In Pacific Island countries and territories, the burden of road traffic injuries and their attendant risks are considered significant but are poorly quantified. As with other low and middle-income countries, understanding the epidemiology of road traffic injuries in Pacific countries is critical to informing sustainable research and policy initiatives aimed at reducing this burden.We undertook a systematic review and critical appraisal of the relevant epidemiological literature between January 1980 and December 2010, using key search strings for incidence and aetiological studies focusing on RTIs in less resourced Pacific countries.Nineteen studies were identified. The majority were descriptive and were unable to provide population-based estimates of the burden of road crash injury, or reliable information on risk factors using well-designed aetiological research methods. All studies were published more than 10 years ago, and all but three reported on data from Papua New Guinea, thereby limiting the generalisability of findings to the current status in the region. Studies undertaken in Papua New Guinea suggested that RTIs were more frequent among young males, with head injuries the most common cause of death or hospital admission. Two thirds of fatalities occurred at the crash site or soon after admission. Most road crash victims were passengers or pedestrians. Factors postulated to influence the risk of RTIs were travel in open-back utility vehicles, utility vehicle overcrowding, and alcohol.This review suggests that, despite increasing awareness of the importance of addressing road safety among stakeholders in less resourced Pacific Island countries, road traffic injuries have not been a research priority with little relevant current evidence from the region to inform policy. Robust epidemiological research that can assess the magnitude and key determinants of road traffic injuries in these settings is essential to determine context-specific road safety initiatives that are relevant and affordable. Greater attention to harnessing routinely collected data  to inform policy is also required. Road traffic injuries (RTIs) are a significant public health challenge and projected to be the fifth leading contributor to the global burden of disease by 2030 . Over 90We identified and critically appraised epidemiological studies published between January 1980 and December 2010 focusing on RTIs. The countries of interest comprised 18 of the 22 member states of the Secretariat of the Pacific Community, encompassing all of the countries in the Pacific region but excluding high-income countries as classified by The World Bank : MedlineThe review was restricted to studies published in the English language. All studies identified were screened initially by title and abstract, and then more thoroughly in full text. Figure  AdheringNineteen studies -41 publiAlthough the majority of studies were case series, there was wide variation in study design and quality. Most of the studies conducted outside PNG were small except for one study in Fiji reviewing national road crash data (n = 2277) . In geneThe methodological quality of the studies or the ability to appraise this was compromised by inadequate reporting of population characteristics, case definitions, recruitment methodology , exclusion criteria, data collection and analysis, response rates, and identification of potential biases and confounders. Most research designs failed to consider possible biases in analysis and the interpretation of findings. Since many studies reviewed post mortem records, potential cases may have been excluded if they had not presented to the hospital setting. The majority of studies were retrospective, and the quality of data sources,  was unspecified. This makes it difficult to ascertain the extent to which misclassification and underreporting may have been a source of information and recall bias. No studies reported whether outcome measures or blood alcohol concentration (BAC) measurements were assessed blind to exposure information, nor whether measurement bias was considered when estimating alcohol concentration from breath or blood samples.Regarding measures of occurrence and effect, most of the studies reported unadjusted event counts and proportions, with only three studies providing population-based rates ,38,40, aAcknowledging these limitations, Table In a study of 1,279 post mortems from all causes of deaths in all ages conducted at Port Morseby General Hospital (PMGH) for the years 1962 to 1989, RTIs (n = 573) accounted for 45% of all deaths, 75% of whom were male . AnotherMotor vehicle passengers (46–51%) and pedestrians (34–36%) were the road user groups commonly involved in fatal crashes -40. HeadStudies suggest RTIs were responsible for 14–30% of trauma admissions ,34, 49% RTIs contributed to 14% of injury related admissions (n = 100) to the accident and emergency (A&E) department in Yap hospital , and 25%Although we did not identify any aetiological studies with appropriate control (unexposed) groups, several studies suggested factors that were likely to be important contributory factors to road crashes.An ecological study drew attention to vehicle type, noting increased risks of crashes involving buses and open-back utility vehicles compared with cars . SeveralIn contrast to passenger injuries, driver injuries were reported to be highest for cars, with some studies attributing up to 70% of RTI fatalities to driver error ,37. One Several studies commented on the role of alcohol in RTIs. In a roadside survey of motor vehicle drivers (n = 893), and review of RTI related drivers assessed at the PMGH emergency department (n = 10), BAC levels above 80 mg/dL were detected in 24% and 80% of drivers, respectively . Post moThe literature regarding the burden and risk factors in the Pacific region remains largely limited to descriptive studies in PNG with important limitations in their ability to examine the population-based burden of road crashes and investigate related risk factors. No RTI focused epidemiological studies have been published for over 15 years and few were conducted outside PNG. Notwithstanding these limitations, the published literature indicates that road crashes are a major public health problem. Studies from PNG reported that RTIs contributed to at least 40% of all deaths, 60% of trauma-related deaths, one third of trauma-related hospitalisations, and 40% of all head injuries. Most (two thirds) RTI-related deaths occurred prior to hospitalisation with related fatalities particularly high among pedestrians and passengers. Although head injuries were the most commonly reported RTI-related injury, chest injuries were reported to be particularly common among motor vehicle drivers. The available literature suggests that vehicle type (open-back utility), utility vehicle overloading, and alcohol are potentially important risk factors for RTI.This review was limited to scientific publications and the English language. Therefore, it excluded the grey literature and routinely collected data such as police annual reports and national hospital and mortality statistics, most of which report events but provide little critique or analysis. The diverse methodological characteristics of the studies identified made it inappropriate to undertake a metaanalysis, or infer that the findings from these largely PNG focused studies can be generalised to Pacific countries more generally.Nevertheless, this review adds to the evidence base of previous reviews on RTI in less resourced settings ,43,44, fThe review particularly reveals the need to undertake well-designed aetiological studies that can quantify the contribution of important context-specific risk factors associated with serious road crashes. Indicative findings from the review suggest a key area requiring focused attention in PNG is improved safety considerations relating to the use of utility type vehicles . While tThe World Report on road traffic injury prevention identifies the need for a comprehensive multi-sectoral, integrated, systems approach that focuses on improved information systems, institutional capacity strengthening, research that quantifies common modifiable risks, and resources for targeting these . ReliablThis review found that the burden of road traffic injuries in PNG and other less resourced Pacific countries is significant, however, the contribution of modifiable risks for RTI remain poorly quantified. While some studies revealed the likely importance of factors such as alcohol misuse and vehicle type, effective public health and road safety policy requires attention to population-based studies that can identify and quantify the contributors to RTI in the Pacific context. Improving the quality of secondary data sources from routinely collected hospital and police surveillance systems is essential.A&E: Accident and emergency; BAC: Blood alcohol concentration; PNG: Papua New Guinea; PMGH: Port Moresby General Hospital; RTI: Road traffic injuries.The authors declare that they have no competing interests.JH conducted the literature search, selected included papers, critically appraised the papers, developed the evidence tables, and wrote the initial draft of the paper. SA and RJ contributed substantially to the design of the evidence tables, the outline of the paper, interpretation of findings and writing the paper. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/479/prepubSearch string applied for the review.Click here for filePRISMA checklist for systematic reviews[. reviews.Click here for file


