . Follow‐up of early genetic association studies has revealed novel regulators of haematopoiesis As for other complex traits, we found that GWAS findings for haematological indices predominantly map to non‐coding regions of the genome (Table S1). Genes closest to the association peaks were enriched for genes regulating haematological functions Despite successful gene discoveries, blood GWAS only explain a fraction (4–10%) of baseline differences of measured blood traits in the population To realise the translational benefit of GWAS studies, it is essential to identify the target genes through which identified variants influence traits or phenotypes. This can lead to the discovery of new genes and pathways involved in biological processes or identify those that underlie risk to particular diseases. Here, we outline general strategies in assigning gene targets to GWAS variants and in prioritizing genes for experimental validation Fig. , highligtransWe discussed in the previous section how genes proximal to GWAS variants may be prime candidates for further investigation, particularly those with a known function relating to the trait of interest. However, a potential mechanism through which non‐coding SNPs are believed to act is through the disruption of regulatory elements influencing distally located genes. This implies that the nearest gene is not always the target gene mediating the genetic association PIK3CG kinase gene in platelets and macrophages trans.Expression quantitative trait loci (eQTL) mapping is performed to find statistical association between a genetic variant and the transcript level of a gene considered as a quantitative trait JAK2, which plays an important role in platelet formation with mutations in this gene being associated with myeloproliferative disorders Thus, more accurate methods of target gene identification are required. Recent advances in chromatin conformation techniques provide such opportunities. Chromatin conformation capture (3C) and variants of this approach  probe long‐range interactions by utilizing formaldehyde‐directed cross‐linking of genomic modules that are close in physical space ARHGEF3 ortholog in zebrafish (Danio rerio), leads to ablation of both primitive erythropoiesis and thrombocyte formation, and a novel role in the regulation of iron uptake and erythroid cell maturation in vivo imaging of the transparent zebrafish embryo, the developmental stages of haematopoiesis are easily traceable from primitive to adult haematopoiesis With a list of candidate target genes for each GWAS SNP, it is useful to annotate and then prioritize genes for experimental validation using approaches summarized in Fig. We have discussed methods for prioritizing gene targets where genes are either mapped to the lead SNP or to any variants within an LD region. However, the lead SNP is not necessarily the functional variant. Therefore, without appreciating this, it is possible that genes will be mapped to variants that may not be causally responsible for the phenotypic change. In addition, phenotypic differences could also be driven by a combination of variants. It is therefore important to identify which variants are functional to explain the molecular mechanisms underlying genetic associations.2 ≥ 0·8), that is variants that are highly correlated with the lead SNP. For this purpose, it is recommended to use the haplotype reference of the discovery population. A first intuitive step is to assess whether a variant overlaps a coding region, which potentially leads to amino acid sequence alterations. Changes to protein sequence can in turn influence phenotype, thus indicating that a variant may be functional. However, an altered protein is not always causative and a change in amino acid sequence may not always change protein function.Extensive linkage disequilibrium in the human genome and the incomplete ascertainment of sequence variation in genotyping arrays make it difficult to distinguish between independent genetic contributions. We outline in Fig. To further refine association signals within the LD region, we briefly describe in Fig. cis and distal regulation of sequence variation affecting differences in epigenetic regulation, with the aim to link to transcriptional and phenotypic effect.Assigning functional characteristics to variants within a LD region can help to indicate causality. However, the non‐coding location of a high proportion of reported complex trait GWAS SNPs complicates assignment of molecular mechanism due to our incomplete understanding of the function of large regions on the non‐coding genome. This is where epigenetic information and knowledge of the function of genomic architecture can be valuable in the generic annotation of non‐coding variants, notably those that are in gene deserts. In addition, a variant could be located hundreds of kilobases away in linear scale from the target gene but due to chromatin looping, it is spatially close to directly regulate gene expression. Epigenetic markers such as histone modifications can mark transcriptional activity , cis and distal enhancer regions , and repressed genes . Genomic assays such as DNAse‐seq and ATAC‐seq can identify open chromatins that may be bound by transcription factors or repressors (e.g. CTCF). Sequence variation at the nucleotide level can add or remove the methylation of a nucleotide and for instance can disrupt binding of transcription factors (e.g. CTCF) especially if found in CpG islands Epigenetic and regulatory information does, however, differ based on cell‐type and developmental or other context, so availability of epigenetic data for cell types that are most relevant to the phenotype or disease of interest can greatly enhance the interpretation of functional consequences of GWAS variants DNM3 and consequently leading to reduced proplatelet formation in vitroIntegration with these annotated regulatory genomic features will be important to suggest hypotheses by which potential functional variants may impact phenotype/traits through regulatory effects, but these must be subsequently experimentally tested. As an example, variant rs2038479 in LD with MPV associated lead SNP rs10914144 was validated to mark an alternative promoter site affecting transcription of gene in vitro cellular assays can directly demonstrate whether a variant possesses enhancer or promoter activity through using luciferase reporter systems in vivo assessment of enhancer activity Drosophila genome, uses RNA‐seq based readouts to measure enhancer strength and genomic location. Alternatively, FIREWACh qualitatively assays nucleosome‐free regions of the mammalian genome. In future, it may be possible to adapt these techniques in order to experimentally estimate the proportion of non‐coding variants that possess enhancer activity, thus suggesting potential mechanisms in high‐throughput experiments.Variants are often described as enriched with enhancer or promoter marks and In vitro gel shift experiments can demonstrate interaction with specific proteins in vivo TF binding is assayed using ChIP‐seq, if cells from the individual with the desired genotype are available through recall‐by‐genotype or the generation of iPSC lines Interaction of a variant sequence with a protein can be indicative of function, and disruption of these binding sites can influence gene expression. GWAS studies in complex traits and diseases including blood phenotypes and disorders have until now mainly targeted genetic variants that are relatively common in the general European population (MAF>5%). However, associated common variants across all traits have only accounted for less than 10% of genetic heritability in blood cell traits, despite large sample sizes and dense genotyping. With decreases in cost of whole‐genome and whole‐exome sequencing, the reach of association studies should soon extend to low frequency and rare variants with intermediate to large effect sizes, and more exhaustive evaluations of structural variation  New studies suggest that epigenetics and not genetics may contribute a substantial component of trait heritability in vivo HSC differentiation in vitro, the derived cells are not the exact equivalent of bone marrow‐derived blood cells in terms of their full genomic and epigenetic character and even functionality.Advancing technologies to expand and differentiate pluripotent stem cells into various somatic tissues including blood cells  will provide the means to vastly increase the number of discovered loci. Full description of traits including white blood cell differentials also increases the power of these studies to discover new loci. We now have all the tools in place to improve our understanding of not only the haematopoietic system but also, more generally, the functional consequences of sequence variation and their contribution to complex human traits.Table S1. Summary findings of 23 published GWAS studies in haematological traits. For variant annotation, we used ANNOVAR and GENCODE.Click here for additional data file.


