Pediatric medical and nursing education currently lacks the environmental health content necessary to appropriately prepare pediatric health care professionals to prevent, recognize, manage, and treat environmental-exposure–related disease. Leading health institutions have recognized the need for improvements in health professionals’ environmental health education. Parents are seeking answers about the impact of environmental toxicants on their children. Given the biologic, psychological, and social differences between children and adults, there is a need for environmental health education specific to children. The National Environmental Education and Training Foundation, in partnership with the Children’s Environmental Health Network, created two working groups, one with expertise in medical education and one with expertise in nursing education. The working groups reviewed the transition from undergraduate student to professional to assess where in those processes pediatric environmental health could be emphasized. The medical education working group recommended increasing education about children’s environmental health in the medical school curricula, in residency training, and in continuing medical education. The group also recommended the expansion of fellowship training in children’s environmental health. Similarly, the nursing working group recommended increasing children’s environmental health content at the undergraduate, graduate, and continuing nursing education levels. Working groups also identified the key medical and nursing organizations that would be important in leveraging these changes. A concerted effort to prioritize pediatric environmental health by governmental organizations and foundations is essential in providing the resources and expertise to set policy and provide the tools for teaching pediatric environmental health to health care providers. With the widespread presence of environmental health hazards in our communities, concern about health risks for children has increased among the general public and the media, as well as among public and private organizations. In a national survey of parents, 41% percent stated they “worry a lot” about their children’s exposure to environmental poisons . In 1998Despite this increased interest and the economic burden, pediatric medical and nursing education currently lacks the environmental health content necessary to appropriately prepare pediatric health care professionals to recognize, manage, and prevent environmental-exposure–related diseases. Although nurses are the largest group of health professionals and the first—and often only—contact with the health care system for many individuals, most nurses have received no formal training in occupational or environmental health, and registered nurses do not feel well prepared to address environmental health issues in their practice, which has not changed much over time . Not allLeading health institutions have called for improvements in health professionals’ environmental health education. The Institute of Medicine (IOM) recommends the integration of environmental health concepts into all levels of medical and nursing education and has issued competencies that graduating medical and nursing students should demonstrate, including the ability to take an environmental exposure history, to understand the influence of environmental exposures on human health, and to communicate environmental risks and prevention strategies . SeveralTraining of health care providers on the special environmental health issues related to children is almost nonexistent, yet such education is necessary given the biologic, psychological, and social differences between children and adults. To address this need, two working groups of pediatric physicians and nurses conducted an assessment of and identified points of insertion in the current medical and nursing education structures where environmental health content could be incorporated.a) environmental health education or medical or nursing education in general, b) accreditation programs and systems, or c) curriculum development.Because there are so many differences between medical and nursing education, separate working groups with distinct expertise in the respective fields were created to assess each of those areas. Members of the medical and nursing working groups were selected because of their expertise and knowledge about These working groups met by phone and shared materials electronically. Their task was to describe the two educational processes from undergraduate education to continuing education and to identify potential leverage points that could be used to increase the amount of children’s environmental health information in the education of physicians and nurses. All working group members were involved in all the discussions about all the potential leverage points, irrespective of whether the particular point involved education, accreditation, or curriculum development.In this section we first outline the medical and nursing educational processes, including coursework, clinical practice experiences, and formal examinations. Medical school is the first phase in the education structure of physicians. The curriculum provides instruction in the underlying sciences of medical practice (basic sciences) and in information-gathering, decision-making, and patient-management skills. Students take, and in some schools must pass, step 1 and step 2 of the U.S. Medical Licensing Examination (USMLE), between the second and third years and before graduation from medical school, respectively. Upon successful completion of medical school, students receive their MD degree and undertake the next phase of medical education, residency.Residency offers physicians an organized educational program with guidance and supervision of the resident to facilitate the resident’s professional and personal development while ensuring safe and appropriate care for patients. Residents take step 3 of the USMLE during or after their first year of residency. A physician interested in a career in pediatric environmental health could choose a residency in one of three specialties: family medicine, pediatrics, or preventive medicine. Residents are prepared to undertake independent medical practice upon satisfactory completion of a residency and can apply to take a certifying examination to certify competency in their specialty.Fellowships provide an optional, usually 3-year-long period of training after the completion of residency, for subspecialization. Fellowships offer a path to a faculty position in a medical school and/or a residency training program. When a specialty board offers certification in the field, completion of a fellowship can be a step toward certification by a specialty board or subboard. There is no specialty board or specialty certification available in pediatric environmental health. Currently, the Ambulatory Pediatric Association (APA) offers a 3-year pediatric environmental health fellowship training program, and the Cincinnati Children’s Hospital offers the general pediatric research fellowship with a strong emphasis on pediatric environmental health.In most states, physicians must obtain 150 continuing medical education (CME) credits every three years on any topic they choose to maintain a medical license. Credits can be obtained by attending seminars, lectures, or workshops; by pursuing web-based programs; or by doing research projects, writing manuscripts, or reading material and taking a test.Recertification ensures that physician specialists remain up-to-date in their specialty by requiring them to pass an exam to remain certified. Physicians certified by the American Board of Pediatrics after 1987 must be recertified every seven years, and those certified by the American Board of Preventive Medicine after 1997 must be recertified every 10 years. Currently, there is no requirement to include children’s environmental health content in the recertifying examinations for pediatrics or preventive medicine.To become a nurse, individuals must accomplish one of three undergraduate programs of study: a 2-year associate degree (AA), a 3-year diploma, or a 4-year baccalaureate degree (BSN). The curricula for the AA and diploma programs provide students instruction in the underlying sciences of nursing practice as well as the application of information in clinical settings. Nurses from AA and diploma programs can continue undergraduate nursing education with completion of the BSN. The first 2 years of the baccalaureate curriculum focus on the underlying sciences for practice, and the last 2 years provide opportunities for developing information-gathering, decision-making, and patient-care skills in a broad array of clinical and public health settings, including hospitals, clinics, public health departments, government, and workplace settings.At the completion of the basic nursing program , graduates must pass the National Council Licensure Examination (NCLEX) to obtain a Registered Nurse (RN) license.Baccalaureate-educated nurses can go to graduate school to develop advanced knowledge in a particular nursing specialty. Depending on the specialty and outcome focus of the nursing program of study, graduate nursing education curriculum may include advanced basic sciences, evidence-based nursing practice, health policy, advanced nursing assessment, research coursework, clinical coursework, and program planning and evaluation, usually with supervised practicum experiences in the specialty—for example, pediatrics, adult health, and occupational and environmental health.Upon completion of the master’s degree, nursing graduates of certain clinically focused specialties must become certified by their state board of nursing based on graduation from an approved program and/or completion of the national board exam. National board exams are available for all nurse practitioner specialties, certified nurse midwives, certified nurse anesthetists, and some clinical nurse specialists. There have been significant efforts by nursing leaders to make the board exam requirements consistent across specialties.Nurses with a master’s degree may continue for doctoral education in a specialty of their choosing. These specialties may or may not be in nursing . The doctoral degree generally provides the graduate with advanced knowledge for teaching or research in nursing. There are no further board examinations or certifications for doctoral program graduates.Nurses may also become certified in their chosen specialty through national nursing specialty certification boards, which generally require examination, experience, and continuing/academic education. National specialty boards offer programs to maintain/renew certification every 5–7 years. Requirements generally include continuing education contact hours at approved courses, self-assessment exercises, practice requirements, and/or retaking the national board examinations. Continuing education course approval is given by specialty organizations and must meet nationally recognized quality standards.The working group identified several organizations and strategies that could be used to insert children’s environmental health content into medical schools. These include medical students and medical-student organizations, the creation of designated faculty leaders within schools of medicine, the Association of American Medical Colleges (AAMC), the Liaison Committee on Medical Education (LCME), and the National Board of Medical Examiners (NBME).Medical students and medical-student organizations have some influence over the curriculum of their own medical school . StudentMedical school faculty members are key to implementing curricula and influencing career choices of students by setting examples and providing direct counseling . There sThe AAMC, LCME, and NBME have no direct input into medical school curricula. The AAMC, however, sponsors regional meetings where innovative curricular activities are presented to others for consideration. Similar presentations are also made at APA meetings. It is recommended that faculty members teaching children’s environmental health