To foster student development, critical thinking, and application skills among public health students at the University of Hawai‘i at Mānoa, a three-course capstone series was developed as a key component of the public health Bachelor of Arts degree program. Over the course of 1.5 academic years students are actively involved in developing an interdisciplinary project proposal, then executing and presenting an independent, supervised, applied learning project. In the first course, students are introduced to a diverse range of public health projects and methods while working to develop their own project proposal – the foundation for the applied learning experience. The project execution course is designed to allow students to execute their proposed applied learning projects. This experience focuses on the application and integration of public health knowledge, skills, and practice acquired during the bachelor’s degree course of study. Finally, students will be involved in reflecting on, finalizing, and sharing their completed projects in an undergraduate capstone seminar. Through implementation of this series, the program hopes to provide students with the opportunity to actively apply academic skills to real-world application. It has been recommended by several entities that undergraduate programs, particularly those focused on public health, include opportunities for integrative and experiential learning –4. ExperDuring the development of the Bachelor of Arts degree in Public Health at the University of Hawai‘i at Mānoa , a three-course integrative learning experience capstone was created so as to provide students with an opportunity to apply course knowledge and skills to a real-world issue, develop a passion for a topic of personal interest, and gain experience working with collaborators (possibly in the community). This capstone series has been named the applied learning experience.The three-course applied learning experience was initially developed and proposed by a departmental committee comprises faculty, staff, and a student representative, formed to develop the B.A. Public Health program for the University of Hawai‘i at Mānoa (UHM). The need for a capstone experience was supported during preliminary meetings with both local community members, many of who would be potential employers of our graduates, and key on-campus stakeholders. The UHM Honors Program initially inspired the three-course progression, where students are guided through development of a project proposal in one semester then execute the project in subsequent semesters. The process was further refined to reflect the needs of students, faculty, and community members as identified from past experiences with the Master of Public Health (MPH) practicum and subsequent MPH capstone course.The intent of the culminating experience in the B.A. program is to provide students the opportunity to actively apply classroom knowledge and associated skills to real-world application in the public health field. This is facilitated by a three-course series required for graduation with the B.A. Public Health degree: PH480 Application of Public Health Principles in Research and Practice, PH485 Applied Learning Experience, and PH489 Public Health Undergraduate Capstone Seminar.Student project selections may have either a research or practice-based focus, depending on the preference of the individual student, as well as their post-graduation plans. For example, a student interested in employment with a non-profit organization following graduation may prefer a service-learning oriented experience with a local non-profit, whereas a student applying for a graduate program may be more interested in working with, or designing their own, research project. Examples of selected student topics are included in Table Throughout the applied learning experience each course instructor evaluates students on performance and competence through class assignments and class activities. The student’s selected, and approved mentor or advisor additionally assesses the execution of the applied learning experience during PH485. Additional Public Health departmental faculty members, other University of Hawai‘i at Mānoa faculty, or approved community experts are encouraged to serve as advisors and mentors to specific applied learning experience projects, as appropriate to the student-selected topics.The Undergraduate Public Health Summit is a semi-annual, open, public forum, and a vital opportunity for students to interact with faculty , program alumni, and other community resources. Students participate in the Undergraduate Public Health Summit twice during their capstone series. First, they are involved in presenting their applied learning experience project proposals as poster presentations within the last 2 weeks of PH480. Students are also required to present their final applied learning experience projects  as both poster and oral presentations during the last weeks of the PH489 capstone seminar. This experience provides students with practice presenting their projects and outcomes in a professional format and both interacting and receiving feedback from a range of forum participants.This course is typically taken during the first semester of a student’s third (junior) year of the Bachelor of Arts degree program, and is the students’ first introduction to the applied learning experience. The purpose of PH 480 is to prepare students for an independent, supervised, integrated learning project to be performed as part of the public health undergraduate capstone experience. The course begins with career counseling and post-graduation preparation in a group setting. By focusing on both short- and long-term personal objectives students are better able to create an experience that will support their future goals. This course also exposes students to common research tools and practices, including writing a literature review, creating a written and oral project proposal, designing a poster for public presentation, seeking external funding, ethics education, and working with an Institutional Review Board.PH480 additionally introduces students to a diverse range of public health projects and associated methods. Throughout the semester, students are exposed to short, 10-min research and practice profiles called “Public Health in Action Profiles.” Profiles are presented by program faculty as well as community partners and provide a brief overview of current public health projects, what responsibilities the presenter’s specific role entails. Profiles are intended to provide undergraduate students with ideas of what public health research looks like in practice and also provide inspiration as students work toward developing their own applied learning experience proposals. For some students, meeting faculty and community partners during presentations also serves as a valuable networking opportunity. Student feedback to Public Health in Action Profiles has been overwhelmingly positive.At the conclusion of PH480, students will have a written proposal for an applied learning experience project, as well as experience presenting their project proposals at an open, public forum – the Undergraduate Public Health Summit.Essential components of experience proposals include (1) project objective, (2) project abstract, (3) significance of study or experience, (4) background and literature review, (5) proposed research or experience methodology, (6) expected deliverables, outcomes, or results, (7) proposed collaborators, partners, and next steps, and (8) references. Optional components include an itemized budget, estimate of costs, description of host organization or host research project, and Institutional Review Board application, as appropriate to the specific project.These components are written in draft form and submitted throughout the semester (roughly four months) of PH480. Feedback is provided for each section, and the final versions of individual components are compiled as a complete project proposal submitted as the final product of the PH480 course. Generally, completed proposals range from 8 to 12 pages (excluding references). Additional research tools developed  are included as appendices as appropriate.Based on each student’s individual applied learning project proposal, developed during PH480, students are involved in independent research projects under the supervision of both a course instructor and an appropriate, approved project mentor or advisor. Mentors and advisors may be university faculty or approved community experts in a student’s identified research or practice area.The applied learning experiences take place over the course of a full semester, and involve roughly 100–125 hours of project execution. Students who are executing research-based projects primarily spend their time conducting a more thorough literature review and, in most cases, working to collect data and/or conduct supervised data analyses. Students with practice-focused projects spend the majority of their specified time actively working within an organization under a service-learning format.Finally, students will be involved in reflecting on, finalizing, and presenting their completed applied learning experience projects throughout an Undergraduate Capstone Seminar (PH489).The Public Health Undergraduate Capstone Seminar is taken near the completion of the B.A. degree program. It focuses on integration of public health knowledge, skills, and practice acquired during the course of study. Students will be involved in assessing their level of achievement of educational degree objectives, develop professional goals, and reflect on, finalize, and present their applied learning experience projects. This course also summarizes key content and skills applied throughout the B.A. public health degree program, prepares students for a higher level of learning , and addresses pragmatic post-graduation skills . Key deliverables following completion of this course include an applied learning reflection paper, a final applied learning experience report, and a final oral and poster presentation delivered at the Undergraduate Public Health Summit.Address a key issue, concern, or research problem related to the field of public health;Apply knowledge and skills accumulated through public health course work to address the selected issue/problem;Demonstrate integration and practical application of public health concepts; andDemonstrate appropriate written and oral communication skills.The instructor of the PH489 course and the Undergraduate Program Chair make the final assessment of the undergraduate capstone experience jointly. The undergraduate culminating expectations include the following:Written project proposal for applied learning experience;Poster presentation of applied learning experience project proposal at Undergraduate Public Health Summit;Completion and submission of signed mentor/advisor agreement form;Completion and submission of final applied learning experience assessment of advisor or mentor;Completion and submission of applied learning reflection paper;Completion and submission of final applied learning project report; andOral presentation of final applied learning project at Undergraduate Public Health Summit.Concrete evidence of successful completion of culminating experience include the following:Students must also complete and obtain passing grades (above “C−”) in all required and elective coursework associated with the B.A. in Public Health degree as evaluated by faculty instructors indicating mastery of the content and competency.The applied learning experience serves as a capstone to the B.A. Public Health degree program at the University of Hawai‘i at Mānoa. Through a three-course series, students engage in inquiry-based learning centered on a topic of interest of their choosing. As previously discussed, there are two potential tracks for Applied Learning Experience projects – research or practice based, so as to allow students to select which type of experience would be most suitable to their academic needs and future plans. Both tracks provide an opportunity for integrative and experiential learning through slightly variable approaches. The research-based track exposes students to the inner workings of academic investigation, whereas the practice-based track provides real-world work experience. Both tracks include continuous application of critical thinking skills and student reflection, particularly throughout the execution of the applied learning experience in keeping with a service-learning framework.Preliminary feedback from B.A. students who are currently participating in the applied learning experience has been very positive overall. The primary adjustment made based on student feedback has been to place more emphasis on advising of students preparing for the undergraduate culminating experience during mandatory advising session. The intent of this emphasis would be to help students begin thinking about possible projects and to increase awareness of the three-course series in the context of their full undergraduate degree program.Through the applied learning experience, this program hopes to better prepare undergraduate public health students for both public health practices in the workforce, improve transition into graduate programs, and more broadly, fully embrace application of the educated citizen framework .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.