The symposium entitled “Non‐selective cationic channels in chemical and physical stress?”, which took place at Physiology 2015 in Cardiff, UK, 6–8 July 2015, lasted two hours and comprised five talks by invited speakers from France, Spain, the UK and USA who presented engagingly and informatively on concepts and new findings for seven proteins which assemble into what are thought to be seven distinct broadly expressed non‐selective cationic channels: polycystin‐2 channels, Piezo1 and Piezo2 channels, TRPA1 channels, TPC1 and TPC2 channels, and TRPM2 channels. The session was very well attended and the atmosphere vibrant; members of the audience had to resort to standing, reflecting the high level of interest in the speakers’ work and the intriguing nature of these proteins in physiology.3) receptors. She spoke about hypotheses for how mutations in the polycystin‐2 gene might lead to cysts in the kidney, showing interesting 3‐D culture results which suggested that loss of IP3 receptor functionality might mediate cyst formation. In the question time there was discussion about how this might arise via changes in polycystin‐2. Her zebrafish and murine studies suggested unexpected roles also in cardiac physiology. Barbara's review with her colleague Yifei Yang nicely summarizes current perspectives on the structural aspects of these channels , he persuasively made the case for rapid actions of LPS on TRPA1 independently of TLR4. New data on lipid A further strengthened the case. His review article provides state of the art analysis of the field Viana, .et al. Samantha Pitt from St Andrews took us back to intracellular membranes: this time, the lysosomal membrane and two‐pore channels formed by TPC1 and TPC2. She explained her ideas about how the channels might have distinct functions in the lysosome, suggesting important proton permeability of TPC1 channels. She showed strong pharmacological differences between the channels and raised the possibility that ion selectivity might be modulated by the lipid composition of the lysosomal membrane. She took us through current controversies in the field and proposed a model to bring together apparently contradictory findings; keen discussion followed in the question session. Her review article with colleagues Benedict Reilly‐O'Donnell and Rebecca Sitsapesan puts down in writing several of the key challenges of this hot topic (Pitt Last but not least, Barbara Miller from Penn‐State brought us back out from the inside of the cell to the plasma membrane, or so we thought. She spoke about her interest in the TRPM2 channel and took us on a journey from what has been classed as a bad channel – a channel of cell death – to a channel which we need and which protects our cells from death. She described how she found deleterious effects of cardiac‐specific knock‐out of TRPM2 in mice subjected to ischaemia–reperfusion, suggesting a protective role of the channels in this stressful context. To explain the findings she developed a compelling case for an intimate relationship between calcium permeability in TRPM2 channels, mitochondrial calcium uptake and reactive oxygen species. Her follow‐up review with Joseph Cheung elegantly presents the case and its wider context (Miller & Cheung, et al. So, in the heart of Wales we watched how the ionic dragon fared in the physiologist's den. We wondered at how easily it beguiles and pondered over how we might better understand it. I thank the speakers and audience for making the symposium such a pleasure and I already find myself looking forward to the next time. Whether you could attend or not, I hope you enjoy and learn from the excellent reviews provided by participating speakers (Miller & Cheung, None declared.


Cumulative evidence indicates increasing HIV infection among married individuals. Voluntary Counselling and Testing for HIV (HCT) is known to be an effective intervention to induce safer sex behaviour and access to early treatment, care and support among married individuals, which are important for HIV prevention. In this context, knowledge of factors associated with HCT uptake among married individuals is critical in promoting the use of the services. This study therefore intended to identify the social cognitive factors associated with acceptance of HCT among married individuals.In a cross-sectional analytical study face to face questionnaires were administered among 200 randomly selected married individuals in Kinondoni district, Dar es Salaam Tanzania. The questionnaire included self-reported HCT, socio-demographic variables and social cognitive variables . Logistic regression was used to identify the independent association of social cognitive predictors of HCT among married individuals.Nearly half (42%) of the respondents had never had HCT. Of the social cognitive constructs, the strongest predictor of HCT uptake was attitude  followed by perceived behavioural control . Subjective norm and perceived risk were not associated with HCT uptake.Public health interventions targeting married individuals should be designed to enhance their positive attitude towards HCT and empower them to overcome barriers to the use of the services. More evidence in sub-Saharan Africa (SSA) indicates the shift of HIV infections being primarily contracted by people who are in casual relationships to those in stable relationships -3. SpeciTesting and Treatment for every HIV-infected person as soon as diagnosis is done [Evidence indicates that HIV counselling and testing (HCT) is effective in reducing the risk of HIV transmission among married partners. For instance, access to HCT has been reported to contribute in reducing the number of sexual partners and increasing condom use with spouses for both HIV-negative and HIV-positive respondents -12. HCT  is done ,14. The  is done ,16.Despite ample evidence on the significance of HCT and the widespread HCT services, most married individuals are unaware of their sero-status -19 and lBeliefs, contextual and social barriers have been associated with HCT uptake among adults. These include: a belief that discordance cannot exist within couples , educatiAlthough numerous researchers have investigated the barriers to HCT uptake among adults with the scaling-up of these services, to date, very few studies have used theoretical model in explaining HCT uptake among married individuals. To the best of our knowledge, this is the first study to apply the TPB in a population of people in steady relations. Guided by the theory of Planned Behaviour (TPB) this study contributes to the existing knowledge by examining the social cognitive correlates of HCT uptake among married individuals.The TPB  is a socThe TRA is composed of two constructs; attitude and subjective norms, considered as immediate determinants of behaviour performance . TRA assThe TPB has been widely tested and validated in various social cultural contexts including Tanzania -37, and A cross sectional survey was