Background: Some observational studies suggest that a higher selenium status is associated with a lower risk of prostate cancer but have been generally too small to provide precise estimates of associations, particularly by disease stage and grade.Methods: Collaborating investigators from 15 prospective studies provided individual-participant records (from predominantly men of white European ancestry) on blood or toenail selenium concentrations and prostate cancer risk. Odds ratios of prostate cancer by selenium concentration were estimated using multivariable-adjusted conditional logistic regression. All statistical tests were two-sided.Results: Blood selenium was not associated with the risk of total prostate cancer . However, there was heterogeneity by disease aggressiveness , with high blood selenium associated with a lower risk of aggressive disease  but not with nonaggressive disease. Nail selenium was inversely associated with total prostate cancer , including both nonaggressive  and aggressive disease .Conclusions: Nail, but not blood, selenium concentration is inversely associated with risk of total prostate cancer, possibly because nails are a more reliable marker of long-term selenium exposure. Both blood and nail selenium concentrations are associated with a reduced risk of aggressive disease, which warrants further investigation. There has been great interest in the possible role of selenium in cancer prevention, largely because of its antioxidant properties, although it also has other potentially anticarcinogenic effects . The effThe Endogenous Hormones, Nutritional Biomarkers and Prostate Cancer Collaborative Group (EHNBPCCG) was established to conduct collaborative analyses of individual participant data from prospective studies on the associations of circulating concentrations of hormones and nutritional biomarkers with the subsequent risk of prostate cancer . The objA detailed description of the EHNBPCCG is reported elsewhere . In 2010Seventeen eligible studies were identified, of which 15 are included in the current analysis, comprising 6497 men with prostate cancer (case patients) and 8107 men without prostate cancer (control subjects) , includiSupplementary Table 1, available online).Information on recruitment, informed consent, ethical approval, and inclusion criteria for all studies is available in the original publications. Eight studies used a nested case-control study design in populations with no organized screening program but with varying levels of population-wide prostate-specific antigen (PSA) testing ,11,14–19Supplementary Table 2, available online, for details of the assay methods), date and age at sample collection, fasting status, marital status, ethnicity, educational attainment, family history of prostate cancer, height, weight, waist and hip circumference, smoking status, and alcohol intake. Most studies included men of white European ancestry; those studies that did include men of different ethnic backgrounds included this as a matching criterion –node (N)-metastasis (M) categories of T2 or lower with no reported lymph node involvement or metastases, stage II or lower or equivalent; advanced if it was T3 or T4 and/or N1+ and/or M1, stage III or IV or equivalent; or stage unknown. Aggressive disease was defined as T4 and/or N1+ and/or M1, or stage IV disease and/or death from prostate cancer; nonaggressive disease was defined as TNM stage lower than T4 with no reported lymph node involvement or metastases or the equivalent, or unknown. Histological grade was categorized as low-intermediate grade , high-grade , or unknown. Our definition of high-grade disease used in this and other analyses  is more Blood and nail selenium concentrations were logarithmically transformed for all statistical analyses to approximate a normal distribution. All analyses were run separately for blood and nail selenium. Analysis of covariance was used to investigate geometric mean differences in selenium concentration among the controls by baseline characteristics, with adjustment for study and age at blood collection. Tests for trend across the categories were obtained by scoring the categories 1, 2, 3, etc., as required.Men were categorized into fifths of selenium concentration with quintile cutpoints defined by the overall distribution among control participants in all studies combined. This approach maximizes the ability to examine associations across the full selenium distribution across all studies and assumes that the differences in absolute values between studies are because of true population differences rather than assay differences between the studies . AnalyseTo provide a summary measure of risk, a linear trend was calculated by replacing the categorical variable representing the fifths of selenium with a continuous variable that was scored as 0, 0.25, 0.5, 0.75, and 1. As the midpoints of the lowest and highest fifths are the 10th and 90th percentiles of the study-specific selenium concentration, a unit change in this continuous trend variable (which represents an 80th percentile increase) is comparable with the relative risk comparing the highest with the lowest fifth.2, not known), height , marital status , educational status , and cigarette smoking . These factors were found to be associated with prostate cancer risk in this dataset and hence were included in the final models.Conditional logistic regression was used to calculate odds ratios (ORs) and their corresponding 95% confidence intervals (CIs), conditioned on the matching variables within each study and with additional adjustment for age at blood collection (exact), body mass index  x (linear trend) interaction term. Tests for heterogeneity of trends for the case-defined factors were obtained by fitting separate models for each subgroup and assuming independence of the odds ratios using a method analogous to a meta-analysis. Tests for heterogeneity for the non-case-defined factors were assessed with a χ2-test of interaction between subgroup and the continuous trend test variable. Further analyses of the association of selenium with disease stage, aggressiveness, and grade were conducted by calculating odds ratios in fifths of the distribution.Heterogeneity in linear trends between studies was tested by comparing the χP values reported are two-tailed, and a P value of less than .05 was considered statistically significant. All statistical analyses were carried out using Stata .All Supplementary Table 3, available online, for details of the number of cases by stage, grade, and other tumor characteristics by study).Details of the 15 participating studies are shown in Supplementary Figure 1 (available online). Blood selenium concentrations were slightly lower in men who were older, who had a higher BMI, and who were current smokers and were slightly higher in men who had fasted for longer at the time of blood collection. Nail selenium concentrations were lower in current smokers and slightly higher in men who were married and highly educated.The cross-sectional associations between baseline characteristics and blood and nail selenium concentrations are shown in Ptrend = .92), based on 4527 case patients and 6021 control subjects; for nail selenium, the corresponding odds ratio was 0.29 , based on 1970 case patients and 2086 control subjects. Adjustment for the potential confounders listed above made little difference to the risk estimates . Associations were qualitatively similar when the analysis was performed using study-specific cutpoints although the risk estimate was attenuated for nail measures, reflecting the narrower ranges of selenium concentration when using these cutpoints  and a strong inverse association with nail selenium (OR for the highest [midpoint = 1.08 ppm] vs lowest tenth (midpoint = 0.17 ppm) = 0.25, 95% CI = 0.17 to 0.37, Ptrend < .001).In order to examine the association at the extremes of the distribution, selenium concentration was categorized into deciles and analyzed using overall cutpoints for all studies combined. There remained no association with blood selenium  (Pheterogeneity = .09) (Ptrend = .02).There was no evidence of heterogeneity between the contributing studies in the linear association of blood selenium concentration with risk (y = .59) . There wy = .09) , and thePheterogeneity = .01), with a higher blood selenium concentration associated with a lower risk of aggressive disease , with no association with nonaggressive disease  . These findings support the linear trend estimates although the numbers are small in some categories. There were no statistically significant differences in the association between nail selenium concentration and prostate cancer risk by stage or grade of disease, although nail selenium was associated with a particularly low risk for aggressive disease  compared with nonaggressive disease  (There was evidence of heterogeneity in the linear association of blood selenium concentration with prostate cancer risk according to disease aggressiveness (to 1.41) . The dify = .08) .Figure Pheterogeneity = .02 and .01, respectively) and for nail selenium by family history (Pheterogeneity = .04)  .This international collaboration has brought together and re-analyzed almost all of the available data on the association of blood and nail selenium concentrations and prostate cancer incidence. The majority of the data were from studies with blood measures, which showed no association with risk of total prostate cancer (based on 4527 case patients and 6021 control subjects) but an approximate halving in risk for aggressive disease in men with high blood concentrations (based on 527 case patients and 634 control subjects). Combining (using a weighted average) our collaborative risk estimate with those from the two blood-based studies that were unable to contribute data ,20 produFour studies provided data on nail measures, which showed a 70% reduction in risk for total prostate cancer (based on 1970 case patients and 2086 control subjects), with no statistically significant difference by disease subgroups, although the association was somewhat stronger for aggressive compared with nonaggressive disease. The majority of the data are from a single study (NLCS), which also had substantially lower selenium concentrations than the other studies and a high proportion of advanced and aggressive disease, owing to an enriched sampling of such cases.all rac-α-tocopheryl acetate) for 5.5 years, based on 848 cases  with or without vitamin E  and aggressive disease (38% vs 15%) and more men whose samples were taken before 1995 (48% vs 18%). Widespread use of PSA testing was introduced in many countries from the mid-1990s onwards  while PSA screening was used systematically in two of the collaborating studies (PCPT and PLCO), contributing to an increase in the detection of small, asymptomatic tumors in recent years .Because a substantial proportion of PSA-detected cancers remain biologically indolent for many years , the ideAlthough it is possible that the inverse association found with blood and nail selenium concentration and risk of aggressive prostate cancer might be because of confounding, the analyses were adjusted for a range of lifestyle factors in addition to the matching factors used in the individual studies, none of which materially influenced the risk estimates. There was also no statistically significant heterogeneity in the association of blood or nail selenium concentration with risk of prostate cancer according to the number of years between blood collection and diagnosis, which does not suggest that reverse causation has affected the results, although this cannot be excluded. Finally, while there was some evidence of statistical heterogeneity in the association of selenium with risk by smoking status, the pattern of the association differed between blood and nail measures and the statistically significant heterogeneity may have been because of chance because of the large number of statistical tests performed.Relatively little is known about the performance of blood and nail specimens as measures of long-term selenium status. Studies have shown that both blood and nail measures are correlated with selenium intake (r = 0.6 to 0.7) , 35 and This collaborative re-analysis of the association of selenium status