The financial cost of biodiversity conservation varies widely around the world and such costs should be considered when identifying countries to best focus conservation investments. Previous global prioritizations have been based on global models for protected area management costs, but this metric may be related to other factors that negatively influence the effectiveness and social impacts of conservation. Here we investigate such relationships and first show that countries with low predicted costs are less politically stable. Local support and capacity can mitigate the impacts of such instability, but we also found that these countries have less civil society involvement in conservation. Therefore, externally funded projects in these countries must rely on government agencies for implementation. This can be problematic, as our analyses show that governments in countries with low predicted costs score poorly on indices of corruption, bureaucratic quality and human rights. Taken together, our results demonstrate that using national-level estimates for protected area management costs to set global conservation priorities is simplistic, as projects in apparently low-cost countries are less likely to succeed and more likely to have negative impacts on people. We identify the need for an improved approach to develop global conservation cost metrics that better capture the true costs of avoiding or overcoming such problems. Critically, conservation scientists must engage with practitioners to better understand and implement context-specific solutions. This approach assumes that measures of conservation costs, like measures of conservation value, are organization specific, and would bring a much-needed focus on reducing the negative impacts of conservation to develop projects that benefit people and biodiversity. Biodiversity is declining at a rapid rate  but therThese early analyses were instrumental in shifting the focus from single species to more holistic biodiversity conservation schemes , but felThe strong influence of management cost on global prioritizations highlights the importance of using a cost metric that reflects the true, realized costs of achieving conservation goals ,27. HoweSuccessful project implementation depends on a range of factors beyond the direct costs of staff wages, equipment and time ,32. For Conservation planning efforts must also consider implications for local people, as any negative impacts can reduce human wellbeing and erode support for conservation. This is particularly important because many nations with low predicted management costs are developing countries with large populations of rural, disenfranchised poor ,37. It iConservation NGOs are committed to improving project success and minimizing negative impacts on project stakeholders, but the costs of achieving these goals are rarely considered in global prioritization exercises. There is, therefore, a need to investigate whether using modeled management costs in global conservation prioritizations highlights countries where implementation is more difficult and negative impacts on people more likely. Here, we investigate the relationships between national-level protected area management costs and a range of factors that broadly relate to conservation effectiveness and impacts on people.Conservation actions involve a range of costs beyond direct management costs, including acquisition, transaction, damage, and opportunity costs . In thisIn this paper we compare modeled country-level conservation management costs to widely used global indicators for civil society involvement in conservation, governance, and human rights. We hypothesize that countries with low predicted management costs also tend to have lower levels of civil society involvement in conservation, less effective and stable governments, and less protection of human rights. Support of these hypotheses would suggest that the management cost estimates most often used in global conservation prioritization are simplistic and neglect important factors that impact project implementation and outcomes. Therefore, achieving long-term conservation success in countries with low predicted costs, and avoiding unintended negative impacts on people, may be more difficult or more expensive than current cost models predict.Our analysis adopted the most widely used approach for calculating the protected area management costs for each country, the Balmford-Moore equation ,23. ThisThe Balmford-Moore equation states that the cost of managing land as protected areas is a non-linear function of the nation’s gross national income (GNI) scaled by its total area, its purchasing power parity (PPP), and the size of a protected area (PA):2 for all countries to enable comparison of conservation costs for equal-sized protected areas across countries. While data on the extent of protected areas exist for most countries [For this analysis we used a standard reserve size of 100 kmountries , we usedThe extent to which civil society is involved in conservation efforts is difficult to measure and quantify, particularly at the national level. To our knowledge, there are three datasets that provide unbiased, quantifiable, and comparable information about this issue for many countries globally (i-iii below). We used all of these datasets in an effort to capture as much information as possible regarding civil society involvement in conservation. All data are available in BirdLife International (BLI) is the world’s largest global partnership of conservation organizations, maintaining partnerships with local, independent, membership-based NGOs in over 100 countries on all inhabited continents. Data on citizen membership for BirdLife partner NGOs is available online for 86 of these countries  is the world’s oldest and largest global environmental organization, with more than 1200 member organizations (200+ government and 900+ non-government) in 160 countries (www.iucn.org). The number of IUCN organizations per million people was one of many variables used to create the Environmental Sustainability Index (ESI) . We obtaAgenda 21 is a voluntary action plan of the UN regarding sustainable development, intended to motivate action at international, national, regional, and local levels (http://www.un.org/esa/dsd/agenda21/). Local Agenda 21 initiatives are measures undertaken and overseen by local authorities to address problems of environmental sustainability, and represent the involvement of civil society in environmental governance. The number of Local Agenda 21 initiatives per million people was another variable calculated for the 2005 ESI , and we One of the most widely used systems for measuring quality of governance at the national level is the Worldwide Governance Indicators (WGI), constructed by the World Bank and based on consultations and surveys with citizens, experts, businesses, and international organizations . We usedThe most comprehensive, national-level global dataset on protection of human rights is the Cingranelli-Richards Human Rights Dataset (CIRI) . The CIRFor all datasets we used the most recent data available. Years of the data range from 2001  to 2012 (membership in BLI partner organizations). We separately examined the relationships between national-level modeled protected area management costs and each socio-political variable: civil society involvement in conservation , quality of governance , and human rights (Empowerment Rights Index). We also investigated the relationships between each of the three measures of civil society involvement. Because none of the individual datasets satisfy the normality assumptions for parametric correlation, we used nonparametric Spearman rank correlations for all analyses. Analyses were performed in the statistical packages JMP  and R 55.2 terrestrial protected area in each country ranges between US$34 for Mongolia and US$1.7 million for Monaco, with a median value of US$4,260. Political stability is correlated with protected area management costs , gross national income , purchasing power parity , and calculated values for Balmford-Moore conservation management cost by country. Area, GNI, and PPP data are from the United Nations Statistics Division (unstats.un.org).(CSV)Click here for additional data file.File S2Citizen membership in BirdLife International (BLI) partner NGOs by country (2012).Data are from BLI .(CSV)Click here for additional data file.File S3Country population data (2010).Data are from United Nations Statistics Division (unstats.un.org).(CSV)Click here for additional data file.File S4Environmental Sustainability Index (ESI) values for IUCN Organizations per million people (2003-2004) and Local Agenda 21 Initiatives per million people (2001) by country.Data are from ESI 2005 .(CSV)Click here for additional data file.File S5World Governance Indicators for Control of Corruption, Government Effectiveness, and Political Stability & Absence of Violence by country (2010).Data are from the World Bank (info.worldbank.org/governance/wgi/index.asp).(CSV)Click here for additional data file.File S6Cingranelli-Richards (CIRI) human rights data for Empowerment Rights Index by country (2010).Data are from CIRI (www.humanrightsdata.org/).(CSV)Click here for additional data file.


Mitochondrial DNA (mtDNA) hypervariable region (HVR) sequences of prehistoric Polynesian chicken samples reflect dispersal of two haplogroups—D and E—by the settlers of the Pacific. The distribution of these chicken haplogroups has been used as an indicator of human movement. Recent analyses suggested similarities between prehistoric Pacific and South American chicken samples, perhaps reflecting prehistoric Polynesian introduction of the chicken into South America. These analyses have been heavily debated. The current distribution of the D and E lineages among contemporary chicken populations in the Western Pacific is unclear, but might ultimately help to inform debates about the movements of humans that carried them.We sought to characterize contemporary mtDNA diversity among chickens in two of the earliest settled archipelagoes of Remote Oceania, the Marianas and Vanuatu.We generated HVR sequences for 43 chickens from four islands in Vanuatu, and for 5 chickens from Guam in the Marianas.Forty samples from Vanuatu and three from Guam were assigned to haplogroup D, supporting this as a Pacific chicken haplogroup that persists in the Western Pacific. Two haplogroup E lineages were observed in Guam and two in Vanuatu. Of the E lineages in Vanuatu, one was identical to prehistoric Vanuatu and Polynesian samples and the other differed by one polymorphism. Contrary to our expectations, we observed few globally distributed domesticate lineages not associated with Pacific chicken dispersal. This might suggest less European introgression of chickens into Vanuatu than expected. If so, the E lineages might represent lineages maintained from ancient Pacific chicken introductions. The Vanuatu sample might thus provide an opportunity to distinguish between maintained ancestral Pacific chicken lineages and replacement by global domesticates through genomic analyses, which could resolve questions of contemporary haplogroup E chicken relationships and inform interpretations of debated sequences from archaeological samples. The discovery and settlement of the thousands of islands of Micronesia, Polynesia, and Eastern Melanesia beginning around 3,500 years ago The distribution of these domesticates can inform our understandings of human movements The issue remains unresolved because the data currently available are consistent with both prehistoric and historic introductions. Storey and colleagues The distribution of haplogroup D in Southeast Asia, Island Southeast Asia, and Polynesia, and its scarcity elsewhere , suggestWe sought to characterize genetic diversity of contemporary chickens in Vanuatu and, in particular, to examine whether the D and E lineages are present today. We also included analyses of contemporary samples from Guam in the Mariana archipelago, another of the earliest settled regions of Remote Oceania. We collected samples from contemporary chicken populations in these two regions , analyzed mtDNA HVR sequences, and compared them to sequences from contemporary and prehistoric samples from the Asia-Pacific region. We expected to observe diversity among contemporary chicken populations, but hypothesized that lineages observed among ancient Pacific samples would be maintained in Remote Oceanic populations. These analyses not only help to highlight the current distribution of chicken lineages in the Pacific, but