Hypericum perforatum L.), wormwood (Artemisia absinthium L.), garlic (Allium sativum L.), gentian (Gentiana lutea L.), lovage , and lesser periwinkle (Vinca minor L.). While Ukrainian ethnic groups favored the use of guilder-rose (Viburnum opulus L.) and yarrow (Achillea millefolium L.), Polish inhabitants especially valued angelica (Angelica archangelica L.) and carline thistle (Carlina acaulis L.). The region also holds a strong potential for collection, cultivation, and manufacture of medicinal plants and plant-based natural specialty ingredients for the food, health and cosmetic industries, in part due to high degree of biodiversity and ecological preservation. Many of these products, including whole food nutritional supplements, will soon complement conventional medicines in prevention and treatment of diseases, while adding value to agriculture and local economies.Plants were an essential part of foraging for food and health, and for centuries remained the only medicines available to people from the remote mountain regions. Their correct botanical provenance is an essential basis for understanding the ethnic cultures, as well as for chemical identification of the novel bioactive molecules with therapeutic effects. This work describes the use of herbal medicines in the Beskid mountain ranges located south of Krakow and Lviv, two influential medieval centers of apothecary tradition in the region. Local botanical remedies shared by Boyko, Lemko, and Gorale ethnic groups were a part of the medieval European system of medicine, used according to their Dioscoridean and Galenic qualities. Within the context of ethnic plant medicine and botanical classification, this review identified strong preferences for local use of St John's-wort ( Beschad Alpes Poloniae) denote the Carpathian mountain ranges that historically separated kingdoms of Poland from Ruthenia (Ukraine) and Hungary as described in the 1269 Hungarian deed  advancing slowly toward the mountain ridges along the Spis-Borzhava axis in the south and Myslenice-Sanok-Dolyna axis in the north . In the fourteenth century, continuous colonization of the Beskids was described as of Ruthenus, Ruthenus-Valachus, Ruthenos seu Valachos, or Valachus origin , Dioscorides (De Materia Medica), Pliny , Avicenna (Liber Canonis), and Galen of Pergamon  as the science of using fresh plants and dry herbs to improve human health , Regimen Sanitatis , Physicians of Myddvai , and various editions of [H]ortus Sanitatis (1491) based on the German Herbarius Maguntie impressus of 1484 and Herbarius zu Teutsch of 1485. The latter monographs were intended to treat of cheap and homely remedies for the use of the poor, as most herbs listed in these books were native or garden plants, while very few exotic remedies were described in details.The use of plants and their preparations in European medicine, drawing upon the traditions of both the classical and Arab civilizations, was formalized by works of Hippocrates of Kos  that described medicinal uses of several plants, including henbane (Hyoscyamus niger), hemlock (Conium maculatum), and wormwood (Artemisia absinthium). Subsequent herbal manuscripts  from sixteenth to eighteenth centuries often combined traditional herbal medicines with irrational magical applications. For example, while the seventeenth century vertograd described management of fever and pain with cabbage (Brassica oleracea) and beet (Beta vulgaris) leaves, and infection diseases with onion (Allium cepa) and garlic (Allium sativum), it also prescribed a mixture of horse and goat manure to cure alopecia in 3 days  with plants names translated into Polish for the first time by Simon de Lowicz in 1532. Its significance lies in the fact that it was the first document of such length to indicate a renewed interest on this subject and to reveal direct influence of Dioscorides and Pliny. Even though there was no evidence of experimentation, and whether or not the author actually ever attempted to use any of the herbs of which he wrote, this herbal had a tremendous influence on medical and botanical literature from the early Middle Ages  compiled various Latin [H]ortus Sanitatis manuscripts, translated them into Polish, and released a first popular encyclopedia of traditional medicines entitled O ziolach i o mocy ich (On herbs and their power) in Krakow (1534). The subjects covered herbs and herbal medicines (including the first use of Polish term wodka meaning “little water” to describe high proof spirit distilled from grain), medicinal properties of animals and minerals, obstetrics, surgery, and were profusely illustrated with over 550 mostly original woodcuts. Plants were described in a set of 261 articles on European and 69 exotic herbal remedies. Descriptions of plants and their use, however, were mostly translations from the previous sources and likely unknown to the author  attempted an adaptation of Stefan Falimirz's work by publishing O ziolach tutecznych y zamorskich y o mocy ich  with improved woodcuts. The monograph contained similar and often identical descriptions of several medical guides to practical use of herbal remedies. The catalog of herbs was focused on local plants listed under Polish and Latin names, with a shorter list of exotic plants identified only in Latin. Compared to other herbals, it contained narrower descriptions of plant species with no mention of their origin or occurrence.Marcin Siennik  compiled another adaptation of Falimirz's herbal 26 years later as Herbarz to jest ziol tutecznych, postronnych i zamorskich opisanie . Quick comparison among these editions revealed minor changes in the order of the chapters, woodcuts, and plant names. Siennik held neither a professional title nor a degree, and seemingly edited books solely to make income in accordance with publisher's instructions. The only freedom that he enjoyed was expanding the list of plant nicknames, to which he contributed many new names, however both descriptions and uses of various remedies were transcribed intact, together with all previous errors and omissions. The resulting monograph was published under a new name, with modified woodcuts and an expanded index including German names  compiled Herbarz polski, to jest o przyrodzeniu ziol i dzew rozmaitych  that was printed after his death and included descriptions of 372 local plant remedies and 105 exotic herbs. Plants were listed in Latin alphabetical order and were heavily influenced by independent translations from Dioscorides Materia medica and Fuchs Cometraii insignes. Among those, only 259 chapters described wild native plants characteristic of the Polish countryside. The woodcuts, however, were the same ones used in Siennik herbal to depict 240 local herbs–and for this reason, the rest of the herbal remedies were illustrated by woodcuts that were repeated or omitted altogether. The individual reports lacked a particular order of presentation, with some chapters organized by location, description and use, while others discussed herbal properties prior to their looks and origins  of Oswiencim, a graduate of Krakow and Padua Universities, moved to Lviv and established his medical office there in 1578. He spent next 30 years collecting botanical flora from the northern slopes of Beskids mountain ranges, including trips to more distant regions of Podolia and Pokuttya. Here he compiled the most extensive Polish herbal to date–Zielnik herbarzem z iezyka lacinskiego zowia , printed 2 years subsequent to his death. Similarly to previously described monographs, this volume was largely based on translations of Dioscorides Materia medica and its adaptation by Petri Matthioli, known as Senensis midici, commentarii in sex libros (1565), including the original woodcuts from Matthioli's work  with the Hebrew title of Seyfer derekh ets ha-khayim was printed in Poland in 1613. While the exact printing place of the book is unknown, as is the name of the author, Krakow was one of the possible places of its origin , currently kept at the Jagiellonian Library in Krakow. It was likely written by an unknown physician or monk of German origin who worked in Poland and had first hand knowledge of Polish plants  of Luban near Wroclaw, a graduate of Padua University and a royal physician to Polish King Kazimierz Jagiellonczyk . He listed 20,000 scientific and medicinal terms of Latin, Greek, Arabic, Italian and other origins, translated into German, Polish, and Czech languages. The Antibolomenum served as an apothecary index identifying 433 domestic and 90 foreign plants, 219 domestic species of animals and the minerals used as the ingredients of the apothecary remedies. While useful for quick identification of medicinal ingredients and their equivalents, the manuscript was never published, and had no major impact on the development of the natural sciences at the time.Johann Placotomus (Breitschneider) under the title of Pharmacopoeia in compendium redacta and published in 1560. This book was developed on the basis of Dispensatorium written by Valerius Cordus (1546). The work included information on individual materia medica (simples) and complex recipes for powders, pills, syrups, decoctions, ointments, and oils. It also included recipes and instructions for preparation of theriacs–panacea-type medical concoctions as general antidotes against poisons and infectious diseases. Another pharmacopeia was compiled by Polish physician and apothecary in Krakow, Jan Woyna of Jasienica under the title of Pharmacopoea Cracoviensis and published in 1683, in compilation with two other works, Experemintorum medico-chymicorum and Observationes medicochirurgico by Daniel Matthia. This monograph was rather short; although it listed circa 1,500 apothecary ingredients in alphabetical order, the descriptions were very brief or nonexistent. Instead, multiple cross-references to other, mostly foreign pharmacopeias and dispensatoria, were provided. The only exceptions were made for new recipes developed by the author, in which case more detailed information on ingredients and methods of preparation were given. Certain new recipes were very complex, for example a novel preparation named Spiritus Castorei Cracoviensis consisted of four herbs, Castorei , Anacardini , Asa (Asa foetida from Persia or Afghanistan), and Storacis (Styrax liquidum from Asia Minor). All four monographs, however, were private publications without any official character or certification.The first printed pharmacopeia that had significant impact on the apothecary tradition of Poland was compiled by a German physician Dispensatorium Brandenburgicum. This monograph was released in Latin language, contained descriptions of over 1,000 apothecary ingredients, including 906 complex mixtures. The most demanding recipe was that of Theriaca Andromachi that comprised a mixture of 71 individual components. Duke of Warsaw Frederick Augustus I made Dispensatorium a required apothecary regulatory document for all Polish lands in 1714 