Annually around 40 million mothers give birth at home without any trained health worker. Consequently, most of the maternal and neonatal mortalities occur at the community level due to lack of good quality care during labour and birth. Interventions delivered at the community level have not only been advocated to improve access and coverage of essential interventions but also to reduce the existing disparities and reaching the hard to reach. In this paper, we have reviewed the effectiveness of care delivered through community level inputs for improving maternal and newborn health outcomes. We considered all available systematic reviews published before May 2013 on the pre-defined community level interventions and report findings from 43 systematic reviews.Findings suggest that home visitation significantly improved antenatal care, tetanus immunization coverage, referral and early initiation of breast feeding with reductions in antenatal hospital admission, cesarean-section rates birth, maternal morbidity, neonatal mortality and perinatal mortality. Task shifting to midwives and community health workers has shown to significantly improve immunization uptake and breast feeding initiation with reductions in antenatal hospitalization, episiotomy, instrumental delivery and hospital stay. Training of traditional birth attendants as a part of community based intervention package has significant impact on referrals, early breast feeding, maternal morbidity, neonatal mortality, and perinatal mortality. Formation of community based support groups decreased maternal morbidity, neonatal mortality, perinatal mortality with improved referrals and early breast feeding rates. At community level, home visitation, community mobilization and training of community health workers and traditional birth attendants have the maximum potential to improve a range of maternal and newborn health outcomes. There is lack of data to establish effectiveness of outreach services, mass media campaigns and community education as standalone interventions. Future efforts should be concerted on increasing the availability and training of the community based skilled health workers especially in resource limited settings where the highest burden exists with limited resources to mobilize. Annually around 40 million mothers give birth at home without any trained health worker . ConsequCommunity based delivery is now widely recognized as an important strategy to deliver key maternal and child survival interventions -10. It hHome-based strategies to support optimal maternal and neonatal care practices have emerged in the last decade to complement facility-based care and promote universal access to and utilization of health services with a specific focus on low- and middle- income countries (LMICs).These services mainly include ANC, skilled birth attendance and early PNC. Such programs involve standardized or individualized interventions for additional support provided during home visits, regular ANC visits, and/or by telephone throughout pregnancy by multidisciplinary teams of health professionals and trained lay workers. The major benefit of these programs is that the service is brought to the remote population in their own homes and allow care providers to deliver a more tailored health care service.Task shifting for human resource management involves substituting specialized personnel with healthcare workers that are lesser trained but can perform some aspects of their tasks. A range of both skilled and semi-skilled health workers can play a major role in MNH service delivery. Community health workers (CHW) and traditional birth attendants (TBA) are considered semi-skilled workers, while mid-level health workers (MLHW) such as nurses, midwives, associate clinicians, medical assistants and nurse auxiliaries are skilled workers certified for their work. Health service delivery through these skilled and semi-skilled healthcare workers has been practiced in both high-income countries (HIC) and LMIC all over the world for the past several decades. Evidence suggests that they can contribute significantly in improving health of the populations. More recently, due to the growing human resource crisis especially in LMICs, task shifting has re-emerged for extending services to hard-to-reach groups by substituting health professionals for a range of tasks -14. Coun. Many LMIC are increasingly facing difficulties in producing, recruiting and retaining health professionals as they tend to migrate to wealthier countries due to low salaries, poor working conditions, lack of supervision, low morale and motivation and lack of infrastructure [Globally there is a growing shortage of 7.2 million healthcare workers and around 90% of all maternal deaths and 80% of still births occur in countries that lack trained healthcare workforce . Althougtructure ,22. To otructure ,24. ThesSoon after the Alma-Ata Declaration, it was recognized that community participation was important for the provision of local health services and for delivering interventions at the community level. Since then, it has been advocated to build its links with improving MNH . CommuniIn this review, we aim to systematically review and summarize the available evidence from relevant systematic reviews on the impact of the outlined community level inputs Figure We considered all available systematic reviews published before May 2013 on the pre-defined community level interventions as outlined in our conceptual framework . A separOur priority was to select existing systematic reviews of randomized or non-randomized controlled trials, which fully or partly address the a priori defined community delivered interventions for improving quality of care for MNH. We excluded reviews on home visits for prevention or screening for child abuse, maltreatment and childhood injury prevention as these were not included in the scope of our review. Search was conducted in the Cochrane library and PubMed and reviews that met the inclusion criteria were selected and data was abstracted by two authors on a standardized abstraction sheet. Quality assessment of the included reviews was done using Assessment of Multiple Systematic Reviews (AMSTAR) criteria  as detaiOur search yielded 310 potentially relevant review titles. Further screening of abstracts and full texts resulted in the inclusion of 43 eligible reviews: 17 for outreach services , 6 for task shifting, 18 for human resource training and 2 for community mobilization , tetanus immunization coverage, breast feeding initiation within 1 hour  and clean cord care  . CommuniNurse- or midwives- based home visit programs did not report any significant impact on birth outcomes, hospital admission for complications and neonatal morbidity and mortality. However, some positive impacts were reported on immunization rates ; child health outcomes including mental and physical health; and injury prevention ,38,45. HWe included six ,46-50 reCare provided by midwives was found to be associated with significant improvements in antenatal hospitalization , episiotomy , instrumental delivery , initiation of breast feeding  and hospital stay  . AnotherWe found eighteen ,39,51-66In LMIC settings, training TBA  as a part of community based intervention packages showed significant improvement in referrals  and early breast feeding rates  with significant reductions in maternal morbidity , neonatal mortality (RR: 0.76 95% CI: 0.68-0.84) and perinatal mortality  . TBA traFor outcomes other than MNH, educational outreach visits and meetings were associated with improved compliance , prescription , professional practice , and some of the patient healthcare outcomes ,59. The We found two ,67 revieCommunity based intervention packages involving family members through community support and advocacy groups and community mobilization along with additional training of outreach workers was reported as one of the most successful strategies showing significant impacts on maternal morbidity , neonatal mortality (RR: 0.76 95% CI: 0.68-0.84), perinatal mortality , referral  and early breast feeding  . AnotherThere is a greater body of existing evidence on the effectiveness of community based inputs for improving MNH outcomes in LMIC compared to district and facility level inputs (discussed in papers 3 and 4) ,69. At cAlthough the process pathways for the effectiveness of community delivered interventions are uncertain, they seem to influence community awareness, behavior change and practices, such as accessing skilled birth, use of clean delivery kits, breastfeeding and care seeking for maternal and newborn illnesses. Our overview findings greatly add to the global evidence base of intervention and delivery strategies that may improve MNH outcomes. It implies that within the community level inputs, three interventions have unparalleled significance: first, CHW who provide primary health care, can mobilize community members and impart knowledge; second, training of and linkages to TBA can provide basic prenatal and obstetric care, as well as referrals where skilled birth attendants are absent; third, community support groups, especially women’s groups, can empower communities and help in problem solving and planning to improve opportunities for women’s health, as well as care for mothers and newborns.Countries in Asia and sub-Saharan Africa are facing critical shortages of healthcare workers despite of bearing 25% of the world’s diseases burden . ReasonsWith the established effectiveness of task shifting and training of CHW, future studies should focus on the factors affecting the sustainability and cost effectiveness of these interventions when scaled up . There iOutreach services may confer the most benefit to access and health outcomes in rural and underprivileged settings hence there is a need for good comparative studies in resource deprived settings rather than in HIC . Among tCommunity based interventions have promising potential to provide range of services throughout the continuum of care and also reach the hard to reach population groups. Current evidence emphasizes that effective community based strategies exist to deliver a range of preventive and promotive interventions to improve the quality of care delivered for MNH and many of these interventions have the potential to reduce maternal, perinatal and neonatal morbidity and mortality. There is now a need to implement them on a larger scale throughout the LMIC. These interventions exist within the current health systems in most of the LMIC and hence policies are needed to integrate and sustain various task shifting and training interventions with the maternal health programs within their health systems. All stakeholders including governments, communities and donors need to work together to form these policies and develop models of health care to suit the needs of their own population. Still more work needs to be done in areas of recruitment, deployment and retention of the community based health care workers in the rural and underprivileged areas and improve the working conditions for them.ANC: Antenatal Care; AMSTAR: Assessment of Multiple Systematic Reviews; CHW: Community Health Workers; CI: Confidence Interval; ENC: Emergency Newborn Care; HIC: High Income Country; LBW: Low Birth Weight; LHV: Lady Health Visitor; LHW: Lay Health Workers; LMIC: Low and Middle Income Country; MD: Mean Difference; MLHW: Mid Level Healthcare Worker; MNH: Maternal Newborn Health; NLS: Newborn life Support; NRP: Neonatal Resuscitation Programs; PNC: Postnatal Care; RD: Risk Difference; RR: Relative Risk; SBA: Skilled Birth Attendant; TBA: Traditional Birth AttendantWe do not have any financial or non-financial competing interests for this review.All authors contributed to the process and writing of the manuscript.Peer review reports are included in Additional file Click here for file


The Efficient Trial Conduct subgroup of the Work Programme of the UKCRC Registered Clinical Trials Units (CTUs) Network aimed to identify inefficiencies during the two key stages of the trial conduct life cycle: (i) from grant award to first participant, (ii) from first participant to final reporting of results.An online survey we sent to email lists for Quality Assurance, Information Systems, statistics, trial managers, and pharmacovigilance staff at registered clinical trials units. An email reminder was sent after two weeks.There were 43 respondents from 25 registered CTUs; one third were trial managers. From grant award to first participant R&D approvals were reported as a top inefficiency by 23 respondents, contracts by 22 and other approvals by 13. Site selection, feasibility, piloting at site, and site training were also issues.From recruitment of first patient to publication the top inefficiency was recruitment targets not met, with data collection (including CRF design) the next most common, followed by writing up. Delays in approvals for new sites and poor planning were also issues.Efficiency of trial conduct would be improved further improvement in the approvals process, better training of site staff, improved working relationships between Chief Investigators and CTUs, and by sharing good practice across CTUs. Better information is needed about how to improve the efficiency and quality of trial conduct.


