This study aimed to examine perception, knowledge and concerns developed by patients and their family as regards venous thromboembolism (VTE) risk.We conducted a qualitative study. Participants were: (1) patients with unprovoked VTE with either factor V Leiden mutation or G20210A prothrombin gene mutation or not; and (2) their first-degree relatives. Interviews took place mostly at Brest University Hospital. Participants produced narratives of the patient’s illness, stressing their perception of the disorder, its mechanisms, etiology, circumstances and risk factors. Interviews were audiotaped and transcribed verbatim. On an ongoing basis, central themes were identified and data from narratives were categorized by these themes.A total of ten patients and 25 first-degree relatives were interviewed. Analyses of patient’s narratives suggested 4 main themes: (1) concerns about initial symptoms and suspicion of VTE. The longer the duration of the initial phase, the more likely anxiety took place and persisted after diagnosis; (2) underestimation of potential life-threatening episode once being managed in emergency; (3) possible biographical disruption with inability to cope with the event; and (4) secondary prevention attitudes motivated by remains of the episode and favoring general prevention attitudes. Analyses of the first-degree relatives narratives suggested 3 main themes: (1) common interpretation of the VTE episode shared within the family; (2) diverse and sometimes confusing interpretation of the genetic status; and, (3) interpretation of clinical signs linked to VTE transmission within the family.Construction of the risk of VTE is based on patient’s initial experience and shared within the family. Collection of narratives illustrates the gap between these perceptions and current medical knowledge. These results support the need to collect the perceptions of the VTE episode and its consequences, as a prerequisite to any health education process. Venous thromboembolism (VTE) is a multifactorial disease caused by hereditary and acquired risk factors . More thMeanwhile, frequent interactions between patients, their family members and physicians from our team during this study shed light on the complex mechanisms developed by participants to adapt their VTE risk perception and to adopt potential preventive attitudes. It also appears that patients and family members interacted on these topics, especially in the context of the discovery of genetic variations in their family. Keeping in mind the interest for caregivers of a better appraisal of actual patient’s perceptions and knowledge, we herein developed a qualitative approach and worked on situations of patients and their first-degree relatives who had received an announcement on VTE risk factors.This study was nested in a previous study of factors that predicts risk of venous thrombosis in 1,752 first-degree relatives of 369 patients with unprovoked symptomatic venous thromboembolism (VTE), either pulmonary embolism (PE) or deep vein thrombosis (DVT). Patients and first-degree relatives were recruited from 5 centers in Canada and one center in Brest, France. The French center included 158 patients and their first-degree relatives. Data on participants had been previously described  are encouraged to provide feedback on the event and its consequences, including daily life and work, information is shared and follow-up scheduled. Pending on the results of this appointment, special needs, such as psychological or social support, are then considered.


Each year, the tobacco epidemic kills an estimated 6 million persons worldwide, including about 600,000 who die because of secondhand smoke exposure. If current trends continue, this number is expected to reach 8 million deaths annually by 2030 .Sponsored by the World Health Organization (WHO) and observed on May 31 each year, World No Tobacco Day highlights the health risks associated with tobacco use and encourages effective actions to reduce tobacco consumption. This year, WHO calls for international collaboration to stop the illicit trade of tobacco products .Protocol to Eliminate Illicit Trade in Tobacco Products (Illicit tobacco trade is characterized by tax avoidance and tax evasion, such as bootlegging, counterfeiting, and smuggling. This practice undermines tobacco use prevention and control by increasing the accessibility and affordability of tobacco products and can reduce government tax revenue . An estiProducts .


Research indicates that exposure to war-related traumatic events impacts on the mental health of refugees and leads to higher rates of posttraumatic stress disorder (PTSD), depression, and anxiety symptoms. Furthermore, stress associated with the migration process has also been shown to impact negatively on refugees' mental health, but the extent of these experiences is highly debatable as the relationships between traumatic events, migration, and mental health outcomes are complex and poorly understood.This study aimed to examine the influence of trauma-related and post-migratory factors on symptoms of PTSD, depression, and anxiety in two samples of Bosnian refugees that have resettled in two different host nations—Austria and Australia.Using multiple recruitment methods, 138 participants were recruited to complete self-report measures assessing acculturative stress, PTSD, depressive, and anxiety symptoms.Hierarchical regressions indicated that after controlling for age, sex, and exposure to traumatic events, acculturative stress associated with post-migratory experiences predicted severity of PTSD and anxiety symptoms, while depressive symptoms were only predicted by exposure to traumatic events. This model, however, was only significant for Bosnian refugees resettled in Austria, as PTSD, depressive, and anxiety symptoms were only predicted by traumatic exposure in the Bosnian refugees resettled in Australia.These findings point toward the importance of assessing both psychological and social stressors when assessing mental health of refugees. Furthermore, these results draw attention to the influence of the host society on post-migratory adaptation and mental health of refugees. Further research is needed to replicate these findings among other refugee samples in other host nations. Epidemiological research in the area of posttraumatic mental health indicates that prior trauma is a significant predictor of posttraumatic stress disorder (PTSD)  there will be no difference in levels of traumatic experiences reported by those refugees resettled in Australia and those resettled in Austria; (2) there will be no difference in levels of PTSD, and depressive and anxiety symptoms reported by refugees resettled in Australia and those resettled in Austria; (3) traumatic experience will be associated with increased levels of severity of PTSD and depressive and anxiety symptoms across both groups; and (4) increased acculturative stress would be associated with increased levels of severity of PTSD and depressive and anxiety symptoms more so in the sample of Austrian Bosnians than in the sample of Australian Bosnians.Participants were eligible for inclusion in this study if they were older than 18 years of age, resided in Australia or Austria during data collection, and were exposed to war events in Bosnia anytime between 1992 and 1995.snow-balling; online recruitment; advertising in local media including newspapers, radio, and television; and recruitment through social clubs and groups whose members were of Bosnian background. Participants responded to an anonymous self-report survey via hosted website or a hard copy of the survey which was returned anonymously in a prepaid envelope. The majority of participants  utilised a hard copy version. There were no statistical differences between those who filled a hard copy or an online version of the survey for any of the outcomes including levels of PTSD , depressive , or anxiety symptoms .Participants in this study were recruited between January 2010 and January 2013 using various recruiting options including All measures used in the study were translated from English into Bosnian by the first author who is a native speaker and then back-translated by an independent bilingual academic allowing for comparison between the two translations. Any discrepancies in translation were resolved by discussion and mutual agreement between the first author and the bilingual academic.The questionnaire included a set of demographic questions . Trauma history questions (yes/no) were assessed in relation to war-related  and other traumatic events  experienced during their lifetime.Posttraumatic Diagnostic Scale   is a 21-item self-report inventory designed to provide measures of the three related negative affective states of depression, anxiety, and stress . Alpha coefficients for the depression (α=.95) and anxiety (α=.92) scales in the current sample were excellent.The Loss , Novelty (unfamiliarity with the tasks of daily living), Occupation (difficulty finding acceptable work), Language accommodation (having an inadequate level of English/German), Discrimination (perceived), and Not feeling at home . Items are rated along a 6-point Likert scale . In the present study the Cronbach's alpha for the total DI scale was excellent (α=.94) and ranged between .75 and .87 for the subscales, indicating good internal consistency.The Demands of Immigration (DI) Scale  to examine the effects of acculturative stress on PTSD, depression, and anxiety symptoms in the subgroups of refugees resettled in Australia and Austria. All data were analysed in SPSS version 22. This study was reviewed and approved by the Monash University Human Research Ethics Committee, certificate number CF09/3238–2009001758.Differences in demographics, mental health, and subscales of the DI between the refugees resettled in Australia and Austria were examined using The demographic characteristics of the sample are presented in t(136)=4.02, p<.001.Eighty-two percent of the whole sample reported experiencing at least one traumatic event, while 70% reported experiencing three or more traumatic events in their life . Similarly, 80% of the whole sample reported experiencing at least one war-related event, and 64% reported experiencing more than three war-related traumatic events . As can be seen in Language, levels of acculturative stress did not differ significantly between Australian and Austrian Bosnians. As indicated in Except for the subscale F=18.49, p<.001. When models were tested separately for each refugee sample, the model was only significant for the Austrian Bosnian group. In particular, only the subscales of Loss contributed significantly to explain 58% of the variance in the PTSD symptoms F=12.26, p<.001.Hierarchical regression analyses were conducted to examine significant predictors of PTSD, depressive, and anxiety symptoms separately for the Austrian and Australian samples, while controlling for exposure to traumatic events and demographic variables. As can be seen in Language and Novelty contributed significantly to explain 49% of the variance in anxiety symptoms F=9.01, p<.001 for the Austrian Bosnian group.Similarly, acculturative stress was not a significant predictor of anxiety symptoms in the total sample or in the Australian Bosnian group . HoweverThis study investigated the level of traumatic exposure and prevalence of mental health symptoms in two samples of Bosnian refugees resettled in Australia and Austria. Furthermore, mental health impact of age, sex, exposure to traumatic events and acculturative stress was investigated across both samples.The results show high levels of exposure to traumatic events and high prevalence rates of PTSD, depressive, and anxiety symptoms across both samples, confirming prior research conducted with refugees in general , the host society can impact on the acculturation process of refugees by imposing either encouraging or less desirable acculturative strategies that consequently either encourage or oppose ethnic diversity and participation in the larger society. As described in the current study, Austrian Bosnians generally experienced temporary residence with limited benefits and rights, while their counterparts in Australia experienced a supportive migration context, as they immediately received permanent residency, language training, access to health services, and income support. Such a supportive approach to resettlement may have left refugees free to engage and practice their own culture and/or engage with the host culture, which may have removed the additional cumulative impact of acculturative stressors identified in the Austrian Bosnian sample. Besides, establishing secure residence has been found to be a stabilizing factor in the recovery process from trauma-related symptoms  indicating the continuing need for support from health and social services , post-migration risk factors , and resettlement trajectories . It should be pointed out that no causal pathway can be established with these results and further research is needed to replicate these findings in larger samples of refugees of different cultural backgrounds living in different host nations.