under a modified title. Following the first partition of Poland, the Carpathian foothills were divided between Poland and Austria, and two new pharmcopeias were published to regulate the apothecary practices including Pharmacopoea Regni Poloniae (1817) and Phаrmасороеа Austrica (1820)  to protect children from the evil enchantments of the “old women,” the same “old women” often used this plant to aid in apotropaic and love magic . If the dating is correct, this manuscript was translated at the same time as Hortus sanitatis books known as “vertograds” were printed in Moscow (1534) and Kolomna (1588) . Other sections contained discussions on hygiene, Galenic commentary on Hippocrates, notes and quotations from Avicenna and other medieval physicians, exerts from the pseudo-Aristotle tractates, descriptions of common medicinal practices such as bloodletting, and magical spells. Large numbers of spelling errors, incorrect interpretations and misrepresentations, all point to the fact that the manuscript was written not for personal use, but rather for sale by a professional transcriber with little knowledge on the subject. Extensive references to old Ruthenian terms zhuravly (cranes), zubry , tryascia , tsybula (onion), pevne (probably), and many other words suggested Volhynia or Carpathian forelands as possible places of its origin.One of the earliest examples of such manuscripts, recorded somewhere in Grand Duchy of Lithuania and self-described as “a translation from Latin and Polish books,” was created in the mid sixteenth century . Some of the plant descriptions from this manuscript, for example, plantain (Plantago major), St. Benedict's thistle (Cnicus benedictus), Norwegian angelica , and lesser burnet (Pimpinella saxifraga) were very close if not identical to other subsequent manuscripts, showing continuation of handwritten tradition in time . This manuscript was a compilation of various texts, legends, poems, and prayers in addition to herbal tradition. The territory to which the manuscript was localized, had formed a border line between two ethnic groups of Ruthenian origin, Boyko in the east and Lemko in the west , cornflower (Centaurea cyanus), rue (Ruta graveolens) and lesser periwinkle (Vinca minor), as well as the use of infusions from the bark of rowan (Sorbus aucuparia) and mezereon (Daphne mezereum) in love magic , milk thistle (Silybum marianum), scentless chamomile (Anthemis arvensis), chamomile (Matricaria chamomilla), wormwood (Artemisia absinthium), galipot , a mixture of water and burned aspen (Populus tremula) for treatment of osteomyelitis, and a fermented mixture of oat hulls and goose feces for treatment of abscesses among the inhabitants of the Carpathian foothills , zillya troyan , and garlic mustard (Alliaria petiolata).Early ethnographic studies in the region were general descriptive compilations of oral traditional medicines recorded by Ukrainian and Polish enthusiasts without further analysis or comparison to the previous written works on the subject.  Lepkij, . Oskar KKolberg, . Ivan Kuf Kuziw, . Julian  Franko, , includiVolodymyr Szuchewycz, an Ukrainian ethnographer and teacher residing in Lviv, observed extensive use of traditional herbal medicines by Hutsuls (a neighboring ethnic group of Ruthenian origin to the east of Boykos) and described some of the remedies in the 5th volume of his monograph , yarrow (Achillea millefolium), marsh woundwort , mistletoe , and yellow gentian (Gentiana lutea). Josef Schneider, a Polish ethnographer born in Stebnyk, documented the use of herbal remedies by Boyko people from the Dolyna region  and periwinkle (Vinca minor) for treatment of various skin disorders, baked onion (Allium cepa) for alleviation of abscess, green cones from spruce (Picea abies) for syphilis, flower petals for leg pain, and decoction of beet (Beta vulgaris) leaves for ringworm. Jan Falkowski, a Polish ethnographer, described treatment of the Polish plait  with chorne zillya (Pulsatilla vulgaris). Tinctures made with yellow gentian (Gentiana lutea) were a popular remedy against cholera. Special attention was paid to ashes of burned medicinal plants. Cataracts were treated by burning periwinkle (Vinca minor) and using the ashes to wash the eyes. Burn wounds were treated with ashes from burned wool or black ligules of sedge (Schoenus nigricans). Open cut wounds were treated with juice from yarrow (Achillea millefolium)  to treat ulcers. Crude, crushed herb was applied for heel pain or, if mixed with fat, into the ear to reduce earache. In Sacz Beskids it was also used internally to treat flu or urinary tract diseases. Its relaxant and emetic properties were used in food poisoning. Sedum maximum leaves were applied externally crude or crushed on ulcers, bruises or edema. Sap of its leaves was mixed with barley flour and as a plaster applied to slow healing wounds . The Silesian Beskids inhabitants used it both internally and externally. Its root boiled with milk or water and drank once a day on empty stomach was used in kidney and bladder disease. Leaves were put on ulcers because of its properties of getting pus out. Moreover, herb infusion was used internally to treat colic and stitching pain , charm heals, and whispering prayers to treat diseases and cast magical incantations  could be of particular interest in this matter as it was largely unused by the Western cultures. Similarly, the endemic species of Arran whitebeam (Sorbus arranensis), unknown in Roman healing tradition, was used as an antimicrobial remedy in the Scottish Highlands , garlic (Allium sativum), periwinkle (Vinca minor), St. John's wort (Hypericum perforatum), and juniper (Juniperus communis), which was strictly in line with previous observations across various centuries. Two plants, yarrow (Achillea millefolium) and coltsfoot (Tussilago farfara) were also recognized as the most versatile remedies with multiple pharmacological indications.Fischer's survey reported 179 plant taxa from the Galicia region. However, only 87 (49%) of them were used as medicines and targeted predominantly respiratory (24), digestive (24), and skin (23) illnesses. The remaining herbs (53 or 30%) were used for blessing during various religious ceremonies  often received education at the University of Padua, similar to their Ruthenian and Polish counterparts . Subsequent handwritten manuscripts and surveys reported both smaller numbers of total medicinal plants, as well as those used for wound healing. Only 3 plant species are recommended to treat wounds across all 6 sources studied, including derevij (Achillea millefolium), babka (Plantago maior) and shalvia , but at least 14 plants are shared among the majority of the sources. Comfrey root  was used on multiple occasions to heal wounds associated with bone fractures, minced in animal fat. The type of fat used in this ointment varied depending on the location: in Silesian Beskids, pork fat was preffered, in Zywiec Beskids, goose lard was believed to possess the best curative properties, while in Sacz Beskids they were both considered as effective. Another treatment that remained largerly uniform among the discussed regions was application of galipot of conifer trees to wound healing ointments after heating it with bee wax and butter.To illustrate our assumption that the original Carpathian herbal remedies were either substituted by knowledge gathered from classical medicinal monographs or were identical to them, we attempted a direct comparison of descriptions of herbal medicines used to treat wounds among printed herbals and subsequent traditional folk knowledge in the region. Falimirz's herbal 1534) listed 63 plants that were used for wound healing out of 246 plants shown in Table 4 listed Matricaria chamomilla) and senna , while chestnut (Castanea sativa), buckthorn , and milk thistle (Silybum marianum) are leading exports in recent years  is also a very attractive factor, however it is partially offset by lack of modern cultivation practices and delayed returns due to intial 2 to 3-year establishment of annual crop harvest (Mirzoyeva,  Figures . This is Figures . A curreThe first printed herbals published in the Carpathian forelands were early compilations of transcribed Greek and Roman works on the subject, and set a continuous trend of ethnic use of local botanical remedies according to their Dioscorides and Galenic qualities. The Padua-Krakow axis was identified as a key putative factor in introduction of this knowledge to Ruthenian and Polish medical students during the fifteenth–sixteenth centuries. Subsequently, this tradition was incorporated into oral and written legacy of Boyko, Lemko, and Gorale ethnic groups, and fused with Slavic use of charm and prayer heals to treat diseases and cast magical incantations. However, the traditional use of several endemic plant species in the region could provide an exciting opportunity to observe pre-Christian folk healing traditions from the Beskid Mountains. The study also highlighted the vast potential for growing and processing medicinal plants in the region, and cited low awareness among farming communities, inadequate processing capacities, price risks, and non-availability of planting material as critical constraints that need to be addressed.WK drafted ethnobiology sections of the manuscript. CW drafted and contributed knowledge on classical and Celtic medicines. EM drafted and contributed knowledge on skin and wound healing applications. AM and SK conceived, designed, and wrote the manuscript. All authors read and approved the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Chlamydia, gonorrhoea and syphilis are readily treatable sexually transmitted infections (STIs) which continue to occur at high rates in Australia, particularly among Aboriginal Australians. This study aimed to: explore the extent of variation in delivery of recommended STI screening investigations and counselling within Aboriginal primary health care (PHC) centres; identify the factors associated with variation in screening practices; and determine if provision of STI testing and counselling increased with participation in continuous quality improvement (CQI).n = 16,086) were conducted at 137 Aboriginal PHC centres participating in the Audit and Best Practice for Chronic Disease Program, 2005–2014. STI testing and counselling data were analysed to determine levels of variation in chlamydia, syphilis and gonorrhoea testing and sexual health discussions. Multilevel logistic regression was used to determine factors associated with higher levels of STI-related service delivery and to quantify variation attributable to health centre and client characteristics.Preventive health audits  3.40; 95% Confidence Interval (CI) 3.07-3.77) and having conducted 1–2 cycles of CQI . Client factors associated with higher levels of STI testing and counselling were being female , Aboriginal  and aged 20–24 years . For females, having a Pap smear test was also associated with STI testing and