Animal origin foods are widely distributed and consumed around the world due to their high nutrients availability but may also provide a suitable environment for growth of pathogenic and spoilage microorganisms. Nowadays consumers demand high quality food with an extended shelf life without chemical additives. Edible films and coatings (EFC) added with natural antimicrobials are a promising preservation technology for raw and processed meats because they provide good barrier against spoilage and pathogenic microorganisms. This review gathers updated research reported over the last ten years related to antimicrobial EFC applied to meat and meat products. In addition, the films gas barrier properties contribute to extended shelf life because physicochemical changes, such as color, texture, and moisture, may be significantly minimized. The effectiveness showed by different types of antimicrobial EFC depends on meat source, polymer used, film barrier properties, target microorganism, antimicrobial substance properties, and storage conditions. The perspective of this technology includes tailoring of coating procedures to meet industry requirements and shelf life increase of meat and meat products to ensure quality and safety without changes in sensory characteristics. Animal origin foods (AOF) constitute a good nutrients source for human diet, where their protein provides high biological value and essential amino acids which complement the quality of cereals and other vegetable proteins . HoweverEdible coatings are food grade suspensions which may be delivered by spraying, spreading, or dipping, which upon drying form a clear thin layer over the food surface. Coatings are a particular form of films directly applied to the surface of materials and are regarded as part of the final product . On the The use of films in foods dates back to the 12th century in China where waxes were used to coat citric fruits to retard water loss, whereas the first edible film used for food preservation was made in the 15th century from soymilk (Yuba) in Japan. In England lard or fats were used as coating to prolong shelf life of meat products in the 16th century and in Europe; this process was known as “larding” . In the Edible films and coatings (EFC) are an alternative to extend the shelf life of AOF by acting as barriers to water vapor, oxygen, and carbon dioxide and as carriers of substances to inhibit pathogenic and spoilage microorganisms. Natural antimicrobial agents may be incorporated into the corresponding suspensions, adding functionality to edible films and coatings, leading to the antimicrobial edible films and coatings (AEFC) obtaining.There is increased interest in development and use of AEFC to preserve meat quality for longer shelf life periods while maintaining food safety, which is based on consumers demand for natural and safe products. Industry is concerned about these issues, while keeping competitive production costs . Other kDue to similar properties of edible films and coatings this review discusses characteristics of both types of coverings applied to meat products. This work focuses on a critical discussion of issues raised by recent research findings on the effectiveness of antimicrobial films and coatings and their potential application to enhance safety and quality of meat products.Meat (including poultry and fish) is the first-choice source of animal protein for many people all over the world . AccordiNutritionally, meat importance is derived from its high quality protein containing all essential amino acids and its highly bioavailable minerals and vitamins . In 2010Meat quality is highly dependent on preslaughter handling of livestock and postslaughter handling of meat . Among tThere are three mechanisms involved in meat and meat products deterioration during processing and storage: microbial spoilage, lipid oxidation, and enzymatic autolysis. Microbial population may arrive from native microflora of the intestinal tract and skin of the animals or through environmental, human, handling, and storage conditions associated to the production chain . MicrobiMeat products outbreaks are often due to inadequate cooking or cross-contamination from other foods. However, contamination may occur while meat is processed, cut, packaged, transported, sold, or handled. Pathogenic microorganisms do not survive thorough meat cooking, but several of their toxins and spores do . Salmonella spp., Listeria spp., Clostridium spp., and Staphylococcus spp. [ Salmonella was the main pathogen involved [ Listeria infection is often considered as the most lethal; for instance, in 1998 hot dogs consumption caused 21 deaths and >100 illnesses [ Salmonella typhimurium was linked to the consumption of ground beef which caused hospitalization of seven people [Red meat is frequently involved in outbreaks, mainly due to the presence ofcus spp. . Most ouinvolved . Listerillnesses . Recentl Salmonella and Campylobacter account for most of the cases of food poisoning associated with chicken [ Clostridium perfringens caused 135 illnesses in Kansas (USA), whereas in 2011 ground turkey contaminated with Salmonella Heidelberg infected 136 people in 34 USA states [In the case of poultry chicken , 20. In  Vibrio parahaemolyticus and V. cholerae in raw oysters have been reported; additionally Clostridium botulinum, Staphylococcus aureus, Salmonella enterica, and Escherichia coli were also involved in illnesses due to fish consumption [Most outbreaks caused by fish and fish products are caused by natural toxins (scombrotoxin and ciguatoxin), rather than by bacteria or viruses. However, outbreaks caused mainly bysumption , 21.™, which contains spices and bilayer protein films that are used to enhance ham glaze and Coffi™, that is made from collagen nettings used to wrap boneless meat products [EFC act as barrier between food and the surrounding environment to enhance the quality of food products protecting them from physical, chemical, and biological deterioration. Design and application of EFC on meat products arises from the search of new preservation methods, the need to add value to by-products from renewable sources, the desire to give food products a more natural or ecological image, and reduction of environmental impact of using oil-derived plastic packaging materials . Additioproducts . Antimicproducts , 25.A wide range of hydrophobic compounds has been used to produce EFC, including animal and vegetable oils and fats , waxes , natural resins , essential oils and extracts , and emulsifiers and surface active agents  . In meatPalmitoylated alginate is the only lipid-containing material of AEFC recently reported to wrap beef muscle and ground beef  Table 1Table 1. Film-forming proteins are derived from animals  or plant sources . Protein-based films adhere well to the meat hydrophilic surfaces and provide barrier for oxygen and carbon dioxide but do not resist water diffusion . Plastic2 and CO2 and resistance to fats and oils [Polysaccharide coatings are generally poor moisture barriers, but they have selective permeability to Oand oils . Polysacand oils , 44, 45.and oils .Materials recently used to obtain AEFC in meat and meat products, poultry, and fish and fish products are shown in column 2 of Tables Incorporation of antimicrobial compounds into EFC as an alternative to their direct application onto the meat surface has the advantage of gradual release of the antimicrobial compound from the AEFC leading to a reduction of added antimicrobial and to reduced sensory changes. Antimicrobial compounds within AEFC are less exposed to interaction with meat surface components than those added directly to the surface and thus maintaining their activity –68.Antimicrobial agents recently incorporated in AEFC for meat and meat products, poultry, and fish and fish products are shown in column 3 of Tables The characteristics and mode of action of most common antimicrobials used to promote meat safety are described below. p-aminobenzoic acid [ L. monocytogenes and 5 log CFU/g S. typhimurium after 28 d of storage at 4°C [ L. monocytogenes after 14 d at 4°C, when used to coat chicken breast [2 of this pathogen when roasted turkey was stored at 4°C for 8 weeks [The antimicrobial effect of organic acids depends on concentration of undissociated form, which can penetrate the bacterial cell membrane. Inside the cell, their dissociation leads to interference with membrane transport and disruption of proton motive force . Organicoic acid . WPI coae at 4°C   films and tested for its diffusivity and antimicrobial effect on salmon slices  and alsoβ-(1-4)-linked D-glucosamine and N-acetyl-D-glucosamine. Chitosan is believed to chelate certain ions from the lipopolysaccharide (LPS) layer of the outer membrane of bacteria or to exhibit electrostatic interactions among its NH3+ groups and the negative charges of microbial cell membrane. In both cases cell permeability increases releasing key cellular components of bacteria. The antimicrobial action of chitosan is influenced by type of chitosan, degree of polymerization, and environmental conditions. Chitosan coatings act as barrier against oxygen transfer leading to growth inhibition of aerobic bacteria [ L. monocytogenes population in sliced turkey deli meat [Chitosan is a linear polysaccharide composed of randomly distributed bacteria . In addibacteria  and as feli meat   is a food-grade cationic surfactant that is highly active against a wide range of food pathogens and spoilage microorganisms including bacteria, yeasts, and molds. It is obtained through the reaction of L-arginine, hydrochloric acid, ethanol, thionyl chloride, sodium hydroxide, lauryl chloride, and deionized water . LAE affll cases , 47 (TabAntimicrobial agents recently incorporated in AEFC for meat and meat products, poultry, and fish and fish products are shown in column 3 of Tables Few reports have considered the migration extent of antimicrobial agents from edible films to the food surface. A study showed the effect of film thickness, solution pH, and temperature on nisin migration from an active WPI edible film to an aqueous solution. Results indicated that nisin is able to migrate from the film where diffusivity increased at lower pH and thickness, while it increased at higher temperatures . Sorbic Antimicrobial packaging can be a promising tool for protecting meat from pathogens contamination by preventing microbial growth by direct contact of the package with its surface. The gradual release of an antimicrobial substance from a packaging film to the food surface for extended period of time may be more advantageous than incorporating the antimicrobial into foods .Studies using chitosan films incorporated in meat products demonstrated that lipid oxidation is reduced, suggesting that it may be due to the antioxidant activity of chitosan , as wellPotential benefits of using AEFC for the meat industry are prevention of moisture loss, avoiding texture, flavor, and color changes, producing a significant economic impact by increasing saleable weight of products. Other advantages include reduction of dripping enhancing products presentation and reduced use of absorbent pads at the bottom of trays. Low oxygen permeability leads to decreased lipids oxidation and brown color-causing myoglobin oxidation, reduced load of spoilage and pathogenic microorganisms, and partial inactivation of deteriorative proteolytic enzymes at the surface of coated meat. Volatile flavor loss and foreign odors pick-up by meat, poultry, or seafood could be restricted by using edible films and coatings and incorporation of additives such as antimicrobial agents can be used for direct treatment of meat surface. There are, however, some factors that may represent disadvantages of using AEFC; there is wide diversity of meat products whose characteristics may vary making it difficult to standardize a single application procedure. Composition and properties of AEFC will provide different functionality and may affect scaling up of application methods for coatings.Selection of the appropriate AEFC for a specific meat product will depend on its nature, characteristics, specific needs, costs, and benefits that this technology can offer to the manufacturers and the consumer. Thus, more research is needed to improve production and application processes of AEFC intended for the meat industry to be economically feasible and appropriate for each product.The application and effects of AEFC of different nature have been investigated in several AOF. Effectiveness shown by each one depends on meat source, polymer used, film barrier properties, target microorganism, antimicrobial substance, and conditions of storage among others. EFC are a good alternative to improve the quality and safety of food and also to add value to food industry by-products. However, some challenges remain such as the need to improve and standardize coating procedures according to industry requirements aiming to reduce costs and increase shelf life to meet consumer demands without altering sensory characteristics of meat and meat products.


