Organizational culture is manifest in patterns of behaviour underpinned by beliefs, values, attitudes and assumptions, which can influence working practices. Cultural factors and working practices have been suggested to influence the transition of young people moving from child to adult mental health services. Failure to manage and integrate transitional care effectively can lead to young people losing contact with health and social care systems, resulting in adverse effects on health, well-being and potential.The study aim was to identify the organisational factors which facilitate or impede transition of young people from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) from the perspective of health professionals and representatives of voluntary organisations. Specific objectives were (i) to explore organizational cultures, structures, processes and resources which influence transition from child to adult mental health services; (ii) identify factors which constitute barriers and facilitators to transition and continuity of care and (iii) make recommendations for service improvements. Within an exploratory, qualitative design thirty four semi-structured interviews were conducted with health and social care professionals working in CAMHS and AMHS in four NHS Mental Health Trusts and four voluntary organizations, in England.A cultural divide appears to exist between CAMHS and AMHS, characterized by different beliefs, attitudes, mutual misperceptions and a lack of understanding of different service structures. This is exacerbated by working practices relating to communication and information transfer which could impact negatively on transition, relational, informational and cross boundary continuity of care. There is also evidence of a cultural shift, with some positive approaches to collaborative working across services and agencies, involving joint posts, parallel working, shared clinics and joint meetings.Cultural factors embodied in mutual misperceptions, attitudes, beliefs exist between CAMHS and AMHS. Working practices can exert either positive or negative effects on transition and continuity of care. Implementation of shared education and training, standardised approaches to record keeping and information transfer, supported by compatible IT resources are recommended, alongside management strategies which evaluate the achievement of outcomes related to transition and continuity of care. Organisational culture is ‘that which is shared by members of groups and expressed in patterns of behaviour’  and can Although few studies have specifically investigated the influence of cultural factors and working practices, recognition that these could adversely influence the transition of young people from CAMHS to AMHS rests on variable sources of evidence relating to the evolution of separate child and adult mental health systems , complexInvestigation of continuity of care in AMHS has highlighted emergent cultures in patterns of integrated, multi-disciplinary working by community mental health teams (CMHT) within and across organisational boundaries ,29. InteEffective management of transition requires CAMHS and AMHS managers to face the challenge of implementing and monitoring uptake of standards and guidelines contained within national service frameworks, recent policy reviews and recommendations of professional bodies -34. ThesThe aim was to identify the organizational factors which facilitate or impede effective transition of young people from CAMHS to AMHS from the perspective of health professionals and representatives of voluntary organizations. Specific objectives were:•To explore the organizational cultures, structures, processes and resources which could influence the transition from CAMHS to AMHS;•To identify specific organizational factors which constitute barriers and facilitators to transition and continuity of care;•To make recommendations for changes in services which could improve young people and carers’ experiences of transition and experienced continuity of care.This exploratory, qualitative study was conducted between 2007–2009, constituting the organisational strand (Phase 3) of the wider TRACK investigation, a multi-perspective, multi-site mixed methods study . Wider objectives of TRACK included the conduct of a mapping study auditing policies and procedures relating to transition between NHS Mental Health CAMHS and AMHS; evaluation of the process of transition utilising a retrospective case note survey and exploration of the views of users, carers and mental health professionals on the process of transition. Findings of the organizational strand presented in this paper focus on two core themes of organisational culture, communication and working practices and nine related sub-themes, comprising the fifth in a series of papers reporting findings from the TRACK study . The defThe study received ethical approval from Wandsworth Local Research Ethics Committee.In the United Kingdom, the National Health Service (NHS) provides a service free at the point of delivery financed through taxation. Mental health care for children and adolescents is delivered through a multi-agency model, encompassing community based Child and Adolescent Mental Health Services (CAMHS) delivering both medical and psycho-social care, together with a range of statutory and voluntary health and social care providers and education services. In terms of age cut-offs, CAMHS provide care up to 16–18 years and most AMHS have a lower age limit of 18 years . AMHS arWithin AMHS, health and social care are integrated, with continuity of care an important quality benchmark. In addition to acute in patient services, CMHT are intrinsic to the delivery of a multidisciplinary service to adult service users. Approaches to modelling community care have resulted in the inception of generic CMHT delivering a range of interventions to adults and specialist teams with specific remits for assertive outreach (difficult to engage service users), crisis resolution/ home treatment  and early intervention teams .A total of thirty-four health and social care professionals working in four NHS Mental Health Trusts in Greater London and the Midlands and four staff each representing local voluntary sector organisations were recruited by RB Tables  and 3 frA semi-structured interview schedule was developed based on pilot fieldwork and review of the literature. Interviews of 40–60 minutes duration were conducted by telephone, arranged at a time convenient to the participant. Interviews were audio-recorded and transcriptions were independently checked for accuracy prior to analysis. Qualitative data analysis was conducted using a structured thematic approach  to systeTranscripts were imported to QSR Nu*Dist v.6.0 software to assist systematic and consistent coding and to identify patterns within the data suggesting possible differences in perceptions between Trusts, professional groups and/or CAMHS/AMHS. Illustrative quotes are provided to aid transparency of categorisation and theme representation . CAMHS was perceived as more family-oriented, inclusive and holistic than adult services, which were perceived as focused more exclusively on the individual service user. CAMHS services were therefore seen as enabling a more proactive approach in engaging young people within their broader context of care. In contrast, AMHS were seen as crisis and medication intervention focused by the voluntary sector participant (1c). This raised issues about carers’ expectations of communication and level of involvement with AMHS, during and post-transition and how and by whom those expectations are managed.However, whilst an AMHS nurse participant acknowledged a tendency not to engage with families (1e), both AMHS nurses and a psychologist stated that they considered family involvement, acknowledging the benefits of inclusion subject to the wishes of the young person . One AMHS nurse also perceived that differences in professional background might impact on AMHS counterparts’ approaches to service users’ families and carers (1e). Ethical issues of confidentiality in relation to sharing of information were also raised by this participant. However, no reference was made to the use of ethical guidelines on sharing confidential information.Psychiatrists from CAMHS and AMHS managers all perceived anxiety and lack of confidence in AMHS staff in managing young people which has important implications for continuing professional development and training . From the perspective of one AMHS manager, this was partly explained by the shift toward post qualifying specialization, reducing staff confidence in their skills and abilities (2c). In contrast, the other AMHS manager suggested that AMHS staff possessed the skills to work with young people, but acknowledged a need for more generic training and practice aimed at anxiety reduction and restoration of confidence (2d).There was also recognition, particularly by a CAMHS nurse (participant 2g), that the transition period from CAMHS to AMHS was difficult not only for young people, but also for parents. Psychiatrist and nurse CAMHS participants referred to the impact on parents and carers in terms of ‘loss’ or feeling ‘cut out . As a consequence, from the perspective of a CAMHS nurse preparing families for the withdrawal of CAMHS input and with it a form of support they were unlikely to receive once a young person had left CAMHS needed to be carefully managed (2g).CAMHS nurse and social worker participants identified a lack of two-way communication, whether verbal or written, with AMHS as a challenge affecting transitions . A CAMHS psychologist explained that often administrators and gatekeepers to CMHTs were not co-located with the rest of the team, hindering effective communication (3c). Where communication was reciprocal it was perceived as facilitating transition by a CAMHS psychologist (3f). Another related challenge for communication between CAMHS and AMHS was seen by AMHS nurses to be different approaches to record keeping and care planning . Different electronic record keeping systems between AMHS and CAMHS were cited as partly responsible, but also a lack of mutual understanding of formal Care Programme Approaches  processAn AMHS manager and CAMHS nurse stressed the need for, and benefits of, early communication with regard to smooth and effective transition, allowing more time for the young person and their families to adjust to coming changes . The importance of not leaving it too late to commence transition was also emphasized. An AMHS psychiatrist emphasised the importance of sharing information by all concerned in transition, together with a need for transparency on risks and care planning at handovers between professionals (4c).Besides joint working (see below), three nurse participants from AMHS and CAMHS all agreed that staff having experience of working in the other service was very helpful in resolving day to day problems . Having a shared professional identity with AMHS