conducted between May and June, 2010 among married individuals living in Kinondoni district in Dar es Salaam municipality, Tanzania. Dar es Salaam is located on the eastern coast of Tanzania and is a centre of commercial and social activities. Kinondoni is a multi-ethnic district with a population of 1,083,913 , locatedThe study involved married individuals aged 18 years and above. We only considered married individuals living with their spouses at the time of study and selected the age of 18 years and above since this is the legal age for marriage in Tanzania . To avoiKiswahili, the national language which is widely spoken and understood in Tanzania. This questionnaire had been translated from English to Kiswahili and back-translated to ensure validity of the language used. The interviews were conducted by trained and experienced research assistants in a location within the household preferred by the respondent. Participants were asked about their social demographic information  and their opinions with regards to the theoretical constructs under study .Face to face interviews were conducted with eligible married individuals using a pre-tested questionnaire. The questions were administered in In this study we defined married individuals as those (a man and a woman) who were in marital or cohabiting relations. Reported use of complete HCT by individuals was the main dependent variable. Complete HCT was defined as having gone through all three of the components of HCT, i.e. pre-test counselling, HIV test and receiving results following post-test counselling . IndividConstructs  from the TPB and one construct from the HBM (perceived risk) were the main variables of interest in this study. The items used to measure theoretical construct variables were adopted from previously used items in a study on HCT behaviour among teachers in Tanzania . To incrWe assessed attitude by asking respondents to indicate the extent to which they think that HCT is likely to provide certain benefits (behaviour beliefs) and the extent to which they think that if they use the HCT the indicated benefits are going to occur (belief outcome). We used items of ‘behavioural beliefs’  together with those of ‘outcome evaluation’ (belief outcomes) to compose attitude. ‘Behaviour beliefs’ comprised the following statement; please tell me the extent to which you think your use of HCT services is likely to: avert your chances of HIV infection, make it possible for you to avoid transmitting HIV to a spouse, result in a happy life if test results are negative, help you plan confidently for their future and facilitate your seeking of anti-retroviral therapy (ARVs) if HIV test results are positive. Respondents were asked to indicate their opinion to the statements based on valuation of the following items ranging from 1 = Not likely at all, 2 = unlikely, 3 = not sure, 4 = likely, 5 = very likely. ‘Belief outcome’ was assessed by asking the respondents to rate how good or bad they thought that visiting a HCT centre would be important. The evaluation scores ranged from 1 = extremely bad, 2 = bad, 3 = Not sure, 4 = good, 5 = extremely good. To calculate the attitude scale, each item of ‘behavioral belief’ score was multiplied with items of ‘outcome evaluation’ score, to calculate the attitude scale. And later the summation of the total scores was generated. Number ‘1’ indicated a least favourable attitude and number ‘5’ more favourable attitude towards HCT services. Such that the higher the scores the more favourable attitude towards HCT. The same process was applied in other social cognitive variables.In this study, subjective norm denoted a respondent’s perception of significant others’ opinions on whether one should or should not use the HCT. We asked respondents to indicate the extent to which they thought their spouses/partner, in-laws, children, relatives, religious leaders, best friend, counsellors, doctors, parents, best man or best lady for your wedding and neighbours would be likely to endorse their use of HCT (normative beliefs). A five Likert scale comprised of 1 = not likely at all, 2 = unlikely, 3 = not sure, 4 = likely, 5 = very likely, was used to assess respondents opinions. Respondents were also asked to rate the extent to which they thought it was important for them to comply with the wishes of their referents (Motivation to comply). Respondent’s opinions were assessed using the following items: 1 = not important at all, 2 = not important, 3 = not sure, 4 = important, 5 = very important.Perceived behaviour control reflected the respondent’s perception with regards to their capacity to overcome barriers for using HCT. Respondents were asked to indicate their opinion on the extent to which the following items would deter them from using the HCT services: cost related to HCT testing was high, they will die more quickly if tested positive for HIV, HCT service providers cannot keep the test results confidential, you would be stigmatized if you are known or suspected to be HIV-infected (control beliefs). The scale measurement comprised of 1 = not at all, 2 = not, 3 = not sure, 4 = much, 5 = very much. Then, we asked respondents to rate how difficult or easy was it for them to use the HCT services next time they go for a health facility if the above barrier items under ‘control beliefs’ were true (power of control). The scale measurement comprised of 1 = very difficult, 2 = difficult, 3 = not sure, 4 = easy, 5 = very easy.We measured perceived risk by asking respondents to indicate the extent to which they considered AIDS as a threatening disease. The scale items comprised of 1 = not likely at all, 2 = unlikely, 3 = not sure, 4 = likely, 5 = very likely. Then, respondents were asked to indicate the extent to which they disagreed or agreed with the following statements; ‘AIDS is a dangerous disease’, AIDS is a dangerous disease in Tanzania’, ‘AIDS is a dangerous disease in your communities’, AIDS is a dangerous disease among married individuals’, ‘AIDS is a dangerous disease to you. The scale items comprised of 1 = strongly disagree, 2 = disagree, 3 = not sure, 4 = agree 5 = strongly agree.t-test was used to compare their mean scores across categories of HCT uptake. Finally, we performed multivariable analysis using logistic regression to assess independent factors associated with HCT uptake among married individuals in the study area. Selection of variables for multivariable analysis was based on their ability of each one to improve the model. This was tested using the log-likelihood ratio test [We performed descriptive analyses for all the categorical variables using frequencies and percentages. We then conducted bivariable analysis to assess the extent of HCT uptake by each of the independent variables. We used Chi-square test to test the degree of association between HCT and each of the categorical independent variables. For continuous predictors, specifically attitude, subjective norm, perceived