To describe the epidemiologic characteristics and adverse events of patients submitted to total hip and total knee replacement.A cross-sectional study retrospectively assessing medical chart data of all total hip and total knee replacements performed at a private hospital, between January 2007 and December 2010 Patients submitted to total hip and total knee replacement, with consent of surgeons were included. Incomplete records and/or missing data of the hospital database were excluded. The categorical variables analyzed were age, gender, type of arthroplasty (primary or secondary), type of procedure, duration of surgery, use of drains, risk of infection, compliance to protocol for prevention of deep venous thrombosis and embolism pulmonary, and compliance to the protocol for prevention of infection. The outcomes assessed were adverse events after surgery.A total of 510 patients were included; in that, 166 admissions for knee replacements  and 344 admissions for hip replacements . The mean age of patients was 71 years (range 31-99 years). Adverse events were reported in 76 patients (14.9%); there was no correlation between assessed variables and number of complications.The results showed no individual factors favoring complications in patients submitted to total hip and total knee replacement; hence, surgeons should consider prophylaxis to avoid complications. The data of Brazilian patients undergoing THR or TKR showed that osteoarthritis was the primary indication for both procedures and hypertension was the prevalent comorbity among patients.Total hip replacement (THR) and total knee replacement (TKR) are indicated for treating chronic refractory joint pain and some types of proximal femoral fractures. The most frequent condition for both THR and TKR is osteoarthritis (OA); other diseases that commonly lead to THR and TKR are rheumatoid arthritis, fractures and avascular necrosis–7.Joint replacement is a reasonably safe intervention that can result in considerable pain relief and reduce disability for allowing the new joint to work normally.The use of these procedures has increased due to the good results obtained. Taking into consideration only the demographic changes, it is estimated that the number of indications for THR will increase by 40% by 2021 in the United Kingdom.A cross-sectional study taking into account data from 2006 to 2007 reported there were 62,196 hospitalizations for THR and TKR in Canada, with an overall incidence of 81.2 per 100,000 people per year.A literature review evaluated the prevalence and incidence rates for THR and TKR; the authors found the rates of indication and utilization of both interventions vary according to socioeconomic status and healthcare systems, patient preferences and prevalence of osteoarthritis. The authors also concluded that future studies should be conducted to examine the causes of these differencesThe objective of this study was to describe the epidemiologic characteristics of total hip replacement and total knee replacement interventions performed at a Brazilian private hospital, according to patient demographics and tendencies in the clinical practice over time.Hospital Israelita Albert Einstein (HIAE), São Paulo, Brazil, were prospectively collected and stored from January 2007 to December 2010.Institutional review board approval (number 5162) was obtained to retrospectively review medical records and analyze pertinent data. Data of every THR and TKR performed at the The inclusion criteria were adults (18 or more years) who underwent primary or revision THR and TKR at our hospital and had a consent form signed by surgeons. The exclusion criteria were incomplete records and missing data from the hospital database. and to the protocol for deep venous thrombosis (DVT) and pulmonary embolism (PE) prevention.The following variables were recorded and analyzed: age , gender, type of arthroplasty (primary or secondary), type of procedure (THR or TKR), duration of surgery time, use of drains, compliance to the protocol for infection preventionThe postoperative adverse events of all patients were gathered and recorded using a standardized form. The surgeons and nurses were audited on their gathering rate of data on adverse events and re-oriented on proper completion of data. All patients and their primary care physicians were instructed to contact the hospital in case of any suspicion of infection. Those who did not come for follow-up were contacted by telephone. Infection, DVT, PE, failure of treatment and all-cause mortality were assessed as adverse events.. We also calculated the surgical site infection (SSI) risk index, a score used to predict a surgical risk of acquiring an infection in the surgical site. The SSI risk index, ranging from 0 to 3, consists of data obtained from three risk factors: a) American Society of Anesthesiologists' physical status classification (ASA); b) wound classification and; c) duration of operation. Patients who underwent surgical interventions with a risk index of 3 had a higher risk of developing SSI than those with a score of 0,13.All cases of potential superficial, deep local infection and systemic infections were recorded and analyzed according to the definitions and guidelines  used in the United Kingdom,15. PE was diagnosed by ventilation-perfusion scintigraphy, pulmonary angiography, or spiral computed tomography.For patients suspected of symptomatic DVT, bilateral ultrasound Doppler and/or venography were performed according to the standardized technique previously described in the literatureTreatment failure was considered when patients were submitted to a non-routine secondary surgical intervention for symptomatic aseptic or septic loosening, instability, or dislocation after 30 days of the first surgery.2 test was used to assess discrete data; the significance of various risk factors was calculated by multivariate logistic regression analysis in which the odds ratio and 95% confidence intervals were calculated.Data of all primary and revision THR and TKR from January 2007 to December 2010 were gathered from the hospital database and analyzed using the statistical package Excel (Microsoft Office Excel 2007.Ink). The prevalence rates were given as percentages. Pearson's χThe study population consisted of 510 patients; there were 166 hospitalizations for knee replacements  and 344 admissions for hip replacements . The mean age of patients undergoing TKR was 71 years (range 31 to 87 years) and also 71 years (range 33 to 99 years) for THR. The main preoperative diagnosis for patients was osteoarthritis (84.9% for TKR and 49.1% for THR). Moreover, most admissions for joint replacement in our population were for primary procedures (86.7% for TKR and 92.4% for THR). The most frequent preoperative medical condition diagnosed in all patients was hypertension (50.4%) .,11.All patients received deep venous thrombosis prophylaxis and prophylactic antibiotics according to the current literatureSome adverse events, such as infection, DVT, PE, failure of treatment and death are shown in In our cohort of patients, seven (five in the THR and two in the TKR group) presented superficial wound infection, which demanded a four-week antibiotic therapy, but there was no need to change treatment or new surgical procedure. Fifty-nine patients (11.6%) experienced other complications; genitourinary conditions were the most prevalent complications presented by patients .2=3,962), age (χ2=0.191) and comorbidities (χ2=0.553) were not statistically significant predictors of complications .The multivariate logistic regression analysis for patients undergoing THR revealed that ISS  were observed, demonstrating that surgeons should be cautious.Our outcomes support some recommendations regarding total joint replacementThe mortality rate was very low - four patients described as follows: the first patient  had metastatic adenocarcinoma, required THR for femoral neck fracture and died 46 days after surgery. The second patient  had femoral neck fracture and no co-morbid conditions, and passed away 3 days after surgery; the third  was a chronic patient with respiratory insufficiency (chronic obstructive pulmonary disease - COPD) and acute renal failure, who underwent THR for femoral neck fracture and died during the surgery. The fourth patient  presented atrial fibrillation, had femoral neck fracture, and died 19 days after surgery.In our view, it is important to be aware of the data from this cohort study, such as complications, infections, costs and admission. Some useful data were described in this study, and based on our results some strategies could be established to reduce complication rates.When reporting on some characteristics of patients submitted to THR and TKR at a private hospital, it is essential to compare with other hospitals and countries. This analysis is complex because of diversity of population among countries, reporting methods, study design, periods of studies, different healthcare systems. Nevertheless, cross-sectional and qualitative analyses are fundamental to improve care in health systems.–25. The orthopedic implants, mostly knee and hip prostheses, account for more hospital expenses than any other procedures. Despite elevated hospital costs and more orthopedic implants, decrease in infection and complication rates, healing of the orthopedic diseases and better patient satisfaction have not been observed.The increased health-related costs all over the world and the restrictions on economic resources led to great emphasis on cost-effective procedures in healthAiming to enhance quality of clinical practice, to support decision-making processes, to offer appropriate usage of medical technologies, to establish a better and more productive management, in addition to standardize treatments and avoid waste of resources, protocols were implemented at our hospital. One of the most important characteristics of these protocols is to provide an overview of each procedure to be performed, with its expected results, so that they can be monitored by the clinical team and by the patients. Future investigations will be conducted to assess effectiveness of these protocols.In order to reduce the costs and better use the hospitals resources, it is essential to have a multidisciplinary team. Professionals with diverse backgrounds, including those from the financing and human resources departments, nurses and doctors, amongst others, should share information about their specific areas and continuously assess their routines, and make changes, whenever necessary. By discussing hospital procedures and their specific daily activities, as well as using evidence-based studies in their meetings to support decision-making, the teams will be able to better use the resources and to avoid unnecessary expenses.Because of our study design and the small number of patients undergoing THR and TKR at the hospital, no significant conclusions could be drawn on this group. In addition, there are several limitations to the results obtained. First, the data were analyzed retrospectively from our database, which means there are some concerns about data collection. Second, the cross-sectional study is descriptive and typically there is no hypothesis, hindering causal inferences. Moreover there are many aspects that influence the incidence, prevalence and complications of THR and TKR for OA. We are not able to presume if the characteristics described in this study will maintain the same rates. Finally, there are some reservations about the findings since the study was limited and did not gather data from other private or public hospitals.Our results found no individual significant predictors of complications in patients submitted to THR and TKR. When taking into account joint replacement, our data showed that orthopedic surgeons and patients should be aware of some adverse events that could occur. Hence surgeons must consider prophylactic management to avoid some complications.