also provide a framework for discussing the complications inherent in distinguishing prehistoric, historic, and recent commercial introductions and in inferring origins based on current lineage frequencies and distributions.Samples were collected and analyzed in accordance with Binghamton University Division of Research guidelines. Following the Binghamton University Institutional Review Board (IRB) guidelines, samples were taken with animal owners' consent and without harm to the animals involved; full IRB review was not necessary. Chicken feathers were collected from 12 sampling sites representing nine villages and four islands in the Vanuatu archipelago: Ambae, Aneityum, Efate, and Tanna see , and fro5′-ACCCATTATATGTATACGGGCATTAA-3′ and 5′-AGTTATGCATGGGATGTGCCTGACCGAG-3′. Approximately 420 bases of the mtDNA control region were sequenced in both directions with the BigDye Terminator Kit on an ABI 3730xl DNA analyzer .The cumulus of feathers was washed with ethanol, rinsed with distilled water, and cut into small pieces. DNA was extracted using the QIAamp DNA Tissue Kit  according to the manufacturer's instructions, with the addition of preliminary overnight incubation in Proteinase K at 56 degrees. DNA was amplified by PCR using primers Phylogenetic analysis: 420 base pairs from the mtDNA HVR  were aligned and compared to published sequences Twenty-four polymorphic sites were identified across 420 bp of mtDNA HVR from comparisons of the Vanuatu and Guamanian samples to the reference sequence Among the three Guamanian haplogroup D samples, three lineages were observed. One matched contemporary samples from the Philippines, Indonesia, and Japan. The other lineages were unique, but were closely related to contemporary samples from Indonesia, Japan, the Philippines, and China as well as India, Sri Lanka, Thailand, and Madagascar. Among the 40 haplogroup D samples from Vanuatu, seven lineages were observed. Four were exact matches to contemporary samples from Indonesia, Japan, the Philippines, and Southern China, as well as prehistoric Easter Island samples. The major Vanuatu lineage (n  =  17), also found in a Red Jungle Fowl from the Philippines, was distributed across all four islands sampled see .Ancient DNA analyses suggest that both D and E lineages were transported into Remote Oceania prehistorically, but there has been little sampling among contemporary populations in Remote Oceania to address the question of whether these patterns remain. Our data indicate that lineages observed among prehistoric Pacific samples are present in Remote Oceania today. The signature of haplogroup D, previously suggested to be erased across the Western Pacific with the introgression of European chickens th and 19th centuries The lineages observed in Vanuatu were closely related to other ancient Vanuatu and Polynesian samples: the major lineage (n  =  17) matched four of the six prehistoric samples from Easter Island assigned to haplogroup D6, and Vanuatu haplogroup D lineages were also closely related to contemporary samples from southern China, Indonesia, and the Philippines, consistent with the theorized homeland of the Lapita settlers of Remote Oceania As among the Araucana chickens in Chile, the lineages in our Remote Pacific samples – especially the E lineages, which are observed among contemporary samples around the globe – might have persisted from those introduced prehistorically, they might have been historically introduced, they might reflect recent expansion of commercial domesticates, or they might result from any combination of these patterns. In Guam, for example, one field report documents bird bones up to 2000 years old that may be from chickens The maintenance of Pacific chicken lineages in Vanuatu might provide an opportunity to resolve questions about South American chicken origins that have remained unanswered with available data sets. Just as the origins of contemporary haplogroup E lineages in Vanuatu are not firmly known, whether the haplotypes observed among contemporary Chilean Aracauna chickens reflect the persistence of ancient Polynesian haplotypes, the spread of European chickens introduced post-colonially, or the introgression of common commercial lineages today, has not been and cannot be resolved with mtDNA HVR sequences alone. The presence of both Pacific chicken lineages among contemporary Vanuatu samples might suggest that this population contains descendents of the original Pacific chickens. Genomic data from this sample could be compared to data from European and contemporary Chilean haplogroup E lineages, which have otherwise identical mtDNA HVR sequences, to resolve their relationships. While interpretations of past introductions based on contemporary distributions are difficult, the generation of more extensive data sets from carefully selected populations that have maintained Pacific chicken diversity could provide the context necessary for resolving the relationships between contemporary samples, and the interpretations of continuous human movement of domestic animals they inform.Figure S1Location of Vanuatu in relation to Australia and New Guinea (inset) and sampling locations.(TIF)Click here for additional data file.Table S1Nucleotide polymorphisms in contemporary Vanuatu samples.(XLS)Click here for additional data file.


The National Rural Health Mission (NHRM) aims to increase the uptake of safe institutional delivery among rural communities in Karnataka. Previous studies in India have found that while there has been increasing numbers of institutional deliveries, those who had lower socio-economic status, were from scheduled caste (SC), or had less education or media exposure were less likely to use hospitals for delivery. A few studies on quality of care consistently found a more positive perception and experience at private hospitals. The purpose of this study was to explore the factors influencing choice of birthing site, specifically home, public and private hospitals, and the decision-making processes involved in the choice, in North Karnataka.Kannada and English for analysis. Thematic analysis was undertaken in which codes were identified through review of transcripts and categories were created based on the codes. Comparative analysis was completed looking for similarities and differences in experiences, perceptions and decision-making by birthing site, participant type, district and sociodemographic characteristics. Ethics approval was obtained from St. John’s College, Bangalore and the University of Manitoba Human Research Ethics Board, Winnipeg, Canada.In the context of the Karnataka Heath Promotion Trust’s (KHPT) maternal, neonatal and child health (MNCH) program, 112 qualitative interviews were conducted among pregnant women, mothers of neonates (≤ 30 days), grandmothers and husbands in three North Karnataka districts: Bagalkot, Bellary and Gulbarga. Local residents with previous research experience were hired and trained to conduct the interviews. Interviews were completed between October and December 2010. Interviews were conducted in local languages and then translated to Of the 112 participants just over half were living below the poverty line (54%), belonged to scheduled caste (42%), and were uneducated (55%). A greater proportion of pregnant women and grandmothers were uneducated and below poverty than the new mothers and husbands. While some participants indicated that hospital delivery is becoming more favoured among the younger generation, others described many factors that dissuaded them from institutional delivery. First, some perceived or experienced poor quality of care and poorly equipped and unclean facilities, particularly at public hospitals. In addition, some participants reported having to pay for supplies and/or schemes at public hospitals. While private hospitals, in general, were seen as delivering high quality services some cited the high cost for private hospital delivery as prohibitive. Having a ‘normal’ delivery was highly valued among all participants, therefore many participants offered that the common practice of performing Caesarean sections and assisted deliveries at both public and private hospitals was a concern and factored into their decisions about delivery site. Practices associated with ‘normal’ birth, such as hot water, dietary preferences were more likely to be available at private versus public hospitals. However, some preferred practices that were available at home births were not available at either hospital type. Finally, though some received the benefits of incentive schemes or aid from Accredited Social Health Activists (ASHA), many others did not.The perceptions of poor quality of care and facilities at government institutions in north Karnataka among the study respondents appears to play a significant role in discouraging public institutional delivery; the influence of these perceptions is perhaps even more than actual experience of. This indicates a need to address negative perceptions and actual quality of hospital care, particularly that of government hospitals in poor areas. In addition, perceptions of institutional delivery may be improved by reducing the number of medically unnecessary C-sections, as well as ensuring consistent coverage by schemes and comprehensive outreach to marginalised communities by ASHAs.None declared.The study was funded by Bill and Melinda Gates Foundation.


The incidence of esophageal and gastric cancer has been increasing rapidly worldwide in recent years, although the reason for this increase is unclear. Here, a statistical synthesis of studies that evaluated the association between physical activity, a well-known protecting factor against death and other chronic diseases, and the risk of esophageal and gastric cancer was performed.Potentially suitable studies were identified using Medline and Embase. The reference lists of all included articles and those of several recent reviews were searched manually. Studies were included if they (1) were published as case-control or cohort studies evaluating the association between physical activity and risk of esophageal or gastric cancer; and (2) reported point estimates  and measures of variability  for physical activity and risk of esophageal or gastric cancer.Fifteen studies were identified . Collectively, they indicated that the risk of gastric cancer was 13% lower among the most physically active people than among the least active people  and that of esophageal cancer was 27% lower .Pooled results from observational studies support a protective effect of physical activity against both esophageal and gastric cancer. The incidence of esophageal and gastric cancer has been increasing rapidly worldwide in recent years, although the reason for this increase is unclear. Every year, an estimated 934,000 new cases of gastric cancer and 450,000 cases of esophageal cancer are diagnosed Physical activity (PA) is defined as movements produced by skeletal muscles that results in energy expenditure The relationship between physical activity and the upper digestive tract has between