Cerebral small vessel disease (SVD) is a frequent finding on CT and MRI scans of elderly people and is related to vascular risk factors and cognitive and motor impairment, ultimately leading to dementia or parkinsonism in some. In general, the relations are weak, and not all subjects with SVD become demented or get parkinsonism. This might be explained by the diversity of underlying pathology of both white matter lesions (WML) and the normal appearing white matter (NAWM). Both cannot be properly appreciated with conventional MRI. Diffusion tensor imaging (DTI) provides alternative information on microstructural white matter integrity. The association between SVD, its microstructural integrity, and incident dementia and parkinsonism has never been investigated.The RUN DMC study is a prospective cohort study on the risk factors and cognitive and motor consequences of brain changes among 503 non-demented elderly, aged between 50-85 years, with cerebral SVD. First follow up is being prepared for July 2011. Participants alive will be included and invited to the research centre to undergo a structured questionnaire on demographics and vascular risk factors, and a cognitive, and motor, assessment, followed by a MRI protocol including conventional MRI, DTI and resting state fMRI.The follow up of the RUN DMC study has the potential to further unravel the causes and possibly better predict the consequences of changes in white matter integrity in elderly with SVD by using relatively new imaging techniques. When proven, these changes might function as a surrogate endpoint for cognitive and motor function in future therapeutic trials. Our data could furthermore provide a better understanding of the pathophysiology of cognitive and motor disturbances in elderly with SVD. The execution and completion of the follow up of our study might ultimately unravel the role of SVD on the microstructural integrity of the white matter in the transition from "normal" aging to cognitive and motor decline and impairment and eventually to incident dementia and parkinsonism. Cerebral small vessel disease (SVD) includes white matter lesions (WML) and lacunar infarcts and is a frequent finding on computer tomography (CT) and magnetic resonance imaging (MRI) scans of elderly people . It is aHowever, individuals with a virtually identical WML burden on conventional FLuid Attenuated Inversion Recovery (FLAIR) imaging present with a wide variance in cognitive and motor performance ranging from no complaints at all to subjective cognitive complaints and mild parkinsonian signs to dementia and parkinsonism. Apparently there are other factors that determine whether identical appearing WML on FLAIR lead to for example cognitive or motor decline in one person, while leaving others unaffected.One of the other factors could be the presence the coexisting manifestations of cerebral SVD on conventional MRI such as lacunar infarcts and cerebral microbleeds which might influence the cognitive and motor performance .As identical appearing WML on conventional MRI are actually histopathologically heterogeneous , it coulAnother explanation for the clinical diversity due to WML could be the efficiency of compensation mechanisms that prevent further cognitive and motor (gait) deterioration. Support for the existence of compensatory mechanisms comes from a study among young carriers of a pre-senilin mutation , but still without cognitive impairment) who showed altered functional connectivity (assessed with fMRI) compared with controls . With inIn the RUN DMC (Radboud University Nijmegen Diffusion tensor and Magnetic resonance imaging Cohort) study we prospectively investigate the effect of SVD on the transition from non-demented, independently living elderly people with cerebral SVD between 50 and 85 years towards cognitive and motor (gait) decline, and ultimately dementia and parkinsonism in a population with cerebral SVD. The primary objective of the RUN DMC study is to prospectively investigate the risk factors for and cognitive and motor (gait) consequences of longitudinal functional and structural changes in the integrity of the cerebral white matter as assessed by DTI, resting state fMRI and conventional structural MRI. To the best of our knowledge there are no other prospective cohort studies investigating the development of incident dementia and parkinsonism using these novel imaging techniques. Here we describe the study design and protocol of the RUN DMC study.Cerebral SVD is characterized on neuroimaging by either WML or lacunar infarcts. Symptoms of SVD include acute symptoms, such as transient ischemic attack (TIA) or lacunar syndromes, but also subacute manifestations such as cognitive and motor (gait) disturbances . As the Accordingly, in 2006, consecutive individuals referred to the Department of Neurology between October 2002 and November 2006, were selected for possible participation. Inclusion criteria were: (a) age between 50 and 85 years; (b) cerebral SVD on neuroimaging (WML and/or lacunar infarcts). Subsequently, the above mentioned acute and subacute clinical symptoms of SVD were assessed by standardized structured assessments  presence of dementia  and (b) All participants signed an informed consent form. The Medical Review Ethics Committee region Arnhem-Nijmegen approved the study.After 5 and 10 years all participants alive will be contacted for the prospective assessment of possible outcome events. This evaluation is currently being prepared for July 2011.Between 2006 and 2011 we contacted all participants every year by letter for an update on their address information and telephone number and for their survival status.In 2011 all participants alive will be invited by letter and subsequently contacted by telephone to visit our research centre. During their visit to the research centre a cognitive, gait, balance and parkinsonian signs assessment, a structured interview, physical examination, neurological examination, and an extensive MRI protocol, an electrocardiogram and an ultrasonography of the carotid arteries will be performed. All tests will be performed by the same two trained neurology residents and all MRI scans will take place on the same scanner.Primary measures of outcome of the study are incident dementia and parkinsonism according to international diagnostic criteria,27, as wSecondary outcome measures are defined as change from baseline examination in cognitive function, gait and balance and parkinsonian signs.Incident outcome events are to be identified by three different approaches.1. During the follow-up a structured questionnaire on the possible occurrence on these outcome events is administered to each participant. When an incident event is suspected the treating physician will be contacted for the most recent information on that particular outcome event.2. When a participant died before follow-up, the general practitioner will be contacted for the most recent information on the cause of death and presence of primary outcome events. In case of presence of primary outcome events the treating physician will be contacted for the most recent information available.3. When during follow-up assessment participants' test results are suggestive for incident dementia or parkinsonism, subjects will be referred to our outpatient clinic. In case the diagnosis is established according to the international criteria, this will be considered an incident case.All outcome events will be adjudicated independently by two specialised physicians, if the two classifications differ, the outcome event will be discussed and consensus will be made.Two trained residents in neurology will administer the complete outcome assessment.We will use an extensive neuropsychological test battery that encompasses items from other large scale epidemiological studies that cover virtually all cognitive domains ,28. A me® MAP/CIR Inc., Havertown, PA) with sensor pads (12.7 mm apart from each other) connected to a computer. This system has strong concurrent validity and test-retest reliability, also in older people [All participants will perform a tandem walk by walking ten steps heel to toe . A quantitative gait analysis will be performed with a 5.6-meter long, 0.89-meter wide electronic walkway  and 8 for gait (score 0-12), with a maximum score of 28 . It gradAs a measure of disability the Barthel Index will be used . The actStandardized questionnaires on demographics, education , maritalWith the aid a of structured, standardized questionnaire each participant will be asked for a history of: hypertension, diabetes mellitus, atrial fibrillation, TIA, stroke, myocardial infarction, coronary artery bypass graft, per-cutaneous transluminal coronary angiography, aortic prothesis, vascular prothesis, carotid endartectomy -4,21 andhttp://www.whocc.no/atcddd/)Current medication use will be noted and classified according to the Anatomical therapeutic chemical (ATC) classification system. , part A, which is a short diagnostic structured interview based on the DSM IV . AdditioFor the assessment of sleep disorders we will use the SCOPA-Sleep scale  and for Height and weight will be measured without shoes in light clothing. The body mass index (BMI) is calculated as weight divided by height (in meters) squared. The maximal waist circumference will be measured without shirt, in standing position, between the lowest rib and the iliac crest, at the end of normal expiration . Blood pThe presence of the glabella, snout and grasp reflex, the applause sign  and the ® hand-held dynamometer) [The strength of the biceps, hand grip, iliopsoas, quadriceps and foot extensor muscles on both sides will be measured by the medical research council scale (MRC) and by a dynamometer. (Citecmometer) .Sensory system will be assessed by a quantitative measurement by vibration tuning fork (Rydel-Seiffer®) on both first toes and both medial malleolus, also registering ankle oedema and ankle jerks.2) and resting state imaging using a gradient echo EPI ). During resting state, subjects will be told not to concentrate on any particular subject, but just to relax with their eyes closed. The complete scanning protocol takes 31 minutes.MRI scanning will be performed on a 1.5-Tesla Magnetom scanner . The scanning protocol includes whole brain 3 D T1 magnetization-prepared rapid gradient-echo (MPRAGE) sequence ; FLAIR pulse sequences ; transversal T2* weighted gradient echo sequence ; DTI  and gray andwhite matter tissue and cerebrospinal fluid probability maps is computed by using SPM5 unified segmentation routines on the T1 MPRAGE images . Total gLacunar infarcts are defined as hypo-intense areas > 2 mm and ≤ 15 mm on FLAIR and T1, ruling out enlarged perivascular spaces  and infraputaminal pseudolacunes . TerritoMicrobleeds are defined as small, homogeneous, round foci of low signal intensity on T2* weighted images of less than 10 mm in diameter . Microblhttp://sourceforge.net/projects/spmtools[The diffusion weighted images of each participant are realigned on the unweighted image using mutual information based Matlab  routines from SPM5. Then, the diffusion tensor and its eigenvalues are computed using an SPM5 add-on /spmtools. Unphysi/spmtools. The meaAn electrocardiogram (ECG) will be performed and evaluated by a standardized assessment by an experienced cardiologist, registering frequency, cardiac rhythm, cardiac ectopias, cardiac axis, conduction time over the PQ, QRS and QTC intervals, conduction disturbances, left ventricle hypertrophy, pathologic Q's, infarction, repolarisation disturbances and acute ischemia. A final diagnosis is defined as normal, abnormal without clinical significance, abnormal with clinical consequences or pathologic ECG with immediate consultation of a cardiologist when necessary.