Core outcome sets (COS) can reduce waste in research, through measurement of an agreed set of outcomes across all trials in a particular area of health. The COMET Initiative was launched in 2010 to (i) raise awareness of problems with outcomes in trials; (ii) encourage COS development and uptake; (iii) promote patient and public involvement in COS development; (iv) provide resources to facilitate this; and (v) encourage evidence-based COS development.This talk will review progress and challenges over our first five years. It will describe our work with multiple stakeholders to facilitate engagement, including funders, trialists, patient organisations, systematic reviewers, editors, industry, regulators, and guideline developers. The perception that COMET was a ‘UK thing’ has been dispelled, with the establishment of an International Advisory Group and meetings in Rome (2014) and Calgary (2015).Highlights include the development of a searchable repository of COS studies, and completion of the first comprehensive systematic review of published COS (recently updated to December 2014). Over 7800 searches have been done of the online repository, most visitors in 2014 were from outside the UK and we will present findings from a pop-up survey of why people search it.Promoting broader uptake of COS by researchers and securing funding for initiatives aimed at reducing waste in research remain major challenges. As awareness of the need for COS continues to grow and knowledge of the COMET Initiative increases, this is an appropriate moment to present our future proposals, including a research agenda, to the trials methodology community.


This book is a gem of a textbook about the principles of evolutionary thinking and the relevance of evolutionary biology to clinical medicine. The authors draw upon decades of experience teaching medical students at Yale, with interesting examples, including experimental observations in other species. Their format with a detailed table of contents and cogent summaries within each chapter is helpful.Every trait/every organism has a history. A transposon insertion enabled the emergence of the vertebrate adaptive immune system with antibody diversity. Invasive placentas carry the tradeoff risk of metastasis by cancers of glandular tissues. Some genetic variations are associated with specific infectious disease risks. In pharmacogenomics, copy number variants of CYP drug metabolizing genes guide drug developers to design drugs around such highly variable human traits. Mismatches of species inheritance and modern environments test ‘reaction norms’ and lead to risks of metabolic syndrome and related disorders, though the relevance of sterotyped ‘paleodiets’ is challenged in the closing chapter. Allocation of energy probably explains tradeoffs of number of offspring versus survival of individuals.Early chapters draw the interest of students/readers with the themes ‘What is a patient?’ and ‘What is a disease?’ Humans have an unusual life history in several traits with medical significance. Our infants are large, fat and relatively underdeveloped at birth, compared with chimps, with brain size increasing for 7 years and large adolescent growth spurts, three years earlier in girls than in boys. Chimps do not have menopause. The authors seem dubious about the ‘thrifty genotype’ and ‘thrifty phenotype’ hypotheses. They note associations with reported changes in microbiomes, including autoimmune disorders. Patients are mosaics of traits of different evolutionary ages and bundles of tradeoffs with plastic responses to their current environments. In classifying diseases, they properly emphasize genotype × environment and gene × gene × environment interactions. They recognize the complexities of diseases that are by-products of defense systems or homeostasis or maternal-paternal conflicts. An overarching principle is that most diseases have both mechanistic and evolutionary explanations. Such an analysis enriches our thinking about disease and disease prevention, with inflammatory bowel disease and the vulnerability of neurons, myocardium, and kidney as terrific examples.The characteristics and costs of our evolved defenses constitute a particularly intriguing chapter, embracing the interrelations of homeostasis, maintenance and constitutive and inducible defense mechanisms of many types. The examples are current, including proteosomal, lysosomal and autophagocytic removal of damaged proteins and lipids; degradation in these mechanisms is associated with various processes of aging. Of course, the evolutionary logic of a particular cost-benefit ratio for a defense mechanism may now be obscure because it was determined long ago for environmental exposures and physiological priorities of that era, as illustrated with starvation, dehydration, extreme heat and cold, predators and pathogens.Subsequent chapters address pathogen and symbiont exposure, cancers , reproductive medicine and mismatches, and mental disorders and drug addiction (important but poorly characterized phenotypes). The closing chapters are particularly useful in stimulating deeper consideration of the need to understand cross-consequences of interventions for individual health and population health, and by raising ‘open questions’ that should help readers and observant clinicians to expand the applications of evolutionary medicine, thereby enhancing medicine and public health. For example, in the important context of bacterial resistance, they highlight the potential usefulness of bacteriophage therapy, of siderophore quenching and quorum sensing , and of late-acting insecticides .Referring to the flipped classroom and active learning, Stearns and Medzhitov have made You Tube and iTunesU presentations for student on-line access under ‘Stearns Evolutionary Medicine’, currently 65 videos, aimed at stimulating classroom discussion and exploration of the cited literature and other sources. General readers will find this book quite stimulating, too.


Drosophila group B proteins SoxNeuro and Dichaete are involved in central nervous system development, where they play both similar and unique roles in gene regulation. Sox genes show extensive functional redundancy across metazoans, but the molecular basis underpinning functional compensation mechanisms at the genomic level are currently unknown.Sox proteins encompass an evolutionarily conserved family of transcription factors with critical roles in animal development and stem cell biology. In common with vertebrates, the Using a combination of genome-wide binding analysis and gene expression profiling, we show that SoxNeuro directs embryonic neural development from the early specification of neuroblasts through to the terminal differentiation of neurons and glia. To address the issue of functional redundancy and compensation at a genomic level, we compare SoxNeuro and Dichaete binding, identifying common and independent binding events in wild-type conditions, as well as instances of compensation and loss of binding in mutant backgrounds.Drosophila group B1 proteins also play prominent roles during later aspects of neural morphogenesis. Our analysis of the functional relationship between SoxNeuro and Dichaete uncovers evidence for redundant and independent functions for each protein, along with unexpected examples of compensation and interdependency, thus providing new insights into the general issue of transcription factor functional redundancy.We find that early aspects of group B Sox functions in the central nervous system, such as stem cell maintenance and dorsoventral patterning, are highly conserved. However, in contrast to vertebrates, we find that  EF and SR wrote the paper. EF, BF and SR read and approved the final manuscript.SoxN mutants.Expression data, gene lists and Gene Ontology enrichments for genes differentially expressed in Click here for fileComparison of the different SoxN gene expression and binding datasets.Click here for fileGenomic coordinates, gene lists and GO:BP enrichments of the SoxN core dataset.Click here for fileGeneral features of SoxN binding.Click here for fileComparison of SoxN genome-wide binding with that of other TFs, chromatin-binding proteins and histone modifications.Click here for fileGenomic coordinates, gene lists, GO:BP enrichments for SoxN direct targets and tables of upregulated, downregulated and variably expressed direct targets.Click here for fileSoxN mutant embryos.Expression of SoxN direct targets in wild-type and Click here for fileGene lists and GO:BP enrichments for genes bound by SoxN and Sox2 or Sox11.Click here for fileDichaete and SoxN mutants.Genomic coordinates, gene lists and GO:BP enrichments of SoxN and Dichaete binding in wild type and Click here for fileDifferential enrichment of genes targeted by SoxN and Dichaete.Click here for fileSoxN and Dichaete mutants.Differential enrichment of genes associated with the five types of events observed in Click here for fileSoxN and Dichaete binding intervals targeting FlyLight enhancers with reported CNS expression.Click here for fileSupplementary Methods and Legends.Click here for file


To seek a shared vision between families and clinicians regarding key aspects of health as outcomes, beyond mortality and morbidity, for children and young people with neurodisability. To appraise the appropriateness and measurement properties of multidimensional patient reported outcome measures (PROMs) to assess the outcome domains.Relevant outcomes were identified from (i) qualitative research with children and young people with neurodisability and parent carers, (ii) Delphi survey with health professionals, and (iii) systematic review of PROMs. The International Classification of Functioning Disability and Health provided a common language to code aspects of health. A stakeholder group participated in a prioritisation Q-sort task. Participants 54 children and young people with neurodisability and 53 parent carers participated in either focus groups or interviews; 262 multidisciplinary health professionals took part in one or more rounds of a Delphi survey. 15 stakeholders participated in a consensus meeting: 3 young people, 5 parent carers, and 7 multidisciplinary health professionals.The qualitative study and Delphi survey suggested a range of aspects of health that are important to service users and targeted by health professionals. There was partial but not complete overlap. Key outcome areas prioritised were: communication, emotional wellbeing, pain, sleep, mobility, self-care, independence, mental health, social activities; behaviour, toileting, and safety were also important to many parents. No single multidimensional PROM was identified that captured all the key aspects of health. Evidence was lacking of one or more measurement properties for all candidate PROMs in children and young people with neurodisability, and especially for preference-based measures.This research proposes a core suite of outcome domains for children and young people with neurodisability that can be used to assess health services routinely and in trials. Further work is required to produce a single PROM to measure these outcomes efficiently across neurodisability.