Hispanic stroke patients also reported greater barriers related to medical knowledge, medication adherence, and healthcare access . Hispanics scored higher on the “powerful others” sub-scale  of the MHLC. Of 177 members of the general public surveyed, Hispanics had lower stroke awareness compared to NHWs and tended to have lower awareness than Hispanic stroke patients. These results suggest that Hispanic stroke patients perceive less control over their health, experience more healthcare barriers, and demonstrate lower rates of stroke literacy. Interventions for stroke prevention and education in Hispanics should address these racial/ethnic differences in stroke awareness and barriers to risk factor control.Barriers to risk factor control may differ by race/ethnicity. The goal of this study was to identify barriers to stroke awareness and risk factor management unique to Hispanics as compared to non-Hispanic whites (NHWs). We performed a prospective study of stroke patients from an academic Stroke Center in Arizona and surveyed members of the general community. Questionnaires included: the Duke Social Support Index (DSSI), the Multidimensional Health Locus of Control (MHLC) Scale, a stroke barriers questionnaire, and a Stroke Awareness Test. Of 145 stroke patients surveyed , Hispanics scored lower on the Stroke Awareness Test compared to NHWs (72.5%  Stroke is the leading cause of adult disability and among the top five causes of death in America . ApproxiStroke education and prevention remains the greatest opportunity for decreasing stroke incidence and mortality ,12. HoweMultiple barriers exist that can impede optimal risk factor management in stroke patients. These include barriers in stroke education/literacy, health locus of control, social support, as well as barriers relating to medical knowledge, medications, and healthcare access. Yet, few studies have systematically assessed these barriers to stroke risk factor management in Hispanics. With this study, our aim was to evaluate and identify these potential barriers to risk factor management and stroke prevention in Southern Arizona, with a particular focus on barriers within the Hispanic population. The barriers identified in this proposed study will form the foundation of a community-based and culturally-tailored intervention program that will address stroke risk factor management and prevention of subsequent strokes among Hispanic stroke survivors with the ultimate goal of reducing health disparities in stroke within this population.Stroke patients were recruited from Banner-University Medical Center Tucson, an academic stroke center and the main teaching hospital affiliated with the University of Arizona in Tucson, Arizona. Banner-University Medical Center is certified by the Joint Commission as a primary stroke center. All potential patients were identified by the daily log of patients seen by the stroke service. Eligible participants were identified prospectively and approached for participation while in the hospital. Inclusion criteria were as follows: stroke diagnosis abstracted from medical record , age ≥18. Only patients that were functionally able to complete the survey were included in this study.All stroke patients admitted to the hospital receive standardized stroke education during their hospitalization. Patients are given a stroke booklet covering the following topics: ischemic stroke, hemorrhagic stroke, transient ischemic attack; managing risk factors and stroke prevention; improving language skills, coping with difficult swallowing; mood swings and depression; medications; lifestyle changes. In addition to patient education provided by the stroke team physicians, nurses review the booklet with patients on an individual basis, focusing on the risk factors relevant to the patient. Spanish booklets and Spanish-speaking nursing staff are available for patients that do not speak English.Additionally, members of the general public from Tucson, AZ were recruited for this study and given a modified version of the inpatient survey. General public participants were recruited and completed the surveys at Tucson community events that were expected to attract attendees that were representative of the overall Tucson population. The study protocol was approved by the University of Arizona Institutional Review Board  and all aspects of the study were in accordance with the latest revision of the Declaration of Helsinki. All participants provided written informed consent prior to study.vs. non-Hispanic). The DSSI quantifies the amount and satisfaction of the stroke patient’s social support and is composed of three separate sections: social score (range: 4–12), satisfaction score (range: 7–21), and total score (range 11–33). The social score quantifies the amount of support, the satisfaction score assesses how content an individual is with the amount of support they have, and the total score is a sum of the two [The survey included the following components: a demographic questionnaire, the Duke Social Support Index (DSSI), the Multidimensional Health Locus of Control (MHLC) Scale, a questionnaire assessing perceived barriers to healthcare, and a modified Stroke Awareness Test (SAT). The demographic questionnaire included age, gender, and self-reported race  and ethnicity . Calculation of sample size was performed using G*Power software  [p = 0.05, power of 80%).All statistical comparisons were performed using the SPSS statistical software package . Baseline characteristics and survey results were compared between groups employing Student’s A total of 145 stroke patients were recruited (72 Hispanic and 73 NHW). Hispanic study participants included a combination of English and Spanish-only speaking individuals. vs NHWs. Hispanics scored lower on the stroke awareness test compared to NHWs . A larger percentage of Hispanic stroke patients was not aware of tPA existing as an acute treatment for stroke compared to NHW inpatients . Hispanics consistently had significantly lower scores for all three barrier categories ; on this scale lower scores translate to Hispanics experiencing higher barriers as compared to their Caucasian counterparts. Hispanics and whites were found to score similarly in the social, satisfaction and total score categories on the Duke Social Support Index. On the Multidimensional Health Locus of Control Scale, Hispanics and NHWs had similar scores for the internal and chance score categories; however, Hispanics had a higher score for the powerful others category .In the sub-study of 177 members of the general population, a total of 117 Hispanics and 60 NHWs completed the survey. Hispanic and NHWs had similar age and gender representation . HispaniOverall, the results from this study suggest Hispanic stroke patients experience more barriers to stroke prevention and lower stroke-specific health literacy compared to non-Hispanic whites. An ancillary study of the general public confirmed that these barriers extend to the larger Hispanic population. Some of these barriers may be unique based on cultural and/or ethnic differences.Health literacy is crucial to management of chronic diseases, including stroke, by influencing healthcare system navigation, treatment-seeking behavior, and adherence to medical treatment ,25,26,27In the sub-study of members of the general public we found that: (1) Hispanics had lower stroke awareness than NHWs, and (2) Hispanic stroke patients had higher knowledge of stroke than Hispanic members of the general Tucson population. This data shows that Hispanics do benefit from inpatient stroke education, albeit not to the same extent as NHWs. Collectively, suggest that further study is necessary to improve stroke patient education and also highlights a potential role for culturally-tailored stroke education materials for all Hispanics . Cultural tailoring, defined as “the development of interventions, strategies, messages, and materials to conform with specific cultural characteristics” may make this educational material more effective as it increases the relevance to the receiver and is better at capturing attention and stimulating information processing among targeted audiences. Prior studies have demonstrated the efficacy of culturally tailored health interventions ,37,38,39all surveyed stroke patients; only 8.5% of Hispanics and 20.8% of NHWs had knowledge of tPA. Again, these results highlight the knowledge deficiencies in both Hispanics and the NHWs, and point to the need for further widespread educational campaigns regarding stroke education.Another important aspect of stroke education is knowledge of acute stroke treatments, particularly administration of tissue plasminogen activator (tPA), a clot dissolving agent that has been shown to improve outcomes when administered within 3–4.5 h of stroke onset. Knowledge of tPA is important as it encourages individuals to call emergency services when stroke symptoms occur. We found that Hispanics had a lower awareness of tPA as an acute stroke treatment than NHWs. However, the knowledge of tPA was surprisingly low for This study tested for three specific barriers