or using children’s environmental health case material submit abstracts to present their activities at these meetings.At the residency training level, leverage points include directors of residency education, pediatric department chairs, chief residents, residency review committees, and pediatric primary care education guidelines. Chief residents have influence within each residency-training program over the scheduling of conferences and educational activities and could require all residents to complete education on children’s environmental health. The American Academy of Pediatrics (AAP), with funding from the U.S. EPA, has created a 1-day program to train pediatric chief residents about children’s environmental health.Pediatric residency review committees (RRC) can play a role in increasing children’s environmental health by requiring pediatric residency education to include children’s environmental health content. For programs that do not have faculty members qualified to teach that content, a web-based self-instructional module could be developed for residents, similar to the ATSDR’s web-based continuing education case studies. The ATSDR and U.S. EPA, through their cooperative agreement with the Association of Occupational and Environmental Clinics (AOEC), could task a PEHSU with developing and disseminating such a module. Training programs regarding the content and use of the module could be developed for residency program directors and chief residents.Another strategy is to include teaching about children’s environmental health in the guidelines for pediatric primary care education. In one academic setting, the incorporation of a pediatric environmental health course resulted in physicians’ increased consideration of environmental causes for illness . The APAAnother strategy to prepare more experts in the field, who could meet growing patient demand and train the next generation of pediatricians, is to increase the number of fellows in pediatric environmental health. The Centers for Children’s Environmental Health and Disease Prevention Research and the PEHSUs could provide the platforms upon which to build these fellowship programs. In 2003, the APA published a list of competencies for specialists in pediatric environmental health . Twenty-The creation of a specialty board offering certification in pediatric environmental health serves as a leverage point to formalize pediatric environmental health as a subspecialty and allow physicians to specialize and become leaders in the field. The American Board of Preventive Medicine (ABPM) offers specialty certification in occupational medicine or general preventive medicine, and the American Board of Emergency Medicine, the American Board of Pediatrics (ABP), and the ABPM have a subboard in medical toxicology. Some physicians choose one of these specialties as a route to a career in pediatric environmental health. The ABP and/or the ABPM could seek permission from the American Board of Medical Specialties (ABMS) to develop a sub-board in pediatric environmental health.CME is a means to provide environmental health education to physicians postresidency and at later stages in their careers. CME on environmental health issues, such as environmental asthma triggers, has been effective in improving the health of patients and decreasing associated medical costs . The PEHMedical insurance companies influence medical practice. If services are reimbursable, they are more likely to be offered to patients. Fellowships can be funded in part from service-related income. The organizations involved in children’s environmental health, such as the AAP and the AOEC, should request reimbursement from insurance companies for environmentally related health care services provided to children and should lobby state legislatures and state insurance boards for such coverage.Many undergraduate nursing education organizations and groups could introduce children’s environmental health content into nursing curricula: nursing students and nursing-student organizations, the National League for Nursing Accrediting Commission (NLNAC), and the Commission on Collegiate Nursing Education (CCNE).Nursing students have influence over the content of the curriculum in their schools. Nursing-student organizations, by linking students in various schools and providing information at meetings for students to take back to their schools, can influence the curricular content. Nursing professionals and environmental organizations interested in children’s environmental health should strive for input into local, regional, and national nursing student groups to teach them about the importance of this topic. One existing effort in this realm is the AOEC’s sponsorship of two focus sessions on occupational and environmental health nursing at the National Student Nurses Association annual meeting.NLNAC and CCNE should work to include examples of children’s environmental health issues throughout the undergraduate nursing curriculum. For example, cases related to children’s environmental health could be used for curriculum content on epidemiology that all nursing students take. Case studies covering a number of issues are available through the AOEC, the Great Lakes Center for Occupational and Environmental Safety and Health, and the ATSDR.When nursing students do their fieldwork, they should be encouraged to work with local and regional agencies that focus on children’s environmental health issues.AA, diploma, and baccalaureate degree nurses must pass the NCLEX to be licensed to practice as an RN. Influencing the NCLEX’s content is difficult because content is determined by a survey of the work of practicing nurses, and most practicing nurses have limited environmentally related activities in their day-to-day nursing activities. However, as practice changes to embrace environmental health content, the inclusion of environmental-health–related questions will influence curricula.As in medical education, nursing faculty with pediatric environmental health background can significantly influence curricular content and practice activities at the undergraduate, graduate, and continuing nursing education levels. Development of children’s environmental health nursing faculty leaders is essential.The National Organization of Nurse Practitioner Faculties (NONPF) and the Association of Faculties of Pediatric Nurse Practitioner Programs should use their influence on the curricula and standards for education and competencies to increase children’s environmental health content in the programs for advanced practice nurses. For example, a competency requirement on environmental health education has been accepted by NONPF, which could expand this activity and ensure its inclusion in the curriculum of all nurse practitioner programs.Organizations such as the Pediatric Nursing Certification Board (PNCB); the American Nurses Credentialing Center; the National Certification Corporation for Obstetrical, Gynecological, and Neonatal Nurses; the American College of Nurse Midwives; and the American Board of Occupational Health Nurses, which develop the certifying examinations for their respective specialties, should include children’s environmental health material in their examinations. Environmental health was included in a recent PNCB self-assessment exercise for certification maintenance of pediatric nurse practitioners.As with CME, continuing education for nurses is a key point at which to educate nurses about pediatric environmental health. One such example is the innovative children’s environmental health continuing education program conceived by the University of Maryland School of Nursing Environmental Health Education Center in conjunction with the American Nurses Association. It should be expanded to include other topics and repeated on a regular basis to provide education to newly trained nurses or nurses with a newly identified interest in children’s health and the environment. Organizations such as APHA, the National Association of Pediatric Nurse Practitioners, and the School Nurses Association, should sponsor pre- or postconference workshops on children’s health and the environment for nurses at their annual conferences. The train-the-trainer format would be a useful technique for spreading children’s environmental health expertise.We have identified several strategic opportunities to incorporate much-needed pediatric environmental health into the existing medical and nursing education process. Medical, nursing, and public health organizations, as well as patients, have expressed the need for health care providers to be better equipped to recognize and treat environmentally caused illness. We provide this comprehensive list of insertion points to guide medical and nursing education accrediting bodies, licensing bodies, and other key personnel that determine and influence medical and nursing curricula. Future efforts in this area should include evaluation of the existing pediatric environmental health education programs to determine the most effective formats for incorporating this subject. In addition, because knowledge and research in many areas of children’s environmental health are still developing, future efforts should focus on ensuring curriculum development and updates as the field advances. A concerted effort to prioritize pediatric environmental health by governmental organizations and foundations will be essential in providing the resources and expertise to set policy and provide the tools for teaching pediatric environmental health to health care providers.The following individuals participated in the review of medical education opportunities: Rob Amler, MD, MS—(then) Chief Medical Officer, ATSDR; Lois Colburn—Assistant Vice President for Minority and Community Programs, AAMC (Curriculum Development); Susan Cummins, MD, MPH—(then) Director, Board of Children Youth and Families, National Academy of Sciences, IOM; Deborah Danoff, MD—Assistant Vice President for Medical Education, AAMC; Ruth Etzel, MD, PhD—George Washington University School of Public Health and Health Services; Leyla Erk McCurdy, MPhil—National Environmental and Education Training Foundation, Project Director; Jerome A. Paulson, MD—(then) Soros Fellow, Children’s Environmental Health Network, and Co-director, Mid-Atlantic Center for Children’s Health and the Environment, Region 3 PEHSU; James Roberts, MD, MPH—Assistant Professor, Department of Pediatrics, Medical University of South Carolina; Chris Rosheim, DDS, MPH—(then) Health Education Specialist, ATSDR; Bernhard L. Wiedermann, MD—Associate Professor and Vice Chair for Education, Department of Pediatrics, George Washington University School of Medicine, and Director, Medical Education and Pediatric Residency Training Program, Children’s National Medical Center, Washington, DC.The following individuals participated in the review of nursing education opportunities: Robert Atkins, MSN, CRNP—Director of Pediatric Nurse Practitioner Program, Temple University, Department of Nursing; Cathie Burns, PhD, RN, CPNP—Professor Emeritus, School of Nursing, Oregon Health Sciences University; Hurdis Griffith, PhD, RN—Dean of Rutgers School of Nursing; Barbara Kelley, EdD, MPH, MS—Associate Professor and Director for Graduate Nursing Program Northeastern University; Rita Lourie, MSN, RN—Director of Academic and Community Outreach, Temple University, Department of Nursing; Leyla Erk McCurdy, MPhil—National Environmental and Education Training Foundation; Grace K. Paranzino, MS, RN, CHES, FAAOHN—Assistant Professor, Drexel University School of Medicine, Department of Family, Community and Preventive Medicine, and Adjunct Assistant Professor, Department of Environmental and Occupational Health, Drexel University School of Public Health; Dorothy Powell, EdD, RN, FAAN—Associate Dean, College of Pharmacy, Nursing, and Allied Health Sciences, Howard University/Director Mississippi Delta Project; Bonnie Rogers, DrPH, COHN-S, FAAN—Director of Occupational/Health Safety and Nursing Programs, University of North Carolina School of Public Health; Izzat Sbeih, MPH—Health Policy Analyst, American Public Health Association.


