Namibia has made tremendous gains in malaria control and the epidemiological trend of the disease has changed significantly over the past years. In 2010, the country reoriented from the objective of reducing disease morbidity and mortality to the goal of achieving malaria elimination by 2020. This manuscript outlines the processes undertaken in strengthening tactical planning and operational frameworks for vector control to facilitate expeditious malaria elimination in Namibia.The information sources for this study included all available data and accessible archived documentary records on malaria vector control in Namibia. A methodical assessment of published and unpublished documents was conducted via a literature search of online electronic databases, Google Scholar, PubMed and WHO, using a combination of search terms.To attain the goal of elimination in Namibia, systems are being strengthened to identify and clear all infections, and significantly reduce human–mosquito contact. Particularly, consolidating vector control for reducing transmission at the identified malaria foci will be critical for accelerated malaria elimination. Thus, guarding against potential challenges and the need for evidence-based and sustainable vector control instigated the strengthening of strategic frameworks by: adopting the integrated vector management (IVM) strategy; initiating implementation of the global plan for insecticide resistance management (GPIRM); intensifying malaria vector surveillance; improving data collection and reporting systems on DDT; updating the indoor residual spraying (IRS) data collection and reporting tool; and, improving geographical reconnaissance using geographical information system-based satellite imagery.Universal coverage with IRS and long-lasting insecticidal nets, supplemented by larval source management in the context of IVM and guided by vector surveillance coupled with rational operationalization of the GPIRM, will enable expeditious attainment of elimination in Namibia. However, national capacity to plan, implement, monitor and evaluate interventions will require adequate and sustained support for technical, physical infrastructure, and human and financial resources for entomology and vector control operations. Malaria remains the most important vector-borne disease globally and continues to severely undermine the socio-economic growth in sub-Saharan Africa where it exacts its greatest toll, particularly in children and pregnant women , 2. In 2To mitigate vector control constraints, the World Health Organization (WHO) recommends adoption and implementation of integrated vector management (IVM) along the five key strategic elements as a platform for effective vector control  and the In 2009, the elimination eight (E8) initiative was established consisting of countries with potential of malaria elimination: Botswana, Namibia, South Africa and Swaziland including their neighbours Angola, Mozambique, Zambia and Zimbabwe . The govAdaptation of interventions both to the biology and behaviour of local vector species counting the geography and epidemiology of the targeted malaria foci is imperative in the preparatory phase . As NamiThe National Vector-borne Disease Control Programme (NVDCP) in Namibia with its endeavour to strengthen tactical planning and implementation frameworks for vector control to accelerate achievement of malaria elimination was the ‘case’ for this study. WHO Namibia in collaboration with the African Regional Office (AFRO) developed the terms of reference for the study to: harmonize and build consensus on DDT reporting; train staff in vector resistance monitoring techniques; develop guidelines for conducting vector surveillance for regional entomological teams; develop a national insecticide resistance monitoring plan, and to review and update the national IRS data collection and reporting tool. Information sources for this study included all available data and accessible archived documentary records on malaria vector control in Namibia. A methodical assessment of published and unpublished documents was conducted via a literature search of online electronic databases, Google Scholar, Pub Med and WHO, using a combination of search terms. Additional, non-peer reviewed literature was examined for information related to the subject.The epidemiological trend of malaria disease in Namibia has changed significantly over the past years . There hThough malaria is endemic in nine out of the 14 regions of Namibia, the intensity of transmission is generally low . The norPlasmodium falciparum accounts for 97% of malaria cases, the remaining 3% is due to Plasmodiumvivax [Anopheles gambiae s.s., Anopheles funestus and Anopheles arabiensis in Namibia [An. gambiae and An. funestus due to effective indoor-targeted vector control, leaving An. arabiensis as the solitary principal malaria vector [Anopheles arabiensis, a vector with facultative resting and feeding behavioural attributes, and predominates in arid areas with low rainfall, has the widest distribution in the northern region of the country [An. arabiensis less amenable to control by conventional control tools [In Namibia iumvivax . Histori Namibia . Howevera vector . Anophel country . This ve country . This diol tools .An. arabiensis was demonstrated to 4% DDT and 0.05% deltamethrin insecticides currently used for IRS and insecticide-treated nets (ITNs) in the country. In 2010 and 2013, the results for the two insecticides still remained the same in An. gambiae s.l. WHO contact bioassay to assess and compare the residual efficacy of DDT 75% WP at 2 g/m2 and K’othrine 50 WP and WG 250 at 20 mg/m2 for IRS on cement and mud-rendered walls inside houses consistently indicated complete killing effect post 24 h exposure during the entire study period [To ensure that transmission-interrupting tools remain effective, and their choice is evidence based, insecticide surveillance and monitoring, and contact bioassays are essential . In Namiy period .The NVBDP is responsible for developing the overall operational design, policies and strategies, and coordination and management of all vector control programmes in Namibia. Transmission-reducing interventions  are implemented as the main malaria vector control tools and are recorded at district level by the Ministry of Health and Social Services in collaboration with community health workers .Intra-domiciliary spraying using DDT dates back to 1965 in northern Namibia –33. MoreDistribution of ITNs to women only began in 1993 in northern Namibia. In 2002, targeting of ITNs to only children <5 years of age and pregnant women was commenced. Between 2002 and 2004, about 52,000 ITNs were distributed at no cost . In 2005Targeted winter larviciding has been used as an effective intervention for reducing malaria transmission in the southern part of Africa. The NVBDP has been applying winter larviciding during the dry season, which is conducted at limited vector breeding sites in malaria endemic regions .An. arabiensis remains the solitary vector in Namibia. No county-specific rational vector surveillance guidelines existed and entomological monitoring has been conducted on an ad hoc basis. Furthermore, the country lacks adequate entomological laboratory and insectary capacity. Vector control and entomological data collection, management and dissemination have been hampered by a lack of institutionalized databases and repository including limited coordination and collaboration. The IVM strategy has not been fully harnessed for effective vector control resulting in minimal or lack of intersectoral collaboration between agriculture, health and environmental programmes, as well as weak cross-border coordination and collaboration with Angola and Zambia. The situation is further compounded by minimal documentation and reporting for DDT. Supplementary interventions such as LSM have been inconsistently conducted in Namibia. Operational experience with IRM to facilitate systematic IRM deployment is relatively minimal together with implementation of new policies in the context of the GPIRM to optimize their impact. Addressing these challenges would enable evidence-based deployment and optimal assessment of interventions to inform future policies for effective operational vector control.In Namibia, malaria vector control efforts have been characterized by several technical, institutional, infrastructural and programmatic constraints Table : insectiIn 2014, Namibia sought for technical support from WHO/AFRO to develop and update the existing vector control strategic and operational frameworks.The national IVM guidelines have been developed to facilitate evidence-based deployment of tools and thus strengthen vector control . These gTransitioning to strategic IRM required elaboration of a resistance management and monitoring plan based on a thorough situation analysis of insecticides registered for public health and agricultural use, main vector species and their insecticide susceptibility status, data management, dissemination and mapping, vector control interventions, evidence and knowledge gaps and constraints, risks and mitigating measures . The objAs Namibia transitions to malaria elimination, vector surveillance will be an integral aspect of the IVM strategy in two ways: (1) to provide evidence for decision-making in IVM and (2) for evaluating a programme’s impact on vector populations. It will also be used for monitoring and evaluation where the surveillance sites are located in or near the implementation settings. These investigations would provide information on malaria vector species composition, their distribution, population density, feeding and resting behaviour, infectivity rate, longevity of vectors, seasonal activities, larval habitats, susceptibility to insecticides, and quality and residual effect of insecticides used for malaria control . BecauseCountry-specific vector surveillance guidelines have been developed and include: entomological field and laboratory techniques, WHO contact and susceptibility bioassays, mosquito rearing in the insectary, organization of entomological teams, geographical information systems (GIS) and supervision of entomological teams and operations . NamibiaNamibia was among the first countries to ratify the Stockholm Convention but delayed the development of the National Implementation Plan and could not establish mechanisms for reporting to the secretariat of the Stockholm convention. To facilitate expeditious implementation of planned activities of the project on “establishment of efficient and effective data collection and reporting procedures for evaluating the continued need of DDT for disease vector control” , a works2), quantities (Kg/Li), cost of insecticides, total cost of IRS and source of funds). It also includes IRS implementation (who conducted IRS), supervision (checklist and reports) and quality monitoring using cone bioassay including vector surveillance. The tool also incorporates current pesticide management capacity of the IRS programme  [A methodical review of national published and unpublished data from all relevant documents and staff in the MoHSS and involved partner institutions was collected and collated. The national IRS information/data collection and reporting tool has been updated in line with the regional and global relevant documents, and compiled in the WHO standard format for IRS . The datagement) .Following many years of IRS in Namibia, it would be expected that the programme has a clear knowledge of number and location of structures. However, the IRS programme in Namibia experiences various challenges, including: (1) planning—number and type of structures, location of structures and spray operators needed; (2) targeting—using incidence from previous year only