that influence stroke care: general medical knowledge, medication access and cost, and healthcare access in general. In each category, Hispanics reported significantly greater barriers compared to NHWs. These factors are crucial to stroke care as they directly affect vascular risk factor control and stroke prevention measures. Similar to the stroke patients, Hispanic members of the general public perceive more barriers than whites. Though healthcare access is not easily modifiable, the gaps in medical knowledge and medication adherence provide areas for improved education that may benefit Hispanics.Social support is crucial to risk factor control in any chronic illness, including stroke; for this reason, this study sought to assess the social support structure of stroke patients using the Duke Social Support Index. Positive social support is associated with engagement in medication adherence, self-management behavior, and overall positive health outcomes (including improved blood pressure control), all of which are factors that affect stroke outcomes ,41,42,43Health locus of control refers to the extent to which an individual perceives their health to be within their own control and is usually classified as either internal or external . An inteSeveral limitations exist in our study. Stroke severity was not included as a variable in the analysis; it is possible that results may differ across different stroke severities. Our goal was to include only patients who were able to directly participate in the survey so the population was likely biased towards less severe strokes. Additionally, though information on stroke subtype  was collected, we did not compare results by these subtypes due to small numbers. Furthermore, the research coordinators did not track stroke patients or members of the general public that declined participation or their reasons for declining; therefore, there is a possibility of selection bias in our study.In this prospective, single center study of stroke patients in Southern Arizona, stroke survivors who self-identified as Hispanic experience an increased perception of barriers relating to general medical knowledge, medication adherence, and healthcare access, have decreased stroke knowledge (including knowledge of acute stroke therapy), and have higher reliance on “powerful others” for control of their health. Similarly, surveyed Hispanics in the general population of Tucson, AZ display lower awareness of stroke and report perceiving higher barriers compared to NHWs. In the future, these areas can be targeted in culturally-tailored interventions aimed at improving risk factor control and health literacy for stroke prevention in Hispanics, which would ultimately reduce incidence of recurrent stroke in this population.


To perform a systematic review of measurement tools utilized for the diagnosis of nasal septal deviation (NSD).Electronic database searches were performed using MEDLINE (from 1966 to second week of August 2013), EMBASE (from 1966 to second week of August 2013), Web of Science (from 1945 to second week of August 2013) and all Evidence Based Medicine Reviews Files (EBMR); Cochrane Database of Systematic Review (CDSR), Cochrane Central Register of Controlled Trials (CCTR), Cochrane Methodology Register (CMR), Database of Abstracts of Reviews of Effects (DARE), American College of Physicians Journal Club , Health Technology Assessments (HTA), NHS Economic Evaluation Database (NHSEED) till the second quarter of 2013. The search terms used in database searches were ‘nasal septum’, ‘deviation’, ‘diagnosis’, ‘nose deformities’ and ‘nose malformation’. The studies were reviewed using the updated Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool.Online searches resulted in 23 abstracts after removal of duplicates that resulted from overlap of studies between the electronic databases. An additional 15 abstracts were excluded due to lack of relevance. A total of 8 studies were systematically reviewed.Diagnostic modalities such as acoustic rhinometry, rhinomanometry and nasal spectral sound analysis may be useful in identifying NSD in anterior region of the nasal cavity, but these tests in isolation are of limited utility. Compared to anterior rhinoscopy, nasal endoscopy, and imaging the above mentioned index tests lack sensitivity and specificity in identifying the presence, location, and severity of NSD. Nasal septal deviation (NSD) is a common diagnosis made by otolaryngologists but is one that is not usually based on objective measurements. As a result, there can be a significant inter-observer variability in terms of diagnosing the condition, verifying its precise location, quantifying the degree of deviation, and assessing its clinical impact on patients. This subjectivity can lead to unnecessary surgical treatments, patient complications and low patient satisfaction rates. In the current era of evidence-based medicine, society demands that surgical interventions demonstrate clinically significant improvements. Since there is no consensus agreement about diagnosing NSD objectively, interventions treating NSD lack a strong evidence base. Interventions not supported by evidence-based medicine are at risk of being curtailed by publicly funded healthcare systems.The nasal septum is a midline support structure of the nasal cavity. Aside from being a key support mechanism of the nose and a major determinant of its shape, the space between the septum and lateral walls of the nasal cavity regulates nasal airflow and respiration. Within the nasal cavity, a straight septum enables laminar airflow, allowing the inspired air to be warmed, cleaned and humidified and thus optimized for gas exchange. Conversely, a deviated nasal septum can contribute to various degrees of nasal obstruction and altered nasal respiration ,2.Deviation of the nasal septum is a common structural cause of nasal obstruction and can arise from dislocation of the quandriangular cartilage from its bony boundaries, or from an intrinsic deformity affecting the vomer, perpendicular plate of ethmoid and/or the quadrilateral cartilage itself . In neonOverall, the etiology of NSD can be classified as congenital, genetic effects causing aberrant growth, trauma , infectiDepending on the severity and location of NSD in adults, it can lead to mouth breathing, nasal crusting, epistaxis, and sinusitis . In infaThe wide range of reported incidences of NSD mentioned above is largely due to a lack of standardized objective criteria for making the diagnosis of NSD. However, other mitigating factors such as presence of turbinate hypertrophy, rhinitis, nasal valve collapse, nasal cycle and the complexity of the three dimensional geometry of the nasal cavity make the diagnosis even more challenging. Essentially, there seems to be no acceptable protocol for establishing the diagnosis of NSD. Diagnostic tests namely acoustic rhinometry (AR), rhinomanometry (RMM) and nasal spectral sound analysis (NSSA) have been documented in the literature to assess septal deviation. Acoustic rhinometry (AR) assesses nasal patency based on the measurement of acoustic reflection of a sound signal in the nose by structures within the nasal cavity . RhinomaThe purpose of this systematic review is to investigate the diagnostic modalities utilized to assess NSD. To our knowledge, no such review has been conducted, and considering the clinical manifestations and consequences of NSD, it would be beneficial to have an evidence-based diagnostic schema for NSD.An electronic database search was conducted with the assistance of a senior librarian specializing in health sciences database searches. The electronic databases were MEDLINE (from 1966 to second week of August 2013), EMBASE (from 1966 to second week of August 2013), Web of Science (from 1945 to second week of August 2013) and all Evidence Based Medicine Reviews Files (EBMR); Cochrane Database of Systematic Review (CDSR), Cochrane Central Register of Controlled Trials (CCTR), Cochrane Methodology Register (CMR), Database of Abstracts of Reviews of Effects (DARE), American College of Physicians Journal Club , Health Technology Assessments (HTA), NHS Economic Evaluation Database (NHSEED) until the second quarter of 2013. The search terms used in database searches were ‘nasal septum’, ‘deviation’, ‘diagnosis’, ‘nose deformities’ and ‘nose malformation’  independently reviewed the title and abstracts of the database searches. Full text of all studies that appeared to meet the inclusion criteria were retrieved along with ones that had insufficient information in the abstracts to make a final decision regarding their inclusion. The references of retrieved articles were also manually searched for additional studies that could be included in the systematic review. The authors (T.A and K.A.) independently assessed full articles obtained for inclusion in the systematic review and any disagreement was settled through discussion until a consensus was reached.The following exclusion criteria were finally applied to the studies after retrieval of full text of articles: Any concurrent sino-nasal pathology in patients