and prostate cancer risk based on the totality of the worldwide data shows that relatively high blood and nail selenium concentrations are associated with a reduced risk of aggressive prostate cancer. Further investigation in large, representative populations that have selenium measurements from both blood and nail samples and that include information on screening history, as well as stage and grade of tumors, is needed to examine these possible associations in more detail.Cancer Research UK . We thank the men who participated in the collaborating studies, the research staff, the collaborating laboratories, and the funding agencies in each of the studies. BLSA was supported by the National Institute on Aging Intramural Research Program, Prostate Spore Grant (CA58236). CARET was supported by the US Department of Health and Human Services and the National Institutes of Health (U01 CA63673), Clinical Nutrition Research Unit (P30 DK35816). Campaign against Cancer and Stroke was supported by the US National Cancer Institute, the National Institutes of Health (CA94028), and the Department of Defense (DAMD1–94-J-4265). European Investigation into Cancer and Nutrition was supported by Cancer Research UK; Europe Against Cancer Programme of the European Commission; German Cancer Aid; German Cancer Research Center; German Federal Ministry of Education and Research; Danish Cancer Society; Health Research Fund of the Spanish Ministry of Health; Centros de Investigacion Biomedica en Red Epidemiología y Salud Publica, Barcelona, Spain; the participating regional governments and institutions of Spain; Medical Research Council, UK; the Stroke Association (UK); British Heart Foundation; Department of Health (UK); Food Standards Agency (UK); Greek Ministry of Education; Greek Ministry of Health and Social Solidarity; Hellenic Health Foundation; Italian Association for Research on Cancer; Italian National Research Council; Dutch Ministry of Public Health, Welfare and Sports; Dutch Ministry of Health; Dutch Prevention Funds; LK Research Funds; Dutch Zorg Onderzoek Nederland; World Cancer Research Fund; Swedish Cancer Society; Swedish Scientific Council; and Regional Government of Skane, Sweden. EPIC-Heidelberg was supported by the German Federal Ministry of Education and Research (FK 0313846A), Deutsche Krebshilfe (10-1793 Scholl). Finnish Mobile Clinic Health Examination was supported by the Cancer Society of Finland. Health Professionals Follow-up Study was supported by the US National Cancer Institute, the National Institutes of Health (CA55075), and the National Heart, Lung, and Blood Institute (HL35464). Multiethnic Cohort was supported by the US National Cancer Institute and the National Institutes of Health . Nutritional Prevention of Cancer Trial was supported by the US National Cancer Institute and the National Institutes of Health (RO1 CA49764). Netherlands Cohort Study was supported by the Dutch Cancer Society (UM 2009–4556). Prostate Cancer Prevention Trial and Selenium and Vitamin E Cancer Prevention Trial (SouthWest Oncology Group) were supported by the US National Cancer Institute and the National Institutes of Health (CA37429). Physicians’ Health Study was supported by the US National Cancer Institute and the National Institutes of Health . Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial was supported by the US National Cancer Institute, the National Institutes of Health , and the Intramural Research Program. SUpplementation en Vitamines et Mineraux Anti-oXydants Trial was supported by the French Ministry of Health/Direction Générale de la Santé.This work was supported by The authors are solely responsible for the study design; the collection, analysis, and interpretation of the data; the writing of the article; and the decision to submit the article for publication. All authors contributed to these analyses and read and approved the manuscript. The sponsors had no role in the study design, data collection, data analysis, data interpretation, writing of the report, or the decision to publish. The authors have no conflicts of interest to declare.


Cambodians receive 0.8–5.9 therapeutic injections per person per year, one of the highest reported rates worldwide (A case-control study conducted as part of an investigation of an outbreak of 242 new cases of HIV infection among residents of Roka Commune, Battambang Province, Cambodia, from December 2014 through February 2015, (From September 26–29, 2016, a team of medical officers from CDC and a clinical team from Becton Dickinson with expertise in infection control assisted the Cambodia MOH in implementation of the rapid assessment. A cross-sectional studyA total of 115 injection events were observed, and 39 health care workers were interviewed ; 99% of Although this study found little reuse of injection equipment and high knowledge of the risks of unsafe injection practices related to HIV transmission, none of the observed injections fully adhered to WHO standards of practice, thus potentially compromising both patient and health care worker safety. To address these gaps, an intensive training curriculum on safe injection practices for health care workers is being developed by Becton Dickinson with technical support from CDC. After review and approval by the Cambodia MOH, expert master trainers will administer this training in the same health care facilities where the baseline assessment was conducted. The impact of the training on the improvement of injection and phlebotomy practices will be measured with a follow-up assessment in the same facilities where the baseline assessment was conducted. Health assessment findings are also contributing to the revision of current policies, information education and communication resources, and the development of job aids on safe injection practices.


Starting in 2015, microcephaly associated with Zika virus emerged as a public health emergency of international concern. Initial cases in the United States were travel-associated; however, there are increasing reports of local transmission in pockets of the country, and therefore public concerns may escalate.Fetal microcephaly and other congenital malformations are devastating consequences of Zika virus infection.Ultrasound findings in fetuses with congenital Zika virus infection include microcephaly, intracranial calcifications, ventriculomegaly and arthrogyposis, as well as abnormalities of the corpus callosum, cerebrum/cerebellum and eyes  and 2.4,5While the detection of specific point-of-care fetal ultrasound findings associated with Zika virus disease is beyond the scope of knowledge expected for EPs, any unusual appearance should prompt an assessment of the patient’s risk factors for the infection. This is particularly critical as the vast majority of patients will be asymptomatic. Through knowledge of US findings indicative of Zika-virus related congenital malformations, EPs will be empowered to facilitate timely referrals for concerned or possibly exposed pregnant patients who may otherwise only present to the ED for routine POCUS testing.


Climate change and species invasions represent key threats to global biodiversity. Subarctic freshwaters are sentinels for understanding both stressors because the effects of climate change are disproportionately strong at high latitudes and invasion of temperate species is prevalent. Here, we summarize the environmental effects of climate change and illustrate the ecological responses of freshwater fishes to these effects, spanning individual, population, community and ecosystem levels. Climate change is modifying hydrological cycles across atmospheric, terrestrial and aquatic components of subarctic ecosystems, causing increases in ambient water temperature and nutrient availability. These changes affect the individual behavior, habitat use, growth and metabolism, alter population spawning and recruitment dynamics, leading to changes in species abundance and distribution, modify food web structure, trophic interactions and energy flow within communities and change the sources, quantity and quality of energy and nutrients in ecosystems. Increases in temperature and its variability in aquatic environments underpin many ecological responses; however, altered hydrological regimes, increasing nutrient inputs and shortened ice cover are also important drivers of climate change effects and likely contribute to context‐dependent responses. Species invasions are a complex aspect of the ecology of climate change because the phenomena of invasion are both an effect and a driver of the ecological consequences of climate change. Using subarctic freshwaters as an example, we illustrate how climate change can alter three distinct aspects of species invasions: (1) the vulnerability of ecosystems to be invaded, (2) the potential for species to spread and invade new habitats, and (3) the subsequent ecological effects of invaders. We identify three fundamental knowledge gaps focused on the need to determine (1) how environmental and landscape characteristics influence the ecological impact of climate change, (2) the separate and combined effects of climate and non‐native invading species and (3) the underlying ecological processes or mechanisms responsible for changes in patterns of biodiversity. Our focus is on high latitude subarctic freshwater ecosystems  risen by 0.85°C since 1880, exceeding rates experienced in previous centuries IPCC, , and theAs water temperature is primarily determined by ambient air temperature and solar radiation  is an important source of energy for clear water ecosystems  contribute to increased nutrient inputs from terrestrial sources , Percids , and Centrarchids   and Atlantic salmon , temperature has a positive effect on growth only in the second year  is linked with the increased production of zooplankton as prey associated with increasing temperature , body growth is positively linked with lake productivity  , are also influenced by increases in productivity , ruffe, European perch, yellow perch (Perca flavescens), smallmouth bass, largemouth bass, roach, and ide have either been observed or predicted to expand their range into subarctic regions due to temperature increases with climate change  via oxygen depletion, especially in unstratified lakes in North American lakes  exhibit vertical segregation in deep, cold lakes, thereby reducing resource overlap  that are important prey sources for fish   suggest that temporal variation in bottom‐up and top‐down controls of population size within food webs occurs due to the effect of climate  of climate change and also a potentially important driver (cause) of ecological change  and facilitating the invasion success and competitive advantage of cool‐ or warm‐water species   niches available to be filled by new species  and global spatial extents. However, despite the concern of climate change and the subsequent risks to ecosystems, biodiversity and ecosystem services, this synthesis also highlights three key knowledge gaps relevant to drawing inferences and making predictions of the effects of climate change on both subarctic freshwaters and other ecosystem types. These gaps limit our understanding of the mechanisms by which of climate change induces ecological effects, which in turn restricts the ability to make strong predictions of climate change impacts.What is the role of habitat characteristics  and landscape  context in the effects of climate change? In freshwater systems, we have a poor understanding of how ecological effects of climate are mediated by habitat characteristics. Much of this is due to limited replication of studies  means there is a risk in extrapolating knowledge of invasive species impacts as being consistent under different climate scenarios or along strong climate gradients. This question is important to identify the extent to which non‐native species are drivers, passengers, or “backseat drivers” (sensu MacDougall & Turkington, How do the mechanisms linking climate change with ecological responses determine patterns of freshwater biodiversity across local, landscape, and regional spatial scales? An extensive body of evidence details how freshwater biodiversity in northern latitude regions is changing in association with climate change (Buisson et al., None declared.