LMNA leading to the production of a mutated form of Lamin A precursor called progerin. In HGPS, progerin accumulates in cells causing progressive molecular defects including nuclear shape abnormalities, chromatin disorganization, DNA damages and delay in cell proliferation. Although two clinical trials have recently produced promising results, as well as in vitro and in vivo, there is currently no cure for HGPS patients. In collaboration with the teams of Dr Nicolas Lévy (UMR_S 910) and Dr Lino Ferreira (University of Coimbra), we have addressed this challenge by developing two high throughput screenings using the unique self-renewal and pluripotency properties induced pluripotent stem cells (iPS cells). Accordingly, these studies revealed the potential therapeutic effect of two new classes of compounds rescuing both nuclear shape abnormalities and defects of differentiation through on one hand, an inhibition of the prenylation process and on the other hand, a decrease of progerin expression.Progeria, also known as HGPS, is a rare, fatal genetic disease characterized by an appearance of accelerated aging in children. This syndrome is typically caused by mutations in codon 608 (p.G608G) of the


Unsaturated oil-containing fruits such as avocados are nutritionally unique among fruits in that they are lower in sugar and higher in fiber and monounsaturated fatty acids than most other fruits, and they also have the proper consistency and texture for first foods with a neutral flavor spectrum. Taken together, avocados show promise for helping to meet the dietary needs of infants and toddlers, and should be considered for inclusion in future dietary recommendations for complementary and transitional feeding.Infant dietary patterns tend to be insufficient sources of fruits, vegetables, and fiber, as well as excessive in salt, added sugars, and overall energy. Despite the serious long-term health risks associated with suboptimal fruit and vegetable intake, a large percentage of infants and toddlers in the U.S. do not consume any fruits or vegetables on a daily basis. Since not all fruits and vegetables are nutritionally similar, guidance on the optimal selection of fruits and vegetables should emphasize those with the greatest potential for nutrition and health benefits. A challenge is that the most popularly consumed fruits for this age group ( Proper nutrition is one of the most influential factors for insuring normal growth and development during a child’s first years of life, yet there are currently very few research-based dietary recommendations for parents and caregivers regarding this critical time period . CurrentNutrition delivery to infants is influenced by physiological development, growth demands, and to some extent by family dietary practices. During the first six months after birth, breast milk is recommended as the exclusive source of nutrition necessary for early infant health and development , especiaAlthough the timeframes for complementary and transitional feeding are not officially defined, for this review, the complementary feeding period is considered to start when the first foods (other than breast milk or formula) are consumed and continues throughout the infant’s first year of life (approximately six to 12 months), while the transitional feeding period covers a toddler’s dietary pattern during their second year of life 13–24 months). Nutrient and energy deficiencies during the early developmental stages can have lasting effects on the health of the offspring  months. ,6. Therei.e., apples, pears, bananas, grapes, strawberries, and peaches) . The sugar content is less than 1 g per serving, which is the lowest amount compared to all other fresh fruits. A 1-ounce (30 g) serving of avocado is higher in key developmental nutrients such as folate, vitamin E, and lutein compared to a Nutrition Labeling and Education Act (NLEA) serving size of the most popular complementary and transitional feeding fruits (peaches)  [11,12,1peaches) . The fati.e., from the time of conception to the end of a toddler’s second year). The first paper in the series provides evidence for the regular inclusion of key nutrients as well as low-glycemic fruits and vegetables, such as avocados, in a maternal diet for improving birth outcomes and various aspects of maternal health extending from the pre-conceptional period through pregnancy and lactation [What types and amounts of complementary foods are necessary for infants fed human milk, formula, or mixed feedings to promote favorable health outcomes, such as (1) growth and physical development; (2) cognitive, behavioral or neuromotor development?What strategies can be used to improve dietary quality and micronutrient intake in infants six to 12 months of age?What are the evidence-based strategies to enhance acceptance of nutrient-dense foods like fruits and vegetables?Does exposure  to nutrient-dense foods in weaned infants increase acceptance of nutrient-dense foods?Does increased acceptance/preference for nutrient-dense foods in the first year of life persist? Does it improve dietary intake of nutrient-dense foods at 12–24 months?Does the intake of foods with added salt and sugar in infancy influence the preference and analgesic appeal of dietary salt and sweet in infants, young children, and adults?What are the energy requirements for toddlers, ages 12–24 months, to promote optimal growth and physical development?What is the relationship between observed intakes of fiber, vitamin A, and folate and the estimated average requirement (EAR) and upper limits (UL) for toddlers 12–24 months of age?What food characteristics  impact the development of food preferences and dietary intake?This paper is the second of a two-part series on ideal food and nutrient intake and related health outcomes covering the first 1000 days of life  and other leading developed countries is consistent in the recommendations that complementary feedings should begin at about six months of age to support sufficient infant growth and development ,20,21,22A consensus statement from the American Heart Association (AHA) on dietary recommendations for children acknowledged that only a small percentage of infants in the U.S. remain exclusively breastfed after four months of age . Corroboi.e., iron, zinc, calcium, provitamin A/carotenoids, vitamin C, and folate) [Infants will usually triple their body weight between birth and the end of their first year, and much of this growth occurs in the complementary feeding period . In orde folate) .i.e., first year versus second year of life); (2) the texture and consistency of foods recommended, which require more developed mastication and digestive abilities; and (3) the portions consumed, based on individual appetite, breast milk and/or formula consumption, and nutritional needs. Toddlers typically consume an increasingly complex diet, moving further away from milk and/or formula towards a diet more focused on a variety of table foods, especially those consumed by other family members [Similarly to complementary feeding, transitional feeding (13 to 24 months) is defined as all solid and liquid foods consumed other than breast milk and infant formula. The main differences between complementary foods and transitional foods are: (1) the timeframe in which they are consumed . The existing evidence is further complicated by datasets that do not distinguish between age groups and combine one- and two-year-olds together without teasing out the differences between these age groups . Toddler2015 Dietary Guidelines for Americans (DGA) [Many of the nutrient-rich foods recommended by the ns (DGA)  for chilns (DGA) ,37, althns (DGA) ,39. Othens (DGA) ,20. Furtns (DGA) .Data from the landmark Feeding Infants and Toddlers Studies (FITS I and FITS II) along with recent National Health and Nutrition Examination Survey (NHANES) data (from children over two years old) show that young children consume nearly 40% of their total energy from foods like refined grains, sugar-sweetened beverages, and fruit juice. . The fini.e., nutrient-rich, colorful, naturally soft texture, low in sugar/not overly sweet, low-glycemic). This positions avocados as both a unique and ideal food for infants and toddlers.The most popular fruits consumed by infants were apples, bananas, peaches, and pears , and oftFruits and vegetables are vital to a healthy eating pattern as they contain essential nutrients, various forms of fiber, and potentially beneficial bioactive components such as antioxidants and phytosterols ,45. Yet,Experts suggest that vegetables and low-sugar fruits, such as avocados, should be introduced in the early stages in order to avoid invoking an early preference for sweet foods, which may influence early childhood and later life eating behaviors ,8. The dObservational studies have demonstrated later health benefits of healthful early nutrition choices. Better body weights in later years were observed in infants who consumed higher amounts of fruits and/or vegetables and thus less total energy in their diets . InfantsIn infancy, fat should comprise about 50% of energy intake in order to provide adequate energy for rapid growth and the essential fatty acids for brain development . With thn = 9), while a lesser amount comes from other MUFA, polyunsaturated fatty acids (PUFA), and saturated fatty acids (SFA). Although oleic acid is not considered an essential fatty acid because the human body can synthesize it from other fatty acids, it is the most abundant fatty acid in breast milk [n-6) [A joint statement from Health Canada, the Canadian Pediatric Society, Dietitians of Canada, and Breastfeeding Committee for Canada suggests that parents and caregivers should provide adequate amounts of healthy fats in addition to breast milk, and specifically includes avocados as an example of a nutritious fat-containing food for infant health . Avocadoast milk . MUFA, sast milk , as wellast milk ,16. A 30lk [n-6) , which clk [n-6) . Evidenclk [n-6) .Since avocados provide energy, MUFA, and PUFA, they would contribute to achieving nutrient balance in infant diets, as well as aiding in absorption of fat-soluble nutrients, providing a source of antioxidants, and thereby potentially contributing to health benefits ,64,65.Breast milk contains various non-digestible oligosaccharides, which are small-chain prebiotic fiber compounds that are important for infant gut health and immune development ,67. WhilNeither the appropriate amount nor type of fiber for infants is as yet determined, with both too little and too much dietary fiber posing their own unique set of problems. Too little fiber can lead to constipation , and excConcern is expressed by practitioners and researchers about both too much fiber intake in the early feeding periods, and inadequate fiber consumption throughout every life stage thereafter ,68,69,75Avocados could contribute to infant fiber intake as they have approximately 2 g of fiber in a 30 g serving , which ii.e., prebiotics such as oligosaccharides) from breast milk are known to have potent beneficial effects on infant health [The higher soluble fiber content of avocados compared to other fruits may be of benefit to the development of an infant’s/toddler’s gut microflora as it is fermented by the colonic microflora to a greater extent. While fermentable soluble fibers  that are associated with infant health and development [Breast milk is known to have numerous bioactive properties  with a neutral flavor profile in the early complementary period [In order to establish a varied eating pattern—which includes neutral, sour, and bitter taste acceptance—the ideal initial foods should be those that are both nutritious and have a low to moderate sweet and salty flavor profile . Such pry period . AvocadoIn addition to flavor preferences, infants also have texture preferences due to their developing abilities to chew and swallow. When foods are being introduced to infants it is important that caregivers provide a variety of soft textures—such as