behaviour control, and perceived risk, tio test  on conseWritten informed consents were sought from the participants prior to interviews. We did not interview a husband and a wife from the same household. Prior to interviewing a spouse of a head of household, the household head was asked for consent for the interviews to be conducted in the household. In the context where the respondent was the head of the household, s/he only provided own consent to participate in the study. The Ifakara Health Institute’s Institutional Review Board (IRB) approved the study.A total of 200 married individuals participated in the study (97.4% response rate). As presented in Table Table Table Table Guided by the TPB model, in this study, we identified the social cognitive factors associated with HCT uptake among married individuals. Attitude towards HCT and perceived behavior control were the main TPB constructs that contribute significantly to HCT uptake among married individuals in the study area. These findings are similar with previous studies conducted in Ethiopia and Tanzania. A study done in Ethiopia found that among the high school teachers, attitude accounted for a significant proportion of variability for intention to use HCT services followed by PBC . AnotherAs indicated in the present study, attitude was the most important predictor of HCT uptake than other TPB constructs. This implies that attitude towards HCT plays an important role in the use of HCT services and that individuals within marital unions are likely to use the HCT services if they develop a favourable opinion about the values of HCT services. The reason for this may be that married individuals may have feelings that they are safer since they live in dyadic committed relationship. They may also have optimistic bias in terms of perception about their susceptibility to HIV infection such that decision to use the HCT services would be most likely to be influenced by what they perceive to be the benefits of their participation in HCT services rather than their susceptibility to HIV infection. This may also be a possible explanation on the non-significant association of perceived risk and HCT uptake among married individuals as found in the present study. A favourable opinion towards HCT services among married individuals could be attained if the benefits and values of HCT services such as ability to avert HIV transmission within and outside the marriage, early access to treatment and support programmes are integrated in the HCT promotion messages targeting married individuals rather than simply instructing spouses to go for HCT.We found perceived behavioral control to be another strong determinant for HCT uptake among married individuals. Perceived behavioral control was shown to be a significant predictor of the intention to use HCT among teachers in Tanzania  and in EThe subjective norm construct, which was not a significant predictor of HCT uptake in this study, was found to be the strongest predictor of intention for HCT among the health professionals in Ethiopia . This diThe findings that subjective norm and perceived risk were not associated with HCT uptake, might be explained by married individuals’ feelings of being safe in their marriage. This may influence their general perception of how risky HIV is at different levels. Married individuals might also feel that for the decision to use the HCT services they may not need an influence of significant others.The study relied on self-reports by the married individuals. This may have led to reporting bias. However, this was minimized because during the informed consent processes spouses were assessed to check whether they understood the essence of the study and they committed to provide information relevant for the study. We also couples from different households which could have enhanced the reliability of the information. Also the completeness of the data set suggests that this may not have been a significant limiting factor.No causal inferences may be drawn from these findings because of the cross-sectional design of our study. We thus recommend future studies to use powerful designs with which temporality in the association is possible to assess.Our results clearly suggest that attitude and perceived behaviour control are the social cognitive factors that determine HCT uptake among married individuals. Subjective norms and perceived risk of contracting HIV had no influence on the use of HCT among the study participants. It is thus recommended that public health programmes should be designed to enable married couples to attain a positive attitude towards the HCT services. One possible way is for the educational messages to clearly promote the benefits of HCT services instead of instructing couples to use the services. Furthermore, education programmes should be designed to empower individuals to attain a sense of capacity to overcome barriers to the use of the HCT services. This need to be accompanied by providing a supportive environment for couples to undergo counselling and testing, which may include free HCT services, couple friendly HCT, antiretroviral treatment for the infected partners, addressing stigma related to HIV testing and enhancing social support.


Unacceptably high levels of preventable maternal mortality persist as a problem across sub–Saharan Africa and much of south Asia. Currently, local assessments of the magnitude of maternal mortality are not often made, so the best available information for health planning may come from global estimates and not reflect local circumstances.A community–based cross-sectional survey was designed to identify all live births together with all deaths among women aged 15–49 years retrospectively over a one–year period in six randomly selected districts of Tigray Region, northern Ethiopia. After birth and death identification, Health Extension Workers trained to use the WHO 2012 verbal autopsy (VA) tool visited households to carry out VAs on all deaths among women aged 15–49 years. All pregnancy–related deaths were identified after processing the VA material using the InterVA–4 model, which corresponds to the WHO 2012 VA. A maternal mortality ratio (MMR) was calculated for each District and expressed with a 95% confidence interval (CI).2 = 0.86).The MMRs across the six sampled Districts ranged from 37 deaths per 100 000 live births (95% CI 1 to 207) to 482 deaths per 100 000 live births (95% CI 309 to 718). The overall MMR for Tigray Region was calculated at 266 deaths per 100 000 live births (95% CI 198 to 350). Direct obstetric causes accounted for 61% of all pregnancy–related deaths. Haemorrhage was the major cause of pregnancy–related death (34%). District–level MMRs were strongly inversely correlated with population density (rThis simple but well–designed survey approach enabled estimation of maternal mortality in Tigray Region on a local, contemporary basis. It also provided insights into possible local