EHP 115:221–225; Miranda et al.][.Many water treatment systems around the nation have stopped using chlorine to disinfect drinking water. Chlorine reacts with dissolved organic matter in water to create by-products that are suspected of causing human health problems, including some forms of cancer. Many water treatment plants now use disinfectants called chloramines, combinations of chlorine and ammonia. But in some water systems this switch has coincided with an increase in lead in drinking water, perhaps because chloramines cause lead to leach from pipes, fixtures, and solder. Now a team of researchers from Duke University has measured the potential effect of switching from chlorine to chloramines on blood lead levels The scientists used geographic information system–based software to link blood lead data, housing data , drinking water sources, and census data for 7,270 children in Wayne County, North Carolina. Blood lead data were obtained from a statewide registry of all blood lead screens conducted on North Carolina children under the age of six. The authors noted that the lead-screened children were well distributed across different ages of housing in Wayne County.The county has two main public water systems. About 70% of the residential tax parcels get drinking water through Wayne Water Systems, which uses chlorine for disinfection. Another 28% of parcels get drinking water through the Goldsboro Water System, which has used chloramines for disinfection since March 2000.The Goldsboro Water System’s change to chloramines was associated with an increase in children’s blood lead levels, suggesting that use of chloramines could lead to an increase in lead exposure. The impact of the change to chloramines was progressively mitigated in newer housing, however. In houses built after 1950, the newness of the home was a stronger influence on blood lead than the use of chloramines.Much uncertainty still surrounds the underlying environmental chemistry of how combinations of disinfectants, anticorrosives, coagulants, and fluoridation agents combine with water qualities such as pH, alkalinity, temperature, oxidation potential, and concentrations of other chemical species to affect lead in drinking water. Nevertheless, these results provide guidance to both water systems and health departments on which houses should be targeted for monitoring of lead in both water and residents’ blood.


Streptopelia sp.), hard shelled turtle (Kachuga tentoria), sambhar (Cervus unicolor) were also mentioned as important medicinal resources. We would suggest that this kind of neglected traditional knowledge should be included into the strategies of conservation and management of faunistic resources in the investigated area.The present ethnozoological study describes the traditional knowledge related to the use of different animals and animal-derived products as medicines by the inhabitants of villages surrounding the Ranthambhore National Park of India , which is well known for its very rich biodiversity. The field survey was conducted from May to July 2005 by performing interviews through structured questionnaires with 24 informants (16 men and 8 women), who provided information regarding therapeutic uses of animals. A total of 15 animals and animal products were recorded and they are used for different ethnomedical purposes, including tuberculosis, asthma, paralysis, jaundice, earache, constipation, weakness, snake poisoning. The zootherapeutic knowledge was mostly based on domestic animals, but some protected species like the collared dove ( The healing of human ailments by using therapeutics based on medicines obtained from animals or ultimately derived from them is known as zootherapy . As MarqAravalis and the Vindhyas (mountain ranges) is a unique juxtaposition of natural richness, standing out conspicuously in the vast, arid and denuded tract of eastern Rajasthan, barely 14 kilometer from the town, Sawai Madhopur. Being a typical representative of dry-deciduous dhok (Anogeissus pendula) forest, the vegetation of Ranthambhore is considered as i) Tropical Dry Deciduous Forest and ii) Tropical Thorn Forest [Mogya and Bawaria people, which are living around the national park.The Ranthambhore National Park (250 54' N – 260 12' N and 760 22' E – 760 39' E) at the junction of the Informants), to collect information about traditional knowledge regarding use of animals and their products. These informants were local herbalists, healers, farmers, and midwives. The Informants are between 40–74 age groups. The selection of Informants was based on their recognition as experts and knowledgeable members concerning folk medicine. We ask the informants whether they use animals in the healing practices. Then we ask that which animal remedies have been prescribes for which ailment. We also ask the modes of preparation of remedies and how the medicines are administered, since this kind of information indicates how a given medicine can be therapeutically efficient in terms of the right ingredients, the proper dose, and the right length of preparation. According to them, their knowledge of folk medicine was acquired mainly through parental heritage, or because they have experience about medicinal value of animals to heal their kin or themselves. The interviews were recorded and documented. All the animal species were identified by using relevant and standard literature.Data were obtained through field survey conducted from May to July 2005 by performing interview through structured questionnaire with 24 selected people  of villages surrounding the Ranthambhore National Park of India. The information of all local names of the animal, part or product used to cure and methods of preparation were provided by the Informants. In this study, we enlisted 15 animal species, which are being used for 20 medicinal purposes. These animals are used as whole or body part or byproduct like milk, blood, organ, skeleton etc. for the treatment of different kind of ailments including tuberculosis, asthma, paralysis, jaundice, earache, constipation, weakness, snake poison etc.  (figure Kachuga tentoria), sambhar (Cervus unicolor) are also included as important medicinal resources in this studied area. Kakati and Doulo enlisted six species as rare among twenty three species among Chakhesang tribe of Nagaland[Noteworthy is the observation that mostly animal byproducts are used in traditional health care systems without any loss to animal. The therapeutic information's is mostly based on domestic animals, but some protected species like the collared dove  figure , hard sh Nagaland. Inadequ Nagaland. So the  Nagaland. Further


Information on exposure and reaction to sunlight, together with the history of exposure to fluorescent lighting, was elicited by postal questionnaire. Case-control analysis from 58 patients with malignant melanoma, 182 matched controls and 151 unmatched controls showed associations between malignant melanoma and (i) bouts of painful sunburn, (ii) reaction of untanned skin to sunlight, and (iii) number of moles (on right forearm), whereas no association could be found with exposure to fluorescent light at work.


Reaching beyond typical descriptive mapping, this study demonstrates the rich depth of GIS capabilities in analyzing patterns of disease spread from various perspectives.Epidemiologists have long used maps to track the spread of disease, and in the past decade, geographic information system (GIS) technology has added powerful new tools that help reveal far more than simply the “where” and “when” of epidemics. Now P.C. Lai of the University of Hong Kong and colleagues show how GIS technology can be used during an acute infectious disease outbreak to reveal crucial real-time, quantitative information, such as the direction of superspreading events  and distinct disease hot spots The global outbreak of severe acute respiratory syndrome (SARS) in late 2002 and into 2003 ultimately accounted for more than 8,000 cases in 29 countries, according to the World Health Organization. About 20% of the cases were in Hong Kong. Lai and colleagues applied geostatistical methods to analyze the spread of SARS in Hong Kong during this time period.The investigators analyzed an integrated database that contained clinical and personal details on the 1,755 Hong Kong patients confirmed to have had SARS. They plotted patient residence addresses using a GIS to research such aspects as the superspreading event responsible for more than 300 cases in the Amoy Gardens housing development and microclusters of SARS cases (where the density of infection varied widely between districts).The geostatistical analysis was conducted at three levels: elementary , cluster analysis to identify hot spots, and contextual analysis to explain relationships between geographical phenomena. Among the methods the researchers applied were nearest neighbor analysis, which discerns nonrandom distribution of cases and is often used by scientists studying species distribution. For another analysis, they used the kernel mathematical method to create a series of statistical “surfaces” to reveal daily changes in disease hot spots.Elementary analysis revealed the spread of the disease: a clear clustering of cases in certain districts of the Kowloon peninsula, where Amoy Gardens is located, and in Hong Kong’s New Territories region. Next, cluster analysis produced a series of 12 kernel maps based on date of symptom onset. These maps showed the density of SARS patients (adjusted for underlying population density) on typical days representing different stages of the 16-week outbreak; this demonstrated the development and dissipation of disease hot spots over the course of events. Another sophisticated analysis produced a map that summarized SARS hot spots by infection rate per 1,000 population, indicating that the urban population was at the highest risk.With contextual analysis, the researchers developed origin-and-destination plots for three superspreading event clusters: Prince of Wales Hospital, Amoy Gardens, and Lower Ngau Tau Kok Housing Estate. The Prince of Wales Hospital cluster showed a northwest–southwest trend of disease spread that extended over most of Hong Kong . The Amoy Gardens cluster was comparatively more localized, while the Lower Ngau Tau Kok cluster was the most contained of the three.The authors cautioned of limitations in applying GIS technology to infectious disease epidemiology and outbreak investigation, among them the occasional lack and unavailability of the necessary data. Still, the authors wrote, “integration of GIS technology into routine field epidemiologic surveillance can offer a scientifically rigorous and quantitative method for identification of unusual disease patterns in real time.” When linked with point-of-care databases and other sources of environmental data , such geospatial intelligence has the potential to rapidly recognize, locate, and monitor disease outbreaks.