Peritrichs are a major group of ciliates with worldwide distribution. Yet, its internal phylogeny remains unresolved owing to limited sampling. Additionally, ecological distributions of peritrichs are poorly known. We performed substantially expanded phylogenetic analyses of peritrichs that incorporated SSU rDNA sequences of samples collected from three continents, revealing a number of new relationships between and within major lineages that greatly challenged the classic view of the group. Interrogation of a dataset comprising new environmental sequences from an estuary and the open ocean generated with high throughput sequencing and clone libraries plus putative environmental peritrich sequences at Genbank, produced a comprehensive tree of peritrichs from a variety of habitats and revealed unique ecological distribution patterns of several lineages for the first time. Also, evidence of adaptation to extreme environments in the Astylozoidae clade greatly broadened the phylogenetic range of peritrichs capable of living in extreme environments. Reconstruction of ancestral states revealed that peritrichs may have transitioned repeatedly from freshwater to brackish/marine/hypersaline environments. This work establishes a phylogenetic framework for more mature investigations of peritrichs in the future, and the approach used here provides a model of how to elucidate evolution in the context of ecological niches in any lineage of microbial eukaryotes. Ciliates are a large group of microbial eukaryotes encompassing ~8000 described species234Vorticella89101112131415Peritrich ciliates, excluding mobilid ciliates, generally are accepted as a subclass within class Oligohymenophorea. They are characterized morphologically by mode of development of the feeding stage , structure of the stalk/lorica, infraciliature of the oral area, and pattern of the silverline systemDespite the widespread presence of peritrichs in nature, there is still relatively little understanding of their ecological characteristics because of under-sampling and sampling bias. A handful of free-living species that inhabit permanent bodies of fresh water have been studied intensively over the years as indicators of water quality in natural ecosystems and sewage treatment systems171819202123Vorticella gracilis collected from two geographically distant regions (China and Austria) that represents the first discovery of its type in ciliates.The aims of the present study, therefore, were (i) to clarify the internal relationships of the subclass Peritrichia by increasing taxon sampling from a variety of habitats across large geographic regions; and (ii) to reveal the ecological distribution of taxa in a phylogenetic context based on environmental peritrich datasets encompassing a) new environmental data generated from samples collected from previous rarely represented environments, b) newly obtained, nearly full length sequences, and c) sequences with clear taxonomic designations as well as a wide array of environmental sequences from Genbank; and (iii) to describe a group I intron found in three populations of The phylogenies derived from SSU rDNA sequences with maximum likelihood (ML) and Bayesian inference (BI) methods were generally congruent with each other and, thus, were combined into a consensus tree for the following descriptions. Altogether, sequences of nine currently recognized families were included in phylogenetic analyses, which yielded support for a variety of previously unconfirmed or unsuspected relationships between and within taxa .Ophrydium (family Ophrydiidae) with Carchesium polypinum was highly supported in both trees. Both Pseudovorticella and Epicarchesium were paraphyletic, with two sessile, marine species of Epicarchesium grouped with species of Pseudovorticella in one of two sister clades and the free-swimming, freshwater species E. pectinatum in the other one , was sister to the clade consisting of subclade III and Epistylididae. Subclade III consisting of species of Zoothamnium, Zoothamnopsis and Myoschiston was sister to a large clade containing the majority of species in the Epistylididae.The family Zoothamniidae comprised three genetic clusters . SubcladEpistylis, was nested within the clades comprising the family Zoothamniidae891012Epistylis sp4, Epistylis sp. MD-2012, and Opisthostyla sp. The secondarily free-swimming species Telotrochidium matiense (family Opisthonectidae) occupied a separate divergent branch that was basal to the entire epistylidid clade.The family Epistylididae consisted of four genetic clusters . The larCampanella spp. occupied the basal position in the clade. Epistylis galea grouped with species of Opercularia and Propyxidium (family Operculariidae), and a species of Epistylis resembling E. galea clustered with two species of Telotrochidium. Monophyly of the family Operculariidae was fully supported, with a single species of Propyxidium nested within Opercularia spp.  and 2 (410 nt), collected in Austria, were identical except for two insertions of adenine at positions 636 and 660 in the sequence of population 2. The intron of population 3 (402 nt), collected in China, contained a 6 nt deletion compared with that of population 2. According to the reference SSU rDNA sequence of Escherichia coli (accession number J01695), the intron positions were determined to be at nt. 242 for three populations of V. gracilis, thus named as Vgr.S242 following the nomenclature suggested byIntrons that were 402, 408, and 410 nt in length were identified in the SSU rDNA sequences of three populations of V. gracilis were predicted and the differences between the structures of populations 1 and 3 are underlined in The secondary structures of introns of three populations of Sequences of previously reported introns of ciliates were collected from GISSD and Genbank and used to construct an intron tree of ciliates. In the tree, sequences were recovered as two divergent clades, subgroups IC1 and IE . Within Altogether, 147 SSU rDNA sequences of peritrichs from this study and Genbank were included in our phylogenetic analyses. This data set yielded a number of new insights about relationships among and within several families of peritrichs.Ophryidium versatile (family Ophryidiidae) clustered with vorticellids, contrary to morphological evidence109O. eichornii to our analyses confirmed a close relationship to one species of Carchesium  formed a single cluster with E. abrae 10Pseudovorticella, one sequence of Epicarchesium, and three sequences of E. pectinatum  revealed that both genera are non-monophyletic  was on a separate branch that was basal to the entire Vorticellidae with strong support, indicating that it might represent the tip of a branch in a much bigger tree because many species of the family Vorticellidae remain to be sequenced (Species of phyletic  and 2a. equenced .Vorticella (family Vorticellidae) actually are members of family Astylozoidae and redefined both families on the basis of molecular charactersVorticellides) and Opisthonectidae (genus Opisthonecta) in addition to those that were originally assigned to the Astylozoidae (genus Astylozoon). In the present study, newly obtained sequences of Vorticella mayeri, which is a free-swimming planktonic vorticellid and two ectosymbiotic species in the family Scyphidiidae all fell within the Astylozoidae clade which was clearly separated from A small genetic cluster consisting of three symbiotic species of scyphidiidae, suggesting that the family Scyphidiidae is polyphyletic and contains at least some species that should be reassigned to the Astylozoidae . The newly identified members of the Astylozoidae clade certainly conform to this pattern. Vorticella mayeri appears to lack a telotroch stageScyphidia spp. have lost the ability to form a stalk, attaching to a host with a thin layer of material secreted by the scopulaA previous study confirmed that some morphospecies of lozoidae . This alPlaneticovorticella has a complex life cycle that includes a trophont with the helically contractile stalk characteristic of vorticellidsP. paradoxa clustered with species of Zoothamnium in subclade II , clustered with the major clade of epistylididsTelotrochidium was polyphyletic, with T. matiense basal to the major Epistylididae clade and others within the basal clade  having recolonized freshwater , and (ii) introns from three populations of V. gracilis collected from geographically distant places were closely similar nonetheless in their primary sequences and secondary structures, suggesting that the intron originated from an ancient vertical transfer into the SSU rDNA sequence. Relatively few intron sequences of ciliates were available compared to the great number of species (8000+) reported. Therefore, introns must be discovered in many more taxa to reveal their true evolutionary history in ciliates.Group I introns have been found in a number of major eukaryotic lineages , but their distribution is highly scattered because most eukaryotic species appear to lack them. Group I introns have been classified into five major groups (IA-IE) and fourteen subgroups  based on comparative sequence analysisron tree  that wasThe ultimate function of phylogeny and taxonomy is to lay out a pathway for stepwise investigation of integrative roles of organisms in nature. Unfortunately, these disciplines have too often been treated as an end in themselves. Peritrichs and other ciliated protists represent a large proportion of biomass in inverse proportion to their microscopic size and are now known to comprise a key part of many ecosystems, with their participation in “microbial loops” perhaps the most universally recognized exampleForty-nine strains of peritrichs were collected from a wide variety of aquatic environments—shorelines, streams, bogs, lakes, ephemeral habitats, mariculture/aquaculture ponds, and ponds in botanical gardens in Asia, Europe and North America . IsolatiEcological distribution of peritrichs was investigated by collecting samples from two environments, the estuary of the Jiulong River in Xiamen, Fujian, China and the East Tropical Pacific Ocean off the western coast of South America, which were under-represented in previous studies. Eleven estuarine sites  were sampled across the entire salinity gradient. For each sample, 2 L-3 L of surface and subsurface waters were pre-filtered with a 200 μm sieve to remove mesozooplankton and then directly filtered through a polycarbonate filter of 3 μm pore size (Millipore), followed by storage in RNAlater . Approximately 2 L of surface water was collected from three sites  in the East Tropical Pacific Ocean, then were filtered through a 3 μm polycarbonate filter, followed by storage in liquid nitrogen for further treatment.Terminology and taxonomic classification used in the current paper largely followDNA extraction, PCR amplification and sequencing followedGenomic DNA of East Tropical Pacific Ocean samples was extracted using PowerWater DNA isolation Kit . Clone libraries were constructed using primers specific for ciliatesExtraction of RNA, reverse-transcription and nested pcr for estuarine samples followedGenbank accession numbers of newly obtained sequences are shown in Lengths and GC content of sequences are given in The GTR + I + G model was selected for Maximum likelihood (ML) analyses by jModeltest 2Short reads generated by high throughput sequencing were filtered for quality with QIIMEFirst, we interrogated nearly full-length environmental SSU rDNA sequences of peritrichs deposited in Genbank to detect environmental distribution patterns of species. Short sequences (<1400 bp) were filtered out from 1490 putative sequences of peritrichs, and duplicated sequences were de-replicated, leaving 60 environmental sequences from seven previously published studies of freshwater planktonic communities252728Sequences of peritrichs obtained with ciliate-specific primers from habitats that have not been represented in previous investigations, deep hypersaline anoxic basins (DHAB) in the Mediterranean SeaAltogether, 40 short environmental peritrich sequences  were appended to a dataset that included 147 sequences with clear taxonomic designations and 60 nearly full-length environmental sequences. Each short sequence was then aligned to its best blast hit using the pairwise alignment option in Bioedit and verified by visual examination. An ML tree was constructed with RAxML, and alternative phylogenetic placements of short sequences were estimated by EPA using likelihood weights. Placements with support of ≥95% were considered to have high confidence, and those with <95% low confidenceHow to cite this article: Sun, P. et al. An integrative approach to phylogeny reveals patterns of environmental distribution and novel evolutionary relationships in a major group of ciliates. Sci. Rep.6, 21695; doi: 10.1038/srep21695 (2016).