can leave out receptive areas that have had cases in recent past; (3) operations—inadequate number of supervisors, lack of geographical reconnaissance data/not available in field leads to inefficient movements, and managers/supervisors have no access to real-time data; (4) logistics—transportation, spray pumps, paying spray operators; (5) advocacy, and (6) monitoring and evaluation—inaccurate coverage data and difficulty in mapping of sprayed/missed areas). In this regard, conducting a thorough and timely GR supported by GIS-based satellite imagery is critical to circumvent these constraints . This wiFurther to the evidence-based deployment of effective and proven malaria control interventions by the NVDCP, tremendous change in the epidemiology of the disease has been experienced across Namibia . The couThe IVM strategy defined by the WHO as “a rational decision-making process to optimize the use of resources for vector control” is a combination of proven malaria vector control methods based on the knowledge of local vector biology and ecology of the disease transmission . This cakdr) west—the L1014F mutation—has been found in An. gambiae M-form individuals [kdr west (1014F) and east (1014S) alleles to pyrethroids and DDT, and over expression of cytochrome P450s in pyrethroid resistance and glutathione S-transferases (GSTs) in DDT resistance has been reported in An. gambiae s.s, including over expression of GSTs in pyrethroid resistance and carbamate resistance in An. funestus s.s. [An. arabiensis resistance to both DDT and permethrin has been reported in Gokwe District with high activity levels of P450s, GSTs and general esterase activity detected [An. arabiensis has been demonstrated [An. gambiae s.l. [An. funestus [The fact that insecticide resistance selection pressure is driven primarily by gene flow, agricultural and public health use of insecticides as well as cross resistance has got implications for malaria vector control in Namibia. While no insecticide resistance in malaria vectors has been reported so far in Namibia, resistance has been detected in all the neighbouring countries except Botswana. In Angola, knockdown resistance  support will be critical for the sustainability of the malaria elimination campaign. To achieve this, the NVDCP should; (1) coordinate the development of all malaria IEC and advocacy material and ensure the harmonization of its content in collaboration with partners, and (2) advocate for increased and continued political, financial, and technical support and mobilize all stakeholders and partners in its efforts to eliminate malaria .The requisite technical and infrastructure capacity for entomological capacity in Namibia remains minimal or nonexistent at all levels of service delivery i.e. national, regional and local levels. This nominal local science capacity evidenced by the very few publications by in-country scientists remains a major challenge for achieving elimination. Cognizant of the fact that building this capacity will take a long time, deliberate efforts to establish strategies to strengthen this aspect of the NVBDP will be critical for expeditious elimination of malaria. As such, networks for empirical and operations research including malaria vector species, bionomics and insecticide resistance monitoring and management should be established and operationalized. This could be achieved through well coordinated collaboration with research and academia institutions i.e. national universities, as well as by creating an enabling environment for external institutions to develop interest in entomological research in the country.Namibia has implemented a very successful malaria vector control programme using IRS, LLINs and larval control in the context of IVM. The use of other personal protective interventions is being encouraged by the NVDCP and updated malaria vector control policies and guidelines are in place. The success of the malaria control in Namibia has been a function of total government political commitment and deployment of effective control strategies that is decentralized to district level with a strong partnership support and collaboration including the communities. However, the programme has been grappling with a number of challenges in the implementation of interventions including data collection and reporting, technical capacity due to shortage of staff, operational budgets and other requisite resources. As the country re-orients towards malaria elimination, it is imperative that vector surveillance, data collection and reporting, technical and operational constraints are circumvented within the programme. To expedite the transition towards elimination an emergency mode should be adopted by the control programme.Universal coverage with IRS and LLINs, supplemented by LSM in the context of IVM, guided by vector surveillance coupled with rational operationalization of the GPIRM, will enable Namibia to expeditiously attain the goal of elimination. However, national capacity to plan, implement, monitor and evaluate different vector control interventions will require allocation of adequate and sustained support for technical, physical infrastructures, and human and financial resource capacity requirements in entomology and vector control operations.


An improved understanding of the relative influences of climatic and landscape controls on multiple fire regime components is needed to enhance our understanding of modern fire regimes and how they will respond to future environmental change. To address this need, we analyzed the spatio-temporal patterns of fire occurrence, size, and severity of large fires (> 405 ha) in the western United States from 1984–2010. We assessed the associations of these fire regime components with environmental variables, including short-term climate anomalies, vegetation type, topography, and human influences, using boosted regression tree analysis. Results showed that large fire occurrence, size, and severity each exhibited distinctive spatial and spatio-temporal patterns, which were controlled by different sets of climate and landscape factors. Antecedent climate anomalies had the strongest influences on fire occurrence, resulting in the highest spatial synchrony. In contrast, climatic variability had weaker influences on fire size and severity and vegetation types were the most important environmental determinants of these fire regime components. Topography had moderately strong effects on both fire occurrence and severity, and human influence variables were most strongly associated with fire size. These results suggest a potential for the emergence of novel fire regimes due to the responses of fire regime components to multiple drivers at different spatial and temporal scales. Next-generation approaches for projecting future fire regimes should incorporate indirect climate effects on vegetation type changes as well as other landscape effects on multiple components of fire regimes. Fire is an integral component of the earth system and plays a key role in regulating vegetation structure and ecosystem function –3. UnderFire regimes are typically described by statistical distributions of frequency, size, severity, and seasonality in a particular area during a given time period. Thus, the environmental determinants of fire regimes can be assessed by exploring how environmental drivers operating over a range of scales affect the spatial and temporal patterns of these fires . The behBecause climate, vegetation, topography, and human activities interact with fire behavior and effects at different spatial and temporal scales , 15, theOur overarching hypothesis in this research was that different fire regime components  would exhibit characteristic spatial and spatio-temporal patterns that reflected differences in the relative importance of various environmental drivers. We used the western US as a model system to test this hypothesis because of the diversity of fire regimes spanning a broad range of vegetation and climate gradients and the availability of data on multiple characteristics of fires along with high-resolution geospatial climatic and biophysical data. We utilized an ensemble-based decision tree model to analyze how distributions of individual-fire characteristics varied continuously in space and time. We focused on large fires (> = 405 ha) because they are consistently documented across space and time, account for the majority of area burned, and have the most significant ecological and socioeconomic impacts. Specific research questions included (1) Do the spatial patterns and spatial synchrony of different fire regime components  differ? And (2) How does the relative importance of short-term climatic anomalies, vegetation types, topography, and geographic patterns of human activity differ among these fire regime components?The study area encompassed the area west of the continental divide, which covers 2 707 515 km2 . A total of 6071 fires  were included in the analysis after removing duplicate records and prescribed fires. Wildland fire use (WFU) are naturally ignited wildland fires which can be managed to accomplish specific resource objectives when people are not threatened. WFU constituted 1.4% of total fires, and the inclusion or exclusion of these fires did not affect the results. The fires that are being studied are mostly those that escape initial attack, and thus likely occurred under relatively extreme fire weather conditions. Fire ignition and extinction dates were used to calculate climatic conditions before and during the fires. Fire occurrence location, size, and percent of high severity burning were used as response variables. For fire occurrence analysis, we used a case-control approach in which cases were the observed fires and controls were artificially generated fire perimeters with random locations, timing, and sizes (see Sampling Random Fire Polygons for details). Size referred to individual fire extent . Unburned islands within the MTBS fires are not always mapped, sometimes resulting in an overestimation of the area burned ). We use 1000 bootstrap samples to calculate confidence intervals and assumed that the NCF was isotropic. Detailed information on these techniques can be found elsewhere [Spatial synchrony analysis was used to assess whether temporal fluctuations in fire occurrence and other fire characteristics were synchronized across large areas or more localized. We used the spline correlogram, a modification of the nonparametric covariance function (NCF), to characterize spatial synchrony. The NCF denotes how spatial covariance, an indicator of strength of spatial synchrony, varies as a function of geographic distance between locations. The spline correlogram is an adaptation of the NCF that (1) provides a direct estimate of the spatial covariance function; (2) uses a bootstrap algorithm to provide a confidence envelope for the function; and (3) can handle univariate and multivariate spatial data. We computed spline correlograms for the number of fires, mean fire size, and mean percent of high severity burning. We employed a 100 km × 100 km grid to summarize the annual number of fires, mean fire size, and mean percent of high severity burning within each grid cell for each year, and these gridded time series datasets were used to conduct the spline correlogram analyses. This resolution was selected based on a tradeoff between sample size to calculate the correlograms and the amount of data available to compute fire statistics within a grid cell. For example, larger grid sizes reduced the sample size to calculate the correlograms and increased the minimum distance between samples, while smaller grid sizes resulted in highly skewed and zero-inflated distributions of the fire statistics. The mean annual number