® qualification software (V. 4.2.1.). An edge detection algorithm identified the lumen/intima and the media/adventitia interfaces within a region of interest over a 10 mm long segment and calculated the average thickness [All ultrasound measurements will be performed by three experienced and specific trained clinical neurophysiology technicians. A carotid ultrasound assessment at which the intima media thickness (IMT) is measured in the distal left and right carotis communis, near the bulbus, will be performed. All measurements will be performed using a phased array real-time scanner  with a 17-5 MHz broadband linear transducer. Two-dimensional ultrasound imaging of the carotid artery will be performed to measure the IMT. The IMT will be automatically measured by QLabhickness .The same cognitive, motor, gait and balance assessment, structured interview and assessment of other variables and the same ancillary investigation were performed at baseline in 2006.Based on the literature we expect about 60 incident dementia cases during the five year follow up (absolute risk 4-5%/year), as about half of our study population has a relatively high degree of WML . We expeWe will analyze mean baseline MD and FA and change in MD and FA on follow up imaging in relation to incident dementia and parkinsonism by Cox proportional hazard models adjusted for age, sex, education, depressive symptoms, total brain volume, white matter lesion volume and lacunar infracts, where appropriate.The RUN DMC study is a large prospective cohort study on causes and consequences of structural and functional changes in the integrity of the cerebral white matter (in both the WML and the NAWM) as assessed by conventional MRI as well as new techniques, such as DTI and resting state fMRI, among elderly with cerebral SVD, starting to include participants for the follow-up protocol in July 2011.Numerous studies have shown that WML observed on conventional MRI are related to vascular risk factors and have reported associations with cognitive and motor decline and found these relations to be rather weak ,8,10,46.Strengths of the RUN DMC study include the prospective fashion of the study in which all vascular risk factors, clinical and imaging measures will be followed up after five years, and the large and well-established protocol used to explore demographics, vascular risk factors, and cognitive and motor function. The tests chosen are furthermore widely accepted and have been proven specific and sensitive in this population with structural brain changes.Another strength is the fact that it is a single centre study. Moreover, the complete study protocol will take place in one research centre with the use of a single scanner and only two investigators performing all investigations.In conclusion, the RUN DMC study has the potential to further unravel the causes and consequences of changes in white matter integrity in elderly with cerebral SVD by using new imaging techniques, DTI and resting state fMRI. When proven, changes in white matter integrity assessed by these techniques might function as a surrogate endpoint for cognitive and motor function in future therapeutic trials of vascular risk factors in SVD.The execution and completion of the follow-up of our study will ultimately unravel the role of SVD on the microstructural integrity of the white matter in the transition from "normal" aging to cognitive and motor decline and impairment and eventually to incident dementia and parkinsonism.The authors declare that they have no competing interests.AvN, KdL, FEdL: contribution to conception and design; acquisition of data; involvement in drafting the manuscript; final approval of the version to be publishedRG, IvU, LvO: acquisition of data; revising the manuscript critically; final approval of the version to be publishedEvD, RE, BB, BvE, MZ, IT, MOR, MvdV, MZ, DN: contribution to conception and design; revising the manuscript critically; final approval of the version to be publishedThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2377/11/29/prepub


Childhood obesity is a major public health problem. Experts recommend that prevention and control strategies include population-based policies. Arkansas Act 1220 of 2003 is one such initiative and provides examples of the tensions between individual rights and public policy. We discuss concerns raised during the implementation of Act 1220 related to the 2 primary areas in which they emerged: body mass index measurement and reporting to parents and issues related to vending machine access. We present data from the evaluation of Act 1220 that have been used to address concerns and other research findings and conclude with a short discussion of the tension between personal rights and public policy. States considering similar policy approaches should address these concerns during policy development, involve multiple stakeholder groups, establish the legal basis for public policies, and develop consensus on key elements. Childhood obesity has rapidly become a major public health problem; rates may have leveled, but they have not declined . MedicalGiven the enormity of the obesity burden, a collective response is needed for addressing obesity. Opportunities are available at multiple levels — communities, schools, industry, media, families, and individuals — to reduce the prevalence of obesity , and a cPopulation-based obesity control policies are recommended  to affecArkansas Act 1220 of 2003  was amonThe development of Act 1220 has been described in detail elsewhere . BrieflyAct 1220 had 6 key elements: 1) annual measurement of body mass index (BMI) for public school children and a report of each child’s BMI and associated health risks sent to parents (this element was modified in 2007 to require BMI assessment only in kindergarten and even-numbered grades 2-10), 2) elimination of access to vending machines during school for elementary school students, 3) identification of funding to hire community health promotion specialists to work with schools and communities, 4) creation of a statewide Child Health Advisory Committee (CHAC) to recommend evidence-based school nutrition and physical activity regulations, 5) public reporting of vending contracts, and 6) establishment of school nutrition and physical activity advisory committees. CHAC deliberations led to regulations enacted by the state board of education , includiSoon after Act 1220 became law, the Robert Wood Johnson Foundation (RWJF) funded the Arkansas Center for Health Improvement at the University of Arkansas for Medical Sciences (UAMS) to develop and analyze a statewide BMI database. RWJF also funded the UAMS Fay W. Boozman College of Public Health to conduct a process and impact evaluation of the act's implementation. The projects funded by these 2 distinct grants provide data relevant to the concerns surrounding individual rights versus public policy and how Arkansans viewed these concerns. The funding from RWJF for the evaluation will ultimately cover an 8.5-year evaluation period.The evaluation used both quantitative and qualitative methods to obtain data from multiple sources, including principals, superintendents, randomly selected parents and adolescents (aged 14-18 y), minutes from CHAC and other relevant meetings, and perspectives from key stakeholders. Records review, key informant interviews, surveys, and telephone interviews all contributed data for the evaluation, described in detail elsewhere . BaselinThe act passed into law with little controversy, essentially unnoticed by people outside the legislature. Subsequent attention stimulated public concern  in 2 priAct 1220 initially required public school children in grades kindergarten through 12 to have their BMI assessed annually, and reports to be sent to parents on report cards; however, this requirement was immediately modified by the legislature to require that confidential reports be sent to parents. Nonetheless, the following concerns continued to be reported:Informing parents of their children's weight status is unnecessary because they already know it. Although parents commonly reported that they could recognize an overweight child, data indicate that even professionals have difficulty correctly classifying children's weight status  may occur because of BMI assessment. Concerns emerged from both parents and health professionals about adverse consequences related to emotions, unhealthy diets, and increased eating disorders. However, these consequences have not materialized  and police power   . Althouguthority .In addressing the individual and population burden of childhood obesity, Arkansas acted within its established authority to protect and promote the public's health . The effIn our federalist government system, individual rights and freedoms are guaranteed by the US Constitution, state constitutions, and federal and state laws. The US Constitution is the express descriptor of individual rights and limits the federal government's ability to act against them . SelecteIndividuals enjoy certain rights of privacy regarding their activities and personal information, established through federal and state laws (and promulgated through regulation and interpretative guidance). Two are particularly notable for this discussion: the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Family Education Rights and Privacy Act of 1974 (FERPA)  the extent to which government authority to regulate interstate commerce through the Commerce Clause can support federal government action and 2) the boundaries of state police power , involve multiple stakeholder groups, establish clearly the legal basis for public policies, and develop consensus regarding key policy elements. These efforts may help develop greater consensus about approaches to reducing childhood obesity and may lessen concerns.