Advances in magnetic resonance imaging and the introduction of clinical decision support systems has underlined the need for an analysis tool to extract and analyze relevant information from magnetic resonance imaging data to aid decision making, prevent errors, and enhance health care.The aim of this study was to design and develop a modular medical image region of interest analysis tool and repository (MIROR) for automatic processing, classification, evaluation, and representation of advanced magnetic resonance imaging data.The clinical decision support system was developed and evaluated for diffusion-weighted imaging of body tumors in children . Mevislab software and Python have been used for the development of MIROR. Regions of interests were drawn around benign and malignant body tumors on different diffusion parametric maps, and extracted information was used to discriminate the malignant tumors from benign tumors.Using MIROR, the various histogram parameters derived for each tumor case when compared with the information in the repository provided additional information for tumor characterization and facilitated the discrimination between benign and malignant tumors. Clinical decision support system cross-validation showed high sensitivity and specificity in discriminating between these tumor groups using histogram parameters.MIROR, as a diagnostic tool and repository, allowed the interpretation and analysis of magnetic resonance imaging images to be more accessible and comprehensive for clinicians. It aims to increase clinicians’ skillset by introducing newer techniques and up-to-date findings to their repertoire and make information from previous cases available to aid decision making. The modular-based format of the tool allows integration of analyses that are not readily available clinically and streamlines the future developments. Magnetic resonance imaging (MRI) is a fast-growing clinical imaging modality and has become the modality of choice for the evaluation of disease and treatment management across multiple therapeutic areas. It has increasingly been used in oncology, central nervous system diseases, musculoskeletal disorders, and cardiovascular disease due to its superior soft-tissue imaging capabilities, lack of ionizing radiation, and noninvasive nature -4.MRI technology constantly advances with new magnetic resonance applications being pioneered, investigated, mainstreamed, and added to clinical applications and capabilities. Nevertheless, clinical interpretation remains largely by qualitative expert review. In addition, new advanced and computationally intensive medical quantitative image analysis techniques are constantly being developed and validated. These techniques have allowed the discovery of specific biomarkers of both disease and treatment response and have exposed clinicians to new information in a computable format -8. HowevIn the past decade, clinical decision support (CDS) systems have increasingly gained attention, and the routine uptake of these intelligent systems is becoming more common -17. IntrAvailability of a user-friendly and flexible MRI CAD that encompasses a variety of medical image analysis techniques and postprocessing methods and can act as a CDS could facilitate the uptake of new advanced magnetic resonance techniques in the real-time clinical setting; it could also allow health care investigators to interrogate their data in a scientifically informative and convenient manner to determine a robust and efficient diagnosis. The aim of this study was to design, develop, and evaluate a medical image region of interest analysis tool and repository (MIROR) platform for conventional magnetic resonance data aimed at improving clinical performance through the provision of real-time diagnostic support for clinicians.To the best of our knowledge, there is only the International Network for Pattern Recognition of Tumours Using Magnetic Resonance Decision Support System validated and available for the analysis of magnetic resonance spectroscopy (MRS) data . HoweverFeatures available in the presented version of the MIROR are (1) a clinician-friendly graphical user interface; (2) measurement of morphologic properties such as size, shape, volume, length dimensions, and center-of-mass location of the region of interest (ROI); (3) an integrated magnetic resonance diffusion-weighted imaging (DWI) analysis application based on intravoxel incoherent motion (IVIM) model; (4) statistical data analysis of the ROI overlaid on standard MRI images (such as T1-weighted and T2-weighted scans or the advanced quantitative maps) to provide decision support in forms of comparison with other differential diagnosis and several different image volumes to aid diagnosis and determination of prognosis; and (5) a self-archiving repository of the extracted data and features. Availability of the latter 2 options in combination with the first 3 will move the designed tool from a CAD toward becoming a CDS for MRI data. MIROR also allows investigators to further grow, advance, and combine different analysis techniques and types of imaging sequences to extend the tool to a more sophisticated decision support, dependent on their individual center’s needs to better inform diagnosis. MIROR’s self-archiving, evolving repository is the core of its decision support. This unique feature of the MIROR distinguishes it from pervious CADs and CDSs. First, the repository’s continuous development allows for improvement in the predication accuracy for the available biomarkers and disease in the database; second, it permits provision of a decision support system compatible to additional disease types by means of importing and appending the repository.We used a modular and open architecture design  in the dBased on the recommendations of the American medical informatics association , an evidMIROR can import all file formats supported by the National Library of Medicine Insight Segmentation and Registration Toolkit, such as digital imaging and communications in medicine (DICOM) files, Neuroimaging Informatics Technology Initiative files, JPEG as well as text files, and comma spreadsheets. Built-in Mevislab modules and Python were used to create this functionality. Using the module raw images, postprocessed quantitative maps and data files can be imported from the clinical data warehouses, such as hospital picture archiving and communication system (PACS), the local servers, or MIROR for future analysis and visualization .Comparing the MIROR architecture with previously developed CDSs with a clinical data base and domain expert knowledge base, MIROR does not connect to hospital electronic health record (EHR) system or any Internet-based database or medical knowledge representations or guidelines ,35,36. HOne of the main strengths of MIROR is its ability to allow for integration of new advanced and computationally intensive quantitative analyses that are not readily available to be used in routine clinical practice under the Advance Quantitative analysis module . In thisD), pseudo-diffusion coefficient (IVIM-D*), and perfusion fraction (IVIM-f) [This analysis allows the computation of tissue diffusion coefficient (IVIM-(IVIM-f) . HoweverThe MIROR-embedded statistical analysis module provides specialists with instruments for (1) analyzing and interpreting individual patient MRI data and (2) comparing it with results of previous cases directly from the MIROR-evolving repository via powerful statistical techniques to future inform the investigation . MIROR pNote that MIROR is a nonregion-specific MRI CDS, and its novel quantitative image analysis and statistical analysis modules are designed to analyze any region of the body and aid in resolving different demanding diagnostic problems.The frontend of the MIROR is a clinician’s user-friendly graphical interface that displays MRI images as well as quantified parametric maps and allows clinicians to define their ROI. It also provides real-time morphological and statistical results for compassion with the repository data so as to aid clinical evaluation of the disease.MIROR is currently being developed, evaluated, and used at Birmingham Children’s Hospital to determine its role in facilitating noninvasive diagnosis in children presenting with solid body tumors in clinical practice.Solid masses in children represent a diagnostic dilemma, as neoplastic and non-neoplastic lesions can appear similar on conventional imaging. Although in some cases the clinical history and physical examination findings indicate a likely diagnosis, the majority of cases require further evaluation with MRI to assess the extent of the lesion and make a specific diagnosis. It is often difficult to determine whether a lesion is benign or malignant or identify specific tumor type based on conventional MRI alone.This study evaluated the impact of information provided by MIROR in aiding clinicians to distinguish between benign and malignant solid body pediatric tumor types using DWI. Accuracy testing involved examination of MIROR for a cohort of real patient cases with recent visits to Birmingham Children’s Hospital and comparison of the MIROR outcome with the radiologist’s initial opinion and final diagnosis derived based on the opinion of the clinical multidisciplinary team of experts together with pathology.The body tumor patient cohort studied consisted of children (aged 0-16 years) with solid tumors, undergoing diagnostic MRI with multi b-value DWI at Birmingham Children’s Hospital from 2012 to September 2016. A total of 48 children were enrolled, of whom 37 had malignant tumors and the rest had benign tumors. Details of the malignant and benign body tumors along with patients’ demographics are presented in 2, matrix size 122 to 192 × 128 to 192, slice thickness of 5 mm, and in-plane resolution of 1.56 × 1.56 mm2. For all subjects, 6 b-values: 0, 50, 100, 150, 600, and 1000 s/mm2 were acquired in 3 orthogonal directions with TR/TE=3200 to 9900/92 ms and number of averages=3. The signal to noise of the MRI dataset was approximately 30 (SD 10) for b1000 and 60 (SD 10) for b0 images.We performed the MRI on a Siemens Avanto 1.5 T MRI scanner . The diffusion-weighted MRI protocol used an echo-planar imaging sequence in an axial acquisition plane with a field-of-view (FOV) 221 to 350 × 172 to 317 mm0 and b1000), IVIM-D, IVIM-D*, and IVIM-f maps. These values are a quantitative measure of diffusion related to tissue cellularity [D, IVIM-D*, and IVIM-f) and means for direct and real-time statistical analysis of these variables are unavailable clinically, despite the growing body of evidence for their potential value in noninvasive diagnosis.Depending on their ability to cooperate, children were awake, sedated, or under general anesthesia. MRI acquired with different diffusion weightings  was used to compute ADC , it was assigned to that particular group. However, if the value of the parameter under study fell within both tumor group regions, we made use of second-adjusted classification based on distance from the mean of the statistical parameter of the groups in the training set. To further evaluate the significance of the statistical parameters and information provided by MIROR, k-nearest neighbor (KNN) and support vector machine (SVM) pattern recognition techniques, followed by leave-one-out cross-validation, were utilized to test the accuracy of derived data in distinguishing between tumor types, using all parameters as classification features. KNN was chosen for its simplicity and performance on basic recognition problems; it has been a ubiquitous