of fires in each 100 km grid cell was 0.81 , a machine learning method, to examine the influences of landscape and climatic controls on individual fire occurrence, fire size, and percent of high severity burning. The BRT method combines the advantages of regression trees, which relate a response to their predictors by recursive binary splits, and boosting algorithms, which combine many simple models to give improved predictive performance. BRT is well-suited for ecological analyses because of its ability to handle various types of relevant variables, automatically model interactions among variables, and produce easily interpretable results , 48. In To avoid overfitting, BRT uses learning rate (lr), tree complexity (tc), and number of trees (nt) to balance model fit and predictive performance. The lr is used to shrink the contribution of each tree as it is added to the model. The tc controls the number of nodes or variable interactions in each tree. The best combination of parameters  that achieves maximum predictive accuracy, can be determined by 10-fold cross validation . To redutc = 3, nt = 1880, lr = 0.05. The best percent of high severity burning model was also selected by maximizing the variance explained by the model (0.60), with tc = 3, nt = 360, lr = 0.1.In this analysis, we used a binomial model for large fire occurrence probability based on binary case-control fire perimeter data . The best fire occurrence model was selected by maximizing the area under the receiver operating characteristic curve (0.97), with tc = 3, nt = 2600, and lr = 0.075. We used Gaussian models for fire size, and percent of high severity burning based on only the observed fires. The best fire size models were selected by maximizing the variance explained by the model (0.76), with The BRT method automatically models the interactions among variables, because every successive tree node constitutes a potential interaction. We plotted the first trees from the fire occurrence model, fire size model, and percent of high severity burning model, because displaying a single tree  can provide a clear and easily interpretable depiction of complex interactions , 49. We We stratified the study area into forest and non-forest sub-regions based on major vegetation type of Omernik’s level III ecoregions. Non-forest subregions included ecoregions dominated by grasslands and shrublands as well as woodlands and chaparral. We repeated the analysis for each sub-region to test whether relative importance of landscape and climatic controls was consistent across the western US or differed between the two sub-regions .r = 0.34, p<0.001), whereas fire occurrence and percent high severity had a negative correlation . There was a weak positive correlation between fire size and percent of high severity burning .The 6071 large fires reported in the MTBS database burned 24 265 610 ha over 1984–2010 , of which 2 979 817 ha  was high severity. Fire rotations, defined as the estimated time required to burn an area of interest, were 254 and 2077 years for all fire and high severity fire, respectively, based on the total burnable area of the western US. The mean fire occurrence density was 1.37 large fires per million ha per year, and the median fire size was 1207 ha. Smoothed maps revealed that the three fire regime components were spatially heterogeneous, and their spatial patterns were not entirely concordant, suggesting they were potentially influenced by different sets of spatial controls , and 2d.The spline correlograms showed that fire occurrence had the strongest spatial synchrony, followed by fire size, and percent of high severity burning . The strBRT results indicated that precipitation anomaly 90 days before fire ignition had the strongest influence on large fire occurrence, followed by elevation . GeneralVegetation types were the main variables influencing fire size in the western US . Of the Vegetation and topographic variables had the strongest influences on percent of high severity burning . SubalpiThe first three nodes of the simplified BRT tree provide information about the dominant effects of climate and landscape factors on fire regime components. The first node of the fire occurrece tree showed that the precipitation anomaly 90 days before fire was the most important factor, and that it interacted with vegetation type to influence probability of large fire occurrence . In contOverall, the results in forest and nonforest dominated sub-regions were similar to the results for the entire western US. Although the ranks of some individual variables differed, the relative importance of climate, vegetation, topography, and human influences were consistent for the fire regime components that we examined .Spatial and spatio-temporal patterns of large-fire occurrence differed from patterns of fire size and severity in the western US, and these differences can be explained by the distinctive effects of key environmental drivers on various components of the fire regime. In particular, large fire occurrence had higher spatial synchrony and was most strongly associated with short-term climatic anomalies. This finding is supported by previous analyses in the western US, which found that large fires were often preconditioned by frequent or more numerous consecutive days of hot and dry climatic conditions which result in lower fuel moisture, particularly for live fuels and larger dead fuels , 50, 51.Fire size and severity exhibited weaker spatial synchrony and were more strongly influenced by relatively static driving variables characterizing vegetation and topography, consistent with results from a previous study of fire severity patterns in the western US . These dOur findings of vegetation and topographic controls on fire severity are supported by a variety of other, more localized studies. For example, Steel et al  and CollThe finding that different fire regime components are controlled by different sets of drivers suggests that climate change will have varied effects on fire regimes over a range of spatial and temporal scales. Large fire occurrence in the western US was mainly influenced by short-term climate variability during the 90 days preceding the fire, which constrains fuel moisture and the availability of fine fuel to burn. Therefore, short-term variability in the frequency and duration of drought events will likely have the strongest influence on fire occurrence in western US. In contrast, fire size and severity were less affected by these climatic switches and more influenced by the spatial distribution of broad vegetation types , 65–67, Bromus tectorum) invasion in recent decades has increased both fire frequency and size and has therefore substantially altered the regional fire regime across the Great Basin of the western US [These results are supported by other recent studies that have documented distinctive responses of different fire regime components to environmental variability. Another study of fire regimes in the western US based on the MTBS dataset by Parks et al  found thstern US . Simlar stern US , the indstern US , 19.Several limitations should be considered when interpreting these results. First, climate variables were measured at a much coarser spatial resolution than topography, vegetation, and human influences. However, our analysis was conducted at the fire level rather than the pixel level , 73, 74,In this analysis, we characterized climate and landscape effects on fire regimes across the western United States using a consistent analytical framework to produce general insights about the environmental factors that control the spatial and temporal patterns of major fire regime components. Our results showed that landscape and climatic factors had varied effects on fire occurrence, size, and severity. In particular, the spatio-temporal patterns of fire size and severity exhibited weaker spatial synchrony than fire occurrence, and were more strongly constrained by spatial patterns of vegetation, topography, and human activities. In contrast, the probability of fire occurrence was mainly influenced by recent climate anomalies, and showed a stronger spatial synchrony. These findings underscore the value of studying individualistic response of different fire regime components and ultimately incorporating multiple environmental drivers of different fire regime components into projections of future fire regimes. In particular, our results suggest the possibility that fire regimes with novel combinations of frequency, severity, and size may emerge as a result of the interacting effects of changes in climate, shifts in vegetation distributions, and continuing expansion of the human footprint. Ongoing efforts to project the effects of future global change on regional fire regimes should therefore incorporate the indirect effects of climate on vegetation type, as well as other types of landscape controls on multiple fire regime components.S1 Fig(TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S3 Fig(TIF)Click here for additional data file.S4 FigSquare and circle symbols indicate positive and negative associations, respectively. Sizes of the symbols indicate strength of association. Filled symbols indicate significant (p < 0.05) associations.(TIF)Click here for additional data file.S5 FigValues are specified for truncated bars. Abbreviations of variables and their corresponding full names are described in (TIF)Click here for additional data file.S6 FigAbbreviations of variables and their corresponding full names are described in (TIF)Click here for additional data file.S7 FigValues are specified for truncated bars. Abbreviations of variables and their corresponding full names are described in (TIF)Click here for additional data file.S1 File(DOCX)Click here for additional data file.S1 Table(CSV)Click here for additional data file.


Industry Language Training Needs (ILTN) Study, this paper examines how authentic workplace communicative events derived from the qualitative data collected directly shed light on the language needs of industry, and it explores ways of translating the findings into practical pedagogical uses for the existing SGC-based Vocational English modules of the various programs offered by the Vocational Training Council (VTC).For vocational English courses to adequately address the language needs of today’s industries, it is of vital importance to incorporate into the course materials and classroom activities details and characteristics of the real-world communication tasks that trade practitioners are required to perform in their workplaces . As partThe industry sectors involved in the study include catering, communication design, customer services, hotel, human resources, leisure and sports, merchandising, retailing, sales and marketing, tourism, etc. This paper focusses on an analysis of the data collected through semi-structured interviews with industry practitioners and workplace observations, together with the authentic trade texts obtained from the industries.Drawing on a synthesis of Halliday’s  triad coExamples from the analyzed data will be used to illustrate how details of these real-life workplace communicative events, especially contextual dimensions including the subject matters, participants/interlocutors and modes of communication that essentially determine language use, can be translated into actual pedagogical tasks for vocational language training, particularly within a framework of outcomes-based teaching and learning, and howThe paper concludes by recommending that a resource bank of authentic workplace communicative events be developed as a practical means of support for vocational English teaching and curriculum development, pointing towards more research-led professional practice for vocational language training.