Health Services and Outcomes Research Methodology are based on presentations at the ninth International Conference on Health Policy Statistics (ICHPS) held October 5–7, 2011 at The Ritz Carlton in Cleveland, OH. We are very excited to publish nine papers that are not only of the highest quality but also serve as a permanent reminder of the very high standard of research on display at the conference.The papers in this special double-issue of More than 210 statisticians, methodologists, and health policy experts from all over the world gathered for the ninth ICHPS—a biennial meeting jointly sponsored by the ASA and its Health Policy Statistics Section. Conference Co-Chairs James O’Malley (Harvard University) and Thomas Love (Case Western Reserve University) were ably supported by a 29-member Scientific Organizing Committee and 10-member Advisory Board.Health Services and Outcomes Research Methodology, is one avenue of outreach emanating from the conference.ICHPS 2011 was made possible by the Agency for Healthcare Research and Quality (AHRQ), through an R-13 grant. Project Officer Melford Henderson took an active role, challenging attendees to find effective mechanisms for disseminating results so that they translate into actual policy and practice. This special issue of The meeting’s theme—Advancing Methods to Improve Health Care—reflected the growing importance of research methods in facilitating informed discussions regarding health reform and other efforts to improve health care in the United States. The newly minted Patient Centered Outcomes Research Institute’s calls for research reflect the impact of many of the methods showcased at ICHPS 2011.www.amstat.org/meetings/ichps/2011.As evidenced in the papers published in this issue, the presentations included a broad range of topics, including longitudinal data, spatial data, causal inference and treatment heterogeneity, quasi-experimental studies and novel use of randomization, and Bayesian analysis including prior specification, hierarchical modeling and random effects. Details of all sessions at the conference can be found at Rousing plenary addresses were delivered by Steven Nissen, M.D., Department Chair of Cardiovascular Medicine at the Cleveland Clinic on “The Drug Safety Wars”, and Arlene Ash, Ph.D., Chief of the Division of Biostatistics and Health Services Research in the Department of Quantitative Health Sciences at the University of Massachusetts Medical School on “Making Statistics Relevant: Why Not Change The World?” Dr. Nissen’s keynote described the discovery of safety concerns involving the pharmaceutical blockbusters Vioxx, Muraglitazar, and Avandia; the challenge of getting these concerns acknowledged; and subsequent attempted cover-ups. His talk empowered the audience to use rigorous statistical practice to maintain a high standard of integrity. Dr. Ash provided a wonderful description of her work in health policy statistics, offering sage advice and perceptive glimpses of the future. She encouraged the pursuit of problems of real interest, and emphasized the power of independent thought and action.The conference also featured the presentation of the Health Policy Statistics Section’s biennial Awards. Honored with the Long-Term Excellence Award were Drs. Paula Diehr  and Sharon-Lise Normand (Harvard University), while the Mid-Career Award was presented to Dr. James O’Malley (Harvard University). A Thursday evening visit to the House of Blues and Cleveland’s East Fourth Street district afforded opportunities to mingle in a relaxed environment while enjoying Cleveland’s hospitality and delicious food.The eleven conference workshops (together attracting nearly 500 attendees) included sequences on causal inference and patient reported outcomes, plus workshops on quantile regression, multiple comparisons, network meta-analysis, and evaluating the accuracy of medical tests and biomarkers. Jeffrey Rhoades from AHRQ concluded the conference with an entertaining and informative introduction to the Medical Expenditure Panel Survey.This ICHPS was delighted to provide 15 student travel awards, supported by multiple industry and academic partners, including Lilly USA, Harvard Clinical Research Institute (HCRI), Valence Health, Millennium Pharmaceuticals, and ASA’s Cleveland Chapter as well as Case Western Reserve University’s Department of Epidemiology & Biostatistics, the Cleveland Clinical and Translational Science Collaborative and the Center for Health Care Research and Policy. In addition, the Conference Chairs were grateful for ASA’s outstanding support, and in particular, for the stellar work of the conference’s planner, Lisette Werbowetzki.We eagerly anticipate the tenth ICHPS, planned for October 2013. For more information, contact Conference Chairs Andrew Zhou (azhou@u.washington.edu) and Donald Hedeker (hedeker@uic.edu).Assessing the Sensitivity of Treatment Effect Estimates to Differential Follow-Op Rates: Implications for Translational Research by Beth Ann Griffin, Daniel McCaffrey, Rajeev Ramchand, Sarah Hunter, and Marika Suttorp .Bias and variance tradeoffs when combining propensity score weighting and regression: with an application to HIV status and homeless men by Daniela Golinelli (RAND), Greg Ridgeway (RAND), Harmony Rhoades , Joan Tucker (RAND) and Suzanne Wenzel (USC).Perils and Prospects of Using Aggregate Area Level Socioeconomic Information As a Proxy for Individual Level Socioeconomic Confounders in Instrumental Variables Regression by Yenchih Hsu, Scott Lorch, and Dylan Small .Assessing the Privacy of Randomized Vector valued Queries to a Database using the Area Under the Receiver-Operating Characteristic Curve by Gregory Matthews (University of Massachusetts) and Ofer Harel (University of Connecticut).Degrees of health disparities: Health status disparities between young adults with high school diplomas, sub-baccalaureate degrees and baccalaureate degrees by Janet Rosenbaum (University of Maryland).Clinically relevant graphical predictions from Bayesian joint longitudinal-survival models by Laura Hatfield  and Bradley Carlin (University of Minnesota).Joint Modeling of Longitudinal Outcomes and Survival in a Mesothelioma Trial by Ping Wang, Wei Shen, and Mark Boye .Mixed-effects regression modeling of real-time momentary pain assessments in Osteoarthritis (OA) patients by Cynthia Coffman, Kelli D. Allen and Robert F. Woolson .Using AIC in the multiple linear regression framework with multiply imputed data by Ashok Chaurasia and Ofer Harel (both University of Connecticut).We hope that you enjoy reading the papers in this special issue and that they may entice to you attend and contribute to future ICHPS meetings.The papers in this special issue are as follows:


Several anthropometric measurements have been associated with cardiovascular disease, type-2 diabetes mellitus and other cardiovascular risk conditions, such as hypertension or metabolic syndrome. Waist-to-height-ratio has been proposed as a useful tool for assessing abdominal obesity, correcting other measurements for the height of the individual. We compared the ability of several anthropometric measurements to predict the presence of type-2 diabetes, hyperglycemia, hypertension, atherogenic dyslipidemia or metabolic syndrome.In our cross-sectional analyses we included 7447 Spanish individuals at high cardiovascular risk, men aged 55–80 years and women aged 60–80 years, from the PREDIMED study. Logistic regression models were fitted to evaluate the odds ratio of presenting each cardiovascular risk factor according to various anthropometric measures. The areas under the receiver-operating characteristic curve (AUC) were used to compare the predictive ability of these measurements.In this relatively homogeneous cohort with 48.6% of type-2 diabetic individuals, the great majority of the studied anthropometric parameters were significantly and positively associated with the cardiovascular risk factors. No association was found between BMI and