classification method with good scalability. SVM outperforms conventional pattern recognition methods, especially when the number of training data is small and number of input variables is large .To account for the data skewness and imbalanced distribution of the 2 groups, synthetic minority oversampling technique has been used to allow for building a larger decision region that contains nearby instances of the minority class  when KNNFeature selection was performed before classification by means of calculating the significance level of the histogram derived parameters between the tumor groups. Then, benign and malignant tumors’ histogram permanents  were compared using the nonparametric Mann-Whitney U test. The authors used the Bonferroni correction method. Parameters showing a significant difference between the 2 groups were used for classification. All statistical analyses were performed using SPSS Statistics  software.All patients were consented for research to the UK Children’s Cancer and Leukemia Group, Functional Imaging Group database, a UK National Health Service Research Ethics committee-approved study . Informed participation and publication consent was given by parents/guardians.MIROR is aimed at improving clinical practice through the provision of real-time diagnostic support. To ensure achievement of the latter, each individual application and module has been tested in such an environment by allowing clinicians to interrogate it about the most important clinical questions and provide feedback. We used an iterative process of design, testing, and revision of the MIROR by a diverse team, including medical informatics experts, clinical content experts, and end users to ensure reliable translation of the tool to clinical practice. Experts in MRI and medical imaging, including PhD researchers specializing in MRI and data processing, a physician, and a senior consultant radiologist pilot tested MIROR iteratively during the development and refinement of the tool.MRI datasets and ADC produced by the scanner were imported to MIROR from a local PACS. An ROI was drawn around the entire solid tumor for each case on a high-resolution image by one clinician, which was then checked by another (KM and KF) before being transferred to a matched parametric map . The entire tumor volume, including cystic and necrotic areas, was included in the ROI to determine representative data for heterogeneous tumors . A histoP=.12), 90th (P=.22), 95th (P=.82), or 98th centile (P=.41) ADC values between benign and malignant tumors (P=.03), median (P=.005), 2nd (P=.04), 5th (P=.02), 10th (P=.01), 15th (P=.005), 25th (P=.004), and 75th centile (P=.03) ADC values, higher kurtosis (P<.01), more positively skewed histograms (P<.001), and higher entropy (P=.03). These results are in agreement with similar studies published for adults [To establish differences between the malignant and benign lesions histogram parameters, the authors compared the histogram-derived parameters in the repository. Analysis showed apparent differences between malignant and benign tumors, with lower ADC values and higher skewness and kurtosis in malignant lesions. There was no significant difference between 85th  in discriminating between benign and malignant tumors. Note that the threshold classification was performed based on a single feature input and a 2-step classification process, with a less strict rule in second layer to reclassify the cases in the ambiguous group. Using all of the above extracted features, more advanced pattern recognition techniques, and 10-fold cross-validation, an accuracy of 0.89  and 0.93  was obtained by SVM and KNN, respectively. To further evaluate MIROR in terms of its added clinical value, radiologist initial diagnosis from the first MRI scans was compared with the final diagnosis obtained from histopathology, and the outcome of the 3 statistical analyses based on MIROR provided information for classifying the tumor types for this cohort of patients . For theA higher amount of uncertainty was observed in the initial diagnosis of the benign group. The benign group diagnostic uncertainty rate decreased when we used the information provided by MIROR. Moreover, the false diagnosis rate for both the malignant and benign groups was reduced compared with the radiologist’s initial report with all 3 analysis methods. Additional statistical information provided to clinicians by MIROR can allow for a better and more informed noninvasive discrimination of benign and malignant body tumors in children.Net reclassification improvement (NRI)  for KNN,Continuous developments of magnetic resonance systems have transformed this domain from a pure imaging system to a sophisticated precise metric system that generates a substantial amount of information and data. The complex structure of the clinical data generated often does not ease the difficulty in discriminating between different diagnoses and promotes adoption of intelligent CDSs ,56. CDSsRadiologists are moving toward quantitative imaging techniques that are difficult to apply and complex to interpret ,57. MIROMIROR as a diagnostic tool allows its users to extract specific region morphological features, request specific quantified metrics and features (as a biomarker), and compare with relevant findings available in its repository to gain maximal statistical power with regard to outcome prediction for the input case into the support system. MIROR can direct users to refine their search patterns looking for particular diagnoses, even if they themselves are not immediately aware of the significance of these findings.Use of modular programming in the development of MIROR enforces logical boundaries between magnetic resonance analysis applications, thereby improving maintainability ,59. ModuIn terms of its added clinical value and its impact on providing clinical evidence, MIROR will assist clinicians to better understand the pathophysiological difference between the different tumor types and provide information that could help them to better understand the mechanisms of diseases to improve the diagnosis and prognosis of tumors. MRI biomarkers provide information on both the tumor and its interaction with its environment and can potentially provide new information, which is not available from histology or tumor genetics. Analysis of cancer imaging big data will allow uncovering the relation and structure of cancer disease from an angle that has not previously been viewed.f is related to tumor vascularity, which is again an important pathophysiological property of the tumor. Making these advanced MRI techniques available to clinicians in their multidisciplinary team meetings, where imaging and histopathology are evaluated together for individual cases, is an important goal and will allow an improved understanding of pathophysiology for these tumors in vivo and ex vivo.Although we concentrate on developing these advanced MRI methods as a noninvasive diagnostic aid, they provide important information on tissue properties. Apparent diffusion coefficient shows a strong inverse correlation to cellularity—a key feature of tumors and tumor aggressiveness. Likewise, there is an increasing understanding that IVIM-As a part of future research, we plan to work on functionality and intelligent scaling of quantitative applications of MIROR by further enhancing its statistical capabilities and extension to more embedded advanced quantitative analysis modules such as magnetic resonance spectroscopy and integration of real-time interactive machine learning to optimize the use of available data in MIROR based on the guidelines .It should be noted that a major limitation of the study was that MIROR was trained and tested with a rather limited set of data analyzed retrospectively. A major focus of future work will be the validation of the tool based on a prospective dataset in real time and in a multicenter clinical setting to reinforce the credibility, usability, and efficiency of the proposed CDSs applications.The proposed CDS is a diagnostic tool and repository that allows the interpretation and analysis of magnetic resonance images to be more accessible and comprehensive for clinicians. The process and experiences described here provide a model for development of the other CDSs attempting to perform a nonregion-specific quantitative analysis of MRI data. MIROR aims to increase clinician’s skillset by introducing newer techniques and up-to-date findings to their repertoire and make information from previous cases available to aid decision making. The modular-based format of the tool allowed integration of analyses that are not readily available clinically, and streamlines future developments. Pipelines for new analysis applications are available or already in development and will be shortly available under the MIROR platform.


Global strategy and action plan on ageing and healthThe health sustainable development goal (SDG3) aims to “ensure healthy lives and promote wellbeing for all, at all ages.” One of its core targets is to achieve universal health coverage (UHC). However, older adults require different approaches to health care and are often less able to pay for these services; therefore, health systems will need to be realigned significantly to meet these targets.The strategy focuses on strengthening health and long-term care systems at local and national levels to cover the needs of older adults through strengthening national policy, combating ageism, generating new evidence and supportive tools and creating more age-friendly environments. Sustainable financing, a key concern of policy-makers,These challenges call for three interlinked strategies to make health systems fit for purpose and context: strengthening the systems’ foundations, reforming institutions and fostering transformation. Implementing these changes demands shifting away from disease-oriented financing, resources and management, towards a person-centred agenda that values health gain.Although every country is different, steps can be taken towards UHC that is more inclusive of older adults. Integrated care for older people,First, countries need to foster better integration between health and social care to improve and maintain older adults’ physical and cognitive capacities. Older people who benefit from coordinated chronic care that is guided by comprehensive assessments report more satisfaction and experience fewer emergency referrals than when they receive services that treat individual conditions independently.Second, policy-makers must negotiate ways to reduce costs and increase risk sharing. The WHO Survey on Global Ageing and Adult Health in China, Ghana, India, Mexico, the Russian Federation and South Africa, documents that households with people older than 50 years experienced greater financial burden due to health costs,Finally, achieving UHC requires countries to pay attention to health inequities. Differences in functioning during the second half of life reflect the cumulative impact of many social and environmental determinants.To progress towards UHC, policy-makers must address competing priorities for different population groups, services and financing mechanisms. The commitment of the Senegalese Ministry of Health and Social Action to review its plan covering individuals 60 years and older, conduct further analyses in rural areas and develop a new national strategy towards healthy ageing shows that actions can be informed by policy dialogues across government sectors and be inclusive of civil society, so that on the road to UHC, no one is left behind.