The cerebral organization of language in epilepsy patients has been studied with invasive procedures such as Wada testing and electrical cortical stimulation mapping and more recently with noninvasive neuroimaging techniques, such as functional MRI. In the setting of a chronic seizure disorder, clinical variables have been shown to contribute to cerebral language reorganization underscoring the need for language lateralization and localization procedures. We present a 14-year-old pediatric patient with a refractory epilepsy disorder who underwent two neurosurgical resections of a left frontal epileptic focus separated by a year. He was mapped extraoperatively through a subdural grid using cortical stimulation to preserve motor and language functions. The clinical history and extensive workup prior to surgery is discussed as well as the opportunity to compare the cortical maps for language, motor, and sensory function before each resection. Reorganization in cortical tongue sensory areas was seen concomitant with a new zone of ictal and interictal activity in the previous tongue sensory area. Detailed neuropsychological data is presented before and after any surgical intervention to hypothesize about the extent of reorganization between epochs. We conclude that intrahemispheric cortical plasticity does occur following frontal lobe resective surgery in a teenager with medically refractory seizures. Medically refractory epilepsy in children may lead to resective surgery if the epileptogenic zone can be localized. Seizure control is the goal following surgery with or without the need for continued anticonvulsant therapy. Prior to surgery, a variety of tests and mapping techniques are completed depending on the age and cooperation level of the patient, including neuropsychological assessment, Wada testing, Single-Photon Emission Computed Tomography (SPECT), Positron Emission Tomography (PET), Diffusion Tensor Imaging (DTI), functional MRI (fMRI), and a Magnetic Encephalogram (MEG). A subdural grid array is then surgically placed on the brain to better delineate the margins of the epileptogenic zone and to perform extraoperative electrical cortical stimulation (ECS). Together, these localization techniques provide information to pinpoint the epileptic focus that should be removed as well as identify the areas for motor, sensory, and language function so they can be avoided to minimize post-operative functional deficits.While plasticity of motor and language functions to the contralateral hemisphere have been extensively studied in pediatric patients with early acquired lesions or who have undergone functional hemispherectomies , the intThe prefrontal cortex is involved in several cognitive functions, including executive function, attention, memory, reasoning, and language comprehension. There is an extensive literature that explores the concurrent changes in neuroanatomical structure and cognitive maturation throughout childhood ,7,8,9,10versus changes induced by pathology or surgically-induced functional changes in frontal areas.In this paper, we report the case of a pediatric patient who underwent two surgical resections of a left frontal seizure focus at the ages of 12 and 13 and four serial neuropsychological assessments at the ages of 6, 10, 13 and 14. Based on past studies in cortical stimulation, the role of frontal subcortical anatomy and frontal lobe functional development, we hypothesized that we would see a mixture of stable as well as reorganized functional areas in and around the temporal and frontal lobes. Reorganization is discussed in a context of possible age-related changes This 14-year-old left-handed male originally presented at two and a half years of life with new onset seizures. Birth was via emergent cesarean section due to fetal bradycardia. APGAR  scores were six at one minute, and nine at five minutes of life. The patient was reportedly in good health and undergoing normal development until 18 months of age when his first seizure was observed and was characterized by elevation of his right arm. Over the course of the next few months the patient had several more similar episodes, which escalated to include hyperventilation and fits of laughter. Two ambulatory EEGs were performed. The first EEG captured a seizure described as left hemisphere dysrhythmia without spreading. The second EEG did not capture seizure activity but demonstrated interictal epileptogenic regions in the frontotemporal region (F3). Computerized Tomography (CT) scan and Magnetic Resonance Imaging (MRI) of the head were normal  was administered at ages 6 years, 6 months (2005) and at 10 years, 5 months (2009) to calculate four index scores and a Full Scale IQ (FSIQ) using 10 subtests. The Verbal Comprehension Index (VCI) used the Similarities, Vocabulary, and Comprehension subtests. The Perceptual Reasoning Index (PRI) used the Block Design, Picture Concepts, and Matrix Reasoning subtests. The Working Memory Index (WMI) used the Digit Span and Letter-Number Sequencing subtests, and the Processing Speed Index (PSI) used the Coding and Symbol Search subtests. The Wechsler Abbreviated Scale of Intelligence (WASI) is organized into Verbal Scale (Similarities and Vocabulary subtests) and Performance Scale (Block Design and Matrix Reasoning subtests) composites that also give a Full Scale Intelligence Quotient—the WASI was administered at ages 13 years, 1 month (2012) and 14 years, 1 month (2013) in place of the full WISC-IV to yield VCI, PRI, and FSIQ scores. Scores have a mean of 100 and Standard Deviation (SD) of 15, they are represented in Noted trends were that prior to the first surgery, almost all cognitive domain scores decreased by more than one standard deviation from 2005 to 2009 (from Average to Low Average/Borderline) with the exception of the PRI, representing stability in analyzing and synthesizing abstract visual stimuli, abstract categorical reasoning ability, and general nonverbal intelligence. Declines in VCI, WMI, PSI, and FSIQ were concurrent with increases in seizure frequency and decreases in responsiveness to anti-epileptic medications. Lower VCI scores represented declines in verbal reasoning and concept formation, auditory comprehension, and verbal expression. Lower WMI scores represented declines in auditory short-term memory, sequencing skills, attention/concentration, visual-spatial imaging, and mental manipulation, and lower PSI scores represented declines in speed of visual scanning, cognitive flexibility, visual-motor coordination, short-term visual memory, visual discrimination, and concentration. Following the first surgical partial frontal lobe resection, the PRI index decreased by more than one standard deviation (Low Average to Borderline) representing a decrease in analyzing and synthesizing abstract visual stimuli, abstract categorical reasoning ability, and general nonverbal intelligence. Scores for the FSIQ, VCI, and PRI remained stable following the second surgical resection.i.e., pictorial) and minimally related, rote  visual information can be learned and recalled; both indices have implications for both daily and academic tasks. Auditory attention measures speech-sound discrimination, including the ability to overcome the effects of auditory distortion or masking in understanding oral language. Following the first surgical resection, auditory attention continued to decline, while verbal memory remained stable and visual memory improved. Following the second surgical resection, verbal memory again remained stable while all other memory and executive function domains declined to borderline or impaired levels.Memory and executive function showed similar trends in that verbal and visual memory and auditory attention saw declines between 2005 and 2009, while attention-concentration scores remained stable. The Verbal Memory Index estimates how well meaningful verbal information and relatively rote verbal information can be learned and recalled. The Visual Memory Index estimates how well meaningful  frontal and 4 × 6 (24-contact) temporal grid array for seizure localization and extraoperative mapping, with seizure onset characterized by semi-rhythmic sharp activity evolving into faster frequencies, followed by spread . Each gr2 tag A. Brainl2 tag B,C. We uOnce the primary motor cortex was identified both by direct cortical stimulation as well as phase reversal of cortically evoked responses with median nerve stimulation, the patient underwent his first of two surgical resections with a partial frontal lobectomy sparing the gyral bank of the posterior portion of superior, middle, and the operculum portion of frontal gyrus, just anterior to the primary motor strip [The anterior and anterosuperior portions of the inferior frontooccipital fascicle (IFOF) and its projections were resected as was a far anterior section of the corticospinal tract (CST), and an anterior portion of the arcuate fasciculus (AF) that terminated in the inferior and middle frontal gyri; the medial and posterior segments of superior longitudinal fascicle (SLF) and uncinate fascicle (UF) were preserved .The patient was seizure free for four months post-operatively. At five months post-operatively, the patient had a cluster of breakthrough seizures. An EEG performed at this time demonstrated frequent generalized spike and wave discharges originating from the left hemisphere and left-hemisphere slowing. Ten months postoperatively at the age of 13, the patient underwent additional workup which led to the hypothesis that the seizures were still originating from the left frontal region, with no suggestion of temporal onset. Repeat surgery was recommended and a 6 × 8 (48-contact) frontotemporal grid was implanted for seizure localization and extraoperative mapping. ECoG showed a diffuse seizure onset starting with rhythmic spike and slow wave activity covering contacts 13–14, 21–22, 29–30, 37–38 and at the depth electrode just posterior to the prior resection . ElectroMicroscopic examination of the tissue resected at the time of the second surgery revealed disorganized brain consistent with developmental/migrational abnormality. Additional anterior sections of the CST, AF, and medial SLF were removed, while the UF remained preserved. For nine months after his second surgery, the patient was seizure-free. At his most recent follow-up approximately 10 months postoperatively, the patient has had occasional break-through seizures with continuation of his stimulant therapy for ADHD.Cortical areas within the precentral gyrus, primary motor strip, the majority of the sensory strip, and the superior temporal gyrus were mapped across both the 2011 A and 201Patients who have required additional surgery and repeated mapping after a recurrence of seizures appear to undergo little to no change in the localization of language sites that are distant from the margins of resection, which many investigators refer to as the “one centimeter rule” to indicate that a 1 cm margin is needed to avoid inducing a permanent functional deficit ,15,16,17When resections impinge upon language or primary motor areas, however, functional recovery is thought to coincide with not only intrahemispheric, but perilesional reorganization ,4,19,20.In the present patient, both stable and reorganized functional areas were identified with extraoperative stimulation prior to the first and second surgical resections. A stable area across the two grid maps was found in the temporal lobe for auditory naming within the middle portion of the STG. Auditory naming errors with cortical stimulation were primarily semantic paraphasias and comprehension errors. The stability of this area can likely be accounted for by its relatively distant location from the first resection, which spared this cortical area, as well as the anterior indirect segment of the superior longitudinal fasciculus (SLF) subcortical tract. This subcortical fiber tract connects the posterior part of the superior temporal gyrus behind Heschl’s gyrus (Wernicke’s area) with the posterior portion of the frontal operculum lateral to the arcuate fasciculus . AlthougStable areas across the two grid mapping sessions in the frontal lobe were: (1) posterior areas of the SFG and MFG showing no motor, sensory, or language function ; (2) DPrG for hand motor function, found both extraoperatively and intraoperatively B, tag F;A lack of function as seen by cortical stimulation in the SFG and MFG could be due to a number of factors. Cortical stimulation during visual naming has induced errors in the MFG in a similarly-aged patient , though Stable hand motor function in the DPrG and face/mouth motor function in the MPrG/VPrG may be accounted for by their relative distance from the first resection  as well as the preservation of corticospinal tracts (CST) that project into these areas of primary motor cortex. As the head of the caudate nucleus and the frontal horn of the lateral ventricle were spared, the internal capsule fibers passing through the corona radiata into these areas of motor cortex  were alsThe main areas that appear to differ in function across the two grid maps include: (1) tongue sensory in the ventral postcentral gyrus (VPoG), which reorganized superiorly to the middle post-central gyrus (MPoG); (2) visual naming hesitations in the superior area of the operculum of the inferior frontal gyrus (OpIFG); and 3) speech arrest within the inferior area of OpIFG. Motor and sensory areas are some of the earliest to mature developmentally and in terms of grey matter volume, maturing earlier than temporal lobe association areas . Given t speech aNeuropsychological profiles of this patient are likely accounted for by a combination of surgical resections as described above and known cognitive consequences of frontal lobe epilepsy. Prior to the first surgical resection, declines in VCI, PSI, WMI, and FSIQ were seen, which is consistent with profiles seen in frontal lobe pediatric epilepsy studies ,37,38,392, with diffusion encoding in 25 directions.DTI MR images were obtained following the first resection in 2012 with a 3.0-T system  using an echo-planar sequence , 21-cm field of view, matrix 92 × 92, 2.5 mm section thickness, b = 0/1000 s/mmTractography was performed on a dedicated workstation  using commercially available fiber tracking software . The white matter tracts were defined by manually placing a seed region of interest in mirrored locations in the right and left hemisphere based on known tract locations . Tract pParental consent and child assent were obtained in accordance with the guidelines of the Internal Review Board of Duke University Health System . Testing prior to the 2011 resection was performed in two sessions over two days. The area of exposure included frontal, temporal, and parietal areas. Eight electrodes in the frontal grid  and eight electrodes in the temporal grid  were tested in pairs on the first day using visual and auditory naming  or auditory definition (auditory naming). Before each response, the patient spoke the carrier phrase “This is a …” to ensure stimulation was not causing a general speech arrest. The presentation of the picture was accompanied by an aural cue with the presentation software, alerting the neurosurgeon that the stimulus was on the screen. Stimulation was initiated immediately following this aural cue with a delay of approximately 1000 ms, with the stimulus on the screen for 5000 ms. Stimulation for auditory naming was initiated immediately after the beginning of the definition without an additional aural cue. The short delay after the appearance of the stimulus allowed stimulation to proceed immediately after the stimulus was on the screen or began to be heard but before the patient began his oral response of the carrier phrase and stimulus item.The following error types  were notIn summary, widespread and significant cognitive, memory, and IQ declines were seen during a period of increased seizure frequency and intractability to antiepileptic medications prior to the first surgical resection. The two cortical grid maps prior to each resection showed stability in posterior temporal regions that involved auditory naming, consistent with the preservation of cortical areas and SLF subcortical tracts in this region, and as further reflected in verbal domains of neuropsychological testing scores. Grid maps also showed stability in motor areas of face/mouth and hand, also consistent with CST subcortical preservation that projected to these regions. Conversely, areas of reorganization were seen in cortical tongue sensory areas concomitant with a new zone of ictal and interictal activity in the previous tongue sensory area. Increased current stimulation during the second grid mapping most likely accounts for new areas of speech-motor function found in the IFG. Additional cortical and subcortical tract removal  anterior to the motor strip in the second resection appears to have led to additional declines in visual working memory and attention measures in the presence of lowered seizure frequency.