widely researched and reviewed In the present work, Yi Chen and Chaohui Yu independently searched Medline and Embase (from its commencement to May 2013) with no language restrictions for studies in humans of the association between physical activity and cancers of esophagus and stomach. The core search consisted of terms related to physical activity  These were combined with specific terms for cancer sites of interest  and with descriptions of cancer .The reference lists of all included articles and those of several recent reviews were also searched Inclusion criteria were as follows: (1) Published as case-control or cohort study evaluating the association between physical activity and risk of esophageal or gastric cancer; (2) reported point estimates  and measures of variability  for physical activity and risk of esophageal or gastric cancer.The following information was extracted from relevant studies: first author’s name, year of publication, country in which the study was performed , study design , the sexes of the participants, cancer anatomical and histological subtypes included and risk approximations for comparisons between the highest and lowest categories of physical activities. Attention was also paid to physical activity domains and whether confounders that were controlled during the analysis . Extracted data were inspected for concordance by two authors Yi Chen and Chaohui Yu.If a study did not report enough data to be included in the meta-analysis , the corresponding author was contacted via email and the missing data were requested at least twice. If a study reported the effect estimates of two or more domains of physical activity but did not combine them, then the results of recreational physical activity for the primary meta-analysis were used. This was because recreational physical activity is the most commonly measured domain in observational studies of physical activity and cancer. It has been suggested that it is the main modifiable aspect of energy expenditure Methodological quality was assessed using three study components that might affect the strength of the association between physical activity and the risk of gastric or esophageal cancer risk All analyses used the STATA statistical package with the metan and metabias commands . Summary RR estimates were calculated using either RRs (for cohort studies) or ORs (for case-control studies). For case–control studies, odds ratios with 95% CI were evaluated, and for cohort studies, risk ratios with 95% CI were evaluated. With relatively low incidence worldwide, gastric or esophagus cancer affects only a small proportion of general population. Odds ratios and risk ratios were combined in the analysis and reported as a relative risk (RR). If a study reported results for males and females separately, both risk estimates were included in the primary analysis. Heterogeneity was investigated by subgroup analysis, in which the magnitude of the combined risk estimates and the respective tests of heterogeneity, and meta-regression in each stratum to assess the independent contribution of each variable to explain heterogeneity. Publication bias was evaluated using funnel plots Six pre-specified subgroup analyses were conducted, one each by sex ; by study type (cohort vs case-control); by risk of bias (lower vs higher risk of bias); by study population; and by physical activity domain .Meta-regression analysis was used to calculate ratios of risk estimates to test for statistically significant effect modification by sex, study type, risk of bias, study population, and domain of physical activity.879 potentially relevant articles were screened. Of these, 91 were considered potentially valuable and full texts were retrieved for detailed evaluation. Of these 91 articles, 79 were subsequently excluded from the meta-analysis for various reasons. Of these, 70 were excluded for not evaluating the relationship between physical activity and esophageal or gastric cancer specifically. Another 5 were then excluded because the cancer death rate was investigated, and cancer risk was not The main characteristics of the 15 studies included in the primary meta-analysis are given in A total of 16 sets of results were included in the primary analysis of GC  were conducted in the 12 studies that examined whether there was a dose-response relationship between physical activity and esophageal or gastric cancer . A similar result was found for esophageal cancer , again with moderate heterogeneity (I2 = 58.4% P = .019). There was some evidence of publication bias in the primary meta-analysis. Visual inspection of the funnel plots revealed a small degree of asymmetry, due primarily to one or two studies, in both the gastric cancer and esophageal cancer results  on this association . There was results . Meta-reociation .P value of Egger’s test was 0.134 for the highest versus lowest analysis. For studies on EC, the P value of Egger’s test was 0.328 for the highest versus lowest.Results of Begg’s and Egger’s tests gave no evidence of significant publication bias in the studies considered. For the association between physical activity and GC, the No significant difference was found in any subgroup analysis with respect to study designs, sex, risk of bias, study population, PA domain and subtype. This was true of both GC and EC. However, in several subgroup analyses about EC, considerable heterogeneity was discovered with respect to study population, PA domain and histological subtype .Case-control studies and cohort studies turned out to have similar results, but negative associations between physical activity and GC were only observed in case-controls and negative associations between physical activity and EC were only observed in cohort studies. The risk ratio of physical activity and GC was found lower in women [0.91 ] than in men [0.64 ], but neither showed statistical significance. Studies with higher risk of bias howed lower risk ratios in EC, but higher ratios with respect to GC. However, the difference was not significant either. When investigating variation between physical activity domains, some differences were observed. Studies investigating the effects of occupational physical activity showed a slight stronger protection for both GC and EC than studies investigating the effect of recreational activity. In anatomical subtype analysis, noncardiac gastric cancer was found to have slightly stronger relationship with physical activity than the cardiac cancers. Several analyses  of EC could not be conducted because of considerable heterogeneity. Risk estimates were not combined.The results of this meta-analysis suggest that physical activity plays a protective role in both esophageal and gastric cancer. The total estimated risk from the 15 studies indicates that the risks of gastric cancer is approximately 13% lower among the most physically active people compared with the least active people and the risk of esophageal cancer was 27% lower.There was no strong evidence that the results differed in subgroup analysis, between men and women, between studies with a higher or lower risk of bias, between differently designed studies, or between different physical activity domains. In anatomical and histological subtype analysis, cardiac cancer showed a stronger relationship with physical activity, but not statistically significant. Several analyses  of EC could not be conducted because of considerable heterogeneity, so no combined risk estimate was obtained. This may have been because of the small number of studies were evaluated here.The protection against cancer provided by physical activity might be mediated by insulin or adipocytokines: (1) Physical activity reduces insulin resistance and lowers fasting insulin levels. In this way, it may reduce the risk of cancer and the risk of cancer recurrence through inhibition of cell proliferation and cellular transformations However, this meta-analysis has limitations. First, a certain degree of significance was observed in heterogeneity across all the studies included here. Overall, the heterogeneity was significantly less pronounced in cohort studies than in case-control studies with respect to GC, but the reverse was true of EC. Subgroup analyses suggested that this heterogeneity may be partly attributed to differences in methodological quality, study population, and study design. Different methods of measuring physical activity also contributed greatly to heterogeneity. Second, this meta-analysis included 15 studies, which is not enough to conduct analyses of all assumed subgroups, especially in EC. Third, in this meta-analysis, the cancer risk of the most active individuals was compared to that of the least active. The present conclusion should be refined to state that most physically active individuals have a lower risk than the most inactive ones. Fourth, another potential limitation of the present work is the residual confounding factors that were not adjusted for in the included studies. This may have affected the results.In conclusion, a synthesis of existing studies supports the conclusion that physical activity offers some protection against esophageal and gastric cancer. This finding suggests that future research on the relationship between physical activity and gastric and esophageal cancer should focus on those aspects of the association that remain unclear, such as whether sedentary behavior and nonaerobic physical activity are associated with higher risk of cancer and, whether the intensity of physical activity affects the association between physical activity and the risk of gastric and esophageal cancer. More studies are needed to gather more information regarding the mechanism through which physical activity may protect against these cancers and whether increases in physical activity can decrease the risk of cancer.Figure S1Flow diagram of systematic literature search on physical activity and the risk of esophageal or gastric cancer.(DOCX)Click here for additional data file.Figure S2Highest versus lowest meta-analysis of physical activity and the risk of esophageal or gastric cancer. Squares represent study-specific relative risks (RR); horizontal lines represent 95% confidence intervals (CIs); diamonds represent summary relative risks.(DOCX)Click here for additional data file.Figure S3Funnel plot of risk estimates from studies that investigated the associations between physical activity and the risks of gastric cancer (A) and esophageal cancer.(DOCX)Click here for additional data file.Figure S4Subgroup analysis of (A) study design, (B) risk of bias, (C) sex, (D) PA domain, (E) study population and (F) subtype of association between physical activity and gastric or esophageal cancer. Squares represent study-specific relative risks (RR); horizontal lines represent 95% confidence intervals (CIs); diamonds represent summary relative risks.(ZIP)Click here for additional data file.Table S1Results of meta-regression of included studies. (DOCX)Click here for additional data file.Checklist S1PRISMA 2009 Checklist.(DOC)Click here for additional data file.