body weight and diabetes mellitus. The AUCs for the waist-to-height ratio and waist circumference were significantly higher than the AUCs for BMI or weight for type-2 diabetes, hyperglycemia, atherogenic dyslipidemia and metabolic syndrome. Conversely, BMI was the strongest predictor of hypertension.We concluded that measures of abdominal obesity showed higher discriminative ability for diabetes mellitus, high fasting plasma glucose, atherogenic dyslipidemia and metabolic syndrome than BMI or weight in a large cohort of elderly Mediterranean individuals at high cardiovascular risk. No significant differences were found between the predictive abilities of waist-to-height ratio and waist circumference on the metabolic disease. Overweight and obesity are major risk factors for type-2 diabetes mellitus, cardiovascular morbidity and mortality, cancer and other chronic health diseases and conditions Several easily obtained anthropometric measurements, can predict diabetes and other risk conditions, such as hypertension or metabolic syndrome (MetS). Cross-sectional and prospective studies have shown that the waist-to-height-ratio (WHtR), waist circumference (WC), and body mass index (BMI) are able to predict diabetes and other cardiovascular conditions; however, WHtR and WC appeared to be better predictors than BMI, because of the relation between waist circumference and central obesity Although BMI is widely used to assess overweight and obesity, it does not distinguish fat from muscle or different fat distributions In several studies conducted on Asian and Caucasian populations, WHtR outperformed BMI in the detection of impaired fasting plasma glucose (FPG), type-2 diabetes mellitus, hypertension, MetS and atherogenic dyslipidemia For PREDIMED Study the respective local institutional review boards approved the study protocol and all participants provided written informed consent.www.predimed.org and www.predimed.es) . The PREDIMED study was conducted in Spain. Recruitment took place between October 2003 and January 2009, and the 7447 participants were randomly assigned to one of three interventions . The design and methods used in the PREDIMED study have been described elsewhere The PREDIMED study (PREvención con DIeta MEDiterránea) is a large, parallel-group, multicenter, randomized, controlled clinical trial which aims to assess the effects of the Mediterranean diet on the primary prevention of cardiovascular disease (CVD) (2), and family history of premature CVD (≤55 years in men and ≤60 years in women). The exclusion criteria for the PREDIMED study were the presence of any severe chronic illness, previous history of CVD, alcohol or drug abuse, BMI ≥40 kg/m2 and history of allergy or intolerance to olive oil or nuts.Participants were men aged 55–80 years and women aged 60–80 years, who were free of CVD at baseline but who had either type-2 diabetes mellitus or fulfilled at least three or more coronary heart disease risk factors: current smoking, hypertension (blood pressure ≥140/90 mmHg or treatment with antihypertensive medication), high plasma LDL-cholesterol (≥160 mg/dL or lipid-lowering therapy), low plasma HDL-cholesterol (≤40 mg/dL in men and ≤50 mg/dL in women), overweight or obesity  fewer number of individuals (ranging between 3335 and 7447) were included in the analyses because the biochemical parameters from all participants were not available.The criteria for cardiovascular risk factors analysed were the following: Type-2 diabetes mellitus was defined as previous diagnosis done by a physician using the WHO criteria 2; and body weight) and cardiovascular risk conditions. The adjusted odds ratios (ORs) and 95% confidence intervals (95%CI) were presented per one standard deviation change in the respective anthropometric parameter. Four models were fitted for each measurement: the unadjusted model; model 1, adjusted for sex, age (continuous) and region; model 2, adjusted for sex, age, region, current smoking (yes or no), education  and marital status ; model 3 or fully-adjusted model, adjusted for sex, age, region, current smoking (yes or no), education  and marital status , total energy intake (continuous variable) and physical activity (continuous). Secondly, we calculated the areas under the receiver-operating characteristic (ROC) curves (AUC) for each model.Because no interactions were observed between sex and the main outcomes, analyses were conducted for men and women together. To determine which anthropometric index was the best predictor of the metabolic risk factors, two statistical methods were used. First, multivariable logistic regression analysis was used to evaluate the association between baseline anthropometric measurements  showed higher discriminative ability for FPG, diabetes, atherogenic dyslipidemia and MetS than BMI or body weight, but not for hypertension. Contrary to our expectations, no significant differences were found between the predictive abilities of WHtR and WC.The general findings of the present study are in agreement with those of previous studies which showed that the AUC for WHtR was similar to WC at predicting diabetes and related risk factors Some authors have suggested correcting waist circumference for the height of the individual, so the waist-to-height-ratio has been proposed as a useful tool for assessing abdominal obesity In our study, BMI appeared to be the anthropometric measurement which better discriminates the prevalence of hypertension. This result is consistent with a previous study of 3006 Chinese adults in which, the BMI OR for hypertension was higher than measures of central obesity in men In line with other studies, our results suggest that measures of central obesity (WHtR and WC) are more associated with MetS than other anthropometric measurements. The AUCs of WHtR and WC were significantly higher than the AUCs of BMI and body weight, and the predictive capability of these measures for MetS is quite good (higher than 70%). Previous studies also found that WHtR may be the most effective anthropometric index for screening MetS in different populations Several studies have examined the association between anthropometric measurements and hypertriglyceridemia or hypercholesterolemia The main limitation of the present study was the use of cross-sectional data to assess the ability of anthropometric measurements to predict CVD risk factors. Further longitudinal analyses will provide stronger evidence of these associations. Another limitation was that the analyses were conducted in an elderly population at high risk for CVD, these individuals were included in the PREDIMED study for having either type-2 diabetes or other CVD risk factors, so they do not represent the usual variability that we could find in the general population, and results may not be extrapolated to the general population. It should be kept in mind the potentiality for reverse causality bias. It is highly plausible that individuals who have several cardiovascular risk factors or are obese receive more advice from their physicians or dieticians than general population, so they would be more likely to improve their lifestyle and their dietary habits. However, the sample of individuals studied was larger than that of most previous studies and they were all subjects at high cardiovascular risk. This strongly reinforces the interest of our results. Moreover, no previous studies have been conducted in elderly Mediterranean individuals at high cardiovascular risk, so our results extend knowledge on the association between adiposity and disease in this particular population where the earlier detection of cardiovascular risk factors is essential if CVD is to be prevented.In conclusion, measures of abdominal obesity (WHtR or WC) showed higher discriminative ability for diabetes mellitus, high fasting plasma glucose, atherogenic dyslipidemia and metabolic syndrome than BMI or body weight in a large cohort of elderly Mediterranean individuals at high cardiovascular risk.