was helpful to two CAMHS nurse participants  whilst prior knowledge and experience of the other teams working practices, information requirements, expectations and use of appropriate documentation was also found to be helpful to transition by CAMHS nurse (4f).Psychiatrists from AMHS (5a) and CAMHS (5b) both described the benefits of having joint posts with a remit to enhance transition seamlessly between CAMHS and AMHS. However, the latter described how staff turnover, funding delays and cuts had resulted in loss of one post with a negative impact on transition (5b). Other approaches to joint working and liaison which facilitated transition included formal meeting arrangements between CAMHS and AMHS staff identified by a CAMHS nurse (5c) and from a CAMHS management perspective, AMHS psychiatrists holding clinics to facilitate joint assessments with CAMHS colleagues (5e). Proactive approaches by CAMHS staff to foster liaison with a range of mental health and learning disability teams identified as helpful by an AMHS manager (5d).Shared responsibilities between AMHS and CAMHS care co-ordinators for a period of 3 months were found to be helpful in facilitating transition for the young person by a CAMHS social worker (6a), whilst a CAMHS manager and psychologist suggested a need not only for more shared meetings with AMHS, but the inception of joint training .A CAMHS psychiatrist (7a) and AMHS psychologist (7b) cited positive examples of inter-agency working with education services. A voluntary sector participant (7c) also described the positive benefit of CAMHS having had an educational psychologist seconded from the education service to work with parents and children in managing children and young people with Attention Deficit Hyperactivity Disorder (ADHD).A CAMHS psychologist (8a) and AMHS nurse (8b) both recognised the challenges for young people encountering transition which, as noted by a CAMHS social worker (8e) and a CAMHS psychiatrist (8f) could lead to resistance to moving to AMHS. Most participants indicated a willingness to improve preparation of service users for transition, with some attempts being more successful than others; AMHS nurses (8b and 8c) noted the importance of clear accountability for care co-ordination and realistic expectations of AMHS provision. An AMHS manager (8c) identified the value of early involvement of parents and carers in visiting in-patient AMHS facilities, in reducing anxiety about transfer. Acknowledging the daunting nature of attending CPA meetings (8b), a CAMHS psychiatrist (8f) and psychologist (8g) also agreed that it was helpful for a CAMHS worker familiar to the young person to attend initial meetings with AMHS.This study aimed to explore the influence of cultural factors and working practices on a collaborative endeavour, the process of transition for young people moving from CAMHS to AMHS and the potential impact on continuity of care. Findings have provided some evidence for a cultural divide in terms of different attitudes, beliefs, understanding and misperceptions between CAMHS and AMHS. Positive and negative working practices which could impact on continuity of care and transition were also identified, with reference to a multiaxial definition of continuity ,40. It iA number of limitations are also acknowledged: these include under-representation in the sample of Trusts from the Midlands region and AMHS. The sample was drawn solely from health professionals and representatives of voluntary organizations; wider findings of TRACK, investigated experiences of service users, parents and other factors influencing transition -38.The existence of a cultural divide in terms of attitudes, beliefs, understanding and some mutual perceptions between CAMHS and AMHS was evident: CAMHS was characterised (by CAMHS) as more person-centred, family oriented, positively focussed in terms of encouraging user resilience and utilizing talking therapies, but ‘talking a different language’ from AMHS. The latter was perceived by others as not such a good service, with a focus on crisis and medication management, problematic attitudes and a skill deficit underpinning staff lack of confidence in caring for young people. These findings extend those of others which have identified cultural differences present at the CAMHS/AMHS interface -17 and rIndicators of more positive attitudes were evident in the acknowledgement by some AMHS staff of the importance of family involvement, notwithstanding the need to maintain confidentiality, which other studies have indicated can create an ethical dilemma for inter-professional working . Other TIn relation to communication and working practices across the CAMHS/AMHS interface, findings revealed a mutual lack of understanding about service structures, location of key personnel and communication. The use of waiting lists was a source of frustration if it hindered further dialogue and different approaches to CPA management, documentation and electronic information transfer were evident. These findings are congruent with others  which haThe challenges faced by young people, parents and carers prior to and during transition were understood by both CAMHS and AMHS staff and the potential for a disruption to established therapeutic relationships, impacting negatively on personal and relational continuity of care has been recognised more widely ,30,33. FA number of working practices were identified which were supportive of smoother and more efficient transition, enhancing cross boundary, information, personal and relational continuity of care and consistent with policy guidance -34. ThesWith emerging evidence that the bulk of adult mental health problems begin at a young age, the current CAMHS AMHS divide has produced a care pathway with maximum weakness where it should be most robust . A radicFindings have demonstrated evidence of a cultural divide between CAMHS and AMHS, marked by different beliefs, attitudes, understanding and some negative misperceptions. Some working practices could constitute barriers to effective transition, relational, informational and cross boundary continuity of care. However, indications of a shift in bridging the cultural divide were also evident in positive approaches to collaborative working between services and external agencies which can support transition and continuity. Recommendations are that shared, multidisciplinary, continuing professional development should be implemented which is linked to appraisal and competency frameworks and focuses on transitional care. In context, this should encompass updating on service structures, utilisation of protocols, models of ‘best practice’ in transition, multi-agency working, communication skills, networking, and the acquisition of skills in working with young people and carers. Improvements in information transfer could be achieved by standardised approaches to record keeping supported by compatible IT resources.Bearing in mind the growing independence of young people, family/carer involvement in transition needs to be sensitively negotiated between professionals, young people and families/carers. In the absence of generalizable strategies to foster cultural change  it is reThis study meets the requirements of the RATS guidelines for the conduct of qualitative research.The authors declare that they have no competing interests.SMcL and RB collected analysed and interpreted data. SMcL drafted the paper and RB, SPS, MP, TF, TK, TW, KH, ZI, SW contributed revisions to content and approved the final version. All authors contributed to the conception and design of the wider TRACK study . All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/13/254/prepubCore Theme: Service Cultures.Click here for fileCore Theme: Communication and Working Practices.Click here for file


Persons with schizophrenia may face barriers to high quality primary care due to communication difficulties, cognitive impairment, lack of social support, and fragmentation of healthcare delivery services. As a result, this group may be at high risk for ambulatory care sensitive (ACS) hospitalizations, defined as hospitalizations potentially preventable by timely primary care. The goal of this study was to determine if schizophrenia is associated with overall, acute, and chronic ACS hospitalizations in the United States (US).We conducted a retrospective cross-sectional study. Hospitalization data for the US were obtained from the Nationwide Inpatient Sample for years 2003–2008. We examined 15,275,337 medical and surgical discharges for adults aged 18–64, 182,423 of which had a secondary diagnosis of schizophrenia. ACS hospitalizations were measured using the Agency for Healthcare Research and Quality’s Prevention Quality Indicators (PQIs). We developed logistic regression models to obtain nationally-weighted odds ratios (OR) for ACS hospitalizations, comparing those with and without a secondary diagnosis of schizophrenia after adjusting for patient, hospitalization, and hospital characteristics.Schizophrenia was associated with increased odds of hospitalization for acute ACS conditions , as well as for chronic ACS conditions characterized by short-term exacerbations. Schizophrenia was associated with decreased odds of hospitalization for diabetes mellitus long-term complications and diabetes-related lower extremity amputation, conditions characterized by long-term deterioration.Additional research is needed to determine which individual and health systems factors contribute to the increased odds of hospitalization for acute PQIs in schizophrenia. Persons with schizophrenia have higher rates of medical comorbidity and mortality compared to the overall population. The literature documents high rates of HIV infection,  respiratGiven the high burden of medical conditions among persons with schizophrenia, access to high quality primary care is important for effective disease management. However, persons with schizophrenia may experience inadequate or delayed access to primary care in the US. A 2003 study reported that veterans with schizophrenia were less likely to have a primary care visit than veterans without schizophrenia . A studyPersons with schizophrenia may also experience poor quality primary care. A 2009 review of 27 studies comparing quality of medical care in persons with and without mental illness found that persons with mental illness experienced worse quality of care than persons without mental illness in 70% of studies . For exaAt the individual level, communication difficulties,  cognitivPoor access to high quality primary care among persons with schizophrenia may lead to ambulatory care-sensitive (ACS), hospitalizations, defined as hospitalizations potentially preventable by timely and effective outpatient care . AmbulatStudies conducted in Taiwan  and AustTo date, we lack a comprehensive picture of the association between schizophrenia and specific types of ACS hospitalizations across the entire US healthcare system. Barriers to high quality primary care