that would preclude diagnosis of nasal septal deviation was excluded, examples of such conditions included, but not limited to, were septal perforation, chronic rhinitis, chonal atresia, enlarged turbinates, nasal polyps etc; computer simulations of airflow to mimic septal deviation were not included, as these were not in vivo studies.; studies including patients with prior septal surgery were not included, as this would reduce the detection rate of diagnosing nasal septal deviation; patients that did not receive any topical nasal decongestant prior to administering the diagnostic test were not included in this study. Minimizing mucosal swelling of septum will reduce the false positive rates of detecting nasal septal deviation.Methodological scoring to assess quality of included studies was performed through use of the updated Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool (changed reference# 28 to QUADAS-2) . It was The flow chart of the electronic database search and final selection of studies to be included in the systematic review is outlined Figure . Online Results from QUADAS-2 tool are listed in Table Nasal septal deviation (NSD) is a common clinical entity encountered in general otolaryngology-head and neck surgery. Upon review of the literature, no single test was identified as a gold standard of diagnosis of septal deviation. The diagnosis of NSD is generally ascertained after assimilating information gathered from a variety of sources including the patient’s history, physical examination of the nose and anterior rhinoscopy, nasal endoscopy, and imaging .Ideally, surgical interventions should be supported be strong evidence based medicine, with a diagnosis based on objective testing and criteria. Clinical inquiry from patients usually lacks sensitivity and specificity, especially as an isolated diagnostic tool in detecting NSD, possibly due to the presence of numerous co-existing and confounding pathologies. Anterior rhinoscopy and nasal endoscopy performed in the decongested state can diagnose the location and severity of nasal septal deviations, but it is an uncomfortable test that is subject to significant inter-rater variability ,31. ImagAcoustic rhinometry (AR) assesses nasal patency based on the measurement of acoustic reflection of a sound signal in the nose by structures within the nasal cavity. AR analyses the initial and reflected sound waves creating a plot of the cross sectional area of the nasal cavity as a function of the distance from the nasal cavity entrance . Once thet al[While AR provides a static view of the nasal cavity, rhinomanometry (RMM) provides a dynamic physiologic assessment of the nose. Based on the laws of fluid dynamics, it quantifies nasal ventilation by measuring transnasal pressure and nasal volume airflow to calculate nasal resistance . Nasal ret al concludeet al on RMM ret al[In contrast to administering RMM, which can be cumbersome and time consuming , nasal set al found a et al NSSA waset al sensitivet al.Standardized criteria for assessing the symptom of nasal obstruction caused by NSD can be quantified using validated visual analog scales. However, the results from subjective assessments of nasal obstruction from visual analog scores (VAS) are flawed in patients with chronic DNS who may have simply become accustomed to breathing with limited nasal airflow. This was demonstrated in a study  found thIn summary, diagnostic modalities such as acoustic rhinometry, rhinomanometry and nasal spectral sound analysis may be useful in identifying NSD in anterior region of the nasal cavity, but these tests alone add little value to diagnosis. Compared to anterior rhinoscopy, nasal endoscopy, and imaging the above mentioned index tests lack sensitivity and specificity in identifying the presence, location, and severity of NSD.The authors declare that they have no competing interests.TA carried out database searches, collected data, performed data analysis and drafted the original manuscript. VB, KA and CF participated in drafting the final manuscript. All authors read and approved the final manuscript.Database searches performed in this systematic review.Click here for file


Duloxetine has been studied in four distinct chronic pain conditions – osteoarthritis (OA), fibromyalgia, chronic low back pain (CLBP) and diabetic peripheral neuropathic pain (DPNP). These trials have involved large numbers of patients with at least moderate pain, and have used similar methods for recording pain intensity, over about 12 weeks.Data from the trials were pooled according to painful condition, and reanalysed at the level of the individual patient and using increasing levels of pain intensity reduction , with different imputation methods on withdrawal.The proportion of patients recording at least 50% pain intensity reduction plateaued after 2–6 weeks in fibromyalgia, and 8–12 weeks in other conditions. The duloxetine-specific benefit [number needed to treat (NNT) for at least 50% pain intensity reduction] was fairly constant after about 2 weeks for DPNP and fibromyalgia and after about 4 or 5 weeks for OA and CLBP. In all conditions, responses were bimodal, with patients generally experiencing either very good or very poor pain relief. Last-observation-carried-forward imputation produced numerically and occasionally statistically better (lower) NNTs than use of baseline-observation-carried-forward (true response).Baseline-observation-carried-forward (true response), which combines the success of high levels of pain relief with the failure to experience pain relief on withdrawal of the drug is conservative and probably reflective of clinical practice experience. The distribution of effect was not normal; few patients had the average response and averages are not an appropriate descriptor for these data.Last-observation-carried-forward (LOCF) imputation overestimates efficacy when adverse event withdrawals are high.Previous analyses of duloxetine in four chronic pain conditions reported mainly average pain changes using LOCF imputation.Responses were bimodal: patients generally experienced very good or very poor pain relief. Last-observation-carried-forward results were numerically lower (better) than true responder.Duloxetine was an effective analgesic in all four chronic pain conditions using highest level of evidence. The recognition of a number of potential biases in clinical trials and meta-analyses in chronic pain has led to the adoption of new standards of evidence . These iA National Academy of Sciences report Panel on  recommenWe have limited knowledge of how true responder (BOCF) analyses impact estimates of treatment efficacy across chronic pain conditions, although an analysis of the effect of different imputation methods has been published for duloxetine in chronic low back pain (CLBP) trials Liu-. True reHere we report the responder analysis findings for a single serotonin-norepinephrine reuptake inhibitor (SNRI), duloxetine, in four distinct chronic pain conditions, OA, fibromyalgia, CLBP and DPNP. To the best of our knowledge, this is the first patient level analysis of an intervention assessed using important patient-centred pain outcomes and across four different chronic pain conditions. We report on speed of onset of effect, different levels of pain relief, and the effect of imputation method (LOCF and BOCF) on measures of treatment efficacy.Data for these analyses were from duloxetine randomized trials Table , conductFor analysis of time course response we used the weekly mean of average pain from daily diary records for the OA, CLBP, and DPNP datasets, and British Pain Inventory average pain for the fibromyalgia datasets. The outcome used was at least 50% pain intensity reduction using BOCF.For the comparison of LOCF and BOCF imputation methods we used the primary endpoints of the individual studies  included in the responder analyses. Of these, 4238 (98%) had at least one pain recording after taking the first dose; because imputation is not possible without at least one post-treatment pain recording, this number was used as the denominator for the LOCF imputation analyses. Analyses were conducted according to painful condition, as different painful conditions can have different levels of response to placebo and active treatment  compared with use of LOCF imputation) was expressed as a percentage [(100 × BOCF/LOCF imputation) − 100] .Fig. The time course of efficacy in the four painful conditions was somewhat different. For the outcomes of at least 50% pain intensity reduction for true responders, Fig. Table Fig. Table Previous research has shown that an excess of adverse event withdrawals is the major driver for overestimation of treatment effect with LOCF compared with BOCF  For eachTo the best of our knowledge, this is the first patient-level analysis of a single intervention (duloxetine 60/120 mg) assessed using important patient-centred pain outcomes and across four different chronic pain conditions, spanning neuropathic pain, musculoskeletal pain and fibromyalgia. The strength of the analysis is that the data come from well-conducted randomized, double-blind