Data on diabetes morbidity and mortality and the quality of care among U.S. minority populations are necessary to assess progress toward eliminating racial/ethnic disparities and to design and implement effective interventions. This paper summarizes the discussions and recommendations of an expert panel to address the use of survey data for diabetes surveillance among minority populations.The Centers for Disease Control and Prevention's Division of Diabetes Translation convened an expert panel of persons with survey experience and awareness of the problems in conducting health-related surveys among minority populations. Panel members were asked to 1) determine ways to enhance the ability of existing survey systems to address diabetes surveillance among minority populations; 2) identify survey systems that could be used to address surveillance needs; and 3) determine whether new minority-specific survey systems need to be developed.Panel members concluded that, although no existing survey system is completely adequate for diabetes surveillance among minority populations, new systems should not be developed. They recommended 1) investigating the use of community-based surveys; 2) exploring the ability of national surveys to increase sample sizes and produce state-level estimates; and 3) encouraging government agencies and public health programs to coordinate and integrate diabetes-related survey data and share analytic methodology.No existing survey is suitable for conducting minority-specific diabetes surveillance. Modifying and expanding existing surveys to establish a diabetes surveillance system of sentinel minority populations would be more feasible than developing a new one. Interagency coordination and collaboration will be critical in this effort. An estimated 17 million people in this country have diabetes, and of these, nearly 6 million are not aware of their condition . ApproprCompared with the general population, certain racial/ethnic communities, as well as older Americans and economically disadvantaged Americans, are disproportionately affected by diabetes and are at increased risk for some diabetes-related complications . PotentiThe Division of Diabetes Translation (DDT) at the Centers for Disease Control and Prevention (CDC) uses many data sources to conduct public health surveillance of diabetes and to estimate the burden of diabetes at the national and state levels. These data sources include surveys such as the Behavioral Risk Factor Surveillance System (BRFSS) and the National Health Interview Survey (NHIS), administrative databases such as the U.S. Renal Data System, databases of the Health Care Financing Administration, and vital statistics data. However, several problems are associated with the use of these data in diabetes surveillance among minority populations: 1) surveys cannot reach all minority populations of interest; 2) administrative data sometimes do not include information on race and ethnicity; 3) small sample sizes of minority populations do not allow for accurate estimates of the diabetes burden at the state or community level; and 4) minority populations often are erroneously treated as homogeneous .In 1998, the Department of Health and Human Services' Initiative to Eliminate Racial and Ethnic Disparities in Health established as a national priority the elimination of racial and ethnic disparities in health outcomes among U.S. residents. Data for monitoring progress toward this objective, however, are lacking for many minority populations. Obtaining high-quality surveillance data on diabetes-related morbidity and mortality and quality of diabetes care among minority populations is thus important in identifying disparities and monitoring progress toward reducing these disparities. To discuss the use of survey data for the surveillance of diabetes among minority populations, DDT convened an expert panel meeting.DDT organized and conducted the August 5–6, 2002, expert panel meeting. The panel consisted of 18 persons from agencies or organizations outside of DDT, most of whom had survey experience and were aware of the challenges in conducting surveys of health-related information among minority populations. Panel members represented 4 federal agencies, 4 university-affiliated institutions, 2 private nonprofit organizations, and one state health department . Panel mThe expert panel members identified numerous national, state, and community-based survey systems and discussed the systems' abilities to address the health information needs of minority populations . Most ofMoreover, the panel questioned whether a national sample of specific minority populations could produce meaningful results given the diversity within these populations. State and community surveys share some of these same problems, but they have the advantage of access to local data, which have more immediate relevancy in planning and evaluating community-based interventions to improve public health. Although local surveys may have the greatest potential for targeting subgroups of minorities, data on such subgroups may not be generalizable to the larger minority populations.The panel members recognized that the list of surveys discussed as potential sources of data was probably not complete and recommended several strategies to identify additional survey systems that could be useful. These strategies included 1) a summary review of existing longitudinal studies and other relevant data; 2) a search of surveys sponsored by federal or public agencies other than the Department of Health and Human Services; and 3) a query of state health programs to establish an inventory of special surveys.Recognizing that diabetes is an important growing public health problem , the panThe panel also discussed the need to examine survey content to ensure that surveys are capable of producing the thorough data necessary to design effective public health interventions. In addition to producing data on minority racial and ethnic groups, surveys also should produce data on other disadvantaged populations as measured by socioeconomic status, social capital, community resources, education, and access to or denial of health insurance, because these factors generally underlie many racial and ethnic disparities.Finally, the panel discussed the need to establish new minority-specific survey systems and concluded that developing and maintaining new survey systems would be too costly and time-consuming. Instead, the panel recommended expanding upon and enhancing existing survey systems at the state and local levels. Specifically, the panel recommended investigating the use of community-based surveys, such as those in the Racial and Ethnic Approaches to Community Health 2010 project, state- and local-specific surveys of the BRFSS, and the State and Local Area Integrated Telephone Survey. The panel also suggested modifying existing surveys by, for example, increasing sample size, adding supplementary content, sampling additional minority groups, and developing the capacity of national surveys such as NHIS to collect state and community-level data.Data on diabetes-related morbidity and mortality and quality of diabetes care among different U.S. minority populations are necessary to 1) assess progress toward eliminating racial/ethnic disparities in the health burden of diabetes, and 2) design and implement effective interventions for minority groups that are disproportionately affected by diabetes.No existing survey is suitable for conducting minority-specific diabetes surveillance. Modifying and expanding existing surveys to establish a diabetes surveillance system of sentinel minority populations, however, would be more feasible than developing a new one. Interagency coordination and collaboration will be critical in establishing such a system.


Remote sensing, as well as the recent advancements of crowd sensing, along with novel and recent geospatial technologies, have great potential to explore and understand the relationships between our surroundings—in particular our urban and rural environments and natural spaces—and public health through environmental factors ,2. EmergTo address these issues, the prime aim of this Special Issue is to present novel sensing and computational techniques in order to better understand public health, developing diverse public health applications, and to explore their underlying implications. Thus, we can move towards securing healthier urban/rural environments and natural spaces. This collection of papers should provide a selection of interesting approaches and methodologies, useful for audiences including researchers, practitioners, and professionals.In February 2016, this Special Issue was started by announcing widely the call for papers, and inviting leading scholars to contribute. It received a great response by a significant number of scholars. By the deadline for submission in September 2016, a total of 23 submissions were submitted. Through a single-blind review process following standard MDPI review guidelines, we invited at least three expert reviewers to review the manuscripts and comment on the quality, originality, relevance, as well as fit for the Special Issue. This led to 12 of the 23 submitted manuscripts being accepted  for publication and thus were included in the Special Issue.2, Enhanced Vegetation Index (EVI), Aerosol Optical Depth (AOD) product, and other meteorological parameters to explain the variation of PM2.5 across China [The Special Issue consists of the following papers: Zhang et al. present a Geographically Weighted Regression (GWR) model using NOss China . They alss China . Their pss China . They exss China . They di2.5 mass concentrations at national scale using the Aqua Moderate Resolution Imaging Spectroradiometer (MODIS) Aerosol Optical Depth product for China [Zhang et al. introduce an adapted semi-physical GWR model for real-time estimation of PMor China . They beor China . Their rYoung et al. , using ESun et al.  investigIn conclusion, these papers demonstrate a great deal of contribution from remote sensing data and geospatial technologies combined with in situ observations which were embedded in order to study factors affecting public health across different global regions. Unexpectedly, there was no submission dealing with crowdsourced data in exploring our landscapes and its connection with public health parameters. This selection addresses a broad range of aspects, leveraging on the multidisciplinary vision of health and environmental research. It should be noted that the wealthy and diversified body of tools available within the field of geoinformation technologies will steer this area to become an increasingly present concept in studying issues concerned with public health planning and decision making.