Objective: In line with Iran’s Comprehensive Health Sector Road Map, the National Institute of Health Research at the Tehran University of Medical Sciences developed the 2012-2025 road map of Disaster Health Management (DHM), including goals and objectives, strategies, activities and related prerequisites. This article presents the process and results of this road mapping project. Methods: The project started with an expanded literature review followed by stakeholder analysis to assess level of interest and impact of related organizations to DHM; STEEP.V methodology to define determinants with a potential impact on Iran’s HDM for duration of 2012 to 2025; strength, weakness, opportunity and threat (SWOT) analysis and formulation of goals and objectives, strategies, activities, and prerequisites. Brainstorming, group discussion and interviews with key informants were used for data collection; nominal group technique was used whenever prioritization was necessary, and Delphi panel methodology was applied for consensus development. Results: STEEP.V analysis revealed the most important Social, Technological, Environmental, Economic, Political and Value-based determinants. Iran’s DHM mission and vision were defined respectively as “Mitigation from, preparedness for, response to and recovery from consequences of natural and man-made hazards at the community level as well as to the health facilities and resources of I.R.Iran” and “In 2025, Iran’s DHM will be the most developed system in the region resulting in the least vulnerability, the highest readiness in health facilities and resources, and the highest and most effective contribution of the Iranian community to disaster resilience”, respectively. Sixteen strategies and related activities, along with the necessary prerequisites, were developed. Conclusions: This was the first attempt at comprehensive strategic planning in the field of DHM in Iran. The current framework provides Iran’s health system with a list of strategies and activities to be considered in operational planning and actions. However, a dynamic process of evaluation and revision is required to ensure that Iran’s health system goals are met by 2025.Address for correspondence: Ali Ardalan, No. 78, Italia Ave, Department of Disaster and Emergency Health, National Institute of Health Research, Tehran University of Medical Sciences, Tehran, Iran. Email: aardalan@gmail.com or aardalan@tums.ac.irCitation: Ardalan A, Rajaei MH, Masoumi G, Azin A, Zonoobi V, Sarvar M, Vaskoei Eshkevari K, Ahmadnezhad E, Jafari G. 2012-2025 Roadmap of I.R.Iran’s Disaster Health Management. PLoS Currents Disasters. 2012 Jul 16 According to the Global Assessment Report on Disaster Reduction 2009), Iran’s natural disasters risk class has been estimated as 8 out of 10 009, IranAlong with global initiatives of strategic planning for DMRR such as the “Hyogo Framework for Action” adopted in January 2005 by the United Nations International Strategy for Disaster Reduction (UNISDR) and those implemented by other countries Since the Bam earthquake in December 2003, Iran’s health sector has initiated several DMRR programs, including establishment of EOCs, revising emergency response plans and performing regular table top and operational exercises, conducting hazard and vulnerability assessments in hospitals and primary health care facilities, and expanding insurance coverage of health facilities. Integration of DMRR in the well established national network of primary health care is another imperative program that is under pilot. Targeting current and next generation disaster health practitioners and policy makers, Tehran University of Medical Sciences (TUMS) has taken initiatives to establish disaster research and education departments and to develop a Master of Public Health (MPH) with Disaster Concentration, offered since 2006, and a PhD in Disaster & Emergency Health, offered since 2011 st to 5th Five-Year National Development Program” To optimize social, technological and economical services and achieve goals identified in “2025 I.R.Iran’s Visions of Development", the country has found strategic planning and framework development as an imperative means of making that vision come true. The most popular instances of development road mapping in Iran are the “National Scientific Roadmap” initiated since 7 March 2011 In line with the Comprehensive Health Sector Road Map, the National Institute of Health Research at the Tehran University of Medical Sciences was assigned to develop the 2012-2025 road map of Disaster Health Management (DHM), including goals and objectives, strategies, activities and prerequisites. This article presents the process and results of this road mapping project.The project was performed from May to September 2011. To achieve the project objectives, we started with an expanded literature review followed by a) stakeholder analysis to assess level of interest and impact of related organizations to DHM, b) social, technological, environmental, economic, political and value-based (STEEP.V) analysis to define determinants with a potential impact on Iran’s DHM for the duration of the period of 2012 to 2025, c) SWOT analysis to assess strengths, weaknesses, opportunities and threats that favor or disrupt Iran’s DHM according to the most important determinants, d) formulation of goals and objectives, strategies, activities and prerequisites. Brainstorming, group discussions and interviews with key informants were used for data collection; nominal group technique (NGT) was used whenever prioritization was necessary and Delphi panel methodology was applied for consensus development. Whenever scoring was required, average score was considered as final score and rounds of Delphi panel consultations through meetings or e-mail were continued until minimum variance of scores was achieved. An advisory panel was held after each step to review the results and decide on possible disagreements. In total, 47 people from 27 governmental and non-governmental organizations and academia participated in the project process.For the purpose of common understanding and dialogue throughout the project implementation, “UNISDR Terminology on Disaster Risk Reduction” was applied To access and review national and international documents related to study objectives, we used the following search strategy for the period of January 2000 to May 2011. The search for international documents targeted both developed and developing countries with a good reputation of disaster planning, including the United States, United Kingdom, Australia and Canada. Regional countries Turkey, Saudi Arabia and Pakistan were considered in addition. Google and Google Scholar were the search engines used, and PubMed, ISI Web of Science and Scopus were the databases searched. The following key-word combinations were used: “Disaster” OR “Emergency” AND  AND (“Framework” OR “Roadmap” OR “Strategic Plan”) AND/OR . “Disaster Risk Reduction” and “Disaster Resilience” were other key words that were searched in combination with other terms. Before each session, the participants were provided with the results of the literature review to assist the brainstorming process.Stakeholder analysis was started through listing all organizations that potentially have an interest in and/or impact on Iran’s HDM, followed by rating levels of interest (from 1 to 5) and of impact (from 1 to 3), with higher score revealing higher level of interest or impact.STEEP.V methodology was initiated by participants’ brainstorming on determinants that might affect Iran’s DHM future in either a favorable or unfavorable manner. A “determinant of DHM” was defined as a factor that could have an impact on elements of disaster risk to health facilities and resources or to the general population, including hazard , vulnerability  and capacity. Participants were asked to briefly explain the effects and trends of each of the listed determinants. Afterward the participants were guided to group the determinants into six categories: Social, technological, environmental, economic, political and value-based. Delphi technique was applied to predict the strength (from 1 as minimum to 5 as maximum) and direction (by positive or negative sign) of the trend of each determinant until 2025 based on previous experience and current and future situation.SWOT analysis was performed for each DHM determinant, starting with listing the potential strengths and weaknesses as internal factors, and opportunities and threats as external factors. To determine the health system’s situation for managing SWOT factors, the steps described below were taken. 1) Each participant was provided with two forms, one for internal factors and the other for external factors. 2) On each form, a scoring system from 1 (lowest) to 4 (highest) was applied to rate levels of impact and accountability. “Impact level” was defined as potential impact of each factor on the health system’s functioning according to related determinant; “accountability level” was defined as the health system’s ability to overcome or control the weaknesses/threats or to rely on strengths and/or use opportunities. 3) For any specific factor, the “impact coefficient” = impact level of specific factor / sum of impact levels of all factors. 4) For any specific factor, “final score” = accountability level ´ impact coefficient. 5) The sum of factor final scores were calculated for each participant and for each factor, the sum of final scores of all participants was calculated. Results of SWOT analysis provided a basis for development of goals, objectives, strategies, activities, as well as the legal and administrative prerequisites. Again, brainstorming, Delphi panel methodology and NGT were applied for these purposes.Stakeholder analysis of Iran’s DHM (Table 1) revealed the following organizations, centers or offices at the MOH&ME as internal stakeholders with the highest interest and impact: Office of the Deputy Minister for Curative Affairs, Office of the Deputy Minister for Public Health, HMSTs at the NDMO and NPDO, DEMC of MOH&ME, DMRR Unit at the Office of the Deputy Minister for Public Health, Center for Management of Communicable Diseases, Center for Environmental & Occupational Health, and National Institute of Health Research. In addition, NDMO, NPDO, IRCS, and medical branch of Basij organization were recognized as the external stakeholders with the highest interest and impact. Positive interaction, participation, advocacy, information sharing and improvement of coordination mechanisms were found as means for enhancement of stakeholders’ participation and collaboration.Table 2 presents the most important determinants revealed by STEEP.V analysis that would affect Iran’s DHM planning and functionality until 2025 (numbers in parentheses show the strength of trends and related signs show trend direction).Iran’s DHM mission and vision were defined, respectively, as “Mitigation from, preparedness for, response to and recovery from consequences of natural and man-made hazards at the community level and to the health facilities and resources of I.R.Iran,” and, “In 2025, Iran’s DHM will be the most developed system in the region demonstrating the least vulnerability, the highest readiness in health facilities and resources, and the highest and most effective contribution to disaster resilience by the Iranian community.” A list of indicators was developed to monitor DHM progress toward this mission (Table 3). In line with the above-mentioned mission and vision, and results of SWOT analysis (provided in full text of the project report) Strategy 1: Inter-sectoral, all-hazard, whole-health approach in DHM.Priority programs: Development and implementation of DHM framework with an inter-sectoral, all-hazard, whole-health approach; continuation of related training and national conferences on an annual basis with contribution of other sectorsStrategy 2: Integration of DHM to primary health care (PHC) network from local to national levelsPriority program: Development and ratification of the integration programStrategy 3: Consider passive defense principles in all DHM policy making and planningPriority programs: Expand health system infrastructures and resources based on passive defense principlesStrategy 4: Proactive approach of health system to disaster risk reduction considering both intensive and extensive risks with a people-centered orientationPriority programs: Community risk assessment with a focus on organizational vulnerability and capacity; profiling health disaster risks produced by other sectors such as construction, industry, hydrometeorology, and informing the related policy makers and administrators; action plan for proactive approach of health system to disaster risk reduction; active contribution in NDMO’s specialized taskforces in addition to HMST; enhancement of early warning system in health system; enhancement of disaster risk perception throughout the community and other sectors; including a community-based disaster risk management module in the integration program of DHM to the PHC network; enhancement of NGOs with a DHM orientationStrategy 5: Build a comprehensive, balanced and dynamic organizational structure inside MOH&ME so that it is able to use full-scale capacities of all internal and external stakeholdersPriority programs: Modify and ratify DHM organizational chart in MOH&ME; conduct annual evaluation of HMST; strengthen specialized committees of HMST through enhancement of participatory mechanismsStrategy 6: Maintain a high standard of structural and non-structural safety in construction and retrofittinghealth facilities from health houses to referral hospitals so that they are resistant to the chief destructive hazardsPriority programs: Conduct periodic vulnerability assessment of health facilities; reconstruct or retrofit vulnerable facilities; standardize non-structural components of health facilities with respect to disaster resilienceStrategy 7: Conduct regular disaster exercises, based on dynamic readiness assessment of health systemPriority program: Design, control and evaluate regular disaster exercises based on bi-annual plans from the local to the district, provincial