Prostate cancer is the most common malignant tumor associated with male reproductive system.The existing eligible randomized controlled trials (RCTs) were critically appraised for the safety and effectiveness of CHM for prostate cancer.A literature search was conducted by using PubMed, CENTRAL, CNKI, CBM, VIP and Wanfang databases until August 2015. RCTs of CHM or CHM plus conventional medicine for prostate cancer patients were included. The primary outcomes appraised were survival time, time to progression and quality of life. The risk of bias assessment according to the Cochrane Handbook was used to evaluate the methodological quality of the included trials. Revman 5.3 software was used for data analyses. Risk ratio and mean difference (MD) with a 95% confidence interval (CI) were used as effect measures. Meta-analysis was to be used if sufficient trials without obvious clinical or statistical heterogeneity were available.A total of 17 RCTs involving 1224 participants were analyzed. One trial was about CHM comparing to no treatment. The remaining 16 trials used CHMs as adjunctive treatment for endocrine therapy. Due to the poor quality of methodologies of most trials, only limited evidence showed that a combination of CHM and endocrine therapy might be more effective in restraining the development of the disease , increasing patients’ survival time (7–15 months) or improving patients’ performance status, when compared to endocrine therapy alone . No severe adverse event was reported related to CHM.Due to the insufficient quality of trials that were analyzed, it is not appropriate to recommend any kind of CHMs in treating prostate cancer at the present time. Well-designed trials with high methodological quality are needed to validate the effect of CHMs for patients with prostate cancer. Prostate cancer is the most common malignant tumor in the male reproductive system. Incidence of prostate cancer is known to relate to geographical area, ethnicity and age . In EuroRadical resection of the prostate is an effective treatment for prostate cancer during early stage. But the applicability of surgery has to consider the patients’ age and the clinical stage of the cancer . BecauseAs a palliative treatment, traditional Chinese herbal medicine (CHM) was commonly used with oral administration for advanced prostate cancer in China. With a strong sense of the overview of a patient’s whole body, CHM does not just aim for tumor eradication, but focuses on improving the body’s strength and reducing the possibility of recurrence, as well as metastasis. Results from previous studies showed that CHM, as an adjunctive treatment following surgery, radiotherapy, chemotherapy, and endocrine therapy, may prolong survival time and improve the quality of life of prostate cancer patients . CurrentThe aim of this review is to critically appraise the existing randomized controlled trials (RCTs) on CHM for treatment of prostate cancer, and provide evidence-based evaluation on the safety and effectiveness of oral administration of CHM against this cancer.The format of this review refers to the checklist of Preferred Reporting Items for Systematic Reviews and Meta-Analyses see .RCTs which compared oral administration of CHM  to those without CHM in treating prostate cancer were included in our analysis. The primary outcomes included survival status , quality of life, and time to progression (TTP); secondary outcomes included measurements of PSA, patient performance status, prostate volume (PV), serum testosterone, and adverse events. At least one of the above outcomes should be reported in the included trials in our evaluation.Two English databases and four Chinese databases were searched from inception to August 2015, including the Cochrane Central Register of Controlled Trials(CENTRAL), PubMED, China Network Knowledge Infrastructure(CNKI), Chinese Scientific Journals Database (VIP), Wanfang Database (for unpublished graduate theses in China), and Chinese Biomedicine (CBM). Details of the search strategies for PubMED were shown as below.#1: Search "Medicine, Chinese Traditional"[Mesh]; #2: Search "Drugs, Chinese Herbal"[Mesh]; #3: Search "Prostatic Neoplasms"[Mesh]; #4: Search (#1 OR #2) AND #3Above strategies were adopted for each specific database, and Chinese characters for relevant key words were used when searching Chinese databases.Two authors (Cao H and Mu Y) independently screened the titles and abstracts of the achieved citations from primary searching. Full text of the articles of potential interest were download for further evaluation, those meeting inclusion criteria were included in the final review. Disagreements between the two authors were resolved by discussion and if needed, arbitrated by a third author (Liu JP).Two authors (Wang Y and Mu Y) extracted the data from the included trials independently on patient characteristics, intervention/control details, clinical outcomes and quality-related information. The discrepancies were resolved through consensus. Missing data were achieved through contacting with authors of the original studies.Selection bias , performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), reporting bias (selective reporting), and other biases were assessed according to the criteria from the Cochrane Handbook for Systematic Reviews of Intervention . Three p2 [2 larger than 50% indicated the possibility of statistical heterogeneity. Both fixed effect model and random effect model were used if there was possibility of statistical heterogeneity among trials. Publication bias was explored by funnel plot analysis. Subgroup analyses were conducted to determine the evidence for the different treatment duration if data were sufficient. Sensitivity analyses were used in order to determine whether the conclusions differed if eligibility was restricted to studies without high risk of bias; or if a fixed/random effect model had been applied.Data were summarized using risk ratio (RR) with 95% confidence intervals (CI) for binary outcomes or mean difference (MD) with 95% CI for continuous outcomes. We used Revman 5.3 software from the Cochrane Collaboration for data analyses. Meta-analysis was used if the trials had an acceptable homogeneity on study design, participants, interventions, control, and outcome measures. Statistical heterogeneity was tested by examining I2 , meaningThe search of 6 databases identified 1657 citations for further evaluation. Full texts of 109 articles were read, and 18 –28 trialAll of the 17 included trials were conducted in China and published in Chinese. Except for one four-arm trial , all theTotally 1224 patients were included in this review, with an average of 72 patients per trial. Average age of those participants was 70 years old. The stages of the prostate cancer for majority of the patients were determined as III/IV, which mean the tumor has been infiltrated or beyond the prostate capsule.CHM included herbal decoction , herbal granule , and herbal pill . The herbal pill, called Juzao Pill (10g three times daily), which is composed of Flos chrysanthemi, Sargassum, Rhizoma sparganii, Semen strychni, Radix rhapontici, Pseudobulbus Cremastrae seu pleiones, Radix polygoni multiflori, Scolopendra, Flos lonicerae, Semen Irispallasii Fisch, and Pariphyllin, may strengthen body strength and soften solid masses, according to Chinese medicine theory. The herbal granule, Jianpi Yiqi Granule (10g twice daily), aiming to strengthen spleen and kidney of patients to alleviate the adverse events of chemotherapy and boost the immune system, was composed of Rhizoma atractylodis macrocephalae, Radix codonopsis, Fructus alpiniae oxyphyllae, Fructus lycii, Fructu sligustri lucidi, and Semen cuscutae. The 16 herbal decoctions (150ml twice daily) with 15 kinds of prescriptions, mainly work on strengthening body strength and suppressing the tumor growth. Details of the prescriptions of those 16 herbal decoctions were shown in Types of comparisons included herbal decoction versus no treatment , herbal Primary evaluated outcomes of this review included survival status, Time to Progression (TTP), and Quality of Life (QOL). Survival time or survival rate was reported in 4 trials , 22, 27,According to the previously mentioned criteria, all included trials were assessed as having high risk of bias .Only seven trials , 21, 23 Sixteen of the included trials used CHM as add-on treatment for endocrine therapy (or combined with chemotherapy); however, placebo was not used in any of them. The remaining trial  comparedOnly three