creamy, lumpy, tender, pureed, mashed or ground—in order to properly develop oro-sensory functions and the swallowing mechanism . DiffereA consistent message from recent literature is that fruit and vegetable intake needs to be increased in infant and toddler dietary patterns; selection of those foods that are lower in sugar and higher in fiber should be recommended above varieties that are higher in sugar and overly sweet. Most specific recommendations for parents and caregivers suggest offering a wide variety of fruits and vegetables on a daily basis, with an emphasis on colorful fruits and dark green, leafy, and deep yellow vegetables . For fruAvocados are a good example of a fruit that could be specifically recommended as an optimal transitional food. Beyond its texture, flavor and nutrient profile, avocado consumption among infants and toddlers may be able to displace empty calorie offerings more effectively than other nutrient-rich complementary and transitional foods due to their higher amount of appetite suppressing fatty acids and fiber ,113. AccContain a spectrum of essential and non-essential nutrients with potential health benefits that minimize undesirable components such as sodium, empty calories, and unhealthy fats.Provide an ideal source of energy  to meet the increasing energy and growth demands of weaning infants and toddlers.By weight and serving size, contain some of the highest levels of the antioxidants lutein, zeaxanthin, and glutathione among complementary and transitional foods.Are rich in unsaturated fatty acids, which significantly enhance the absorption of lipid-soluble compounds.Contain more total fiber and soluble fiber per gram than almost all other complementary and transitional foods, and at the same time contain less mineral-binding phytates and oxalates than other popular high-fiber foods.Have a neutral flavor and smooth consistency that is ideal for early infant foods.Major transitions occur in the dietary patterns of infants and toddlers over the first two years of life. Exposure to certain foods and nutrients during the first two years may impact their future health through metabolic programming or development of specific tastes . The mosi.e., those that meet the majority of recommended guidelines). Future research on ideal infant and toddler foods, including avocados, is warranted to further explore their potential in both early life and later life health outcomes.At present, the current infant feeding recommendations tend to be based on anecdotal and observational findings, which are largely dependent on an infant’s learned preference for sweet foods. Future development of complementary and transitional feeding recommendations should utilize evidence from controlled studies that investigate the critical nutrient needs of infants and toddlers, and should progress toward identifying the most ideal foods (


Early interventions for psychological consequences of traumatic events should be based on the best available evidence while they are delivered in a great variety of contexts Litz, . AdditioThe panelists discussed diverse aspects related to evidence and practice of early interventions. Biological aspects include developing research on prevention by means of pharmacologically reducing hyperarousal and increasing the likelihood of pro-social behavior. The evidence, benefits, and drawbacks of very early psychological structured interventions were highlighted, including the use of new technology as stand-alone interventions or supplementary modules Olff, . The panThe national societies for psychotraumatology may serve as a link to local and regional initiatives for improving psychosocial interventions to international societies. For example, they can provide nationally adapted information about developments in science and practice, and, importantly, facilitate communication and interaction between local researchers and clinicians across countries.This conference was funded by a grant from The Swedish Foundation for Humanities and Social Sciences (F14-1747:1).


To evaluate retrobulbar blood flow characteristics of glaucoma suspects with glaucomatous optic disc appearance (GODA) in comparison to healthy control group (CG) and primary open angle glaucoma patients (POAG) and assess the effect of age.145 patients from a single glaucoma clinic were enrolled and classified into two diagnostic groups (GODA and POAG). Third group of subjects consisted of 67 age matched individuals (CG). Retrobulbar blood velocity measurement in central retinal artery was performed using color Doppler imaging (CDI). CDI images were processed in custom software leading a range of parameter estimates from a continuous waveform signal. The effect of age on the estimated parameters was evaluated with the stepwise forward regression and ANCOVA in which age was used as a continuous factor. One-way ANOVA was used to test for the differences in the CDI parameters between the three considered groups. Correlation between restive index (RI) and pulsatility index (PI) was assessed with a bilinear fitting guaranteeing no discontinuities in RI intercept estimate. Fisher test was used to assess the applicability of a bilinear PI/RI relationship, while the statistics of the RI intercept estimate were evaluated using the bootstrap.ANCOVA showed significant interaction between age and group (p<0.05) for five out of nine considered CDI parameters. The RI intercept for CG and GODA groups was 0.602±0.047, and 0.574±0.044 respectively, while the RI intercept of 0.934±0.066 was found for the POAG.The observed similarity of CG and GODA group and dissimilarity between GODA and POAG groups in terms of PI/RI relationship is remarkable. Age may play some role in the different mechanisms occurring in blood velocity dynamics in GODA and POAG subjects but it is not a strongly determining factor. Measurement of retrobulbar blood velocity with color Doppler imaging is a powerful noninvasive technique for assessing the eye’s hemodynamics –3. GlaucAge is an important factor as it affects both the biomechanical parameters of the eye such as the scleral rigidity as well as the retrobulbar hemodynamics –14. HoweThe majority of works utilizing color Doppler imaging focus on four major parameters of ocular blood velocity including peak systolic velocity (PSV), end diastolic velocity (EDV), Pourcelot’s resistive index (RI) and pulsatility index (PI). Additionally, parameters such as the ratio between PSV and EDV , the meaFor the ocular blood velocity parameters to have a predictive or discriminative value, they need to be characterized by high repeatability and reproducibility –18. In sOcular blood velocity characteristics are usually assessed in the ophthalmic artery (OA), central retinal artery (CRA) and ciliary arteries (CAs). The CRA waveforms (above the zero line) contain information from a single artery and can be acquired in a reproducible manner if taken posterior to the lamina cribrosa . Also, mThis study focused on automatic acquisition of retrobulbar blood velocity parameters in CRA derived from a continuous waveform of several heart cycles to evaluate differences between glaucoma suspects with glaucomatous optic disc appearance, healthy subjects, and primary open angle glaucoma patients and to assess the effect of age.The study had a prospective nature. It comprised of 145 patients  and 67 age matched volunteers . The former group was recruited from the regular patients of the Glaucoma Clinic at the Department of Ophthalmology, Wrocław Medical University. The control group was enrolled from the university staff and their family members who had no ocular and systemic pathologies. Subjects were fully informed of the purpose of the study and all procedures and their requirements. Informed subject consent was obtained before any measurements were taken. Written informed subject consent was obtained before any measurements were taken. The project was approved by the Ethics Committee of the Wroclaw Medical University (KB 481/2009) and adhered to the Tenets of the Declaration of Helsinki. Study exclusion criteria included any systemic disease, history of ocular trauma or eye disease other than glaucoma.The group of patients was divided into two subgroups of those diagnosed as glaucoma suspects with GODA and those with the primary open angle glaucoma (POAG). GODA diagnosis was determined by clinical assessment including narrowing of the neuroretinal rim with optic cup concentric enlargement, localized notching, or both, but normal visual field, an open angle, and intraocular pressure of less than or equal to 21 mmHg. POAG diagnosis was based on glaucomatous changes in the optic nerve head with corresponding visual field defects and high or normal IOP in the presence of an open angle.None of the subjects was taking any systemic medications. In the POAG group, patients were taking prostaglandins (42%), beta-blocker drops (35%), carbonic anhydrase inhibitor eye drops (28%) and alpha agonists (15%). Forty one percent of patients were taking medications in the GODA group: prostaglandins (17%), carbonic anhydrase inhibitor eye drops (19%) and beta-blocker drops (5%).All participants of the study underwent review of general and medical ophthalmological history and best corrected distance and near visual acuity. This was followed by the measurement of central corneal thickness , measurement of intraocular pressure with Goldman applanation tonometry and dynamic contour tonometry , measurement of systolic and diastolic blood pressure , and measurement of blood velocity in central retinal artery (CRA) with color Doppler imaging device . Up to three measurements per subject were acquired. For DCT, output data included estimates of IOP, OPA, and HR. For CDI, output data consisted of the raw images that were processed in a custom written software to lead estimates of PSV, EDV, RI, PI, MV, ESA, areas under the systolic and diastolic part of the waveform , and the ratio between them (S/D).Additionally the glaucoma clinic patients underwent optic nerve head examination with Heidelberg scanning laser ophthalmoscope  and automated visual field examination  with dynamic test strategy. Output data from the HRT3 included retinal nerve fiber layer (RNFL) and cup/disk ratio (CDR) while the output of automated visual field examination included the mean defect (MD).Raw images, exported from the instrument in a DICOM  format were used to extract the CDI waveform signal, that normally consisted of several (up to five) wave pulses. A smoothing filter was applied, each individual pulse was identified using standard peak detection, and a set of parameters PSV, EDV, RI, and PI, MV, ESA, S, D, and S/D was calculated as a median from the several wave pulses see . In thisFollowing Pinto et al.  correlatz-test for the two proportions was used. For testing the effect of age and group on the CDI parameters, analysis of covariance (ANCOVA)  with age being used a continuous factor was utilized. The significance level for all the tests was set to 0.05.Single factor analysis of variance (ANOVA) was used to test the hypothesis of equal means in GAT IOP, DCT IOP, OPA, HR, CCT, mean systolic and diastolic blood pressures. Student t-test was applied for the RNFL, CDR, and MD as those were compared between GODA and POAG groups. The analyses were preceded with testing for data normality (Jarque-Bera test). The Levene’s test did not reject the hypothesis of equal variance. To test the gender distribution between each pair of groups, the p < 0.05).The main group demographics together with the group mean GAT IOP, DCT IOP, OPA, HR, CCT, MD, RNFL, CDR, and systolic and diastolic blood pressures are shown in p <0.05) between the three considered groups were obtained for EDV, RI, PI, and MV parameters. ANCOVA results for the CDI parameters, with age set as a continuous factor, are collated in the last column of The group mean and range of the nine considered parameters derived from the blood velocity waveform are collated in Correlation analysis