trials, of trial duration longer than 8 weeks, and with large enough treatment arms to limit some known biases, such as sample size . The anaThe proportion of patients recording at least 50% pain intensity reduction plateaued after 2–6 weeks for fibromyalgia, and 8–12 weeks for the other conditions  was fairly constant after about 2 weeks for DPNP and fibromyalgia, and after about 4 or 5 weeks for OA and CLBP  NNTs than use of BOCF (true response); the latter combines both the success of high levels of pain relief with the failure to experience pain relief on withdrawal of the drug for any reason and is probably more reflective of clinical practice experience .The key findings from this analysis were that:It is instructive to compare these results for duloxetine with what is known about other drugs used in chronic pain conditions, despite the lack of any comprehensive background information in any individual painful condition. For example, findings have been published on pain relief with non-steroidal anti-inflammatory drugs (NSAIDs) in OA , CLBP M, and ankPrevious work has also demonstrated a tendency for NNTs to increase over a 12-week study period, sometimes quite substantially, with NSAID use in CLBP , with ibWhat is consistent between the current findings and those from previous analyses is the bimodal distribution of response by the end of trial, with the majority of patients having either a substantial level of pain relief or very little; few experienced the ‘average’ result. Averages are not appropriate descriptors for these data, especially when the standard deviation of the average response is of the same magnitude as, or even larger than, the average, as here Fig. .The consistency of the bimodal distribution is remarkable, in this study over four different chronic pain conditions for duloxetine, and generally in other studies across different pharmacological interventions in acute pain , NSAIDs Another feature where the results of this analysis are generally in keeping with those reported for other drugs is in the relationship between NNT calculated using either BOCF or LOCF and the degree of pain intensity reduction. The finding of lower (better) NNTs with the 30% and 50% cutpoints compared with lower or higher cutpoints is similar to the findings with etoricoxib in OA and ankylosing spondylitis , and witWhat we have, then, are consistent findings across chronic pain studies for the bimodal distribution of pain response and an overestimation of treatment effect in the presence of high adverse event withdrawals with active drug. This has a potentially major impact on the development of guidelines unless all potential sources of bias are considered so that like is only compared with like. What we do not have is consistency in terms of time to response or evolution of efficacy, which seem to differ between conditions and drugs; this may be the type of drug, or the condition, or an interaction between both. We do not know enough to be sure.This analysis of responder rates of duloxetine in four different chronic pain conditions is possibly unique, and has the potential to induce a radical shift in everyday chronic pain treatment. Currently available medications for symptomatic treatment of chronic pain are traditionally grouped into different medication categories – NSAIDs, opioids, anticonvulsants and antidepressants. These categories are reflections of either the pathophysiological concept behind the particular pain category (e.g. nociceptive vs. inflammatory vs. neuropathic) or where these treatments were first developed. Chronic pain treatments have often ‘borrowed’ drugs developed in other areas as much as using therapies developed on a mechanistic basis.If we could identify individual patients with any pain condition in whom specific biological mechanisms were responsible for their pain , individualized treatment specifically targeting those mechanisms might be employed. Any practical method of ascertaining which mechanism was responsible for an individual patient's pain , and using the ideal outcome of at least 50% pain intensity reduction are needed before we can be confident of making appropriate indirect comparisons between treatments, especially in guideline development. Last but not least, the clinical data show that the current concept of using certain drug classes for specific chronic pain states should be abandoned.RAM and VS developed the original idea for the study and the broad aims and objectives. NC and RAM performed the analyses. TT provided clinical insights. RAM and VS developed the original draft, and all authors contributed to the development of interim and final drafts.


Non-timber Forest Products (NTFPs), an important provisioning ecosystem services, are recognized for their contribution in rural livelihoods and forest conservation. Effective management through sustainable harvesting and market driven commercialization are two contrasting aspects that are bringing challenges in development of NTFPs sector. Identifying potential species having market value, conducting value chain analyses, and sustainable management of NTFPs need analysis of their use patterns by communities and trends at a regional scale. We analyzed use patterns, trends, and challenges in traditional use and management of NTFPs in the southern slope of Kangchenjunga Landscape, Eastern Himalaya and discussed potential implications for conservation and livelihoods. A total of 739 species of NTFPs used by the local people of Kangchenjunga Landscape were reported in the reviewed literature. Of these, the highest number of NTFPs was documented from India (377 species), followed by Nepal (363) and Bhutan (245). Though the reported species were used for 24 different purposes, medicinal and edible plants were the most frequently used NTFP categories in the landscape. Medicinal plants were used in 27 major ailment categories, with the highest number of species being used for gastro-intestinal disorders. Though the Kangchenjunga Landscape harbors many potential NTFPs, trade of NTFPs was found to be nominal indicating lack of commercialization due to limited market information. We found that the unsustainable harvesting and lack of marketing were the major constraints for sustainable management of NTFPs sector in the landscape despite of promising policy provisions. We suggest sustainable harvesting practices, value addition at local level, and marketing for promotion of NTFPs in the Kangchenjunga Landscape for income generation and livelihood improvement that subsequently contributes to conservation. Non-timber forest products (NTFPs) are the most important provisioning services people obtain from forest ecosystems . The impThe ecological diversity of the Himalaya makes the area a habitat of a vast range of NTFPs. In the Himalayan region, harvesting NTFPs is a tradition that also contributes significantly to the local economy. Some NTFPs play an important role in traditional health care systems, while others have important cultural values and are sources of food and housing material –11. AmonCommon threats to NTFPs in the Himalayan region include unsustainable harvesting and habitat loss due to land use change, deforestation and over-grazing , 14. SevThe demand for NTFPs is increasing not only in local markets, but also in international markets. Therefore, some important steps to facilitate integration of NTFPs into the development agenda that benefits local communities include identifying potential species having trade value and conducting research on their ecology and sustainable harvest levels; conducting analyses on value chain and use patterns; and analyzing trends and challenges in marketing and management . Here we0 21′40.49″ to 2807′ 51.25″ North latitudes and 87030′30.67″ to 900 24′31.18″ East longitudes  in terms of cultural and biological diversity and forms part of the Himalaya Biodiversity Hotspot, one of 34 global Biodiversity Hotspots . It exteThe Kangchenjunga Landscape provides a range of ecosystem services that supports millions of people . HoweverSwertia chirayita), Panch aunle (Dactylorhiza hatagirea), Kutki (Neopicrorhiza scrophulariiflora), Laghupatra (Podophyllum hexandrum) and Lauth salla .Recognizing the global and regional significances and challenges that lie within this landscape, the Kangchenjunga Landscape Conservation and Development Initiative (KLCDI) has been initiated by the governments of Bhutan, India and Nepal to achieve biodiversity conservation and sustainable development by applying ecosystem approaches to transboundary landscape management . One of http://www.theplantlist.org and http://www.tropicos.org). Vernacular names when available have also been provided. A master list was produced providing Linnaean taxonomy, vernacular name(s), mode(s) of use, and reference(s) for each species  using specific search terms such as ‘non-timber forest products’, ‘medicinal plants’, ‘wild edible plants’, and ‘Kangchenjunga Landscape’, ‘Nepal’, ‘India’, ‘Sikkim’, ‘Darjeeling’, and ‘Bhutan’. We also explored hard copies of relevant publications. We reviewed a total of 47 publications