may differ for acute and chronic ACS conditions among persons with schizophrenia, making it important to describe the likelihood of acute and chronic ACS hospitalizations, respectively, in this population. To our knowledge, no study to date has examined the association between schizophrenia and specific types of ACS hospitalizations in the US.Hospital discharge data were obtained from the Nationwide Inpatient Sample (NIS), the largest all-payer inpatient care database in the US, comprised of about 1,000 hospitals across 35 states, with stratified sampling designed to represent all US census regions. The NIS is stratified by geographic region , location , teaching status (teaching or non-teaching), ownership , and bed size . It contains data on age, sex, race, length of stay, and ICD-9-CM codes for up to 15 diagnoses and 15 procedures. Discharges are linked to information on hospital characteristics from the American Hospital Association’s Annual Survey Database.The outcomes of interest were ACS hospitalizations. Based upon work by Billings , the AgeThe primary exposure of interest was secondary diagnosis of schizophrenia (ICD-9-CM code 295). Potential confounders were included in the model based on previous research in this field, differences found in Table The study sample included hospital discharges with a primary medical or surgical diagnosis for years 2003–2008 among adults aged 18–64 years. As universal Medicare coverage for persons aged 65 years and older may affect the likelihood of ACS hospitalization among older adults, this age group was excluded from analysis. Hospitalizations included in the sample reflect the risk set for a particular ACS hospitalization, as defined by AHRQ. For example, the risk set for perforated appendix includes hospitalizations with a primary diagnosis of appendicitis . To protDifferences in nationally weighted proportions of patient, hospitalization, and hospital characteristics among hospitalizations with and without secondary schizophrenia diagnosis were tested using Wilcoxon rank sum tests for continuous variables and chi-square tests for categorical variables Table . We alsoTo test the association between schizophrenia and ACS hospitalizations, we developed logistic regression models to obtain odds ratios (ORs) comparing the likelihood of hospitalization for an ACS condition in admissions with versus without secondary diagnosis of schizophrenia. Odds ratios were calculated for the four acute and nine chronic ACS hospitalizations identified by AHRQ, as well as for composite overall, acute, and chronic ACS hospitalizations. Models adjusted for the covariates listed above Figure . AnalyseThe study sample included 182,423 and 15,092,914 medical and surgical hospitalizations for adults with and without schizophrenia, respectively  and chest, back, or shoulder pain (angina) that physicians could be misperceived as psychosomatic among persons with schizophrenia . It is aOur study has several limitations. The NIS data does not link hospitalizations to individuals, so there may have been more than one hospitalization per person. While ACS hospitalizations have been shown to be associated with poor access to high quality primary care at the population level,  this is Schizophrenia is associated with increased likelihood of hospitalization for acute and some chronic ACS conditions characterized by short-term exacerbations, suggesting poor access to timely and effective primary care for these conditions in the United States. Additional research is needed to determine factors within health systems that contribute to the increased odds of acute ACS hospitalization in schizophrenia. Potentially modifiable barriers to coordination between mental health and primary care providers should be examined.The authors declare that they have no competing interests.All authors : 1) have made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) have been involved in drafting the manuscript or revising it critically for important intellectual content; and 3) have given final approval of the version to be published.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/13/37/prepub


Multiple existing tools provide guidance for developing and evaluating patient reported outcome measures (e.g. Scientific Advisory Committee (SAC) of the Medical Outcomes Trust guidelines, FDA guidance for Patient Reported Outcomes). Guidance is absent, however, for diet and eating behaviour outcome measures that can be used to evaluate community-based interventions.To develop a framework to guide the development and appraisal of behavioural outcome measures of diet and eating behaviours.An appraisal framework, based on relevant items from existing tools  was developed. Initial testing was conducted as part of a systematic review, in which data were extracted from 100 papers describing parental feeding practices measures (HomeSTEAD). Next, the framework was expanded to include a scoring system for items related to conceptual framework, reliability, validity and responsiveness testing. The expanded framework was then used in a systematic review of 353 papers describing outcome measures used in childhood obesity treatment evaluations (CoOR).An appraisal framework guided the development of extraction forms for diet and eating behaviour outcome measures. A key part of the framework was a scoring system, which enables individual outcome measures to be scored (1-4) to appraise measurement development ; reliability ; validity ; and responsiveness.This work provides a framework to enable researchers to appraise existing outcome measures for use in behavioural intervention trials and can guide development of new diet and eating behaviours outcome measures.


Cancer cachexia is characterised by a progressive loss of muscle, resulting in functional impairment and shorter survival. Eicosapentaenoic acid, an n-3 polyunsaturated fatty acid found in fish, has been studied for its role as an anti-cachexia therapy. Initial results of eicosapentaenoic supplementation in advanced cancer were promising with improvements in lean body mass (LBM), appetite and quality of life. However, subsequent larger phase III clinical trials reported minimal benefits of supplementation. Recently, several studies have used different study designs, which may provide insight on the effectiveness of eicosapentaenoic in cancer cachexia and also on potential sources of divergent results in previous trials. This review examines the potential benefit of eicosapentaenoic supplementation on LBM and discusses limitations with current studies to identify methods which may aid in progressing the research of future clinical trials. Cachexia is a complex metabolic syndrome characterised by unintentional weight loss and depletion of skeletal muscle, with or without loss of adipose tissue  and docosahexaenoic acid (DHA). Through the time-course of studies that have examined the potential benefits of supplementation with EPA and DHA or EPA alone in cancer cachexia, we have identified divergent results of EPA on lean body mass (LBM). LBM primarily consists of skeletal muscle, with the remainder comprised of metabolic tissues , and intracellular and extracellular water. LBM is commonly used as a surrogate measure of skeletal muscle in clinical trials in the absence of methods such as computed tomography (CT) and magnetic imaging resonance, which are capable of distinguishing skeletal muscle. In this review, we focus on the effect of EPA on LBM or skeletal muscle when assessed directly, as depletion of skeletal muscle is the defining characteristic of cachexia  is appealing, because it is portable and cost effective. However, BIA and other methods of LBM assessment such as skin folds cannot distinguish between skeletal muscle and other lean tissues. BIA also relies on predictive equations to generate an estimate of lean tissue, but equations that are representative of cancer populations are limited. In a comparison of LBM assessment using BIA and dual-energy X-ray absorptiometry (DXA), discrepancies ranged from −9.3 to +7.3 kg, with overestimation likely in patients with low LBM, and underestimation likely in patients with high LBM  pre-cachexia: early clinical or metabolic signs of cachexia, low-grade weight loss, which may progress to cachexia, (2) cachexia: weight loss >5% in the last 6 months or a combination of >2% weight loss with low muscle or low BMI, and (3) refractory cachexia: occurs close to death due to rapidly progressing disease, which is unresponsive to anti-cancer therapy (Traditionally, cachexia has been viewed as an end-of-life condition, but cachexia and related muscle loss may occur early in the disease trajectory. In the study by Refractory cachexia may have been present in the patient populations of previous EPA trials. Despite general inclusion criteria of life expectancy >3 months, previous EPA trials have been plagued by significant patient morbidity and loss of patients due to disease progression . Recent In summary, it seems likely that the encouraging results from


Arvicola sapidus) responds to variables describing patch-network and matrix properties within replicated Mediterranean farmland mosaics, across a gradient of agricultural intensification. Patch-network characteristics had a dominant effect, with the total amount of habitat positively influencing both the occurrence of water voles and the proportion of area occupied in land mosaics. The proportions of patches and area occupied by the species were positively influenced by mean patch size, and negatively so by patch isolation. Matrix effects were weak, although there was a tendency for a higher proportion of occupied patches in more intensive, irrigated agricultural landscapes, particularly during the dry season. In terms of conservation, results suggest that water voles may be able to cope well with, or even be favoured by, the on-going expansion of irrigated agriculture in Mediterranean dry-lands, provided that a number of patches of wet herbaceous vegetation are maintained within the farmland mosaic. Overall, our study suggests that the mosaic-level approach may provide a useful framework to understand the responses of patchy populations to land use change.The ability of patchy populations to persist in human-dominated landscapes is often assessed using focal patch approaches, in which the local occurrence or abundance of a species is related to the properties of individual patches and the surrounding landscape context. However, useful additional insights could probably be gained through broader, mosaic-level approaches, whereby whole land mosaics with contrasting patch-network and matrix characteristics are the units of investigation. In this study we addressed this issue, analysing how the southern water vole ( Understanding the impacts of land use change on biodiversity is a core issue in landscape ecology and conservation biology The mosaic-level approach has proved useful for drawing inferences on generalist and wide ranging species