and national levelsStrategy 8: Develop an effective coordination mechanism in the prevention, preparedness and recovery phases and an effective command system in the response phasePriority programs: Activate specialized committees of HMST; implement training programs with a focus on teamwork at the community and organizational levels; follow up development of Incident Command System (ICS) from the Higher Coordination Committee of NDMO; strengthen and expand EOCs at the national, polar, provincial and district levelsStrategy 9: Improve Disaster Information System (DIS) for both response and developmental phasesPriority programs: Develop necessary databases using geographic information systems (GIS) with clear levels of access authorization; conduct surveillance of occurrence and impact of hazards; develop and ratify health system access protocol to the internet bandwidth of other organizations at the time of disasters; develop linkage protocol of other organizations’ databases to MOH&ME’s DIS; follow up development of a multi-layer disaster information system based in NDMOStrategy 10: Expand a multi-layer communication system from field to national levelPriority programs: Follow up with the National Radio Communication Organization to provide MOH&ME with a UHF frequency; establish a digital communication system in MOH&ME from field to national level; establish a global positioning system (GPS) in the national Emergency Medical Service (EMS); establish satellite communication system in EOCs; situate a Disaster News Studio in MOH&MEStrategy 11: Establish Disaster Rapid Assessment Teams (DRAT) and Disaster Rapid Response Teams (DRRT) with self-sufficient logistic and financial supportPriority programs: Develop DRAT and DRRT standards and protocols including medical and public health teams; develop disaster logistic support structure and process; provision disaster funds and petty cash; establish disaster warehouses in organizational chart of MOH&ME; formulate immediate access protocol to regular health system warehouses at the time of disastersStrategy 12: Develop human resources through recruitment and training of an adequate number ofknowledgeable, skilled and passionate disaster respondersPriority programs: Develop appropriate positions within MOH&ME with clear job descriptions; develop and carry on quality training programs to train disaster technicians, officers and nurses (bachelor and master levels); expand existing disaster MPH and PhD programs; develop a training matrix for MOH&ME’s disaster human resources; include disaster training as part of medical, paramedic and public health students’ education; develop standards and protocol of disaster staff recruitment in terms of technical and personal eligibility; activate Chapter 3 of NDMO law regarding disaster responders’ overpayment; complete insurance coverage of disaster responders; motivate human resources by providing recreational facilities, building peer network, and expanding access to updated knowledge and skills; contribute in regional and international training and operational programs and experiencesStrategy 13: Evidence-based decision makingPriority programs: Develop DHM research network; establish research centers; develop DHM’s research puzzle based on priority needs; develop utilization process of DHM’s research findings and training of both researchers and decision-makers in this regard; support scholar publication and establish peer-reviewed journalsStrategy 14: Enhance learning capacity from lessons identified, domestic exercises, and international knowledge and experiencePriority programs: Document, analyze and present national and international experiences; debrief experienced human resources leaving MOH&ME; develop best practice models of DHM; develop continuous quality improvement of DHM processes using lessons learnedStrategy 15: Expand regional and international relations in terms of education, research, consultancy and operational programsPriority programs: Develop a regional network of educators, researchers and professionals; develop a strategic plan for regional and international relations; develop and carry on training programs focusing on Farsi-speaking countries; develop and carry on training programs in English; enhance distance education facilities; organize regional and international conferences and seminars; operationalize the G5 member states’ work plan, including Afghanistan, Iran, Iraq, Pakistan and WHO; develop a joint virtual academic department including regional countries; modify the national law specifying IRCS’ exclusive role in contributing to international humanitarian assistance efforts so that MOH&ME can contribute as wellStrategy 16: Strategic and operational planning along with disaster metrics and evaluationPriority programs: Develop HDM 3- to 5-year strategic plans followed by annual operational plans up to 2025; train policy makers, managers and technical staff for DHM strategic and operational planning; standardize input, process, results chain and related indicators of DHM regarding the current roadmapThis was the first attempt at comprehensive strategic planning in the field of DHM in Iran. In this project we developed a framework for 2012-2025 DHM planning and action. The project benefited from analysis of the main determinants with potential impact on DHM during the next 13 years. However, it was limited by the shortage of supportive local or national evidence in terms of research-driven information, so we had to rely mostly on expert opinions. Nevertheless, by using experts from a wide diversity of disciplines and organizations, we believe that we were able to overcome this limitation to some extent, although it is recommended that more valid information be obtained in order to modify the framework over time.th National Development Program, MOH&ME has taken the initiative to improve health system management through a consolidated step by step approach to operational planning. The current framework provides MOH&ME with a list of clear strategies and priority programs to be considered in operational planning and actions.In line with achieving the goals of the 5The well-established PHC network in the country DHM is, however, dependent on policies and structure of disaster management at the national level, specifically NDMO and NPDO. It is expected that these organizations will support the sectoral programs, including health, based on existing or developing national frameworks and on command and coordination tools and mechanisms.Timely and effective health response operation is limited by the lack of a well-established emergency logistical aid fund. Although the country proved that it can mobilize resources at the time of disasters, the efficiency of operation remains an imperative issue. At the national level, UMSHS and the Office of the Deputy Minister for Management Development & Resources of MOH&ME have been assigned to provide the logistic support for disaster operations, while DEMC is supposed to have logistic facilities in hand.The health system has had several successful experiences of response to major disasters, including the Bam 2003) and Lorestan (2006) earthquakes, Golestan floods (2000-2005) and Gonu cyclone (2007) 003 and LMore attention is generally paid to major disasters, but extensive geophysical and hydro-meteorological disasters are threatening the people as well. The country faces hazards of high frequency but low impact, which, by definition, each kill fewer than 50 people or damage no more than 500 buildings The health system is responsible for the preservation, maintenance and promotion of people’s health, so it must be concerned about any direct or indirect health consequences of disasters. The deaths of more than 100,000 Iranian people due to non-resistant buildings, along with flood-related deaths all over the country because of poor land use planning combined with non-effective early warning systems and evacuation plans, call for a proactive approach by the health system to disaster risk reduction, while emphasizing readiness for response operations. This approach is becoming prominent on the agenda in Iran’s health system and some models of best practices have been developed By law, IRCS is the only organization that is permitted to act in international humanitarian assistance. MOH&ME is hoping to modify the law and be allowed to contribute in regional and international operations.To strengthen the capacities of human resources, during the last five years Iran’s health system proceeded to develop, with a leading role of Tehran University of Medical Sciences, an MPH program with disaster concentration, a PhD program in disaster and emergency health, and short-term training courses like Disaster Health Management & Risk Reduction and Refugee Health Care Since the Bam earthquake (2003), several organizations such as the IRCS and the International Institute of Earthquake Engineering & Seismology (IIEES) have worked on public education to enhance community disaster preparedness. The media have also played a prominent role in increasing community awareness. Despite this fact, a study in three disaster-prone provinces showed low household readiness for natural disasters, specifically earthquakes and floods Despite technological limitations, early warning systems (EWS) of hydro-meteorological hazards are getting established and expanded throughout the country. But the health system needs to be linked to the warning process.Structural safety of health facilities is a concern of MOH&ME. In this regard, MOH&ME has assessed the structural vulnerability of public hospitals and established a steering committee on safety of health facilities for disasters. The Islamic Parliament has also developed a plan to assist MOH&ME with the required financial resources for retrofitting of vulnerable hospitals during a 10-year period. In addition, all public buildings including health facilities are required by law to be covered by insurance.A situation of war and political instability in regional countries requires Iran’s health system to be prepared for refugees fleeing to the country, as has been the experience during the last several decades with Iran accepting refugees from Iraq and Afghanistan.The developed road map requires a dynamic process of evaluation and revision to ensure meeting Iran’s health system goals by 2025.This was the first attempt at comprehensive strategic planning in the field of DHM in Iran. The current framework provides Iran’s health system with a list of strategies and activities to be considered in operational planning and actions. However, a dynamic process of evaluation and revision is required to ensure that Iran’s health system goals are met by 2025.Based on a summary index developed by multiplying levels of interest and impact so that Group 1= Score 11-15, Group 2 = Score 6-10 and Group 3 = Score 1-5, MOH&ME: Ministry of Health & Medical Education, UMSHS: University of Medical Sciences & Health Services, NGO: Non-Governmental Organization, UN: United Nations, EMS: Emergency Medical Service, EOC: Emergency Operations Center, NPDO: National Passive Defense Organization, NDMO: National Disaster Management Organization, IRCS: Iranian Red Crescent Society*Numbers show strength of trends and related signs show trend direction.DHM: Disaster Health Management, MOH&ME: Ministry of Health & Medical Education


EHP 119(11):1583–1589; Rager et al.].Most studies and regulations of air pollutants address individual substances in their unaltered primary form. But people typically are exposed simultaneously to multiple pollutants, and primary pollutants can be photochemically transformed in the atmosphere into secondary, tertiary, and additional generations of substances. Scientific limitations have hampered study of these real-world conditions and impaired our understanding of exactly how air pollutants affect health. Findings by a team of University of North Carolina researchers provide insight into the biological effects of air pollution and suggest that current air pollution regulations and mitigation approaches should consider products of atmospheric reactions, which have received scant attention in the past [The researchers used a toxicogenomics approach to evaluate the impacts of primary and secondary pollutants on human epithelial lung cells. They found that 4 hours of exposure to a mixture composed largely of primary pollutants  at environmentally relevant concentrations changed the expression of 19 genes, compared with 709 altered genes following similar exposure to a mixture of primary and secondary pollutants . They also found that release of the enzyme lactate dehydrogenase, a marker of cell injury and death, was 9 times higher after exposure to the secondary pollutants compared with the primary pollutants.The authors identified molecular networks related to sets of genes expressed in response to exposure. One network was identified for genes affected by the primary pollutant mixture, which included proteins relevant to cancer biology. Twenty-five networks were identified for genes affected by the secondary pollutants, including those relevant to biologic processes associated with cancer; cellular movement, growth, and proliferation; tissue development; and cardiovascular disease. The authors also identified transcription factors that might regulate responses to the pollutant exposures. Both primary and secondary pollutants affected hepatocyte nuclear factor 4α signaling, which plays a role in the function of organs such as the kidney, liver, and intestine.The authors acknowledge this study offers only a glimpse of what’s occurring in real-world conditions. Future studies will need to consider long-term exposures, defense mechanisms in living beings, specific health impacts linked with altered gene expression, many other primary pollutants, and myriad combinations of primary, secondary, and subsequent generations of pollutants. In addition, research is needed to pin down the roles of individual substances within any given mixture. But these initial results provide insights into what is missing in current knowledge and should spark more in-depth investigations.