Rabies is a prime example of a neglected tropical disease that mostly affects communities suffering from inequitable health care http://www.rabiesblueprint.com), which we describe herewith.Global rabies experts from the Partners for Rabies Prevention have therefore gathered to translate evidence-based knowledge on rabies control into user-friendly guidelines. Existing information obtained from different sources, including previously published guidelines by international health and animal welfare organizations and scientific findings, has been packaged into a novel online document, the Blueprint for Rabies Prevention and Control  to develop their own programs for preventing human rabies through canine rabies elimination and control of wildlife rabies. This document is not meant to replace national legislation or existing guidelines. Rather, it brings all relevant information into one accessible document to make the design of rabies management programs easier globally, both in areas where rabies is endemic or has been re-introduced.This toolkit has been developed based on the following principles: (1) create a multi-disciplinary working group combining all disciplines/institutions required for formulating comprehensive guidelines for a “One Health” approach to controlling rabies http://www.rabiesblueprint.com/spip.php?article119).The current version of the Rabies Blueprint focuses on dogs as reservoirs, in recognition of the amplified risk to human health from canine rabies. The Rabies Blueprint provides step-by-step guidelines to prevent human rabies by eliminating canine rabies. It addresses key issues that users should consider to achieve this goal, as summarized in the diagram in The “Roles and Responsibilities” section identifies relevant agencies for all activities related to rabies control programs and defines roles and responsibilities of all sectors involved, emphasizing the importance of building political commitment and establishing cooperation and dialogue amongst all parties. The minimum amount of infrastructure required, legislative frameworks, resource requirements, and funding opportunities are provided in a subsequent section.Given the importance of enhancing public awareness on rabies prevention and control, the website devotes an entire section (“Communications plan”) to health communication strategies and provides the first rabies communications plan for incorporation into a canine rabies elimination program. This section includes information on how effective communication planning can help raise awareness on rabies; the eight interrelated steps of communication planning; and guidelines for developing country-specific rabies communication plans adaptable to the cultural, political, and behavioral needs of any location.Finally, the “Operational activities” section contains details of the actual program implementation: epidemiological information required; supplies needed; personnel and training requirements; surveillance mechanisms and diagnostics; operational activities related to the “attack/elimination” component ; indicators of success; and requirements to ensure maintenance of a rabies-free status once the disease has been eliminated, including sustainability mechanisms.Just over one year after the launch of the website in late June 2010, evaluation of its performance indicates that the initiative has had a global impact. Visitors have come from 157 countries/territories and 1,719 cities within the Americas, Europe, Asia, Africa, and Oceania. The number of visits has exceeded 46,000, with consistently >2,000 visitors per month and an average of 80 users daily. Most users (75%) have accessed the English interface. To date, there are several examples of the adoption of this toolkit in a range of countries, such as Uganda, Benin, Afghanistan, Peru, Bolivia, Haiti, and Bali, and evaluation of its impact on rabies control efforts in individual countries is currently being undertaken.The multi-disciplinary approach required for the design of effective rabies elimination strategies has linked together veterinarians, public health workers, ecologists, and vaccine producers, which is the first of two important achievements of the Rabies Blueprint initiative. The truly innovative feature of this project is undoubtedly the delivery of a powerful and practical tool directly into the hands of all those with a desire to achieve rabies elimination , which mhttp://www.rabiesblueprint.com)Freely accessible through the Internet  or access to a computer (CD)Potential language barriersPotential conflicts with existing national guidelinesIt does not overcome financial and political barriers to canine rabies elimination


Indigenous populations of Australia and Canada experience disproportionately high rates of chronic disease. Our goal was to compare cardiovascular (CVD) risk profile and diabetes complications from three recent comprehensive studies of diabetes complications in different Indigenous populations in Australia and Canada.We compared participants from three recent studies: remote Indigenous Australians , urban Indigenous Australians , and remote Aboriginal Canadians .The three groups were similar for HbA1c, systolic BP, diabetes duration. Although leaner by body-mass-index criteria, remote Indigenous Australians displayed a more adverse CVD risk profile with respect to: waist-hip-ratio ; HDL-cholesterol ; urine albumin-creatinine-ratio ; and C-reactive protein. With respect to diabetes complications, microalbuminuria  was more common among both remote groups than urban Indigenous Australians, but there were no differences for peripheral neuropathy, retinopathy or peripheral vascular disease.Although there are many similarities in diabetes phenotype in Indigenous populations, this comparison demonstrates that CVD risk profiles and diabetes complications may differ among groups. Irrespective, management and intervention strategies are required from a young age in Indigenous populations and need to be designed in consultation with communities and tailored to community and individual needs. The burden of type 2 diabetes, chronic kidney disease (CKD) and cardiovascular disease (CVD) has had devastating effects on Indigenous populations of both Australia and Canada, and there appear to be close similarities in the disease presentation and impact between the Indigenous populations of these geographically disparate continents. Both populations have earlier onset of chronic conditions such as diabetes and CVD compared to the non-Indigenous population, and chronic conditions are the greatest single contributor to the premature mortality in both Indigenous populations -5.Despite the high prevalence of diabetes, CVD and CKD among Indigenous populations globally, there is little published data from studies using detailed participant examinations for assessment of complications of diabetes ,7. DiabeIn light of these apparent similarities in early onset and high prevalence of both type 2 diabetes and CVD among the Indigenous populations of Australia and Canada, we aimed to compare cardiovascular risk profile and microvascular complications of diabetes from three recent comprehensive, although small clinical studies of Aboriginal cohorts with diabetes from Australia and Canada: 1) a remote Aboriginal community in Northeast Arnhemland, Northern Territory, Australia; 2) the Darwin Region Urban Indigenous Diabetes (DRUID) Study, Northern Territory, Australia; and 3) the Sandy Lake Diabetes Complications Study, from a remote First Nations community from northwestern Ontario, Canada -16.Methods for the three studies have been described previously ,15,17-19The DRUID Study was a volunteer cohort of approximately 1000 urban Indigenous people from Darwin, Australia, undertaken from September 2003 to March 2005. Darwin is a tropical port city of approximately 100,000 people located on the northern coast of Australia. Participants met the following eligibility criteria: identified as Aboriginal or Torres Strait Islander; aged ≥ 15 years; had resided within a specified geographical region around Darwin for at least 6 months; and were living in a private dwelling. The DRUID cohort represented approximately 14% of the estimated target population, and therefore is not necessarily representative. The DRUID study represents a heterogeneous and diverse population group with significant ethnic admixture , diversity in language, and participants from a broad range of social and economic circumstances, from impoverished people living in insecure housing to senior public servants and business leaders. Participants ranged from those who had lived in Darwin all their lives to those who had relocated from a remote Aboriginal community to Darwin within recent years (but not in the previous 6 months). Participants accessed a variety of primary health care providers, from private general practitioners (45%), to Aboriginal health services (32%) to nil (11%) [The Canadian study was The Sandy Lake Diabetes Complications Study, implemented as part of the Sandy Lake Health and Diabetes Project, a population-based cohort study involving participants aged 10 years and over, with collection of baseline data from 1993-1995 . Crude dFor consistency across the three study groups, only those with a previous diabetes diagnosis are included here, not those newly diagnosed by the Australian studies. Remote Australian study: previous diabetes diagnosis confirmed from medical records, n = 37 (100% of diabetic patients known to the clinic and currently living in the community). Urban Australian Study: participants classified as having known diabetes if a diagnosis was self-reported and they were either on current diabetes medication or their glucose values on 75 g oral glucose tolerance test (OGTT) met the 1999 WHO criteria for diabetes . Both paThe full protocols for assessment of diabetes complications have been previously described -16,18,19Data analysis was performed using Stata version 10.1 . Variables with distributions significantly different from normal were log transformed. Data are presented as frequency (%), mean (S.D.) or geometric mean . To determine associations between variables across study groups, Pearson chi-square tests  or independent sample t-tests (continuous variables) were conducted in the whole group as well as stratified by gender, due to differences between groups in proportion of female participants. Median duration of diabetes was compared between groups on pair-wise comparison using the Kruskal-Wallis test. Multiple regression analysis of albuminuria was performed using the backwards selection method, for groups combined and stratified by study. Established risk factors and variables with p < 0.05 on univariate analysis were considered for entry into the model. Model fit was assessed using likelihood ratio-chi square. Statistical significance was accepted at p < 0.05.A comparison of the characteristics of diabetic participants of the three study groups is presented in Table Remote Canadian