counselling . There was no clear association between CQI experience beyond two CQI cycles and higher levels of documented delivery of STI testing and counselling services.A number of Aboriginal PHC centres are achieving high rates of STI testing and counselling, while a significant number are not. STI-related service delivery could be substantially improved through focussed efforts to support health centres with relatively lower documented evidence of adherence to best practice guidelines. Preventable and curable sexually transmitted infections (STIs) including chlamydia, gonorrhoea and syphilis continue to be a major cause for concern in Australia, particularly among Aboriginal and Torres Strait Islander  Australians. There are large disparities in STI notification rates between Aboriginal and non-Aboriginal Australians with gonorrhoea, syphilis, and chlamydia, 10 times, 6 times and 3 times higher among Aboriginal compared to non-Aboriginal Australians . FurtherA number of guidelines provide recommendations on frequency of STI testing among Aboriginal clients attending primary health care (PHC) centres in Australia , 4, withUnder the ABCD Program, health centres undertake preventive health clinical audits to assess documented provision of preventive health care for their clients, including delivery of sexual health care services, to determine levels of adherence to best practice. The audit processes allow health centres to benchmark themselves against other health centres, make judgements about their delivery of care, and determine priorities for improvement. Over 270 health centres have been involved in the ABCD/One21seventy program and 175 health centres voluntarily provided their audit data to the ABCD National Research Partnership (NRP) for further data analysis .The aim of this study was to quantify the extent of variation in specific processes of care related to sexual health among Aboriginal primary health care centres using data obtained through the ABCD NRP. Specifically, the study aimed to: determine the factors at health centre and client level associated with variation in STI testing and counselling; quantify the variation attributable to health centre and client characteristics; and determine if provision of sexual health prevention/screening services increased with participation in CQI.One hundred and thirty seven participating primary health centres in the ABCD NRP provided preventive health audit data between 2005 and 2014. These centres predominantly serve Aboriginal clients and include urban, regional and remote government- and community-controlled primary health care centres from 5 jurisdictions in Australia: NSW, NT, WA, SA and QLD. Based on a comprehensive care model and providing clinical services, health promotion and community care, Aboriginal PHC centres range in size and staffing and employ a range of health workers including general practitioners, nurses, allied health practitioners, mental health professionals, and Aboriginal health workers . Some reDetails of the audit process have been documented elsewhere , 14. In STATA version 14 software  was used for statistical analysis. To assess delivery of STI testing and counselling, a sexual health delivery composite outcome measure was created which included sexual and reproductive health (SRH) discussion, NAAT test for gonorrhoea and chlamydia, and syphilis serology test by calculating the proportion of screening/counselling services received out of the total number of services the client should have received based on the audit protocol. The composite measure is expressed as a percentage; for instance if a client received all three services, this is expressed as “100% of recommended services were delivered to the client”. To determine variation in STI testing and counselling at the health centre level, the mean number of recommended tests/counselling delivered by each health centre to their eligible clients within an audit cycle or year was calculated. For logistic regression analysis, each composite measure score was converted to a binary outcome variable that categorised ‘higher’ performance as attaining 100% of service delivery, and anything less as ‘lower’ performance.For unadjusted analysis, crude odds ratios were calculated to determine the association between the predictor variables  and the composite measure; the odds in this instance are ‘the odds of a patient receiving 100% of service delivery’ in comparison to the reference group. For multilevel logistic regression analysis a step-wise model was used starting with Model A to test the influence of health centres and jurisdictions on sexual health service delivery over audit years; health centre characteristics were added in Model B and in Model C, patient characteristics were included. This model allowed for the hierarchical structure of the data, that is, patients nested within health centres, nested within jurisdictions . Only siA median odds ratio (MOR) was used to quantify the variance in odds ratio scale, i.e. the increase in median probability of better delivery if a client moved from one randomly selected health centre/jurisdiction to another . The MOROf the 137 centres that audited for preventive services between 2005 and 2014, 45% were in the NT and 36% in QLD , 46% had a documented history of a sexual and reproductive health discussion, with the highest in NT (49%)   3.40; 95% confidence interval (CI) 3.07-3.77) and having conducted 1–2 cycles of CQI   allows for the Health Assessment for Aboriginal and Torres Strait Islander People Item 715 (MBS 715) at least once every nine months including a sexual health history, Pap smears and testing for STIs . CombiniThere are several limitations to this study that have to be taken into consideration when interpreting the findings. The auditing process collects a limited amount of data so potential important factors may not be measured; health centre factors, contextual factors in the wider community and structural and legislative factors that may impact on delivery of care are not readily measured and quantified. Workload pressures at health centre level were considered during development of the audit tools; selecting indicators of relevance to Aboriginal primary care centres reflects the service-orientation of the ABCD projects. Lack of workforce data both in terms of number and cadre of health workers at service level and data on access to male and female service providers precludes analysis through our current dataset of the impact of these factors on sexual health service delivery in this context. The fact that less than 50% of variation could be accounted for by the available health centre and client factors indicates that there are other factors underlying variation. Furthermore, the variation in documented STI counselling and testing between regions reflect a differing background STI prevalence, local and regional guidelines and clinical practice. Variation in testing may also be a reflection of access to laboratory services, particularly in rural and remote regions. It is expected that point-of-care testing will enhance early diagnosis of STIs, particularly in remote areas where there are significant delays in the management of STIs . Future Another limitation of this study is that auditing depends on documentation of care in the client’s medical record and audit data may not be a true reflection of actual service delivery. This study could have underestimated the number of STI tests and sexual health consultations provided by the health centre, for instance in circumstances where health centres facilitate community outreach to increase clients’ access to STI testing and counselling if this is not incorporated back into patient information record systems. It is also not possible to estimate the number of clients who could have accessed these services outside their regular health centres, for instance, highly mobile persons or those who have access to other health services e.g. mainstream general practices. The preventive audit is limited to 15–54 year olds and excludes pregnant and postpartum women and those with a diagnosis of a chronic disease; this may lead to an underestimation of STI testing and counselling conducted by health centres. Underlying assumptions in the analysis were that all clients were sexually active and that all females had an intact cervix, that is, not undergone a hysterectomy, thus possibly overestimating the need for STI testing and counselling. Participation in One21seventy and the ABCD National Research Partnership is voluntary; health centres were invited to participate in the ABCD/One21seventy program  and furtThis study has elucidated several areas for improvement and demonstrated that variation in STI-related service delivery between health services is highly dependent on health centre factors rather than client factors, which highlights the critical need for structural and organisational changes, rather than client-centred interventions, to overcome the specific barriers to provision of adequate care and improve sexual health care delivery. Organisational-level interventions, including creation of multidisciplinary clinical teams, revision of professional roles, skills mix changes, and structural changes , could hThis study has shown that a number of jurisdictions and Aboriginal PHC centres are achieving high rates of STI testing, providing an opportunity for better understanding of what contributes to higher levels of performance in sexual health care. There are a significant number of health centres with relatively low documented evidence of adherence to best practice and analysis shows that variation is mainly attributed to health centre factors. STI-related service delivery could be substantially improved through focussed efforts to support delivery of services in health centres, and to groups of clients, with relatively lower documented evidence of adherence to best practice guidelines. Documentation of AHCs and Pap smear testing is associated with more testing for STIs and may contribute to earlier detection and treatment of STIs, and STI testing should be included with these interventions. Nevertheless, all PHC personnel should be encouraged to consider STI screening for all young men and women presenting to the health centre for any reason, at every opportunity, without necessarily waiting until the next AHC or Pap smear is due, in conjunction with other approaches to increase STI testing in high risk groups. Further analysis of local, regional and jurisdictional factors that impact on sexual health service delivery will assist health workers, PHC service managers and policy makers develop targeted interventions to improve service delivery. These approaches could help enhance equity in quality of sexual health care, contribute to the reduction in the high burden of STIs in the Aboriginal population in Australia and contribute to an overall improvement in quality of life for Aboriginal Australians.