of RI and PI has been considered for the three subject groups see . For theCorrelation analysis was performed between RI and other parameters of ocular blood velocity including MV, ESA, S, D, and S/D. Significant bilinear relationships were obtained for several pair of parameters but results showed at most moderate correlation. Similarly, correlation analysis was performed for all CDI parameters and MD, CDR and RNFL for the glaucoma clinic patients. Weak or moderate correlations were observed but some were statistically significant  waveform, but it is not a strongly determining factor. They also indicate potential for the onset and progression of glaucomatous optic neuropathy (GON). Compared with a group of age-matched healthy control subjects, the glaucoma suspects and the POAG patients showed reduced retinal blood velocity and more pulsatile blood velocity in retinal arteries. To our knowledge, this is the first study to examine the influence of age upon ocular hemodynamics including GODA subjects.The exact mechanism driving these changes is unclear, however, a reduction in the vessel diameter, an increase in peripheral vascular resistance or loss of autoregulatory processes that are strongly influenced by the endothelium have been suggested as likely causes of reduced blood velocity associated with the development of glaucomatous optic nerve damage and age –24. PrevA number of previous CDI studies found reduced peak systolic (PSV) and end-diastolic (EDV) velocities, and increased resistivity index (RI) in retrobulbar vessels of glaucoma patients compared to healthy normal controls –32. InteOther CDI parameters of CRA such as ESA, S, D, S/D although showed some significant differences did not add more information to the exact nature of the perturbation of ocular blood velocity than that already achieved by the four main CDI parameters.Given that a decrease in EVD was shown to be a sensitive indication of increased downstream impedance, which also leads to increased resistivity indirectly measured by RI and PI indices , our resTo our knowledge only one study , has preThe reason for the discrepancy between Pinto et al.  and our It is widely recognized that blood velocities in the CRA are influenced by IOP and show an inverse relationship with IOP , 44; thup = 0.05) in the three groups. Moreover, the OPA results showed positive correlation with RI and PI indices and negative relationship with PSV and EVD in glaucoma and GODA patients. These findings are in contrast to previous studies that demonstrated a positive correlation between the OPA and RI in the CRA only in the healthy population [Similarly, the OPA measured with DCT of the glaucoma patients was significantly different to that of the CG, while GODA patients demonstrated similar to glaucoma subjects’ relation between OPA and blood flow-related parameters; the OPA was not significantly different to normal subjects. This result was consistent to our previous findings  but in cpulation , 49. ThiWhile there is general consensus that ocular blood velocity is reduced in glaucoma, the precise relationship among visual field loss, ocular hemodynamics and structural damage remains debatable. Our data are in agreement with data obtained by Yamazaki et al.  and GalaOnly few studies evaluated the correlation between the RNFL thickness and ocular hemodynamics and they illustrated a positive correlation between blood flow parameters (PSV and EDV) and the mean RNFL in POAG patients –55. Our The present study demonstrated that assessing differences in ocular hemodynamic parameters using an automated acquisition of a continuous CDI waveform may help in the future to detect patients with the increased risk of developing glaucoma.S1 Table(XLSX)Click here for additional data file.


Quantum mechanics has an important role in photosynthesis, magnetoreception, and evolution. There were many attempts in an effort to explain the structure of genetic code and transfer of information from DNA to protein by using the concepts of quantum mechanics. The existing biological quantum channel models are not sufficiently general to incorporate all relevant contributions responsible for imperfect protein synthesis. Moreover, the problem of determination of quantum biological channel capacity is still an open problem. To solve these problems, we construct the operator-sum representation of biological channel based on codon basekets (basis vectors), and determine the quantum channel model suitable for study of the quantum biological channel capacity and beyond. The transcription process, DNA point mutations, insertions, deletions, and translation are interpreted as the quantum noise processes. The various types of quantum errors are classified into several broad categories: (i) storage errors that occur in DNA itself as it represents an imperfect storage of genetic information, (ii) replication errors introduced during DNA replication process, (iii) transcription errors introduced during DNA to mRNA transcription, and (iv) translation errors introduced during the translation process. By using this model, we determine the biological quantum channel capacity and compare it against corresponding classical biological channel capacity. We demonstrate that the quantum biological channel capacity is higher than the classical one, for a coherent quantum channel model, suggesting that quantum effects have an important role in biological systems. The proposed model is of crucial importance towards future study of quantum DNA error correction, developing quantum mechanical model of aging, developing the quantum mechanical models for tumors/cancer, and study of intracellular dynamics in general. Recently, quantum biological studies have gained momentum, which can be judged by the number of recent publications related to this topic ,19,20,21quantum biological channel capacity is still an open problem. On the other hand, the classical biological channel capacity has been determined by Yockey  denotes the von Neumann entropy. The elements in the i-th row and the j-th column of the information matrix U can be found as Equation 7.The genetic noise introduces uncertainty about the genome, and the amount of information related to initial density state essed as   gives the entropy of the environment. By employing the HSW theorem  stands for the biological channel output (input) entropy, and H(Y|X) [H(X|Y)] represents the conditional entropy (or the equivocation) of biological channel output (input) given the biological channel input (output) X (Y). The entropy of biological channel output and conditional entropy are defined respectively as Equations 10 and 11.p(iX)} denotes the probability of occurrence of codons in DNA, and {p(jY|iX)} denotes the conditional probability of the received codons {iY} given the transmitted codons {Xi}. Since the source information encrypted in DNA is discrete, the maximum information rate in (9) is achieved for the uniform distribution of codons; that is ip=0 for stop codons  and ip = 1/61 for other codons. The classical biological channel capacity curve in mnp required in Equations 10 and 11 are obtained numerically by using the model shown in For completeness of presentation, in We presented the quantum biological channel model suitable for study of quantum information transfer from DNA to proteins. By using the transition probabilities of codon basekets, the quantum channel model is developed by exploiting the operator-sum representation. The quantum genetic noise originates from the imperfections in transcription process, DNA point mutations, insertions, deletions, and imperfect translation process. This quantum channel model has been adopted to evaluate both quantum and classical channel capacities in the presence of genetic noise. The proposed quantum biological channel model is of crucial importance for future study towards quantum DNA error correction and study of various biological systems from a quantum information theory point of view. It can also be used to develop the quantum mechanical model of aging, and the quantum mechanical models for tumors and cancer. The similar channel model can be developed to study other aspects of intracellular dynamics. Regarding the complexity, the quantum processes in the cell do not require very complicated quantum information-processing devices. For instance, the DNA replication process described in terms of Grover’s search algorithm requires only the rotation and oracle operators, which can be quite straightforwardly implemented . Based o


Protected areas (PAs) are at the forefront of conservation efforts, and yet despite considerable progress towards the global target of having 17% of the world's land area within protected areas by 2020, biodiversity continues to decline. The discrepancy between increasing PA coverage and negative biodiversity trends has resulted in renewed efforts to enhance PA effectiveness. The global conservation community has conducted thousands of assessments of protected area management effectiveness (PAME), and interest in the use of these data to help measure the conservation impact of PA management interventions is high. Here, we summarize the status of PAME assessment, review the published evidence for a link between PAME assessment results and the conservation impacts of PAs, and discuss the limitations and future use of PAME data in measuring the impact of PA management interventions on conservation outcomes. We conclude that PAME data, while designed as a tool for local adaptive management, may also help to provide insights into the impact of PA management interventions from the local-to-global scale. However, the subjective and ordinal characteristics of the data present significant limitations for their application in rigorous scientific impact evaluations, a problem that should be recognized and mitigated where possible. The Wor(PoWPA)) , p. 5.Since the mid-1990s, various methodologies have been developed for assessing PA management effectiveness (PAME) –14. AssePAME assessments were originally developed to support adaptive management of PAs at site level and system level. Their primary purposes were (i) to improve PA management through information sharing and adaptive management; (ii) to more effectively allocate resources to the PAs or the management themes most in need (e.g. shifting attention to law enforcement or pest plant management); (iii) to provide accountability and reporting at local, national or international levels; and (iv) to increase community awareness of PA management and issues.