Patients with coagulation disorders may present to a variety of physician specialties; however, accurate and efficient diagnosis can be challenging for physicians not specialized in hematology, due to identified gaps in knowledge around appropriate laboratory assays and interpretation of test results. Coags Uncomplicated was developed to fill this unmet educational need by increasing practical knowledge of coagulation disorders among nonexpert physicians and other health care professionals (HCPs) in a point-of-care (POC) setting.The aim of this study was to assess patterns of use of the mobile app Coags Uncomplicated, a tool designed to support education regarding accurate and efficient diagnosis of bleeding disorders.App metrics were obtained by tracking registered user data. Additionally, a survey was distributed to registered users, to assess circumstances and frequency of use.The most common specialties of 7596 registered US users were hematology-oncology , hematology , and emergency medicine ; most identified as physicians . Specialties accounting for the greatest numbers of screen views were hematology-oncology , hematology , emergency medicine , and internal medicine . The most common diagnostic endpoints reached were disseminated intravascular coagulation , liver disease effect (2108 times), and vitamin K deficiency (1584 times). Of 3424 users asked to take the survey, 262 responded (7.65%); most were physicians in direct clinical care (71%) and specialized in hematology-oncology (39%) or emergency medicine (21%). Most frequent use was reported by hematologists  and hematologists-oncologists . Most physicians (89.2%) reported using the app for patient-case-related education around appropriate use of laboratory tests in diagnostic evaluation. Physicians rated Lab Value Analyzer (mean 4.43) and Lab Test Algorithm (mean 4.46) tools highly on a 5-point “how helpful” scale and were likely to recommend the app to colleagues.App use among physicians and other HCPs is consistent with value as a POC educational tool, which may facilitate differential diagnoses and appropriate early consultation with hematologists. For many physicians who first encounter patients with severe bleeding symptoms, the potential contribution of an underlying bleeding disorder may often be overlooked. When presented with an acutely bleeding patient, the focus of many primary care physicians, physicians working in the emergency and hospital settings, and physician trainees is “where” rather than “why” the patient is bleeding, and how to best manage the symptoms at hand. Underlying bleeding disorders are perceived to be rare; however, approximately 1% of individuals in the United States have von Willebrand disease (VWD) , approxiBleeding disorders encompass a large number of unique conditions that require specialized knowledge and a stepwise strategy for accurate and efficient diagnosis, and they may be difficult for nonhematologists to diagnose. Many of these knowledge gaps were demonstrated through administration of a large survey to practicing physicians from various specialties, which presented a hypothetical case scenario of a patient with acquired hemophilia, a rare bleeding disorder . NonhemaFor physicians faced with acutely bleeding patients, education regarding specific laboratory tests, interpretation of results, and potentially applicable diagnoses may be valuable in supporting early referral and initiation of treatment. A potentially important tool to increase awareness of important diagnostic considerations is mobile technology, as mobile devices are emerging as a useful platform for health care professionals (HCPs) to quickly access medical information, including traditional sources such as medical textbooks, professional society guidelines, drug references, and institution-specific therapy standards, as well as Web-based tools and mobile phone apps . The CoaHere, we present information regarding physician and other-HCP use of Coags Uncomplicated and assess its value as an educational tool. Data include results from a survey of Coags Uncomplicated users, as well as app tracking metrics with data collected from actual app use, to assess real-world patterns of use over time.The concept for the initial gap assessment leading to the development of Coags Uncomplicated came from hematologist advisors in 2009 and was crystallized in a case study that became the focus of a quantitative Internet survey and subsequent qualitative interviews conducted in early 2010 . The firThe initial focus of the app was on case scenarios presenting with abnormal PT or a PTT test results, for which published diagnostic algorithms could be adapted toward a primary care or first responder  audience by eliminating common disorders earlier in the algorithm . This process identified 30 diseases for which educational content was developed and 26 coagulation laboratory tests associated with the diagnosis of these disorders. Content around all disorders and tests was referenced to 79 sources and comprised 270 app scrolling screens occupying 623 distinct screenshots. Important diagnostic caveats were included, and emphasis was placed on the need for expert consultation in the ultimate differential diagnosis. The app was launched in December 2010 (United States) and July 2011 , and included 4 separate tools: the Lab Test Algorithm  neonatal bleeding disorder differential diagnoses and challenges associated with gestational age-adjusted “normal” laboratory values and (2) VWD, platelet function disorders, and other disorders associated with normal PT and aPTT results and often normal platelet counts. Because these disorders were associated with fewer published algorithms and wider variability in diagnostic approaches, additional experts were engaged  in developing the second-generation platform. The expanded scope of this platform included educational materials on a total of 66 diseases and 34 laboratory tests supported by 193 references and comprised 583 scrollable screens captured by 1733 screenshots. This version included the Neonatal Module as well as additional Lab Test Algorithms see -6.In order to better understand the usage patterns of the app and to guide further content development, in the United States, registration was required before using the app. App tracking metrics describing patterns of use from the initial launch in December 2010 through February 2016 were obtained. Data include total numbers of screen views  and the most frequent diagnostic endpoints reached. App users outside of the United States were not required to register.Initial tracking metrics demonstrated greater use of the app by hematology and hematology-oncology specialists than by nonspecialists. To better understand whether specialist app use was primarily for education or teaching or for case-based education and whether app use differed between hematology specialists and nonspecialists, a Web-based survey was developed. Participants were recruited from a database of 3424 registered (US-based) app users who had downloaded the app (version 1.0 or 2.0), and they were screened to ensure that they had used the app at least once. Participants were required to be adults (at least 18 years of age), and they had to have completed the survey between October 1 and October 11, 2013. Survey questions provided an assessment of respondent demographics and frequency of app use  and ratings of app helpfulness and likelihood to recommend the app. Helpfulness was rated on a 5-point scale from 1 to 5 with 5=very helpful. Likelihood to recommend the app was rated on a 5-point scale from 1=not at all to 5=very likely.As of February 2016, the most common specialties listed by 7596 registered users included hematology-oncology , hematology , and emergency medicine , hematology , emergency medicine , and internal medicine . Most respondents (71%) were physicians in direct clinical patient care ; the majMore than one-third of respondents (37%) reported using the app at least 6 times since downloading it, and some (6%) reported use of more than 50 times . Nearly A majority (89.2%) of physicians reported using the app for education related to actual patient cases . Among physicians who used the app for education in at least 1 actual patient-case-related instance, the most common circumstances of educational use were related to differential diagnosis (mean 6.35 cases per physician) and to review of educational materials on a disease to confirm a suspected diagnosis  and Lab Test Algorithm (mean 4.46) tools highly on a 5-point “how helpful” scale . On a 5-The goal of developing Coags Uncomplicated was to address educational gaps around the appropriate sequence and interpretation of laboratory tests and to encourage referral to hematology specialists in cases of suspected bleeding disorders. To assess whether the app was reaching the target audience in the United States and whether the types of information sought matched relevant diagnoses and tests, user tracking data were collected and a survey of registered users was performed.Results of these analyses demonstrated that hematologists and hematologists-oncologists account for the majority of app screen views and report the most frequent app use for POC education to support patient-case-related information about differential diagnostic considerations, disorders, or tests. Most nonhematologists may be less likely to gain awareness of the app and to encounter patients with coagulation disorders, although users specializing in emergency medicine also accounted for high numbers of registered users and screen views. Value of the app among nonhematologists is supported by high “helpfulness” ratings, which were similar between hematologists and physicians overall, and high rates of repeated use across specialties and HCP types.Due to the high prevalence of use by specialists in hematology and hematology-oncology, who may have variable training and clinical practice experience in benign hematology , the survey was designed to explore the reasons why users were turning to Coags Uncomplicated, and to identify whether the app is being used more as an educational resource in clinical situations or as a teaching tool. Overall, survey data and app tracking metrics describe app use among physicians and other HCPs in a pattern consistent with value as a clinical POC educational tool. Reported use in patient-case-related circumstances to quickly review relevant educational materials about making a differential diagnosis, to review educational materials on a disease to confirm a suspected diagnosis, and as a teaching aid supports a practical value for filling unmet educational needs and suggests that use of the app may facilitate rapid and efficient differential diagnosis. A majority of physician app users reported using the app to support actual patient-case-related educational needs, suggesting high practical utility and less frequent use as a teaching tool. Additionally, most physician app users worked in a hospital-based practice setting, indicating that most frequent use may occur in the acute care setting.Data obtained from the survey also assessed the tools that were used most frequently within the app. Whereas a large majority of survey respondents reported having used the Lab Value Analyzer (93%), this tool was associated with the lowest number of screen views. The Lab Value Analyzer was developed largely to help hematology-oncology specialists and those without easy access to specialists experienced in the interpretation of laboratory studies that may have been performed as part of a screening profile, and therefore infrequent use may suggest limited use for these purposes. This pattern of use is also consistent with lower use of the Lab Value Analyzer than the Lab Test Algorithm in actual patient cases, and suggests that the clinical value of the app may be highest in the early stages of diagnosis (before laboratory tests have been run). The Coag Challenge had the lowest rate of respondent use (65%), but the second highest number of screen views, suggesting high rates of repeated use among a subgroup of users who complete the whole challenge, supporting the value of competitive aspects to reinforce learning in adults.The data regarding most common diagnostic endpoints reached seem to reflect preferential app use in cases of complex and acutely severe conditions that would be seen by those in an emergency room or hospital situation. For example, the most frequently reached endpoints, DIC, liver disease effect, and vitamin K deficiency, are each complex disorders that vary widely in bleeding symptoms -9. InterAdditional tools that may be considered for future versions of Coags Uncomplicated include use of bleeding scores or bleeding assessment tools (BATs) and standard workups for specific bleeding presentations. General diagnostic tools, such as the International Society on Thrombosis and Haemostasis BAT  and the An analysis of Coags Uncomplicated use among US physicians and other HCPs suggests value as a POC educational tool to support differential diagnosis of bleeding disorders. App tracking metrics and survey responses indicate most frequent use among hematologists, hematologists-oncologists, and emergency physicians, and frequent use for education to support actual patient-case-related circumstances. Patterns of use seem to suggest preferential use in cases of complex and acutely severe conditions, which may be encountered by physicians of various specialties. Because bleeding disorders may be challenging to diagnose for those who are not experienced in performing and interpreting advanced hematologic assessments, app use may facilitate efficient and accurate differential diagnoses, reduce delays to appropriate consultation with hematologists, reduce inappropriate use of therapeutic resources, and ultimately reduce mortality of bleeding patients.