On September 30, 2014, the Texas Department of State Health Services reported a case of Ebola virus disease (Ebola) diagnosed in Dallas, Texas, and confirmed by CDC, the first case of Ebola diagnosed in the United States . Based oInterim U.S. Guidance for Monitoring and Movement of Persons with Potential Ebola Virus Exposure  as well as contact with 10 friends and family members and 60 patrons and employees at one store. Seventeen airline and airport personnel and 76 airline passengers also were monitored in Ohio because of contact with patient 3. Some exposures were brief, whereas others lasted several hours; some likely included direct skin-to-skin exposure. Contacts were interviewed to determine risk for exposure and monitored by local health jurisdictions in Ohio, with the majority of contacts residing in metropolitan areas near Cleveland and Akron. All 164 Ohio contacts were asked to monitor their temperature and symptoms twice a day for the 21-day incubation period. Based on Ohio’s risk stratification, which was similar but slightly more restrictive than CDC’s Onsite technical consultations were conducted rapidly with seven hospital systems across the northeast Ohio region, identified by local health jurisdictions, to assess preparedness to care for a contact who developed symptoms of Ebola. All seven hospitals were determined to have capacity for isolation and transfer of a patient with suspected Ebola; five were deemed fully capable of providing care during the 72-hour Ebola evaluation period.This response required substantial time, resources, and coordination between local health jurisdictions in 19 Ohio counties, the state health department, federal public health authorities, and the regional health care system. This response highlighted the need for specific plans to be developed in advance for various potential situations, including identification of screening facilities for the triage of persons under investigation if the designated Ebola treatment facility reaches capacity


Background: In production animal agriculture, the cost of feed represents 60–70% of the total cost of raising an animal to market weight. Thus, development of viable biomarkers for feed efficiency  to assist in genetic selection of breeding stock remains an important goal in commercial breeding programs.Methods: Global gene  and protein expression (shotgun proteomics) analyses have been conducted on breast muscle samples obtained from pedigree broiler males (PedM) exhibiting high and low FE phenotypes. Using the entire datasets  the number of genes or proteins that were expressed numerically higher or lower in the high FE compared to the low FE phenotype for key terms or functions, e.g., ribosomal, mitochondrial ribosomal, tRNA, RNA binding motif, RNA polymerase, small nuclear ribonucleoprotein, and protein tyrosine phosphatase, were determined. Bionomial distribution analysis (exact) was then conducted on these datasets to determine significance between numerically up or down expression.Results: Processes associated with mitochondrial proteome expression  were enriched in breast muscle from the high FE compared to the low FE pedigree male broiler phenotype. Furthermore, the high FE phenotype exhibited enrichment of ribosome assembly , as well as nuclear transport and protein translation processes compared to the low FE phenotype. Quality control processes (proteosomes and autophagy) were also enriched in the high FE phenotype. In contrast, the low FE phenotype exhibited enrichment of cytoskeletal proteins, protein tyrosine phosphatases, and tyrosine kinases compared to the high FE phenotype. These results suggest that processes of mitochondrial and cytosolic ribosomal construction, activity, and protein translation would be enhanced in high FE breast muscle, and that phosphorylation of tyrosine moieties of proteins could be prolonged in the high compared to low FE phenotype. The results indicate the presence of a proteogenomic architecture that could enhance ribosome construction, protein translation, and quality control processes and contribute to the phenotypic expression of feed efficiency in this PedM broiler model. Continued improvement in animal agriculture production efficiency is critical for maintaining sustainable poultry and livestock production. Simultaneously, enhancing feed efficiency (FE) helps meet the protein needs of an ever increasing human population, while making better use of available resources. As animal feed comprises 60–70% of total cost of raising an animal to market weight across poultry and livestock  between groups which produces well defined, differentially expressed genes or proteins datasets that are verifiable, manageable, and can be discussed in a cohesive manner. This approach enhances understanding of fundamental mechanisms associated with given condition, but a tremendous amount of potentially informative data is discarded from further consideration. This is particularly true for high throughput genomic data where the number of assays  vastly exceeds the number of biological replicates. In these cases multiple testing penalties can be very severe and may lead to few, if any, significant differences being identified. Here we present an alternative approach that may especially lend itself to samples with subtle phenotypes such as feed efficiency within a single genetic line. We argue that individually, small effects can be considered significant if they combine cumulatively in a given biological process or pathway.In global gene and protein expression studies, emphasis is placed on using cutoff values for fold differences  analyses were developed to identify molecules that have a large effect on a given phenotype due to their interconnectedness with many cellular processes, but may not be differentially expressed : Protocol #14012.ad libitum during the 1 week phenotyping period (from 6 to 7 week of age). From this group of 100 birds, those exhibiting the highest and lowest FE (n = 6 per group) were obtained. The average weight gain (g), feed intake , and FE (gain/feed) for the high and low FE groups is provided in Table n = 4/group) were analyzed in the proteomic study  on an Illumina HiSeq using 100 base paired end read sequencing. Shotgun proteomics analysis was conducted on breast muscle from a total of 4 high and 4 low FE samples by in-gel trypsin digestion and tandem mass spectrometry (MS/MS) at the University of Arkansas Medical Science (UAMS) Proteomics Core Lab .5. The numbers of molecules in which mean values were numerically higher (H) or lower (L) in breast muscle of the high FE compared to the low FE PedM phenotype were determined and used in the exact binomial distribution analysis test offered in the 2010 version of Microsoft Excel™. In this study there was no gating of terms based on significant or fold difference in expression for a given transcript or protein. The mean values for the proteomics dataset  are very different from cytoplasmic (80S) and bacterial ribosomes (70S)  DNA and imported into the mitochondria, to form enzyme complexes of the electron transport chain, Kreb cycle, and other mitochondrial processes  in the microarray data but a significant enrichment in the high FE phenotype with the RNAseq dataset  out of the nucleus, and cytoplasmic synthesized proteins into the nucleus that are requisite for RNA synthesis outlined above. The nucleopore complex is comprised of a large family of karyopherin proteins with several protein subfamilies; e.g., nucleoporins, importins, and exportins  is another degradative repair process that degrades damaged structures ranging from proteins to entire organelles , are there greater numbers of genes or proteins expressed at higher levels (enriched) in the high or low FE phenotype? This analysis builds upon a series of studies that have been conducted with this line of PedM broilers individually phenotyped for FE .This work is supported by USDA-NIFA (#2013-01953), Arkansas Biosciences Institute  and the Agricultural Experiment Station (University of Arkansas).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer DC and handling Editor declared their shared affiliation, and the handling Editor states that the process nevertheless met the standards of a fair and objective review.