Epilepsy, a complex spectrum of disorders, merits enhanced public health action. In 2012, the Institute of Medicine (IOM) released a seminal report on the public health dimensions of the epilepsies, recommending actions in 7 domains. The report urged a more integrated and coordinated national approach for care centering on the whole patient, including heightened attention to comorbidities and quality of life; more timely referral and access to treatments; and improved community resources, education, stakeholder collaboration, and public communication. The US Department of Health and Human Services responded to this report by accelerating and integrating ongoing initiatives and beginning new ones. This article summarizes recent federally supported activities promoting an integrated public health approach for epilepsy, highlighting progress in response to the landmark 2012 IOM report and identifying opportunities for continued public health action. Epilepsy Across the Spectrum: Promoting Health and Understanding  and nonprofit organizations in Vision 20–20 (a group of epilepsy stakeholder organizations), joined together in 2010 to commission the first epilepsy report from the IOM. After receiving input through public meetings across the country and from health professional boards and associations, the IOM created a roadmap for the future. In March 2012, the IOM unveiled its seminal publication The report emphasized that epilepsy is a common spectrum of disorders that affects not only health but also quality of life for people of all ages; that a more coordinated approach is needed for care centering on the whole patient; that although effective treatments are available, timely referral and access to treatments fall short; and that it is an area filled with complexity and stigma. To address these and other challenges, the IOM recommended actions for a wide range of stakeholders in 7 domains  2)..2).For HHS, the IOM report served as a catalyst for accelerating projects under way, launching new ones, and integrating departmental efforts ,7. In 2 The IOM report urged validation and implementation of standard definitions and criteria throughout all aspects of epilepsy care, treatment, and prevention as well as expansion of data collection and surveillance efforts.The National Institute of Neurologic Disorders and Stroke (NINDS) recently led the Common Data Element Project, which now standardizes the collection of epilepsy data by using common definitions and terminology throughout the National Institutes of Health (NIH) and for researchers nationwide. This standardized format should lead to common documentation, allow incorporation of epilepsy into clinical research on related conditions , and facilitate data collection. Dissemination of this resource may foster universal adoption by epilepsy researchers and help them to reduce study start-up time, improve data quality, and promote data sharing across clinical research studies .The IOM report stimulated new Centers for Disease Control and Prevention (CDC) efforts to clarify the burden of epilepsy in the United States. After the 2012 IOM report release, the CDC epilepsy program published updated figures on national prevalence (for the first time since 1994) using data from the 2010 National Health Interview Survey (NHIS), the flagship HHS survey that assesses some 42,000 households annually   .International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) codes  in a statewide administrative database that captures data on 2 million patient encounters for about 409,000 people with epilepsy (2000–2011). Using these data, a 2014 study found that about 57% of people with epilepsy (and only about 28% of controls) had both somatic and psychiatric/neurodevelopmental comorbidities  estimates of the burden of epilepsy ,12,13. FBy urging broader attention to documentation of epilepsy comorbidities, the IOM report supports the HHS Strategic Framework for Multiple Chronic Conditions, which emphasizes a patient-centered approach to care coordination . In thisCDC also incorporated examination of epilepsy as a co-occurring condition into its existing cerebral palsy surveillance activities. Since its 2006 surveillance year, CDC has used its Autism and Developmental Disabilities Monitoring (ADDM) Network to track the co-occurrence of epilepsy among 8-year-old children with cerebral palsy in 4 US communities; 35% in 2006 and 41% in 2008 had co-occurring epilepsy ,18. The Despite overall mortality rates among people with epilepsy 3 times higher than rates among people in the general population and sudden death risk 20 times higher . RegistrAlso, to expand surveillance of epilepsy-associated mortality, CDC is examining the National Vital Statistics System’s all-cause mortality files to identify possible cases of SUDEP among adults and also analyzing the National Violent Death Reporting System to clarify the rates of suicide among people with epilepsy.2014 Benchmarks for Epilepsy Research to encourage fuller exploration of the relationship of comorbidities with epilepsy and seizures, underlying disease mechanisms, and effects of epilepsy treatment  joins NIH agencies, Vision 20–20, IOM, and key epilepsy stakeholder organizations, such as Citizens United for Research in Epilepsy (CURE), to promote research. Established several years ago, ICARE now uses the IOM report recommendations as a framework for its meetings, which bring more research attention to conditions beyond seizures that commonly affect epilepsy patients . In support of these efforts, NINDS has updated reatment .NIH recently established the NIH NeuroBioBank, which coordinates human brain and tissue repositories. The NeuroBioBank website provides information about the donation process and about how postmortem tissue research can advance knowledge about brain disorders . PresideNIH-funded research could lead to improved prevention by identifying biomarkers of epileptogenesis in populations at risk (including those with tuberous sclerosis complex and traumatic brain injury and children with prolonged febrile seizures). The Epi4K multisite international collaboration funded by NINDS, which analyzes the genomes of more than 4,000 individuals with epilepsy and their families, recently identified new gene mutations associated with infantile spasms and Lennox–Gastaut syndrome , 2 severThe IOM report calls attention to epilepsy self-management , a themehttp://www.webease.org). Project UPLIFT (Using Practice and Learning to Increase Favorable Thoughts) and PEARLS (Program to Encourage Active Rewarding Lives) offer treatment for depression in adults with epilepsy, delivered by telephone, Internet, or home visits  . WebEasee visits ,31. UPLIe visits . Other MSince the IOM report release, CDC has expanded its MEW Network from 4 to 6 university-based sites to evaluate self-management programs for adults with epilepsy and memory problems, adults with epilepsy and serious mental illness , and adults with epilepsy who live in rural areas. A request for proposals issued in March 2014 supports replication studies and cost-effectiveness studies of MEW Network programs and the development of new self-management programs in vulnerable groups .In the realm of devices and drugs for possible secondary and tertiary prevention, the Food and Drug Administration (FDA) announced in 2013 approval of a cranially implanted neurostimulator, which reduces seizure frequency (in people aged ≥18 years) with partial onset seizures refractory to 2 or more antiepileptic medications . FDA alsAlthough effective treatments are available for some people with epilepsy, too many lack access to specialist care, insurance coverage, care coordination, and quality care and treatment. The IOM report recommends earlier identification of epilepsy and its comorbidities, greater focus on quality of care, stronger epilepsy networks including epilepsy centers, and enhanced professional education.Healthy People 2020 now includes as a national goal to increase the proportion of people with epilepsy and uncontrolled seizures  who receive appropriate care  from a baseline of 57.7% (in 2010) to 63.5% (in 2020)  .The ACA in 2020) . Young aAdditionally, the provision of mental health coverage as part of essential health benefits made available through the ACA could also improve care for the large numbers of people with epilepsy and comorbid mental illness .The ACA authorizes demonstration projects to promote care coordination and team-based approaches to care delivery. In this spirit, the Health Resources and Services Administration’s (HRSA’s) Maternal and Child Health Bureau funds Project Access, which focuses on improving access to coordinated, comprehensive care for children and teens with epilepsy in medically underserved and rural areas. Consistent with IOM recommendations, these state and community-based demonstration projects, supported by a coordinating center at the American Academy of Pediatrics, promote patient/family–professional partnerships; link primary and specialty care, educational services, public health, and other community resources; focus on early detection and treatment; and address cultural and linguistic barriers to care.In its third round of funding in 2013, Project Access commits to quality measurement and the use of quality improvement methods  to implement and validate a well-functioning community-based system of services for children and teens with special health care needs . As partExpanding the evidence base on quality and documenting possible cost savings could lead to new payment models. As part of the ACA, the Centers for Medicare & Medicaid Services (CMS) enhanced support for care coordination in numerous areas. Also, a recent change in Medicaid rules allows for reimbursement for preventive services by qualified professionals established by the state if the service is recommended by a physician or other licensed practitioner . States The University Centers for Excellence in Developmental Disabilities (UCEDDs) , a natioSome Project Access grantees and UCEDDs are using telemedicine and telehealth as a way to extend access to quality care and improve outcomes in rural and underserved areas. Telemedicine can overcome the physical distance between the care site and the health care expert to connect patients and their families, primary care practitioners, and epilepsy specialists in a patient-centered medical home, enhance real-time monitoring of test results and scans, and deliver health professional education. Early data from West Virginia, Michigan, and Nebraska indicate reduced wait times for neurology visits and less time and money spent by families traveling to specialist visits. In particular, the Nebraska UCEDD, as a Project Access grantee, was preliminarily able to reduce the wait time for telehealth consultation appointments for children; more formal evaluation of this program is needed. Also, the IOM report has spurred regional planning, including telecommunication technology options, in the 4-state region of Kansas, Nebraska, Iowa, and Missouri, which has almost 14 million people but only a few epileptologists.Professional education can involve many types of providers, including primary care providers, school nurses, first responders, and law-enforcement personnel. These