Multiple drivers of the double burden of malnutrition (DBM) include a rapid shift from predominantly plant-based diets to energy-dense foods based on meats, milk, animal fats and vegetable oils. The shift to overweight and obesity is driven by increased exposure to mass media, urbanization, technological advances in food processing, rising income and increased population density associated with increased access to cheap foods. At the same time, undernutrition persists mainly due to food insecurity and lack of access to safe water, sanitation and adequate health care. All known nutrition interventions result in only one third reduction in stunting. Little consideration has been given to hazardous exposure to endocrine disrupting chemicals (EDCs) and microbial toxins as major components of the malnutrition-causal framework. These hazards include microbial toxins, for example, mycotoxins, and environmental pollutants such as persistent organic pollutants (POPs), some of which are known to disrupt the endocrine system. These hazards sit at the cross road of undernutrition and overweight and obesity since the exposure cuts across the critical window of opportunity (the first 1000 days). In this review, we update on the role of food and environmental contaminants, especially EDCs and aflatoxins, in child growth and on the implications for metabolic dysfunction and disease risk in later life, and discuss potential applications of nuclear and isotopic techniques to elucidate the underlying biological mechanisms, outcome indicators, as well as occurrence levels. The United Nations General Assembly proclaimed the Decade of Action on Nutrition on 1 April 2016 in response to the urgent need to reverse the increasing trend of the number of people globally affected by the double burden of malnutrition characterised by co-existence of chronic undernutrition and micronutrient deficiencies on the one hand and overweight and obesity on the other. The double burden of malnutrition (DBM) affects at least 40% of countries worldwide [The Decade of Action on Nutrition recognizes the emergence of local, national regional and global movements to end all forms of malnutrition . All couIn order to achieve the objectives of the Decade of Action on Nutrition and the global targets on nutrition by 2025 and 2030, respectively, the global community must have a broader sense of what drives the DBM and associated adverse health effects. The DBM has multiple drivers including a rapid shift from predominantly plant-based diets to energy-dense foods based on meats, milk, animal fats and vegetable oils . Low andLittle consideration has been given to hazardous exposure to endocrine disrupting chemicals and microbial toxins as a major component of the malnutrition-causal framework. These hazards include microbial toxins, for example, mycotoxins, and environmental pollutants such as persistent organic pollutants (POPs), some of which are known to disrupt the endocrine system, amongst others. These hazards sit at the cross road of undernutrition and overweight and obesity since the exposure cuts across the critical window of opportunity (the first 1000 days) from pregnancy to the first 2 years of life.Accumulating evidence shows that exposure to numerous chemicals, both natural and man-made, may have an impact on the endocrine system, with far-reaching health implications in humans and wildlife . ScientiAlthough, the biological pathways through which EDCs and mycotoxins may affect child growth and development are not well defined, prenatal and postnatal events including disrupted hormonal synthesis and function, disorders in protein, enzyme synthesis, lipid metabolism, nutrient transport, immune modulation and toxicity which may partly lead to intra-uterine growth restriction and ultimate low birth weight and postnatal growth retardation ,20,21,22Exposure to EDCs and mycotoxins likely leads to growth retardation through foetal programming occasioned by disturbed hormonal, enzyme and nutrient synthesis, transport and metabolism and immune modulation resulting in intrauterine growth restriction and eventually low birthweight. Rapid catch up growth linked to low birth weight then leads to metabolic programming favouring excess adiposity eventually resulting in overweight and obesity. Changes in microbiota composition and function and gene alterations may also be involved but more research needs to be done in humans. Dotted lines indicate areas where more research is needed in future.Adverse health effects associated with EDCs include abnormal growth patterns, male and female reproductive abnormalities, neurobehavioral deficits, metabolic syndrome, bone disorders, immune disorders and some types of cancer .EDCs represent a broad class of molecules which affect various endocrine functions, including hormonal synthesis and transport in a dose-dependent manner . While mHuman exposure to EDCs occurs by a number of mechanisms, including ingestion of contaminated food or water, inhalation of gases and particles, through dermal absorption, through invasive medical instruments or during pregnancy. Due to the consumption of more calories per body surface and a higher minute ventilation compared to adults, children may be at higher risk of exposure to EDCs than adults .Furthermore, food and environmental contaminants can be transferred from a pregnant woman to the foetus or neonate through the placenta or via breastfeeding. Pregnant women and children are the most vulnerable groups to exposure to EDCs. Moreover, the developmental consequences of exposure may often not be apparent until later in life ,29.Key Messages:“A holistic consideration of all potential drivers of the double burden of malnutrition will maximize the desired results of the Decade of Action on Nutrition and the achievement of the global nutrition targets. Despite accumulating evidence on their potential adverse effect on child health, environmental contaminants have received less attention from the nutrition community.”“Food and environmental contaminants may modify child growth bi-directionally, either leading to retardation or undesirably rapid height gain related to increased energy efficiency. Endocrine disruptors are also associated with increased fasting insulin, increased body mass index and reduced cognitive and neuro-development. Mycotoxins have been strongly linked to stunting and immune function impairment.”“Nuclear techniques, especially stable isotope techniques have been applied for decades to understand biological pathways underpinning human health including assessment of body composition, energy expenditure, nutrient absorption and bioavailability in addition to assessment of infant and young child feeding practices. Nevertheless, these techniques have so far not found use in the understanding of the link between POPs and child growth and later health.”“Current methods to characterize exposure to POPS from dietary sources are inaccurate. The underlying biological pathways linking POPs and aflatoxins to child growth metabolic dysfunction are not fully understood.”“Nuclear and stable isotope techniques can be applied for characterization of exposure and understanding physiological and metabolic changes such as body composition, energy balance and physical activity associated with these exposures, as well as determining concentrations in food and environmental matrices.”So far, little is known about the association between the exposure to EDCs and child growth. However, accumulating evidence indicates that prenatal or early-life exposure to EDCs has the capability to adversely affect foetal as well as later growth in children ,21,25,28Although the underlying mechanisms between EDCs and metabolic dysfunction have not yet been fully elucidated, there is growing evidence that EDCs may interfere with epigenetic, structural, and functional pathways which are involved in the regulation of lipid metabolism and adipogenesis ,36. ThisObesogens, including EDCs, may interfere with critical metabolic signalling, for example nuclear hormone receptors, particularly the peroxisome proliferator-activated receptors , which play important roles in the transcriptional control of lipid metabolism and adipogenesis ,39, leptp,p’-dichlorodiphenyldichloroethylene (DDE) has been linked to increased body mass index (BMI), waist circumference and change in BMI from 5 to 7 years of age among girls with overweight mothers [Prenatal exposure to polychlorinated biphenyls (PCBs) and  mothers  as well  mothers . This ef mothers . As such mothers . Indeed, mothers . Insulin mothers .Aspergillus flavus and Aspergillus parasiticus [Aflatoxins are secondary metabolites produced by moulds, especially asiticus . Aflatoxasiticus . Furtherasiticus ,47,48.Infants may be exposed to aflatoxin via maternal food intake in utero , via breCommonly used biomarkers for aflatoxin exposure are aflatoxin albumin adduct in serum and aflatoxin M1, a less toxic metabolite of AFB1, in body fluids such as urine and breast milk ,51. AflaIt is possible that aflatoxin exposure in infants may exacerbate the adverse effects of HIV exposure such as growth faltering  and immuAlthough the mechanisms by which aflatoxin exposure affects infant growth are not well understood, the possibilities include: immune function modification, disorders in protein and enzyme synthesis and lipid metabolism; this may be associated with changes in body composition  and changes in intestinal integrity down-regulation of genes associated with energy production and fatty acid metabolism .Nuclear techniques, especially stable isotope techniques have been applied for decades to help in understanding the biological pathways underpinning human health including assessment of body composition, energy expenditure, nutrient absorption and bioavailability in addition to assessment of infant and young child feeding practices . Stable Breast milk is the best food for infants; breastfeeding reduces child mortality and is linked to improved IQ . However2O), which is distributed throughout her body within a few hours and is incorporated into her milk. The baby receives deuterium only during breastfeeding. The saliva and urine of both the mother and child is enriched with deuterium and this can be measured using a Fourier Transform Infrared Spectrometer (FTIR) or an Isotope Ratio Mass Spectrometer (IRMS) [Numerous studies have reported the estimation of exposure to POPs from breast milk . The limr (IRMS) . Saliva Body composition refers to the components into which the body is divided. The assessment of body composition can be considered as an indicator of nutritional status and healthy growth . Body co2O and a post-dose saliva sample is collected 3–5 h later. Based on the D2O enrichment in saliva, FFM can be determined by measuring total body water (TBW) and then using an appropriate hydration factor to calculate FFM [Tracking of fat mass can be a very good indicator of how exposure to EDCs may affect the body’s metabolic function. The deuterium dilution technique has been applied over time to accurately measure fat mass and fat-free mass (FFM) in different contexts. In this technique, a pre-dose saliva sample is collected from a person before she or he drinks an accurately weighed amount of Dlate FFM . Fat maslate FFM .The proportion of nutrients absorbed and retained by the body for function is a critical determinant of child growth and development. No study has reported on how EDCs may affect the absorption of nutrients, especially of amino acids, iron, and zinc, for example. Existing isotopic techniques that can assess nutrient absorption are therefore likely to be of immense use in contributing much needed data in this area. Stable isotopes have been applied widely to measure the absorption and bioavailability of iron, zinc, and vitamin A. The development of a method to assess the digestion and bioavailability of proteins and amino acids from food legumes intrinsically labelled with stable isotopes is at an advanced stage  and oxygen-18 (H218O) has been widely used to assess habitual energy expenditure over a time-period of 7–20 days. This enables the calculation of the level of individual physical activity [To our knowledge, no study has investigated how exposure to EDCs may influence energy balance and physical activity in children. Physical inactivity is a major risk factor for NCDs. This is an area where stable isotopes may add value. Doubly labelled water (DLW) with both deuterium  may be determined using the aforementioned analytical techniques, and this may be alongside dietary intake surveys . To bett