(1) discuss the conceptual roots of PAME and to what extent understanding management impacts forms part of the rationale for the development of PAME;(2) explore the different types of PAME assessment, including how PAME methodologies capture information on PA management and biodiversity outcomes, and the users and uses of PAME to date;(3) present available PAME datasets and discuss the regional and ecological coverage of these data, measuring progress towards the CBD PAME targets;(4) review the available evidence for a link between PAME scores and PA management outcomes and impacts; and(5) identify limitations and propose approaches for overcoming them.The PAME assessments hold a wealth of information on PA management efforts. They have been applied globally, and use standardized methods for collecting management data. Given this, the collated dataset provides a potentially valuable resource for measuring and understanding the impacts of PA management interventions. Impact evaluation aims to understand the intended and unintended impacts that are caused by an intervention , in thiset al. [To standardize our use of terminology, we use the monitoring and evaluation definitions of Mascia et al. .2.Conceptually, most PAME approaches relate to the International Union for Conservation of Nature World Commission on Protected Areas (IUCN WCPA) framework , which iet al. [PAME assessments evaluate the management elements of planning, inputs, processes, outputs and outcomes within an assessed context. These elements form a results chain similar to that of logic models, but are more often depicted as steps around a management cycle , to stress the feedback of information into an adaptive management process. In an overview of approaches to conservation monitoring and evaluation, Mascia et al.  suggest et al. , p. 39 s3.a,b; methods in electronic supplementary material, S4). Among major biomes  and ecoregions  [As of January 2015, 17 739 PAME assessments had been collated in the GD-PAME, representing 9037 PAs, with 3666 sites having multiple assessments. Some 17.5% of countries have already met the CBD PoWPA 2015 60% PAME assessment target  , the freNinety-five PAME assessment methodologies are recorded in the GD-PAME –14. MostThe most widely used PAME methodologies are the management effectiveness tracking tool (METT)  , with large PA project portfolios across many countries . The GEFThe past decade has seen an increase in assessments led by national PA agencies and government ministries  to assess the current knowledge on the correlations between PA management, as measured using PAME data, and biodiversity outcomes measured by external methods. We reviewed 185 papers at the level of title and abstract, retaining 23 papers for detailed review of the main text, which yielded a final set of five peer-reviewed papers. Papers excluded at both stages were (i) papers that did not employ a PAME methodology; (ii) those that did not relate PAME results to a measure of outcome or impact owing to the PA. Individual reasons for exclusion of papers at the second-review stage are given in electronic supplementary material, S6. In addition, four ‘grey literature’ reports were identified by searching online libraries and web pages of agencies and organizations known to use PAME assessment tools. This gave a total of nine studies for further analysis, all from tropical developing countries, mostly in Africa and Latin America .Table 2in situ on changes in animal populations, species distributions or expert assessments of the state of biodiversity. Six of the nine studies focused on overall management performance and used a single total PAME score per site.Three studies used remotely sensed data on tree cover change to measure the impact of PAs on deforestation rate, using statistical matching methods to construct counterfactuals, and then investigated correlations between PAME scores and the size of the measured impacts –8. The rFive of the nine studies found a positive relationship between PAME scores and biodiversity outcomes; the other four, including the three studies that measured impact using a counterfactual comparison, found no correlation ,41,42. I6.Previous studies using PAME data for impact assessment have suffered from small sample sizes. However, management data are now collated and available for over 9000 PAs, predominantly in biodiverse tropical regions, potentially allowing for more extensive analysis.PAME methodologies are a useful management tool for PA managers with a limited budget. However, they are unlikely to fulfil the data requirements of robust impact evaluation. Methodologies such as the METT and RAPPAM provide a rapid and cost-effective means of communicating the effectiveness of current management and changes in management practices over time to managers and stakeholders. The approach can be easily implemented across a wide range of PA types. However, PAME tools use a relatively simple subjective, ordinal scoring system with limited collection of validating information or systematic auditing of results.Furthermore, owing to the self-assessment nature of PAME methodologies, the process used to gather expert knowledge for PAME assessment has significant influences on the results and their credibility . EspeciaMost previous analyses of PAME results in relation to outcomes and impacts have calculated a total PAME score for each PA , and useCurrent studies have generally relied upon one-off assessments using PAME data and biodiversity outcome measures from the same period. Static data on PA management may hide important improvements or declines in management over the time period being studied. In addition, the effects of management interventions on outcomes of PAs will rarely be instantaneous; for example, increases in hunted mammal populations may only be measurable years after a reduction in poaching has been achieved. Over 3600 PAs globally now have repeat assessments held in the GD-PAME, of which over 2100 PAs have been assessed three or more times . Therefore, the impact of changes in management on biodiversity outcomes could now be considered. Continued collection of PAME data through repeat assessments from the same PAs, leading up to and continuing after 2020, will be critical to assemble a significant global time-series dataset.7.The large amount of data now held in the GD-PAME provides an opportunity to measure the impact of PA management on biodiversity outcomes at the global scale. Suitable large-scale datasets on biodiversity outcomes, such as changes in terrestrial and marine species populations (e.g. living planet index (LPI), ; The SeaStudies of the effects of PA management at the local or system level can investigate whether specific management interventions achieve desired management goals; studies could focus, for instance, on the effect of a weed-eradication programme, or law-enforcement efforts to reduce tiger poaching. For rigorous impact evaluation, we would require time-series data on the management interventions, together with time-series data on expected outcomes  from both within the PA and an appropriate counterfactual. Some PAME methodologies such as SOP do collect data on individual management interventions such as pest control, as well as data on changes in specific outcomes such as pest population estimates, but do not collect data from appropriate counterfactuals. Data on counterfactuals are unlikely to exist for many PAs, owing to budget, time and staff constraints, and because counterfactual thinking is not mainstream within the conservation community . MeasureEven when quasi-experimental methods cannot be used to assess impacts in comparison with appropriately selected counterfactuals, instilling counterfactual thinking into adaptive management processes is a useful way for park managers and advisors to be more explicit about the assumptions they are making, and the possible impacts that are caused by specific interventions. Some PAME evaluations such as SOP are already designed to foster counterfactual thinking, by asking PA managers whether they consider changes in outcomes to be owing to management interventions or external influences. In comparison, tools such as METT and RAPPAM that are relatively weak at capturing outcome-level data  may bene8.The establishment and management of PAs remain a primary strategy for biodiversity conservation involving the investment of substantial effort and resources by a wide range of institutions and stakeholders . Over thDifferent monitoring approaches and tools will meet different needs; there is no one monitoring and evaluation approach that fits all conservation efforts . The majAlthough not their primary purpose, PAME data have been used for both performance and impact evaluation . HoweverDespite the above-noted challenges, we strongly believe there is a continued need for rigorous scientific impact evaluations of PAs and individual management interventions. There is an emerging evidence base that PAs do work, especially when they are well managed ,61,62, b


To examine associations between workplace injury and musculoskeletal disorder (MSD) risk and expert ratings of job-level psychosocial demand and job control, adjusting for job-level physical demand.Among a cohort of 9260 aluminium manufacturing workers in jobs for which expert ratings of job-level physical and psychological demand and control were obtained during the 2 years following rating obtainment, multivariate mixed effects models were used to estimate relative risk (RR) of minor injury and minor MSD, serious injury and MSD, minor MSD only and serious MSD only by tertile of demand and control, adjusting for physical demand as well as other recognised risk factors.Compared with workers in jobs rated as having low psychological demand, workers in jobs with high psychological demand had 49% greater risk of serious injury and serious MSD requiring medical treatment, work restrictions or lost work time . Workers in jobs rated as having low control displayed increased risk for minor injury and minor MSD  compared with those in jobs rated as having high control.Using expert ratings of job-level exposures, this study provides evidence that psychological job demand and job control contribute independently to injury and MSD risk in a blue-collar manufacturing cohort, and emphasises the importance of monitoring psychosocial workplace exposures in addition to physical workplace exposures to promote worker health and safety. Psychosocial hazards in the workplace are recognised as emerging threats to worker well-being, but the bulk of research examining adverse health and safety outcomes associated with these hazards has relied on worker self-reports of exposures, outcomes or both, raising concerns that individual psychological traits may confound reported results.Applying an expert-based job exposure matrix for assessment of physical job demand, psychological job demand and job control, multivariate mixed effects models were used to examine associations between the expert assessments of job-level demand and control, and acute injury, and musculoskeletal disorder (MSD) risk, adjusting for manufacturing process, plant and individual-level covariates.Workers in jobs within the highest tertile of rated job demand showed elevated risk of serious injury and serious MSD, while those in the lowest tertile of rated job control had increased risk for minor injury and minor MSD. No interactions were observed between physical demand, psychological demand and job control, suggesting independent contribution of these exposures to injury and MSD risk.With technological changes, new management ideologies, and increases in global competition for manufacturing, considerable changes in the organisation and management of work have occurred, requiring employees to work harder, faster, more productively and with less influence over daily work tasks.5–7Work-related injuries and MSDs remain a public health concern worldwide with potentially severe consequences for both workers and employers.Most research examining associations between psychosocial job demands and injury or MSD risk has relied on self-report by job incumbents.As companies in the manufacturing sector strive to maintain economic viability in a globally competitive marketplace, more thorough examination of associations between concomitant physical and psychosocial workplace exposures and injury and MSD risk is a critical step toward improving worker health and safety. The primary objective of this study is to assess expert ratings of physical demand, psychological demand, and job control as predictors of injury and MSD risk among a prospective cohort of aluminium manufacturing workers. We hypothesise that expert ratings of exposure assigned by job title using a job exposure matrix will predict risk for work-related injury and MSDs.Data used for this study is available through a longstanding collaboration between the investigators and a multinational aluminium manufacturing company. All production and maintenance workers at eight aluminium manufacturing plants, covering a range of processes including smelting, fabricating and forging, who worked between 1 January 2004 and 31 December 2005 in jobs for which expert ratings of physical demand, heat exposure, psychological demand and job control were obtained in late 2003 comprised the study cohort.We constructed job histories for each worker during the 2-year study period immediately following rating