Low fruit and vegetable (FV) consumption is one of the top 10 global risk factors for mortality, and is related to increased risk for cancer, cardiovascular disease and diabetes. Many environmental, sociodemographic and personal factors affect FV consumption. The purpose of this review is to examine the effects of interventions delivered in the home, school and other nutritional environments designed to increase FV availability for five to 18-year olds.The search included: 19 electronic bibliographic databases; grey literature databases; reference lists of key articles; targeted Internet searching of key organization websites; hand searching of key journals and conference proceedings; and consultation with experts for additional references. Articles were included if: in English, French and Spanish; from high-, middle-, and low-income countries; delivered to anyone who could bring about change in FV environment for 5 to 18 year olds; with randomized and non-randomized study designs that provided before-after comparisons, with or without a control group. Primary outcomes of interest were measures of FV availability.The search strategy retrieved nearly 23,000 citations and resulted in 23 unique studies. Interventions were primarily policy interventions at the regional or state level, a number of curriculum type interventions in schools and community groups and a garden intervention. The majority of studies were done in high-income countries.The diversity of interventions, populations, outcomes and outcome measurements precluded meta-analysis. The most promising strategies for improving the FV environment for children are through local school food service policies. Access to FV was successfully improved in four of the six studies that evaluated school-based policies, with the other two studies finding no effect. Broader state or federally mandated policies or educational programs for food service providers and decision makers had mixed or small impact. Similarly family interventions had no or small impact on home accessibility, with smaller impact on consumption.The studies have high risk of bias but more rigorous studies are difficult to impossible to conduct in naturalistic settings and in policy implementation and evaluation. However, there are promising strategies to improve the FV environment, particularly through school food service policies. According to the World Health Organization (WHO) low fruit and vegetable (FV) consumption is one of the top 10 global risk factors for mortality. IncreasA recent systematic review of determinants of FV consumption among children and adolescents, identified availability and accessibility of FV in the home was positively associated with increased consumption after controlling for individual socio-demographic factors. ReviewsThe determinants of FV consumption are many and complex. InterveWe searched the following 19 databases up to June 2012:MEDLINE and Pre-MEDLINE (from 1966); EMBASE (from 1980); CINAHL and Pre-CINAHL (from 1982); the Cochrane Central Register of Controlled Trials (CENTRAL); the Cochrane Public Health Group Specialized Register; PsycINFO (from 1967); Dissertation Abstracts (from 1980); ERIC (from 1966); Effective Public Health Practice Project Database (1998); Sociological Abstracts (1952); Applied Social Sciences Index (1987); CSA Worldwide Political Science Abstracts (1975); ProQuest  (1923); PAHO Institutional Memory Database (1902); WHO Database on Child Growth and Malnutrition; Healthstar; Current Contents; ScienceDirect; and LILACS. Search terms were adapted according to the requirements of individual databases in terms of subject heading terminology and syntax.The search strategy for MEDLINE is shown in the Additional fileThe World Health Organization database and the Global Health Database were searched for relevant grey literature. Reference lists of all relevant articles were hand searched for additional relevant references. In our contact with authors of included studies, we asked for a list of other potentially relevant articles. These lists were reviewed for additional relevant references.http://www.who.int/en/), the Food and Agriculture Organization of the United Nations (http://www.fao.org/), and Pan American Health Organization (http://new.paho.org/).We conducted a targeted Internet search of key organization websites, including the World Health Organization  based on our consultation with experts in the field to determine rich publication sources: Health Policy; Journal of Public Health Policy; Journal of Health Politics, Policy, and Law; Health Economics, Policy, and Law; American Journal of Clinical Nutrition; Journal of Health Services Research; American Journal of Public Health; Journal of the American Dietetic Association; Nutrition Reviews; Maternal and Child Nutrition; Nutrition and Dietetics; Nutrition Research; Public Health Nutrition; American Journal of Preventive Medicine; and Journal of Human Hunger.To identify additional relevant references we consulted with policy-makers and researchers with experience in promoting, implementing and studying strategies to improve the FV environment for children.We sought articles in any language. Articles in English, French, and Spanish were reviewed for inclusion, assessment, and data extraction for inclusion in the review; however, we did not have capacity to translate articles in other languages for inclusion in the review.Randomized and non-randomized controlled trials , studies with interrupted time series designs (to assess changes that occur over time), and before-after studies with comparison groups  were included in the review. The study had to report both baseline and outcome data. The clusters within studies that answer this review question include school units, classrooms and communities rather than individuals as the unit of analysis.This review included populations from low-, middle-, and high-income countries and focused on children aged 5 to 18 years since childhood is a critical time period for establishing food habits and routines. We included interventions delivered to anyone or any institution that can bring about change in FV environment for 5 to18 year olds . This age group was chosen because another review on this topic, focusing on children under the age of five, was underway and has recently been published.Interventions included those aimed at modifying the FV environment through provision of FV, policies, and/or education: child nutrition programs such as breakfast/lunch and summer food service programs; community programs ; economic supplements and subsidies to purchase FV, including subsidies for schools and food stamp programs; environmental school change strategies ; environmental interventions/industry partnerships focused on point-of-purchase ; campaigns to draw attention to healthier products in grocery stores or to highlight the health benefits of certain foods; Internet, telephone and media interventions; farm-to-school programs that use locally produced foods; social marketing campaigns; policies that affect accessibility factors , or seek to increase FV consumption .Acceptable settings included: homes, schools, health department settings, religious institutions, family/child centres, community/recreation centres, non-governmental organizations, and primary healthcare settings. We excluded programs or strategies delivered through hospitals; outpatient clinics located within hospital settings; commercial programs, such as Health Check; universities/colleges; and metabolic or weight loss clinics.Primary outcomes included: FV supply ; change in food environment ; FV disappearance/food transition . Measures could be at the individual, family, school, or community level. Secondary outcomes included consumption of FV; awareness of importance/impact of FV consumption among targeted individuals; attitudes towards consumption of FV; general health measures (including changes in weight); and any reported adverse outcomes or unintended consequences.The search strategy identified titles and abstracts, which were independently examined by two reviewers for relevance. All articles selected by either team member were retrieved for full text review. Two reviewers independently examined the full text of retrieved articles for relevance. A third review author was consulted to resolve disagreements related to inclusion of articles. Two review authors independently assessed risk of bias of each article. Differences were resolved through discussion. Reasons for exclusion were documented and are available from the authors.Data were extracted from all included articles on: study design; participant, setting and intervention characteristics; and outcomes.One reviewer extracted the data and a second verified the data extraction form. A third reviewer resolved discrepancies through discussion. Reviewers attempted to contact lead authors a minimum of three times to obtain missing data. The review authors were not blinded to the names of authors or institutions.Relevant studies were evaluated for risk of bias using the Cochrane Collaboration’s tool for assessing risk of bias. Two revWe attempted to contact 14 authors regarding missing data; we were unable to obtain current contact information for two, two did not respond, and one responded but did not provide the clarifying information requested. We report all statistically significant and non-significant outcomes, however, we were not able to conduct a meta-analysis due to diverse definitions and measurements used.The search strategy retrieved nearly 23,000 citations; following full text review, 1,984 (98.8%) studies were excluded with 23 (1.2%) unique studies remaining. See Figure This review includes one trial that was conducted in American schools and threMaking distinctions to classify intervention type is difficult given the multiple components of some studies. Some interventions that were primarily focused on policy targeted food services and afterschool programs,27 whileInterventions that were more program or curriculum focused included one aimed at teachers, food seMost included studies reported on changes in the food environment,34,36-40In addition to reporting food environment outcomes, 15 studies reported on secondary