All six studies were individual patient case studies; therefore, further prospective studies involving larger number of subjects should be encouraged.Whiplash is a bony or soft tissue injury resulting from an acceleration–deceleration energy transfer in the neck. Although patients with whiplash injury often complain of cerebral symptoms, and previous studies have reported evidence indicating brain injury, such an association has not been clearly elucidated. Traumatic axonal injury (TAI) is tearing of axons due to indirect shearing forces during acceleration, deceleration, and rotation of the brain or to direct head trauma. Diffusion tensor imaging (DTI) has a unique advantage to detect TAI in patients whose conventional brain CT or magnetic resonance imaging (MRI) results were negative following head trauma. Since the introduction of DTI, six studies using diffusion tensor tractography (DTT) based on DTI data have reported TAI in patients with whiplash injury, even though conventional brain CT or MRI results were negative. A precise TAI diagnosis in whiplash patients is clinically important for proper management and prognosis. Among the methods employed to diagnose TAI in the six previous studies, the common diagnostic approach for neural tract TAI in individual patients with whiplash injury were (1) whiplash injury history due to car accident; (2) development of new clinical symptoms and signs after whiplash injury; (3) evidence of neural tract TAI in DTT results, mainly  Whiplash is a bony or soft tissue injury resulting from an acceleration–deceleration mechanism of energy transfer to the neck . PatientNeural axons in the brain are reported to be vulnerable to mechanical loading through diffuse head trauma , 10. TraIn this study, DTI studies that have demonstrated TAI in patients with whiplash are reviewed. Relevant studies reported between 1966 and 2017 were identified by accessing electronic databases . In those database searches, the following keywords were used: DTI, DTT, whiplash injury, brain injury, cerebral concussion, traumatic brain injury (TBI), TAI, and head trauma. This review is limited to studies of humans with whiplash injury. We excluded patients whose head had hit the car steering wheel or car windows to rule out the possibility of TAI due to direct head trauma. Finally, six studies that demonstrated TAI by performing DTT were selected for review and are discussed below –26.via conventional MRI  region of interest (ROI) method in which measurement of DTI parameters in an ROI of the brain can be used for diagnosis of TAI and (2) DTT method involving analysis of DTT images of neural tracts. DTT allows for three-dimensional visualization and estimation of the neural tracts by permitting reconstruction of the neural tracts from DTI data; thus, TAI can be diagnosed by measurement of DTT parameters and/or from configurational analysis of the reconstructed neural tracts , 19, 28. region oAfter the introduction of DTI, six studies using DTT have reported diagnoses of TAI of the corticospinal tract (CST), corticoreticulospinal tract (CRT), dentato-rubro-thalamic tract, ascending reticular activating system (ARAS), and spinothalamic tract (STT) in six patients with whiplash injury Table  21–26).–26.21–26In 2014, Kwon and Jang reported a patient who, following whiplash injury, showed delayed gait disturbance due to injury of the CRT . The 14-In 2015, Seo and Jang reported on a patient who revealed TAI of the CST following whiplash injury . While dIn 2015, Jang and Kwon reported a TAI of the dentatorubrospinal tract, which connects between the dentate nucleus in the cerebellum and the contralateral thalamic ventrolateral nucleus and is involved in motor coordination, in a patient following whiplash injury . The 41-In 2016, Jang et al. reported on a patient with whiplash injury who showed TAI of the inferior cerebellar peduncle (ICP), which is involved in the control of balance by integrating proprioceptive and vestibular functions . The patIn 2017, Jang and Kwon reported on a patient who revealed aggravation of excessive daytime sleepiness (EDS) concurrent with aggravation of an injured ARAS following whiplash injury . The 42-In 2017, Jang and Lee reported on a patient who revealed severe and extensive TAI in several neural tracts following whiplash injury . The 26-In this review, six DTT-based studies on TAI of the neural tracts in six patients with whiplash injury were reviewed. A precise diagnosis of TAI in patients with whiplash injury is clinically important for proper management and prognosis. Among the methods these six studies used to diagnose TAI of the neural tracts, the commonest diagnostic approaches for neural tract TAI in individual whiplash patients were (1) whiplash injury history due to car accident; (2) development of new clinical symptoms and signs subsequent to a whiplash injury; (3) evidence of neural tract TAI in DTT results, mainly from configurational analysis; and (4) coincidence of the newly developed clinical manifestations and the function of the injured neural tracts. However, we could not determine the vulnerable neural tracts by whiplash injury because all six studies were case reports on six individuals, which were focused on limited neural tracts relevant to the clinical features of each patient; therefore, further prospective studies involving a larger number of subjects is needed. Especially, analysis of many neural tracts or whole brain using tract-based spatial-statistics would be necessary to find the vulnerable neural tracts or brain regions by whiplash injury. On the other hand, four of the six patients showed delayed onset or aggravation of clinical features with the passage of time, which suggests the possibility of secondary TAI that refers to a condition in which axons were not injured at the time of head trauma, but axonal injury is caused by the sequential process of impaired axoplasmic transport, continued axonal swelling, and subsequent disconnection rather than primary TAI, which indicates that the axons are damaged by shear/strain injury at the time of head trauma , 25, 26.SJ is supervisor. YK wrote the manuscript.Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.


National herbaria with significant historical plant collections are critical to tracking floristic changes and patterns, which include the introduction and spread of non-native plant species. To explore the importance of herbarium specimen data in understanding floristic changes in Zimbabwe, the plant collections housed by the National Herbarium (SRGH) in Harare, Zimbabwe were utilized with historical specimens dating back to 1870. A list of naturalised plant taxa and collection data were compiled. A total of 2916 plant specimens were recorded, comprising of 401 taxa, 237 genera and 76 plant families. Twenty eight specimens (1.0%) were collected between 1870 and 1908, prior to the establishment of the National Herbarium in 1909 and 123 specimens (4.2%) were collected in the first 25 years of the establishment of the institute (1909–1934). Intensive collection of herbarium specimens of casual, naturalised and invasive alien plant species occurred between 1950 and 1970. This data demonstrates the utility of plant species data housed in the National Herbaria and how such data can be used to map floristic changes and patterns. Specifications TableValue of the data•The data are critical in tracking floristic changes and patterns of spread of exotic plant species.•This data are important for monitoring purposes and also to fill the gaps in plant distributional ranges.•This data will contribute to better understanding of the ecological impacts of exotic plant species.•List of herbarium specimens of exotic plant species will help in future research on this category of plant species.1Many non-native plants in Zimbabwe were introduced decades ago through agriculture and horticulture. A number these exotics now occupy large stretches of land and form characteristic features of the Zimbabwean flora. The number of plant exotics increase with time, 1449 exotic taxa have been recorded in Zimbabwe, a country comprising about 6000 plant species The herbarium specimens usually contain important historical information about plant species which is critical for scientific studies. Such information on herbarium labels includes the identity of the species and other details such as family, habit, plant height, leaf arrangement, shape, size, flower colour, shape and size. Other important information usually included on the herbarium label include details about the collector, his or her name, collector’s number, the locality, year of collection of the plant species, description of the habitat and notes on uses of the plant species if any and also size of the population. For exotic species, experienced collectors usually include information such as life history traits, such as habit, population size and perceived invasion status, whether casual, naturalised or invasive. Pyšek et al. 2www.ipni.org), the Missouri Botanical Garden's Tropicos Nomenclatural database (www.tropicos.org) and the Royal Botanic Garden and Missouri Botanic Garden plant name database (www.theplantlist.org).Included in this data are those plant species considered to be naturalized in Zimbabwe A total of 2916 plant specimens were recorded, comprising of 401 taxa, 237 genera and 76 plant families . Appendi