Intellectual disability (ID) is the most prevalent disability in the world. People with intellectual disability (PWID) frequently experience extreme violations of numerous human rights. Despite greater prevalence in South Africa than in high-income countries, most ID research currently comes from the Global North. This leaves us with few contextually sensitive studies to draw from to advance inclusive citizenship.Our scoping review aims to investigate pertinent ID rights issues in South Africa, synthesise quantitative and qualitative studies, and provide a synopsis of available evidence on which to base future work. We aim to clarify key concepts, address gaps in the literature and identify opportunities for further research.We followed strict eligibility criteria. Medical subject heading terms were entered into seven databases. Seven reviewers worked independently, two per paper. Quantitative and qualitative data extraction forms were designed. We followed Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and registered a protocol. An inductive approach enabled a thematic analysis of selected studies.By following PRISMA guidelines, 82 studies were assessed for eligibility of which 59 were included. Ten sub-themes were integrated into four main themes: the right not to be discriminated against, the right to psychological and bodily integrity, the right to accommodating services and challenges to rights implementation.People with intellectual disability face compound difficulties when trying to assert their constitutionally entitled rights. This ongoing project requires serious commitment and action. Statutory obligations to nurture every South African’s human rights naturally extend to PWID and their supporters who forge ahead in a disabling environment. Most people with disabilities live in low-income countries and represent nearly a quarter of the world’s poorest people Emerson , 2011b. Medical definitions ascribe ID to deficits in intellectual and adaptive functioning across various domains with onset during the developmental period AAIDD . The AmeRegardless of subjective experiences, the medical model regards impairment as an inherent problem of the individual that is addressed through medico-psychological skill  , parents in countries like South Africa easily become unpaid caregivers because care burdens and lack of support hinder their pursuit of employment Geiger . Being oOther frequently violated rights of PWID in South Africa pertain to physical abuse, exclusion, barriers to accessing medical and mental health services, involuntary confinement, denial of marriage or parenting, financial exploitation, unemployment, occupational restrictions and living safely outside of institutions . We set out to study the ID advocacy, awareness and rights promotion research; describe outcomes of studies on realising human rights entitlements; and identify publications that address claims to citizenship of South African PWID. Following Peters et al.’s  suggestiWhat do we know about the state of human rights of PWID in South Africa?Are there barriers jeopardising rights realisation?Are PWID participating in socio-political lives of communities?Is rights advocacy needed?Which studies can we use to address these questions?We also aim to identify areas for future investigation by highlighting gaps in the available research.We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and registered a protocol with PROSPERO (CRD42016036100). An inductive approach accommodated thematic analyses of selected studies.Included studies are on rights of PWID in South Africa published between 1992 and 2017. Research sites and participants are in South Africa. Comparative country studies on ID had to include South Africa (World Bank Reviewer panel consensus minimised study selection bias by resolving issues like the eligibility of studies on FASD and autism spectrum disorder (ASD). Intellectual disability is not required for an FASD diagnosis, and low or average intellect is actually more common in FASD  to increase the likelihood of locating South African publications among international studies. Electronically unavailable records were hand searched, authors were contacted or subject librarians at Stellenbosch University were approached. Backward and forward citation searches identified additional studies. The last search ran on 31 August 2017 which was also the author contact cut-off date.Data were sought for outcome, setting and participants by using medical subject headings (MeSH) terms  as per sBox 1Search by medical subject heading terms.TOPIC: ‘Intellectual disability’ OR ‘developmental disabilities’AND TOPIC: ‘South Africa’ (includes Republic of South Africa)AND TOPIC: ‘Adult’OR ‘adolescent’ OR ‘child’ OR ‘infant’ (includes newborn)AND TOPIC: ‘Human right’ In an attempt to minimise risk of bias across studies that may affect the overall review results, seven reviewers worked independently, two per paper, to assess each study according to the review’s eligibility criteria . Three experts were available for data verification . Future systematic reviewers can critically appraise individual bias within studies by means of checklists suitable to study design and available in the public domain as offered in Data extraction forms for quantitative and qualitative studies used PICOS  and SPIDER  elements, respectively .By following PRISMA guidelines, 156 records were identified overall. Ninety-six studies remained after deleting duplicates. Two reviewers screened each abstract resulting in 14 exclusions. Eighty-two studies were assessed for eligibility of which 59 were included for qualitative synthesis .n = 59) are summarised in n = 26), qualitative (n = 31) and mixed-methods (n = 2) designs.Characteristics of included papers (n = 36) and addresses inclusive education, inclusive communication and the right to be understood, acknowledgement of competence and capacity to be included, and socio-political participation and inclusive citizenship. The second theme addresses the right to psychological and bodily integrity (n = 11) in terms of protection against abuse, and the right of abuse victims to appropriate treatment. Thirdly, the right to be accommodated (n = 8) speaks to availability of appropriate services and subsequent access to these services. Finally, main theme four touches on challenges to rights realisation (n = 4), warns of barriers to support and considers obstacles to rights implementation.Individual study findings were synthesised into 10 sub-themes. These were then integrated into four main themes . The firn = 36) with inclusive education (n = 14) and acknowledgement of competence and capacity (n = 13) also enjoying focus. The right to psychological and bodily integrity (n = 11) enjoyed slightly more research interest than the right to be accommodated (n = 8) and challenges to realisation of rights (n = 4).The majority of included studies pertain to the right not to be discriminated against (n = 4) and availability of appropriate services (n = 2). Results show that the right to socio-political participation and inclusive citizenship requires urgent investigation (n = 1).Rights issues that received the least amount of research attention throughout the review period include the right to be understood (The Bill of Rights (Act 108 of 1996) enshrines universal dignity (s7.1), equality (s9.2), protection against discrimination by persons or the state on grounds of disability (s9.3), life (s11), bodily and psychological integrity (s12.2), voting in elections (s19.3a), health care (s27.1a) and primary and secondary school education (s29.1a) (Republic of South Africa [RSA] n = 36).The right to inclusive education, inclusive communication, competence and capacity, and socio-political participation speaks to issues of discrimination , urban caregivers believe more firmly that CWID have rights (p < 0.001)  can support PWID who have difficulties with conventional communication in various settings . Yet, safe inclusion of PWID as members of South African communities is yet to be aligned with these principles .The second theme addresses the right to psychological and bodily integrity  programme exemplifies a not-for-profit project established for complainants with ID in sexual assault cases (Dickman & Roux n = 8) speaks to subsequent access to available and appropriate services for PWID.The lack of reliable and affordable public transport infrastructure and expenses incurred to access private transport, as well as the high rate of human immunodeficiency virus infection and acquired immune deficiency syndrome (HIV and AIDS) and its prioritisation in the primary health care system, serve to complicate access to state-subsidised primary care medical services throughout South Africa. The right to be accommodated   warns of barriers to necessary levels and kinds of support and considers obstacles to rights implementation. People with intellectual disability struggle to exercise their constitutional rights when confronted with service barriers and low political prioritisation of care  and General Regulation Amendment (DoH 2016) supports institutional state care for adults with severe and profound ID, but lacks rights governance for adults with any severity of ID living in community settings. Beyond the inadequate Mental Healthcare Act  UN , the prot 13 DoJ , no act ment DoH  supportsIn light of the lacking legislation as discussed above, we turn to the Esidimeni care crisis, violations of the constitutional right to life RSA  and the Despite deinstitutionalisation, PWID remain isolated from communities in which they feel victimised, rarely participate in basic education and skills development programmes and struggle to find appropriate work placements without help. The need remains for protective and participatory community-based services, but these must be developed and monitored in line with purposeful care and safe community inclusion. This is particularly urgent as results have shown. When family caregivers burn out or die, PWID are left with limited options. Few relatives or neighbours willingly take on the support needs of PWID Geiger , whereasAs it is the right to inclusion of every person in South Africa, PWID should also be able to have their health needs initially assessed or met at primary health care level, yet are often redirected to specialist settings for services that could have been delivered at their local clinics. In the same vein, a lack of ID awareness at primary care level results in PWID getting lost to referral services in cases where they should have been receiving specialist intervention.We end this discussion by suggesting that one way to reduce discrimination against PWID is to encourage equitable practices that include and rely on the expertise of people living with ID. In just societies that celebrate self-determination, assistance is commonplace, and barriers to developing adaptive abilities are removed to increase competency.In returning to our aims and objectives, we now see that PWID in South Africa face more difficulties than the general population when attempting to access justice, health, educational, employment and social services. Prejudice increases violence against PWID, but negative bias excludes them from public health and safety campaigns. There is a need to address such discrimination through advocacy interventions similar to those employed in other national rights campaigns, like the HIV/AIDS Treatment Action Campaignthe United Kingdom Care Act  and the lack of appropriate services (n = 2). The right to socio-political participation and inclusive citizenship requires urgent investigation (n = 1). There are opportunities for researching the experiences and attitudes of primary health care workers towards PWID and for addressing a lack of South African evidence regarding support and interventions for offenders with ID. The sexual rights and health of PWID, and rights to parent, can be included as neglected fields of study and advocacy.Rights issues that received the least amount of research attention throughout the 25-year review period include the right to be understood , and this limitation can contribute to publication bias.Although arguments on therapeutic sterilisation were rationally and logically presented by Nash and Navias  over twoDonohue et al.  recognisOur scoping review investigated pertinent issues relating to the rights of PWID in South Africa. We incorporated available research evidence in a synopsis of 59 eligible studies, addressed implications for practice and identified areas for future investigation. Realising the rights of PWID in South Africa to participate as socio-political equals, access services, own their psychological and bodily integrity, and move freely without discrimination is an ongoing project. Barriers to exercising these rights were highlighted. Research evidence advocates that – for a start – the rights and needs of PWID be taken up with serious commitment by the South African state, its legislature and public service departments. Statutory obligations to protect and realise the rights of any South African must extend to PWID and their supporters who are forging ahead in a disabling and service constrained socio-political environment.Turning back to the continuum of ‘changing states of impairment and health’  continuum, we may find it difficult to imagine ourselves in a future impaired, ill or injured state. But we must take cognisance of a universal human frailty so that we can face our own inescapable fragility with dignity and justice, secure in the protection against violence of moral, psychological and physical abuse.