Under physiological conditions, a balance between oxidants and antioxidants exists. Reactive oxygen species (ROS), are continuously generated by aerobic cells and eliminated through scavenging systems to maintain redox homeostasis. The two main sources of ROS are mitochondria and the NADPH oxidases family, but ROS are produced also by the cytochrome P450 system, xanthine oxidase and nitric oxide synthase  , via its binding to antioxidant response element (ARE), regulates the expression of cytoprotective genes: classical antioxidant enzymes including SOD and catalase, phase 2 detoxifying enzymes, and stress response proteins such as heme oxygenase 1  is a multifunctional protein with both DNA repair and transcriptional regulatory activities by facilitating DNA binding of numerous transcription factors involved in cancer promotion and progression,   proteins are a family of transcription factors that, regulated by several stimuli, modulate genes involved in differentiation, proliferation, survival, apoptosis, migration and DNA repair (Dansen and Burgering, Several approaches have been undertaken to combat MDR. In the light of these findings, modulation of cellular redox levels could have important implications for the development of potential anticancer therapies. Several reports have demonstrated that Nrf2 silencing in cancer cells could decrease cell proliferation and enhance sensitivity to chemotherapeutic agents in lung, gallbladder, and ovarian tumors (Meijerman et al., Although in the past antioxidants were seen as tumor suppressors, recent research uncovered the “dark side of antioxidants” (Wang et al., The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Independent associations of physical activity (PA) and sedentary behavior (SB) with obesity are well documented. However, little is known about the combined associations of these behaviors with obesity in adolescents. The present study examines the prevalence of concurrent levels of PA and SB, and their associations with obesity among US adolescents.Data from a total of 12 081 adolescents who participated in the Youth Risk Behaviors Survey during 2012–2013 were analyzed. A latent class analysis was performed to identify latent subgroups with varying combined levels of subjectively measured PA and screen-based SB. Follow-up analysis examined the changes in the likelihood of being obese as determined by the Center for Disease Control and Prevention Growth Chart between latent subgroups.Four latent subgroups with varying combined levels of PA and SB were identified across gender. The likelihood of being obese was significantly greater for the subgroups featuring either or both Low PA or High SB when compared with High PA/Low SB across genders . Low PA/High SB showed the greater likelihood of being obese compared to subgroups featuring either or both High PA and Low SB  for female adolescents only.The findings imply that promoting sufficient levels of PA while reducing SB should be encouraged in order to reduce obesity risk among adolescents, particularly for males. The risk of obesity for female adolescents can be reduced by engaging in either high levels of PA or low levels of SB. Although some research has shown an interdependent relationship between these two behaviors, suggesting a possible tradeoff between one and the other,27 This approach may introduce redundant classification errors, which may not be comprehensive enough to fully reflect various components of PA and SB simultaneously. Such limitations can be potentially overcome using latent class analysis (LCA), a person-centered approach identifying latent subgroups of a population with varying response patterns of multiple observed variables. LCA has been successfully employed in a previous PA study27; however, that study failed to adequately control for the possible influence of covariates on estimating the latent subgroups and in evaluating links with obesity in LCA model, which might produce biased estimates of population parameters.One factor that might lead to inconsistent results may be the way in which PA and SB are combined to identify concurrent levels of PA and SB. A majority of large-scale observational studies, in which subjective measures of PA and SB are commonly preferred, have used a variable-centered approach that directly combines one or few implicit variables of PA and SB  rather than relying on empirical evidence.The overarching goal of this study was to develop and examine a comprehensive LCA model examining the concurrent associations of PA and SB with obesity among United States (US) adolescents. Specific goals were to identify latent subgroups with varying concurrent patterns of PA and screen-based SB and to examine the association of latent subgroups with different level of PA and screen-based SB with obesity status among a national representative sample of US adolescents.Data for this study came from the 2013 national Youth Risk Behavior Survey (YRBS), a biannual cross-sectional survey conducted by the Center for Disease Control and Prevention (CDC). The 2013 YRBS employed a three-stage cluster sampling design to obtain a national representative sample of adolescents in 9th to 12th grades attending public and private schools in the United States. In the first stage of sampling, the primary sampling units  were organized into 16 strata based on their metropolitan statistical area status  and the percentages of minority (black and Hispanic) students in the PSUs. The 54 PSUs were sampled with probability proportional to the total size of school enrollment in the PSU. In the second stage of sampling, secondary sampling units  were categorized into two strata based on the size of schools. 193 schools with any of grades 9–12 were selected using probability proportional to school enrollment size. In the third stage of sampling, one class per grade was selected in each SSU (two classes per grade in SSUs with high minority enrollment) by varying selection methods from school to school . All students in a sampled classroom were eligible for the survey.28The survey is primarily used to monitor a variety of health risk behaviors among youth, including PA and screen-based SB, using a standard questionnaire. Local parental permission was obtained from the participating schools prior to survey administration, and the protocol of the national YRBS was approved by the CDC’s Institutional Review Board. The response rates at the school and student levels were 77% and 88%, respectively, and adjustment for student and school non-responses was made when calculating the weights of students in participating schools. The detailed protocol of the 2013 national YRBS can be found elsewhere.n = 1460). In addition, 42 adolescents with ≥3 missing values among five questions asking about PA and screen-based SB were further excluded from the analysis. The final analytic sample consisted of 12 081 adolescents , which represents 88.94% of the original sample.A total of 13 583 adolescents completed a questionnaire in the 2013 national YRBS. Of these, the adolescents who provided valid responses on study variables were included. Those with missing values in gender, grade, body mass index (BMI), and three questions asking about healthy diet behaviors were excluded (9 The number of sports teams (in the school or community group) in which the adolescents participated during the past 12 months was used for categorizing adolescents into either Active-STP (≥1 STP/year) or No-STP categories. In addition, the number of days engaging in MSEx  during the past 7 days was obtained for categorizing adolescents into either sufficient-MSEx (S-MSEx) or insufficient-MSEx (I-MSEx) categories in accordance with the PA guideline for youths (≥3 days a week).9The adolescents were asked to disclose the frequency of PA behaviors, including MVPA, sports team participation (STP), and muscle-strengthening exercise (MSEx). MVPA was determined by the question asking the number of days they had been physically active  for a total of at least 60 minutes per day during the past 7 days. The adolescents were dichotomized into either sufficient MVPA (S-MVPA) or insufficient MVPA (I-MVPA) categories based on the PA guideline for youths (≥60 minutes of MVPA per day).29,30Two questions asking about screen-based SBs provided the number of hours watching TV and using a computer for non-school work on an average school day . Excessive exposures to TV and computer were determined using a criteria of ≥3 h per day for each behavior, respectively.2) was at or above 95th percentile according to the CDC sex-specific BMI-for-age growth chart.31Body mass index (BMI) calculated using self-reported height (cm) and weight (kg) was used to determine obesity. Adolescents were considered obese if BMI , and race/ethnicity  were obtained. In addition, information on healthy dietary behaviors was obtained from the questions asking about the frequency of having breakfast, consuming fruits and vegetables, and drinking soda during the past 7 days, as these diet behaviors may be confounding factors influencing the relationship of PA and screen-based SB with obesity.k; 1 through 6) in order to identify the model that best represents the heterogeneity of response patterns of PA and screen-based SB across a given number of latent subgroups. The model with the best model-data fits was determined using 1) the relative fit indices, including the Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), and sample size adjusted BIC (SABIC), where a lower value indicates a better model; 2) Lo-Mendell-Rubin adjusted likelihood ratio test (LMR-LRT), which compares the models with k and k − 1 latent subgroups; and 3) average classification probability (ACP) ranging between 0 and 1, in which a higher value indicates greater certainty in classification. In particular, BIC was preferred when comparing models based on results from a recent simulation study,33 and the practical interpretation of latent subgroups was also considered.34LCA is a family of finite-mixture models representing the population heterogeneity by unobservable subpopulations. We first fitted a series of unconditional LCA models with differing number of latent subgroups  the likelihood of being classified as a