European cancer nurses have to face many challenges as a result of the rapidly changing economic and political context in which balancing health care needs has become strategic for healthcare delivery. Currently, cancer nurses must overcome many obstacles arising from clinical, organisational, and educational issues. Within this scenario, the European Oncology Nursing Society (EONS) shaped its tenth congress programme to boost discussion and reflections, to share experiences and research, and to see how cancer nurses try to anticipate and embrace changes. The aim of this was to promote innovative solutions and to address the many issues involved with cancer care.EONS10 was held on 17–18 October in Dublin, Ireland. The congress was attended by more than 500 delegates. The programme covered the following themes: caring for families and carers, inequalities and access to cancer care, caring for patients with haematological cancers, palliative care, communication and information exchange, community cancer care , roles and responsibility for advanced nursing practice, International Psycho-Oncology Society (IPOS)-Academy workshops (i.e. workshops), cancer survivorship, clinical leadership and new roles, oncology nursing research, symptom experiences and management, palliative care (i.e. proffered papers), poster presentations, and satellite symposia. The aim of this paper is to highlight and discuss the contents of the EONS10 congress. The context in which cancer nurses work in Europe is rapidly changing, considering the challenges brought about by demographic changes (i.e. ageing population), treatment innovations and complexity, the need to deliver care for cancer patients, for their families and survivors, issues related to the nursing workforce, competencies , and theThus, cancer nurses and other key members of multi-professional teams discussed here the care needs of patients, their families, and the challenges nurses have to face in order to deliver care in a fast-changing world. This is particularly significant in a field where innovation develops quickly in every nuance of clinical practice such as cancer care. They addressed the weaknesses between different approaches and profiles. EONS10 was also a unique occasion to thoroughly understand the importance of roles within the nursing workforce given the increasing number of cancer patients and therapeutic options available. This all involves providing education and supportive care to patients and their families by them.Considering the varied and important issues discussed at EONS10, a conference report could be useful to summarise the main topics presented. For this reason, the aim of this paper is to highlight and discuss the contents of the EONS10 congress.The EONS10 congress opened with welcome speeches from the EONS president (Professor Daniel Kelly), the Irish Association for Nurses in Oncology (IANO) president (Pauline Kehoe), the chair of the EONS10 scientific committee (Professor Mary Wells), and the minister for health of Ireland (Mr Simon Harris). Then, Professor Meinir Krishnasamy  gave a lecture on the congress topic ‘Balancing health care needs in a changing context’, highlighting (a) how the global healthcare industry is in crisis because of the increase of cancer epidemiology worldwide, (b) the challenges brought about by personalised cancer therapies and technology, (c) the role of prevention (e.g. a third of new cancer cases can be prevented through modification of lifestyle behaviours and access to screening), (d) the importance of enhancing cancer patient outcomes, (e) and key reflections to redress the balance of care needs in a changing global context.parallel sessionsproffered papersworkshopsposter presentationssatellite symposiaThis paper is structured in five main sections to highlight the contents of EONS10  which arA session entitled ‘Caring for families and carers’ was chaired by Professor Daniel Kelly . The first presentation of this session entitled ‘Supporting parents with cancer who have young children’, was presented by Cherith Semple (UK), and it aimed to describe how nurses can support the needs of parents diagnosed with cancer who have young children. The second presentation was presented by Sylvie Lambert (Canada), and it aimed to show the findings of a longitudinal study on caregivers’ well-being over the first five years after diagnosis. Naomi Fitzgibbon (Ireland) gave the third presentation which aimed to discuss traditional and non-traditional technologies to support cancer patients and their families.The session titled ‘Inequalities and access to cancer care’ was chaired by Andreas Charalambous (Cyprus) and Aoife McNamara (Ireland). Edel McGinnity (Ireland) highlighted how much the current structure of health services discriminates against patients with the highest health need, showing the specific challenges of delivering care in areas of deprivation, and how to improve access and outcomes in these areas. Kathi Apostolidis (Greece) presented a communication aimed at raising awareness about inequalities in cancer care across Europe, suggesting some tips, and a political agenda to tackle the issue of health inequalities. Then Nick Hulbert-Williams (UK) presented a lecture on cancer experiences in demographic minority groups. He showed how the variation in sociodemographic characteristics  can affect a range of healthcare experiences. His presentation also pointed out the experiences of cancer in people with an intellectual disability and the inequalities existing between sexual orientation groups.The session entitled ‘Caring for patients with haematological cancers’ was chaired by Barry Quinn (The Netherlands) and Patrick Crombez (Belgium), and it was in conjunction with the European Group for Blood and Marrow Transplantation (EBMT). The first speaker, Melanie Charalambous (Cyprus), described the pathophysiology of oral mucositis, highlighting its pharmacological and non- pharmacological management. The second speaker was Barry Quinn (UK) who pointed out the important role of patients’ self-assessment and personalised information aimed at providing better choices and health for patients. The third speaker was Susan Schneider (USA) and she spoke about nutritional support in high dose chemotherapy, highlighting how there is a lack of research on that topic.Another interesting session was entitled ‘Communication and information exchange’, and it was chaired by Paul Trevatt (UK) and co-chaired by Gabriella Pravettoni . The first speaker was Lena Sharp (Sweden) with a presentation entitled ‘Nursing handover sessions’, highlighting how nursing handover could be a potential threat to patient safety, and how a lack of research still exists with the aim of comparing the effectiveness of different models of handover. She also described the experience of Karolinska University Hospital (Sweden) in implementing a person-centred bedside nursing handover. The second speaker was Paul D’Alton (Ireland) and his presentation described the ways in which nurses can respond more effectively in different interpersonal situations. Then the third speaker proposed some reflections on sharing knowledge about death and dying at different levels .The session entitled ‘Community cancer care’ was chaired by Eileen O’Donovan (Ireland) and discussed by Theresa Wiseman (UK). The first speaker was Janice Richmond (Ireland) who proposed an integrated approach to face cancer challenges, establishing a community oncology nursing programme to improve cancer care. The second speaker was Eila Watson (UK) with a presentation which described the role of primary care for cancer survivors. The third speaker, Natasha Campling (UK), described the implications of opioid medicines management at home for patients, nurses, and carers.The session ‘Cancer survivorship’ chaired by Lena Sharp (Sweden) and discussed by Mary Wells (UK) highlighted (a) the role of physical exercise, (b) the alternative models of cancer survivors follow-up, (c) the role of self-efficacy in recovery following cancer treatment, and (d) the role of patients’ self-management. Then, the sessions ‘Alternative and complementary approaches’ chaired by Andreas Chralambous (Cyprus) and discussed by Iveta Nohovovà (Czech Republic) aimed (a) to describe the current research challenges in complementary and alternative therapies (CAM), (b) to describe the power of therapeutic touch for people living with a diagnosis of cancer, (c) to report some patients’ experiences of CAM.The session ‘Psychological health and wellbeing in nurses’ was chaired by Erik van Muilekom (The Netherlands) and was discussed by Rosario Caruso . This session aimed (a) to describe what compassion fatigue is for nurses, (b) to describe European policy on how to face the challenges of stress in cancer nursing, and (c) to describe an experience of professional supervision to improve nurses’ coping. Another interesting session, entitled ‘Patient reported outcomes’, was chaired by Wendy Oldenmenger (The Netherlands) and was discussed by Patrich Jahn (Germany). It aimed (a) to describe the main patient-reported outcomes, (b) to understand psychosocial difficulties, and (c) to describe an experience of patient reported outcomes at a population level in Ireland.The EONS10 congress was very rich in proffered papers which were selected by the scientific committee from among many abstracts. During the congress, delegates had the opportunity to choose which proffered papers sessions they would attend after considering the different proposed topics. There were seven sessions related to proffered papers, and the presentations were grouped according to the following topics: (a) Long term consequences and cancer survivorship; (b) Clinical leadership and new roles; (c) Oncology nursing research; (d) Symptom experiences and management; (e) Palliative care; (f) New developments and roles; (g) Psychosocial care.EONS10 was also a great occasion to attend interesting workshops dealing with some important challenges related to cancer care delivery. The challenges addressed by those workshops were concerning (a) the roles and responsibilities of advanced nursing practitioners, (b) the management of psychological distress for cancer patients, (c) ways to help parents with advanced cancer to talk with their children, (d) and a discussion on the myths and challenges related to living and dying for cancer patients.More than 200 posters were displayed covering the most challenging areas of cancer nursing practice such as advanced nursing roles, end of life care, impact of cancer on patients and families, new developments, supportive and palliative care, survivorship and rehabilitation, symptom management and transitions in care. Many posters were presented by authors coming from different countries in discussion sessions, characterised by interesting debates where delegates shared their experiences, also strengthening their networks. Poster presentations have been shown to be a high quality method for knowledge exchange.http://ecancer.org/education/module/266-new-optimism-for-advanced-breast-cancer-patients-failing-antiestrogens.php.Delegates also had the opportunity to participate in many interesting satellite symposia dedicated to some innovative cancer treatments. Among these symposia, ecancer organised a session entitled ‘New optimism for advanced breast cancer patients failing antioestrogens’, available on the ecancer website at the following address: EONS10 was a high quality conference aimed at discussing how nurses could help to balance healthcare needs in a changing context. EONS10 was a unique occasion to thoroughly understand how the nursing workforce has an important role in meeting the increasing needs of an increasing amount of cancer patients. Moreover, the congress offered a fantastic opportunity to the delegates to strengthen their networks and to be involved with the challenges brought about by the current epidemiological and economic scenario.