variations in MMR and their determinants. Consequently, this approach could be implemented at regional level in other large sub–Saharan African countries, or at national level in smaller ones to monitor and evaluate maternal health service interventions. Maternal mortality is one of the most sensitive indicators of the health disparities between poorer and richer nations, but also one of the most difficult health outcomes to measure reliably. Many estimation exercises and much debate have occurred around persistently unacceptable levels of maternal mortality in the world’s poorer countries, not least in relation to the fifth Millennium Development Goal (MDG5) . HoweverIn an ideal world, all maternal deaths would be routinely registered, but in reality civil registration of deaths with cause is extremely scanty in sub–Saharan Africa and south Asia, where most maternal deaths occur . ConsequThe alternative approach, for a country or a region, is to undertake direct measurement of maternal mortality, in order to inform health service management and planning, and to provide strategic insights in terms of necessary interventions. We characterize this as a “bottom–up” approach. Despite high top–down MMRs reported for Ethiopia ,7, no cuTherefore, the aim of this study was to undertake a bottom–up assessment of maternal mortality for Tigray Region, in northern Ethiopia, identifying overall levels, specific causes and local determinants, and to compare the findings in relation to the various top–down estimates of maternal mortality that are available for Ethiopia.2, with a mean population density of 102 km–2. The maximum distances within the Region are 360 km east–west and 250 km north–south, and altitude above mean sea level varies between 600 m and 3950 m. The Region contains 1 165 575 households (HH), with an average of 4.4 persons per HH . Health services in the Region are administered in six rural Zones, which are further divided into 34 Districts , each containing about 25 000 to 30 000 HHs  as a stratified sample of one District per Zone, as shown in The study was conducted in six rural Districts in Tigray region, namely Welkayat, Laelay Adiyabo, Tahtay Maychew, Saesi Tsaedaemba, Hintalo Wajirat and Alamata, which were randomly selected  model, using probabilistic modelling to assign cause of death instead of physicians ,18. ThisEthical approval for the study was granted by the Institutional Review Board (IRB) of the College of Health Sciences of Mekele University, Ethiopia.A total of 181 deaths among women of reproductive age and 19 179 live births were identified in the six selected Districts within the 12–month study period. Of the 181 deaths, 51 (28%) were ascertained as pregnancy–related deaths. 2 = 0.86, P = 0.005), as shown in In contrast to these bottom–up results, The major findings from this study were a new assessment of MMR for six districts in the Tigray Region at 266 deaths per 100 000 live births (95% CI 198–350), and an indication of possible wide variations between the sampled Districts. The confidence interval for the six districts’ MMR overlaps the uncertainty intervals for the UN national estimates for Ethiopia, which reported 350 deaths per 100 000 live births  for 2010  and 420 Findings on MMR in this study were much lower than those from various rounds of the Ethiopian Demographic and Health Survey (EDHS), which reported an MMR of 676 per 100 000 live births (95% CI 541–810) for the period 2005–2011 , even thTigray Health Bureau has introduced a number of innovations targeted at reducing maternal mortality in recent years. These include leadership commitment and innovative approaches to supporting organized community mobilization for health. A woman–centred “one to five network” encourages every woman of reproductive age to engage voluntarily with small, local groups of neighbouring women (with 30 households on average being organized into a “Women’s Development Team”). Health facilities are being made more friendly to community members, preparing pregnant mothers for skilled delivery and post–natal care through monthly meetings, establishment of maternity waiting rooms, and offering traditional Ethiopian coffee ceremonies at delivery facilities. There is substantially increasing coverage of four–wheel drive ambulance services in every District, as well as “traditional ambulances” . Additionally, one or two midwives trained in basic emergency management of neonatal care (BEMONC) have been assigned for every 25 000 population and basic emergency obstetric services like emergency surgery units placed in primary hospitals (designed to provide comprehensive preventive and curative service for every 100 000 population) are substantially more accessible than previously .Our study showed that the majority of pregnancy–related deaths  occurred at home. This finding is comparable with studies conducted in India  and otheIndirect causes of maternal mortality are difficult to account for using verbal autopsy methods because of the need to make a judgment about the extent to which final illnesses might be ascribed to pregnancy. Garenne and colleagues have discussed the relevance of the concept of indirect maternal mortality, particularly in relation to the impact of HIV infection on pregnancy–related mortality . Consequkebeles) did not have Health Extension Workers in place. The high turnover of health workers due to difficult living environments and less participation by development partners such as non–governmental organizations and faith–based organizations may lead to higher MMRs in remote areas. Maternal deaths were reported to be clustered in one district in another study conducted in Artibonite, rural Haiti [The wide variations in MMR across the six Districts surveyed were somewhat surprising. Some of this variation might be accounted for by factors such as remoteness of some Districts, with hard–to–reach and scattered populations, which in turn might lead to limited access to health services, transport and other infrastructure. In Welkayat District, which recorded the highest MMR, five sub–districts . The correlation we found between MMR and population density suggests that logistic factors remain a major determinant of maternal mortality in Tigray. The majority of pregnancy–related deaths, as determined using the WHO 2012 and InterVA–4 verbal autopsy tools arose from potentially preventable causes. This highlights the need to provide preventive and emergency obstetric care that is not only clinically effective but also accessible. The use of community mass media to increase the awareness of mothers about the advantages of skilled delivery services and involvement of male decision–makers regarding maternal health services also need to be given priority. Additionally, providing better incentives for health workers to stay in the more remote areas, and enhancing the ambulance system in those areas, should ensure a better and more sustained service.