outcome measures. Of these, most included a measure of consumption,35,39,40Most studies included children as a target audience, with three exceptions. Two studies targeted the general population,35 and oEach of the included studies n = 23) was rated as having high risk of bias . The intIn a cluster-controlled study, in-school fruit tuck shops were implemented in intervention schools (n = 23) with no tuck shops available in control schools (n = 20). Due to To examine the effects of an intervention to improve snack offerings based on the Programme national nutrition sante, Thibault and colleagues used a before-after design to study snacks offered by preschool teachers (n = 343 participating schools) in the Aquitaine region of France in two separate surveys (2004 to 2005 and 2007 to 2008). DiffereOther program evaluation studies found no significant impacts on FV accessibility as a result of intervention implementation.A cluster-controlled study examined a multifaceted whole school intervention through School Nutrition Action Groups with a goal of improving food provision and choices for adolescents in 12 intervention schools compared to adolescents in 12 control schools who did not receive these groups. ChangesIn the Peterborough Schools Nutrition Project, a 2-year multifaceted school based program, was implemented and evaluated using a cluster-controlled design. The intA number of studies demonstrated the effectiveness of programs in improving FV access among children 5 to 18 years. Tanner et al. conducted a pilot quasi-experimental study involving an after-school media and nutrition literacy intervention, family fun nights and a media campaign developed by the children in the intervention group and delivered to their parents. This piSeveral studies that examined the effects of home food environment interventions failed to demonstrate positive significant changes. A pilot quasi-experimental study examined the long-term effects of the Dutch Schoolgruiten Project to promote FV consumption among primary school children. As partIn 2008 Cullen and colleagues conducted a pilot before-after study that examined the feasibility of an 8-week web-based intervention to promote healthy eating behaviours in 67 families of African American girls aged 9 to 12 based on a modified version of the Texas Expanded Fruit and Nutrition Education Program. The FamBlom-Hoffman et al. evaluated a literacy-based, interactive component of a multi-year school-based education program to communicate nutrition information with families using a cluster-controlled design (n = 4 schools). The conA large quasi-experimental study including more than 600 participants evaluated the impact of a nutrition education program delivered to one urban and three rural communities and implemented by local nutrition advisors to improve nutrition knowledge and behaviours. RandomlAnother community-based program was evaluated using a cluster-controlled design. The 9 week multi-component 5-a-day Achievement Badge Program intervention implemented in 42 Boy Scout troops to increase FV consumption was comprised of weekly 30-minute in-troop Boy Scout education sessions augmented by 25 minutes of weekly online activities that targeted behaviour change and goal setting and BaraMozaffarian and colleagues evaluated the impact of an organizational change on the quality of snacks and beverages served in 11 Young Men’s Christian Association (YMCA) after-school programs in seven American states using a before-after study design. The orgA pilot before-after study examined the short-term impact of an educational intervention delivered within a YMCA summer camp to promote FV intake among fourth to sixth grade children (n = 93). As partThere are promising results for specific school food service policies,  with four of six studies finding improved FV environments. In attempting to account for differences in impact, six of seven policy studies included large numbers of schools with only one finding no significant impact on FV, and theInconsistent findings were frequently found according to types of food associated with interventions, often with changes resulting in improved sales or consumption of fruits but not vegetables. For example, fifty per cent price reductions in high school cafeterias for fruit, carrots, and salad increased consumption of fruit and carrots, with a corresponding decrease in consumption when prices reverted to usual. No differences were found across price points for salad.Broader policy interventions aimed at changing decisions of school principals or food service managers had little impact, with one broader community intervention that increased FV affordability and FV offerings in restaurants but decreased consumption among high school students. There aFew programs altered home FV availability. When consumption was assessed, the change was small even when statistically significant, and it would be difficult to determine if the small change would impact other health outcomes. All five studies that assessed knowledge or awareness reported significant improvements. Five of the seven studies reporting change in attitudes found positive results. No studies reported on general health measures  or on adverse effects of the interventions, except for one that found a decrease in FV consumption and provThis review provides a narrative synthesis of available international evidence on the effectiveness of interventions to improve the home and school and other FV environments for children aged 5 to 18 years of age. This literature is heavily based on studies conducted within high-income countries, which limits applicability to low- to middle-income contexts. Other than the small number of studies that focused on a particular ethnic target population or comparisons between urban and rural settings, the included studies did not report subgroup differences by gender, ethnicity, or socioeconomic gradients. This limits our understanding of how interventions that were found to be effective could be operationalized in different populations and contexts to address health inequities, and whether similar effects would be found.For the narrative analysis, the review has classified interventions according to policy or program interventions. However, these interventions take place on a continuum and are often not either/or. The theoretical basis of the interventions was often unstated, with curriculum/program interventions most often stated or inferred to have social learning or behavioural basis. There are insufficient studies that test similar intervention across by ethnicity, socioeconomic gradients or countries, to allow any analysis of different interventions according to these variables.The overall quality of evidence within the included studies is classified as weak, as every study was determined to have high risk of bias associated with its methodological approach. However, the nature of policy implementation and community-based interventions are such that randomization is rarely feasible, nor is blinding of participants and outcome assessors. The level of rigour in methodology may be close to the highest that could be expected for these sorts of naturalistic studies.There was large variation in duration of the intervention (one month to three years) and length of follow-up (immediate post-intervention to four year follow-up) with the longer duration and follow up related to policy changes. Many different approaches were taken to assess the FV environment, and within one outcome (like fruit access) the measurement varied across appearance (for example in vending machines), sales, requests, choice and consideration of wastage. This variability of outcomes and measurement did not allow for meta-analysis. Thus the review is limited by the narrative nature of the analysis. Outcome measurements usually were based on measurement tools that had not been tested for reliability and validity. Similarly, self-reported intake was sometimes measured by valid and reliable tools such as 4-day recall. However, they were often based on self-report using questions of unknown reliability and validity. Use of consistent, valid and reliable outcome measures would be a great step forward for research in this area.Some population-based intervention studies that may have the potential to impact FV accessibility for children were excluded since they did not report outcome measures for children aged 5 to 18 years specifically. It should also be noted that many of the included studies were focused primarily on impacting FV consumption and may not have had FV access as a primary outcome measure, but rather a process indicator or secondary outcome.With many reviews available about childhood obesity prevention and treatment, and nutrition more generally, this review adds to knowledge about the state of research about interventions to alter the food environment in schools and homes. The most promising strategies are local school food service policies. The FV environment was successfully improved in four of the six studies that evaluated school-based policies, with the other two studies finding no effect. Broader state or federally mandated policies or educational programs for food service providers and decision makers had mixed or small impact. Similarly family interventions had no or small impact on home accessibility.Controlled study designs to examine the effects of implementing policies and programs to increase FV accessibility to address health inequities within and across communities, especially those implemented in low- and middle-income contexts would be of particular interest to the field. Controlled study designs are, however, difficult to implement within a naturalistic setting, such as a school, and when evaluating policies. FV policies and programs emerge and evolve in response to contextual factors and, as such, are often not developed as research studies. At the same time, fuller description of contexts within reports and explicit identification of a theoretical basis would be useful. Where randomization is done, authors need to report on sequence generation and allocation concealment. A core of standard food environment or access, and even consumption measurement tools that are reliable and valid would move the field forward.No known potential competing interests.All authors  contributed their skills and expertise to this review including the protocol development, reviewing included studies, and reviewing manuscripts. All authors read and approved the final manuscript.Search strategy.Click here for fileCharacteristics of Included Studies.Click here for file