Cells are fundamental function units of multicellular organisms, with different cell types playing distinct physiological roles in the body. The recent advent of single-cell transcriptional profiling using RNA sequencing is producing ‘big data’, enabling the identification of novel human cell types at an unprecedented rate. In this review, we summarize recent work characterizing cell types in the human central nervous and immune systems using single-cell and single-nuclei RNA sequencing, and discuss the implications that these discoveries are having on the representation of cell types in the reference Cell Ontology (CL). We propose a method, based on random forest machine learning, for identifying sets of necessary and sufficient marker genes, which can be used to assemble consistent and reproducible cell type definitions for incorporation into the CL. The representation of defined cell type classes and their relationships in the CL using this strategy will make the cell type classes being identified by high-throughput/high-content technologies findable, accessible, interoperable and reusable (FAIR), allowing the CL to serve as a reference knowledgebase of information about the role that distinct cellular phenotypes play in human health and disease. In many cases, abnormalities in gene expression form the physical basis of disease dispositions. Thus, understanding and representing normal and abnormal cellular phenotypes can lead to the development of biomarkers for diagnosing disease and the identification of critical targets for therapeutic interventions.Cells are probably the most important fundamental functional units of multicellular organisms, since different cell types play different physiological roles in the body. Although every cell of an individual organism contains essentially the same genome structure, different cells realize diverse functions due to differences in their Previous approaches used to characterize cell phenotypes have several drawbacks that limited their ability to comprehensively identify the cellular complexity of human tissues. Transcriptional profiling of bulk cell sample mixtures by microarray or RNA sequencing can simultaneously assess gene expression levels and proportions of abundant known cell types, but precludes identification of novel cell types and obscures the contributions of rare cell subsets to the gene expression patterns present in the bulk samples. Flow cytometry provides phenotype information at the single cell level, but is limited by the number of discrete markers that can be assessed, and relies on prior knowledge of marker expression patterns. The recent establishment of methods for single-cell transcriptional profiling ,2 is revin vivo cell types in humans and major model organisms  is a biomedical ontology developed to provide this standard reference nomenclature for rganisms . Howeverrganisms . In this focused on mouse cerebral, visual and somatosensory cortices . More re,16; howe.et al. profiled 65 neuronal cells into six categories: neural progenitor cells, radial glia, newborn neurons, inhibitory interneurons and maturing neurons  and neurons  and identified 11 distinct inhibitory cell types , using cell sorting, scRNAseq and in vitro differentiation assays  and four different monocyte subtypes (Mono1–4), and went on to show that these different subtypes, which were defined based on their transcriptional profiles, exhibited different functional capabilities for allogeneic T cell stimulation and for cytokine production following TLR agonist stimulation  and one plasmacytoid dendritic cell subtype, See n assays . Villanimulation .et al. found that the non-malignant tumor microenvironment was composed of T cell, B cell, NK cell, endothelial cell, macrophage and cancer-associated fibroblast (CAF) subsets  or internally (e.g. transcription factors) would be used as the main differentia for the asserted hierarchy  Foundry , providerganisms . The semierarchy . Diehl e full CL . As of Dnecessary and sufficient marker genesselectively expressed by the cell typeThe minimum set of parent cell classin the CLA specimen source description(anatomic structure + species).A We recently discussed some of the challenges faced by the CL in the era of high-throughput, high-content single-cell phenotyping technologies, including sc/snRNAseq . One of minimum number of differentiallyexpressed genes, working in concert, that are sufficient to define a cell type from a given dataset. These marker genes can then be used for a variety of purposes, including the construction of semantic definitions in an ontological context. In order to identify the set of necessary and sufficient marker genes from an sc/snRNAseq experiment, we have developed a method—NSforest—that utilizes a random forest of decision trees machine learning approach. The methodology described here is unique in that it determines the To illustrate how this approach can produce standard cell type definitions, we have applied the method to a transcriptomic dataset derived from single nuclei isolated from the MTG, cortical layer 1 of a post-mortem human brain specimen . TranscrIn the first step , NSforesIn the second step, NSforest constructs single decision trees using first the top gene, then the top two genes, top three genes, etc., until a stable tree topology and optimal classification accuracy is achieved. The minimum number of genes necessary to obtain this stable classification result corresponds to the necessary and sufficient set of marker genes defining each cell type cluster within this experimental context.The expression of the complete set of marker genes obtained from applying NSforest to the single nuclei dataset is illustrated in rosehip neuronColloquial name—KIT-expressing MTG cortical layer 1 GABAergic interneuron, humanAlternative name—A humanMTGcortical layer 1 GABAergic interneuron that selectively expresses KIT, NTNG1and POU6F2 mRNAsDefinition—For one of the inhibitory interneuron cell types defined in this study (i5), we were able to connect the distinct transcriptional profile with a previous cell type defined based on its unique cellular morphology—the Rosehip cell . This thA complete set of cell type names and definitions for all cell type clusters identified in this experiment is provided in These informal textual definitions can then be converted into formal ontological definitions, represented in OWL as equivalent classes, using a set of logical axioms that combine assertions about the parent cell class (interneuron), anatomic locations of the neuron cell body (soma), functional capacity of the cell type (gamma-aminobutyric acid secretion) and marker gene expression (expresses some KIT) requirements . Using sin situ validation and multi-modal data acquisition will guide refinement of cell type definitions. This review shows a path for defining cell type markers that can be used for these validations and will help guide these refinements.The challenge remains of ensuring that these cell type definitions, whose necessary and sufficient conditions are derived from analysis of data from one particular methodology (scRNAseq), are compatible with both existing cell type classes in the CL and cell types defined using alternative experimental methods and data analysis approaches. Working with CL developers, we are now establishing an extension ontology module containing provisional definitions for novel cell types that we and other research groups will contribute. Ontological reasoners will be used to link these cell types to more general classes in the CL proper, structure them into an extended hierarchy, and determine when separate research groups have defined similar or identical cell types. CL developers will review these provisional cell types periodically to determine when multiple lines of evidence provide sufficient support to promote particular cell type classes to the CL itself. In this way we will ensure the integrity of the CL reference, while still allowing for the rapid expansion of its content to accommodate cell types defined via these new technologies. However, it should be noted that defining cell types will likely be an iterative process where The application of high-throughput/high-content cytometry and single-cell genomic techniques is producing an explosion in the number of distinct cellular phenotypes being identified in human specimens. For biomedical ontologies to stay relevant, it will be critical for ontology developers to establish procedures for the processing and incorporation of representations derived from these data-intensive technologies into reference ontologies in a timely fashion. The representation of defined cell types and their relationships in the CL will serve as a reference knowledgebase to support interoperability of information about the role of cellular phenotypes in human health and disease.Conflict of Interest statement. None declared.This work was supported by the Allen Institute for Brain Science, the JCVI Innovation Fund, the U.S. National Institutes of Health (R21-AI122100 and U19-AI118626), the California Institute for Regenerative Medicine (GC1R-06673-B), the Wellcome Trust 208379/Z/17/Z and from the Chan Zuckerberg Initiative DAF, an advised fund of the Silicon Valley Community Foundation (2018–182730). We thank Nik Schork, Jamison McCorrison, Pratap Venepally, Lindsay Cowell, Bjoern Peters, and Sirarat Sarntivijai for helpful discussion. Funding to pay the Open Access publication charges for this article was provided by the Chan Zuckerberg Initiative DAF, an advised fund of the Silicon Valley Community Foundation (2018-182730).