included trials , 17, 23 Protocols of thirteen of the included trials could not be found to assess the risk of reporting bias of the studies. Three, 19, 20 No funding issue or methods of sample size calculation were apparent in all of the included trials, and it was difficult to determine whether a study was fraudulent. We evaluated all of the trials as at an unclear risk of other bias.Survival time/rate. Three trials [e trials , 15, 22 e trials  found noTwo trials compared CHM plus MAB (and chemo-therapy) versus MAB (and chemo-therapy) alone and reported survival time of participants. However, one of them  did not Quality of life (QOL) assessment. Six trials [x trials , 22, 25 All of the three trials , 21, 25 The remaining one trial  did not The progress of the disease. Only two trials reported time to progression  as an outcome measurement. One of them [I2 = 0%, fixed-effect model) in restraining the development of the disease (including the radiographic progression and the progression to metastatic disease). of them  was a fo of them  only comPSA. Fourteen out of seventeen included trials reported PSA (ug/l or ng/ml) pre and post treatment; baseline PSA levels among trials were different and the treatment duration varied from 3 months to 15 months. Meta analysis was not conducted due to the obvious clinical and statistical heterogeneity among trials. One trial [ne trial  showed ane trial , 23, 25 ne trial , 26, 27 Performance status. Within the five trials which reported KPS scores, three of them [ of them , 18, 19  of them  found a  of them  only repSerum testosterone. Only one trial [ne trial  reportedProstate Volume (PV). Two trials reported the patients’ PV before and after treatment; both of them showed that the average PV of the participants before the treatment was over 50 ml. However, one trial [ne trial  found a ne trial  showed nAdverse events. Five trials mentioned adverse events in the herbal medicine group. Four of them [ of them , 14–16 r of them  reportedSince none of the meta-analysis in this review included more than 10 studies, funnel plot was not conducted to assess the potential publication bias.With concerns on 16 of the 17 trials, we have no confidence on determining the add-on effect of oral administration of herbal medicine for increasing survival rate and improving main symptoms (including PSA and PV) of patients with prostate cancer. Due to the poor methodological quality of the included trials and the insufficient number of trial participants, only limited evidence showed combination of herbal medicine and MAB may have better effect on increasing patients’ survival time (7–15 months) or improving patients’ performance status compared with MAB alone (KPS scores average changed 15 between groups).The remaining trial  found anSafety of herbal medicine was rarely reported in the included trials; thus, we could not make any confirmed conclusions on this outcome.We found one review  assessedCompared to the above review, our study included 17 trials with different types of herbal preparations. Though the strength of the evidence was low, we found potential effect of oral herbal preparations for patients with prostate cancer on some key symptoms’ improvement.Low levels of evidence in this review were mainly caused by the poor quality and small sample size of original included trials. The inconsistency of findings of herbal medicine’s effect on improving main symptoms of prostate cancer among these trials further reduced the internal validity of the evidence.Although we searched both Chinese and English databases, all of the included trials were retrieved from Chinese literature, which may have introduced potential selection bias and limited the external generalization of the evidence.Types of clinical stages of prostate cancer determine the details of treatment. In this review, almost half of the included trials did not report or classify clinical stages of the participants, which made the subgroup analysis regarding to the different clinical stages of the disease unavailable.First aim of the treatment for patients with prostate cancer is to strengthen their self immune-function to alleviate the symptoms and get better quality of life. According to this review, herbs or herbal prescriptions with the function of strengthening the spleen and kidney “qi” are commonly used to achieve this objective. Top five of most frequently used herbs were Astragalus mongholicus , Rhizoma atractylodis macrocephalae , Codonopsis pilosula , Herbah edyotis , and Poriacocos . The first three and Poriacocs were commonly used for tonifying (taking a tonic or nourishing food to build up) one’s qi and enhancing body immunity. Herba Hedyotis was reported to be used in several studies –33, whicHerbal medicine may have effects on alleviating the symptoms or reducing the incidence rate of adverse events caused by endocrine therapy; however, insufficient evidence was seen supporting this conclusion.First of all, the protocol of the clinical trial should be pre-defined according to the research question. Ideally, preclinical data should be provided to support the design of the clinical trials. Authors are encouraged to register their study protocols before trial implementation to ensure the research can be conducted according to the pre-defined standard. In the protocol, the primary and secondary outcomes should be defined for the research. While one can argue whether PSA is a good marker for prostate cancer, it is the only approved marker to indicate the development of prostate cancer, and testing of serum PSA has been standardized. Therefore, PSA values should be included as a parameter to evaluate the outcome of prostate cancer trials. If possible, PSA doubling time during treatments should be determined. A documentation of a decrease of PSA could be more informative than a single measurement of PSA value. Secondly, there should be unified scales for assessing the quality of life of patients with prostate cancer (such as EORTC QLQ-PR25 and FACT-P). Therefore, those scales should be used and interpreted appropriately. Furthermore, in order to observe the long-term efficacy of treatment with assessment of patients’ survival time or time to progression, follow-up with adequate duration should be considered during clinical study.According to this review, for outcomes like patients’ survival time or change of PSA after treatment, a combination of herbal medicine and endocrine therapy did not show advantages compared with endocrine therapies themselves. Thus, the sample size of future studies should be calculated carefully to make sure that data could achieve enough power for statistical analysis. Meanwhile, factors that may influence or downgrade the methodological quality of studies should be controlled during the research. Adequate methods are requested for random number generation, allocation concealment, missing data handling, avoiding performance bias and other bias. Reporting of the clinical study should follow the international standard or criteria, such as CONSORT statement .In addition to treatment trials, prostate cancer prevention trials involving CHM should not be overlooked. Although it is not easy to carry out primary prevention trials, it is possible that the use of CHM could prevent or delay of the recurrence of prostate cancer. One of the authors (Shiuan Chen) has recently completed a trial to determine the effects of white button mushrooms (WBM) against biochemically recurrent prostate cancer . TherapyCHM has been applied in China for more than 2,000 years and shown to be useful in many ways. CHM is complex in nature and used mainly for symptom management. Our analysis was not able to reach a clear conclusion mainly due to inconsistency of the trial design, variable outcome measurements, and the complexity of CHM regimens. Furthermore, patient population might not be well controlled. It is also possible that during the trials, participants also took various supplements without telling the doctors. Through a careful and well-designed trial with a definitive outcome measurement, it is more likely that conclusions addressing the usage of CHM in prostate cancer treatment will be generated.Due to the insufficient quality of trials that were analyzed, it is not appropriate to recommend any kind of CHMs in treating prostate cancer at the present time. Well designed trials with high methodological quality are needed to validate the effect of CHMs for patients with prostate cancer.S1 Table(DOC)Click here for additional data file.