and one database to enumerate the NTFPs in the Kangchenjunga Landscape. The precision of species identification in this review was dependent on the original source. However, we verified currently accepted name(s) in online nomenclature sources  was used to test the null hypothesis that there is no difference in use of NTFPs under various use categories among the three countries in the Kangchenjunga Landscape.We listed ailments as mentioned in the publications but we followed the method proposed by Cook  to classMajority of publications on NTFP were from India (60 %), while 34 % were from Nepal and 6 % from Bhutan. This is quite obvious as Darjeeling and the state of Sikkim in India make up a large part of the KL (56.3 %). The presence of two state level universities and research institutes has made significant contribution to the research in KL India . Except We reported on a total of 739 species of NTFPs used by the local people of Kangchenjunga Landscape. Of these, the highest number of NTFPs was documented from India (377 species), followed by Nepal (363) and Bhutan (245). These numbers, however, overlap in terms of distribution. The NTFPs used only in India were 185 species, while this number was 189 for Nepal and 166 for Bhutan.Angiosperms were predominant with 705 taxa belonging to 137 families followed by Gymnosperms (10), Pteridophytes (17), Fungi (3), Lichens (2), Bryophyte (1) and Algae (1). Families with the highest number of species used belong to Asteraceae (56 species), Fabaceae (41), Lamiaceae (27), Rubiaceae (24), Poaceae (23), Moraceae (16), Ranunculaceae (16), Rosaceae (15), Zingiberaceae (15), Polygonaceae (14), Ericaceae (13), Rutaceae (13), and Liliaceae (11). NTFPs were distributed into different life forms, with herbs having the most species followed by trees and shrubs  in medicinal plants use pattern in major disease/ailment categories in India and Nepal. These results indicate differences between the traditions of NTFP use in different cultures of India and Nepal. Similar results were also obtained from East Timor [The relatively higher number of diversity in wild edible NTFPs in Nepal could be because of higher diversity of ethnic groups living in the lowland Tarai to highland regions. There was a significant difference  purpose, while fewer were used for two (147) or multiple (42) purposes. Local people were well aware of collecting seasons, mode of collection, and frequency of collection of specific parts of plant species. Medicinal plants such as d potent . Similar seasons .The use of medicinal plant in treatment of particular ailment and the preparation method were not specified from Bhutan. In India and Nepal, a total of 27 major ailments were reportedly treated with medicinal plants with most species being used to treat multiple ailments Table . Gastro-Mode of preparation included juice, paste, decoction, powder, infusion, and chewing raw plant parts Fig. , Table 1Almost all plant parts were used to prepare different medicinal formulations: roots, rhizomes, tubers, bark, leaves, flowers, fruit, seeds, young shoots, whole plants, and gum and latex Table . The mosThe role of NTFPs is particularly important in the Himalayan region where a large proportion of the rural population depends on them as a source of medicine, food, fibre, dye and other useful materials –41. In tEdgeworthia gardneri) is the only NTFPs that was sold after value addition in Nepal. Many of the species documented in this study possess high economic potential , with only a few collectors selling or exporting NTFPs directly in local and cross-border markets. The total amount of NTFPs traded from Nepal in the last five years was 2,029,960 kg and the amout of revenue generated was around US$ 76,066 , and Lauth salla . The trade also includes some plant species under legal protection of the Government of Nepal like Orchids, Champ (Michelia champaca), Jhyau (Lichens), Jatamansi (Nardostachys grandiflora), and Sughandhawal  [Illegal trade of NTFPs from the landscape often includes some of the CITES Appendix listed species such as Sunakhari (Orchids), Kutki (tamansi) . These stamansi) , 51. Contamansi) . Tradititamansi) , 52, 53.Monitoring is one of the key components to promote the NTFP sector. Follow-up of rules, regulations and strategies related to NTFPs is necessary for contributing to changes in policy that are able to mainstream sustainable management of NTFPs with livelihoods improvement. Limited progress has been achieved in the Kangchenjunga Landscape in controling over-harvesting, enforcing effective harvesting regimes, and maintaining conducive and adaptive adminstrative processess. Recently adopted economic tools such as certification of sustainable harvests should also be applied as a means of ensuring that NTFPs collected sustainably can be identified as such by the consumers , 55.Nardostachys grandiflora, Neopicrorhiza scrophulariiflora, Rauvolfia serpentina and Taxus wallichiana are the most threatened species. Therefore, the economic, socio-cultural and conservation values of these NTFPs are extremely high.NTFPs reported from the Kangchenjunga Landscape also include many species under different threat categories as well as under priorities of the governments. For example, of the total 30 national priority herbs of Nepal, 26 are abundantly available in the Kangchenjunga Landscape, while all species prioritized for cultivation and research in Nepal are also reported from the Landscape . Among tA comparision of NTFP policy frameworks in the Kangchenjunga Landscape shows that Bhutan, India and Nepal have supportive policies for the NTFP sector, thereby providing enabling environments and support for NTFP programs and marketing . As a reGender participation in policy formulation is also challenging. For example, 75 % of people collecting NTFPs in India were women and 100 % involved in NTFP processing were women, but their inclusion in Joint Forest Management committees was less than 10 % . SimilarConsiderable efforts have been made to develop the NTFP sector, but the contribution of NTFPs in national economies remains insignificant. As pointed by Shackleton and Pandey , the reaLike in other parts of the Himalayas, there is still a severe paucity of in-depth field based information on the abundance, reproductive biology and ecological impacts of harvesting of NTFPs in the Kangchenjunga Landscape. There is no standard method available to estimate the economic contribution of NTFPs and their products. Research on the inventory, life history of NTFPs, and impact of harvesting on the ecosystem is a prerequiste for their sustainable management, yet very few such activities have been documented from the landscape . SimilarMarket size, structure and value chain of NTFP species depend on the demand and supply characteristics of products and their beneficiaries in different areas. Understanding market information is important for value addition and in devising investment strategies  for NTFPIndigenous knowledge and management systems have been recognized for contributing to sustainable use of NTFPs, and consequently they have secured legal rights to manage forest resources . In the We documented NTFPs collected and used for various purposes by the local people of the Kangchenjunga Landscape. The diversity of NTFPs was highest in India, followed by Nepal and Bhutan. Though the landscape possesses many potential species for trade, their nominal contribution to local livelihoods was due to lack of value addition and commercialization. Unsustainable harvesting and lack of value addition and commercialization could be considered as major challenges for conservation and development of the NTFP sector in the landscape.Tracing the trend of NTFP research and exploitation, it shows much focus on medicinal plants resulting in over-harvesting of some highly potential medicinal plants, with very negligible amount of other plant species reported for other purposes. At present, NTFPs are synonymous with medicinal and aromatic plants and vice versa. Only small amounts of other NTFPs are marketed. Therefore, research must also focus on other potential categories of NTFPs. NTFP collectors need to be educated about forest ecology and the adverse impacts of unsustainable harvesting for conservation and local livelihoods. Sustainable harvesting techniques should be provided through training and capacity building programs to local people. Biological studies of high value NTFPs must be carried out in order to ensure sustainability of these resources.Phytochemical screening of medicinal plants and nutrient value analysis of wild edible plants would foster their commercialization. Traditional knowledge of medicinal plant use could be integrated with ‘modern’ health care systems . Highly Conservation and development organizations, together with government agencies and private sectors, must provide technical and innovative inputs to add value to NTFP products. They must also facilitate community mobilization for assessment and identification of potential NTFPs. The latter role will be of significant importance considering the limited human and financial resources of government agencies in the Kangchenjunga Landscape. An integrated approach will promote sustainable use of NTFPs while contributing to income generation and livelihood improvement for local people. Transboundary landscape conservation programs will provide opportunities for transboundary cooperation through policy reforms, as well as providing opportunities to diversify livelihoods of forest dependent communities. However, marketing and commercialization of NTFPs can be successful only if the activity is transparent, equitable and sustainable, with important implications for poverty reduction and better resource management . Increas