To achieve compliance with the revised World Health Organization International Health Regulations (IHR 2005), countries must be able to rapidly prevent, detect, and respond to public health threats. Most nations, however, remain unprepared to manage and control complex health emergencies, whether due to natural disasters, emerging infectious disease outbreaks, or the inadvertent or intentional release of highly pathogenic organisms. The US Centers for Disease Control and Prevention (CDC) works with countries and partners to build and strengthen global health security preparedness so they can quickly respond to public health crises. This report highlights selected CDC global health protection platform accomplishments that help mitigate global health threats and build core, cross-cutting capacity to identify and contain disease outbreaks at their source. CDC contributions support country efforts to achieve IHR 2005 compliance, contribute to the international framework for countering infectious disease crises, and enhance health security for Americans and populations around the world. To contain health threats and ensure global health security, all countries must rapidly detect and respond to public health emergencies and, when overwhelmed, call upon global deployment capacity. This need is clearly evident, as the world is more susceptible to infectious disease threats due to increased international travel and trade, spread of newly emerging or reemerging microbes, and inadvertent release of dangerous pathogens from laboratories or bioterrorism acts.Following the 2002–2003 severe acute respiratory syndrome (SARS) coronavirus outbreak, which demonstrated how rapidly a pathogen could spread to 26 countries  has established a global health protection platform that works with ministries of health (MOHs); other partners ; CDC country offices; and agency programs, including those dealing with influenza, emerging zoonotic diseases, HIV, malaria, and polio . In in 2017 .The 2014–2016 West Africa Ebola epidemic was the largest emergency response in CDC’s history .During September 2015–June 2017, these responders were mobilized >420 times and contributed >14,000 cumulative person-days to emergency response in the field, in Atlanta’s Emergency Operations Center (EOC), or both . During ,–Humanitarian crises resulting from natural disasters ; armed conflict; or civil strife routinely lead to large-scale population displacements. Whether migrating outside their countries as refugees or internally displaced in their homelands, disrupted populations routinely experience increased illness and death from respiratory and diarrheal pathogens associated with overcrowding; disrupted health services ; and lost access to food, clean water, and sanitation . During 2011–2016, CDC deployed staff for >380 missions in >40 countries to apply public health principles and epidemiologic science to mitigate the health impacts of complex emergencies  program  in early 2007 to identify and monitor health threats to the American public and global community. Using event-based surveillance for early alerting and situation awareness, a team of analysts routinely monitor numerous information sources  for disease events using keywords in >50 languages, and validate accuracy with MOHs, WHO, Food and Agricultural Organization of the United Nations, World Organisation for Animal Health, and other partners. GDDOC monitors 30–40 public health threats daily, tracking situations that could develop into public health emergencies of international concern .GDDOC outbreak response support has included staff deployments and the provision of personal protective equipment, laboratory diagnostic test equipment, reagents, and supplies. GDDOC deploys CDC staff directly to the host country and through the WHO-hosted Global Outbreak Alert and Response Network. Emergency funding from the US Congress in 2014 for Ebola and GHSA made it possible to dramatically augment bilateral and Global Outbreak Alert and Response Network deployments for the West Africa Ebola epidemic. During 2016–2017, GHSA support substantively enhanced GDDOC’s capacity to conduct event-based surveillance.Following the 2002–2003 SARS outbreak, in 2004, the US Congress authorized funding for CDC to establish a regional Global Disease Detection (GDD) Program. Currently, CDC works with MOHs in 10 countries  to host With growing recognition that infectious disease outbreaks can become pandemics, resulting in considerable loss of life and economic cost, GHSA was launched in February 2014 by 29 countries, WHO, the Food and Agricultural Organization of the United Nations, and the World Organisation for Animal Health to rapidly identify and mitigate infectious disease threats at their source . The gro–). To reduce the risk of emergent zoonotic infections, 13 countries have expanded surveillance systems in humans, wildlife, and animals to foster prevention  has provided reagents to national influenza laboratories and other respiratory disease laboratories worldwide.Since the 1980s, CDC has supported influenza surveillance and laboratory capacity globally. As of June 2017, CDC supports influenza activities in 79 countries, assisting MOHs and other laboratory partners in the Global Influenza Surveillance and Response Network in the early detection of potential pandemic threats and provides the world with access to new influenza strains to enable the development of effective seasonal influenza vaccines and vaccines against novel influenza strains that have pandemic potential   program of the Global Polio Eradication Initiative  (39). ST,National governments are responsible for keeping their citizens healthy and addressing public health challenges. To that end, many countries have established national public health institutes (NPHIs) to carry out essential public health functions, including outbreak detection and response ,. With IA–Outbreaks, regional epidemics, and pandemics are costly (Because of the recognized need to achieve IHR 2005 compliance worldwide to ensure health security, increasing number of countries that have made GHSA commitments, and early progress achieved with GHSA implementation, the world is becoming better prepared to respond to threats. CDC is helping advance health security through its global health protection platform. More work is needed and momentum in GHSA implementation needs to be sustained so Americans and citizens around the world will have enhanced protection from newly emerging infectious diseases and other health threats.