Jenny Hill and colleagues conduct a systematic review and meta-analysis of womenâ€™s access and healthcare provider adherence to WHO case-management policy of malaria during pregnancy.Please see later in the article for the Editors' Summary WHO recommends prompt diagnosis and quinine plus clindamycin for treatment of uncomplicated malaria in the first trimester and artemisinin-based combination therapies in subsequent trimesters. We undertook a systematic review of women's access to and healthcare provider adherence to WHO case management policy for malaria in pregnant women.p = 0.02), was consistently reported. Prescribing practices were driven by concerns over side effects and drug safety, patient preference, drug availability, and cost. Determinants of provider practices were access to training and facility type (public versus private). Findings were limited by the availability, quality, scope, and methodological inconsistencies of the included studies.We searched the Malaria in Pregnancy Library, the Global Health Database, and the International Network for the Rational Use of Drugs Bibliography from 1 January 2006 to 3 April 2014, without language restriction. Data were appraised for quality and content. Frequencies of women's and healthcare providers' practices were explored using narrative synthesis and random effect meta-analysis. Barriers to women's access and providers' adherence to policy were explored by content analysis using NVivo. Determinants of women's access and providers' case management practices were extracted and compared across studies. We did not perform a meta-ethnography. Thirty-seven studies were included, conducted in Africa (30), Asia (4), Yemen (1), and Brazil (2). One- to three-quarters of women reported malaria episodes during pregnancy, of whom treatment was sought by >85%. Barriers to access among women included poor knowledge of drug safety, prohibitive costs, and self-treatment practices, used by 5%–40% of women. Determinants of women's treatment-seeking behaviour were education and previous experience of miscarriage and antenatal care. Healthcare provider reliance on clinical diagnosis and poor adherence to treatment policy, especially in first versus other trimesters  has recommended that uncomplicated malaria (an infection that causes a fever but does not involve organ damage or severe anemia) should be treated with quinine and clindamycin if it occurs during the first trimester (first three months) of pregnancy and with an artemisinin-based combination therapy (ACT) if it occurs during the second or third trimester; ACTs should be used during the first trimester only if no other treatment is immediately available because their safety during early pregnancy has not been established. Since 2010, WHO has also recommended that clinical diagnosis of malaria should be confirmed before treatment by looking for parasites in patients' blood (parasitology).Prompt diagnosis and treatment of malaria in pregnancy in regions where malaria is always present (endemic regions) is extremely important, yet little is known about women's access to the recommended interventions for malaria in pregnancy or about healthcare providers' adherence to the WHO case management guidelines. In this systematic review and meta-analysis of qualitative, quantitative, and mixed methods studies, the researchers explore the factors that affect women's access to treatment and healthcare provider practices for case management of malaria during pregnancy. A systematic review uses predefined criteria to identify all the research on a given topic. Meta-analysis is a statistical method for combining the results of several studies. A qualitative study collects non-quantitative data such as reasons for refusing an intervention, whereas a qualitative study collects numerical data such as the proportion of a population receiving an intervention.The researchers identified 37 studies (mostly conducted in Africa) that provided data on the range of healthcare providers visited, antimalarials used, and the factors influencing the choice of healthcare provider and medicines among pregnant women seeking treatment for malaria and/or the type and quality of diagnostic and case management services offered to them by healthcare providers. The researchers explored the data in these studies using narrative synthesis  and content analysis (which identifies key themes within texts). Among the studies that provided relevant data, one-quarter to three-quarters of women reported malaria episodes during pregnancy. More than 85% of the women who reported a malaria episode during pregnancy sought some form of treatment. Barriers to access to WHO-recommended treatment among women included poor knowledge about drug safety, and the use of self-treatment practices such as taking herbal remedies. Factors that affected the treatment-seeking behavior of pregnant women (“determinants”) included prior use of antenatal care, education, and previous experience of a miscarriage. Among healthcare providers, reliance on clinical diagnosis of malaria was consistently reported, as was poor adherence to the treatment policy. Specifically, 28% and 72% of healthcare providers followed the treatment guidelines for malaria during the first and second/third trimesters of pregnancy, respectively. Finally, the researchers report that concerns over side effects and drug safety, patient preference, drug availability, and cost drove the prescribing practices of the healthcare providers, and that the determinants of provider practices included the type (cadre) of heathcare worker, access to training, and whether they were based in a public or private facility.These findings reveal important limitations in the implementation of the WHO policy on the treatment of malaria in pregnancy across many parts of Africa and in several other malaria endemic regions. Notably, they show that women do not uniformly seek care within the formal healthcare system and suggest that, when they do seek care, they may not be given the appropriate treatment because healthcare providers frequently fail to adhere to the WHO diagnostic and treatment guidelines. Although limited by the sparseness of data and by inconsistencies in study methodologies, these findings nevertheless highlight the need for further systematic assessments of the extent of substandard case management of malaria in pregnancy in malaria endemic countries, and the need to develop interventions to improve access to and delivery of quality case management of malaria among pregnant women.http://dx.doi.org/10.1371/journal.pmed.1001688.Please access these websites via the online version of this summary at malaria  and on malaria in pregnancy; the 2010 Guidelines for the Treatment of Malaria are available; the World Malaria Report 2013 provides details of the current global malaria situationInformation is available from the World Health Organization on malaria; a personal story about malaria in pregnancy is availableThe US Centers for Disease Control and Prevention also provides information on Roll Back Malaria Partnership on all aspects of global malaria control, including information on malaria in pregnancyInformation is available from the Malaria in Pregnancy Consortium is undertaking research into the prevention and treatment of malaria in pregnancy and provides links to the consortium's publications and an online library on malaria in pregnancyThe malaria (in English and Spanish)MedlinePlus provides links to additional information on  Malaria in pregnancy is an important public health problem for both maternal and neonatal health programmes. The manifestation of maternal infection with malaria depends on transmission intensity, and prompt diagnosis and treatment of malaria illness in pregnancy is important in all malaria endemic regions. Since 2006, WHO recommends quinine plus clindamycin for the treatment of uncomplicated malaria in the first trimester, and artesunate (AS) plus clindamycin for treatment failures. Artemisinin-based combination therapies (ACTs) known to be effective in the country/region, or AS plus clindamycin, are the recommended combinations for case management of uncomplicated malaria in the second and third trimesters Many countries in high transmission settings have made ACTs available free of charge to pregnant women in efforts to achieve universal coverage We undertook a systematic review of the factors affecting pregnant women's access to and health provider adherence to the 2006 WHO policy http://library.mip-consortium.org) is a comprehensive bibliographic database created by the Malaria in Pregnancy Consortium that is updated every 4 mo using a standardised protocol to search over 40 sources, including PubMed, Web of Knowledge, and Google Scholar. Searches were run separately for “pregnant women” and “health providers” . Studies were included if they met the following criteria: (1) study contained data on treatment seeking among women and/or case management practices for malaria in pregnancy, (2) study population included pregnant women and/or healthcare providers, (3) study reported original research data, and (4) study was conducted following the introduction of ACTs for the treatment of uncomplicated malaria in pregnancy in the study country. No restrictions were placed on study design , or quality of reporting. Studies limited to knowledge of malaria in pregnancy amongst pregnant women, i.e., without information on practices, were excluded. The Kappa (K) statistic was used as a measure of the inter-rater agreement on study eligibility between reviewers. Discrepancies between reviewers were resolved through discussions with a third reviewer (J. W.) until consensus was reached.Studies meeting the inclusion criteria were assessed and grouped according to content. Among pregnant women primary outcomes included (1) treatment-seeking practices for malaria, (2) barriers to accessing malaria treatment, and (3) determinants of treatment seeking for malaria. Among healthcare providers primary outcomes were (1) case management practices for malaria in pregnancy, (2) factors affecting malaria case management practices, and (3) determinants of knowledge, diagnosis, and treatment of malaria.Two authors extracted data and appraised the quality and content of included studies. Data for pregnant women or healthcare providers were extracted and analysed separately for description and frequency of practices, barriers/facilitators, and determinants . Two autNarrative synthesis was used to summarise, compare, and contrast the type, range, and frequency of practices from each study evaluating treatment seeking among pregnant women and case management practices among healthcare providers. To make a comparison between national policy and healthcare provider practices by country and region, we used the national or global malaria policy cited in the included studies.Barriers and facilitators were explored using content analysis with a previously defined thematic framework for pregnant women and healthcare providers We appraised the quality of reporting of each study using a checklist of criteria based on methods described in a previous review http://www.meta-analysis.com/), which was also used for sub-group analysis. We used forest plots to visualise the extent of heterogeneity between studies. For studies that reported source of treatment for more than one episode of fever, we included the response to the first episode I2 was used to quantify heterogeneity We pooled the frequency data for source of treatment among pregnant women and adherence to treatment policy among healthcare providers across different types of providers using random effect meta-analysis in Stata version 12 (StataCorp) and Comprehensive Meta-Analysis  of the quantitative studies was assessed to be moderate-high (scored 6–8/10), with ten low-moderate-quality studies (4–5/10) and three high-quality studies (9–10/10) . The quaThe 19 studies that contributed data on the treatment-seeking practices of pregnant women were undertaken in ten countries across Africa  and in one country in Asia  and 3.The proportion of women reporting at least one episode of malaria during their current or recent pregnancy ranged from 25% to 75% of respondents in three population-based Pregnant women in three population-based I2 ranging from 60% to 99%) (p = 0.008), whereas urban women made more use of health facilities .Data on sources of treatment extracted from nine studies showed