Formalin fixation followed by paraffin embedment (FFPE) is the most common method of preserving resected tissues. FFPEs can be easily stored, retrieved and processed for further analysis when compared to the logistical complications of processing fresh frozen (FF) material. Conversely, they may not be ideal for sequencing because of the nucleic acid fragmentation and artifacts introduced by fixation. Here we report our efforts in performing next-generation sequencing on more than 70 specimens comprising >40 FFPE samples, from low to high quality, and compared the performance of FFPE, FF and commercially available cell lines.


As treasures of the traditional Chinese medicine (TCM), acupuncture and Chinese herbal medicine have a history of more than 2,500 years and have achieved sound effects in the clinical practice . The effIn recent years, the researches of acupuncture and Chinese herbal medicine have improved significantly due to the prosperity and development of modern life science technology –7. At thZang and Fu organs.” The review by Yu Wang et al. presented a comprehensive overview of the researches on acupuncture effective biomolecules, covered diverse carriers such as cerebrospinal fluid, serum, organs, and tissues, and discussed how to promote the development of biological medicine based on the discovery of acupuncture effective biomolecules. The other 3 review articles also provided us with current understanding of biological values of acupuncture and Chinese herbal medicine on inflammatory bowel diseases, amblyopia, and glucose and lipids metabolism, respectively.We are excited to present our readers with this special issue that summarizes recent discoveries and knowledge of acupuncture and Chinese herbal medicine. This specialized issue collects 24 original research articles and 4 reviews that provide the clinical or animal-based evidence elucidating the impacts of acupuncture and Chinese herbal medicine on the life science. Among these original research articles, the biological functions and potential mechanisms of acupuncture and Chinese herbal drugs in disease treatment were demonstrated in animal models of diseases such as focal cerebral ischemia, pain, atopic dermatitis, insomnia, fatty liver, and Crohn's disease. Two papers are on cancer cells: Han-Peng Kuo et al. reported that Ganoderma tsugae extract inhibited the growth of HER2-overexpressing cancer cells and enhanced the growth inhibitory effect of antitumor drugs via the modulation of HER2/PI3K/Akt signaling pathway; Xiu-Feng Wang et al. showed that PC-SPESII herbal extract could impair human breast cancer metastasis by regulating proteolytic enzymes and matrix dynamics through the p38MAPK and SAPK/JNK pathway. Additionally, You Ning et al. reported the molecular mechanisms underlying the antiproliferative and prodifferentiative effects of psoralen on adult neural stem cells using DNA microarray. Interestingly, two research articles  simultaneously focused on the same issue, specific link between the lung and the large intestine, which provide new lines of evidence for the modern biological theory of “exterior-interior correlation between In summary, this special issue provides up-to-date and valuable information about the role of acupuncture and Chinese herbs in the life science. Accordingly, future researches with modern technologies would further advance our understanding of the biological effects and cellular/molecular bases for acupuncture and Chinese herbal medicine in diverse diseases.


Sexual size dimorphism (SSD) is widespread and variable among animals. Sexual selection, fecundity selection and ecological divergence between males and females are the major evolutionary forces of SSD. However, the influences of mating system and habitat types on SSD have received little attention. Here, using phylogenetic comparative methods, we at first examine the hypotheses to that mating system  and habitat types affect significantly variation in SSD in anurans (39 species and 18 genera).Our data set encompass 39 species with female-biased SSD. We provide evidence that the effects of mating system and habitat types on SSD were non-significant across species, also when the analyses were phylogenetically corrected.Contrast to the hypotheses, our findings suggest that mating system and habitat types do not play an important role in shaping macro-evolutionary patterns of SSD in anurans. Mating system and habitat types cannot explain the variation in SSD when correcting for phylogenetic effects. Sexual size dimorphism (SSD) is widespread and variable among animals . In someSSD is often used as an indicator of the intensity of sexual selection in animals . Mating Anurans inhabit a wide range of habitats  and exhibit a remarkable diversity of mating system  that is unique among vertebrates ,11. If tF1, 77 = 3.059, P = 0.043) and terrestrial, arboreal, semiaquatic and aquatic habitats , but did not differ among sequential polyandry, simultaneous polyandry and monoandry . However, there were also non-significant mating systems*sex interaction  and habitats *sex interaction , revealing that the degree – but not direction  – of SSD did not differ among mating system and habitats  and habitats , but did not differ among mating system . However, the non-significant interactions between mating system and sex  and between habitats and sex  revealed the evidence that intensity of sexual selection and habitats were not associated with variation of SSD contrasts.We tested for the effects of mating system and habitats on SSD contrasts using generalized least squares. We found the mean SVL contrasts significantly differed between the sexes /log10 ) - 1, arbitrarily set positive when females are larger and negative when males are larger. All animals used in this study were treated humanely and ethically following all applicable institutional Animal Care guidelines in China.We obtained sex-specific demographic and morphological data on mean size across 39 species and 18 genera from the literatures , mean body size in males and females of 39 species and references of published papers.Click here for fileThe phylogenetic tree of the 39 anuran species used in the comparative analysis following Frost et al. (2006) and Pyron and Wiens (2011).Click here for file


Various reports suggest a high contemporaneous prevalence of herb-drug use in both developed and developing countries. The World Health Organisation indicates that 80% of the Asian and African populations rely on traditional medicine as the primary method for their health care needs. Since time immemorial and despite the beneficial and traditional roles of herbs in different communities, the toxicity and herb-drug interactions that emanate from this practice have led to severe adverse effects and fatalities. As a result of the perception that herbal medicinal products have low risk, consumers usually disregard any association between their use and any adverse reactions hence leading to underreporting of adverse reactions. This is particularly common in developing countries and has led to a paucity of scientific data regarding the toxicity and interactions of locally used traditional herbal medicine. Other factors like general lack of compositional and toxicological information of herbs and poor quality of adverse reaction case reports present hurdles which are highly underestimated by the population in the developing world. This review paper addresses these toxicological challenges and calls for natural health product regulations as well as for protocols and guidance documents on safety and toxicity testing of herbal medicinal products. With the burst in the use of herbal medicinal products (HMPs) globally, either for primary treatment or as complementary and alternative medicine, safety and efficacy of herbal medicine have become a public health concern. Till date, it has been difficult to make reliable estimates of ill health caused by herbal products particularly because (i) the perception that “natural” equates to “safe” and therefore herbal medicine users would not realise that a herbal remedy may be responsible for adverse symptoms they have experienced; (ii) the lack of communication between patients and medical practitioners regarding the use of herbal medicine; (iii) the presence of low-grade herbal products on the market, and (iv) the supply of counterfeit products. The World Health Organisation (WHO) estimates that 80% of Asian and African populations rely on traditional medicine as the primary method for health care needs. The scenario in developed countries is very similar with 70% to 80% of the population using some form of complementary and alternative medicine . CommonlAdverse health effects associated with herbal products exist since time immemorial though and could be attributed to both the inherent toxic effects of herbal medicine and toxicities induced by adulterants/contaminants. The low incidence of adverse reports associated with HMPs in developing countries may be explained by the fact that consumers generally regard them as safe and therefore believe their symptoms are not attributable to the use of those products. In addition, the reluctance to indicate the concomitant use of HMPs to health care professionals, the impression that the adverse effects are known, forgetfulness, unwillingness to report based on suspicion alone, pressures of clinical practice, and uncertainty about the reporting process are key factors which if addressed can certainly help in risk mitigation. Whilst evidence-based studies indicating the efficacy of herbal drugs are still being unveiled, increasing evidence, regarding side effects of herbal medicine, has highlighted the demand for and consequently the necessity of toxicological studies for herbal products. With the increased discussion on safety assessment of herbs, toxicology constitutes an essential role in the development of herbal medicines and advancements of analytical techniques and molecular technology, in particular the “-omic-” technology comprising transcriptomics, proteomics, and metabonomics, can make a significant contribution to the predictive and preclinical toxicology assessment of herbal medicine , 29.Apart from the toxicity of the intended herb(s) itself, the lack of a stringent and harmonised quality control and effective monitoring system imposed on herbal medications may lead to contamination or adulteration that could prove harmful to humans. Possible contaminants/adulterants such as heavy metals, pesticides, toxic herbs, and conventional drugs are commonly