Salmonella enterica serovar Heidelberg. Since case-patients in the cluster reported consumption of a variety of chicken products, FSIS used a simple likelihood-based approach using traceback information to focus on intensified sampling efforts. This article describes the multiphased product sampling approach taken by FSIS when epidemiologic evidence implicated chicken products from multiple establishments operating under one corporation. The objectives of sampling were to (1) assess process control of chicken slaughter and further processing and (2) determine whether outbreak strains were present in products from these implicated establishments. As part of the sample collection process, data collected by FSIS personnel to characterize product included category (whole chicken and type of chicken parts), brand, organic or conventional product, injection with salt solutions or flavorings, and whether product was skinless or skin-on. From the period September 9, 2013, through October 31, 2014, 3164 samples were taken as part of this effort. Salmonella percent positive declined from 19.7% to 5.3% during this timeframe as a result of regulatory and company efforts. The results of intensified sampling for this outbreak investigation informed an FSIS regulatory response and corrective actions taken by the implicated establishments. The company noted that a multihurdle approach to reduce Salmonella in products was taken, including on-farm efforts such as environmental testing, depopulation of affected flocks, disinfection of affected houses, vaccination, and use of various interventions within the establishments over the course of several months.On June 28, 2013, the Food Safety and Inspection Service (FSIS) was notified by the Centers for Disease Control and Prevention (CDC) of an investigation of a multistate cluster of illnesses of  Centers for Disease Control and Prevention (CDC) and state and local public health partners as described in FSIS Directive 8080.3 FSIS,  to invesIn the hypothesis-generation phase of an investigation, questionnaires capture a variety of exposures that occurred before illness onset. Once a food source is identified, a focused questionnaire may be used to obtain detailed information on consumption of products of interest, such as brand name and place and date of purchase. Regulatory action in response to foodborne illnesses typically requires a combination of epidemiological, microbiological, and product traceback evidence sufficient to implicate a specific food and production establishment.Salmonella Heidelberg with a rare pulsed-field gel electrophoresis (PFGE) pattern and a high proportion of ill persons reporting chicken consumption before illness onset  assess process control of chicken slaughter and further processing FSIS,  and (2) FSIS worked with public health officials to request shopper card numbers for case-patients in the outbreak to obtain shopper histories and pursue traceback to producing establishments. Traceback was focused on chicken that was purchased raw and cooked at home, based on food histories reported by case-patients during interviews. A likelihood-based approach using traceback information was used to identify establishments potentially associated with illness. This approach accounted for the number and types of chicken products case-patients reported consuming in the week before illness onset, including establishments determined from case-patient food history and traceback. Rankings were used to prioritize establishments for intensified sampling of raw chicken products available for consumers to purchase. Using this approach, four establishments under the same corporate entity (“Company X”) were selected for initial intensified sampling of chicken parts and whole chickens, focusing on the raw chicken products most frequently mentioned during case-patient interviews. Later in the investigation, additional establishments from the same corporation were included in sampling to rule out their involvement in the ongoing outbreak. As part of the sample collection process, data collected by FSIS personnel included category (whole chicken and type of chicken parts), brand, injection with salt solutions or flavorings, and whether product was skinless or skin-on. Analyses were performed using SAS software version 9.4 . Odds ratios and confidence intervals for variables of interest  were calculated by chi-square tests of independence and proc logistic maximum likelihood estimates. The intensified sampling for this investigation was performed in phases, where the frequency, types of samples, and/or the establishments that were sampled during each time period were informed by ongoing findings from the investigation.Salmonella exposures, the products were shipped to one of the FSIS Field Service Laboratories  where samples were rinsed in accordance with FSIS chicken carcass or chicken parts sampling procedures: 400 mL of buffered peptone water was used to rinse either a whole chicken carcass or 4 pounds of raw chicken parts. A 30 mL test portion of the rinsate was analyzed for Salmonella according to the FSIS Microbiology Laboratory Guidebook (MLG), Chapter 4  of the isolates were Salmonella Heidelberg , followed by Salmonella Enteritidis (4.2%). All Salmonella isolates were analyzed for antimicrobial resistance (AMR), 26.9% were pansusceptible and 48.2% were resistant to three or more Clinical and Laboratory Standards Institute classes of antibiotic compounds  of positive samples and ∼2% (n = 197/8816) of all samples analyzed during 2014  of positive samples and about 0.1% (n = 11/8816) of all samples analyzed.Across all phases of sampling, 334 samples were positive for idelberg . The sec14 FSIS, . In 2014Salmonella declined from 19.7% to 5.3%  or external product package swabs (n = 90) were negative for Salmonella , but were less likely to contain outbreak strains  or isolates exhibiting AMR  than were conventional chicken products. Chicken labeled with the primary corporate name had similar Salmonella percent positive  to retailer-labeled or other brands of chicken produced by Company X , but a higher percentage of outbreak strains  and AMR . Skin-on products were slightly less likely to be positive for Salmonella  than were skinless products, and had a similar likelihood of containing outbreak strains  and similar AMR . Injected products were similarly likely to be positive for Salmonella compared with noninjected products , with similar likelihood of containing outbreak strains  and similar levels of AMR . Notably, there was no fluoroquinolone resistance identified in Salmonella isolates recovered during intensified testing. A single isolate from an organic chicken product sample exhibited resistance to ceftiofur and cefoxitin ; however, this isolate was not an outbreak strain. Overall resistance to aminoglycosides, beta-lactams, sulfonamides, and tetracycline was commonly identified, with resistance to chloramphenicol less commonly detected.All the tested preoperational environmental samples  and notice of intended enforcement (NOIE). These findings also prompted the company's response that led to improved control of Salmonella at each of the implicated establishments, as well as an end to illnesses associated with this outbreak investigation. In July 2014, in response to the detection of an outbreak strain in a leftover product from a case-patient's household that was indistinguishable from the case-patient's outbreak strain, the implicated company conducted a voluntary product recall of an unspecified quantity of fresh and frozen raw chicken products , The epidemiologic and traceback portions of a large outbreak investigation are resource intensive and are constrained by somewhat limited data  , which was the basis FSIS used for evaluating process control for chicken parts in these establishments  proposing new pathogen reduction performance standards for Salmonella and Campylobacter in raw chicken parts and comminuted chicken and turkey products (FSIS, Salmonella on poultry carcasses, chicken parts, and comminuted chicken and turkey products. In February 2016, FSIS published final performance standards for these products. FSIS is committed to encouraging reduction of Salmonella and Campylobacter in poultry products with the goal of foodborne illness prevention.The actions taken by FSIS during and after this outbreak will help reduce the ts FSIS, . The FRN


A novel service oriented platform has been developed under the framework of the Telerehabilitation Service funded by the Cross Border Cooperation Programme Greece Cyprus 2007 – 2013 to support tele-supervised exercise rehabilitation for patients after hospitalization in intensive care units (ICU). The platform enables multiparty, interregional bidirectional audio/visual communication between clinical practitioners and post-ICU patients. It also enables patient group-based vital sign real time monitoring, patients’ clinical record bookkeeping, and individualized and group-based patient online exercise programs. The exercise programs intended for the service are based on successful cardiorespiratory rehabilitation programs, individualized and monitored by a multidisciplinary team. The eligibility study of former ICU patients to participate in such a service as well as a cost benefit analysis are presented to support the cost effectiveness of the telerehabilitation program in addition to the expected health benefits to a large proportion of former ICU patients. Most of the patients who are hospitalized in intensive care units (ICUs) recover  and retuIn most cases, there is no specialized support to cope with the aforementioned long-term problems of the patients discharged from ICUs . At presSystematic exercise in the context of diagnosis-specific rehabilitation programs can positively influence the course of physical and non-physical problems associated with acute and/or chronic pulmonary  or cardiAn effective integrated rehabilitation program should consist of exercise training, educational, psychological and nutritional support, with exercise being the core component . Recent Despite the positive effects of exercise rehabilitation programs, it is not often feasible for patients to join such programs. The exercise programs are not usually accessible to patients either because their situation does not allow easy transportation, or because they imply serious economic expenses and time consuming transportation. Due to the lack of competent exercise programs, patients often fail to regain their skills and their status can gradually deteriorate with impact on mortality, morbidity, and extra cost for their families and health system . ExercisAs reported in a systematic review by A telerehabilitation platformPatients, selected to participate in the program, need to follow a 12-week exercise training rehabilitation program. The exercise program constitutes of consecutively continuous and interval aerobic exercise, endurance exercise and stretching . EnduranThe telerehabilitation platform being used by the Nicosia General Hospital consists of mature, fine-grained services and supports real-time/online and offline interactions between health professionals and patients . An exerFurthermore, the offline interaction of the patients with the platform