high heterogeneity across studies ( to 99%) , and all to 99%) . CompareOnly six of the 14 studies among pregnant women with treatment-seeking practice as a primary outcome included quantitative data on use of ACTs, and of these, only four stratified use by trimester. In a household survey in Uganda, among first trimester episodes, quinine was used in only 6% of first trimester cases, with >80% of episodes treated with drugs not recommended for use in the first trimester either because they are contraindicated (sulphadoxine-pyrimethamine [SP] and artemether-lumefantrine [AL]) or because of high-grade drug resistance (chloroquine [CQ]) A household survey in southeast Nigeria found that 42% of pregnant women who had a fever within the last month had visited a health facility, of which 46% were treated with ACTs, 34% with SP, and 4% with artemisinin monotherapy; however, trimester was not specified The factors affecting treatment seeking for malaria most frequently cited in the content analysis related to the following: women's knowledge and perceptions of risk, perceptions and experience of drug safety, cost, and perceptions and experience of healthcare provider and health facility factors . Women iThe high cost of treatment prevented pregnant women from using the formal health sector in rural population-based surveys in Ghana The range of determinants of treatment seeking among pregnant women explored across the included studies included education, prior experience of miscarriage, and ANC use. The key findings are highlighted in The 24 studies that contributed data on the diagnosis and treatment practices of healthcare providers were undertaken in ten countries, involving a range of cadres, including medical doctors and nurses, pharmacists, drug vendors, traditional birth attendants (TBAs), and community health workers (CHWs)  and 3.Malaria diagnosis in pregnancy by public healthcare providers in the studies conducted in Africa was predominantly performed on the basis of clinical symptoms, as reported by one population-based study in Ghana In west and central Africa, 11 studies on health providers were conducted in Nigeria (eight studies), Ghana (two), and CAR (one), where the national antimalarial treatment guidelines stipulate quinine for treatment of uncomplicated malaria in the first trimester and an ACT in the second and third trimesters In Ghana, Kwansa-Bentum et al. found clinicians prescribing quinine for malaria treatment in the first trimester of pregnancy, per policy, but also SP, and predominantly ACTs were prescribed in the second and third trimesters, though SP and quinine were also prescribed In east and southern Africa, six studies were conducted in Kenya (one study), Malawi (two), Tanzania (one), and Uganda (two), where, again, the national malaria treatment policies recommend quinine in the first trimester, with an ACT (AS-AQ or AL) for the second/third trimester Plasmodium vivax malaria, only 45% of patients received the recommended first line therapy for P. falciparum malaria, with 7% and 18% of prescriptions, respectively, not sanctioned by national guidelines The remaining studies were conducted in Cambodia (one study) and Brazil (two studies). In Cambodia, only 4/27 pregnant women surveyed received the recommended drug, quinine, in the first trimester, and knowledge amongst private providers about first line treatment for malaria in pregnancy was poor I2 98.6%) (p = 0.02) (p<0.001). Studies conducted by self-administered questionnaires showed a significantly lower proportion of adherence to treatment policy  than studies using interviews  or record reviews , and studies describing practices in Nigeria were significantly less likely to report correct treatment  than studies in all other countries combined .Frequency data on adherence among healthcare providers to treatment policy by trimester, extracted from 12 studies, showed wide heterogeneity  , and all = 0.02) . StudiesP. falciparum were available at the village level; hence, people with a negative result were reported to self-treat for P. vivaxFactors affecting diagnostic and case management practices occurred at all levels of the health system and across all of the health system building blocks . ReliancPoor knowledge of and adherence to national treatment policy guidelines among healthcare providers was a consistent finding across countries in east Determinants of healthcare provider knowledge, diagnostic practices, and treatment practices explored across the different studies included the following: individual healthcare provider factors , type of facility , and region/location . There wOnly one intervention study was identified, which evaluated the effect of in-service training of clinicians and pharmacists in the private sector in three governorates in Yemen on malaria treatment in pregnant women To our knowledge this review draws together for the first time findings from disparate studies on the treatment-seeking practices for malaria in pregnant women and the case management practices of a range of healthcare providers globally. The key emerging themes are relatively consistent across a range of study settings in terms of local cultural, socio-economic, health system, and non–health system contexts, and geographical locations. One- to three-quarters of women reported malaria illness during pregnancy, of whom treatment was sought by >85%. Self-medication and traditional healers were reportedly used by 5% to 40% of women, alongside care from the formal health sector (range 42%–92%). Knowledge of drug safety, cost, and perceptions of healthcare services affected treatment choices. Determinants of treatment seeking were education and prior experience of miscarriage or ANC use. Healthcare providers' reliance on clinical diagnosis and poor adherence to treatment guidelines by trimester were consistently reported. Prescribing practices were driven by poor knowledge of national guidelines and concerns over side effects and drug safety, patient preference, drug availability, and cost. Determinants of provider practices were individual provider factors , facility type , and sub-national region.The review highlights important limitations in the implementation of the WHO policy on treatment of malaria in pregnancy Barriers to access among women—in particular, poor knowledge of drug safety, prohibitive costs, and self-treatment practices—suggest ministries of health need to improve women's access to information so that they can make informed choices. Educating women about the risks of malaria in pregnancy will be important, especially as the manifestation of malaria illness in pregnancy may be confused with pregnancy-related symptoms Diagnosis of malaria in pregnancy in many settings is challenging. In stable and high transmission settings, parasitological diagnosis based on microscopy or RDTs potentially reduces the unnecessary use of antimalarials in pregnancy, particularly in areas of high HIV prevalence, where HIV-infected patients have a high incidence of febrile illness Healthcare providers from a range of countries and continents and across a variety of cadres in the private and public sectors, and formal and informal sectors, demonstrated poor knowledge of and adherence to national treatment policy guidelines. Poor knowledge of and availability of treatment guidelines, and concerns over side effects and drug safety suggest the need for refresher training, job aids, and improved supervision. The finding that doctors were less likely to prescribe correctly may reflect personal judgements based on knowledge or individual client needs, as noted in a study in Zimbabwe where many practitioners felt that guidelines would limit their personal flexibility in caring for patients With the advent of the 2006 WHO policy The dearth of implementation research on interventions to improve the quality of case management of malaria in pregnancy underscores the fact that this is a neglected area of research, despite case management constituting one of the three key strategies for controlling malaria in pregnancy in sub-Saharan Africa, and a lifesaving intervention for both mother and child in lower transmission settings in Asia and Latin America. Research using standardised methodologies is needed to systematically document treatment seeking in pregnant women and healthcare provider practices across a range of countries and settings. Implementation research is needed to evaluate the impact of strengthened public sector practices on pregnant women's access to malaria treatment in the public sector, as well as strategies that target private drug sellers, such as better information, communication, and legislation for rational drug use.The review uses data from quantitative, qualitative, and mixed methods studies to increase the comprehensiveness of the review; studies with quantitative data provided frequencies of practices, the qualitative data provided important explanatory factors driving those behaviours, and the content analysis was useful to determine the frequency of reporting of the different factors associated with case management of malaria in pregnancy across studies. We did not attempt a meta-ethnography, as has been done by others The majority of studies of women were undertaken at sub-district, district, or state level, which limits the generalisability of the individual studies. There was reasonable consistency of findings across different studies in the same country and across studies in different countries. The studies of healthcare providers had greater geographic scope, with eight of 18 studies undertaken in more than one district or state, three of which were done at national level.Our review highlights the poor quality of case management practices for malaria in pregnancy across many parts of Africa, Asia, and Latin America. These practices not only threaten the health outcomes for mothers and their infants, but endanger the prospective useful life of several therapeutic drugs, in particular the artemisinins, through the continued use of monotherapies. The challenge for ministries of health will be the deployment of legislative and quality improvement interventions to reach the broad range of healthcare providers that administer antimalarial drugs in the community, in the private and public sectors as well as in the formal and informal sectors. Further implementation research using standardised methodologies is needed to systematically assess the extent of substandard case management practices at the national scale, to review how policies are implemented and disseminated by countries, and to assess practitioner and patient adherence. Research to evaluate targeted or multifaceted interventions aimed to improve the delivery of and access to quality case management services for pregnant women should be a priority.Table S1Search terms and databases used in the review.(DOCX)Click here for additional data file.Table S2Checklist for quality of reporting: quantitative studies.(DOCX)Click here for additional data file.Table S3Checklist for quality of reporting: qualitative studies.(DOCX)Click here for additional data file.Table S4Checklist for quality of reporting: mixed methods studies.(DOCX)Click here for additional data file.Table S5Sub-group analysis for source of treatment among pregnant women.(DOCX)Click here for additional data file.Table S6Sub-group analysis for adherence to treatment policy among health care providers.(DOCX)Click here for additional data file.Text S1PRISMA statement.(DOC)Click here for additional data file.