respective latent subgroup based on grade and race/ethnicity; and 2) the likelihood of being obese based on a latent subgroup membership after controlling for grade, race/ethnicity, and healthy diet behaviors. All LCA analyses were stratified by gender to obtain gender-specific estimates, as there are gender disparities in PA and screen-based SB among adolescents.LCA models were weighted for the three-stage sampling design of the 2013 national YRBS to obtain the population parameters of US adolescents. A robust full-information maximum likelihood algorithm was used for parameter estimations in order to account for missing responses in PA and screen-based SB. SAS version 9.3  and Mplus version 7.2  were used for data management and LCA analyses.Table The model-data fit indices for unconditional LGA models with differing number of latent subgroups are presented in Table The item-response probabilities for each PA and screen-based SB item across latent subgroups are presented in Table Grade and race/ethnicity were all significant correlates influencing the likelihood of being classified as a respective subgroup compared to the High PA/Low SB subgroup Table . SpecifiThe findings for predicting the likelihood of being obese across latent subgroups after controlling for grade, race/ethnicity, and healthy dietary behaviors are presented in Table The likelihood of being obese was not significantly different between the High PA/High SB, Low PA/Low SB, and Low PA/High SB subgroups for males, while the Low PA/High SB subgroup had greater odds of being obese compared to the Low PA/Low SB  and High PA/High SB  subgroups for female adolescents.16 A growing body of literature, however, confirms the independent relationship between these two behaviors, with specific evidence for MVPA and SB,35 and our findings generally support this claim. In particular, our unique analytic approach focusing on intra-individual variations in multiple structured PA and SB indicators provided empirical evidence of the most likely subgroups with varying concurrent patterns of PA and SB among adolescents. The results revealed that the response probabilities for PA and SB indicators are likely interrelated within each domain but not across domains, yielding distinct and independent patterns of PA and SB across latent subgroups .Using a national representative sample of US adolescents, we found that the heterogeneity of PA and screen-based SBs in adolescents can be best captured by four latent subgroups for both genders. Conceptually, it is reasonable to assume that the choice to engage in SB may decrease PA and vise-versa, as they are aligned at opposite ends of the behavioral spectrum.27,36,37; however, a preponderance of evidence has been accumulated for a single variable of PA and SB separately, limiting our understanding of possible gender disparity in concurrent prevalence of PA and SB among adolescents. The present findings extend the literature by describing the gender differences in the latent subgroups identified based on the combined patterns of PA and SB. The largest portion of male adolescents were categorized into the High PA/Low SB  subgroup, while the Low PA/Low SB  subgroup was the largest for female adolescents. More importantly, the Low PA/High SB subgroup, which is potentially the highest risk group for health, was significantly larger for females  compared to males . Considering that PA and SB are important health determinants in later life,14 public efforts to develop and implement gender-specific intervention strategies to promote PA and reduce SB should be made.The findings highlight gender disparity with regards to PA and SB. Gender differences in healthy behaviors have been continuously reported across all age groups. Specifically, it has been well-documented that female adolescents have lower levels of PA and higher levels of SB compared to male adolescents38 Another study also reported a stronger association of screen time with overweight and obesity than PA among 2200 Australian adolescents.19 In contrast, PA has frequently been reported as the only risk factor of obesity among adolescents in several cross-sectional observations.25,26As previously mentioned, the independent associations of PA and SB with obesity have been frequently examined among adolescents; however, findings are mixed and limited, in part, to extending our understanding of combined effects on the risk of obesity. For example, a study examining the independent relationships of objectively measured PA and self-reported TV hours with obesity among 2200 adolescents from 10 European cities demonstrated that excessive TV watching (>4 hours per day) was a significant predictor of increased likelihood of being obese even after adjusting for PA levels.22The present findings provide empirical evidence to support the complexity of combined effects of PA and SB for explaining the risk of obesity in this population. The use of an advanced statistical method based on LCA allowed us to classify the population by the response patterns of multiple PA and screen-based SB indicators and to include the distal outcome of obesity directly into the model while adjusting for covariates, including gender, race/ethnicity, and healthy diet behaviors. For both genders, the High PA/Low SB subgroup showed significantly lower likelihood of being obese compared to other subgroups; however, the relative magnitudes of such effects were greater for females compared to male adolescents. This may imply that increasing PA and reducing SB are equally important to reduce obesity risk among adolescents, in that significant health benefits will likely be obtained by having healthy behaviors for both PA and SB, with greater likelihood for preventing obesity being expected for females than males. Our findings are generally aligned with those of a previous report that both low PA and excessive TV hours are important risk factors for being overweight in adolescents, with stronger associations observed in female adolescents.Our analyses also indicated that there could be some differences in the concurrent effects of PA and SB on obesity between genders. Specifically, the odds of being obese were not significantly different between the High PA/High SB, Low PA/High SB, and Low PA/Low SB subgroups for males, while female adolescents in the Low PA/High SB subgroup showed a significantly greater likelihood of being obese compared to their female counterparts in the Low PA/Low SB and High PA/High SB subgroups. These findings imply that for male adolescents to reduce the risk of obesity, which would be a significant health benefit, they must have both high levels of PA and low levels of SB. Pertaining to adolescent females, having either high levels of PA or low levels of SB may reduce risk of being obese to a greater degree than engaging in both low levels of PA and high levels of SB. Our findings demonstrating distinct combined associations of PA and SB with the risk of obesity across gender may also partially explain the prevalence of obesity being lower in female adolescents (10.8%) than in males (16.6%).14 Energy imbalance is regarded as a common cause of obesity, and gender differences in the response of energy expenditure during daily PA have been previously reported.39 Moreover, the likelihood of having unhealthy foods while engaging in screen-based SB is reportedly increased, with female adolescents being more likely to consume unhealthy foods than males.38Taken together, these findings suggest that gender-specific PA and SB recommendations and intervention strategies might be necessary. Although it is difficult to make a concrete explanation of such gender differences due to the limited resources in this survey, one possible reason could be related to the differences in calories expended and consumed during the engagements of PA and SB, respectively, between genders.40 Furthermore, obesity status was determined based on self-reported height and weight. The objectively measured adiposity levels, PA, and SB across specific contexts would be warranted in future studies in order to strengthen the external validity of the findings.The interpretation of the present findings should account for several limitations. First, the 2013 national YRBS is a cross-sectional survey that precludes assessment of the casual relationships among study variables. As noted above, a longitudinal study examining the trajectories of PA and SB in relation to time-variant determinants as well as the changes in obesity would be a promising way to better understand the complex nature of PA, SB, and the influence of those behaviors on risk of obesity among adolescents. Second, while our findings were controlled for demographic characteristics and healthy diet behaviors, we were not able to control for additional potential confounding factors, such as previous weight status, due to the limited data available in the YRBS. Third, the indicators of PA and SB are subjectively measured and are limited to address only some aspects of PA  and SB . This might lead participants to overestimate their actual levels of PA and SB, which are subject to recall bias.In conclusion, US adolescents can be classified into four latent subgroups based on the response patterns of PA and screen-based SB. The estimated latent subgroups showed significantly different likelihoods of being obese between each other, indicating the complex associations of PA and SB with the risk of obesity. For both genders, both PA and SB are important lifestyle behaviors related to obesity. More specifically, the High PA/Low SB subgroup, who had the highest probability of compliance with current PA and screen-based SB recommendations, had significantly lowest odds of being obese, with greater odds for female adolescents than males. In addition, female adolescents may expect to have some health benefits by complying with either PA or SB recommendations, while male adolescents should be encouraged to comply with both PA and SB recommendations in order to achieve significant health benefits. The present findings imply the need for developing gender-specific PA and/or SB intervention strategies to maximize health benefits of reducing the risk of obesity among adolescents.