allows the browsing of the exercise rehabilitation sessions mainly for educational purposes. Additionally, qualified members of the telerehabilitation staff (ergophysiologists/physiotherapists), can manage offline  rehabilitation groups and teleconference sessions . Finally, the platform includes Folder Automation Software of patients’ rehabilitation methodology that securely stores the patients’ records.Telerehabilitation sessions are monitored and coordinated through specially designed and equipped central stations. Specifically, central stations are equipped with broadband internet access, videoconferencing system, monitoring system of the patients’ biosignals, sound system , and video recording system, in order to remotely monitor the image and the biosignals of patients.A central station can control simultaneously up to eight home stations. A home station is provided to each patient and supports teleconference in virtual rooms, biosignals monitoring and transmission to central stations, online training and consulting and direct communication (even out of the program preset rehabilitation sessions) with remote rehabilitation center, using a network broadband infrastructure . To enable biosignals monitoring and transmission, wearable lightweight, portable (battery powered) wireless (802.11b) devices with biosignal sensors are involved. Specifically, the wearable devices monitor and transmit (via direct connection) to a central unit the patient’s biosignals; that is, 3-lead electrocardiogram, derived respiration rate , blood pThe telerehabilitation platform consists of the following software/hardware components:Each central station is accompanied by dedicated video conferencing equipment. Particularly, video and audio communication is established using business solution VoIP video conference (VC) systems. The Video Conference System leverages a MCU (Multiparty Control Unit) that enables the creation of virtual rooms, automatically establishes calls with all participants (telerehabilitation patients and clinicians), configures the clinician’s view in tile window layout and starts session recording based on pre-scheduled scenarios. The recording of sessions is performed by the Video Center service for further evaluation. To support this, home stations come with specialized video-conferencing software and are equipped with USB high definition (HD) cameras and microphones.Patient clinical data are monitored during the telerehabilitation session using in-hospital clinical information system solutions and the wearable devices that accompany home stations. Specifically, all participating patients are being concurrently monitored and their vital signs are transferred through a central unit to the conference system, thus enabling interregional monitoring and data storage. All data are transferred over virtual private network (VPN - IPSec no-compression) tunnels utilizing less than 100Kbps. Moreover, vital signs are exported offline to the Clinical Report Form (CRF) System in HL7 format.(a) Patient Group Scheduling and Management System that allows qualified health professional to manage  rehabilitation groups and teleconference sessions; (b) Online Training System that facilitates tele-supervised individualized or group based training sessions. A patient’s station is programmed with a predefined time interval for its training material  or consultation. The clinician in charge is able to assign the appropriate training material to a group of patients and/or to each patient individually during a session or offline; and (c) Clinical Report Form System (CRF) that manages private and non-private patient medical data. It consists of two individual services each handling only one class of medical data (private and non-private). CRF stores more than 100 individual fields and eight health surveys and medical examinations. Non-private data are exported to comma separated value (csv) files for further processing using statistical analysis software such as SPSS. All these systems follow the model-view-controller (MVC) software architecture, are written in php language, run on apache web server and leverage the MySQL relational database management system for medical records storage.The Patient Management System (PMS) effectively and securely manages patient medical data. PMS consists of the following systems: To protect clinical records, the private and non-private data are stored and processed in separate servers. Private data are any data that could, directly or indirectly, identify a person. That is, an identification number  or anything that specifies the patient’s physical, physiological, mental, economic, cultural or social view . Private data are encrypted, using AES symmetric-key algorithm; prior storage and access is allowed only from the server itself. Access to the private-data server is restricted to health professionals only. Moreover, the roles of health professionals  are of major importance. Particularly, health professionals have access to specific data views for specific patients based on their role . Only the research coordinator has full access to the data. Lastly, all servers use encrypted file systems to avoid direct access to the data or the source code, and backups are created and securely stored on a regular basis.The synergy of heterogeneous technology systems in the same infrastructure allowed the effective implementation of the described telerehabilitation platform. Among the technology systems used were teleconferences, monitoring of biosignals, electronic patient records and projection systems of customized training materials. Moreover, the huge number of real time streaming patients’ biosignals should be transmitted, displayed, and stored efficiently and effectively in real time. In addition, the adaptation of technology to specific characteristics and skills of different service users  as well as the reaction of users to new methodologies, technologies and practices, presented a lot of difficulties. Finally, the education of health professionals in a diverse (regarding issues of services and systems) technological infrastructure was not an easy task. It was required to prepare manuals and guidelines of use and management of the infrastructure services as well as clinical practice guidelines.Before commencing the implementation of such a challenging service it was necessary to assess the eligibility of former ICU patients to participate, and for researchers to perform a cost benefit analysis.This pilot verification study was undertaken in order to assess eligibility for inclusion of former ICU patients in a tele-supervised exercise training program, applying certain exclusion criteria . In addition, the study aimed to define the prevalence of these limiting factors.exclusion criteria for participation were: (a) mechanical ventilation for less than 48 hours; (b) poor neurological outcome as expressed by a Mini Mental Scale Examination score <23/30; (c) poor functional ability as expressed by a Rivermead Mobility Index <8/15; (d) end stage chronic illness; and (e) hospital discharge to chronic health care facilities or other hospitals.Thus, a prospective study of consecutive admissions to the general ICU of Nicosia General Hospital for the eligibility to participate in a home-based telerehabilitation program was conducted . The The data were collected from February 2013 until October 2013. The analysis was conducted on 451 patients; 77 (17%) died , 55 (12%) were considered eligible and 319 (70%) were non-eligible.Three hundred nineteen non-eligible patients were excluded because of (a) Mechanical Ventilation < 48 hrs 240 (75%), (b) poor neurological outcome  39 (12%), (c) poor functional ability (Rivermead Mobility Index < 8/15) 7 (2%), (d) end stage chronic illness 12 (4%), (e) hospital discharge to chronic health care facilities or other hospitals 21 (7%) . PercentThe cost benefit analysis of the telerehabilitation program was based on a discounted cash flow (DCF) analysis, which estimates the return of investment adjusted for the time value of money using as measures of success the net present value (NPV) at a declared cost of money percentage and the internal rate of return (IRR), both for a declared financial period. DCF analysis is generally considered the best way to assess investment projects. The major advantage is that it takes into account the fact that a certain amount of money today is worth more than the same amount in the future, mainly because of inflation. Such an analysis indicates that a project is likely to be “profitable” – increase the investors’ wealth, when (a) the Net Present Value of the project (NPV) is positive and when (b) the project’s rate of return (IRR) is higher than the cost of capital  .The financial projections assumed an increasing number of Telerehabilitation users (both rehabilitation sessions and successive follow-ups) over a 5-year period. Relevant investigation, as mentioned above, showed that approximately 75–96 patients would use the service each year. Thus, in the fifth year, 122 full users and 200 follow-up patients would use the Telerehabilitation facilities. The initial investment for the entire technical equipment  is estimated to be 382,000 Euros. Consequently, the analysis established that both measures were positive . The sumThe prospective study of consecutive admissions to the general ICU of Nicosia General Hospital gives preliminary evidence that a large proportion of ICU patients are eligible to participate in a planned home-based exercise rehabilitation program. Specifically, 12% of all admissions to the ICU of Nicosia General Hospital during an 8-month period were eligible to participate. Physical disability deterring participation was observed in 14% . The majority of the non-eligible patients (75%) were patients with ICU stay less than 48hrs; therefore, patients with low probability of ICU related disability. A telerehabilitation program for former ICU patients could be addressed with some changes from the above described, not only for the eligible patients of this study but also for patients with poor neurological outcome, poor functional ability, end stage chronic illness and probably hospital discharge to chronic health care facilities or other hospitals. These factors represent approximately 30% of the total patients. This suggests that one-third of former ICU patients can participate in a home-based telerehabilitation program. Furthermore, the above mentioned one-third includes the vast amount of patients who need rehabilitation after ICU hospitalization.Likewise, as shown by the financial appraisal of the service, the telerehabilitation program is worth the initial investment and leads to better financial output compared to re-hospitalization of patients because of incomplete rehabilitation/recovery. This is implied by the fact that the calculated cost of a former ICU patient telerehabilitation program is about the same with one day of readmission in ICU . FurtherIn summary, the design and implementation of a telerehabilitation platform to meet the needs of former ICU patients was a demanding task. The financial appraisal, in addition to the expected health benefits to a large proportion of former ICU patients renders such a project necessary in our society.