encountered toxicological concerns in herbal preparations. Nevertheless, strategies in devising suitable toxicological examination protocols to deal with the wide panoply of components in herbal drugs stand as a challenge to toxicologists.Heavy metal contaminants like cadmium (Cd), arsenic (As), and lead (Pb) can be a risk factor in contributing to the toxicity of these herbal products . The WHOCase reports have played a crucial role in alerting the scientific community on the adverse effects of therapeutic interventions , 37. ThiChelidonium majus L.) in patients from various European countries has been a matter of concern. Teschke et al. [Toxicological problems associated with the use of herbal medicines are complex but have been regularly associated with serious adverse fatalities ranging from cardiovascular problems to psychiatric to neurological effects to liver toxicity or malfunction to hematologic and renal toxicity –41. The e et al.  providedAristolochia spp. exhibited severe renal disease manifested by interstitial fibrosis, which rapidly progressed to renal failure [Aristolochia spp. also used as an aphrodisiac, as an anticonvulsant, as an immune stimulant, and to treat arthritis, gout, rheumatism, eczema, wound treatment, allergic gastrointestinal colic, and gallbladder colic have been subsequently reported to impair renal function due to the presence of aristolochic acid [Sauropus androgynus in weight control was associated with an outbreak of Sauropus androgynus-related obstructive lung disease [Moreover, although weak or no causality of herbal toxicity could be shown in many instances, a number of studies still have reported the potentially toxic nature of herbal drugs. In 1992, in Belgium, consumers of a herbal weight-loss preparation containing  failure . Moreovehic acid , 46. In  disease . Jones a disease  reported disease . Similar disease .Aristolochia species was found responsible for acute renal failure (n = 1), with aconite roots causing aconitine poisoning (n = 2), the Datura species causing anticholinergic poisoning (n = 1), and “yulan” (Stephania sinica) causing tetrahydropalmatine poisoning (n = 3) [Similarly, in 2005, clinical problems arising from the use of herbal medicines were reported in Hong Kong and  (n = 3) . Likewis (n = 3) . The diagnosis of herbal-drug-induced hepatotoxicity continues to be a challenge despite the availability of causality assessment tests. There are only limited number of clinical studies with HMPs reported in the literature despite the fact that they have been used for centuries. Thus postmarket pharmacovigilance providing interesting source of safety information and causality assessment indicates a link between an observed adverse event to a suspected HMP . AlthougGlycyrrhiza glabra) commonly used for inflammation of the upper respiratory tract and gastric and duodenal ulcers has been reported to cause suppression of the renin-aldosterone system, resulting in sodium and water retention, hypokalemia, hypertension, cardiac arrhythmias, and myopathy in cases of prolonged use [Cases with severe intoxications in humans have also been reported after consumption of essential oil rich in thujone. Thujone or thujone-containing products have been reported to cause central nervous system disturbances which can lead to convulsions and ultimately to unconsciousness and death . Similarnged use , 55. Alsnged use , 56. OveAristolochia spp. used in a number of Chinese traditional medicine undergo reduction of the nitro group by hepatic CYP1A1/2 or peroxidases in extrahepatic tissues generating highly reactive cyclic nitrenium ions. The latter can react with DNA to form promutagenic DNA adducts such as 7-(deoxyadenosin-N6-yl) aristolactam I and 7-(deoxyguanosin-N2-yl) aristolactam I as well as protein, resulting in activation of H-ras and myc oncogenes and gene mutation in renal cells and finally carcinogenesis of the kidneys [The toxicity of herbs may also result from the generation of reactive intermediates through metabolic activation of herbal constituents via phases I and II reactions within the human body. The resultant reactive intermediates can bind covalently to DNA and proteins, leading to organ toxicity, mutagenicity, and even carcinogenicity. For instance, aristolochic acids in  kidneys , 58. In Other factors compromising safety may result from herbs harvested from polluted sites or poor farming practices, medicinal plant products contaminated with pesticides and microbial contaminants, heavy metals, toxic substances, and adulterants which can be toxic to the consumer.The contemporary use of herbal medicine is widespread but the challenge that society faces with its use is whether a patient will divulge to his or her medical practitioner the concurrent use of herbal products with conventional pharmacotherapy. A number of observational studies have shown the negative or conflicting interactions of drugs and herb though theoretically herb-drug interactions could also be positive or neutral . Herbal Common examples of herb-drug interactions have been found when cardiovascular medications with a narrow therapeutic index, such as digoxin and warfarin, are coadministered with herbs. For instance, concomitant use of warfarin with St. John's Wort decreases prothrombin time, which may result in reduced anticoagulant effect and need for increased warfarin dose . Other eThe current evidence that herbal medicine may interact with conventional drugs is mainly based on case reports of patients, case series, and a limited number of clinical studies. Drug-herbal interactions are difficult to evaluate because of the lack of compositional reliability of the herbal products though a number of interactions, amongst which are drug-metabolizing enzymes and drug transporter systems, as well as pharmacodynamic interactions can be involved. However since the pharmacokinetic and pharmacodynamic characteristics of most herbal medicine or supplements are not completely recognized, potential interactions cannot be predicted.Evodia rutaecarpa traditionally used in combination with Chinese traditional medicine, had profound effects on the hepatic drug processing enzyme gene expression, CYP enzyme genes and UDP-glucuronosyltransferase, and increased the expression of hepatic uptake and efflux transporters. The authors speculated that all these effects could play an integrated role in rutaecarpine-increased metabolism and elimination of caffeine [In a clinical study involving 313 patients, Jeong et al.  concludecaffeine , theophycaffeine , and acecaffeine .From evidence-based herb-drug interaction in cancer chemotherapy, Cheng et al.  concludeDue to the wide use and easy availability of herbal medicines, herbal toxicity and herb-drug interactions have become an issue of global concern. While HMPs provide opportunities for complementing the armoury of existing drugs, for their purportedly preventive and therapeutic purposes, the major problem with the use of herbal-based treatments is the lack of definite and complete information about the composition of extracts, resulting mainly from the trade secrecy of a number of herbal practitioners. Despite the fundamental role that traditional medical practitioners play in the provision of health services in developing countries, trade secrecy has been observed and is currently encroaching on the proper assessment of local herbal drugs. The lack of Good Manufacturing Practices, Good Agricultural Practices, Good Laboratory Practices, and metabolic, pharmacokinetic, and toxicologic characteristics further characterized the dangers of HMPs in developing countries.Hence, in many developing countries involved with the active production and use of HMPs, regulations distinct from the one for food and drugs are warranted. The existence of such regulation can emphasise a premarket system, which provides market authorisation for each HMP based on evidence that the product is safe under the recommended conditions of use without a prescription, effective for the proposed claims, and of high quality, and is mandatory. In addition, a licence issued on the basis of evidence of compliance with Good Manufacturing Practices to importers, manufacturers, packagers, and labellers of HMPs will certainly aid in reducing health-related risks. Such an effort should be in concert with WHO International Regulatory Cooperation for Herbal Medicines (IRCH), established in 2005 to protect and promote public health and safety .There is also a strong need for scientific evidence of the pharmacological qualities and safety of herb-derived remedies employed for centuries as traditional medicines in these countries. This is particularly because sound knowledge of the mechanisms of actions and interactions is essential for a clinical risk assessment. In addition, the design of an appropriate postmarket pharmacovigilance system will help address the fatalities of herbal drugs. Surveillance for HMP-related adverse responses should consist mainly of prompting voluntary reporting from consumers and health care practitioners. It should be noted that even if the interactions between medicinal herbal products and drugs may be clinically insignificant, susceptibility to them may be enhanced by a wide variety of patient-related factors, such as the presence of multiple diseases, other pharmacotherapies, or genetic predisposition.At the same time, it would be helpful to set up a national and/or regional accessible database to document the use of herbal medicines. Concurrently, efforts should be made to educate both healthcare professionals and patients about the use of herbal medicine. It should also be emphasised that besides its role in primary healthcare, traditional medicines have been and continue to be a strategic option in drug discovery .The previously mentioned long-term strategies could certainly help to address the toxicological concern of herbal drugs in developing countries. But more immediate actions are also warranted and should be geared towards (1) greater communication between patients and physicians about the use of herbal medicine, (2) health care professional should be aware of herb-drug interactions and encourage patients to discuss herbal medicine use, (3) physicians should question patients about their use of herbal medicines, and (4) surveillance of HMP-related adverse responses should be monitored. In the meantime, preclinical and clinical studies should be conducted to ascertain herb-drug interactions and government regulatory authority should put more efforts into natural health product regulations.