that occupy multiple land uses and elements within land mosaics e.g., . Much leArvicola sapidus), analysing the responses of its patchy populations to variation in patch-network and matrix features in Mediterranean farmland. Specifically, we sampled replicated land mosaics selected across a gradient of agricultural intensification, estimating for each land mosaic (i) the presence/absence of water voles, and the proportions of (ii) patches and (iii) area occupied by the species. In line with previous network-level metapopulation studies Here we provide a case study on the use of mosaic-level inference to understand the effects of agricultural change on patchy populations. We focused on a rodent species of conservation concern, the southern water vole (The Portuguese nature conservation authority (ICNB - Instituto da Conservação da Natureza e Biodiversidade) authorized the sampling of southern water voles, including the capture and handling of animals . The results described in this paper were based on the detection of field signs (mainly droppings and runways on vegetation), without any type of direct contact with voles  at any stage of this study, and so it did not require approval by an Institutional Animal Care and Use Committee (IACUC) or equivalent animal ethics committee. Surveys were carried out in private properties, where authorization of access was obtained. The southern water vole is not a protected species under EU legislation or under the Portuguese national legislation.2 in south-west Portugal  and dense (ca. 100% cover) wet herbaceous vegetation dominated by grasses, sedges, rushes, and reeds, which often occupy gently sloping and soft bank-margins of ponds, small streams and irrigation ditches pe e.g., .The study was based on 75 land mosaics (sampling units) encompassing a wide range of patch network and matrix characteristics, and reflecting the regional gradient of agricultural intensification . Land moWithin each land mosaic, we surveyed the distribution of water voles, and characterised mosaic structure and composition. Because water vole surveys and habitat mapping were time consuming, and we wanted to maximize sampling size at the expense of temporal replication within sites 2, which was well below the minimum home range size recorded for water voles in the study area  were sometimes used for editing and correcting digitizing errors. To reduce eventual subjectivity in polygon delineation, the minimum polygon area admitted for land use mapping was 5 m2.We also characterised the matrix surrounding patch networks, using six variables reflecting the dominant land uses and the density of irrigation structures (irrigation channels and drainage ditches) . The latThe presence and area effectively occupied by water voles within suitable habitat patches were estimated from systematic field searches for their typical presence signs, including fresh latrines or scattered droppings, runways, burrows, and green grass clippings Surveys were used to compute three variables reflecting mosaic-level properties of water vole populations in the study area : (i) lanStatistical analysis aimed to identify relationships between variables reflecting water vole distribution and abundance, and variables reflecting the structure and composition of patch networks and the surrounding matrix. We conducted analysis considering both the entire dataset and the dataset divided per wet and dry seasons, because previous studies pointed out possible seasonal variation of habitat use by water voles at the patch scale Prior to statistical analysis, all variables except indexes and binary descriptors were transformed to approach normality and to reduce the influence of extreme values, using the angular transformation for proportional data and the logarithmic transformation for other continuous variables . AnalysiTo assess whether patch-network gradients were influenced by matrix gradients, we used the subset of 69 land mosaics to perform a Redundancy Analysis RDA, , followeGeneralized linear mixed-effect models (GLMM) were used to analyse the relationships between explanatory and response variables, under an information-theoretic model selection and averaging approach. The season and year of surveys were included as random effects, thereby accounting for potential lack of independence between land mosaics sampled in the same time periods Model selection involved a two-stage procedure based on the Akaike Information Criterion adjusted to small samples (AICc), which measures the relative support of fitted models I coefficients with associated z-values>1.96 We then developed multivariate GLMMs relating each response variable with patch-network and matrix network gradients. Autocovariate terms (ATC) for spatially correlated responses, as assessed from global Moran's p>0.05). The global Moran's I index suggested a positive spatial autocorrelation in water vole land mosaic occupancy , and a random spatial pattern  for both patch occupancy rate (I = 0.02) and extent of occupancy (I = −0.01).Water vole habitats were found in 69 out of 75 land mosaics. Overall, there were 413 habitat patches occupying 2.5% of the total area surveyed. About 90% of patches were smaller than 0.8 ha, and about 90% were at less than 250 m from the nearest patch see , althougThe first three components extracted from the patch-network PCA accounted for 88.2% of the variance in the data . The firResults of RDA  suggestePreliminary univariate screening provided strong support for both patch-network and matrix characteristics influencing water vole occupancy patterns within land mosaics , Fig. S2In multivariate modelling, there was a very strong effect of habitat amount (H1) on land mosaic occupancy , which wThis study examined the value of mosaic-level approaches to understand responses of patchy populations to land use change, with data gathered on water voles inhabiting land mosaics across a gradient of agricultural intensification. We found that mosaic-level attributes of water vole populations  were strongly related to the characteristics of patch networks  and, to a lesser extent, the composition of the surrounding matrix. As the relationships uncovered derived from replicated sampling of land mosaics spanning a large variety of patch network and matrix characteristics, it is expected that they may provide general guidelines to address the conservation management of water voles over a wide range of landscape types. Overall, results were consistent with previous network-level field studies of metapopulations Water vole occupancy of land mosaics was primarily influenced by the total amount of habitat available, including the correlated effects of total habitat area and number of habitat patches. These results are consistent with other empirical studies examining the factors affecting metapopulation persistence in patch networks Variation in the proportion of patches occupied by water voles across land mosaics appeared to be driven primarily by average patch area and isolation. This result is consistent with metapopulation theory The extent of occupancy was unrelated to patch-network features during the dry season, but during the wet season it was positively related to the amount of habitat and average patch area, and negatively so with average patch isolation. As individuals are reproducing during the wet season, they may be able to occupy rapidly the entire habitat available, which may justify the positive effects of total habitat amount and average patch size. However, average isolation may slow down the occupation of the entire habitat available within the patch network, thereby underlying the negative relationships observed with this variable. In contrast, during the dry season there is little breeding and the population is declining, and so the extent of occupancy may be more related to other limiting factors such as fine-scale habitat quality, or predation, which may influence the depletion of individuals at local patches e.g., .A. amphibius populations in the UK, and other semi-aquatic mammals The characteristics of the matrix had relatively little influence on water voles, which is in line with previous studies of the species In terms of conservation, results suggest that water voles may be favoured in farmland landscape by maintaining land mosaics with a number of patches dominated by wet herbaceous vegetation, even if these are embedded in an intensive agricultural matrix. Achieving this goal requires the conservation of marginal herbaceous vegetation of temporary ponds, small streams and ditches, and areas with elevated water tables, which provide the habitat conditions needed by the species Conservation planning in fragmented landscapes requires the identification of the attributes of habitat networks and the surrounding matrix that maximise the persistence of patchy populations of conservation concern The key aspect of the mosaic-level approach as applied to patchy populations is that it involves replication of habitat networks, potentially encompassing a wide range of variation in composition and configuration attributes of patch networks and the surrounding matrix Despite their potential value, mosaic-level approaches may also have some limitations, and may not be applicable to all types of patchy populations. One potential problem is that these studies require a number of patch networks with different sizes and configurations, which may either be unavailable, or to be too costly or time-consuming for sampling. This probably explains why these studies have remained relatively scarce, and have focused primarily on invertebrates occupying relatively small habitat networks, with most examples being based on relatively small sample sizes Considering their potential strengths and limitations, we suggest that the mosaic-level approach may be particularly suited for studies focusing on patchy populations occupying relatively small patch networks , which can thus be sufficiently replicated at the regional scale e.g., . HoweverFigure S1p-values of permutation tests for independence of residual variance always greater than 0.05, after Bonferroni correction for 9 simultaneous tests).Variogram plot of the multiscale ordination (MSO) of redundancy analysis (RDA) relating patch-network and matrix gradients of land mosaics. The number of pairs of observations within each distance class is presented above the x-axis. The maximum extent for the interpretation of the variogram  is ca. 38 km. The residual variance shows no spatial correlation and the overall variogram is essentially flat, suggesting that patch-network and matrix relationships are scale-invariant ((TIF)Click here for additional data file.Figure S2Scatterplots showing linear and quadratic relations of water vole response variables with patch-network and matrix characteristics of land mosaics. In each case, the best fitting curve (in red) was carried forward to multivariate analysis, based on Akaike weights (wi).(TIF)Click here for additional data file.