In the mid-1990s, Cambodia faced one of the fastest growing HIV epidemics in Asia. For its achievement in reversing this trend, and achieving universal access to HIV treatment, the country received a United Nations millennium development goal award in 2010. This article reviews Cambodia’s response to HIV over the past two decades and discusses its current efforts towards elimination of new HIV infections.A literature review of published and unpublished documents, including programme data and presentations, was conducted.Cambodia classifies its response to one of the most serious HIV epidemics in Asia into three phases. In Phase I (1991–2000), when adult HIV prevalence peaked at 1.7% and incidence exceeded 20,000 cases, a nationwide HIV prevention programme targeted brothel-based sex work. Voluntary confidential counselling and testing and home-based care were introduced, and peer support groups of people living with HIV emerged. Phase II (2001–2011) observed a steady decline in adult prevalence to 0.8% and incidence to 1600 cases by 2011, and was characterized by: expanding antiretroviral treatment (coverage reaching more than 80%) and continuum of care; linking with tuberculosis and maternal and child health services; accelerated prevention among key populations, including entertainment establishment-based sex workers, men having sex with men, transgender persons, and people who inject drugs; engagement of health workers to deliver quality services; and strengthening health service delivery systems. The third phase (2012–2020) aims to attain zero new infections by 2020 through: sharpening responses to key populations at higher risk; maximizing access to community and facility-based testing and retention in prevention and care; and accelerating the transition from vertical approaches to linked/integrated approaches.Cambodia has tailored its prevention strategy to its own epidemic, established systematic linkages across different services and communities, and achieved nearly universal coverage of HIV services nationwide. Still, the programme must continually (re)prioritize the most effective and efficient interventions, strengthen synergies between programmes, contribute to health system strengthening, and increase domestic funding so that the gains of the previous two decades are sustained, and the goal of zero new infections is reached. Situated in the heart of South East Asia, Cambodia is a low-income country that is recovering from several decades of regional and internal conflict. Its population of 14.86 million . With a The first HIV infection was officially detected in 1991 during screening of blood donors , at whicDespite the 53% growth of Cambodia’s population from 9.72 in 1992 to 14.86 million in 2012 [This article reviews Cambodia’s response to HIV over the past two decades, concentrating on the strategic decisions taken and the many efforts that dealt vigorously with the epidemic. Describing all three phases of the HIV response, the article outlines Cambodia’s current efforts to achieve the elimination of new infections.This article is based on a literature review of available data, documents and reports (published and unpublished), corroborated by the personal insights and experiences of the authors.Health services in Cambodia are delivered via two facility types: health centres providing basic services such as antenatal care (ANC), delivery, diagnosis and treatment of tuberculosis (TB) and referral hospitals  providing a broader range of clinical care including ART and laboratory services. Operational districts, which are clusters of administrative districts, oversee health service management. There are 80 operational districts across Cambodia’s 25 provinces, and each contains at least one referral hospital.The National Centre for HIV/AIDS, Dermatology and STI (NCHADS) is the body within the Ministry of Health responsible for the health sector response to HIV and other sexually transmitted diseases in Cambodia. As such, it collaborates with relevant departments and centres of the Ministry of Health, the National AIDS Authority and other government institutions, as well as health service providers, non-governmental and other civil society organizations, and development partners.Cambodia classifies its response to one of the most serious HIV epidemics in Asia into three phases .Phase I took place while the country was recovering from the previous decades of national instability, when HIV was expanding most rapidly. Unprotected sex work was fuelling the spread of HIV and other STI . The ratIn the early to mid-1990s, social marketing of condoms, peer education and outreach were directed at sex workers. Then in 1999, the Prime Minister of Cambodia adopted the 100% Condom Use Programme (CUP), and it was rolled out nationwide .Three key structures were established in the mid-1990s to create an environment in which people living with HIV (PLHIV) could seek health and social support services. First, in 1995, Voluntary Confidential Counselling and Testing (VCCT) sites were introduced. While not yet “linked” to other service delivery points, their co-location with health facilities became conducive to access to treatment. Second, home-based care (HBC) networks were formed, comprising health centre staff and volunteers, many of whom were PLHIV. Third, PLHIV peer support groups and networks emerged from the HBC network, helping members cope with the social and emotional aspects of living with HIV.During the latter half of Phase I, the trends among direct brothel-based sex workers in Phnom Penh began improving; self-reported condom use at last paid intercourse increased from less than 40% to consistently over 90%, STI prevalence halved and HIV prevalence started to decline from 42%  Figure . By 2001In the second Phase of Cambodia’s response, there was rapid scale-up of HIV counselling, testing, care and treatment . SystemaWhen expansion of ART services emerged as a national agenda in 2002, the country had only a few isolated ART services at national level hospitals with specialized clinicians. Local hospitals were not fully functional, as the nation was still recovering from decades of conflict. NCHADS led extensive consultations among key stakeholders to determine how to manage the expansion, which resulted in the decision to decentralize treatment services to operational district level. Providing services at this level would build on and support the extensive network of HBC and PLHIV peer support groups (described in the next section).VCCT was expanded from less than 20 sites in Phnom Penh and some provincial towns to all operational districts, and later into one in five health centres. As the expansion data in A rapid test-based algorithm was implemented throughout VCCT services, and provider-initiated testing and counselling (PITC) was made available to pregnant women and TB cases in health centres. Procedures for referring blood samples to VCCT sites were established, since health centres without VCCT were not equipped with test kits. Key populations were targeted and referred in person by non governmental organizations (NGOs) outreach teams to VCCT twice per year. Outreach testing by VCCT staff was also explored late during this phase.While the strategy for ART expansion was being conceptualized, NCHADS and other stakeholders noted the many barriers to PLHIV accessing services. Formal and informal dialogue with PLHIV peer support group members highlighted the burdens of stigma, discrimination, and financial, social and psychological pressures. Having explored a range of service delivery models through extensive consultation, a single model was adopted whereby each operational district was to forge partnerships between public health sector facilities, PLHIV networks, NGOs and the community. To guide this process and lay the foundation for systematic expansion of a standard service package, the Continuum of Care framework  was deveThe Continuum of Care Framework was applied at the operational district level, where the Vice Governor and the Referral Hospital Director or pre-ART/ART Team Leader co-chaired the Continuum of Care Coordination Committee. This leadership ensured coordination of stakeholders and facilitated communication among them. Meetings were well attended by representatives from health facilities, NGOs, PLHIV and the local community, which was also a key to their success.After being involved in HBC teams for a time, health centre staff were instructed to give up their membership because of the time commitments that impinged on their facility-based duties. Self-help groups subsequently grew to play a major role in supporting HBC, and the two networks were responsible for encouraging those who were at high risk of HIV infection (such as spouses and children of PLHIV) to access HIV testing and counselling (HTC). HIV-positive cases were linked to care and treatment services at operational district-level referral hospitals, where PLHIV volunteers would help them enrol in pre-ART care. Conversely, hospitals referred patients back to HBC teams and self-help groups to ensure that they were supported in their communities.Attached to pre-ART/ART services, Centres for Friends Helping Friends  also played a key role in facilitating social support and community education. MMM services were equally extended to children where paediatric AIDS care services were available on the paediatric ward (designated as mmm). With facilities located within the compound of the hospital, MMM/mmm was understood to be the space in which connections could be made among PLHIV, families, NGOs, health workers, religious leaders and local authorities. As such, MMM/mmm activities contributed significantly to the improvement of the health and wellbeing of PLHIV, as well as to the reduction of stigma and discrimination.The Continuum of Care coordination meetings and MMM/mmm successfully aligned with health facilities and community structures, and so the standard model laid out in the framework was expanded progressively across the nation, together with ART. The expansion process was guided by consideration of factors such as geographic distribution of disease burden, projected capacity of referral hospitals, and existence of HBC and PLHIV support groups.After the late 1990s, several unsystematic attempts were made to introduce prevention of mother-to-child transmission and TB/HIV collaborative activities . At the By 2006, it was clear that collaboration among HIV, MCH and TB programmes would succeed if an agreed service delivery model explicitly prescribed linkages between the programmes. The roles and responsibilities of respective programmes were identified through concerted efforts to establish systematic linkages between the concerned services. In particular, it was important to situate PITC at health centre level, as this was where pregnant women presented for ANC and where TB cases were being seen. As such, there was a major breakthrough in collaborative service delivery.For PMTCT, the “Linked Response”  strategyThis experience gave substantive justification to scaling up the “Linked Response” nationwide, and resources were readily mobilized towards that