Aboriginal and non‐Aboriginal men and to describe prostate cancer treatments received by Aboriginal men.To compare prostate cancer mortality for New South Wales (NSW) in 2001–2007 linked to hospital inpatient episodes and deaths. More detailed information on androgen‐deprivation therapy and radiotherapy was obtained from medical records for 87 NSW Aboriginal men diagnosed in 2000–2011. The main outcomes were primary treatment for, and death from, prostate cancer. Analysis included Cox proportional hazards regression and logistic regression.We analysed cancer registry records for all men diagnosed with prostate cancer in Aboriginal men among 35 214 prostate cancer cases diagnosed in 2001–2007. Age and spread of disease at diagnosis were similar for Aboriginal and non‐Aboriginal men. Prostate cancer mortality 5 years after diagnosis was higher for Aboriginal men  12.4–23.3) than non‐Aboriginal men . Aboriginal men were 49% more likely to die from prostate cancer  after adjusting for differences in demographic factors, stage at diagnosis, health access and comorbidities. Aboriginal men were less likely to have a prostatectomy for localised or regional cancer than non‐Aboriginal men . Of 87 Aboriginal men with full staging and treatment information, 60% were diagnosed with localised disease. Of these, 38% had a prostatectomy (± radiotherapy), 29% had radiotherapy only and 33% had neither.There were 259 Aboriginal men with prostate cancer compared with non‐Aboriginal men. In the meantime, ongoing monitoring and efforts are needed to ensure Aboriginal men have equitable access to best care.More research is required to explain differences in treatment and mortality for  Prostate cancer is the most commonly diagnosed cancer and the third most common cause of cancer death in Australian men The optimal management of localised prostate cancer is difficult to define as evidence showing a clear survival benefit of one treatment over another is sparse The aim of the present study was to investigate differences in prostate cancer‐specific mortality in Aboriginal and non‐Aboriginal men diagnosed with prostate cancer, and to explore how various factors, including treatment patterns, might contribute to mortality differences. An additional objective was to describe in more detail the staging and primary treatment for Aboriginal men diagnosed with prostate cancer through medical record review.We respectfully use the descriptor ‘Aboriginal’ throughout this paper to refer to the original people of Australia and their descendants, as endorsed by the Aboriginal Health and Medical Research Council of NSW and NSW Health 2004 Linked datasets from two studies were analysed: the NSW Population‐wide Study (2001–2007), which included NSW Central Cancer Registry (CCR) records of incident prostate cancers in NSW linked to hospital and death records, and the Patterns of Primary Treatment Study (2000–2011), which was an audit of the medical records of Aboriginal men diagnosed with prostate cancer linked to CCR and hospital records. Eligible patients for both studies were diagnosed with primary prostate cancer (ICD‐0‐3 topography code ‘C61’ and morphology codes with a suffix of ‘3’), aged ≥18 years and resident in NSW at diagnosis.Demographic and disease information for all eligible men diagnosed with prostate cancer in 2001–2007 (37 271 men) was obtained from the CCR. Cases were matched by the Centre for Health Record Linkage (CHeReL) with inpatient records from the NSW Admitted Patient Data Collection (APDC), death records from the NSW Registry of Births, Deaths and Marriages (RBDM), and cause of death data from the Australian Bureau of Statistics (ABS). As this was a study of care and outcomes for men with prostate cancer, we excluded 375 men with death certificate or autopsy notification only and an additional 1682 men who did not link to APDC records. In this analysis a man with prostate cancer was determined to be Aboriginal if he was listed as Aboriginal in any of his records.The CCR data included month and year of diagnosis, age and spread of disease at diagnosis categorised as localised, regional, distant and unknown. Based on the Local Government Area of residence at diagnosis men were assigned to geographical location categories according to the Accessibility/Remoteness Index for Australia (ARIA+) Analysis of treatment was restricted to surgical treatment as the APDC has been shown to be an incomplete source of information for other treatment methods All analyses were performed using SAS statistical software  and R 2.15.1 Prostate cancer‐specific mortality was analysed using cumulative incidence curves Logistic regression was used to identify variables that significantly influenced the odds of having a prostatectomy within 12 months of diagnosis. The fully adjusted model included the following variables: Aboriginal status, age at diagnosis, year of diagnosis, spread of disease, comorbidities, socioeconomic disadvantage and place of residence. We tested for interactions between Aboriginal status and the other variables.We collected medical records for Aboriginal people resident in NSW diagnosed with any cancer in 2000–2011. Data were collected from 23 public hospitals and three clinical cancer registries for 1324 people of whom 87 were Aboriginal men with prostate cancer. We estimate there were about 407 Aboriginal men diagnosed with prostate cancer in NSW in that period. Records for these 87 men were linked by the CHeReL to CCR and APDC records for additional information.Information collected included age, year of diagnosis, spread of disease, place of residence and comorbidities. Tertiles of socioeconomic disadvantage and ARIA+ category were assigned using postcode of residence. PSA levels and Gleason score at diagnosis were recorded. We also recorded start and end dates for treatments received . We collected and merged data for men who attended multiple hospitals.Of the 35 214 eligible men, 259 (0.7%) were identified as Aboriginal  compared with non‐Aboriginal men  . After adjusting for all covariates the HR for prostate cancer death in Aboriginal men, relative to non‐Aboriginal men, was 1.83 (95% CI 0.92–3.24) for localised disease, 3.66 (95% CI 1.13–8.63) for regional disease, 0.75 (95% CI 0.34–1.41) for distant disease and 1.81(95% CI 1.11–2.76) for men with unknown spread of disease.There was a significant interaction between spread of disease and Aboriginal status  and regional (47% vs 62%) disease, although the difference for regional disease was not statistically significant Table . The medP < 0.05.Aboriginal men were significantly less likely than non‐Aboriginal men to receive prostatectomy for localised or regional disease after accounting for differences in age at diagnosis, year of diagnosis, spread of disease, comorbidities, socioeconomic disadvantage and place of residence at diagnosis . No interaction between Aboriginal status and any other variable had a Most of the 87 Aboriginal men in this study (56%) were aged 60–69 years when diagnosed Table . In all,The men in the ‘Patterns of Primary Treatment Study’ were on average younger, more likely to live in rural and more disadvantaged areas and had later stage disease than Aboriginal men in the NSW Population‐wide Study Tables  and 2.It is notable that 41% of the Aboriginal men received neither surgery nor radiotherapy Table  for theiOf the 36 men who received neither prostatectomy nor radiotherapy, most (58%) were treated with ADT within 12 months of diagnosis, while 28% men did not receive ADT and five had no information available.The risk of death from prostate cancer was higher in Aboriginal men than non‐Aboriginal men diagnosed with prostate cancer in NSW. Differences in age at and year of diagnosis, spread of disease, treatment