participants displayed a significantly lower diastolic blood pressure than urban Indigenous Australians and lower heart rate than both Australian groups Table , with diThe remote Australian group had significantly lower HDL-cholesterol and higher urine ACR than both urban Australians and remote Canadians. Of note, compared to each of the Australian groups, the remote Canadian group demonstrated higher HDL-cholesterol and lower triglycerides, C-reactive protein (CRP) and homocysteine. However, compared to urban Indigenous Australians, remote Indigenous Canadians had higher urine ACR (but better kidney function as determined by MDRD formula for eGFR). Differences between urban Australian and remote Canadian participants remained for all biochemical variables on stratification by gender with the exception of ACR for women.A comparison of current diabetes management is presented in Table Table Systematic reviews have drawn attention to the high prevalence of diabetes, CVD and CKD among Indigenous populations globally but studies from detailed clinical examination of participants are limited, and much of the available data stems from medical records or administrative databases ,7. This The three population groups reveal similarly common anthropometric, metabolic and lifestyle factors such as young age, mean HbA1c (8-8.7% across the groups), duration of diabetes (median duration 6 to 9 years across groups) and high rates of cigarette smoking (particularly in both remote groups with 50% current smokers). Consistent with previous reports, obesity and related comorbidities were also very common in all groups ,26. InteWhen compared to population-based data for the overall Australian population (from the AusDiab Study), achievement of therapeutic targets by urban Indigenous Australian participants with diabetes from the DRUID study was better for blood pressure and total cholesterol, but worse for glycemic control . Althoug30, 31; similar findings of higher inflammatory markers in urban India were postulated to relate to high rates of socioeconomic disadvantage [We reported a gradient of CVD and metabolic risk factors across the three groups with respect to central obesity, dyslipidemia and inflammatory markers with the most abnormal values being among remote Australians. The greater risk seen in remote compared to urban Indigenous Australians is consistent with previous reports relating to both CVD and end-stage kidney disease (ESKD). Cass et al. described a 20-30 fold gradient in rates of ESKD in Indigenous Australians across different regions of Australia , with hidvantage -37. Althdvantage . We havedvantage . There wdvantage ,41.A striking finding of the current study relates to albuminuria - an exception to the above described gradient of risk from remote Indigenous Canadians to urban Indigenous Australians to remote Indigenous Australians. Rates of albuminuria were higher in both remote groups compared to the urban Australian group, with risk of albuminuria remaining independently higher in both remote groups after adjustment for other risk factors. This is consistent with previous reports of high rates of ESKD among Indigenous Australians and Canadians and the remote-urban gradient for ESKD among Indigenous Australians . Of noteRates of microvascular complications other than albuminuria were similar across the three groups. There was no difference in neuropathy (by 10 gm monofilament), PVD or retinopathy rates. The trend to lower retinopathy rates among remote Australians could be explained by methodological differences . There was a difference between the Australian groups in that a lower rate of wearing footwear was evident in the remote compared to the urban group, perhaps reflecting the relatively recent European contact for the remote group and different lifestyles between these groups. However rates of current foot ulcers did not differ between the three groups. The similar rates of microvascular complications of retinopathy and peripheral vascular disease across the three population groups may relate to similarities in HbA1c, but CVD risk factors show prominent differences between population groups. These differences may translate to different CVD outcomes and thus further study is required.A limitation of this study is that the relatively small sample size of the cohorts which represent three distinct communities within Australia and Canada. It is fully appreciated that although there are many similarities in metabolic and CVD risks described here to those previously reported for other Indigenous groups within Australia and Canada, the results of this study may not reflect those of the general Indigenous populations of Australia and Canada. The urban Indigenous group were a volunteer cohort who represent only 14% of the target population, thus we are unable to comment as to whether they are representative of this population. Nevertheless, the DRUID Study is the largest and most comprehensive dataset on diabetes and related conditions in an urban Indigenous population in Australia. This is of importance as 73% of the Indigenous Australian population live in urban centres . There iDespite similarly high rates of diabetes, associated complications and premature CVD in these Indigenous populations, several key CVD risk factors were higher in the remote Australian group  while albuminuria was notable for higher rates in both remote Indigenous Australians and Canadians than urban Indigenous Australians. In order to address the increased risk of diabetes and CVD in Indigenous communities, action is required from a young age both to prevent diabetes, and to improve management once it is established. As there are important differences in risk profile between Indigenous populations, including within the one country, this action needs to be designed and performed in partnership with communities and tailored to both community and individual needs.The authors declare that they have no competing interests.KOD and LMB designed and conducted the remote Australian study, JC, JS, KOD and LMB designed and conducted the DRUID study. AJH, SBH, MM, PC and BZ designed and conducted the Canadian study. LMB designed and performed the statistical analyses guided by AH, JC and KOD. LMB drafted the manuscript and all authors contributed important intellectual content. All authors approved the final version for publication. All authors read and approved the final manuscript.


The Department of Veterans Affairs (VA) is a key player in emergency management for both veterans and civilians. Unfortunately, limited evidence-based research findings exist regarding the role and experience of VA during disasters. The present study is a systematic literature review of 41 published, peer-reviewed articles regarding VA and emergency management. Trained researchers utilized a data abstraction tool and conducted a qualitative content analysis. A description of article characteristics include methodology, phase of emergency management addressed in the research, and study design. Five topic categories emerged from the review including effects of disaster on mental health status and services use, effects of disaster on general health services use, patient tracking, evacuation, and disaster planning/preparation. Findings were used to generate suggestions for future research.Keywords: Veterans Affairs, veterans, disaster, emergency In addition to its primary mission to provide health services for veterans, the Department of Veterans Affairs (VA) is responsible for assisting federal agencies and the general public during emergencies as directed by the 1982 VA/Department of Defense Health Resources Sharing and Emergency Operation Act (Pub. L. 97-174). Given its nationwide presence, VA must respond to the range of emergencies and disasters through participation in the mitigation, preparedness, response, and recovery stages of emergency management. It does so, in part, through collaboration with other governmental, non-profit, and for profit agencies.Collaboration requires effective communication through information dissemination. Existing research outside of VA does not adequately address the needs of those in disasters or VA’s activities in assisting its partners. Information about VA and emergency management is most often found in VA internal “after action reports” and is not widely disseminated. There is an urgent need for evidence-based research related to disaster and emergency response processes that VA is likely to engage in. This review thus aimed to explore and summarize the current scientific literature about VA and emergency management and make suggestions for future research.The first step included searching for relevant emergency management peer-reviewed articles published between 1982 and 2012. RAND Corporation librarians used disaster-related search terms using relevant academic databases (see Table 1) to provide the research team with a list of articles (n=877) that met initial search criteria . Of the 877 articles, 798 were rejected at title review as clearly irrelevant to the project or were excluded as they were not published in peer-reviewed journals. This left 79 peer-reviewed articles that were then reviewed using the following inclusion criteria: 1) the article discussed emergency management, and 2) the article discussed services directly provided by VA, services for which VA contracted from outside entities, or veterans served by VA. Thirty-nine articles met the criteria. The reference lists for these articles were then reviewed for possible inclusion; all but 5 articles were rejected at title review. Of the 5, only 2 met the full inclusion criteria. Thus, 41 total articles were included in the final review for meeting criteria .All of the articles were then fully reviewed using a data abstraction instrument designed for this study and reviewed by the VA/UCLA/RAND Southern California Evidence-Based Practice Center . The data abstraction instrument categories were compiled from literature reviews, pilot testing of the instrument, and input from experts in emergency management research and practice. The categories on the data abstraction instrument reviewed in the current study included: 1. Study design ; 2. Methodology ; and 3. Role of VA in emergency management . Two members of the research team independently reviewed the articles and compared data coded on the data abstraction instrument. In cases where coding diverged, the team obtained reliability by reaching consensus about the code or via input from a third team member. Finally, the articles were reviewed using content analysis techniques The study design of the final group of articles was experimental (n=0), quasi-experimental (n=12) or pre-experimental (n=29). Methodologies included qualitative (n=21), quantitative (n=19), and mixed (n=1). The role of VA in the emergency management phases included mitigation/prevention (n=5), preparedness (n=2), response (n=8), or recovery (n=14). Several articles (n= 12) addressed more than one emergency