obtainment, calculated active time worked in each job held, and obtained demographic characteristics for the cohort using the human resources database, which has been well described in previous reports.Separate analyses were conducted to examine each of the following outcomes: minor injury and minor MSD requiring first aid only; serious injury and serious MSD that required medical treatment, restricted work or lost work time; the subset of minor MSDs requiring first aid only, and the subset of serious MSDs that required medical treatment, restricted work or lost work time.Expert ratings of job-level physical demand, heat exposure, psychological demand and job control were obtained in late 2003 from one senior health and safety professional at each of eight plant locations using a pilot job demand survey . The surOverall physical job demand was rated using the US Department of Labor physical demand characteristics of work classification scheme with the raters classifying each job into the well-defined categories of Sedentary, Light, Medium, Heavy or Very Heavy.Because very few of the plant-jobs received physical demand ratings of sedentary or very heavy, the physical demand ratings were collapsed into three categories: sedentary/light, medium or heavy/very heavy for analysis. The heat exposure ratings were collapsed into three categories: more than half the time, up to half the time or never. Ratings for the three psychological demand questions and the two job control questions were summed to yield a composite demand and control score for each job. Tertiles were used to designate job demand and job control as high, moderate, or low as was done in the Whitehall II study.Descriptive statistics for the study cohort were calculated. Unadjusted minor incident (injury and MSD), serious incident (injury and MSD), minor MSD only, and serious MSD only rates were calculated for each category of physical demand and heat exposure, and each tertile of psychological demand and job control by dividing the number of category-specific events by the summed number of category-specific person-years and multiplying by 100. Spearman rank correlation coefficients were calculated to assess collinearity between exposure variables.<half the time or >half the time) with never used as the referent, psychological demand tertile  with low demand used as the referent and job control tertile  with high control used as the referent. Multivariate models were additionally adjusted for age, sex, job tenure <1 year, race/ethnicity, manufacturing process and plant. For the minor incident outcomes: minor injury and minor MSD, and minor MSD only, a Poisson distribution with a log link and offset of the log person-days which contributed to each job was chosen. To better fit the distribution of the serious injury and MSD and serious MSD only outcomes among the cohort, we selected a binomial distribution with a logit link for those outcomes. Summed person time contributed to each job was the injury rate denominator for the serious incident and serious MSD outcomes. Random intercepts for person clustered within job, and job clustered within plant were incorporated to allow for within and between person and job variation, and account for correlation resulting from clustering. An unstructured covariance structure was specified.Multivariate generalised linear mixed models were used to estimate relative risks (RR) for injury along with corresponding 95% CIs for physical demand category  with sedentary/light used as the referent, heat exposure category . This study received ethical approval from the Yale University School of Medicine Human Investigations Committee.There were 391 unique plant-job combinations for the eight study plants for which expert ratings of physical and psychological job demand, heat exposure and job control were obtained. During the 2-year period immediately following rating obtainment, 9260 production and maintenance workers contributed 15 232 person-years to rated jobs within the study plants. Eighty per cent of the study cohort held only one job during the 2-year study period, while 15% held two jobs and 5% held more than two jobs. The results of the multivariate random intercept models simultaneously adjusted for physical demand, heat exposure, psychological demand, job control, age, sex, race/ethnicity, job tenure <1 year, plant and manufacturing process are shown in Compared to workers in jobs rated as having a high level of job control, low job control was associated with increased risk for minor injury and minor MSD . RR estimates for the lowest tertile of job control were also elevated for the serious injury and serious MSD outcome as well as the serious MSDs only outcome though the test for trend indicated no statistically significant difference between exposure categories. Moderate job control was associated with increased risk only for the minor injury and minor MSD outcome . The estimated fraction of minor injury and minor MSDs that could be reduced through increases in job-level decision latitude was 9%.Both female sex and job tenure less than 1 year were consistently associated with increased risk for each of the outcomes examined, while race/ethnicity did not predict risk for any of the outcomes. Increasing age was associated with reduced risk for both minor outcomes examined but did not attain statistical significance in predicting more serious outcomes among this cohort. No significant interactions between physical demand, psychological demand, job control or heat exposure were observed.Our study results are consistent with existing evidence that physical demand, psychological demand and job control are each independent predictors of injury and MSD risk among blue-collar manufacturing workers. Using expert ratings of job-level demand and control, and applying generalised linear mixed models with random intercepts for job within plant and person within job along with adjustment for manufacturing process and individual-level covariates, we show that an increasing level of physical demand is consistently associated with increasing injury and MSD risk. Associations between decreasing levels of job control and increasing levels of psychological demand and injury and MSD risk are less clear. High levels of psychological demand predicted risk for the serious injury and serious MSD outcome, as well as the subset of serious MSDs only, although the trend for the latter did not attain statistical significance at the p<0.05 level. However, psychological demand did not predict risk for the minor outcomes in this cohort. Low levels of job control clearly predicted risk only for the minor injury and minor MSD outcome, although the RR estimates for the serious injury and serious MSD outcome and the subset of serious MSDs only were suggestive of elevated risk for the lowest tertile of job control. We found no significant interactions between expertly rated physical demand, psychological demand and job control, suggesting no synergistic or antagonistic effects of these predictors on outcomes within our study cohort. This provides evidence that the adverse effects of psychosocial workplace hazards are not limited to the subset of workers in the highest strain jobs, that is, jobs conferring a combination of high psychological demand and low job control.Our findings are consistent with the general theory that psychosocial workplace exposures extend their influence beyond the domain of health, and build on previous, albeit limited evidence that psychosocial demands are important determinants of injury and MSD risk among hourly manufacturing workers,et alIn partial support of findings from a recent study in which associations between psychosocial job strain and new onset low back pain were observed only among automobile workers with high physical work exposures,Consistent with findings from previous reports, increasing physical demand predicted increased injury and MSD risk among our study cohort.Although our approach of using highly experienced, plant-based health and safety professionals to provide ratings of job-level demand and control arguably lends more objectivity than reliance on worker self-report alone, this methodology introduces rater subjectivity, another source of potential bias.22Interestingly, high correlation has been shown between expert ratings of job control and individual self-report, especially among blue-collar workers, though workers rated their level of job control systematically higher than did the expert raters.This study has several strengths. The large cohort and array of available data allowed for precise job history construction, accurate assignment of job-level exposure ratings and thorough identification of work-related injury and MSD records by job for each member of the study cohort. The completeness of the study company's incident surveillance data, which has been previously validated,Further, available data on several covariates previously shown to predict injury risk allowed us to control for these predictors thereby increasing accuracy of the RR estimates attributed to physical demand, psychological demand and job control. Inclusion of random intercepts for job within plant and person within job in statistical models allowed us to account for correlation resulting from clustering, and provide increased confidence in our study results. Additionally, our use of expert ratings of job-level physical and psychosocial demand offers increased efficiency and cost effectiveness compared to conducting a field survey of individual workers, a potentially appealing feature to companies facing increasing time and resource constraints. This approach could be easily replicated in other workplaces with potential to serve as a catalyst to enhance existing strategies for injury risk mitigation.Despite these strengths, there are some limitations to this study worthy of mention. We relied on a single expert rater at each of the eight plants, introducing a degree of rater bias inseparable from more general plant differences. While having more than one rater to provide the expert ratings of job-level exposures for each study plant would have been preferable, this approach was not practical because availability of expert raters with sufficient intimate knowledge of job-specific exposures was limited. Although we attempted to control for indistinguishable plant and rater differences by incorporating a fixed effect for plant in our statistical models, a measure of inter-rater reliability would be vastly superior. In addition, because the job-level ratings were obtained at a single time, we were unable to account for any changes in exposures during the study period. However, restricting our study period to the 2 years immediately following rating obtainment likely reduced any misclassification resulting from changes in job-level exposures. Further, previous reports suggest that female workers may perceive psychosocial job demands, particularly decision latitude, differently than their male counterparts performing the same job.40Using an efficient and cost-effective approach to obtain expert ratings of job demand and control, and adjusting for the contribution of physical workplace exposures as well as plant, manufacturing process and individual-level covariates, our findings highlight the independent contributions of psychological demand and job control to injury and MSD risk in a blue-collar manufacturing cohort. Our results indicate a need for further study to more clearly elucidate associations between psychosocial workplace exposures and injury and MSD risk, as well as potential mechanisms through which these exposures may increase risk. However, regardless of the precise mechanism through which psychosocial workplace exposures increase risk for injury and MSD, these findings, in combination with evidence from previous reports, highlight the importance of monitoring and reducing not only physical but also psychosocial workplace stressors to promote worker health and safety.