professionals can be trained to provide appropriate care and help link people with epilepsy to community supports. For example, the CDC-supported Epilepsy Foundation program, Managing Students with Seizures, trains school nurses about epilepsy and the needs of students with epilepsy. An evaluation of this program demonstrated increased confidence among nurses across numerous domains  . AnotherSimilarly, CDC-supported law-enforcement training programs aim to improve recognition of seizures and awareness of the unique needs of people with epilepsy who may otherwise be subjected to physical restraint and be taken into police custody. Other CDC-supported training programs in local communities focus on child day care staff, adult day care staff, and middle- and high-school students and teachers. Initial evaluation results from these educational programs are promising, but additional studies are needed .Beyond seizures, the impact of epilepsy involves challenges in schools, uncertainties about social and employment situations, limitations on driving, and questions about independent living. To address these needs, the IOM report urges improving community resources and improving education for people with epilepsy, their families, and the public.The CDC MEW Network provides free webinars and podcasts to patients, their caregivers, and health and social service providers about the benefits of epilepsy self-management. Since 2012, CDC has also supported provider training for UPLIFT (at no cost) and PEARLS with professional certification credits.CDC continues to partner with the Epilepsy Foundation to conduct public education and awareness campaigns . AlthougEpilepsy Foundation outreach campaigns that previously focused on African Americans and Hispanic Americans were extended in 2013 to Asian Americans. With combined English- and Chinese-language media in targeted US markets , the foundation’s Asian American outreach campaign reached almost an estimated 3 million people . More formal evaluation is needed.The last 2 domains from the IOM report highlight the critical roles of epilepsy stakeholders — including people with epilepsy and their families — in fostering and sustaining public health action , and potThe 21st century is the time for a more integrated public health approach to epilepsy. People with epilepsy need better coordinated care, social support, and treatments and greater social acceptance. The convergence of HHS and nonfederal partner interest has not only yielded a major public health roadmap through the 2012 IOM report but also accelerated the integration of activities through HHS agencies and nongovernmental partners.Healthy People 2020 process, which can monitor progress for the future.Implementation of the IOM report recommendations stimulated activities to improve understanding of the burden of epilepsy, establish new surveillance systems for SUDEP, renew attention to comorbidities, accelerate new models for care coordination in the era of the ACA, explore improved outreach through telehealth, increase emphasis on improved access and quality of care, heighten collaboration on research for better prevention, and improve public and professional education for an array of stakeholders. Moreover, the country established targets for epilepsy as part of its Although the challenges ahead are considerable, these and future activities, in close collaboration with community-based partners and others, can bring renewed understanding of epilepsy as a public health priority. Continued commitment and momentum can move the country closer to a true integrated public health system for epilepsy for the 21st century.


Biomedicine is undergoing a revolution driven by high throughput and connective computing that is transforming medical research and practice. Using oncology as an example, the speed and capacity of genomic sequencing technologies is advancing the utility of individual genetic profiles for anticipating risk and targeting therapeutics. The goal is to enable an era of “P4” medicine that will become increasingly more predictive, personalized, preemptive, and participative over time. This vision hinges on leveraging potentially innovative and disruptive technologies in medicine to accelerate discovery and to reorient clinical practice for patient-centered care. Based on a panel discussion at the Medicine 2.0 conference in Boston with representatives from the National Cancer Institute, Moffitt Cancer Center, and Stanford University School of Medicine, this paper explores how emerging sociotechnical frameworks, informatics platforms, and health-related policy can be used to encourage data liquidity and innovation. This builds on the Institute of Medicine’s vision for a “rapid learning health care system” to enable an open source, population-based approach to cancer prevention and control. Biomedicine is undergoing a revolution driven by innovation in high throughput and connective computing ,2, big dpredictive profiles of risk, preventive clinical and wellness systems, personalized medicine, and participative research and practice, proponents of P4 medicine extend its purview beyond genomics to include multiple data vectors such as longitudinal molecular, cellular, and phenotypic data for predicting disease progression and targeting intervention [The growing speed and capacity of genomic sequencing technologies are advancing the utility of individual genetic profiles for anticipating risk and targeting therapeutics for cancer . Combinirvention . Thus, PP4 medicine can be viewed in conjunction with the Institute of Medicine’s (IOM) concept of a learning health system, which simultaneously links effective, efficient clinical health care to the biomedical research enterprise . As presBoth of these innovative approaches to health research and practice—P4 medicine and the learning health system—require robust technology infrastructure and data liquidity to realize the ambitious aim of transforming biomedicine for cancer and other diseases. Moreover, in presenting the rapid learning health system framework for cancer research and practice, members of the National Cancer Policy Forum’s planning committee identified five challenges to developing a learning health system for cancer that are also directly relevant to the realization of P4 medicine: (1) data collection , (2) incentivizing data-sharing, (3) data standards, harmonization, and computation, (4) meaningful use of health IT, and (5) the central role of government entities such as the National Institutes of Health (NIH), the Food and Drug Administration, and the Centers for Medicare and Medicaid Services .One example of a rapid learning health care system that is currently being implemented for oncology is the American Society of Clinical Oncology’s Cancer Learning Intelligence Network for Quality (CancerLinQ) system . CancerLth P standing for a population perspective is needed to realize the full potential of P4 medicine [Adding both promise and complexity to the previously described frameworks of modern care, proponents of the public health sciences assert that a 5medicine . LimitedPredictive: Predicting health using systems biologic and phenotypic information augmented with the ecological model of health to account for multilevel determinants of health and life-course approaches.Preventive: Early disease detection and prevention also incorporate population screening principles to assess benefits, harm, and costs of primary prevention.Personalized: Targeted therapeutics and diagnostics enhanced by principles of evidence-based medicine using formal analytic frameworks for comparative effectiveness.Participatory: Engaging patients, providers, and systems including the public health enterprise .In addition to the rapid learning health system approach, which incorporates notions of translational, comparative effectiveness and health services research, adding a population focus to P4 medicine explicitly addresses broader, structural issues such as costs and potential for harm that result in greater social, economic, and health disparities. Population science also helps focus on the need for enhanced population level interventions  in addition to individual level interventions to improve health and prevent disease .One innovative example of an effort incorporating a P5 approach to cancer biomedicine can be found in the Moffitt Cancer Center’s Total Cancer Care (TCC) proposal for a new federated model for research and health care . Based oScaling the biomedical research enterprise to tackle cancer and other diseases with unknown therapeutics and unclear diagnostics will require recruiting new communities of investigators such as those in engineering and computational disciplines, often earlier in their careers. In addition to exploring new models of cancer research and practice, the Medicine 2.0 conference panel also delved into how big data, emerging technologies, and commoditized access to sophisticated wet lab tools and computational methods can spark scientific innovation in basic and applied research. Individuals have greater access to potentially disruptive technologies in medicine to accelerate basic discovery science and reorient clinical practice for patient-centered care. Publically available molecular measurements can be used to discover novel biomarkers of disease  and can On a policy level, examples such as the federal Open Government Initiative, the America COMPETES Act, and NIH requirements for data sharing in grant proposals, combined with public and private sector initiatives by donors, journals, and foundations, have led to unprecedented amounts of data being available for secondary research. Two examples include the Data.gov platform, which enables public access to “nearly 450,000 datasets…across 172 federal agencies” , and theIn addition to greater availability of data, public and private entities are leveraging prize and challenge mechanisms to accelerate innovation with health-related data. Biomedically related open innovation challenges such as these often involve the release of data first, with the expectation that the “winner” of the challenge is awarded a prize. This is the reverse of the typical grant funding mechanism, with money given first, potentially followed by results . In the In many respects, cancer is the prototypical workspace for applying new models of scientific discovery and medical practice. The story of cancer is a story of how the body’s complex coding systems go awry through the creation of self-perpetuating errors in cellular replication and growth. Fortunately, advances in genetic sequencing technologies, high throughput data architectures, massively networked public and scientific communities, and the wide availability of sophisticated wet lab tools may be sparking the innovation in “open source” science needed to accelerate progress against the disease. As one panel member put it, “individuals in garages and dorm rooms have greater access to potentially disruptive technologies in medicine than the most well-resourced scientists of the last decade.” This exciting era of distributed and open source science holds great potential for accelerating basic discovery and reorienting clinical practice for patient-centered care and population health.