Sexual and other forms of gender-based violence are common in conflict settings and are known risk factors for mental health and psychosocial wellbeing. We present findings from a systematic review of the academic and grey literature focused on the effectiveness of mental health and psychosocial support interventions for populations exposed to sexual and other forms of gender-based violence in the context of armed conflicts.We searched the Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, PubMed/ Medline, psycINFO, and PILOTS, as well as grey literature to search for evaluations of interventions, without date limitations.Out of 5,684 returned records 189 full text papers were assessed for eligibility. Seven studies met inclusion criteria: 1 non-randomized controlled study; 3 non-controlled pre- post-test designs; 1 retrospective cohort with a matched comparison group; and 2 case studies. Studies were conducted in West and Central Africa; Albania; UK and USA, included female participants, and focused on individual and group counseling; combined psychological, medical, social and economic interventions; and cognitive behavioral therapy (two single case studies).The seven studies, while very limited, tentatively suggest beneficial effects of mental health and psychosocial interventions for this population, and show feasibility of evaluation and implementation of such interventions in real-life settings through partnerships with humanitarian organizations. Robust conclusions on the effectiveness of particular approaches are not possible on the basis of current evidence. More rigorous research is urgently needed. Since the end of World War II, 248 armed conflicts have been recorded in 153 locations ,7. SexuaSexual and other forms of gender-based violence can have multiple consequences for survivors, including social impacts and negative health outcomes. Recorded social impacts include rejection by family and community, strain on marital relations, impaired parenting skills, children born as a result of rape, exclusion from schools and jobs, being perceived as unfit for marriage, further violence, repeated assault, and isolation ,10. HealInternational consensus guidelines for prevention and response to sexual and other forms of gender-based violence have been published by the Inter-Agency Standing Committee (IASC) . These gDespite the increasing use of MHPSS interventions and publication of consensus guidelines on good practice, a wide gap has been reported between popular practices and knowledge on effectiveness of interventions in this field . The aimIn line with guidelines based on international consensus ,13, we asexual and gender-based violence ; (b) mental health and wellbeing  a broad range of interventions . Internet searches using Google were limited to the first 200 hits.Second, we searched the grey literature  and academic literature. With regard to grey literature, we searched the internet using identified territories in the first steps as keywords, in combination with Boolean phrases including categories of keywords to narrow the search to: (a) http://www.alnap.org) advanced search function, we searched the countries / territories described above using a smaller set of keywords after piloting. Finally, we searched 14 websites of key agencies and initiatives in this field (selection based on our searches using Google and ALNAP) for relevant reports. These searches were conducted between May 13 and August 30, 2011.Using the website of the Active Learning Network for Accountability and Performance in Humanitarian Action’s  specifically noted the context of armed conflict; (2) assessed sexual and gender-based violence in accordance with above cited definitions; (3) described procedures which were followed to prevent mental disorders, promote mental health and wellbeing, or treat psychological distress or mental disorders  ; and (4)After (a) excluding all articles returned by the searches that were clearly not relevant based on abstract and title and (b) excluding duplicate records, two reviewers independently reviewed all manuscripts in full for inclusion and exclusion criteria  study type ; (b) evaluation objectives and hypotheses; (c) research site; (d) study design; (e) selection ; (f) sample characteristics ; (g) sample size; (h) outcomes of interest and measures used; (i) analytic approach; (j) major results (including any quantitative changes observed); and (k) recommendations.Quality of papers was assessed using the Downs & Black’s checklist for the assessment of the methodological quality both of randomized and non-randomized studies of health care interventions, which systematically assesses quality of reporting on issues ranging from research aims, power calculations, intervention, and outcome instruments . The cheOut of 5,684 returned records, we assessed 189 full text papers for eligibility  individual and group counseling (n = 34 at follow-up) and (b) support groups and skills training  with a waitlisted control group (n = 10 at follow-up). Sixty-eight percent of the participants reported exposure to sexual violence, with 19% reporting having been raped at least once, and 11% reporting gang rape. Both interventions were implemented in community settings by trained para-professionals employed by non-governmental organizations. Counseling consisted of at least 8 sessions of individual counseling and group counseling, focused on reducing stress and trauma with the group counseling covering themes of “stress management, conflict resolution, hygiene, and peace building” (p.21). Despite challenges in implementation, women reported being positive about the interventions in qualitative interviews. Quantitative results showed a decrease of PTSD symptoms in the counseling group, and slight increases in the support and waitlist conditions, but no statistical significance of these effects was reported. Although this study is the only controlled study of a popular counseling approach in armed conflict settings, the study has limitations including a lack of randomization, which is of particular concern given that women in the counseling condition reported higher exposure to sexual violence and levels of PTSD symptoms at baseline. In addition, authors report large loss of participants at follow-up (54.5%); implementation of the intervention in the context of other on-going socio-economic interventions in research communities; and a lack of specific training of counselors on issues of sexual violence and sexuality .Bolton reports on a non-controlled mixed methods program evaluation of psychosocial activities implemented by the International Rescue Committee (IRC) in South Kivu, Eastern Democratic Republic of Congo (DRC). A qualitative study explored local concepts of psychosocial problems related to gender-based violence and functioning. Subsequently, 240 women participated in pre-program assessments, 200 of whom were assessed after the intervention, and 66 of whom participated in a follow-up measurement. At baseline, women reported particularly high levels of impairment in functioning , anxiety and fear. The author reports that in addition to the lack of a control group, the type of interventions changed between the start and closure of the study -from a variety of economic and/or psychosocial interventions implemented by various partner organizations to a more structured intervention delivered by four partner organizations trained by the IRC, making it hard to infer which intervention was responsible for changes over time. Nonetheless, women reported substantial improvements in both functioning and symptomatology at follow-up assessments .Hustache and colleagues report the evaluation of services implemented by Médecins Sans Frontières in conflict-affected Republic of the Congo, including medical services and psychological support. Psychological support, delivered by a psychologist, included offering a safe environment for sharing of experiences and expression of distress, active listening, normalizing reactions, work on coping strategies and development of future plans. Pre- and post-test comparisons of 59 women participating in at least 2 sessions (median 3) showed a decrease in ratings of severe impairment  .Plester describes the evaluation of group counseling for women in Albania implemented by a psychiatrist and social worker from Medica Tirana in a non-controlled pre-, post-test design. Counseling included a mix of psychodrama, cognitive behavioral therapy, imagination exercises and relaxation techniques over 10 to 12 sessions, and focused on talking about traumatic experiences or current difficulties experienced by women. The author reports significant decreases in PTSD symptoms and general psychological symptoms, and a non-significant increase in empowerment in a group of women persecuted and detained during the Communist regime, but no statistical tests are reported. Similarly to the study by Leskes, et al., participants with the highest PTSD scores improved the most .Ager and colleagues report on a retrospective cohort design in Sierra Leone focused on a community reintegration program with girls and young female former combatants, implemented by Christian Children’s Fund. In the absence of pre-intervention assessments, girls and young women who received services  were interviewed up to 5 years afterwards and were compared with girls in matched communities who did not participate in interventions (n = 68). Interventions included access to traditional cleansing ceremonies led by local spiritual healers; payment of medical services ; skills-training ; provision of micro-credits loans (e.g. to facilitate schooling and business activities); and raising awareness in communities on the plight of former female combatants. Measurements consisted of structured interviews focused on six local indicators of integration based on prior qualitative research. As many participants turned out to have achieved these indicators before implementation of the program, sub-analyses focused on matching intervention and comparison participants who had not achieved reintegration outcomes prior to program implementation. These analyses showed significantly more girls in the intervention condition achieving integration outcomes on five out of six indicators, including schooling, community acceptance, inclusion in traditional women’s initiation societies, cessation of drug use, and attainment of “steady head” , but not marriage .Finally, both Vickers  and SchuSchulz and coworkers describe a phased approach to cognitive processing therapy (CPT) with a female 64-year old Bosnian refugee who was repeatedly sexually and physically assaulted by an acquaintance during the war in the former Yugoslavia, in addition to witnessing war atrocities, bereavement and losses during flight and resettlement. Assessments were conducted through clinical interviews and use of the PTSD Symptom Scale (PSS). Modification of the CPT protocol, applied in 25 sessions over 9 months rather than the standard 12 session protocol, included keeping a dream journal to record a repetitive nightmare during the exposure part of treatment, and the client continued taking an anti-depressant (paroxetine). Scores on the PSS went from 33 (severe PTSD) at pre-treatment, to 11 two months into treatment and 4 at post-treatment .The aim of this systematic review was to summarize knowledge on the effectiveness of mental health and psychosocial support interventions for populations exposed to sexual and other forms of gender-based violence in the context of armed conflicts. Despite a systematic combing of the academic and grey literature, we identified only 7 studies addressing this important topic. None of the studies were RCTs. We did not attempt a meta-analysis of results because of the methodological limitations of the identified studies. Before discussing this body of literature, we note an important limitation of our study: we searched using English language keywords only and may have missed studies reported in other languages or those available through regional databases only.With regard to the identified evaluation studies, an obvious conclusion is that the number of studies conducted does not match the significance of the problem. Despite reports of large amounts of people surviving sexual and other forms of gender-based violence in the context of armed conflicts , high leIn addition to their relative scarcity, it is difficult to draw any robust conclusions from the identified evaluation studies because of serious methodological limitations, as indicated by the scores on the quality assessments. Without randomization, it is possible that the larger decrease reported in the one study  that appIn addition, the quantitative studies included in this review -39 suffeDespite their limitations, the 7 studies together tentatively suggest potential beneficial effects of intervention. In addition, the studies suggest that evaluations can be conducted in challenging situations. This is further supported by the Bass et al. study published after this review was completed . CounselMore focused and intensive research efforts are necessary to isolate the effects of specific strategies to improve well-being and prevent or treat mental disorders in order to strengthen the knowledge base of effective practices for the regrettably large population of survivors of sexual and other forms of gender-based violence in the context of armed conflict. Given the mental health problems that many people suffer as a consequence of sexual and other forms of gender-based violence it is critical that more attention be paid to research and action in this area, both to improve the health and wellbeing of survivors but also to prevent further ill health and promote wellbeing.The authors declare that they have no competing interests.WT VS MvO CGM conceptualized and designed the study. WT VS MCG CM conducted the searches and analyzed the data. WT wrote a first draft of the paper. VS MCG CM MvO CGM critically revised the manuscript, and all authors read and approved the final manuscript.