with prostatectomy, place of residence, socioeconomic disadvantage and comorbidities did not fully explain this disparity. We found that Aboriginal men were significantly less likely than non‐Aboriginal men to receive prostatectomy for localised or regional disease after accounting for differences in demographic, disease, and health‐access factors and comorbidities. We also found that 33% of Aboriginal men diagnosed with localised prostate cancer received neither surgery nor radiotherapy early in the disease course, and this was true regardless of the pathologically assessed disease recurrence risk. In comparison, in a 2000–2002 study of NSW men aged <70 years with localised prostate cancer, 20% received neither surgery nor radiotherapy Diagnosis with more aggressive disease is another possible explanation for a higher risk of death in Aboriginal men. Aboriginal men in our Patterns of Primary Treatment Study had a higher median PSA level at diagnosis (10.9 ng/mL) than found in other Australian population studies  is another limitation to our present findings. It cannot be assumed that the disease characteristics of men in the ‘unknown stage’ group are similar in Aboriginal and non‐Aboriginal men or that their expected outcomes would be similar. Using administrative datasets means that detailed clinical information that could be used to stratify the men into risk categories or describe their PSA testing history was not available. A further limitation is the potential under reporting of comorbidities in the hospital records, although diabetes has been shown to be reasonably reliably recorded The Patterns of Primary Treatment Study has some limitations. While the present study, to our knowledge, is the most detailed study of Aboriginal patterns of prostate cancer care conducted, it was small and had limited coverage of all hospitals that treat prostate cancer, and thus may not be representative of the treatment of all NSW Aboriginal men with prostate cancer.Previous research into prostate cancer treatment patterns for Aboriginal men is limited to one older Western Australian study, which also showed that Aboriginal men had lower rates of prostatectomy than non‐Aboriginal men Larger and more detailed population‐based studies of Australian Aboriginal men with prostate cancer are needed to investigate if the mortality disparity we observed is due to differences in diagnosis, aggressiveness of disease, treatment received or other factors; and if there is a treatment disparity, why. Ideally, ongoing population‐based monitoring of prostate cancer treatment and outcomes in NSW, which is already available in the Australian state of Victoria In conclusion, Australian Aboriginal men diagnosed with prostate cancer are at higher risk of subsequent death from prostate cancer than other Australian men. Adjustment for demographic, disease stage at diagnosis, having surgical treatment or comorbidities did not explain this disparity. However, Aboriginal men appear less likely to have surgery or radiotherapy when diagnosed with prostate cancer than other Australian men. Further research on, and ongoing population‐based monitoring of, prostate cancer treatment and outcomes are required to understand and address the reasons for these disparities. In the meantime, efforts are needed to ensure Aboriginal men have equitable access to best care when diagnosed with prostate cancer.This work was produced as part of the APOCC, which was funded by a National Health and MRC Health Services grant (Application Ref: 440202). Linkage of the ‘Patterns of Primary Treatment’ data set to the APDC was funded by a Cancer Institute NSW Epidemiology Linkage Grant (10/EPI/2‐05).The ‘Patterns of Primary Treatment Study’ was approved by the Human Research Ethics Committees of the Royal Prince Alfred Hospital and the AH&MRC. Local Regional Governance Offices granted site‐specific approval for data collection in participating hospitals and CCRs. The ‘NSW Population‐wide Study’ and linkage of the ‘Patterns of Primary Treatment Study’ to the population datasets were approved by the NSW Population and Health Services Research Ethics Committee and the Human Research Ethics Committee of the AH&MRC.All authors have no conflicts of interest to declare.ABSAustralian Bureau of StatisticsADTandrogen‐deprivation therapyAH&MRCAboriginal Health and Medical Research Council of NSWAPDCAdmitted Patient Data CollectionAPOCCAboriginal Patterns of Cancer Care ProjectARIA+Accessibility/Remoteness Index for AustraliaCCRCentral Cancer RegistryCHeReLCentre for Health Record LinkageHRhazard ratioNSWNew South WalesORodds ratio


Data gathering and optimal path selection for wireless sensor networks (WSN) using existing protocols result in collision. Increase in collision further increases the possibility of packet drop. Thus there is a necessity to eliminate collision during data aggregation. Increasing the efficiency is the need of the hour with maximum security. This paper is an effort to come up with a reliable and energy efficient WSN routing and secure protocol with minimum delay. This technique is named as relay node based secure routing protocol for multiple mobile sink (RSRPMS). This protocol finds the rendezvous point for optimal transmission of data using a “splitting tree” technique in tree-shaped network topology and then to determine all the subsequent positions of a sink the “Biased Random Walk” model is used. In case of an event, the sink gathers the data from all sources, when they are in the sensing range of rendezvous point. Otherwise relay node is selected from its neighbor to transfer packets from rendezvous point to sink. A symmetric key cryptography is used for secure transmission. The proposed relay node based secure routing protocol for multiple mobile sink (RSRPMS) is experimented and simulation results are compared with Intelligent Agent-Based Routing (IAR) protocol to prove that there is increase in the network lifetime compared with other routing protocols. Wireless sensor network is self-organized, scattered, sensing, and data propagation network. Nodes are resource constrained tiny autonomous devices. They are used to sense the environmental conditions in their immediate surroundings and transmit the data to the sink . WSN canData Gathering Using Mobile Sink. Data gathering using mobile sink minimizes the precious sensor node energy. The effectiveness of it can be determined by the total sensor energy saved and the time saved in gathering the sensory data from its field or from the trajectory length of the mobile sinks  is the primary and a daunting task because of its characteristics such as unreliable wireless communication, constraints with respect to the resources, unknown topology, and unprotected environment. The primary security goals here would be to maintain data confidentiality by not leaking data to neighboring node, to provide data freshness, and to provide high availability and authenticity by verifying that the data is always sent by an authentic source.Kim et al.  proposedSimilarly,  have higIn one attempt, the mobile sink is a moving strategy based on remaining energy of the sensor nodes which balance the network workload and increase the network life time . ConsequReference , proposeReference  uses an An alternative protocol to minimize the energy consumption and overhead during the data retrieval process is proposed in . AdaptivA new data gathering scheme named as Maximum Amount Shortest Path to increase the network throughput and to save energy by efficiently assigning the sensor nodes is discussed in . A weighIn , a modelBased on the literature review of the mobile sinks, this paper proposes a protocol called relay node based secure routing protocol for multiple mobile sink, which is used for data gathering, and the simulation results are compared with IAR protocol. The results are demonstrated in such a way that the proposed protocol performs better in terms of performance metrics like delivery ratio and energy efficiency and reduces the delay and overhead in the WSN.The reminder of the paper is prepared in such a way that Reference  proposedThis process can be enhanced for multiple numbers of sinks and designing an efficient routing protocol for data gathering. Here a relay node based secure routing protocol using multiple mobile sink for data gathering for WSN is proposed.The source and sink know their location. It is also assumed that multiple sinks move in the network. The proposed architecture is shown in  S be the source node.Let  D be the sink node.Let  Let QP be query packet. mr be rendezvous point.Let ReP i be the relay node.Let RN n be the new relay path.Let RP o be the old relay path.Let RP Let RP_seq be the sequence number of relay path. Let RP_mes and R_CLR be the relay path setup and clear message with RP_seq.