Emergency admission risk prediction models are increasingly used to identify patients, typically with one or more chronic conditions, for proactive management in primary care to avoid admissions, save costs and improve patient experience.To identify and review the published evidence on the costs, effects and implementation of emergency admission risk prediction models in primary care for patients with, or at risk of, chronic conditions.We shall search for studies of healthcare interventions using routine data-generated emergency admission risk models. We shall report: the effects on emergency admissions and health costs; clinician and patient views; and implementation findings. We shall search ASSIA, CINAHL, the Cochrane Library, HMIC, ISI Web of Science, MEDLINE and Scopus from 2005, review references in and citations of included articles, search key journals and contact experts. Study selection, data extraction and quality assessment will be performed by two independent reviewers.No ethical permissions are required for this study using published data. Findings will be disseminated widely, including publication in a peer-reviewed journal and through conferences in primary and emergency care and chronic conditions. We judge our results will help a wide audience including primary care practitioners and commissioners, and policymakers.CRD42015016874; Pre-results. The strength of this review is its extensive, unbiased search of multiple databases, journals, references and citations, combined with consulting experts. The review is broad to ensure a thorough understanding of evidence relating to the impact of emergency admission risk models from a range of study designs.Limitations are that our review does not include grey literature (as we are focusing on peer-reviewed literature), and that study heterogeneity may present challenges for data synthesis.The results of this systematic review will help strengthen the evidence base and inform the debate over best practice for managing patients at risk of emergency admission.An ageing population and rising incidence of chronic conditions places unprecedented demand on healthcare services.5–7Emergency admission predictive risk models have been widely developed in response to the growing international burden of disease. They use mathematical formulae to interpret patient-level data  to identify those at risk of emergency admission. A recent systematic review of the technical performance of emergency admission risk models identified 27 validated models for use in primary care and considerable international research into their development and validation.9Other approaches to patient selection for interventions targeting high-risk patients, such as simple referral criteria—known as ‘threshold modelling’—or identification by clinicians unaided by a risk model, have been largely discredited owing to poor predictive accuracy,Emergency admission risk prediction models are widely advocated in international policy and practice, most notably in the UK, Europe and USA.6In this systematic review, we aim to examine the effects, costs and implementation of using risk prediction models in primary care to identify patients with chronic conditions at risk of future emergency admissions. To our knowledge, no review has been undertaken into the effectiveness of these risk prediction models. Given international interest and policy focus on these models, this review is needed to identify and review published studies, strengthen the evidence base and inform best practice in managing patients at risk of emergency admission.We registered this systematic review with PROSPERO—the International Prospective Register Of Systematic Reviews on 14 April 2015 (reference: CRD42015016874). The protocol conforms to the Preferred Reporting Items for Systematic review and Meta-Analysis for Protocols (PRISMA-P) guidelines,17What are the effects, costs and facilitators of, and barriers to, implementing emergency admission risk prediction models in primary care for patients with, or at risk of, chronic conditions?In addressing our research question, we shall include peer-reviewed studies published since 2005, with no language restrictions, that meet the criteria in et al.We shall carry out a comprehensive electronic search in ASSIA (via ProQuest), CINAHL (via EBSCO), the Cochrane Library , HMIC (via Ovid), ISI Web of Science, MEDLINE (via EBSCO) and Scopus. We shall develop and pilot a search strategy with the support of a specialist librarian in an iterative process using the clinical prediction and prognostic search filters outlined by Ingui and Rogers10.1136/bmjopen-2015-009653.supp1Supplementary appendixOnce the MEDLINE search strategy has been reviewed and finalised, we shall adjust and develop it for our other data sources. We selected 2005 as the earliest publication date to precede relevant policy initiatives that prompted risk model development using routine data,BMC Family Practice, the British Journal of General Practice, and the International Journal of Integrated Care; use ISI Web of Science and Scopus to search the references and citations of included articles; undertake a secondary search using the names (or other identifiers) of risk models used in included articles; and consult experts in emergency admission risk prediction.We shall also: hand search three journals known to have published in this field—We shall use EndNote reference software to collate search results and remove duplicates. Two reviewers (MRK and KN) will independently assess initial eligibility of identified studies by screening titles, abstracts and keywords. KN will then obtain potentially eligible full texts for definitive assessment against the inclusion and exclusion criteria by MRK and BAE. Disagreements will be resolved through discussion. We shall record reasons for excluding full-text articles, and summarise the study selection process in a PRISMA flow diagram.17Details of the risk model used and of validation of the model;Use of non-emergency healthcare resources, implementation costs, reported facilitators and barriers, and clinicians’ and patients’ views, notably satisfaction;Study characteristics ;Study population, notably selection criteria;Nature and purpose of risk prediction model; andImplementation of risk prediction model—who used it and how.We shall develop a data extraction form that reflects the review aims and conforms with guidance from the National Health Service (NHS) Centre for Reviews and Dissemination.Where study data are unclear, we shall try to contact the corresponding author of the paper for clarification.As we expect to include randomised and non-randomised studies, we shall use a quality and bias assessment toolTwo reviewers (MRK and HH) will independently assess general study quality as strong, moderate or weak. They will resolve differences through discussion with a third reviewer (BAE).2 test and I2, which assesses how much variance is attributable to heterogeneity.We shall tabulate the characteristics of included studies, including narrative summaries of risk prediction models, how they were implemented and their effects. If feasible, we shall analyse outcomes relating to clinical and cost-effectiveness by metaregression. We shall assess study heterogeneity by two statistics—Q based on the χet al:Developing a theory of how the intervention works, why and for whom;Generating a preliminary synthesis of findings of included studies;Exploring relationships in the data; andAssessing the robustness of the synthesis.We shall use narrative synthesis to review qualitative data on model implementation, patients’ and clinicians’ views, and cost and clinical data too heterogeneous for meta-analysis through the four-step framework developed by Popay We shall report our findings through peer-reviewed publication and conferences—in primary care, emergency care and chronic conditions. We shall consult representatives of patients, primary care, health policy and commissioners to tailor outputs to these audiences.As this study uses published data, ethical permission is not necessary. Nevertheless, we shall set high ethical and governance standards in managing our data and presenting findings.The effectiveness of emergency admission risk prediction models is poorly understood. Although it is not clear whether their use influences patient outcomes or resource use, healthcare agencies are expected to use the models to allocate limited resources.