Posidonia oceanica meadows, coralligenous formations, and marine caves, were determined through a systematic planning approach. Available information on the distribution of these habitats across the entire Mediterranean Sea was compiled to produce basin-scale distribution maps. Conservation targets for each habitat type were set according to European Union guidelines. Surrogates were used to estimate the spatial variation of opportunity cost for commercial, non-commercial fishing, and aquaculture. Marxan conservation planning software was used to evaluate the comparative utility of two planning scenarios: (a) a whole-basin scenario, referring to selection of priority areas across the whole Mediterranean Sea, and (b) an ecoregional scenario, in which priority areas were selected within eight predefined ecoregions. Although both scenarios required approximately the same total area to be protected in order to achieve conservation targets, the opportunity cost differed between them. The whole-basin scenario yielded a lower opportunity cost, but the Alboran Sea ecoregion was not represented and priority areas were predominantly located in the Ionian, Aegean, and Adriatic Seas. In comparison, the ecoregional scenario resulted in a higher representation of ecoregions and a more even distribution of priority areas, albeit with a higher opportunity cost. We suggest that planning at the ecoregional level ensures better representativeness of the selected conservation features and adequate protection of species, functional, and genetic diversity across the basin. While there are several initiatives that identify priority areas in the Mediterranean Sea, our approach is novel as it combines three issues: (a) it is based on the distribution of habitats and not species, which was rarely the case in previous efforts, (b) it considers spatial variability of cost throughout this socioeconomically heterogeneous basin, and (c) it adopts ecoregions as the most appropriate level for large-scale planning.Spatial priorities for the conservation of three key Mediterranean habitats, i.e. seagrass  Understanding the distribution of marine organisms and processes is of great importance for marine conservation planning Posidonia oceanica beds, estuaries, mudflats and sandflats not covered by seawater at low tide, coastal lagoons, large shallow inlets and bays, reefs, submarine structures made by leaking gases, as well as submerged or partially submerged sea caves. This list has further been expanded by the Barcelona Convention which established a List of Specially Protected Areas of Mediterranean Importance (SPAMI's List), through the Protocol on Specially Protected Areas and Biological Diversity in the Mediterranean In order to protect marine biodiversity the European Union (EU) has identified and classified a number of marine habitat types within the Habitats Directive (92/43/EEC) that should be represented in a pan-European network of protected areas (named Natura 2000). The list of marine habitats includes sandbanks that are always slightly covered by sea water, P. oceanica seagrass meadows, coralligenous formations, and marine caves. These habitats were selected because they have been designated as Mediterranean priority habitats by the EU Habitats Directive and/or the Barcelona Convention and a large amount of distribution information exist, albeit in a non-synthesized state.In the present study we have focused our efforts on three benthic habitats of high conservation importance: P. oceanica are considered a priority habitat for conservation by the EU Habitats Directive and the Barcelona Convention. Posidonia oceanica meadows are important nursery grounds for a large number of fish and invertebrate species, thereby contributing to the maintenance of marine biodiversity P. oceanica beds are one of the most productive ecosystems on the planet; their primary production is comparable to or greater than that of tropical forests and coral reefs 2 yr−1 since 1980 P. oceanica meadows, and climate change further exacerbates the effects of local threats −1; P. oceanica recovery and recolonization may take centuries depending on the severity of impacts. Regression of seagrass meadows results in decline of the services they provide, emission of vast quantities of stored carbon, decline in the distribution range of associated species, and disruption of critical linkages with other habitats.The seagrass beds and bio-constructions of the endemic P. oceanica meadows Coralligenous formations are the second most diverse benthic habitat of the Mediterranean Sea after Corallium rubrum. The survival of the Mediterranean monk seal Monachus monachus, which is a critically endangered species, has been favoured by a plethora of suitable caves for resting and pupping predominantly in the eastern Mediterranean Sea Coralligenous rims are commonly formed at the entrance zone of “submerged or partially submerged sea caves” that are protected by the EU Habitats Directive as a distinct habitat type. Semi-dark caves are also included in the aforementioned Action Plan regarding the coralligenous and other calcareous bio-concretions Although all three habitat types under study are to some extent represented in Mediterranean Marine Protected Areas (MPAs), they are not adequately protected Adequate representation of the three examined habitats, especially coralligenous formations and marine caves, in existing Mediterranean MPAs or proposed conservation plans P. oceanica beds, coralligenous formations, and marine caves in different ecoregions is crucial from both a functional and genetic point of view P. oceanica exhibits low genetic variability across the basin The use of biogeographic classification can support effective and representative marine conservation that protects the full range of biodiversity  Spatial variability is not only a characteristic of biodiversity, but also of anthropogenic activities taking place in the human-dominated environment of the Mediterranean Sea P. oceanica, coralligenous formations, and marine caves across the entire Mediterranean Sea (excluding areas deeper than 1000 m), considering concurrent ecoregional representation of habitats and opportunity cost. The selection of priority areas within eight marine ecoregions The present study aims at identifying priority areas for the conservation of the seagrass The study area comprises the entire Mediterranean Sea, excluding areas deeper than 1000 m . We did We divided the study area into 13212 planning units each of 10×10 km. This resolution was chosen following EU guidelines on the use of a pan-European 10×10 km grid for spatial planning (Directive 2007/2/EC). All planning units were assigned to one of the eight marine ecoregions proposed by Notarbartolo di Sciara and Agardy P. oceanica meadows, coralligenous formations, and partially or totally submerged marine caves was compiled from several source types for the production of distribution maps. As the Mediterranean scientific community has not yet reached a consensus on the exact definition of the coralligenous habitat, we consider the clarification of the data incorporated in our analyses important. The coralligenous habitat data set includes all benthic assemblages thriving on hard substrates of biogenic origin under low irradiance levels that are most commonly observed between 20–120 m depth Information on the distribution of the seagrass P. oceanica beds and coralligenous formations, and to achieve large-scale integration of the compiled dataset, we transformed all spatial information to presence/absence in the 10×10 km planning units of our standard grid. The total number of marine caves was estimated for each planning unit.To map the spatial distribution of habitats we used the following data sources: scientific and grey literature , on-line databases and national catalogues , unpublished data provided by scientific officers and researchers affiliated with universities, research institutes, NGOs and governmental agencies, situated in several Mediterranean countries (including the authors), published (in the form of booklets and diving guides) and unpublished information provided by diving and caving clubs, divers and cavers through scientific and naturalist fora on the web, and direct personal communications. A complete list of all sources used for each habitat type is presented in detail in the Supplementary Online Material . Moreovehttp://en.fishprices.net/home; The cost surrogate layer used in the analyses was developed by Mazor et al. (unpublished data) refining methods devised in Mazor et al. http://data.worldbank.org/indicator/PA.NUS.PPPC.RF), and the value of catch per year. Those variables were based on the limited available information on recreational fishing in the Mediterranean Sea Estimation of opportunity cost for non-commercial fishing was based on the number of recreational fishers per country, the cost of expenditure on fishing gear (adjusted for each country based on purchasing power parity (PPP) rates; Sparus aurata)/sea bass (Dicentrarchus labrax) ratio (as those are the main fish species cultivated), the market value of the sea bream and sea bass, and the spatial distribution and area coverage of each aquaculture unit. All methods applied for the creation of cost surrogates and the importance of using cost in large-scale conservation planning are thoroughly analyzed and discussed in a separate paper recently submitted by Mazor et al.The opportunity cost for aquaculture was based on the work of Trujilo et al. P. oceanica and 40% for the other two habitat types. These targets were based on the EU additional guidelines for assessing sufficiency of Natura 2000 proposals (SCIs) for marine habitats and species Posidonia beds)”. Although coralligenous and marine caves are considered priority habitats under the Barcelona Convention, the EU formally recognizes only P. oceanica meadows as a priority habitat. Using the same targets we produced two planning scenarios: a) selection of priority areas across the whole Mediterranean Sea, and b) selection of priority areas across each ecoregion separately.To select priority areas for conservation features that minimize conflict between conservation objectives and sectors of marine resources exploitation we used the conservation planning software Marxan For our priority areas to have the desired level of spatial compactness we calibrated the Boundary Length Modifier (BLM) to generate a reasonable trade-off between boundary length and cost Finally, the spatial distribution of the priority areas identified in the ecoregion scenario was compared to the distribution of 677 existing MPAs, including national MPAs, Natura 2000 sites, and SPAMIs. Data on current MPAs distribution was provided by MAPAMED; The database on Mediterranean Marine Protected Areas The use of presence/absence data and the coarse resolution used in our analyses (10×10 km grid) did not allow us to perform a detailed coverage