end. Subsequently, coverage of PMTCT cascades, HIV testing and triple ARV prophylaxis or ART in pregnant women improved dramatically.Throughout the decade, the national HIV and TB programmes worked on developing a framework for collaboration ; TB/HIV Together, the respective linking of HIV with MCH and TB services resulted in progressive coverage of HIV testing of pregnant women and TB cases to over 80% in 2011. Also by 2011, coverage of ARV (including single dose nevirapine) among estimated HIV-positive pregnant women had reached 69.2%. Of all newly diagnosed TB cases with HIV infections in 2012, 89% received ART. However, pregnant women and TB cases were not able to receive the same day test results under this model. In the cumbersome referral process of linking first test, confirmatory test, pre-ART care enrolment and other elements of PMTCT and TB/HIV services, substantive drop-outs and delays in accessing treatment were observed.In 2008, the Trafficking Law was revised to prohibit the public solicitation, procurement and management of an establishment for prostitution and the provision of premises for prostitution . While iThen the global financial crisis, which affected Cambodia in 2009, resulted in loss of employment for around 50,000 garment workers. Roughly 14,000 female workers entered the entertainment sector at this time , 25.When the Commune/Village Safety Policy was introduced in 2011, utilization of HIV services by high-risk groups  is reporMeanwhile, rising HIV transmission was noticed among men who have sex with men, TG persons, and people who use and/or inject drugs. Reaching all of these populations required new, more innovative approaches.To respond to the changing situation, NCHADS, implementing NGOs and partners developed a new approach in 2009, called the Continuum of Prevention to Care and Treatment for key populations . This neQuality assurance of HIV services has been conducted through: (1) Continuum of Care coordination meetings; (2) clinical mentoring; (3) regional network meetings for clinicians and counsellors; (4) HIV drug resistance surveillance surveys, including monitoring for early warning indicators; (5) HIV/AIDS care and treatment symposia; and (6) roll-out of a continuous quality improvement (CQI) strategy. As part of the CQI strategy, operational districts are supported to collect indicators that measure the quality of patient management across the continuum of care, measure their own performance against these, and monitor and improve these measures as an integral part of their work. These activities were designed to maximize PLHIV retention in treatment. In 2011, retention in ART at 12, 24 and 60 months reached 92.6, 84.2 and 78.0% respectively .One of the major constraints for government health services is the low civil servant remuneration. Health workers’ salary is well below subsistence, which tends to lead to under-the-table payments by patients and demotivated staff seeking to supplement their incomes with other work. NCHADS introduced a standard salary incentive scheme, the first of its kind in the health sector, which enhanced health worker motivation. The scheme was soon handed over to other operators as part of a broader performance-based financing and social health protection/insurance scheme linked to national health system strengthening efforts. More sustainable solutions are yet to be found .In addition to expanding HIV services and linking them with other relevant programmes, NCHADS made substantive efforts to strengthen health system. For example, since 2004, NCHADS has been working with 17 hospitals to integrate their multiple independent laboratories . Merging them with the support of development partners into a single comprehensive “integrated laboratory” for the entire hospital created a model for subsequent nationwide expansion within the context of health system strengthening initiatives. Also, in 2005, when expansion of ART for children was planned, it was found that a majority of referral hospitals had no functioning paediatric outpatient or inpatient services. As this was largely due to lack of facilities and/or equipment and a shortage of paediatricians, NCHADS mobilized resources from development partners to build or renovate facilities and provide equipment to 22 hospitals in 2011. In the newly equipped and revitalized paediatric services, HIV care and treatment for children were introduced.Cambodia was able to achieve universal access by:Investing in strategic information for a clear understanding of the national HIV epidemic, to be able to deliver effective and efficient interventions;Taking a vertical approach (e.g. 100% CUP) to controlling the epidemic in its early years;Working with all partners to develop a single service delivery framework for preliminary learning and subsequent expansion of an evidence-based model rather than having many pilot projects and parallel programmes;Involving the community meaningfully , not only in service delivery but also policy formulation, programme design and monitoring and evaluation; andEvolving from a vertical approach to the “linking” model as the epidemic and the response matured, and then adopting an integrated approach to maximize resources.The early response of Phases I and II managed to curb the transmission that was driving Cambodia’s HIV epidemic . As per At the United Nations General Assembly High Level Meeting on AIDS in New York in June 2011, Cambodia expressed its support of the global goals and targets to intensify efforts to achieve the “Three Zeros.” As such, it has set an ambitious goal of eliminating new HIV infections by 2020 under the “Cambodia 3.0” framework . The maiIn continuing to strengthen prevention among key populations and improve their access to health services (component 1), a rapid response mechanism will be introduced in line with communicable disease outbreak investigation and control principles. The three functions of the mechanism are: (1) enhanced vigilance of potential transmission, risk behaviours and underperforming programmes; (2) targeted investigation of outbreaks and new pockets of risk, and assessment of the adequacy of the response; and (3) immediate strengthening of interventions . Priority target populations at higher risk include people who inject drugs, people who use and/or inject drugs and sell sex, male and TG entertainment workers who sell sex, men who have sex with men frequenting saunas and bars, and partners of all these persons. Female entertainment workers who have more than seven clients a week are also an important population due to the large number of these women.To accelerate timely HIV diagnosis among key populations (part of component 3), outreach HIV testing using finger-prick testing is being expanded by mobilizing NGOs and outreach workers. Finger-prick testing is also being introduced at most health centres where ANC and TB services are offered. The finger-prick testing is intended to streamline and simplify procedures for HIV diagnosis by significantly reducing referral steps, abolishing blood sample referral from health centres, and averting in-person referral from VCCT without pre-ART/ART. Drop-outs and delays are being mitigated through direct referral of all first test reactive cases found in the community to VCCT services co-located at pre-ART/ART sites. The same applies for first test reactive cases found at health facilities .Furthermore, integrated active case management is being introduced to maximize retention along the HIV cascades. A case management coordinator will be appointed in each operational district to ensure active follow-up of individuals from first test reactive in HTC through pre-ART/ART, PMTCT, TB/HIV and partner tracing and testing processes. He or she will be provided with case information regularly and authorized to mobilize and coordinate concerned service providers, HBC teams and outreach workers.The current ART eligibility criteria are in line with the 2010 WHO guidelines , which rBuilding on the past achievements in linking HIV, MCH and TB services and further strengthening health service delivery systems, the development of comprehensive linked/integrated service delivery models will be explored in collaboration with stakeholders engaged in sexual and reproductive health including adolescent health, non-communicable diseases, blood safety and hepatitis.There are plans to strengthen surveillance, case reporting and programme monitoring systems. A unique identifier system is being piloted to enable the confidential tracking of service delivery to PLHIV, to strengthen case management and to enhance programme monitoring. Also, mathematical modelling and ad hoc studies will be conducted in order to monitor and assess the impact of innovative interventions, and to inform the adjustment of Cambodia 3.0 strategies.Challenges remain on both demand and supply sides of service delivery. Access to services by key populations remains constrained by a sub-optimal policy, legal and social environment. Cambodian health and community systems are still in a fragile state, with health workers chronically overloaded and receiving wages that have not kept pace with the cost of living. Despite strong leadership at national level, and although decentralization of HIV services during Phase II was successful, there is limited leadership and management capacity at sub-national level. Logistic and supply management of HIV-related medicines and other commodities is emerging as a significant concern. Without the strengthening of these systems, it will be difficult indeed to be able to verify whether and when there are zero new infections. It is equally crucial that the systems of data generation, analysis and use are robust, not only for surveillance but also for programming and budgeting purposes, and to inform policy dialogue and planning.Compounding these challenges and potentially undermining the Cambodia 3.0 goals and aspirations is Cambodia’s marked dependence on international funding. In 2012, 87% of financial resources for the national response to HIV came from donors – mainly the Global Fund and the U.S. President’s Emergency Plan for AIDS Relief initiative . Only 3%In May 2013, a National Health Sector HIV Program Review concluded that Cambodia was on track to achieving its goal of eliminating new HIV infections in the country by 2020. Indeed, combined, comprehensive prevention, care and treatment efforts and the linking of services have had a positive impact on the epidemic. Tens of thousands of new infections have been prevented, and tens of thousands of PLHIV have been given the prospect of a longer and more active life. Nevertheless, Cambodia must now protect the gains of the past amid on-going and emerging health system challenges and declining international funding. The approaches and linkages that have been developed over the past 20 years must be consolidated and at the same time remain flexible to respond effectively to the ever-changing nature of the epidemic. HIV services need to be integrated and mainstreamed gradually into the broader health system as the overall health system improves and new financing strategies are identified and implemented.