Spanish Rare Diseases Registries Research Network (SpainRDR) is a project aimed to build the National Rare Diseases Registry in Spain based on the input of two different methods: patient outcome research registries and population-based registries. The project has been approved within the IRDiRC framework and is co-funded by the Institute of Health Carlos III (ISCIII), the Health Departments of the Autonomous Communities (regions) and the Spanish Ministry of Health, Social Services and Equity (MSSSI) of Spain. The project addresses one of the main recommendations of the National Rare Diseases Strategy and also collaborates with some other RD registering actions like GRDR-NIH, RD-CONNECT and EPIRARE.The With the unprecedented collaboration and support of medical societies, researcher networks, patient organizations, pharma industry and health policy makers, SpainRDR is running an effective and necessary way to develop knowledge and raise awareness of the rare diseases burden, which will contribute to design the provision of health and social services as well as the improvement of diagnosis, prognosis, treatment and quality life of patients and families affected by RD.The project is leading by the Institute of Rare Diseases research  and it is organised in six work packages: WP1 Coordination and Management, WP2 Registering activity related methods, WP3 Data analysis and outcomes research, WP4 Quality Assessment and ELSI issues, WP5 Dissemination and impact, and WP6 Patient registries.A Manual of Procedures including a quality assurance plan, common data elements, coding and classifications criteria, standard operating procedures, ELSI rules, statistical analysis methods and the official website network are actions already carried out or being finalized.Specific CDE have been also consolidated for those patient registries already implemented at the central RDR repository . At the same time, some other patient registries' CDE´s are currently being developed, such asCongenital Suprarenal Hyperplasia and Bradykinin linked angioedema. We are preparing also CDEs for cystinosis and congenital anaemia.After the necessary pilot study developed during 2013, we are now collecting prevalence cases from 2012-2012 and the first preliminary results are already available using specific applications designed by SpainRDR.


Dolphin Morbillivirus (DMV) epidemic which occurred between 1990 and 1992 was particularly dramatic for Western Mediterranean striped dolphins . This was followed by a second outbreak that simultaneously involved, between 2006 and 2008, long-finned pilot whales  and striped dolphins from the same area. Two additional “unusual mortality events” (UMEs), mostly affecting the Western Mediterranean striped dolphins' population, were reported in 2010–2011 along the Spanish coastline and during the first half of 2013 along the Tyrrhenian coast of Italy, respectively -related UMEs which mainly affected, between 1982 and 2014, wild bottlenose dolphins (Tursiops truncatus) from the USA and Mexico (1994 UME) Atlantic seaboards  and sperm whales  stranded along the Italian coastline  hosted by an aquatic park near Rome  strain, named Beaked Whale Morbillivirus (BWMV) and quite distantly related to DMV, has been recently characterized from 15 individuals belonging to 12 different cetacean species stranded in Hawaii between 1997 and 2014 , in a Blainville's beaked whale (Mesoplodon densirostris) and in a newborn, Brucella spp. and Morbillivirus-coinfected, sperm whale from Hawaiian Islands , to which GD, AF and SM have also contributed in a substantial manner. Furthermore, AF and SM have carefully reviewed, thereby integrating it, the initial Commentary's draft, written by GD, with the last version of the manuscript having been fully agreed by the three authors.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.


Global Health: Science and Practice supplement presents lessons learned, research findings on demand creation, and cost comparisons of various models of EIMC introduction.Introducing early infant male circumcision (EIMC) can sustain voluntary medical male circumcision (VMMC) programs. This  Global Health: Science and Practice supplement presents lessons learned, research findings on demand creation, and cost comparisons of various models of EIMC introduction.Introducing early infant male circumcision (EIMC) can sustain voluntary medical male circumcision (VMMC) programs. This  VMMC, which reduces the risk of heterosexually acquired HIV infection in men by approximately 60%,The main thrust of VMMC programs has been to circumcise men ages 15 to 49 years to reduce their risk of HIV infection. Scaling up VMMC to reach the target of 80% coverage among men ages 15 to 49 years in the 13 countries would mean that approximately 20 million circumcisions would need to have been performed by the end of 2015. This would have averted 3.4 million new HIV infections over 15 years, 22% of the total projected infections.The 2007 WHO–UNAIDS Joint Strategic Action Framework lays the foundation of a two-phase approach to scaling up VMMC: the catch-up phase that focuses on reaching at least 80% of VMMC prevalence among 15- to 49-year-old men and the sustainability phase.In the first sustainability scenario, the country maintains high circumcision coverage among the adolescent population (ages 10 to 19 years) and does not introduce EIMC. The second scenario is to scale up EIMC while maintaining high coverage among adolescents, and when 80% of the cohort of circumcised infants reaches 10 to 14 years of age, the focus shifts entirely to EIMC. The third scenario is to introduce EIMC but continue circumcision of both adolescents and infants indefinitely. EIMC has several advantages over adolescent and adult VMMC: it costs less, the surgery heals more quickly and has less risk of adverse events, and it can be integrated into routine maternal, newborn, and child health platforms.Three sustainability scenarios have been identified depending on whether a country introduces and scales up early infant male circumcision.Integrating a one-time surgical intervention with long-term benefits into routine health care packages is not straightforward. Although interventions for both the mother and infant delivered at the same time in the same place by the same health care provider or team save more lives and improve health outcomes of mothers and infants better than providing services separately, there are many policy, programmatic, and logistical issues to consider.Integrating a one-time surgical intervention with long-term benefits such as EIMC into routine health care packages is not straightforward.Every Newborn action plan was developed in response to country demand, and based on the latest epidemiology and evidence, it outlines specific actions to improve access to and improve the quality of health care for women and newborns within the continuum of care.The Global Health: Science and Practice, sponsored by the United Nations Children’s Fund (UNICEF) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), brings together several articles on EIMC, including reviews that highlight lessons learned and challenges of providing circumcision services to young male infants; formative research findings on the perceptions of parents, providers, and other stakeholders to inform demand creation for EIMC; and cost comparisons of alternative service delivery models as a result of task shifting and integration into newborn care. The supplement also includes a commentary on an important consideration for successful and sustainable national EIMC programs: service delivery through maternal, newborn, and child health service platforms.This supplement to Fast-Track strategy. VMMC is a proven, effective prevention approach and a component of combination prevention packages. This supplement provides country experiences on scaling up as well as options for sustaining efforts in VMMC and their cost benefits.Prevention is a cornerstone of the momentum toward ending AIDS by 2030, following the UNAIDS


The purpose of this study is to investigate healthcare access disparity that will cause delayed and unmet healthcare needs for the elderly, and to examine health inequality and healthcare cost burden for the elderly. To produce clear policy applications, this study adapts a modified PRECEDE-PROCEED model for framing theoretical and experimental approaches. Data were collected from a large collection of the Community Tracking Study Household Survey 2003–2004 of the USA. Reliability and construct validity are examined for internal consistency and estimation of disparity and inequality are analyzed by using probit/ols regressions. The results show that predisposing factors  are negatively associated with delayed healthcare. A 10% increase in enabling factors  are significantly associated with a 1% increase in healthcare financing factors. In addition, information through a socio-economic network and support system has a 5% impact on an access disparity. Income, health status, and health inequality are exogenously determined. Designing and implementing easy healthcare accessibility  and healthcare financing methods, and developing a socio-economic support network  are essential in reducing delayed healthcare and health inequality. The number of uninsured population in the United States with access to healthcare services at reasonable costs has been a social and economic problem for their access to healthcare services with reasonable cost. Insufficient insurance coverage, rising healthcare cost and widening disparity in access to healthcare services have adversely affected the elderly population ,2,3,4. TDisparity in access to healthcare services, under the mixed private and public US healthcare programs, elevates inequality of health and health status among Americans ,6. Healtet al. [Various research literature supports that access disparities lead to unmet healthcare needs ,9,10,11.A focus of healthcare financing characteristics with the sample age groups reveals differences in Medicaid, Medicare, private insurance, and those uninsured. As healthcare costs rises, more of the increasing costs are transferred to certain disadvantaged populations, and patients would have to spend a considerable share of their healthcare costs out-of-pocket. Access disparity for unmet needs and delayed care is relatively complex health policy measures. Studies may convincingly engage with defined measures using concepts from a behavioral model. A study would require a comprehensive analysis of the interfaces and interactions in the nexus of financial characteristics, cognitive aspects, disparity, and inequality.i.e., unmet needs and delayed healthcare services after retirement. Delay in healthcare services is related to compliance with illness treatment, and unique preventive healthcare needs to avoid further health complications. A major goal of the behavioral model is to understand the