assessment of the spatial overlap between the priority areas identified and current MPAs. Hence, we calculated the percentage of planning units for each ecoregion that: a) did not contain an MPA but was identified as priority area, b) contained an MPA and was identified as priority area, c) did not contain an MPA and was not identified as a priority area, and d) contained an MPA but was not identified as priority area.P. oceanica meadows  was greater in the Ionian Sea, as well as in the Tyrrhenian Sea and the Algero-Provencal Basin , higher priorities were mostly located in: a) the Greek Ionian Archipelago and Patraikos Gulf, b) the Aegean Sea, particularly in the Cyclades Archipelago and along the Turkish coast, and c) the Adriatic Sea along the Croatian coast. According to this scenario, 25% of the Ionian, 23% of the Aegean, and 15% of the Adriatic Sea constitute areas highly selected as conservation priorities (planning unit selection frequency >50%), whereas no area was selected in the Alboran Sea ; Table 2In the ecoregion scenario (targets set for each ecoregion separately), the Ionian, Aegean, and Adriatic Seas remained high priorities but to a lower extent ; Table 2The spatial overlap between priority areas identified in the ecoregion scenario and current MPAs was more pronounced in the Algero-Provencal Basin (12% of the ecoregion planning units), the Ionian Sea (10%) and the Tyrrhenian Sea 9%; . Less ovP. oceanica meadows, coralligenous formations, and marine caves and identified priority areas for their conservation. When planning at a whole-basin scale, priority areas were mostly concentrated in the Ionian, Aegean, and Adriatic Seas due to the high occurrence of these three habitat types and the relatively low opportunity cost. When planning and setting targets for our conservation features at an ecoregional scale, the total required percentage area for protection remained the same (approx. 11%), but the priority areas identified were more evenly distributed across the Mediterranean Sea. However, while this prioritization was spatially more uniform it had higher opportunity cost, making it less cost efficient than the whole-basin plan. These results are in accordance with the findings of previous studies, where the trade-off between cost and planning scale was also observed Delay in achieving the Aichi goals set by the Convention on Biological Diversity, specifically Target 11 committing states to protect 10% of the Mediterranean Sea by 2020, has often been attributed to the lack or scarcity of data on biodiversity distribution Despite the fact that planning at an ecoregional scale may increase the overall opportunity cost for the exploitation sectors of living marine resources, representation of all Mediterranean ecoregions is desirable from both a biodiversity and social point of view P. oceanica and coralligenous beds  have been undertaken, mainly in MPAs , we did not manage to collect a substantial amount of data as they were either lacking or, when available, rigid bureaucratic structures made access to them almost impossible. The establishment of long-term relationships with research institutions and governmental agencies in these countries may facilitate data availability. Species distribution and habitat suitability models could assist with filling the gaps in data poor regions P. oceanica, it is worth noting the reported absence of its meadows in the extreme south-east of the basin , in the northern Italian coast of the Adriatic Sea, and the south-western extreme of the Alboran Sea, due to unfavorable temperature or salinity conditions related to river discharge (namely Nile and Po Rivers) The uneven distribution of data, especially of coralligenous formations and marine caves, is not only a matter of invested research effort or data availability, but also depends on the geomorphological heterogeneity of the Mediterranean coastline and seabed; the northern basin encompasses 92.3% of the Mediterranean rocky coastline, while south and extreme south-eastern areas are dominated by sandy coasts Bode et al. P. oceanica meadows are fairly well represented in the western Mediterranean basin since 49.7% of their distribution is found within the limits of MPAs (aside Pelagos sanctuary), out of which 19.1% is found within MPAs that have a management structure, while coralligenous habitats are represented at a level of 11.6% of all MPAs (aside Pelagos sanctuary), out of which 4.9% is in MPAs that have a management structure. On the other hand, habitat representation in the eastern Mediterranean Sea is considered poor; despite the presence of several marine Natura 2000 sites most of them currently have no established management structure. Furthermore, a considerable proportion of eastern Mediterranean MPAs is poorly studied, species' and habitats' inventories remain incomplete and few management plans or monitoring schemes are being implemented Spatial overlap between current Mediterranean MPAs and priority areas identified at the ecoregional planning scale was higher in the northwestern Mediterranean Sea  as well as in the Ionian Sea, especially due to the presence of Natura 2000 sites in these ecoregions. Croatia's entry into the EU in July 2013 and its subsequent proposal of Natura 2000 sites is expected to significantly increase the overlap between MPAs and priority areas in the Adriatic Sea (one of the two ecoregions with the lowest overlap). It is worth mentioning that in the present analysis only MPAs belonging to Croatian national categories were taken into account. The mismatch between our priority areas and current MPAs in the Algero-Provencal Basin and Tyrrhenian Sea is justified by the presence of large off-shore protected areas, SPAMIs, mainly targeting conservation of pelagic features . Gabrie et al. P. oceanica meadows, coralligenous formations and cave habitats P. oceanica is reconstituting its reserves P. oceanica meadows and coralligenous habitats occur P. oceanica meadows. Information on depth distribution and present ecological status of coralligenous habitats and marine cave assemblages is urgently needed However, MPAs alone cannot safeguard the conservation of The present study, despite its limitations, builds upon previous efforts focusing on large-scale spatial prioritization in the Mediterranean Sea, e.g., Text S1(DOC)Click here for additional data file.


External radicular resorption is a pathological process that generates the loss of cementum, dentin and bone, almost irreversibly, involving vital and pulpless teeth. The early stage is asymptomatic and might be diagnosed by a routine radiograph or a clinical examination. Radicular resorption appears because of cementoclastic, dentinoclastic or/and osteoclastic activity. The process of resorption is associated with a damage of the periodontal ligament as a result of injury and necrosis, macrophages are the first cells that are detected, followed by multinucleated cells, odontoclasts, which affect the cementum and dentin. External radicular resorption is a pathological process that generates the loss of cementum, dentin and bone, almost irreversibly, involving vital and pulpless teeth. The early stage is asymptomatic and might be diagnosed by a routine radiograph or a clinical examination. Radicular resorption appears because of cementoclastic, dentinoclastic or/and osteoclastic activity. There are several types of external root resorption; the most common is the external inflammatory root resorption. The damage of cementum and the infection of the endodontic system may stimulate the osteoclastic activity in periapical tissue and the external root resorption can be initiated. The treatment is related to the stimulation factors (infection or pressure), so, the adequate root canal treatment can almost influence the evolution of the resorptive inflammatory process.The process of resorption is associated with a damage of the periodontal ligament as a result of injury and necrosis, macrophages are the first cells that are detected, followed by multinucleated cells, odontoclasts, which affect cementum and dentin.The etiology is multifactorial: trauma, (luxation avulsion replantation), periapical and parodontal inflammation, orthodontic movement, dentoalveolar surgery, periodontal treatment, excessive pressure, occlusal forces, malocclusion, root morphology, chemical irritation (bleaching using hydrogen peroxide 30%), associated systemic diseases, endocrine disorder (Paget’s disease). The etiology requires two phases, injury  and stimulation (by infection or pressure), that act on osteoclasts.Fig. 1).The denuded mineral tissue is colonized by multinucleated cells and resorption process is initiated  and tumor necrosis factor alpha (TNFα)). There might be a genetic component susceptible for the external root resorption that is responsible for the initiation of the resorptive process [Endodontically treated teeth are more susceptible to resorption than normal teeth. 5].According to Tronstad (1981), inflammatory resorption might be internal and external; he describes transient, progressive and replacement resorption [1], there are three types of external resorption: superficial, external resorption with anchylosis and external inflammatory resorption.As far as Andreasen’s classification (1988) is concerned [2].In 2009, Hulsmann describes tree types of external radicular resorption: progressive inflammatory, cervical  and replacement resorption  for the inflammatory resorption process is represented by the pulpal infection, [4] so, Ca(OH)₂ and chlorhexidine 2% as a vehicle was used as root canal dressing. This intracanalar drug inhibits dentinoclasts by the neutralization of the bacterial lipopolisacharides [3] and initiates the reparation process of the resorptive lacunae.The most common stimulation factor [We used chlorhexidine 2% as an irrigation solution and a vehicle for Ca(OH)₂ powder, because of its relative decreased cytotoxic effect and its stable antibacterial property . Chlorhexidine increases the pH of dentine, inhibits the osteoclastic activity of acid hydrolase in the periodontal tissue, and, in the same time, it activates the alkaline phosphatase. Chlorhexidine is a long acting antiseptic drug with a remnant effect, which increases the antibacterial effect of Ca(OH)₂.• The treatment of inflammatory external root resorption might be predictable, depending on the etiology.• Pulpal infection may perpetuate the resorptive process, being the most important stimulation factor for the root resorption.• The non-surgical treatment of the inflammatory resorption has to reduce the bacterial content of the endodontic system and allow the healing of the periradicular space. In addition, an adequate debridement and disinfection - intracanalar medication with calcium hydroxide and additives (chlorhexidine 2%) for 3-6 months was used.• Subsequent follow up period is needed to correct the estimation about the prognosis of the resorptive process.