Many service members and veterans seeking treatment for alcohol problems also have post-traumatic stress disorder (PTSD). This article considers the effectiveness of treating alcohol problems and PTSD simultaneously. The authors begin by summarizing the extent of excessive alcohol use among military service members and veterans. They then explore the relationship between combat exposure and subsequent alcohol use; identify and briefly describe evidence-based treatments for alcohol problems and PTSD, separately; and review research on the effects of single treatments for both PTSD symptoms and alcohol use. Many service members and veterans seeking treatment for alcohol problems have experienced the life-threatening stress of combat, many have post-traumatic stress disorder (PTSD), and many service members and veterans seeking treatment for PTSD have alcohol or other substance problems. Sensitivity to these issues can influence how a therapist relates to the patient and also has possible implications for developing a treatment strategy . HistoriFor more than 30 years the Department of Defense (DoD) has conducted recurrent surveys to determine rates of excessive alcohol use among active-duty personnel. The most recent of these  revealedLess is known about alcohol use problems among veterans. One analysis examined results from the National Survey on Drug Use and Health from 2004 through 2010 . The stuAs of September 30, 2013, 2.6 million service members had been deployed to Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn since 2001 . Due to PTSD is the most common mental health diagnosis for the nearly 1 million U.S. veterans who served in Iraq and Afghanistan between October 1, 2001, and September 30, 2013, and who accessed services through the Veterans Health Administration (VHA) . NineteeDiagnostic and Statistical Manual of Mental Disorders (DSM–5) are illustrated in the accompanying textbox Marked psychological and/or physiological response to cues that symbolize or resemble the eventAvoidanceOf memories, thoughts, or feelings about the eventOf reminders of the eventNegative Alterations in Cognitions and MoodInability to recall an important aspect of the eventPersistent, exaggerated negative beliefs or expectations about self, others, or the worldPersistent negative emotional stateDiminished interest/participation in significant activitiesDetachment/estrangementPersistent inability to experience positive emotionsMarked Alterations in Arousal and ReactivityIrritability/outbursts or angerReckless or self-destructive behaviorHypervigilanceExaggerated startle responseDifficulty concentratingDifficulty falling or staying asleep or restless sleepSubstance use disorders (SUDs) are another common reason for seeking mental health services. PTSD and substance use disorder frequently co-occur . As illuIndividuals with AUD and PTSD tend to have greater risks for other psychiatric disorders, respond less favorably to interventions for the AUD, and are at increased risk of relapse to problematic drinking .Citing data from the National Comorbidity Survey , JacobseA study of patients receiving treatment for SUD indicated that improvements in PTSD symptoms over 2-week periods during the 26-week study were associated with decreases in cocaine and opioid use and possibly reductions in alcohol use (p=.056) . These fData from the large-scale Air Force Community Assessment Survey conducted in the spring of 2008 demonstrated a relationship between the total number of deployments and cumulative time deployed with the subsequent likelihood of an Air Force member becoming a problem drinker. Each additional year of deployment increased the risk of becoming a problem drinker by 23 percent, and each additional deployment period increased the risk by 14 percent. Interestingly, the risk of becoming a problem drinker was not associated with how recently a soldier was deployed .Another survey  given toAlcohol problems among military personnel exceed those of civilian populations in part because of demo-graphic differences in age, gender balance, and education level among military populations. However, other factors contribute to the risk of alcohol misuse among service members, including deployment stress, combat exposure, and PTSD. Reflecting this, an increasing number of veterans are being treated by the VHA for comorbid SUDs and PTSD. The challenge is to implement treatments found to be effective for both conditions, as well as to continue to develop more effective interventions.Several psychosocial interventions for treating alcohol problems have shown strong evidence for effectiveness. The VHA’s policy is that patients with alcohol problems have access to at least two of the following:Cognitive–Behavioral Therapy for Relapse Prevention, which assists patients in identifying internal and external stimuli that prompt drinking, and in learning skills and alternative ways of thinking to cope with these cues and avoid alcohol use.12-Step Facilitation, which promotes participation in Alcoholics Anonymous and working the steps of the program. It employs a treatment manual with activities and homework assignments and is conducted in a one-on-one counseling relationship.Community Reinforcement Approach, which helps patients establish a strong environmental support system to help sustain sobriety.Substance Use Disorder–Focused Behavioral Couples Counseling/Family Therapy, which emphasizes the participation of significant others in treatment. Sessions focus on improvements in communication and interactional patterns of the couple or family, especially as they relate to drinking.Motivational Enhancement Therapy, which builds on principles of motivational interviewing. It employs treatment processes that reflect the patient’s level of readiness for change.For detailed descriptions of these treatments, see VA/DoD Clinical Practice Guideline for Management of Substance Abuse Disorders . Shortly thereafter, the VHA began promoting the use of two trauma-focused, manualized cognitive–behavioral psychotherapies : ProlongPE includes four essential elements: psychoeducation, in-vivo exposure, imaginal exposure, and in-session discussion following imaginal exposures to facilitate emotional processing and corrective learning . In the CPT  consistsVA/DoD Clinical Practice Guidelines for the Management of Post-Traumatic Stress (VA/DoD Guidelines only recommend this as an adjunctive therapy for nightmares associated with the disorder.A wide range of psychotropic medications have been explored for treating PTSD. c Stress  most strFew well-controlled studies have assessed the efficacy of trauma-focused, cognitive–behavioral treatments, such as PE or CPT, in patients dually diagnosed with PTSD and SUD or AUD. This likely reflects a bias toward excluding patients with dual diagnosis from clinical trials because of traditional clinical concerns that concurrent misuse of substances could diminish the benefits of PTSD treatment , or thatCochrane Review that consolidates outcomes from over 1,400 participants (Taken in concert, the literature on treatments for co-occurring PTSD and AUD indicates that dually diagnosed patients can tolerate and benefit from psychotherapies specifically formulated to address trauma and PTSD. In fact, a forthcoming meta-analytic icipants  concludeicipants . AdditioSeveral descriptions and reports also have been published on the use of present-focused, skills-based psychotherapies specifically targeted to the needs of dually diagnosed patients. Of these, Seeking Safety, a manualized cognitive–behavioral treatment that can be delivered to individuals or groups, has received the greatest attention . Each seAlthough participants have generally accepted Seeking Safety and 22 reports have found mostly beneficial outcomes with PTSD-related symptoms and alcohol or substance use , the larLess is known about the clinical value of combining pharmacological treatments with psychosocial treatments for co-occurring PTSD and alcohol dependence , but an VA/DoD Clinical Practice Guidelines for the Management of Substance Use Disorders (There are no direct contraindications to prescribing patients with PTSD any of the pharmacotherapeutic agents recommended in the isorders  for the isorders  suggest Benzodiazepines are an effective treatment for relieving symptoms of alcohol withdrawal. However, the VA/DoD PTSD guidelines  raise coAlthough the 2010 VA/DoD Clinical Practice Guideline for the Management of Post-Traumatic Stress lists topiramate as having no demonstrated benefit for PTSD, a pilot study suggests that this anticonvulsant may have some value for treating both PTSD and AUD . HoweverAUD and PTSD are common and severe problems in veterans and military service members and merit intervention. Fortunately, a number of psychological treatments and medications have been demonstrated as effective for each problem and should be incorporated into clinical practice whether the conditions occur independently or together. When AUD and PTSD occur in the same patient, they should generally be addressed simultaneously, either in closely coordinated or integrated care. Contrary to earlier clinical concerns that substance abuse should be reduced or resolved before treatment for PTSD, it seems that for most patients the treatments can be performed simultaneously with good results. In fact, clinical experience and emerging research suggests that it is best to combine modalities and targets within a comprehensive treatment plan. As in other areas of clinical practice, clinicians should systematically and frequently monitor patient progress to determine if some modification may be needed in the treatment protocol. It also is important to assess the patient’s medical status before prescribing pharmacotherapies. In many cases, especially those involving alcohol dependence, adjunct medications will prove useful.


The welfare state is potentially an important macro-level determinant of health that also moderates the extent, and impact, of socio-economic inequalities in exposure to the social determinants of health. The welfare state has three main policy domains: health care, social policy  and public health policy. This is the protocol for an umbrella review to examine the latter; its aim is to assess how European welfare states influence the social determinants of health inequalities institutionally through public health policies.A systematic review methodology will be used to identify systematic reviews from high-income countries  that describe the health and health equity effects of upstream public health interventions. Interventions will focus on primary and secondary prevention policies including fiscal measures, regulation, education, preventative treatment and screening across ten public health domains . Twenty databases will be searched using a pre-determined search strategy to evaluate population-level public health interventions.Understanding the impact of specific public health policy interventions will help to establish causality in terms of the effects of welfare states on population health and health inequalities. The review will document contextual information on how population-level public health interventions are organised, implemented and delivered. This information can be used to identify effective interventions that could be implemented to reduce health inequalities between and within European countries.PROSPERO CRD42016025283The online version of this article (doi:10.1186/s13643-016-0235-3) contains supplementary material, which is available to authorized users. Socio-economic inequalities are associated with unequal exposure to social, economic and environmental risk factors, which in turn contribute to health inequalities. People with higher income, employment and educational opportunities have lower mortality and morbidity . Social Many commentators have sought to define what is meant by public health. The World Health Organization  emphasisPublic health policies can operate on a number of different levels, which affects population health and health inequalities. Following Mackenbach and McKee , public The nature of public health interventions means their influence percolates into many aspects of how we behave, live and work. For the purposes of this review, we categorise these interventions into fiscal policy, regulation, education, preventative treatment and screening. It is also helpful to consider the broad areas by which local and national governments may intervene and regulate. An example of the public health domain groupings (and intervention types) we propose can be found in Table Whilst there are many excellent reviews which focus on specific public health areas e.g. , 16), to, to16]),Our systematic review was designed using the Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) guidelines . A PRISMWhat are the effects of population-level public health policies on health and health inequalities in European welfare states?A systematic review methodology will be used to locate and evaluate published systematic review-level evidence on the effects of public health policy regulation on health and inequalities in health (‘umbrella review’) , 22, 23.Population: Children and adults  in any high-income country (defined as Organisation for Economic Co-operation Development (OECD) members) and additional EU-28 members not OECD members.Intervention: Upstream, population-level and public health policies defined as primary and secondary interventions. The inclusion criteria are purposely broad to allow for a range of different public health interventions to be located. Table Comparison: We