characteristics of an individual’s access to healthcare. Second, research conducted in this study will offer insight into different health insurance coverage regarding financing aspects: income, out-of-pocket medical costs, Medicare and Medicaid. Furthermore, health insurance includes managed care (HMO) and supplementary Medicare insurance. The public and private health insurance implications are essential to improve the health of the population. Third, this study underscores an improvement in patient trust, patient satisfaction, and effective communication with healthcare providers. In addition, it will lead to a healthier population and decrease unmet needs and delayed care. This will improve the efficiency of delivering healthcare. Clearly this notion is what underlies the broad public uneasiness concerning the health of the population, such as the quality of life as indicated by the absence of access disparity, and also restrain in the rise of medical expenditures under the current complex healthcare system in the United States.In order to fill the gap of precise health financial characteristics with individual behaviors, this study employs three dimensions of behavioral measures in addition to socio-demographic factors with different cognitive influences. The three behavioral measures are enabling, predisposing, and reinforcing factors, which are used to determine the influence of health insurance and different cognitive characteristics on unmet needs and delayed healthcare for individuals sixty-five years or older with Medicare. There are three main objectives for this study. First is to shed light on the effects of behavioral characteristics on accessibility of healthcare services, Medicare benefits consist of two parts: hospital insurance plan, Part A and physician insurance plan, Part B. A person with hospital insurance protection (Part A) may have benefits paid on his/her behalf or, in certain cases, paid to him/her for covered healthcare services. Part B adds additional protection by providing a basic hospital insurance plan and covering a substantial part of physician services in both hospital and nonhospital settings that include an emergency room or outpatient clinic, including same-day surgery, ambulance services, and clinical laboratory. Parts A and B are provided automatically to a person aged 65 or over who is entitled to Social Security Retirement Benefits. The Medicare Part A is financed primarily through a mandatory payroll deduction. Part B is financed through premium payments and contributions from the general fund of the U.S. Treasury.Beginning in 2006, an additional plan, Part D, has provided subsidized access to prescription drugs insurance coverage. Part D is financed primarily through premium payments and contributions from the Treasury general fund. Part D works differently from Medicare Part A and Part B, beginning with the fact that Part D is an optional plan. However, those eligible need to choose among plans offered by health insurance providers or other companies approved by Medicare. Any person who enrolls in either Medicare Part A or Medicare Part B is eligible to enroll in a Medicare Part D part. If qualified individuals do not enroll in a plan when they first become eligible for Medicare, they might be subject to a Medicare-imposed late enrollment penalty.There are many types of private health insurance coverage that the elderly can purchase in order to fill the gaps that are not covered by Medicare. These types of private health insurance/coverage include: employee or retiree coverage from employers and Medigap insurance from private insurance companies. The supplemental insurance pays for parts or all of healthcare costs . These tImproving health status is the central objective of policies designed in the United States today, as emphasized in Healthy People 2020. One of the growing debates in health policy and strategy wages over how to eliminate health disparities . PolicymHealthy People 2020 defines health disparity as the unequal burden in disease, morbidity and mortality rates experienced by socioeconomic status, race, national origin, and language as compared to the dominant group. There are many reasons for health disparities in the United States. These include lack of access to affordable health insurance coverage, barriers to enrollment in public programs, and patient-provider relation. In addition low health literacy, which is associated with poverty, limited education, and lack of affordable health insurance, is another important factor.Health disparities are affected by at least two important factors: first, the individual’s ability to produce or maintain their health ,21 and sThe questions posed in this study are: (1) Do public health programs, such as Medicare and Medicaid, play an effective role in reducing unmet needs and delayed care? (2) How important is the difference of income disparity and out-of-pocket costs in determining the choices made in unmet needs and delayed care situations? (3) What are the influences of predisposing factors such as education, patient trust, patient satisfaction, and patient-provider communication on unmet needs and delayed care? In the remainder of this study, we will strive to provide answers and insights to these inquiries. We used data from the 2003–2004 Community Tracking Study (CTS) Household Survey. The data collection started in February 2003 and was completed in February 2004. The Household Survey contains information from approximately 46,587 individuals in 25,419 families. The individuals ages 16 and older, and represents the national civilian, non-institutionalized population who live in the United States. Non-institutionalized population are individuals who are not in a institution  or an active duty military personnel. The sample is clustered in 60 CTS sites: 51 metropolitan areas and nine nonmetropolitan areas, which were randomly selected to form the core CTS and to be representative of the nation as a whole. The survey was administered by telephone, using computer-assisted telephone interviewing technology. Majority of respondents were selected through list-assisted random-digit-dialing. The CTS Household Survey is the last data with a large sample population and was replaced by the Health Tracking Household Survey (HTHS) with the sample size of 17,797  individuals in 9407 (9165) families in 2007 (2010). Both 2007 and 2011 HTHSs focuses on only 12 metropolitan areas unlike, the CTS Household Survey 2003–2004: 51 metropolitan areas and 9 nonmetropolitan areas. The CTS Household Survey 2006 was created before the Medicare prescription program started in 2006. This study reveals the relationship between unmet prescription drugs, perceived delay in healthcare, and unmet needed healthcare. In addition, it evaluates the effect of unmet prescription drug on health before the Medicare prescription program.The Household Survey instruments covered a large variety of topics including: health insurance, use of health services, and satisfaction with care, health status, and certain demographic information. A family informant provided information on insurance coverage, health resource use, usual source of care, and the general health status of all family members. The informant also provided information on family income, employment, earnings, employer-offered insurance plan, and race/ethnicity of all adult family members. Each adult in the family answered questions from a self-response module that covered the issues of unmet needs, patient trust, satisfaction with physician choice, risky behaviors such as smoking, and the last visit to a doctor.In this study, healthcare accessibility is divided into two dimensions: the general perceived delayed healthcare and unmet healthcare needs. Capturing generally perceived delayed healthcare, the survey included the question, “Was there any time during the past 12 months when you put off or postponed getting medical care you though you needed?” This study then evaluated the different influences of enabling, predisposing, and reinforcing factors on this perceived delay in care. The question about generally perceived unmet needs was “During the past 12 months, was there any time when you didn’t receive the medical care you needed?” However, the information does not provide any information on specific illnesses or conditions. The respondent either recognizes the existence of a health problem or perceives needed care sometime in the near future. The same survey item is used to measure unmet needs . If the It is crucial to understand that unmet healthcare and delayed care needs are different concepts . In our The line of research on health behavior and its policy implications originated from the PRECEDE-PROCEED model (PP model) ,30,31. Tetc. Attributable to knowledge by higher education, health illiteracy and skills in health information seeking, individuals know how to evaluate quality of health and healthcare [Individual delayed healthcare and unmet needs healthcare can be attributed to the quantity and quality of physical and environmental domains, which can affect health inequality, as well as quality of life. Enabling factors include: access to healthcare services, availability of recourses, and referrals to appropriate healthcare providers, for example income, healthcare financing , and available methods of healthcare services . Predispalthcare . Reinforalthcare .The PP model offers some concepts and analytical tools that help analyze policy influences on behavioral decisions  = 0. ωUNMET is an unobserved error, generally assumed to satisfy E = 0.Equations (1) and (2) represent the relationship between the health behavioral choice of individual “DELAY) and unmet healthcare needs (UNMET) consist of enabling (EN), predisposing (PR), reinforcing (RE), and socio-demographic factors (SD) that will influence healthcare disparity of the elderly. The study incorporates the extended PP Model to observe health inequality and the influential determinants.Both delayed healthcare , usual source of care, and time related accessibility measures. This study analyzes a variety of health insurance aspects to fill the gap in literature. In order to capture coverage and managed care cost saving aspects, this study includes Medicare HMO, private health insurance with HMO, and Medicare Supplementary Medical Insurance ,32,33. IPredisposing factors are education as a substitute for knowledge, patient trust, patient satisfaction, patient-provider communication, and lifestyle risk. The educational level as knowledge is associated with unmet needs and delayed care. Higher education levels affect health capital development and increase efficiency in health status. Years of education represent health capital related to health knowledge, allowing individuals to make better behavioral decisions, which is related to educational attainment . AnotherThere has been a dramatic increase in the interest of measuring patients’ trust in their physicians. Trust is a defining element in any interpersonal relationship and it is particularly central to the patient-provider relationship . Any conetc. [An increasingly important role in the provision of clinical process and outcomes are related to patient satisfaction through service improvements in nursing homes, hospitals, and clinics. The scope of patient satisfaction includes physician’s inpatient care, primary care services, patient-perceived nurse care, waiting time for services at clinics, etc. . Patientetc. ,42.The relationship between patients and their physicians is influenced by lack of cultural competence of physicians to improve communication with patients, lack of knowledge about procedural issues, inconsistencies of recommendation guidelines to patients, lack of physicians’ encouragement of patients’ interest, lack of evidence for benefit from patients’ health insurance coverage, and failure to call back patients for screening. These are all barriers that stem, in part, from the communication between patients and physicians ,44, and In socio-demographic factors, behavioral aspects of choosing unmet/met needs and delayed care in relation to maintaining good health, use healthcare services which vary by the factors that include age, gender, race/ethnicity, and poverty level. In socio-demographic factors, an individual’s health status based on subjective health is included in a base specification without making a health index because of the lack of ADL objective measurements ,46. Estii.e., health knowledge. This is seen as a factor that improves the efficiency with which the elderly can produce better health. The income level of the elderly affects the living standard, which contributes to the health of elderly. In addition, the correlation of educational attainment and income is generally positive. An elderly person with a higher education level is more likely to raise health stock because of his/her health knowledge. Both variables are theoretically important to evaluate the elderly with delayed healthcare services and unmet healthcare needs. Therefore, there are multiple included endogenous variables in this empirical study.For this empirical study, there are three issues of reliability of estimation: exogeneity/endogeneity, multicollinearity, and heteroskedasticity in probit estimation. Health status of the elderly is included in a base specification and educational level, DELAYi which an error term of DELAY Equation (1), and health variable and ωUNMETi which is an error term of UNMET Equation (2) should be zero, asymptotically. The residual of health is included in the structural form. The study used two instrument variables, body mass index (BMI) and subjective mental health in Regarding the issue of exogenity/endogeneity, the study used the Hausman Specification Test to examine the endogeneity of this empirical model, and to examine delayed care, unmet needs, and health variables. Under the null hypothesis, there is no simultaneity and correlation between, health variable and ωThe hypothesis that both the coefficient on the health status and the coefficient on education are zero is an example of a joint hypothesis on the coefficients in the multiple regressions (1 and 2). The regressors are possibly multicollinear and linear relationship among some or all-explanatory variables of a regression model makes precise estimation difficult. The variance-inflation factor (vif) detects multicollinearity by using condition indices. The variance-inflation factor (vif) for the general perceived delayed healthcare range from 1.02 to 2.28 in All of the results reported in i.e., factor analysis), the initial eigenvalues for all three factors were greater than 1, and the eigenvalues dropped toward later components . This implies that there is a uni-dimension of these three factors. To evaluate consistent estimate of reliability of the scale, Cronbach’s coefficient alpha, based on standardized items, was examined for each factor. Cronbach's coefficient alphas are items of patient distrust (α = 0.453 with a poor estimate), items of patient dissatisfaction (α = 0.582 with a questionable level), and items of patient-provider miscommunication (α = 0.667 with an acceptable estimate).To determine whether the items in each factor could be used for probit regression, dimensionality and reliability  and consistent estimate of reliability (Cronbach α): the interrelated issues of dimensionality and reliability of responses to a scale, were performed. In The results of regression for this study are: general perceived delayed healthcare ; generalFor enabling factors, as stated earlier, an increase in income is statistically significant and negatively associated general perceived delayed healthcare and general perceived unmet needed healthcare in Comparing healthcare financing the public programs, Medicare HMO, Medicare supplementary medical insurance, and Medicaid indicates that there is no clear cut behavioral difference in regarding the general perceived delayed healthcare and the general perceived unmet needed healthcare. For predisposing factors in The results of The elderly persons who are not able to afford prescription medicine are strongly associated with evaluated health status in both delayed and unmet needed healthcare. The elderly persons who do not get needed prescription medicines are predicted to raise the health of the general perceived delayed healthcare by 44.2% and general perceived unmet needed healthcare by 49.2% more than the elderly persons who do not have those prescription problems. The large impact of the results imply that prescription drug coverage by Medicare is an important factor that influences the health of the elderly who face the general perceived delayed healthcare or unmet needed healthcare.For healthcare financing factors in Regarding health insurance factors, coefficients of Medicare HMO indicate that the elderly under Medicare HMO are associated with a 12.1% reduction of bad evaluated subjective health of the general perceived delayed healthcare within the range between 2 and 10. Similarly, the Medicare HMO influence on the evaluated subjective health of the elderly of the general perceived unmet needed healthcare is by 13.2%. Compared to fee-for-service of the traditional health insurance, the provision of preventive characteristics by the HMO tends to raise better subjective health status of the elderly with general perceived delayed healthcare and unmet needed healthcare. Furthermore, the positive signs indicate that the elderly with the Medicaid insurance are more likely to have weak adherence to have good evaluated subjective health.For the influences of predisposing factors such as education, patient distrust, patient dissatisfaction, and patient-provider miscommunication on the subjective health of the elderly of general perceived delayed healthcare or unmet needed healthcare, both results in For This empirical study concludes unmet needs of prescription drugs for the elderly population have positive influence on the perceived delay in healthcare and perceived unmet needed healthcare. These factors are disproportionally large in the population among the poor (low income) elderly. These three factors raise evaluated ill health status, ranging between 45%~60% among the elderly population. Other interesting findings are that out-of-pocket medical costs elevate perceived unmet needed healthcare and delayed healthcare, and the high out-of-pocket costs raise disproportionally large perceived unmet needed healthcare for elderly population. Our findings also offer insight into the patient-physician relation mechanism. Patient’s distrust and dissatisfaction increase perceived unmet needed healthcare and delay in healthcare. These two factors and patient-provider miscommunication together increase subjective ill health status by about 26%. However, educational attainment of one additional year reduces subjective ill health status by 7%.et al., [Policy makers need to address a diverse amount of issues to make the healthcare more affordable and accessible to reduce inequality of healthcare burden, which in turn lead to health disparity, under the current system. This research reinforces and extends the findings of a previous study for issues concerning health insurance, race, income and satisfaction ; and foret al.,  for educOur findings show a dimension of increase costs of prescription drug for the elderly in the general perceived delayed healthcare and the elderly in general perceived unmet needs. The results of our study clearly show some important aspects of referral issue and medical needs in distrust category for general perceived delayed healthcare and the general perceived unmet needed healthcare. Our detailed patient satisfaction variables support the result of a single trust variable . In addiWhat is the practical implication of our findings? The government’s Medicaid health insurance is limited to consumer medical care choice that is adversely associated with health and healthcare equality in accordance with our finding from generally perceived unmet needs. An increase in subjective health status with a variable of Medicare HMO partially explains the preventive care aspect to receive meaningful healthcare services in consistent with subjective health of the elderly of the general perceived delayed healthcare and unmet needed healthcare from our finding. Most importantly, medicine prescriptions are a well-known fact and the elderly take multi-prescription to prevent a decrease in health capital from aging. The data for this study is from the Community Tracking Study Household Survey 2003–2004 that was taken before the Medicare prescription program started in 2006. Although the current Medicare prescription program is not ideal one, we still need to do research about the influence of the current Medicare prescription program on the elderly population. When assessing Medicare insurance coverage disparities in access based on unmet needs and delayed healthcare, there is little evidence the effectiveness of policy and healthcare and health disparity among disadvantaged population.It is not difficult to explain why two of three measures produced the same results of positive influence of patient distrust and dissatisfaction on health of the elderly of the general perceived delayed healthcare and unmet needed healthcare. A recent rapid increase in medical costs associated with an increase in access disparity causes health disparity among the elderly. Further study is strongly recommended to understand and to comprehend characteristic different behavioral choice about delayed healthcare and unmet needed healthcare for reducing health disparity, especially unequally distributed disadvantaged of income population in the elderly and delayed healthcare and unmet needed healthcare for decreasing disproportionately large in the elderly among the high out-pocket costs.