To investigate obstetric and perinatal outcomes among female survivors of adolescent and young adult (AYA) cancers and their offspring.Using multivariate analysis of statewide linked data, outcomes of all first completed pregnancies (n = 1894) in female survivors of AYA cancer diagnosed in Western Australia during the period 1982–2007 were compared with those among females with no cancer history. Comparison pregnancies were matched by maternal age-group, parity and year of delivery.Compared with the non-cancer group, female survivors of AYA cancer had an increased risk of threatened abortion , gestational diabetes , pre-eclampsia , post-partum hemorrhage , cesarean delivery , and maternal postpartum hospitalization>5 days , but no excess risk of threatened preterm delivery, antepartum hemorrhage, premature rupture of membranes, failure of labor to progress or retained placenta. Their offspring had an increased risk of premature birth , low birth weight , fetal growth restriction , and neonatal distress indicated by low Apgar score (<7) at 1 minute , need for resuscitation  or special care nursery admission . Congenital abnormalities and perinatal deaths (intrauterine or ≤7 days of birth) were not increased among offspring of survivors.Female survivors of AYA cancer have moderate excess risks of adverse obstetric and perinatal outcomes arising from subsequent pregnancies that may require additional surveillance or intervention. In general, cancers that commonly occur among adolescents and young adults (AYAs), ages 15–39 years, have a relatively good prognosis rd edition of the International Classification of Diseases for OncologyInternational Classification of Diseases (ICD) editions 9 and 10, was used to extract data for all hospital admissions.The Western Australian Data Linkage System (WADLS) was used to extract health records of all females diagnosed with cancer in Western Australia (WA) during the period 1st January 1982 to 31st December 2007, as well as a sample of females without any cancer history. The WADLS is a comprehensive system linking population-based health and related data from several statutory datasets through probabilistic matching of routinely collected records from the same individual, with the proportion of valid links estimated through audits and validity studies to be>98.5% of matches Socio-economic disadvantage was measured using Index of Relative Socio-economic Disadvantage (IRSD), which is based on census data of prevalence of low income, low educational attainment, high unemployment, rented dwellings, one parent families, and lacking fluency in English and other measures of social disadvantage Cases were defined as females first diagnosed with histologically confirmed malignancy in WA while aged 15–39 years, in the period January 1, 1982 and Dec 31, 2007, and who had a subsequent delivery, either live or still birth, in WA on or before Dec 31, 2008. Only the first completed pregnancy (≥20 weeks) following cancer diagnosis was included. We created a frequency-matched comparison cohort using completed pregnancies of women with no registered history of cancer on the basis of maternal age (one year either way), delivery year (within 1 year), parity, and Aboriginal status. Any individual with a cancer diagnosis (primary or secondary) prior to their delivery was excluded from the comparison group.Data on the obstetric and perinatal outcomes were obtained from the MNS based on diagnosis by the attending clinician/midwife. Adverse obstetric outcomes included the following: threatened abortion, threatened preterm labor, preterm delivery (gestation <37 weeks); preeclampsia ; antepartum hemorrhage ; pre-labor rupture of membranes (PRoM: rupture of the membranes>12 h before onset of labor irrespective of gestation at the time of membrane rupture); gestational diabetes ; other adverse pregnancy outcomes ; intrauterine death , postpartum hemorrhage (> = 500 ml); Cesarean delivery. Adverse perinatal outcomes included: low birth weight , low 1-min Apgar score (less <7), resuscitation ; admission to a special care unit; neonatal death (infant death during the 1st week of life); and congenital abnormalities identified prior to discharge from hospital.χ2) testing was performed. Stratified Mantel-Haenszel methods were applied to estimate relative risk (RR) with 95% confidence intervals  or weighing <2500 grams  relative to the comparison group. Infants born to females in the cancer cohort had an increased risk of resuscitation , low Apgar score (<7) at 1 minute , and admission to special care unit . The male: female ratios of offspring were similar in the cancer cohort and comparison group. Intrauterine and neonatal deaths and congenital abnormalities occurred in similar proportions in both cohorts.The risks of all adverse perinatal outcomes tend to risk with increasing age of diagnosis. With the exception of low Apgar score, adverse perinatal outcomes were mostly likely to occur in the most study periods. All adverse outcomes were more likely in the offspring of females previously diagnosed with carcinomas. The risk of preterm delivery and LBW, resuscitation were highest in the offspring of survivors of leukemia. The risk of preterm delivery, LBW and resuscitation were highest among offspring of women with malignancies arising in the pelvis. The offspring of women exposed to radiation had a high risk of preterm delivery, LBW and low Apgar score whereas resuscitation was most likely in women who were exposed to chemotherapy.No significant increases in risks for antepartum hemorrhage, postpartum hemorrhage, IUGR, PRoM, failure to progress, retained placenta, intrauterine death or neonatal death were observed across cancer diagnostic and treatment categories (data not shown).In this large study of pregnancy outcomes following AYA cancer, female survivors had a moderately increased risk of obstetric complications such as threatened abortion, cesarean delivery, pre-eclampsia and gestational diabetes, compared to females with no history of cancer. The offspring of female survivors had a higher risk of preterm birth and LBW, and measures of neonatal distress  compared to the offspring of females from the non-cancer cohort.Subgroup analyses according to AYA cancer diagnostic characteristics and treatment details found that threatened miscarriage was higher in survivors of AYA cancer diagnosed at an older age, those with a history of CNS tumors and carcinomas, abdominopelvic site tumors as well as females who had been treated with radiotherapy. Generally speaking, the most important antecedent to miscarriage is chromosomal abnormality We found that gestational diabetes featured more frequently among survivors of CNS tumours, bone sarcoma and carcinomas and patients with tumours arising in the abdominal pelvic region. Our study also found maternal diabetes was more common in females exposed to chemoradiation. Possible associations between maternal diabetes and cancer subgroup are largely understudied. A few studies have reported that childhood cancer survivors whose treatment included cranial Cesareans were more common in females diagnosed with cancer compared with those with no history of cancer and in particular common in those females exposed to chemotherapy or radiotherapy, and females diagnosed with leukemia, bone cancer and primary cancers in the abdomen or pelvis. The combination of psychological and obstetric considerations has probably led to the high frequency of cesarean delivery in females diagnosed with cancer. Possible clinician- and patient-dependent reasons for an increased rate of planned cesarean sections, including concerns over medical malpractice, fear of birth trauma and the potential risk to the child due to difficult vaginal delivery. However, this does not necessarily explain the specific difference identified within the observed results and therefore requires further in-depth investigations.The excess risk of low birth weight and preterm delivery among females treated by radiation therapy is likely related to the radiation dose to the uterus irrespective of cancer type Overall the offspring of female survivors of cancer were more likely to experience fetal distress. The Apgar score, which is assigned to virtually every newborn, evaluates the clinical state of the newborns based on five physical signs  present shortly after birth It is worth noting that, the gender ratio of the offspring of the females in our study was not significantly different from that of the comparison group. This is reassuring because it suggests that there is no deficit of male infants among the offspring of the female survivors, a finding that, were it present, would suggest transmission of lethal X-linked mutations The finding that more female cancer patients used fertility treatment than the non-cancer comparison group was not surprising. We were unable to further investigate specific associations between cancer diagnosis and fertility due to lack of detail information regarding treatment exposure. However, a number of past studies have found that certain chemotherapy treatment regimens This retrospective study used routinely collected statutory data for the entire population of Western Australia, which provided a large sample size and minimized incomplete case ascertainment and loss to follow-up between cancer diagnosis and pregnancy. The MNS provided us with comprehensive data about gestational, delivery, and infant outcomes of completed pregnancies, but excluded pregnancies resulting in completed miscarriage (<20 weeks). Information from the registries included important confounders and well-established risk factors for adverse outcomes, such as smoking. However, we did not have detailed information about cancer therapies, such as radiation dose and field location or specific chemotherapeutic agents. For example, lack of comprehensive treatment information precluded investigating the risk of adverse pregnancy outcomes by dose of radiation received to the reproductive organs; hence, residual confounding by radiation exposure could have distorted the magnitude of the measured associations. Furthermore, survivors included in this investigation were treated between 1982 and 2007 and hence, less is known about the potential adverse effects of more recent therapies which are believed to be much more aggressive than earlier therapies. Survivors treated more recently are still relatively young and the number of offspring born to these survivors will be relatively small. There are inevitable caveats on interpretation of findings from subgroup analyses, particularly as the routinely collected data in this study lacked certain important clinical details, such that causal inferences are necessarily speculative. Further, we lacked information about the patient's childbearing intent, the number and timing of attempts of post-treatment parenthood or whether assisted reproductive technology was actually used because of patient or partners subfertility. Therefore our findings are primarily relevant to females who have attempted parenthood and were able to become pregnant. It is also worth noting that the recording of a number of maternal conditions such as diabetes may be less sensitive, albeit highly specific and that the differential monitoring of females with a cancer history could have resulted in the increased identification of some prenatal conditions.There are number of previous reports of pregnancy outcomes in long-term survivors of diverse types of pediatric cancer Our data indicate that AYA cancer survivors who are have an excess risk of threatened abortions, cesarean delivery, preeclampsia, diabetes and their offspring have a moderately elevated risk of preterm birth and LBW. Our findings also suggest an adverse association between older age at diagnosis, certain cancer diagnoses and therapies, namely radiation therapy and cancer in the abdominal-pelvic region. Although their infants may be more likely to be preterm or of low birth weight, we observed no increases in congenital malformations, or neonatal death and no altered male to female sex ratio that might indicate increased germ cell mutagenicity. Overall, our results indicate a need for close surveillance of female survivors of AYA cancers. Understanding the effects of cancer on future childbearing may assist in the strategic targeting of resources to give these females the best care and access to treatment.This study protocol, including the use of de-identified, administrative health data without patient consent, was approved by the Human Research Ethics Committee of The University of Western Australia and the Department of Health Western Australia Human Research Ethics Committee (RA/4/1/2229). This study was performed in accordance with the Declaration of Helsinki.