management role, including two articles that addressed all four roles.Five topic categories emerged from the review: Effects of disaster on mental health status and services use, effects of disaster on general health services use, patient tracking, evacuation, and disaster planning/preparation.Effects of Disaster on Mental HealthThirteen articles relate to the effects of disaster on mental health, including service use and status. Among studies that explored mental healthcare use for PTSD symptoms Regarding mental health functioning, veterans treated in PTSD clinics experienced fewer symptoms at admission after 9/11 than veterans admitted before 9/11, contrary to expectations In addition to examining PTSD, several studies considered general mental health issues. Following 9/11, there were increases in unscheduled clinic visits by veterans for symptoms of anxiety and depression Effects of Disaster on General Health Services UseEight studies address general health services use affected by disaster. From the provider’s perspective, it is challenging to provide continuity of care because of several barriers including limited or compromised communication infrastructure Despite challenges and uncertainty, VA facilities, mobile clinics, and a VA Disaster Application Center (DAC) successfully served veterans and non-veterans alike in the first days following a disaster. Mobile clinics were effective because veterans favored receiving medical care in their communities, but the availability of care through mobile clinics presented the challenge of treating non-routine populations, such as infants and children. Volunteer practitioners should be thus versed in treating pediatric patients and knowledgeable about types of post-disaster conditions they would likely treat through the mobile clinic and DAC Patient TrackingThree articles emphasize the importance of emergency medical records for optimizing service provision. One case study EvacuationThe five case studies about evacuation following a major disaster share several characteristics and lessons learned while each report includes experiences unique to the particular evacuation. There is a clear need for prompt decisions made by the administration, coupled with an understanding of the chain of command by all involved in the disaster response Working with the community was another topic of importance within evacuation. Pre-existing agreements with community resources and hospital facilities that could host evacuated veterans was cited as critical to the evacuation Continuity of care, as shown in two studies, was not compromised because providers made an effort to follow patients that had been transferred to another hospital due to a loss of utilities and potential explosion All of the studies detailed lessons learned and modifications in disaster planning that have been made since the disaster. These include increased training, stocking indoor supplies, and the development of mitigation teams that supervise improvements in disaster preparedness A disaster response framework Disaster Planning/PreparednessTwelve of the included articles are about disaster planning and preparedness. These articles covered a wide variety of emergency management topics, though a common theme was the importance of collaboration and education Additionally, three articles highlight the importance of VA to ensure its internal effectiveness related to disaster to be able to continue providing emergency assistance to the wider community This literature review identified and synthesized 41 peer-reviewed articles about VA-related emergency management. The majority of articles were pre-experimental. While this affords us with detailed case studies about specific disasters, more experimental research would be beneficial. For example, evidence-based prevention programs for PTSD and other mental health issues following disaster could greatly add to the stress and coping literature on veterans and serve as the foundation for the development of effective intervention. Similarly, few studies used mixed method design. More studies on emergency management that integrates qualitative and quantitative data will afford the field with a more coherent and complete picture of its strengths and gaps. Additionally, among the phases of emergency management, there is need for more work particularly on preparedness. While twelve articles mentioned some aspect of preparedness, only two articles specifically addressed plans to handle an emergency, calling for an increased need of effective communication practices. We suggest more studies on the processes necessary for effective community collaboration and development of plans and protocols to prepare for possible emergencies.Overall, five themes emerged from this review. The first is the effects of disaster on mental health status and services use. This group of articles point to a need for ongoing longitudinal studies on mental health impact due to disaster, as well as increased outreach efforts to victims. Also, only a few studies examined individual differences in mental health impact . This gap could be remedied with increased research efforts related to psychosocial risk factors and individual’s vulnerability to disaster. We suggest including ethnicity, SES, gender, and age as key variables in future research.The second theme, effects of disaster on general health services use, highlighted the need for continuity of care. Several barriers were identified including poor communication infrastructure, although effective collaboration, such as with pharmacists, was shown to mitigate such challenges. Hospital administrators and public health officials would greatly benefit from an inclusive approach to communication practices. Related articles documented patients’ preference for receiving treatment in their community, such as through mobile clinics. This makes salient the need for support and camaraderie in disaster recovery. The need for ongoing discussion about planning for both short-term and long-term health care services was highlighted, as was greater understanding of the specific needs of the community being served.The third theme, patient tracking, sheds light on the need for systematic protocols to organize data on patients receiving care following a disaster. Examples of successful processes were shared. These articles serve as a necessary reminder of the critical need of tracking for patient survival following disaster.The fourth theme, evacuation, indicates an overall need for more evidence-based research, including decision-making and the roles of all personnel during disaster, including plans for ongoing collaboration and communication with city officials and local hospitals, especially as it relates to “back-up” evacuation plans. Efforts to develop plans for long-term evacuation were also deemed as critical. Careful consideration also needs to be given to identifying best practices for evacuation practices for specific, unique populations being served. Community needs assessments prior to and following disaster are thus recommended.Articles related to disaster planning/preparation shed light on the importance of collaboration. This is particularly necessary as it relates to interrelationships between the VHA and community partners during local emergencies and federal disasters. This is also critical as it pertains to ongoing dissemination of research findings related to disaster experiences. With increased collaboration and communication, overall disaster planning and response mechanisms can be strengthened. Interestingly,this call for action reflects the mission of the Evidence Aid project Finally, while additional research is needed within each theme identified, it is also important to note that these themes are not mutually exclusive; rather they influence each other. For example, increased tracking of services following disaster directly informs decision-making regarding service provision. Similarly, continuity of care is not merely a challenge within general health services usage, but should also be a topic of discussion within all phases of emergency management for both general and mental health services usage. An integrated, comprehensive approach to research will provide a clearer picture about the role of VA in caring for veterans during times of disaster and also about VA as a collaborator that provides support to the community before, during and after a disaster.The authors declare the no competing interests existCorresponding Author: Maria Claver (mclaver@csulb.edu)


A patient with suspected malaria was hospitalized successively in 2 hospitals, first in Dakar, Senegal, then in Rennes, France, where tests diagnosed Crimean-Congo hemorrhagic fever. An international incident management group was set up in France and Senegal, which traced 181 contacts and analyzed 50 samples from 3 countries. No secondary cases were identified clinically. A case of imported Crimean-Congo hemorrhagic fever (CCHF) was diagnosed in France in November 2004. Clinical features are described elsewhere , control measures were taken immediately by an ad hoc group of persons and institutions responsible for prevention and control of infectious diseases. Contract tracing at Rennes Hospital was coordinated by the hospital's infection control committee, which identified all contacts among healthcare workers and persons who had handled or analyzed the patient's samples. The regional health authorities and epidemiologists from the Cellule Interrégionale d'Epidémiologie (CIRE) identified and followed-up all contacts in the patient's family. The Institut de Veille Sanitaire (InVS) documented the sequence of medical management and opportunities for accidental blood exposure to blood  in Germany . At the Within 36 hours, the international team had identified 181 contacts among healthcare workers, visitors, fellow patients, and ambulance drivers in France, Germany, or Senegal and immediately informed the head physicians of each team that had cared for the patient since the date of symptom onset. No accidental blood exposure was identified, but extensive casual contact was documented. No secondary cases were identified clinically in any of the 3 countries.,The first symptomatic CCHF case in Senegal was identified in 2003 (,,This investigation of a case of imported viral hemorrhagic fever in France raised several issues. First, the patient did not have Lassa fever, unlike the diagnosis in most imported cases of viral hemorrhagic fever in industrialized countries (Hemorrhagic fever viruses leave no room for complacency. The risk for transmission and available means of prevention, however, are becoming increasingly well documented. This first imported case of CCHF in an industrialized country should lead French health authorities to review available evidence and reexamine the justification and applicability of the existing, stringent recommendations for the management of many patients in whom viral hemorrhagic fever is one of several possible diagnoses.