Women face greater challenges than men in accessing water, sanitation, and hygiene (WASH) resources to address their daily needs, and may respond to these challenges by adopting unsafe practices that increase the risk of reproductive tract infections (RTIs). WASH practices may change as women transition through socially-defined life stage experiences, like marriage and pregnancy. Thus, the relationship between WASH practices and RTIs might vary across female reproductive life stages. This cross-sectional study assessed the relationship between WASH exposures and self-reported RTI symptoms in 3,952 girls and women from two rural districts in India, and tested whether social exposures represented by reproductive life stage was an effect modifier of associations. In fully adjusted models, RTI symptoms were less common in women using a latrine without water for defecation versus open defecation (Odds Ratio (OR) = 0.69; Confidence Interval (CI) = 0.48, 0.98) and those walking shorter distances to a bathing location , but there was no association between using a latrine with a water source and RTIs versus open defecation . Unexpectedly, RTI symptoms were more common for women bathing daily with soap  and for women washing their hands after defecation with soap  or ash/soil/mud  versus water only or no hand washing. WASH practices of girls and women varied across reproductive life stages, but the associations between WASH practices and RTI symptoms were not moderated by or confounded by life stage status. This study provides new evidence that WASH access and practices are associated with self-reported reproductive tract infection symptoms in rural Indian girls and women from different reproductive life stages. However, the counterintuitive directions of effect for soap use highlights that causality and mechanisms of effect cannot be inferred from this study design. Future research is needed to understand whether improvements in water and sanitation access could improve the practice of safe hygiene behaviors and reduce the global burden of RTIs in women. Girls and women experience greater challenges than boys and men in safely accessing water, sanitation, and hygiene (WASH) resources, including social and sexual violence, while seeking locations to address bodily needs.–7 In addThe worldwide burden of RTIs in women is high, affecting as many as a third of all women of reproductive age in some regions of the world. RTIs areInadequate access to a private sanitation location with water for vaginal and anal cleansing may make it more difficult for women to maintain both daily and menstruation-specific vaginal hygiene behaviors, which could lead to chronically unhygienic vaginal conditions., 34 Few Since RTI symptoms can be caused by a variety of sexual and hygiene-related diseases, disentangling the impact of WASH versus social or sexual exposures on RTI risk can be challenging. In addition to the WASH risk factors above, marriage, frequent sexual contact, pregnancy, biological age, and use of intrauterine contraceptive devices (IUDs) for family planning are also risk factors for an RTI. , 38–40 TWritten informed consent was obtained from all participants prior to data collection. The study was approved by the scientific and ethical review committees at the Asian Institute of Public Health, Emory University, the London School of Hygiene and Tropical Medicine, and the University of Oklahoma.We conducted a cross-sectional, population-based surveillance survey between September 2013 and March 2014 in Odisha, India, an area of India with particularly low levels of water and sanitation coverage, and high maternal and child morbidity and mortality  Dataset.Data were collected as part of a larger population-based survey used to identify and recruit women in the first trimester of pregnancy for a cohort study of sanitation access and adverse pregnancy outcomes. In orderInclusion criteria were being female, reporting experiencing menstrual periods, and being between the ages of fourteen and forty-five years, which falls between the mean age of menarche (13.6 years) and menopause (46.1 years) in Indian women., 43 WomeOur primary outcome of interest was symptoms of a RTI, assessed based on self-report of unusual vaginal discharge, itching, or irritation in the previous two weeks. Self-reported symptoms were ultimately used to determine outcome status because a) our primary study population was rural women with extremely low WASH access, most of whom lived far from health care centers with diagnostic laboratories; b) transportation and processing of thousands of swabs from this geographically dispersed set of villages was logistically and economically unfeasible; and c) most importantly, initial evaluation suggested we would experience challenges in recruiting asymptomatic women into a study involving collection of vaginal swabs during a household visit, which would result in skewed sampling of information across the population. To improve the quality of self-reported data, an easily recognized group of symptoms with modest sensitivity and specificity in predicting the presence of bacterial vaginosis and other RTI diseases like vulvovaginal candidiasis and trichomoniasis vaginalis was selected.–50 RecalA priori selected confounders included religion, level of educational attainment, caste, occupation, and ownership of a Below-Poverty-Line (BPL) card as a proxy for household wealth , or biological state (pregnancy) after menarche. Life stages were defined based on a woman’s age and marital and pregnancy status at the time of data collection. Unmarrien’s life., 53 PregData were analyzed using SAS version 9.4 . Data analysis was limited to subjects for whom responses were available on symptoms of a RTI. Two variables were noted to have missing data. A confounding variable for caste of subjects was not included in imputation and analysis because more than 25% of the values were missing. Prior to conducting analyses, multiple imputation was employed to impute for availability of water in a latrine due to missing information for 4.6% of subjects with complete outcome data., 55 MultP<0.05). No interaction term with life stage was significant, so associations between risk factors and RTIs are presented for all life stage groups combined. Multivariable model selection technique involved including all socio-economic confounder (SES) and exposure variables  values was used to assess model fit compared to previous models. Backwards selection was repeated until only district, SES confounders, and the WASH or life stage exposure variables that were associated with the lowest model AIC score remained. As a final model fitting step, interaction terms between WASH exposures were considered. Collinearity was assessed by computation of condition index diagnostics and variance decomposition proportions (VDPs), using condition indices >10 and VDPs >0.5 as an indication of collinearity. To reduce the risk of type I error from multiple comparison tests, a Bonferroni correction was used to estimate conservative CIs.To quantify the associations between RTI symptoms, WASH exposures, and life stage group we used generalized mixed logistic regression models  with binary log link and a random intercept term to account for variance between districts. Effect modification of life stage group on associations between exposures and RTI symptoms was tested by including interaction terms in bivariate models and assessing for statistically significant interaction  women. Complete data on exposures and health outcomes was analyzed for 3,952 women (missing for 19 (<0.5%)) between 14 and 45 years age from rural Khorda District  and Sundargarh District . Differences in socioeconomic confounders are shown by life stage group in Many WASH practices varied across the life stages of girls and women in this study . Use of Self-reported symptoms of abnormal vaginal discharge, itching, and irritation were reported by 402 (10.2%) of girls and women overall. Prevalence was lowest in unmarried youth  and other women , followed by established married , newly married , and pregnant  women. Many WASH exposures were associated with RTI symptoms in bivariate analysis . AlthougGardnerella vaginalis) or vaginal candidiasis microbes in soil or water at open defecation areas.[G. vaginalis in soil or water to vagina has never been described, although transmission of Candida spp. by soil or water is possible.[This study sought to understand the relationships between WASH practices and two-week prevalence of RTI symptoms across reproductive life stages of girls and women in Odisha, India. We demonstrated that self-reported symptoms of RTI disease were less common in girls and women with access to a latrine (vs open defecation) and lower walking times to a bathing location (< 7 minutes vs > 7 minutes). The lower prevalence of RTIs among latrine users may reflect reduced exposure to infectious vaginosis , can elevate RTI risk.[Related to these disease pathways, we had hypothesized that WASH practices and the related risk of RTIs would change for women as they transition through life stages representing different social and sexual roles, from unmarried youth to marriage and pregnancy and finally matriarchy. To our knowledge this is the first study to structure analysis of risk factors for RTIs based upon RTI risk., 39, 40 under-report latrine use or bathing location, or react to symptoms by reverting from latrine to open defecation or moving farther away to bathe are less clear. As with soap ownership, women with latrines could be more knowledgeable about health and health prevention and be more likely to report abnormal symptoms, which in this case would strengthen our confidence that these women lack symptoms of an RTI.The associations between RTIs and washing hands after defecation or bathing with soap is less clear. Post-defecation hand washing has not been assessed in prior RTI studies, and there isn’t a clear biological mechanism for this relationship. In this study, post-defecation hand washing practices were an effect modifier of the relationship between type of material used for bathing of the body and symptoms of an RTI, with use of soap for bathing trending towards protective among post-defecation soap hand washers versus risky for post-defecation ash, mud, or water only hand washers. Some studies have reported that infrequent use of soap for vaginal bathing is a risk factor for RTIs, while others reported that frequent use of soap for vaginal washing, especially inside the vagina, increases the risk of RTIs via disturbance of the healthy vaginal microbiota., 70–72 SWhile a cross-sectional study was a rapid and efficient way for exploring our hypotheses, this design cannot establish causal relationships between exposures and outcomes in this study. In addition to the above, other limitations include understanding whether exposures occurred early in childhood, prior to menarche, rather than in the weeks preceding this survey. RetrospeAnother major limitation of this manuscript was the use of self-reported symptoms as an outcome. The prevalence of reported symptoms in this study was low compared to similar population-based studies in Indian women (16% to 55%), although was higher than the 7.1% of lab-confirmed BV cases reported by a mobile clinic based study of rural women., 76, 77 Clinic-based studies can optimize recruitment of symptomatic women and provide the infrastructure and personnel capable of performing laboratory assays for diagnostic confirmation of disease. However, clinic-based designs introduce significant recruitment bias that could limit generalizability of observations beyond certain populations of women. Seeking treatment at a health care center requires women to be self-aware of symptoms, and to be willing or able to seek treatment. Health care utilization for treatment of RTI symptoms among Indian women is often low (16% to 55%) due to lack of awareness of disease state, perception that symptoms are normal, fear of shame and embarrassment associated with symptomatic status, or restrictions on their ability to travel unaccompanied., 76 LikeMuch of the focus in WASH interventions has historically centered on evaluating their impact on infectious disease in children. But this paper highlights that gender-specific outcome measures, like RTIs, might also be benefits of improvements in water and latrine access. Future research should explore the generalizability of these findings in other contexts and seek to understand the causal relationship between sanitation infrastructure, hygiene practices, and women’s health. Trials of water and sanitation interventions could collect information on indicators of women’s sanitation and hygiene practices and reproductive health to evaluate whether improvements in WASH reduce the burden of RTI disease in women. Reductions in RTI disease could have far reaching implications for other reproductive diseases, including pelvic inflammatory disease, infertility, sexually transmitted diseases ectopic pregnancy, miscarriage, preterm birth, and delivery of a low birth weight infant during pregnancy. –24, 80 AS1 Table(DOC)Click here for additional data file.S2 TableDescription: These are the survey questions used to collect information about socio-economic confounders, WASH practices, 2 week self-reported symptoms of a reproductive tract infection, and life course status of participants.(DOCX)Click here for additional data file.S1 Dataset(XLSX)Click here for additional data file.