About 90,000 preterm infants or babies with birth defects are born in Italy every year, nearly 250 per day. These congenital conditions and their outcomes represent the most important burden of disease affecting the health status and the quality of life during infancy, childhood and beyond. In many cases they are fostered by the presence of maternal and/or paternal preconception risk factors whose effects can be modified by primary prevention.In the contemporary vision of maternal and child health, the traditional gap between preconception period and pregnancy is overcome through promotion of reproductive health and wellness in women, men and couples, regardless of their reproductive plans and possible future pregnancies. This paradigm should become the basic foundation to improve and protect infants’, children’s and adolescents’ health. Useful interventions belong to four broad areas: a) promotion of women’s and couples’ health in general, and protection from risk of adverse events in future pregnancies (if any); b) identification and treatment of conditions that increase the risk of adverse reproductive outcomes; c) help for women (couples) planning for pregnancy; d) identification of genetic risks, and help for independent and responsible decision making.Pediatricians and neonatologists can effectively promote primary prevention in the interconception period, when parents seek consultation for their previous child, in adolescent medicine, in family health education, in socio-sanitary network, and in advocacy activities in favor of infants and children. These actions should be part of an operational framework including perinatal outreach programs, information campaigns, and focus on problems of high-risk women, children and families. The promotion of women’s and couples’ health before conception of their children should become the first-line essential task of the National Health Service if we want to improve future generations’ health.There are at least three good reasons supporting this statement:1. About 90,000 preterm infants or babies with birth defects are born in Italy every year, nearly 250 per day [2. The prevalence of modifiable preconception risk factors is much higher than expected, and there is almost no couple of parents-to-be without at least one;3. Many babies can be born without severe congenital conditions following interventions aimed at modifying the exposure to potential risk factors before conception.Primary prevention in the preconception period is therefore the basic mainstay of any program pointing at promotion and protection of infants’, children’s and adolescents’ health .Adverse reproductive outcomes are numerous and include both pathological and potentially pathological events of reproduction . They maAdverse reproductive outcomes have been usually interpreted as possible consequences of many relatively rare, largely behavioral, risk factors. This approach has generated what has been defined a “fragmented epidemiology”, that in turn has been responsible for fragmented health policies and programs . In partIt is far-back known, although often overlooked, that the biological being starts at conception. This statement is undeniable, independently of any ethical debate about the concepts of life or person. The moment of conception and the earliest steps of embryo development have been recognized as essential for humankind wellness. Epigenetic reprogramming occurs soon after conception . PlacentThe cultural and professional domain of pediatrics should include the primary prevention of the adverse reproductive outcomes. If it is agreed upon that health should be promoted “any time any healthcare provider sees a reproductive age woman” ,10, thenAlthough the effectiveness of women’s health promotion carried out by pediatricians in the interconception period has not been evaluated in formal studies, a good amount of evidence is available about the usefulness of some core preventive interventions in the pre-pregnancy period ,14; thisUseful interventions for the promotion of reproductive health can be grouped in four broad areas:A. Promotion of women’s and couples’ health in general, and protection from risk of adverse events in future pregnancies (if any);B. Identification and treatment of conditions that increase the risk of adverse reproductive outcomes;C. Help for women (couple) planning for pregnancy, in order to face and properly manage the risk factors of adverse reproductive outcomes;D. Identification of genetic risks, and help to make responsible decisions.Each of these areas includes a series of specific activities. For example, in area A we can found: vaccinations against rubella, chickenpox, tetanus, whooping cough; sex education; individual counseling for fertility control; prevention of pregnancies before the age of 20 and information about risks associated with advanced reproductive age; prevention of short interpregnancy intervals; promotion of healthy lifestyle; identification of and action for women/couples with socio-economic difficulties, stress, depression, domestic violence; active advice for daily supplementation with 0.4 mg folic acid. Other examples could be given for the remaining three areas .Pediatricians can represent an important source of advice during every working circumstances: as family pediatricians, in community health centers, in private offices, in health authorities’ districts, in hospitals’ inpatient and outpatient departments. Possible barriers however exist; they include concern about reaction of mothers, inadequate knowledge of possibilities to assist them, and financial obstacles . These dTwo aspects must be highlighted. The first one, that has already been hinted at, implies that risk factors  may occur throughout almost a woman's entire life, in particular from her own conception to the birth of her children, a fact that partly explains the observed differences in health. Many generations might therefore be needed in order to have a disease-burden reduction as a consequence of effective prevention interventions. The second aspect is linked to the need of identifying the most appropriate actions for minority high-risk population groups. In this respect, the so called “vertical” (non-integrated) programs have not produced substantial and long-acting results; they are characterized by distinct short- or medium-term targets, and are based on activities financed separately and running in parallel with those normally offered by the National Health Service. On the other hand, the so called “horizontal” (integrated) programs may represent a valid and more effective option. They can be focused on integrated interventions for interrelated health problems, running in services dedicated to prevention and primary health care, and routinely financed by the National Health Service with no or only small additional funding . Within A unique conceptual framework is needed to promote women’s and couples’ health . Perinatal outreach programs, information campaigns to increase the awareness of people about health gain and preservation, and focusing on problems of high-risk women, children and families, should all become part of such a comprehensive framework.The authors declare that they have no competing interests.Both CC and PM have made substantial contributions to conception and design of the paper, have been involved in drafting the manuscript and revising it critically for important intellectual content, and have given final approval of the version to be published.Carlo Corchia: Consultant neonatologist and epidemiologist; deputy Director, Alessandra Lisi International Centre on Birth Defects and Prematurity, WHO collaborating centre, Rome, Italy; former Director, Neonatal Intensive Care Unit, Bambino Gesù Childrens’ Hospital, Rome, Italy.Pierpaolo Mastroiacovo: Full professor of Pediatrics and epidemiologist; Director, Alessandra Lisi International Centre on Birth Defects and Prematurity, WHO collaborating centre, and Pensiamoci Prima Project, Rome, Italy; Director, Centre of the International Clearinghouse for Birth Defects Surveillance and Research; former Director, Department of Pediatrics, Catholic University, Rome, Italy.