An electronic reporting system for a network of 22 laboratories was implemented in Kansas City, Missouri, with an independent organization acting as a data clearinghouse between the reporting laboratories and public health departments. The system ran in tandem with conventional reporting methods. Laboratory test orders and results were aggregated and mapped to a common nomenclature. Reports were delivered through a secure Internet connection to the Kansas City Health Department (KCHD); during the first 200 days of operation, 359 qualified results were delivered electronically to KCHD. Data were received more quickly than they were with conventional reporting methods: notification of chlamydia cases arrived 2 days earlier, invasive group A streptococcal disease cases arrived 2.3 days sooner, and salmonellosis cases arrived 2.7 days sooner. Data were more complete for all demographic fields, including address, age, sex, race, and date of birth. Two hundred fourteen cases reported electronically were not received by conventional means. Biosurveillance is the automated monitoring of information sources of potential value in detecting an emerging epidemic, whether naturally occurring or the result of bioterrorism. Information sources that can be monitored for early warning include purchases of nonprescription medication , encryption of identifiable information, and virtual private network (VPN) secured communications and ensured protection of confidentiality. Interagency agreements between public health organizations in the Kansas City area provided a further framework for the appropriate exchange of data across jurisdictional boundaries. For example, an agreement between KCHD and the state of Kansas recognized Kansas City, Missouri, as a county of Kansas for purposes of metropolitan surveillance.Batch extraction scripts ran daily at each data contributor, pulling new laboratory test orders, laboratory results, and patient demographic information. Demographic information was encrypted before being transferred to the data clearinghouse through a VPN . The data were loaded into a data warehouse  and checked for errors and duplication; data mapping was then performed . Microbiologic results identifying reportable pathogens were mapped automatically to a common nomenclature to standardize the varying names between the participating organizations. Procedure orders  deemed relevant to the detection of an infectious disease outbreak were also mapped to a common nomenclature. After these processing steps, the results were used to build two reports that were delivered through the Internet to KCHD using a VPN secured account. One report provided trending information on orderable procedures; the other provided results from microbiology tests . KCHD stWe evaluated reports received through both conventional and electronic reporting between March 29, 2002, and September 2, 2002, for data completeness and timeliness. Disease reporting in Kansas City requires that public health officials know the name of the testing facility and the patient’s age, date of birth, race, sex, address, and telephone number. As each conventional or electronic report was received, KCHD documented whether each required data element was provided and documented the date on which conventional reports were received. Timeliness was determined by comparing this date with the date that a reportable pathogen was first posted to LIS.Reports received only through electronic means were evaluated to confirm that they satisfied KCHD reporting criteria. This review included confirmation of appropriate jurisdictional concerns, origin of isolate (appropriate body site), and exclusion of false-positive results.Geographic information system maps, showing the residential zip code of patients with reportable isolates, were delivered to KCHD by using Arc-IMS . Users could select a pathogen and observe the zip codes of patients with confirmed cases. Geographic coverage maps were generated by using the zip codes of all patients whose results were evaluated by the system.Bacillus anthracis, Coxiella burnetii, Yersinia pestis, or any Brucella species would trigger alerts sent to the pagers of on-call public health officers and supervisors.Critical isolate alerts were also built into the system. A single instance of The electronic data clearinghouse study was conducted in tandem with conventional reporting at all sites. In 2002, conventional reports to KCHD originated from laboratories (52%), infection control practitioners (34%), blood centers (6%), private physicians (4%), and other sources (4%). Personnel involved in conventional reporting were generally unaware of the electronic reporting system; their management was instructed in the dual reporting requirement. Our review of reports received through both the clearinghouse and conventional reporting identified 144 isolate reports. An additional 213 cases arrived only through electronic reporting . We reviMany case reports were only received through electronic reporting . In partThe data clearinghouse received all cases reported by traditional means for diseases that were consistently documented by using microbiology reports. The null value precluded the use of the Chandra Sekar-Deming capture-recapture technique used to assess reporting coverage in other electronic reporting systems  to plot the zip codes of patients whose data were evaluated by the system, independent of the result . The breWe evaluated a data clearinghouse approach to biosurveillance using clinical microbiologic laboratory data. Electronic reporting of communicable diseases has been tested in other communities, including Hawaii, Pittsburgh, and Indianapolis  and KCHD (with jurisdiction over the performing laboratory). Reducing underreporting is a critical step in building a threshold-based automated alerting infrastructure because the baseline data gathered by an electronic reporting system is more accurate than that gathered by traditional methods.Bordetella pertussis” on the next line, with the intent of negating the positive result. This type of data entry error, which led to a few false-positive results propagating into the clearinghouse during the first few weeks of operation, has also been an issue for other electronic reporting systems  would be useful as an early warning of a water-supply contamination crises, such as that experienced by Milwaukee in 1993 when cryptosporidium contaminated the city water supply and caused >403,000 illnesses (Most patients whose results were evaluated by the system resided within approximately 150 km of the Kansas City metropolitan area; however, patients from eastern Missouri, western Kansas, and other U.S. states also were evaluated by the system. The area covered by the clearinghouse crosses the state line that transects the Kansas City metropolitan area. Plans for a national public health infrastructure (e.g., the National Electronic Disease Surveillance System [NEDSS] [We considered issues that have proven to be challenging for other electronic reporting projects. In particular, the use of nonstandardized data, subject to errors in either database design or during data entry, created challenges. Overall, we found that the data clearinghouse approach to biosurveillance offers many benefits, including ease and speed of implementation, improved timeliness and completeness of data, efficiency of scale from a central data-mapping operation, and the ability to deliver data to multiple jurisdictions.


To the Editor: Nineteenth century Rio de Janeiro, Brazil, was marked by increased illness and deaths from tuberculosis (TB). By the twentieth century, it was still believed that most TB cases in the Americas originated from Europe; the “virgin soil” hypothesis for African (Mycobacterium tuberculosis complex (MTC) and TB in the Old and New Worlds. Rio de Janeiro was a main entry port for millions of Africans captured for the slave trade. Pretos Novos (New Blacks) Cemetery  was created in Rio de Janeiro as a burial ground for the many slaves who died at market. Comingled bone fragments  from ≈30 persons were recovered at PNC; most bones were broken and had been exposed to fire (M. tuberculosis ancient DNA (aDNA). The thick shafts of femur offered a preserved condition for molecular analysis, and the bones could be individualized, avoiding duplication of samples. Paleogenetic investigation guidelines were followed. Sample preparation, aDNA extraction, and PCR were performed at the Paleogenetics Unit  an isolated environment exclusively dedicated to aDNA research.Femurs from 16 persons were surveyed for Before removal of the bone surface, samples were decontaminated by ultraviolet light , frozen in liquid nitrogen, and subjected to manual trituration. Bone powder (≈200 mg) was then incubated with digestion buffer  as described (Using the hybridization assay with insertion sequence (IS) 6110 target, we detected MTC aDNA in bones from 4/16 persons ; 3 of these samples  were also positive for IS1081 target, confirming MTC infection . HVS-I tHistoric data (The endemicity of TB in Rio de Janeiro during the colonial period was confirmed by Jaeger and colleagues, who demonstrated MTC infection in 56.6% of persons with European ancestry buried at Nossa Senhora do Carmo Church (Our finding that some of the slaves buried in PNC had TB infection when they arrived in Brazil is in agreement with previous findings of the differential distribution of TB and with a tuberculin survey on the African continent, supporting the hypothesis of native African TB (Other evidence showing African contact with Europeans before the sixteenth century, supports the existence of TB in Africa (