The public health burden and racial/ethnic, sex, and socioeconomic disparities in obesity and in diabetes require a population-level approach that goes beyond provision of high-quality clinical care. The Robert Wood Johnson Foundation’s Commission to Build a Healthier America recommended 3 strategies for improving the nation’s health: 1) invest in the foundations of lifelong physical and mental well-being in our youngest children; 2) create communities that foster health-promoting behaviors; and 3) broaden health care to promote health outside the medical system. We present an overview of evidence supporting these approaches in the context of diabetes and suggest policies to increase investments in 1) adequate nutrition through breastfeeding and other supports in early childhood, 2) community and economic development that includes health-promoting features of the physical, food, and social environments, and 3) evidence-based interventions that reach beyond the clinical setting to enlist community members in diabetes prevention and management. Preventing and treating diabetes are major public health priorities in light of the increased risk for disability and premature death associated with the disease. Diabetes is the seventh leading cause of death in the United States, contributes to cardiovascular, renal, vision, and other complications, and results in $245 billion in total costs . In 2005In January of 2014, the Robert Wood Johnson Foundation’s Commission to Build a Healthier America (hereafter referred to as the Commission) recommended 3 broad strategies for improving the nation’s health: 1) invest in the foundations of lifelong physical and mental well-being in our youngest children, 2) create communities that foster health-promoting behaviors, and 3) broaden health care to promote health outside the medical system . These rWithin neighborhoods and communities, features of the built environment , the food environment , and other aspects of community and economic development  should support behaviors that promote obesity and diabetes prevention –11. As tIn the clinical setting and at its interface with the community, there are multiple opportunities to address diabetes prevention and treatment. The emphasis on high-quality treatment and the coordination of patient care  within the Affordable Care Act has prompted a reassessment of health care delivery in the United States. Prevention and treatment of diabetes, particularly in socially disadvantaged and traditionally underserved populations, will require far greater coordination than exists now among providers and between health care systems and community-based partners. The Commission calls for an expansion of the concept of “vital signs” in clinical and public health settings to include nonmedical factors such employment, education, health literacy, and safe housing. The Commission also envisions “prescriptions” for behaviors such as healthful eating that can be “filled” with community-based programs .We provide an overview of the evidence for each of these approaches. We also present a model for how policies can be enacted that will bridge the clinic and the community in diabetes prevention and treatment efforts, while noting examples of best practices. Finally, we will highlight future directions for research, practice, and policy in this area.Caring for Our Children: National Health and Safety Performance Standards  and the Child and Adult Care Food Program (CACFP), are federally funded food programs aimed at ensuring infants and children have access to nutritious food. WIC provides funds for buying healthful supplemental foods from WIC-authorized vendors, nutrition education, and help locating health care and other community services. CACFP provides meals and snacks to children and adults in day care facilities and in after-school programs. Although these federal programs help meet the daily nutritional needs of millions of young, low-income children during a critical period of growth and development, the dietary guidelines, structure, and reimbursements are outdated and complex, leaving many children without the benefits of these programs .Healthy People 2020  have implemented efforts to encourage improvement of meal standards associated with federal programs ; howeverCommunity Guide  , promotiBoth the built environment and food access depend on community and economic development policies within communities that determine zoning for residential, industrial, and commercial space, business activities, and resources such as schools and health centers. Considering health as a key component of policy decisions regarding community and economic development is consistent with the principles of “health in all policies” and the Health Impact Assessment . InformeDiabetes is a chronic disease that requires ongoing patient education, self-management, and clinical care to achieve desired outcomes. It is critical to understand how the patient’s ability to manage diabetes is affected by the Commission’s nonclinical vital signs such as employment, healthful food access, safe housing, and health literacy.The PCMH is a mechanism for the redesign of health care delivery promoted through the Affordable Care Act. The PCMH model seeks to provide comprehensive, patient-centered, coordinated care that is accessible and has a consistent focus on quality improvement and patient safety.The PCMH model incorporates some of the most successful strategies for improving glucose control, such as promotion of self-management, changes in the health care team, and case management, all documented in a meta-analysis to lower hemoglobin A1c (HbA1c) by approximately 0.5% to 0.6% . NumerouAlthough patients with low income and low education from racial/ethnic minority populations may benefit from the coordinated approach in a PCMH, many of these demonstrations have not targeted these groups. In a retrospective cohort study of 1,457 patients with diabetes receiving care in a PCMH academic practice, black patients were less likely to receive HbA1c testing, receive an influenza vaccination, or meet low-density lipoprotein cholesterol or blood pressure targets than non-Hispanic whites, after adjusting for other demographic, health, and socioeconomic factors . Black pAs part of the team-based approach that promotes patient self-management, community health workers (CHWs) are a key resource for connecting clinic to community, particularly in disadvantaged, underserved populations. CHWs are typically lay people from the community who are trained to serve as liaisons between patients and the health care community. They may work in teams with health care providers, provide group education in the community or clinical setting, or conduct home visits to follow up and address barriers to care. Regarding their role in diabetes care, interventions using nurse–CHW teams and CHWs trained as certified diabetes educators have been associated with mean HbA1c reductions of about 0.5% in numerous evaluations .The Chronic Disease Self-Management Program (CDSMP) trains patients with chronic diseases as lay leaders in community settings to promote self-confidence in symptom control, decision-making, and patient–provider communication. A longitudinal study of the program among 1,170 participants demonstrated reductions in emergency department visits at 12 months and hospitalizations at 6 months as well as improved self-reported health, patient–physician communication, and medication compliance . Among pWe highlight 2 successful interventions targeting underserved populations. These interventions seek to connect clinic to community.Project Sugar 2, conducted in Baltimore, Maryland, randomized 542 African Americans in an urban managed-care organization during 2001 through 2003 to either biannual telephone counseling with a lay health educator and educational mailings or to an intensive intervention involving a nurse case manager and CHW visits. CHWs and case managers used clinical algorithms and intervention action plans, addressing topics ranging from nutrition and medication adherence to socioeconomic issues, to determine the frequency and intensity of follow-up and to maintain patient communication with health care providers. There was no significant difference in HbA1c between groups at 24 months after adjusting for age, baseline HbA1c level, and duration of follow-up. However, emergency department visits were significantly reduced in the intensive intervention arm by 23% at 24 months. At 24 and 36 months, those receiving the higher-intensity care  saw the most benefit in reduction of emergency department visits .P = .02)  .Successful prevention and management of diabetes will require efforts that go beyond traditional clinical care, particularly in underserved and socially disadvantaged populations. There are evidence-based and promising strategies for intervening in early life, in the community, and at the nexus between the community and clinical settings. More research is needed to further establish the effectiveness of these approaches, particularly to determine the specific pathways through which clinical–community connections help to improve diabetes prevention and treatment outcomes. Identifying opportunities to intervene outside the examination room will be critical to effectively prevent and manage both obesity and diabetes. The Commission recommendations for health promotion offer a useful guide for areas to target. Policies are needed that support increased investments in 1) adequate nutrition through breastfeeding and other supports in early childhood, 2) community and economic development that includes health-promoting features of the physical, food, and social environments, and 3) evidence-based interventions that reach beyond the clinical setting to enlist community members in diabetes prevention and management.


To undertake a systematic review of existing literature relating to speech recognition technology and its application within health care.A systematic review of existing literature from 2000 was undertaken. Inclusion criteria were: all papers that referred to speech recognition (SR) in health care settings, used by health professionals , with an evaluation or patient or staff outcomes. Experimental and non-experimental designs were considered.Six databases  were searched by a qualified health librarian trained in systematic review searches initially capturing 1,730 references. Fourteen studies met the inclusion criteria and were retained.The heterogeneity of the studies made comparative analysis and synthesis of the data challenging resulting in a narrative presentation of the results. SR, although not as accurate as human transcription, does deliver reduced turnaround times for reporting and cost-effective reporting, although equivocal evidence of improved workflow processes.SR systems have substantial benefits and should be considered in light of the cost and selection of the SR system, training requirements, length of the transcription task, potential use of macros and templates, the presence of accented voices or experienced and in-experienced typists, and workflow patterns. Technologies focusing on the generation, presentation and application of clinical information in healthcare, referred to as health informatics or eHealth solutions , 2 have Health informatics or eHealth solutions enable clinical data to become potentially accessible through computer networks for the purposes of improving health outcomes for patients and creating efficiencies for health professionals –16. LangSpeech recognition, in particular, presents some interesting applications. Speech recognition (SR) systems compose of microphones , sound cards  and speech engine software (that convert the data into text words) . As earlAlthough systematic reviews of health informatics –27 have The aim of this study was to undertake a systematic review of existing literature relating to SR applications, including the identification of the range of systems, implementation or training requirements, accuracy of information transfer, patient outcomes, and staff considerations. This review will inform all health professionals about the possible opportunities and challenges this technology offers.All discoverable studies published in the refereed literature from the year 2000 and in English language only were included in the review. We believed that only studies from 2000 onwards would use speech recognition technology that was sufficiently accurate to be suitable for health care settings. Papers were included if they referred to speech recognition in health care settings, being used by health professionals , with an evaluation of patient or staff outcomes. All research designs, experimental and non-experimental, were included. Studies were excluded if they were opinion papers or describing technical aspects of a system without evaluation. Methods for searching the literature, inclusion criteria, and general appraisal and analysis approaches were specified in advance in an unregistered review protocol.Six databases  were searched by a qualified health librarian trained in systematic review searches, using the following search terms: “automatic speech recognition”, “Speech Recognition Software”, “interactive voice response systems”, “((voice or speech) adj (recogni* or respon*)).tw.”, “.tw.”