(1)mr) is selected.If event occurs, initially, a rendezvous point (ReP(2)mr once the event occurs.Then sink has to transmit QP to ReP The fields in the QP are represented as the following: Sink ID. Hop count. Transmitter distance.(3)mr broadcasts the QP with hop count counter value as zero.ReP(4)mr is estimated that is in one hop communication distance.When the neighboring nodes receive the QP, they rebroadcast the packet by incrementing hop count counter by 1. Thus, as this query propagated, new hop node towards ReP(5)If next new hop node > 1, Then  Two nodes compare the packets arrival time (Tpa) The new next hop node with earlier Tpa is chosen  End if Source transmits the path request message (P_REQ) to all its neighbors and the neighbor, node that sends the (P_REP) is chosen as next new hop node. D move in its radio range of RePmrIf  Then D receives the collected data from the RePmr. Else D chooses RNi from its neighbor nodes to transmit the data from RePmr to sink. (Relay node selection) End if D is selected as RN.Here, the node, which is nearest to (6)S to generate the data reports.If an event occurs, Ni enclosing it collectively processes the signal. One among the nodes becomes (7)S matches the data sent by QP, the data is forwarded to one hop distance node.When (8)If the next new hop node is failed or its battery is exhausted Then S chooses the respective Neighi as next new hop node. End if.D for predefined time interval T, it suspects that they are out of the coverage radio range. In order to prevent this action, the following steps are executed. (i)mr transmits at least one packet at interval of T/n period (n is integer).ReP(ii)mr does not have data to send in T/n duration, it transmits NULL packet. Thus, when S does not receive the data packet for T, it performs the following actions to select the relay node.If ReP(1)i: Relay node request message (R_REQ) is sent to its Neigh(2)i node will reply to the sink:Neigh(3)Sink chooses the node which is nearer to it as immediate relay node.(4)The relay path message is sent through IRN:(5)mr receives the RP_mes, data packets are transmitted in the path traversed by RP_mes. This relay path is flagged with RP_seq.When ReP D moves away from radio range or after completing its relay path setup, there may be possibility of packet drop. This is prevented by RePmr by caching the overhead packets which are transmitted to D. The cached packets are routed to D when RePmr receives RP_mes.The following is noted: When (6)D is again away from its transmission range of IRNi, then it selects new IRNi (as per step (3)).If (7)D then transmits RP_mes to RePmr through the newly selected IRNi in separate relay path RPn which is flagged with RPn_SEQ.(a)mr receives relay path setup message,When RePo exists for the same sinkIf RP Then  End ifmr send R_CLR message along RPo which is flagged with RPo_SEQ.When old relay path exists, then ReP(b)o state. RPo state is maintained until the path receives R_CLR for RPo. When the relay path gets a new RP_mes, then it does not remove the RPWhen data packets are not received by  Si.Secret key of the sensor node is  Ss.Secret key of the sink node is  Ssh.Shared key is  Ni.Prime number is  Code for sink authentication is CSA. Code for node authentication is CNA. Code for message authentication is CMA. d.Cipher text data is CT H.Hash function is Security protocol securely gathers the sensed data and transmits it to the sink. In this proposed model reactive type of data collection is used. This protocol provides high degree of security with minimum overhead. Symmetric key is used in WSN because of less computation as it uses same keys for encryption and decryption. The source and sink communication is showed in  H).CSA =  d ⊕ CSA ⊕ Si = CTd ⊕ CNA.Data = CTConsider the following equations:(1)When the sink comes into a range of rendezvous point it generates a large prime number.(2)H)).Sink calculates CSA (CSA = (3)CSA is broadcasted among the neighbor nodes.(4)Bmsg is broadcasted to all the nodes (Bmsg = Ssh ⊕ Ss ⊕ CSA).(5)d ⊕ CSA ⊕ Si = CTd ⊕ CNA).Cipher message is received and decrypted with its secret key (Data = CT(6)Compare the decrypted data with CMA; if data is same, accept it; else reject the data.(7)If the data is rejected, NAC is sent to the respective node.(8)The process is repeated till all the data is transmitted within its time slot.At the sink node, the cipher text is decrypted to get the original message: Si.CNA = CSA ⊕  d = Data ⊕ CNA.CTConsider the following equations:(1)Si).Sensor node calculates its secret key when CSA is received (CNA = CSA  ⊕  (2)Bmsg and calculates Bmsg  ⊕  CSA  ⊕  Ssh.Sensor receives the (3)The corresponding result is compared with the sink secret key; if it is same accept the message; else reject the message.(4)d = Data ⊕ CNA.Sensor encrypts its data with secret key and generates its cipher text CT(5)CMA is added at the end of the packet for verification.(6)The process is done till the end of the data packets.At the source node the plain text is encrypted with the secret key.NS2 simulation is employed to evaluate relay node based secure routing protocol for multiple mobile sink (RSRPMS). In this case randomly deployed sensor nodes covering the area of 600 × 600 m are varied from 50, 100, 150, and 200, to 250 kbps data rate and nodes are varied from 20 to 100 nodes. The time taken for simulation is 50 sec.This section describes the simulation results when sinks are increased as 1, 2, and 5. All the performance parameters were evaluated for node as well as rate. From the simulation result the proposed protocol proves that it can work better when the number of sinks increases. This increases the availability of the network.From This paper proposes a reliable and energy efficient WSN routing protocol with minimum delay called relay node based secure routing protocol for multiple mobile sink (RSRPMS). The experimental simulations using the proposed protocol are carried out rigorously and the results are compared with Intelligent Agent-Based Routing (IAR) protocol to prove the superiority in delivery of transmitted data and increase in the network lifetime compared with other routing protocols. The proposed routing protocol performance was also additionally compared with traditional schemes like BSMASD and MSREEDG techniques. The parameters of comparison included packet drop, energy, delay, and overhead. The simulations were carried out using NS2 simulator under various conditions of operations like varying the nodes and data rate. The simulation result proves that the proposed relay node based secure routing protocol used for mobile sink increases the delivery ratio and energy efficiency. Thus the proposed routing protocol increases the network lifetime.