Triadica sebifera (L.) Small) invasions related to timber production in southern U.S. forestlands under different management strategies. Expected costs were confined to the value of timber production losses plus costs for search and control. We simulated management strategies including (1) no control (NC), and control beginning as soon as the percentage of invaded forest land exceeded (2) 60 (Low Control), (3) 25 (Medium Control), or (4) 0 (High Control) using a spatially-explicit, stochastic, bioeconomic model. With NC, simulated invasions spread northward and westward into Arkansas and along the Gulf of Mexico to occupy ≈1.2 million hectares within 20 years, with associated expected total costs increasing exponentially to ≈$300 million. With LC, MC, and HC, invaded areas reached ≈275, 34, and 2 thousand hectares after 20 years, respectively, with associated expected costs reaching ≈$400, $230, and $200 million. Complete eradication would not be cost-effective; the minimum expected total cost was achieved when control began as soon as the percentage of invaded land exceeded 5%. These results suggest the importance of early detection and control of Chinese tallow, and emphasize the importance of integrating spread dynamics and economics to manage invasive species.Economic costs associated with the invasion of nonnative species are of global concern. We estimated expected costs of Chinese tallow ( The ecological and economic costs of invasive species have been extensively discussed and the future impacts to global sustainability are a source of great concern Triadica sebifera (L.) Small, Euphorbiaceae, synonyms include Sapium sebiferum (L.) Roxb and Stillingia sebifera Willd.). Chinese tallow was first introduced into the United States in the late 1700's and repeated introductions have occurred throughout the southeastern US until the mid-1900's Among the most aggressive and costly invaders of southern U.S. forests is Chinese tallow tree  of Chinese tallow invasions on southern U.S. forestlands under different control strategies based on the percentage of land presently invaded by Chinese tallow tree. We consider the costs of timber loss as a result of Chinese tallow invasions and the costs associated with searching for and controlling Chinese tallow in invaded areas. This information on costs of different control efforts should help government agencies and private landowners decide whether and when to initiate control measures to maintain timber production.We modified the biological invasion model of Wang et al. To include the economic impacts associated with invasion in the model, we represented expected total costs as a function of three components: damage costs (timber losses in $), searching costs, and control costs as:We estimated damage costs as:We estimated control and search costs based on phone interviews conducted from July 15 to 21, 2009 with personnel from major invasive plant control companies in the region We estimated control costs based on the information from Superior Forestry Service, Inc. , which provided the most detailed information and was licensed to conduct invasion control services in several states . We assu© to Excel files and subsequently imported the Excel files into ArcView® to analyze spatial-temporal patterns of invasion.To evaluate the economic costs of controlling Chinese tallow, we ran 240, 20-year, Monte Carlo simulations from observed pattern of Chinese tallow invasion in the year 2003  under eaTo parameterize the Chinese tallow invasion model for eastern Texas, Louisiana, western Mississippi, and southern Arkansas, we obtained data on environmental and ecological characteristics of geo-referenced USDA Forest Service sample plots from the Forest Inventory and Analysis (FIA) dataset For cost estimation, we obtained data on timber productivity from the Forest Service Timber Product Output dataset Simulated Chinese tallow invasions, if not controlled, spread northward and westward into the forests of Arkansas and colonized lands along the Gulf of Mexico within 20 years, with about 14% of all forest cells invaded to some extent, and >62% of the invaded cells exhibiting >50% of the land occupied by Chinese tallow . AssuminWithout control, both the total area invaded by Chinese tallow and the expected total costs increased exponentially, reaching ≈1.2 million hectares  and ≈$30We have presented a dynamic bioeconomic approach for managing the impact of invasive species range expansion which combines predictions of the spatial-temporal advance of a biological invasion with estimations of the concomitant timber losses and expected total economic costs. Our approach integrates invasion ecology and natural resource economics within a spatially explicit, agent-based, simulation framework to compare the efficacy of alternative invasion control scenarios. In the following sections, we consider the theoretical and empirical basis for our approach, interpret our findings in terms of the bioeconomic implications for Chinese tallow management, and provide some suggestions for future study.Invasive species have had enormous negative environmental and economic impacts worldwide Ligustrum sinense Lour.), European privet (Ligustrum vulgare L.) and Japanese honeysuckle (Lonicera japonica Thunb) Ambrosia artemisiifolia L.) in Austria The dispersal of invasive species has been a subject of both theoretical and empirical study for decades It should be noted that had we assumed a different probability distribution to estimate dispersal distances, our projected dispersal velocities and the resulting economic costs would have been different. Had we chosen a fat-tailed distribution other than the lognormal , projected velocities and costs would have been similar since fat-tail distributions generate long dispersal distances. Had we chosen a thin-tailed distribution , projected velocities would have been slower and projected costs would have been smaller since thin-tail distributions generate short dispersal distances.The post-invasion growth of invasive species also has been a subject of much study, and population growth models have been firmly rooted in population dynamics theory , using both exponential and density-dependent growth models depending on purpose Identification of cost-efficient control strategies for invasive species ideally would be based on estimates of both the costs of control efforts and the economic losses due to damage to the resource Of course, had we assumed a different functional form of the relationship between area invaded and searching costs, we would have obtained different estimates of expected total costs. Had we assumed searching costs increase exponentially with decreasing invaded area Economic losses due to resource damage also are problematic to estimate because they include the impact of invasion on nonmarket as well as market values. A straightforward monetary measure of the impact of invasion on market values of many agricultural products is the average value of the product lost due to invasion damage Our aim in the present study is to provide spatially-explicit, temporally-dynamic, representations of the economic aspects of biological invasions. Most invasive plant management, including that of Chinese tallow, has emphasized controlling either highly-infested areas or areas in the early stages of recruitment and establishment Miconia calvescens) on the islands of Oahu and Molokai in Hawaii until 1400 and 2300 trees were found, respectively. If control was initiated when >5% of the area was invaded, overall total costs were markedly higher due to additional control costs and greater damage costs. Sharov and Liebhold Lymantria dispar) in the southern U.S. increased when the distance from the invasion front to the end of the uninfested area becomes <200 km.Our simulation results re-emphasized the importance of early detection and proactive control of Chinese tallow invasions in southern U.S. forestlands, a finding that echoes the almost universal conclusion of invasion studies focused not only on woody plants (e.g., Cacho et al. Currently, Chinese tallow occupies >5% of the area in ≈26% of the infested forestlands in our study area that it has invaded Providing useful predictions of the rate of spread of biological invasions and their associated economic costs remains a challenge which is of global concern We estimated damage costs based on data on timber productivity We estimated search and control costs based on recent information from invasion control companies The quantitative framework we have described in the present paper, unlike that of previous bioeconomic assessments of the spread of invasive species


We have generated genomic and proteomic profiling to approach cellular and molecular mechanism and to discover diagnostic and predictive biomarkers of gastric and colorectal cancer. Based on these gene expression profiles, we explored the characteristics of molecular changes and its potential for clinical significances.As our present data and systemic analyses for gene expression pattern, pathway distribution, gene function category, biosignature and clinical significance shown, we have been able to document the entire gene expression profiles for intestinal- and diffuse-type gastric cancer (GC) and normal appearing tissues (NATs) matched tumors. A group of specific or typical genes were identified as having dramatic changes in tumors and NATs compared with the verified normal samples. Among these genes, at least three gene sets were analyzed using pathway analysis tools and integrated with biological assay data to construct a network for GC carcinogenesis.Our data show that these genes are involved in several well-studied signaling pathways associated with development and progression of GC. Our results indicated that alterations of MMP11, MT2A, p42.3, Cyr61 and GKN1 at mRNA and protein level were consistently detected in GC cell lines and primary tumors compared with matched normal tissues. Importantly, serum MMP11 levels were also significantly elevated in GC patients compared with those of the control subjects, and the positive expression was well correlated with metastasis and recurrence in GC patients. As its pilot study, we have generated primary data of its genomic alterations, in combination and comparison with the gene expression profiles. Dramatic correlations have been observed between the gene expression profiles and DNA Copy Number Variations (CNVs), with statistically significant differences between tumors of Stages I-II and III-IV GC. We have also defined a group of specific gene or miRNA alterations, which could be associated with metastasis and recurrence in GC patient.Taking together, we have been the first to provide a systematic analysis for comprehensive gene expression profile integrated with microRNA , genomic or proteomic analysis for gastric cancer. Additionally, we have defined a group of genes associated with development and prognosis in gastric cancer.