. It should be noted that EMBASE includes 1000 conference proceedings  also. In addition, a search was undertaken for grey literature in Open Grey. Examples of the searches undertaken from three major databases are presented in Table The search identified 1,730 references to publications that were published in or after 2000. There were 639 duplicates in these 1,730 references which were removed resulting in 1,091. Some 1,073 papers were not found to be relevant as they reflected other topics or applications such as: auditory research (65), cochlear implant or hearing instrument (174), conversations, or multiple speakers (12), discrete speech utterance (2), impaired voice (150), informal research notes including comments or response (6), interactive voice response (199), speech perception (53), synthesized speech (4), thesis (1), and other irrelevant topics (340). The remaining 18 were examined using the inclusion criteria by two independent reviewers and 14 papers  . The scoOf the fourteen studies retrieved, one was a randomised controlled trial (RCT) ; ten werThe studies were conducted in hospitals or other clinical settings including: emergency departments , 38, endThe health professionals or support staff involved were: nurses , patholoTraining varied between studies with some studies providing data based on minimal training 5 minutes  to 30 miThe majority of the papers focused on systems that supported English language, however other languages such as Finnish  and DaniThe quality scores for the studies ranged from two studies at 4 , 30, sixThe main outcome measures in the included studies were: productivity including report turnaround time , 36–38; The findings of the included studies were heterogeneous in nature, with diverse outcome measures, which resulted in a narrative presentation of the studies , or proportions of documents completed within a specified time period. Overall, most papers , 36–38 rResults of another study reported significant differences in RTT between SR systems produced by different companies. The authors reported that Dragon software took the shortest time (12.2 mins) to dictate a 938-word discharge report followed by IBM and L & H .The quality of the reports in seven studies was determined by comparing errors or accuracy rates , 35, 38.Evidence from the included studies also suggests that error rates are dependent on the type of SR system. A comparison of three SR systems indicated that IBM ViaVoice 98 General Medical Vocabulary had the lowest overall error rates compared with Dragon Naturally Speaking Medical Suite and L&H Voice X-press for Medicine, General Medicine Edition, when used for generating medical record entries . A similSome SR systems incorporated generic templates and dictation macros that included sections for specific assessment information such as chief complaint, history of present illness, past medical history, medications, allergies and physical examination , 38. OthThe purpose of this review was to provide contemporary evidence on SR systems and their application within health care. From this review and within the limitations of the quality of the studies included, we suggest that an SR system can be successfully implemented in a variety of health care settings with some considerations.Several studies compared the use of transcribers to SR with human transcription having slightly higher overall word accuracy , 36, 38 Several issues related to the practical implementation of SR systems have been identified.As with any information system , a SR syIn the majority of the included studies the reported error rates and improvements and other outcomes were achieved after only limited training was provided to participants who had no prior experience with SR. Training delivered varied from 5 minutes  to 6 houTechnical aspects of system selection, vocabulary applied, and the management of background noise and accented voices are all challenges during implementation. System selection is important with several systems available with varying levels of recognition errors  , but witAccuracy also varies depending upon the vocabulary used with potential users needing to consider the appropriate vocabulary for the task— using a pathology vocabulary , and usiMost contemporary SR systems have advanced microphones that have noise cancelling capacities that allow for SR systems to be used in noisy clinical environments , 30.the Voice Recognition Accuracy standards- by the National Institutes of Standards and Technology[SR systems now accommodate some accented voices such as Dragon Medical™ providing accented voice profiles, for Australian English, Indian English and South East Asian English . Finallychnology when repWhereas every endeavour was made to optimise inclusivity, the heterogeneity of the studies made comparative analysis and synthesis of the data challenging. The studies included in this review represent comparative designs or descriptive evaluations and only further rigorous clinical trials can confirm or refute the findings proposed here. A thorough examination of the cost benefits of SR in specific clinical settings needs to be undertaken to confirm some of the economic outcomes proposed or demonstrated here. The focus on patient turnaround times in reporting of radiographic procedures or assessment within the emergency department has the potential to increase patient flow and reduce waiting times. Additionally, SR has the potential to automatically generate standardised, terminology-coded clinical records and dynamically interact with clinical information systems to enhance clinical decision-making and improve time-to-diagnosis. Taking into account these areas in future evaluations will allow for a more comprehensive assessment of the overall impact that SR systems can have on quality of care and patient safety, as well as efficiency of clinical practice. We acknowledge the importance of publication bias relating to non-publication of studies or selective reporting of results that may affect the findings of this review.SR systems have substantial benefits but these benefits need to be considered in light of the cost of the SR system, training requirements, length of transcription task, potential use of macros and templates, and the presence of accented voices. The regularity of use enhances accuracy although frustration can result in disengaging with the technology before large accuracy gains are made. Expectations prior to implementation combined with the need for prolonged engagement with the technology are issues for management during the implementation phase. The improved turnaround times of patient diagnostic procedure reports or similar tasks represent an important outcome as it impacts on timely delivery of quality patient care. The ubiquitous nature of SR systems within other social contexts will guarantee improvements in SR systems (software and hardware). The availability of applications such as macros, templates, and medical dictionaries will increase accuracy and improve user acceptance. These advances will ultimately increase the uptake of SR systems by diverse health and support staff working within a range of healthcare settings.MJ Faculty of Health Sciences Australian Catholic University, previously University of Western Sydney and Director, Centre for Applied Nursing Research , Sydney Australia. Affiliated with the Ingham Institute of Applied Medical Research.SL Centre for Applied Nursing Research , Sydney Australia.VL School of Computing, University of Western Sydney, Sydney, NSW, Australia.PS University of Western Sydney, Sydney, NSW, Australia.HS NICTA, The Australian National University, College of Engineering and Computer Science, University of Canberra, Faculty of Health, and University of Turku, Department of Information Technology, Canberra, ACT, Australia.JB University of Western Sydney, Sydney, NSW, Australia.LD University of Wollongong, Wollongong, NSW, Australia.


The consequences of opioid relapse among patients being treated with opioid substitution treatment (OST) are serious and can result in abnormal cardiovascular function, overdose, and mortality. Chronic pain is a major risk factor for opioid relapse within the addiction treatment setting. There exist a number of opioid maintenance therapies including methadone, buprenorphine, naltrexone, and levomethadyl acetate (LAAM), of which the mediating effects of pain on treatment attrition, substance use behavior, and social functioning may differ across therapies. We aim to 1) evaluate the impact of pain on the treatment outcomes of addiction patients being managed with OST and 2) identify the most recently published opioid maintenance treatment guidelines from the United States, Canada, and the UK to determine how the evidence is being translated into clinical practice.www.guidelines.gov and the National Institute for Care and Excellence (NICE) databases to identify the most recently published OST guidelines. All screening and data extraction will be completed in duplicate. Provided the data are suitable, we will perform a multiple treatment comparison using Bayesian meta-analytic methods to produce summary statistics estimating the effect of chronic pain on all OSTs. Our primary outcome is substance use behavior, which includes opioid and non-opioid substance use. We will also evaluate secondary endpoints such as treatment retention, general physical health, intervention adherence, personal and social functioning, as well as psychiatric symptoms.The authors will search Medline, EMBASE, PubMed, PsycINFO, Web of Science, Cochrane Database of Systematic Reviews, ProQuest Dissertations and theses Database, Cochrane Central Register of Controlled Trials (CENTRAL), World Health Organization International Clinical Trials Registry Platform Search Portal, and the National Institutes for Health Clinical Trials Registry. We will search This review will capture the experience of treatment outcomes for a sub-population of opioid addiction patients and provide an opportunity to distinguish the best quality guidelines for OST. If chronic pain truly does result in negative consequences for opioid addiction patients, it is important we identify which OSTs are most appropriate for chronic pain patients as well as ensure the treatment guidelines incorporate this information.http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42014014015#.VS1Qw1wkKGMPROSPERO CRD42014014015  Chronic non-cancer pain is a serious comorbidity impacting the lives of over 95 million people, an estimated 30.7% of the US population . ChronicWhile methadone is employed in the management of chronic pain, its most common use is in the treatment of opioid addiction , known fThe intersection between pain management, opioid dependence, and addictive behavior inflates the challenges of treating both addiction and chronic pain. In addition to psychiatric disturbance and inadequate social support, chronic pain is known to be one of the greatest risk factors for opioid relapse within the methadone setting ,16. ThesThe risk for abnormal cardiovascular function ,20, overIs chronic pain an important mediating factor when evaluating patient response to opioid addiction treatment? Which opioid maintenance therapy is best for improving physical, psychiatric, and substance use behavior outcomes in patients with opioid addiction and chronic pain? We aim to evaluate these questions using evidence gathered from all studies evaluating chronic pain in the opioid addiction patient population. The lack of current summary of evidence evaluating the mediating effects of pain suggests that our current effort to combine the evidence will serve to 1) distinguish the best therapy for opioid addiction patients with comorbid pain and 2) enable clinicians to tailor treatments based on an important and highly prevalent risk factor.We aim to 1) evaluate the impact of comorbid chronic non-cancer pain on all opioid addiction treatment outcomes reported in the literature including treatment retention, illicit substance-use behavior, as well as physical and psychiatric symptoms, 2) determine how different opioid maintenance treatments compare in their effectiveness for patients with comorbid chronic non-cancer pain, 3) provided the data are suitable, combine the evidence from direct and indirect comparisons using network meta-analysis, and 4) identify the most recently published opioid maintenance treatment guidelines from the United States, Canada, and the UK to