Can the onset of PTSD symptoms and depression be predicted by personality factors and thought control strategies? A logical explanation for the different mental health outcomes of individuals exposed to trauma would seem to be personality factors and thought control strategies. Trauma exposure is necessary but not sufficient for the development of PTSD. To this end, we assess the role of personality traits and coping styles in PTSD vulnerability among Israeli and Palestinian students amid conflict. We also determine whether gender and exposure level to trauma impact the likelihood of the onset of PTSD symptoms. Five questionnaires assess previous trauma, PTSD symptoms, demographics, personality factors and thought control strategies, which are analyzed using path analysis. Findings show that the importance of personality factors and thought control strategies in predicting vulnerability increases in the face of political violence: the higher stress, the more important the roles of personality and thought control strategies. Thought control strategies associated with introverted and less emotionally stable personality-types correlate positively with higher levels of PTSD symptoms and depression, particularly among Palestinians. By extension, because mental health is key to reducing violence in the region, PTSD reduction in conflict zones warrants rethinking. Posttraumatic stress disorder (PTSD) resulting from exposure to conflict increases threat perceptions, contributing to support for militant policies . While iThe current study expands on these theories to examine how various mechanisms such as to what degree personality factors and thought control strategies play a role in determining whether an individual exposed to traumatic events will experience PTSD and/or depression symptoms. Furthermore, it is understood that individual circumstances may alter the extent to which these mechanisms apply and the extent to which individuals may experience PTSD and/or depression symptoms. This study therefore uses exposure to traumatic events from Gaza 2008–2009 to compare how Palestinians and Israelis—exposed to the same conflict but having different socio-economic status—differ from one another in each aspect of our theory.Traumatic events’ negative psychological effects have been discussed in several studies –8. RelivWhile exposure to trauma may lead to psychopathology and ill-health for some, others show resilience –14. The Several studies have shown that war and ongoing political violence are associated with higher levels of PTSD symptoms and depression –26. In lThe Israeli-Palestinian conflict imposes high material and psychological demands , 28. It The daily stresses Palestinians face , just asThe indications that continuous exposure to violence has led to heightened levels of distress and threat perception in both groups are of relevance to the underlying mechanisms in our study , 36–38. The big five factor model (FFM) of personality  states tExtraversion–studies show a link between low extraversion and PTSD symptoms [Neuroticism—Higher levels of neuroticism are often associated with higher levels of PTSD and depression [We used two personality factors: extraversion and emotional stability. Studies which examined the other three personality factors as predicting PTSD and depression have been inconclusive; therefore, they were omitted from this study. Research has indicated that these two personality factors significantly predict PTSD and depression: (a) symptoms , 47, 48.pression –57.Cognitive models of PTSD have implicated thought control in the development of, maintenance of, and recovery from, PTSD –61. The Overall, we assumed that the associations between the two personality factors and the five thought control strategies and PTSD as well as depression will be stronger among Palestinians compared with Israeli students. To the best of our knowledge these assumption have not been researched before. However, based on COR theory we may claim that the Palestinians have lost more external resources (e.g. higher level of exposure ) and intIn accordance with the theory previously presented and as stated above we hypothesize:H1: Palestinian students will report higher levels of trauma experience, PTSD and depression than Israeli students.H2: Higher levels of extraversion and emotional stability are hypothesized to predict higher levels of PTSD and depression. These predictions will be stronger among Palestinians than Israelis.H3: The five thought control strategies will significantly predict levels of PTSD and depression: higher use of worry and punishment will predict higher levels of PTSD and depression. These predictions will be stronger among Palestinians than Israelis.Palestinian participants (n = 514) were from Al Quds Open University and An-Najah National University (94%). Men comprised 40% of respondents; the mean age was 22.54 (SD = 3.58), family income (compare to average family income in your country) 2.95 , 17% were married and only 8% reported that they are secular and 25% reported that they are traditional. Israeli participants (n = 256) were from Tel Hai College (21%), University of Haifa (40%), Tel Aviv University, and Ashkelon College. Women comprised 32% of the respondents; the mean age was 26 (SD = 4.67). Family income was 3.08, 17% were married and only 68% reported that they are secular and 14% reported that they are traditional. The Yale University Institutional Review Board and the Haifa University Institutional Review Board approved this study.Participants were recruited from universities and responded to questionnaires on previous trauma experiences; PTSD, depression, demographics, personality factors and thought control mechanisms. Universities provide a representative population cross-section. Students in Israel tend to be older than the international norm due to army and national service, providing a representative cross-section of ages; the universities selected were in geographically diverse locations. Data was collected face-to-face following the 2008–9 Gaza conflict. Students were from varying departments . Trauma Inventory (Brief Trauma Questionnaire). The Brief Trauma Questionnaire (BTQ), developed by Schnurr and colleagues , assesseTrauma questionnaire: The trauma questionnaire is a brief measure of trauma that assesses criterion A1 (DSM IV). The Trauma Questionnaire scale includes the assessment of a wide range of traumatic experiences that are not asked in the BTQ, including age at the time, frequency of occurrence, length of trauma, if more than one trauma was experienced, and the respondent’s worst trauma [t trauma . Questiot trauma .This phase concludes with a summary of the coded answers. For each respondent we sum the answers. We add the sum of both scales (BTQ and Trauma Questionnaire) into one score representing traumatic experience.Ten Item Personality Inventory (TIPI): Gosling’s [osling’s  TIPI is osling’s .Thought Control Questionnaire: A 30-item questionnaire [ionnaire  consistiThe Posttraumatic stress disorder symptom scale , , is a seThe PHQ-9 is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. This instrument scores each of the 9 DSM-IV criteria for depression as: 1-not at all, 2-several days, 3- more than half the days, and 4-nearly every day. We tally each response by the number value under the answer heading, adding the numbers together to get the total score. Total scores are broken up into 3 categories . Cronbach’s Alpha in our study is .88.It assesses gender, age, education level, household income, marital status, religious affiliation, religiosity, place of birth, year of immigration if applicable, place of residence.We analyzed our data according to: (a) descriptive statistics, (b) correlations among research variables, (c) MANOVA analysis to examine differences between the groups, (d) path analysis to examine the unique prediction of PTSD and depression by the independent variables.We examined the distribution of all research variables for the entire sample see . Most vaWe examined the differences between Palestinians and Israelis on each of the research variables . ResultsWe examined the association between the investigated variables by Pearson correlations separately, for each group . ResultsThe unique prediction of exposure, namely that the two personality factors and the five thought control strategies link to PTSD symptoms and depression, were examined using separate path analysis  for eachFrom the context of our second and third hypotheses, we determined a number of conclusions. (a) Exposure to traumatic experiences significantly predicts PTSD and depression among Israelis and Palestinians: The more exposure, the higher PTSD symptoms and depression reported. (b) Extraversion and emotional stability significantly predict PTSD and depression only for the Palestinians: The less extraversion and less emotional stability, the more PTSD and depression. (c) The use of distraction as a thought control strategy significantly predicts PTSD and depression among only the Palestinians: the greater the use of distraction, the less PTSD and depression. (d) The use of worry as a thought control strategy significantly predicts PTSD and depression for Palestinians, and only PTSD for the Israelis: the greater the use of worry, the higher the level of PTSD and depression. (e) The use of punishment as a thought control strategy significantly predicts PTSD and depression among the Palestinians and Israelis: The more use of punishment, the higher level of PTSD symptoms and depression. The model for the Israelis explains 21% of the PTSD variance and 19% of the depression variance. The same model for the Palestinians explains 33% of the PTSD variance and 28% of the depression variance. These results largely support our hypothesis according which the five thought control strategies will significantly predict level of PTSD and depression, and these predictions will be stronger among Palestinians than Israelis see .We find that personality factors can explain both PTSD and depression amongst civilians living in conflict zones. This particularly applies to groups with a lower socio-economic status and higher level of resources loss. Specifically, our work finds depression to be a common comorbidity of PTSD  and thatWe reveal that worry and punishment are positively correlated with PTSD across both groups , 63, 73.An additional way to explain our main results regarding personality and thought control and PTSD and depression, is to claim that prolonged exposure to conflict and political violence leads to high levels of PTSD and/or depression , 32. UndThis study has several limitations to consider. Firstly, as any self-report study is subject to questions of objectivity, it could be that respondents give answers they believe the questioner wants to hear or which they think reflects well on themselves. Furthermore, though the Israeli university-going population is different in make-up to most Western countries, a similar study utilizing a wider sample of respondents from varying backgrounds would be beneficial.Even so, our study shows that the variance between the Israeli and Palestinian results suggests that personality factors and exposure to trauma have a significant impact on the onset of PTSD and depression. The importance of personality factors and thought control strategies increase during traumatic events. More resources toward the healthcare sector and improved healthcare and social policies are required in order to provide support to those struggling with mental health issues and to provide the tools necessary for appropriate thought control strategies in order to minimize instances of PTSD and/or depression. These efforts could reduce the prevalence of threat perceptions and support for militant policies. Improving mental health is key to reducing violence; good mental health may provide the key to long-term conflict resolution.