Theongoing projects resulted in individual and social transformation by improvingcommunity health literacy and behaviors using people-centered care and enhancingpartnership between healthcare providers and community members through advancedpractice nurses. people-centered care starts when community members and healthcare providersforeground health and social issues among community members and families. Thismodel tackles these issues, creating new values concerning health and forming asocial system that improves quality of life and social support to sustainuniversal health care through the process of building partnership withcommunities. a PCC partnership model addresses the challenges of social changes affectinggeneral health and the new role of advanced practice nurses in sustaining UHC. These four groups of diseases account for 82% of all NCD deathsworldwide UHC is firmly based on the World Health Organization (WHO) constitution of 1948, whichdeclares health to be a fundamental human right. The Health for All agenda was set inthe Alma-Ata declaration in 1978. Equity is paramount, which means that countries needto track progress not only simply over the national population but also within groupsdifferentiated by income level, sex, age, residence, and ethnicityIn September 2015, at the General Assembly of the United Nations, the 2030 Agenda forSustainable DevelopmentPeople-centered care (PCC) is a process of health and nursing care that enhances healthliteracy as well as motivates community members of all ages to seek their own healthcare; thus, healthcare providers, especially nurses, must help community members makedecisions in partnershipPCC initiatives have been given additional urgency by the issue of aging, which Japanand other countries are currently suffering from. The life expectancies of Japanesemales (80.5 years) and of Japanese females (86.8 years) This study develops a PCC partnership model in an aging society to address thechallenges of social changes affecting general health and the new role of advancedpractice nurses in sustaining UHC.This study develops the PCC partnership model in two steps. The first step is aliterature review of the concept of PCC and a practice-based assessment of our WHO CCPCC projects. The second is a qualitative meta-synthesis of both results of theliterature review and the projects and the results of participants’ satisfaction for theconstruction of a PCC partnership model.English databases were used for this study, including the Cumulative Index of Nursingand Allied Health Literature (CINHAL); CINHAL Plus with Full Text (EBSCO);MAGAZINEPLUS; PubMed; EMBASE; Nursing & Allied Health Source (NAHS); and theJapanese published medical work database, including Japan Medical Abstracts Society(JAMAS) and Citation Information by the National Institute of Informatics (CiNii).Both English and Japanese articles were included; no language limitations wereimposed. Keyword combinations used in the search were as follows: “people-centeredcare” or “people-centered health care” or “partnership” and “concept analysis.”Search dates for the above databases were from January 1, 1980 to July 30, 2015.Manual search was performed to identify books, articles and project reports in ourinstitution.Eligible studies included published work involving PCC and/or partnerships withhealth care providers and community members. Qualitative, observational, andquasi-experimental studies; pre- and post-implemental studies without comparators;and prospective cohort studies were included. Original articles, research reports,practical reports, and commentaries were reviewed. Published conference proceedingsincluding abstracts of research presented at conferences and article titles withoutpartnership were extracted. Unpublished articles or those not easily accessible viathe above databases were not reviewed.The concept of PCC in each study was assessed in three steps. First, one authorindependently reviewed the abstracts and full texts, applying the selection criteriato identify the concept of PCC. Second, all nine authors reviewed and categorized thefull text of the articles. Each article was analyzed using a customized dataextraction form, created by the first author, comprising the following: PCC processwith resources, partnership, and capacity building; process of change; and outcome ofchange and health care system for community members, healthcare providers, andcommunity. The researchers discussed the extracted categories until a final consensuswas reached.The 14 projects of our WHO CC PCC in 2015 targeting community members of all ageswere analyzed according to participants, health issues, types of partnerships withcommunity members and healthcare providers, satisfaction, and outcomes. The visualanalogue scale (VAS-10) was used to assess participant satisfaction for each projectduring the fiscal year 2015 (April 2015 to March 2016).The results of both the literature review and the PCC project assessment wereintegrated by qualitative meta-synthesis-The literature search identified 196 citations. The keyword “partnership” showed 116citations, 32 for “people-centered care,” and 48 for “people-centered health care.”Of these, 152 were excluded on the basis of extraction criteria. The remaining 42citations were reviewed: 21 original articles, 10 research reports, eightcommentaries on the same projects, two brief reports, and one WHO report, as well astwo books, totaling 44 referencesPCC resources were categorized into easy and expanded access to health services;useful health information for each person; a place in the community to easily gather;and interaction with other people of all ages, health volunteers, and experts such asnurses and counselors. These resources were too convenient to each member who hadprimary health needs.Partnerships were major relation pattern among community members, health volunteers,and healthcare providers, involving shared decision making and responsibilities.Capacity building involved the following capacities of the people involved:acceptance and appreciation of people’s beliefs and worth, healthy behavior andthoughts, health literacy that assists the choice of information appropriate for eachperson’s health; the understanding of where and how to speak of one’s own health; thecapacity and ability to make subjective health behavior or decisions; enduringself-care, self-efficacy, and strength to maintain health; and informationcommunication technology literacy. These capacities led to the improved health andpsychological well-being of the people.The change process involves the following: improvement and changes of healthbehavior; subjective awareness of oneself; experience being healed by others; settingothers’ minds at rest; feelings of comfort; improvement of health consciousness andbehaviors, physical states, and emotional well-being; vigor in daily activities; andhealth volunteers starting a project subjectively.The outcome of change and the health care system showed increased opportunity toreceive health information; creation and spread of sustainable, appropriate servicesfor community members and new values; making a key/core person in the community;collaboration with local government; and shared future targets with community membersand healthcare providers through debriefing of each PCC activity. These outcomes showpeople’s increased interest and motivation to initiate decision making on their ownhealth.Our institution was first designated as a WHO CC for Nursing Development in PrimaryHealth Care (PHC) in 1990 and has been re-designated six times over the last 24years. In 2016, our WHO CC began to assist WPRO and member states in the developmentof community PCC models based on the values of PHC in the context of aging societies.One of our top tasks is the development of a regional action framework to helpcountries achieve UHC by promoting integrated PCC service delivery. In 2015, thenursing faculty and community collaborators applied PCC concepts to 14 projects atthe university building in Tokyo, focusing on the improvement of the health literacy,behavior, and well-being of community members of all ages. The health issues focusedon were as various as those pertaining to families expecting children, stillbirths,mothers with small children, women suffering from infertility, adults and olderadults with chronic illnesses and NCDs, frail older adults needing fall preventionawareness, older adults with neuro-cognitive disorders and dementia, and caregiverswithout health information, as well as an intergenerational program for frail ordementia-suffering older adults and school-aged children in the super-aging Japanesesociety. Our WHO CC provided PCC services through these projects to encouragecommunity members to take initiative of their own health; 4,721 community membersparticipated annuallyThe formation of partnerships between community members and healthcare providers wascategorized into three patterns, namely, the pattern of the Approaching Partnership,that of the Supporting Partnership, and that of the Collaborating Partnership. Thetypes of partnership change along with the progress of PCC, depending on thecharacteristics of the health issues and the community’s degree of consciousnesstoward them. The Approaching Partnership occurs when healthcare providers leadcommunity members; community members in such a partnership are not aware of health orcommunity issues. In the Supporting Partnership, healthcare providers supportcommunity members as needed according to their situations, such as diseases orconditions of aging. At the level of the Collaborating Partnership, community membersare fully aware of their health or community issues and participate in activities anddecision making. The satisfaction of community members, assessed by VAS-10, was at8.9 points for fiscal year 2015.The authors constructed the PCC partnership model using the qualitatively synthesizedand integrated findings of research in the literature and PCC research projects. Thismodel is intended to cover various health and social issues concerning communitymembers and their families, create new values concerning health, and form a socialsystem that guarantees quality of care during the building process of partnershipbetween community members of all ages and healthcare providers to sustain UHC.The three layers of PCC Process are input, process, and outcome. Input begins whenhealthcare providers bring health issues to the surface, showing they share aims andgoals in health behaviors and resolving problems with community members in theirapproach to health and social issues particular in their own health. In the nextstep, healthcare providers and community members build a partnership and setting thegoal of health behavior, which will lead to the embodiment of PCC. There are nineattributes in the three layers of PCC: 1) setting goals in health behavior; 2a)mutual understanding (relationship Basis): the community member and healthcareproviders understand each other’s strengths, roles, and responsibilities; b) mutualtrust (relationship basis): the two trust each other without anxieties; c) mutualrespect (relationship basis): the two respect each other in their activities; d)growing together (relationship basis): community members and healthcare providersgrow and learn from each other; e) shared decision making (activity approach): thetwo share the decision-making processes for the same purpose; f) cooperating witheach other’s strengths (activity approach): the two make the most of each other’sstrengths on an equal footing; g) overcoming obstacles together (activity approach);and 3) mutual sharing of the results of the partnerships: the two overcome obstaclestogether deriving strength from each other. Through these processes, individual andsocial transformations are triggered among community members and healthcareproviders, sharing achievements with each other as an outcome. In this PCC Process,the Approaching Partnership, the Supporting Partnership, and the CollaboratingPartnership were adopted depending on the characteristics of health issues facingcommunity members and the community’s consciousness of health for all .In this study, the authors developed a PCC partnership model through a literature searchand PCC project assessment. The PCC partnership model was structured following the flowof input, process, and outcome. The process includes three types of partnership. Thenine attributes of these partnerships were identified as follows: setting goals, mutualrespect, mutual trust, mutual understanding, shared decision making, cooperating withthe strengths of both, overcoming obstacles together, growing together, and mutualsharing of the results. In the outcome, transformation occurs in individual health needsand social needs. These elements showed a similarity with other former resultsAs aging is a serious and common issue throughout the entire developed world and isdramatically becoming prevalent in middle- and low-income countries, our model isexpected to provide a new model for enlightening local communities on this issue. Basedon its success in our WHO CC projects, it is important to notice the new role of nursinguniversities in providing not only education but also community nursing services, whereanyone can discuss their health issues with nurses literate in research evidence. PCCencourages the growth and development of community members to the point where they willunderstand that they are the ones responsible for maintaining and improving their ownhealth. Nurses are considered agents of change for health care, and it was thought thatthese nursing skills; taking partnerships with community members and changing healthcare, are advanced nursing practices; these new role emerged in response to personalhealth issues and to external social health policies. The next step for this study is todevelop evaluation tools to measure how the PCC partnership model can create socialtransformation. At the same time, as literature and projects stem mostly from the casesof developed countries, it is necessary to evaluate the applicability of the model todeveloping countries.Health systems in an aging society need to be sustainable, strong, and comprehensive. Itis essential to provide sufficient human resources so that community members can partnerwith nurses. Cooperation with nurses and mutual respect will improve quality of life anddignity. Understanding this new role of partnership will enable successfulimplementation and competencies in nursing leadership to ensure nursing’s contributionto UHCIn summary, this study developed a PCC partnership model that emphasizes people’s activeparticipation in health care and the new role of advanced nursing practice. The PCCpartnership model aims to tackle various health and social issues with community membersand their families, creating new values concerning health and forming a social systemguaranteeing quality of life and social capital during the process of buildingpartnerships between community members of all ages to sustain UHC.