will include systematic reviews that include studies with and without controls. Acceptable controls include randomised or matched designs.Outcomes: Health and health inequality outcomes. Primary outcome measures include (but are not limited to) morbidity, health behaviours, mortality, accidents and injuries. Secondary outcomes relate to health inequalities in terms of gender, ethnicity and socio-economic status . When available, cost-effectiveness data will also be collected.Setting: Only systematic reviews will be included in the analysis.Following standard evidence synthesis approaches , the incFollowing the methods of previous umbrella reviews , 22, pubTwenty databases will be searched from their start until March 2016 (host sites given in parentheses): Medline (Ovid), Embase (Ovid), Cumulative Index to Nursing and Allied Health Literature , PsycINFO (EBSCOhost), Social Science Citation Index (Web of Science), Applied Social Sciences Index and Abstracts , International Bibliography of the Social Sciences , Sociological Abstracts (ProQuest), Social Services Abstracts (ProQuest), PROSPERO , Campbell Collaboration Library of Systematic Reviews (The Campbell Library), Cochrane Library , Database of Promoting Health Effectiveness Reviews , Social Care Online (SCIE) and Health Systems Evidence. All searches will be tailored to the specific host site; an example search strategy is shown for Medline in Additional file The proposed search terms used in the search strategy are shown in Additional file The initial screening of titles and abstracts using EndNote will be conducted by one reviewer (KT), with a random sample of at least 10 %  checkedData will be extracted using standard data extraction forms based on previous reviews . The folQuality will be assessed using a checklist adapted from DARE, which has been used successfully in previous umbrella reviews . ArticleIf meta-analysis has been undertaken, the effect size will be used. In cases of narrative summaries where no summary effect sizes are provided, an exploration of patterns in the data will be accompanied by a discussion of similarities and differences between the findings of different studies. A detailed commentary on the major methodological problems or biases in the review will also be included, alongside an assessment of completeness and applicability . We willA pilot search strategy has been conducted in Medline (via Ovid) and is shown in Table This umbrella review will provide evidence of macro, population-level public health interventions which affect health and reduce health inequalities amongst European welfare states. Understanding the impact of specific public health policy interventions will help to establish causality in terms of the effects of welfare states on population health and health inequalities and, most importantly, identify effective interventions that could be implemented to reduce health inequalities across European countries. The umbrella review will consider public health strategies across ten different domains of public health, and, as such, it will also serve as a mapping exercise of the types of interventions that have been systematically reviewed, thereby highlighting any gaps in the systematic review evidence base. The review will also seek to establish (where reported) how such public health interventions are organised, implemented and delivered. Context is increasingly recognised as an important factor in the success of public health interventions  and has


New information based on data released by the World Health Organization (WHO) indicates that practically everyone infected with a major neglected tropical disease (NTD) lives in a Christian-, Muslim-, or Hindu-majority nation. The finding has implications for engaging religious leaders in NTD control and elimination activities.Today, of the estimated 7.4 billion (thousand million)_people living , approxiPLOS Neglected Tropical Diseases, we have pointed out the disproportionate impact of NTDs on Muslim-majority countries [In previous papers published in ountries ,5, Chrisountries ,7, and iountries ,9.With respect to the OIC nations, new studies by the Pew Research Center find that Muslims represent the fastest growing religious group and possibly the only one growing faster than the global population . Pew furSimilarly, some key and highly populated Christian-majority populations are profoundly affected by NTDs, partciularly since for the first time more Christians are now living in developing regions of Africa, Asia, and Latin America than in Europe and North America . Table 1A summary of the three major helminth infections—intestinal helminth infections, schistosomiasis, and LF—is shown in A key implication from these findings is that helminth infections represent critical factors in holding back the health and economic development of Christian-, Muslim-, and Hindu-majority developing nations, while Chagas disease and HAT are also devastating Christian-majority countries in Latin America and Africa, respectively. It is likely that a similar analysis might also hold for additional NTDs such as leishmaniasis and leprosy. These diseases are important causes of poverty because of their deleterious impact on pregnancy and on girls and women in general, child development, and adult worker productivity.Linking NTDs to religion has potential importance because it invites prominent international religious leaders to have a greater role in advocating for and supporting NTD control . For insFinally, there remains the interfaith opportunity to bring these three great religions together in order to cooperate on reducing the global burden of NTDs. NTD control and elimination represents one of the most effective and cost-efficient means to reduce poverty and relieve global suffering.


Osteoporosis is a major global health problem, especially among long-term care (LTC) facilities. Despite the availability of effective clinical guidelines to prevent osteoporosis and bone fractures, few LTC homes actually adhere to these practical recommendations. The purpose of this study was to identify barriers to the implementation of evidence-based practices for osteoporosis and fracture prevention in LTC facilities and elicit practical strategies to address these barriers.We performed a qualitative analysis of action plans formulated by Professional Advisory Committee (PAC) teams at 12 LTC homes in the intervention arm of the Vitamin D and Osteoporosis Study (ViDOS) in Ontario, Canada. PAC teams were comprised of medical directors, administrators, directors of care, pharmacists, dietitians, and other staff. Thematic content analysis was performed to identify the key themes emerging from the action plans.LTC teams identified several barriers, including lack of educational information and resources prior to the ViDOS intervention, difficulty obtaining required patient information for fracture risk assessment, and inconsistent prescribing of vitamin D and calcium at the time of admission. The most frequently suggested recommendations was to establish and adhere to standard admission orders regarding vitamin D, calcium, and osteoporosis therapies, improve the use of electronic medical records for osteoporosis and fracture risk assessment, and require bone health as a topic at quarterly reviews and multidisciplinary conferences.This qualitative study identified several important barriers and practical recommendations for improving the implementation of osteoporosis and fracture prevention guidelines in LTC settings. Osteoporosis is a major public health problem, affecting more than 200 million people worldwide . In CanaThe objectives of this paper were 1) to identify potential barriers to evidence-based practices for osteoporosis and fracture prevention in LTC settings and 2) to provide practical strategies to address those barriers based on a qualitative review of action plans made by members of Professional Advisory Committee (PAC) teams in LTC facilities, whose participation has been shown to increase the likelihood of guideline adoption .This qualitative study was conducted in twelve LTC homes in Ontario, Canada. All homes were active participants in the intervention arm of the Vitamin D and Osteoporosis Study (ViDOS). Briefly, ViDOS was a cluster, randomized controlled trial in 40 LTC homes  that examined the feasibility and effectiveness of a knowledge translation intervention targeting integration of best practices for osteoporosis and fracture prevention. At each home, the target participants were the Professional Advisory Committee (PAC), an interdisciplinary team that meets quarterly to address resident care and quality improvement objectives. This group includes the medical director, director of care, administrator, consultant pharmacist, food services director, and other medical, nursing, and rehabilitation representatives.Details of the study protocol have been published previously . Over twwww.osteoporosislongtermcare.ca) [After the expert presentation, PAC teams engaged in action planning for quality improvement based on the plan-do-study-act (PDSA) cycle  using thcare.ca) .Study outcomes in the ViDOS trial included both feasibility   and clinIn this qualitative study, we focus only on the analysis of the action planning component of the ViDOS intervention. Using a brainstorming technique, PAC teams worked through the action plan work sheets considering 1) the potential barriers to implementing osteoporosis and fracture prevention guidelines and 2) the strategies that needed to be taken to overcome those barriers (What has to happen? Who should be involved? What do you need? What are your next steps?). The ViDOS coordinator assisted in capturing the information on the work sheets and provided updated versions.The team analyzed the action plans produced by each PAC team using Thematic Framework Analysis, a commonly used approach to combine deductive (theme-driven) and inductive (ad hoc) coding and analysis of qualitative data . Two invThis research project was reviewed and approved by the Hamilton Integrated Research Ethics Board (HIREB). Written informed consent was obtained from each participant prior to data collection.Twelve LTC facilities across Ontario, Canada participated in the study with a mean bed size of 114 (SD: 57.0). LTC homes were located in communities that ranged in size from <30,000 people (42 %) to >1,000,000 people (17 %). The majority of homes were characterized as for-profit (92 %) and 75 % were affiliated with multi-facility chain operators.The most commonly reported barriers to providing optimal bone health care in LTC were lack of information and educational resources prior to the ViDOS intervention, difficulty obtaining required patient information for fracture risk assessment and inconsistent prescribing of vitamin D and calcium at the time of admission. Moreover, failure to include osteoporosis and fracture prevention strategies as topics for quarterly reviews and the patient/family out-of-pocket cost of vitamin D were perceived as important obstacles. The full set of barriers is reported in Table The most frequently suggested strategies by the PAC teams were implementation of standard admission orders regarding vitamin D, calcium, and osteoporosis therapies; better use of electronic medical records (EMRs) for osteoporosis and fracture risk assessment; and addition of bone health care as a topic in quarterly reviews and multidisciplinary conferences. They also suggested using educational toolkits and videos for LTC staff, residents, and their families as well as greater input by dietitians for review and monitoring of calcium intake and to ensure adequate amounts of dietary calcium for LTC residents. The full set of strategies is reported in Table In this study, PAC teams from 12 LTC facilities in Canada identified barriers to osteoporosis care in LTC facilities and suggested strategies to overcome them. One of the most frequently reported barriers to the implementation of osteoporosis CPGs was the lack of information and resources prior to intervention educational meetings. Participants identified improved education of staff as well as patients and families as strategies to overcome such barriers. In particular, the use of videos and toolkits to educate staff members about bone health care was frequently suggested. Similar approaches have been shown to modestly improve osteoporosis management by health care providers . Combinen = 87), who reported that barriers to the use of CPGs included lack of access to medical history and test results  [Difficulty in obtaining necessary patient information  was another barrier reported by participants in our study. This finding is consistent with the results of a recent survey conducted with Ontario LTC Physicians (density) . These pdensity)  who demodensity) . Howeverdensity) , 25.Inconsistent prescribing of vitamin D and calcium on admission was also identified as a barrier to guideline adherence. Similarly, Teng et al.  reportedAlthough we found brainstorming a useful technique for exploring barriers and solutions, combining multiple qualitative methods  might have resulted in more data . HoweverThis qualitative study outlined several important barriers to the implementation of evidence-based practices for osteoporosis and fracture prevention in LTC settings. Although tailoring strategies to overcome barriers needs to consider local context, the participants identified several common practical strategies at multiple levels that are relatively easy to implement and have been successfully implemented in the majority of LTC homes that participated in this study .