The Ohio Department of Transportation has more than 60 facilities without sewer access generating approximately 19 million gallons of winter maintenance wash water. Off-site disposal is costly, creating the need for sustainable management strategies. The objective of this study was to conduct an exploratory feasibility analysis to assess wash water disposal and potential reuse as brine. Based on a comprehensive literature review and relevant environmental chemistry, a sampling protocol consisting of 31 water quality constituents was utilized for monthly sampling at three geographically distinct Ohio Department of Transportation garages during the winter of 2012. Results were compared to local disposal and reuse guidance limits. Three constituents, including a maximum copper concentration of 858 ppb, exceeded disposal limits, and many constituents also failed to meet reuse limits. Some concentrations were orders of magnitude higher than reuse limits and suggest pre-treatment would be necessary if wash water were reused as brine. These water quality results, in conjunction with copper chemical equilibrium modeling, show pH and dissolved carbon both significantly impact the total dissolved copper concentration and should be measured to assess reuse potential. The sampling protocol and specific obstacles highlighted in this paper aid in the future development of sustainable wash water management strategies. Heavy metals that are generated on the roadway are the result of brake dust, tire wear, road weathering, vehicle corrosion, exhaust emissions, and oil leaks. A study by Harrison et al.  found thAnother source of traffic-related heavy metals is tire wear. Harrison et al.  found tiWhile the previous studies focused on metal emissions, a study by Jang et al.  characteThe traffic-related heavy metals that are emitted and then deposited on the roadway exist mostly in the particulate form. They become airborne, attach to vehicle parts, and travel with the vehicle until it is washed. The complexity of wash water and the presence of many constituents complicate the management process. In 2004, Virginia Transportation Research Council (VTRC) assessed water quality from on-site retention ponds that collect truck wash water and storm water at Virginia Department of Transportation (DOT) maintenance facilities. Samples collected from 45 retention ponds across nine Virginia DOT districts were analyzed for chloride, total suspended solids, and oil and grease . ConstitA 2004 Indiana Department of Transportation (INDOT) report documented the results of truck wash water quality samples taken after an oil/water separator. The study measured chloride, total suspended solids, and oil and grease  and founLike INDOT, the Ohio Department of Transportation (ODOT) investigated the potential to reuse wash water as brine. A Hull & Associates  report dCurrently, many maintenance facilities without access to sanitary sewer that do not have on-site treatment systems must collect their wash water and pay for its disposal. Miller et al.  conducteThe articles cited above indicate there are many challenges, and heavy metals are likely an important part of effectively managing winter maintenance truck wash water. These previous studies do not include thorough water quality data, including the presence and concentration of heavy metals in wash water originating from winter maintenance operations. Wash water quality results are necessary to evaluate disposal and reuse options for the numerous ODOT facilities lacking sewer access. The objective of this study was to implement comprehensive sampling to evaluate the quality of water generated from the washing of salt trucks at ODOT maintenance facilities and to conduct a feasibility analysis to assess disposal and determine the potential reuse of the wash water as brine.To assess wash water quality, samples were collected by Ohio Department of Transportation (ODOT) personnel  at three ODOT locations once per month during winter 2012 .Locations were chosen based on geographical diversity and included Location S, Location H, and Location M. Characteristics of each location are shown in The metal and nonmetal constituents selected for this study were chosen to adequately characterize and quantify the wash water and assess factors controlling the measured concentrations. The goal of sampling was to obtain wash water samples directly after treatment by an oil/water separator. Grab samples were taken during truck washing operations. At all three sites, samples were collected using a siphon pump from an access point after the oil/water separator . Two additional sampling locations included a retention pond at Location H (sample H2) and a post-treatment sample at Location M (sample M2).Each sample was placed in a 0.5 L high-density polyethylene bottle. A portion of the sample volume (125 mL) was preserved with (1+1) reagent grade nitric acid to pH < 2. The remaining sample volume was left unpreserved for nonmetals analysis. The preserved samples were digested according to EPA 200.7 and analyzed by Inductively Coupled Plasma—Optical Emission Spectrometry (ICP-OES).Unpreserved samples were analyzed by the following methods: chloride (HACH 8113), conductivity (HACH CO150 Conductivity Meter), cyanide (HACH 8027), fluoride (HACH 8029), herbicides (EPA SW-846 Method 8151A), oil and grease (EPA Method 1664A), pesticides (EPA Method 608), pH (Fisher Scientific AB15 pH Meter), phosphorus (HACH 8048), total dissolved solids (TDS)  from Chapter 3745–1 of the Ohio Administrative Code (OAC); Statewide Water Quality Criteria for the Protection of Agricultural Uses ; Statewide Water Quality Criteria for the Protection of Aquatic Life for Water Hardness Dependent Criteria ; and Lake Erie drainage basin water quality criteria for the protection of human health and wildlife . All references to the OAC originate from Ohio Environmental Protection Agency .Currently, there are no known reuse limits required for Location S. If this were to change, the projected reuse limits for Location S would be based on the same standards as Location H. The reuse limits for Location M are based on the following standards: Ohio River Basin Aquatic Life OMZM from Chapter 3745–1 of the OAC; Statewide Water Quality Criteria for the Protection of Agricultural Uses ; Statewide Water Quality Criteria for the Protection of Aquatic Life for Water Hardness Dependent Criteria ; and Lake Erie drainage basin water quality criteria for the protection of human health and wildlife . While Table 33–2 is a standard for the Lake Erie drainage basin, the OMZA criteria for human health and wildlife are required to be maintained for the entire state.The importance of analyzing a comprehensive set of constituents lies in the complexity of the wash water. Heavy metals in wash water exist in several forms and interact with organics and inorganics present in the aqueous environment. Where:Me represents a metalMe+ is the free ionic metalMeXi is the complex formed by the metal bound to an inorganic ligandMeLi is metal bound to an organic ligandThese equations show that, due to complexation, other constituents present in the wash water affect how the metal speciates, as well as the total dissolved metal concentration. Complexation affects solubility, toxicity, surface properties of solids, and adsorption ability of metals from the solution . UnderstTo better understand copper speciation, model chemical equilibrium calculations were performed with Visual MINTEQ v. 3.0. The Gibbs free energy was calculated for the formation of the solids CuCO3, CuO, Cu2O, and Cu(OH)2 under standard conditions and all free energy values and solubility product constants and equations were obtained from Visual Minteq. Metal binding by organic matter was modeled using the NICA-Donnan model and its default parameters. A solid copper concentration estimate of 10 mg/kg was used for the wash water particulates. To understand the effects of DOC and pH on metal speciation, general water quality parameters from USEPA  were entHeavy metals in wash water originate from numerous traffic sources, including brake and tire wear, oil leaks, exhaust emissions, and vehicle and road corrosion. Each source contributes several metals to the environment. Samples were taken once per month at each of the five locations. Monthly samples were taken from January 2012 to April 2012 for a total of 19 samples.Luhana et al.  reportedGeneral wash water quality measures are expected to impact the heavy metal concentration . For exaMetal concentrations shown in While the location of the sample collection  is important, it is also important to consider the location and environment of truck service areas. Traffic-related heavy metals, such as those discussed above, are more abundant in urban environments due to frequent deceleration, acceleration, and turning motions . ResultsDespite variation in the data, copper and zinc are consistently found in elevated concentrations. These elevated concentrations present challenges to managing wash water. Additional treatment in the form of dilution occurs at Location H. The sample taken at Location H2 was collected from the on-site retention pond, which captures truck wash water and runoff from the entire maintenance yard. It is expected that diluted samples would have lower metal concentrations; however, Additional treatment also occurs at Location M, which utilizes a clay-based filtration system. For this reason, Location M2 was expected to have lower concentrations of metals. However, when compared with Location M1, Location M2 only exhibited lower concentrations for four of nine Group A metals. The results discussed above indicate that even after wash water is treated by the oil/water separator, and sometimes additional treatments such as dilution and filtration, further treatment is required to meet reuse and disposal limits. Further treatment should focus on the constituents presented in As shown in Copper was selected for additional analysis with chemical equilibrium modeling because it exceeded the reuse limits by such a large margin. The model output was used to assess the dissolved speciation between free, inorganic-complexed, and organic-complexed copper. While To assess the impact of organics on speciation, A comprehensive sampling protocol that consisted of 16 heavy metal and 15 nonmetal constituents was used to characterize the wash water at three winter maintenance facilities. Nine of the 16 metals were detected in all samples, with copper, zinc, and iron having the highest concentrations. Comparison of raw wash water quality results to disposal and reuse limits showed that 4 of 19 of samples do not meet disposal limits, and 17 of 19 of samples do not meet reuse limits. Copper, oil and grease, and TSS exceed disposal limits. Copper, oil and grease, zinc, cyanide, and surfactants exceed reuse limits, and most samples are greater than 100% above the reuse limits, with copper exceeding by as much as 4,151%. Pre-treatment by an oil/water separator, clay-based filtration, and dilution were found to be inadequate to reduce concentrations to meet reuse limits.Due to its strong presence in wash water, copper speciation was investigated with Visual MINTEQ. The results of the modeling indicated that increasing pH by only 0.2 units resulted in the free copper concentration decreasing from 288 ppb to 132 ppb. Increasing DOC concentrations also were shown to affect speciation. For this reason, DOC and pH are important parameters to consider when evaluating management options. Pretreatment is likely required, but simply monitoring pH and perhaps a surrogate for DOC (like UV 254 nm) could provide valuable insight into the likelihood of compliance prior to sending samples for metals testing. Use of the methods presented in this study provides the DOT with an approach to evaluate options to identify challenges associated with disposal and reuse of winter maintenance wash water.