The collection, analysis, and use of data to measure and improve immunization program performance are priorities for the World Health Organization (WHO), global partners, and national immunization programs (NIPs). High quality data are essential for evidence-based decision-making to support successful NIPs. Consistent recording and reporting practices, optimal access to and use of health information systems, and rigorous interpretation and use of data for decision-making are characteristics of high-quality immunization information systems. In 2015 and 2016, immunization information system assessments (IISAs) were conducted in Kenya and Ghana using a new WHO and CDC assessment methodology designed to identify root causes of immunization data quality problems and facilitate development of plans for improvement. Data quality challenges common to both countries included low confidence in facility-level target population data  and poor data concordance between child registers and facility tally sheets . In Kenya, systemic challenges included limited supportive supervision and lack of resources to access electronic reporting systems; in Ghana, challenges included a poorly defined subdistrict administrative level. Data quality improvement plans (DQIPs) based on assessment findings are being implemented in both countries. IISAs can help countries identify and address root causes of poor immunization data to provide a stronger evidence base for future investments in immunization programs.In 2001, WHO developed a methodology, the Data Quality Audit . ModulesBoxReview of systems, processes, governance, and workforce to create an immunization data flow diagram.Support from a checklist and implemented through individual and focus group interviews.A systematic review of forms, tools, and the reports of previous assessments is performed to identify redundant tools and follow up any actions taken on previous recommendations.Evaluation of the completeness, internal consistency, trends, and external consistency of national administrative vaccination coverage data through triangulation with external sources following a defined protocol.Field teams administer a qualitative questionnaire and triangulate multiple sources of immunization data in a purposive sample of geographic regions, subnational sites, and health facilities.Team members are assigned a thematic area on which to focus observations during site visits.Topics include the following:Recording and data verificationData reporting, analysisDenominatorWorkforce, training, and human resourcesDebrief and review of all data and information gathered in the prior three modules.Develop a plan through root cause discovery using an established framework with engagement of stakeholders.The first IISA was conducted in Kenya in 2015. The desk review and national data review modules were performed remotely over a 3-month period using data and documents gathered by the Kenya Ministry of Health; the reviews were finalized 2 months before fieldwork began . Field qAn IISA was conducted in Ghana during 2016; modules were adapted to suit country needs. The desk review and national data review modules were conducted collaboratively by the Ghana Ministry of Health, WHO, and CDC during a 3-day in-country meeting 2.5 months before commencement of fieldwork. Participants were divided into two teams; one created a detailed description of the immunization data system, and the other analyzed immunization data trends and selected field assessment sites. After piloting the questionnaires, field teams visited four regions, eight districts, 14 subdistricts, and 34 health facilities over 7 days. Teams conducted initial analyses to create region-specific presentations for the debriefing. The DQIP was finalized 4.5 months after completion of the fieldwork.In both countries, four field data collection teams were deployed for the IISA, each composed of three to four members, including national and subnational ministry of health and NIP officials and one partner (WHO or CDC) representative. Subnational staff members evaluated sites outside their jurisdiction. Purposive sampling was used to select diverse sites, accounting for setting, population density, and vaccination coverage. Field teams used standardized questionnaires to gather information on immunization data practices and challenges. To assess concordance among data sources, teams compared aggregate totals of administered third doses of diphtheria and tetanus toxoid and pertussis (DTP3) vaccine and oral poliovirus (OPV3) vaccine among different facility data collection tools . These totals were compared with data at higher administrative levels. After data analysis was finalized, a DQIP was developed.Assessment results indicated a range of performance across indicators in Kenya and Ghana . Staff mIn Kenya, concordance was higher between data reported at the subcounty and health facility levels (63%) than between different data sources within the health facility (0%–31%); in Ghana, concordance was poor between subdistrict and health facility data (25%). In both countries, concordance between immunization tally sheets and child registers at health facilities was low  . Root caIn addition to identifying opportunities to improve NIP vaccination data quality in each country, the updated approach described here for assessing immunization data quality and developing a plan for improvement in Kenya and Ghana can inform future IISAs. Fieldwork was rapid in both countries; however, scheduling all the steps of an IISA in a condensed period can be challenging because of multiple NIP priorities and activities. One year from initiation of planning to consensus on a DQIP might be a realistic timeframe for many countries. Partner engagement and planning should begin at least 5 months before the projected start of fieldwork. The desk review might vary in duration depending upon the amount of information included, size of the team reviewing, and whether the review is done remotely or in-country. Additional time should be allotted for special circumstances such as political instability or the need for document translation.The experiences in Kenya and Ghana illustrate that the desk review and national data review modules can be adapted by countries under flexible IISA guidelines. More expedient implementation of the two modules was accomplished in Ghana by working in-country with the Ghana Ministry of Health and partners. Regardless of where reviews are conducted, ministry of health and in-country partners are necessary for compiling the required data and documents. For fieldwork, three to four member teams were sufficient for data collection, yet manageable for facilities. Diverse field teams composed of national, subnational, and partner staff members incorporated multiple viewpoints into findings. Assigning subnational staff members to geographical subunits outside their jurisdiction reduced the potential for bias and provided staff members with a range of perspectives.Various root causes of data quality challenges were identified. In both Kenya and Ghana, data in health facility registers were incomplete and demonstrated low concordance with other data sources. Other challenges included a low level of confidence in target population data, self-identified need for facility staff member training, and infrequent analysis and use of immunization data. Triangulation of data identified stronger subnational data concordance in Kenya, whereas Ghana had administrative and training support challenges at the subdistrict level.The findings in this report are subject to at least two limitations. First, findings are not nationally representative, which could have resulted in over- or underestimation of the concordance of vaccination event data between data collection tools and administrative levels. Second, this report describes the data from two countries; because each country is unique, these findings might not be generalizable to other contexts.Importantly, IISA guidance emphasizes following up all findings with an evidence-based, feasible DQIP developed collaboratively to fit within existing ministry of health and NIP timelines. Concrete actions have been taken based on the findings of the IISAs described. In Kenya, national and county target-setting workshops were convened; as a result, the DQIP was integrated into Gavi, the Vaccine Alliance health systems, strengthening support to 17 selected counties. In Ghana, pilot changes are being made to improve the managerial and supervisory skills of subdistrict staff members. In addition, data quality content is being incorporated into preprofessional coursework for health professional studies as well as continuing education for current staff members. In this way, the updated IISA guidance and its focus on data for action is providing an impetus for long-term change. Ultimately, higher quality immunization data provide better evidence for subsequent investments and interventions related to immunization programs, vaccine preventable disease surveillance, and outbreak response.The availability, quality, and use of immunization data are widely considered to form the foundation of successful national immunization programs. Lower- and middle-income countries have used systematic methods for the assessment of administrative immunization data quality since 2001, when the World Health Organization (WHO) developed the Data Quality Audit methodology. WHO adapted this methodology for use by national programs as a self-assessment tool, the Data Quality Self-Assessment. This methodology was further refined by WHO and CDC in 2014 as an immunization information system assessment (IISA).Findings of immunization information system assessments in Kenya and Ghana identified some common challenges, such as incompleteness of the facility child register, low confidence in target population data, and infrequent analysis and use of data at the facility level. The assessments also examined larger systemic challenges that could explain the root causes of these problems, such as a poorly defined subdistrict administrative level in Ghana and need for training on data quality and data use among facility staff in both countries.The experience gained from implementing assessments using updated IISA guidance in Kenya and Ghana provides an opportunity to inform other countries interested in best practices for assessing their data quality and creating actionable data quality improvement plans. Data quality improvement is important to provide the most accurate and actionable evidence base for future decision-making and investments in immunization programs. This review provides best practice experiences and recommendations for countries to use an IISA to assess data quality from national administrative structure down to the facility level. This methodology also meets the requirements for use by Gavi, the Vaccine Alliance, for monitoring national immunization data quality at a minimum interval of every 5 years in conjunction with funding decisions.