determine how the evidence is being translated into clinical practice for addiction management.1.1Among patients with opioid addiction being treated with (or randomized to) opioid substitution treatment (OST): 1) does chronic non-cancer pain interfere with the effect of OST, and 2) which OST is best for improving treatment response for patients with comorbid chronic non-cancer pain? We will evaluate response across multiple outcome domains including: substance use behavior, physical health, psychiatric symptoms, as well as personal and social functioning.1.2Do the most recently published United States, Canadian, and United Kingdom OST clinical practice guidelines capture and properly translate the evidence obtained from the studies evaluated in this review?To be included in this review, the study must evaluate the impact of chronic pain on patient’s response to opioid addiction treatment. The study must have provided a comparison of response to treatment outcomes  between patients with and without chronic pain. We also require the studies to have evaluated patients on an OST for opioid addiction. We will not place any restrictions on the types of OST or measurement of chronic pain. All study designs will be accepted into this review, . No restrictions were placed on socioeconomic, geographic, or ethnic backgrounds of participants for this review.To be eligible for inclusion, all studies must be primary , completed , and performed in a human population.The primary outcome in this review is illicit opioid use, which can be measured in various ways including urine toxicology screening or self-report. We anticipate many definitions and measurements of opioid use. For example, some studies measure opioid use behavior as the number of days of opioid use in the last month, while others report the mean number of positive opioid urine screens or days until opioid relapse. We will accept any definition or measurement of illicit opioid use, provided the study performs an analysis comparing opioid use behavior based on patients’ chronic pain status. We will also abstract data on all other efficacy end-points including non-opioid substance abuse, general physical health, psychiatric symptoms, personal and social functioning, intervention adherence , resource utilization  as well as treatment preference. However, short-term outcomes  will not be evaluated.We will perform an electronic search using the Medline, EMBASE, PubMed, PsycINFO, Web of Science, Cochrane Database of Systematic Reviews, ProQuest Dissertations and theses Database, Cochrane Central Register of Controlled Trials (CENTRAL), World Health Organization International Clinical Trials Registry Platform Search Portal, and the National Institutes for Health Clinical Trials Registry. In addition, the reference lists of all Cochrane reviews addressing this topic will be reviewed. We will use the Cochrane reviews to validate our own searches of databases and ensure that we have captured the relevant articles in our field. This supplementary search will be applied to Cochrane reviews since they are considered the gold standard in systematic reviews.We will use a comprehensive search strategy tailored for each database. Please refer to Table Two independent reviewers will screen titles and abstracts and potentially eligible full-text articles using predefined inclusion criteria. Any disagreements or variability between reviewers will be resolved by discussion. If discussion does not lead to a resolution, a third author  will be consulted and have the final judgment over the disputed article. We will calculate and report the kappa statistic for each stage  of screening to display the level of agreement between reviewers.This review will be reported in accordance with the PRISMA guidelines . The revThe two authors (BD and MB) will independently extract data from the studies using a pre-established data extraction form (DEF), which is available upon request. All study information will be recorded onto the DEF and later entered onto an electronic Microsoft Excel sheet. The independent reviewers will extract all eligible studies in duplicate. Similar to the methods for disagreement resolution during the title and abstract screening, the independent reviewers will first discuss the disagreements they have during the data abstraction. When discussion does not lead to a resolution, a third reviewer  will provide the final decision over the disagreement.Information extracted during the data abstraction will include author, date of publication, journal of publication, number of study participants, type of population , eligibility criteria, OST(s), OST dose (by chronic pain status), definition of chronic pain, identification of primary outcome, definition of response outcome(s), measurement of chronic pain, measurement of response outcome(s), percentage/number of participants with chronic pain, statistical analysis performed, study findings, overall statistical findings, factors associated with treatment response (if reported), and author’s conclusions.Two independent reviewers will assess the methodological quality of the studies in duplicate using a modified Newcastle Ottawa scale for case-control and cohort studies , the NIHAll summary estimates obtained from meta-analysis will be subject to evaluation using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines . ProvideThe results of this systematic review will be reported in a narrative and where possible, a combined statistical manner. Agreement levels between the independent reviewers will be measured using the kappa statistic. Provided there is little heterogeneity between studies, we plan to conduct a meta-analysis to derive a summary statistic representing the combined statistical result of multiple studies across our primary outcome (illicit opioid use behavior) and secondary efficacy end-points. As described previously , the lacResearch methodologists highly caution against the pooling of studies with fundamentally different designs, ,32 largeWe will perform a meta-analysis to pool results for our primary outcome as well as all secondary efficacy end-points. Findings abstracted from direct comparisons will be pooled together using a random-effect meta-analysis with Knapp-Hartung (KH) estimator . All anaDichotomous outcome(s) will be combined into a pooled odds ratio, where continuous outcomes  will be pooled using the standardized mean difference. All direct comparisons will be weighted using the inverse of the variance.I2) statistics and P values as the measure of heterogeneity in the results of the studies and whether the actual observed difference can be attributable to chance alone [I2 statistic using the thresholds set forth by the Cochrane Collaboration, these include I2 of 0% to 40% (might not be important), 30% to 60% (moderate heterogeneity), 50% to 90% , and 75% to 100% (considerable heterogeneity) [Results from studies deemed eligible for inclusion into the meta-analysis will be presented in a forest plot, with the associated 95% confidence intervals presented. We will calculate and report the inconsistency index  . The Eggversus self-report) to be important factors accounting for heterogeneity between studies. The methodological quality of individual studies will be captured using the Cochrane Risk of Bias tool, Newcastle Ottawa Scale, and the NIH National Heart, Lung, and Blood Institute: Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Subgroup analyses will stratify on the basis of the study’s performance on the risk of bias assessment. We will stratify our analyses on the basis of Cochrane risk of bias responses, whereby studies will be characterized has having an overall ‘high risk of bias’ if at least one domain on the Cochrane risk of bias tool is rated as high risk. Thus, results of any study with ≥1 ‘high risk of bias’ rating across domains will be considered at risk for confounding. For observational studies, we will need to address risk of bias according to the appropriate assessment tools, thus we will not be able to use Cochrane risk of bias across all studies. For cohort and case-control studies, any study with zero stars in ≥1 section will be considered high risk of bias based on the Newcastle Ottawa Scale. According to the Newcastle Ottawa Scale, receiving stars indicates a lower risk of bias. The lack of stars in any section indicates the study has not addressed a possible source of confounding. For cross-sectional studies rated with the NIH tool, any study receiving a ‘fair’ or overall ‘poor’ quality rating will be classified as high risk of bias and included for subgroup analysis. We anticipate the studies with improper adjustment for important confounding variables to have high susceptibility for confounded treatment effects.We anticipate a study’s scoring on methodological quality assessment as well as differences in measurement selection  database to identify the most recently published guidelines used by the National Health Service in the UK. We will use pilot-tested data abstraction forms to extract data on: the recommendations made by each guideline, the strength of the recommendation, the evidence cited by the guideline for each recommendation, whether the guideline developers interpreted any clinical subgroup effects with caution, and whether the guideline discussed the impact of pain on poor treatment response. We will also quantitatively appraise the quality of the guidelines using the Appraisal of Guidelines for Research & Evaluation II (AGREE) Instrument, a validated tool used for guideline assessment [To identify the most recently published North American guidelines on opioid maintenance treatments, we will search sessment ,41. We wUnderstanding the impact of comorbid disorders on addiction treatment outcomes is essential for enhancing evidence-based practices within the field of mental health and addiction. This investigation will focus on determining the role that chronic non-cancer pain has on the patient’s experience of opioid addiction treatment. Acknowledging the complexity of comorbid pain management within the addiction treatment setting, we aim to understand the extent to which chronic pain is related to negative health outcomes including functional disability, physical difficulty, and mental health problems such as depression and anxiety in the context of opioid addiction . Determi


Sober living houses (SLHs) are peer-managed residences that require sobriety and household participation among residents who rent rooms on a monthly (indefinite) basis and otherwise live normal lives according to personal schedules and needs. The houses do not provide counseling or services, but regular attendance at 12-step or other types of mutual-help groups is generally required. Approximately 1000 sober living houses, members of two state-wide organizations, operate in California to serve a large and complex population. This presentation provides an overview of work conducted to date studying sober living houses in Northern and Southern California.In a study of SLHs in Northern California, 300 residents were followed for 18 months after entry. Our research found that neighbors and key informants  were highly supportive of SLHs. Findings showed resident improvement in a variety of areas, including drug and alcohol use, employment, psychiatric symptoms, and arrests, with improvements that were maintained over the course of the study period. Although residents on parole and probation had substance use reductions that were comparable to voluntary residents, they had far more problems maintaining employment, higher rates of re-arrest and incarceration, and lower attendance to self-help groups. An ongoing randomized clinical trial in Southern California  is currently examining the effectiveness of an intervention to improve access to services and reduce HIV risk among sober living house residents on parole or probation. Residents randomized to the treatment condition receive a Motivational Interviewing Case Management (MICM) intervention specifically targeted to the problems presented for each resident. The list of potential problems that MICM can address is extensive and aims to help in a variety of problem areas inclusive of: 1) adapting to the sober living house environment; 2) complying with parole and probation; 3) finding and maintaining work; 4) successfully accessing and retaining services; 5) addressing HIV risk, testing, and treatment; 6) mobilizing personal and informal resources; and 7) managing setbacks . Study participants are being tracked over a 12-month time period and being assessed on criminal justice, HIV risk, and drug and alcohol outcomes.Sober living houses play an important role in helping individuals in their recovery from substance abuse, and providing additional services in these houses (MICM) to increase access to formal services may further enhance outcomes for high-risk populations.