This study aimed to identify what information triggered social media users’ responses regarding infectious diseases. Chinese microblogs in 2012 regarding 42 infectious diseases were obtained through a keyword search in the Weiboscope database. Qualitative content analysis was performed for the posts pertinent to each keyword of the day of the year with the highest daily count. Similar posts were grouped and coded. We identified five categories of information that increased microblog traffic pertaining to infectious diseases: news of an outbreak or a case; health education / information; alternative health information / Traditional Chinese Medicine; commercial advertisement / entertainment; and social issues. News unrelated to the specified infectious diseases also led to elevated microblog traffic. Our study showcases the diverse contexts from which increased social media traffic occur. Our results will facilitate better health communication as causes underlying increased social media traffic are revealed. Social media have become increasingly useful in digital disease detection and surveillance ,2,3,4, sEquivalent to Twitter, which is blocked by the Chinese authorities, Weibo is a popular microblogging service in China . By the While outbreak detection and incidence prediction are one of the goals of digital epidemiology ,24, a goIn this article, we extend our previous study  to coverOur Weibo data were collected via the Weiboscope project, maintained by KWF and his team in the University of Hong Kong, as described elsewhere ,22. InitAs previously described , the rawLaw of the People’s Republic of China on the Prevention and Treatment of Infectious Diseases, as of 2012 [Similar to our previous study , we pres of 2012  (Table 1News of (a) outbreaks or (b) cases;Health education or information, as released by health authorities, news agencies, education institutions, etc., that conform to modern scientific medicine;Alternative health information that fell out of the realm of modern scientific medicine ;Commercial advertisements or entertainment; andSocial issues, including the conflicts between the medical profession and the patients .The representative post for each group was then translated into English to be presented in The protocol of data processing and anonymization was approved by the Human Research Ethics Committee for Non-Clinical Faculties, The University of Hong Kong, and by the Institutional Review Board, Georgia Southern University (H14167). This paper is the report of a secondary data analysis of the WeiboScope dataset of 2012. All the Weibo posts in the original WeiboScope dataset were publicly available posts. No attempt was made to inform Weibo users of the current study. The data had been de-identified before the current analysis began.Chinese microbloggers reacted to news about outbreaks of cholera, hepatitis C, influenza A(H1N1) and anthrax in different parts of China . An examNews of cases of human infection of avian influenza, epidemic hemorrhagic fever (in the United Kingdom), epidemic encephalitis B, scarlet fever, malaria, echinococciosis and diarrhea also attracted microblog users’ attention . One exaHealth promotion campaigns organized by the Chinese health authorities, such as World AIDS Day  and Natipenis et testis canis, a type of traditional Chinese medicine  about “food that cannot be consumed together with chicken meat”, including medicine ; Table 3Commercial advertisements and the entertainment industry might also lead to an increase in Weibo posts that mentioned certain diseases, as in the case of plague, dengue, influenza and leprosy . An examWeibo users discussed various social issues, such as gender equality (gonorrhea and syphilis), discrimination against carriers of certain viruses (hepatitis B), the loss of trust between the government and the citizens (SARS), and the loss of trust between the medical profession and the patients  ; Table 2News and online discussion that were not pertaining to infectious diseases might mention the infectious diseases (rabies and tuberculosis) for other reasons. An example was the so-called “Miami cannibal attack” in the United States leading to a peak on the keyword for rabies , commercial advertisement / entertainment, and social issues.Identification of these categories of triggers for Chinese microbloggers’ responses is important for digital health communications in two ways. First, digital epidemiologists use time series of search query data or social media data to predict trends of infectious diseases, such as influenza ,32. ThesSecond, public health agencies use social media to communicate messages of health promotion or disease prevention to the public ,11,12,14In addition, social media content analysis can provide public health researchers an additional means to reveal health-related social issues. For example, concurring with previous reports , our conOur study is the first to categorize Chinese microblog contents on 42 infectious diseases and also identify the related news and/or information. While another study compared Chinese and US social media use in health communication at the onset of the H1N1 pandemic, no Weibo data were analyzed therein .In our study, we manually coded Chinese microblog posts to obtain a better understanding of the actual contents. While there are other studies that used computerized machine learning methods ,36, or kThe Chinese microblogger community is a fraction of the 1.3 billion people living in mainland China. According to a random sampling study, Weibo users are more likely to be male and living in provinces/regions that are more economically developed (with some exceptions) . CompareIn the absence of content analysis of Weibo posts for each disease keyword at the baseline, and given the diversity of information that triggered the elevated Weibo activities, we did not attempt to compare across the categories of information that triggered the elevated Weibo activities. Future research along that direction is warranted.Our analysis is only a small step towards a better understanding of the Chinese online community’s understanding and communications about health issues. Many questions remained unresolved. For example, how can we predict users’ reactions to different types of news, events or information? What, if any, behavioral changes will health information on social media bring about? What is the relationship between healthcare-seeking behavior and tweeting behavior? Our study provides the ground work for future research that will shed light upon these issues.Infectious disease-related information triggered Chinese social media users’ reactions to create and repost microblog posts. Our content analysis categorized them into 5 categories, namely, news of an outbreak or a case, health education / information, alternative health information , commercial advertisement / entertainment, and social issues. Our study opens the door towards a better understanding of online health information diffusion and health information seeking behavior that will better equip digital epidemiologists to fine-tune their prediction and detection tools, and will enable health communicators to fine-tune their social media messages.The identification of news and information pertaining to infectious diseases that trigger an elevated microblog activity and the contents thereof has utility and significance in health communications and disease surveillance. Our study covers 42 infectious diseases. We demonstrated how information and issues about these diseases drew social media users’ attention and led to increased social media traffic. Such finding, in turn, will pave the way for future studies about online health communications. This study contributes to the literature by analyzing data from Sina Weibo, the leading microblogging platforms in China, where Twitter is blocked. We analyze the reactions of a sample of influential users in a national online community to health-related news, information and social issues. This helps facilitate better social media health communication and may shed light on the “false positives” in digital disease detection. The lessons learned in our study can be transferrable to other middle income countries.S1 File(PDF)Click here for additional data file.