Dengue is a major cause of morbidity in Puerto Rico and is well-known to its physicians. Early case identification and timely initiation of treatment for patients with severe dengue can reduce medical complications and mortality. To determine clinical management and reporting practices, and assess knowledge of dengue and its management, a survey was sent to 2,512 physicians with a medical license in Puerto Rico. Of the 2,313 physicians who received the survey, 817 (35%) completed the questionnaire. Of the respondents, 708 were currently practicing medicine; 138 were board certified (Group 1), 282 were board eligible (Group 2), and 288 had not finished residency (Group 3). Although respondents clinically diagnosed, on average, 12 cases of dengue in the preceding three months, 31% did not report any suspected cases to public health officials while about half (56%) reported all cases. Overall, 29% of respondents correctly identified early signs of shock and 48% identified severe abdominal pain and persistent vomiting as warning signs for severe dengue with the proportion of correct respondents highest in Group 1. Reportedly about sixty percent (57%) appropriately never give corticosteroids or prophylactic platelet transfusions to dengue patients. One third (30%) of respondents correctly identified administration of intravenous colloid solution as the best treatment option for dengue patients with refractory shock and elevated hematocrit after an initial trial of intravenous crystalloids, and nearly one half (46%) correctly identified administration of a blood transfusion as the best option for dengue patients with refractory shock and decreased hematocrit after a trial of intravenous crystalloids. Even though dengue has been endemic in Puerto Rico for nearly 4 decades, knowledge of dengue management is still limited, compliance with WHO treatment guidelines is suboptimal, and underreporting is significant. These findings were used to design a post graduate training course to improve the clinical management of dengue. Dengue is a major cause of morbidity in Puerto Rico and is well-known to its physicians. Early case identification and timely initiation of treatment for patients with severe dengue can reduce medical complications and mortality. We conducted a survey among physicians who practice in Puerto Rico to determine clinical management and reporting practices and assess knowledge of dengue and its management. We found that although respondents clinically diagnosed, on average, 12 cases of dengue in the preceding three months, one third did not report any suspected cases to public health officials while about half reported all cases. We found that knowledge of dengue management was limited and compliance with WHO treatment guidelines was not optimal. As other dengue endemic countries have reported similar findings, a sustained continuing medical education training initiative may be necessary to improve case detection and clinical management even in countries where the disease is common. Our findings were used to design a postgraduate training course to improve the clinical management of dengue. Dengue is a mosquito-borne disease caused by any one of four dengue virus (DENV) types -1, -2, -3, and -4. Each DENV is capable of causing the full spectrum of disease from an asymptomatic infection to severe, life-threatening illness including dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) The incidence and severity of dengue has been steadily increasing over the last three decades throughout much of South and Central America, Mexico, and the Caribbean including Puerto Rico In 2007, there were 8,051 physicians residing in Puerto Rico who had a Drug Enforcement Administration (DEA) number and active license to practice medicine in Puerto Rico, according to the Puerto Rico Department of Health (PRDH) . PhysiciTo determine physicians' knowledge of how to diagnose and treat dengue according to the 1997 WHO guidelines and to assess their treatment and reporting practices, we determined that 1,068 generalists were needed to be 95% confident of being within ±3% of the assumed population proportion of 50%, used because this value gives the most conservative sample size estimates. We expected, based on the literature, that there would be a 50% non-participation rate, and therefore a simple random sample of 2,150 generalists was selected from the 5635 primary care and emergency medicine physicians. In addition, all 362 specialists were invited to participate. This survey underwent institutional review at the Centers for Disease Control and Prevention (CDC) and was determined to be public health practice and not research; as such, Institutional Review Board approval was not required.We sent a 37-item questionnaire, a personalized cover letter explaining the purpose of the survey, and a pre-addressed, prepaid return envelope to the 2,512 physicians in October of 2007 . One hunThe questionnaire, which was pilot tested among a small, diverse group of physicians practicing in Puerto Rico, asked for demographic information including age, sex, and training history . Further, physicians were asked whether or not they were currently practicing medicine, the location and type of healthcare facility of their current practice, and the average number of suspected dengue patients seen per week. Respondents who reported that they were no longer practicing medicine or did not see patients with dengue were excluded from the final analysis. Respondents who were currently practicing were asked questions about the clinical and laboratory diagnosis of dengue, and how frequently they report suspected dengue cases. Practicing respondents were also asked about their hospital referral criteria for patients suspected of having dengue, and to identify warning signs for severe dengue and early signs of shock. The questionnaire also asked about specific treatment practices including use of corticosteroids, prophylactic platelet transfusions, and intravenous immune globulin for patients suspected of having dengue, and knowledge of when to use intravenous colloid solutions and blood products in dengue patients with refractory shock after an initial trial of an intravenous crystalloid. A copy of the questionnaire is available upon request.A pre-specified analysis of management practices and knowledge of dengue was conducted by respondent level of training; groups included board-certified physicians (Group 1), residency trained physicians without board-certification (Group 2), and physicians who did not complete residency training and were therefore not qualified to take the Board examination (Group 3). Throughout, point estimates, 95% confidence intervals (CI), and statistical tests were computed accounting for the sampling design  and incorporating a finite population correction In order to assess the internal and external validity of the survey's results, we evaluated the questionnaires for completeness and recorded those questionnaires that were discarded and the reasons for doing so. Response proportions were compared to available population proportions for sex and physician location (San Juan metro area or Ponce), and these were assessed using a chi-squared goodness-of-fit test accounting for the sampling design In the tables and text we report both the raw counts of the numbers of respondents in the stated categories and the relevant total numbers of respondents. We also report estimates of population proportions and means based on survey data analysis, a statistical method which incorporates weighting, so these estimates may not match crude proportions calculated from the values reported. All proportions and means are such survey-based population estimates. To ease presentation, we do not include CIs in the text below when these can be found in the tables.Of the total 2,313 physicians who received the survey, 817 (35.3%) completed the questionnaire . Of the Respondent characteristics varied by group . Groups Respondents clinically diagnosed on average 12 cases of dengue in the three months before participating in the survey . SlightlMethods used to clinically diagnose patients with dengue did not differ by group . The majKnowledge of warning signs for severe dengue and early signs of shock was low overall and knowledge varied by group . One-thi3 in the absence of bleeding, hemoconcentration, or shock as a criteria for hospital referral.About one third (31%) of respondents reportedly use hospital referral criteria consistent with the 1997 guidelines . Not allKnowledge of the WHO treatment guidelines varied among groups . When gi3, while 22 (35%) gave ≤20,000 cells/mm3 as their threshold. The overwhelming majority (92%) of respondents appropriately do not give intravenous immunoglobulin to their patients with dengue.Many (57%) of the respondents appropriately never give corticosteroids to their patients with suspected dengue . The majThis survey demonstrates that knowledge and management of dengue vary among physicians practicing in Puerto Rico, particularly between Board-certified physicians and non-Board-certified physicians, especially those who did not complete residency training. There were four important findings from this survey. First, while most reportedly use WHO case definition to clinically diagnose dengue cases, we found that case reporting to public health authorities is not optimal and knowledge of laboratory diagnosis of dengue was poor. Second, many respondents, regardless of their level of training, were unable to identify early signs of shock and warning signs for severe dengue, knowledge needed to effectively give anticipatory guidance and inform triage and referral decisions. Third, reported compliance with treatment guidelines of dengue patients in refractory shock was generally low. Fourth, corticosteroids and prophylactic platelet transfusions were reportedly used by about 40% of respondents; practices that are not recommended by current or past treatment guidelines While respondents reportedly had clinically diagnosed 12 dengue cases on average in the preceding three months, about one-third of respondents did not report any cases to the Puerto Rico Department of Health and half reported all cases as required by law. Taken together, these findings suggest that dengue is underreported in Puerto Rico. This finding is consistent with past studies that estimated that for every case of suspected dengue reported to the passive dengue surveillance system (PDSS) in Puerto Rico, ten to 27 cases are not reported, and for every case of dengue hemorrhagic fever (DHF) reported, 15 DHF cases are not reported 3 concurrent with an elevated hematocrit for age and sex were to be referred to a hospital for further evaluation. Dengue patients with signs of shock and/or warning signs were to be referred for inpatient hospitalization. Consistent with these findings fatal case review studies conducted in Puerto Rico have found missed opportunities for referral and hospital admission Treatment guidelines for the clinical management of dengue were first introduced by WHO in 1975 Both the 1997 guidelines and the current 2009 WHO guidelines have comparable treatment algorithms for the use of intravenous crystalloids, colloids, and blood transfusions in dengue patients with refractory shock. Findings from our survey suggest that these treatment algorithms, especially the use of intravenous colloids for refractory shock due to severe plasma leakage, may not be as widely used as should be. In the same year as the survey was conducted, a medical record review from a case-series of laboratory-positive fatal dengue cases in Puerto Rico found that only one patient was given an intravenous colloid solution before the terminal event even though six of eight case-patients who died in the hospital had refractory shock Even though WHO guidelines Despite a lack of evidence, many of our survey respondents reported giving prophylactic platelet transfusions to their patients with dengue; a practice that may be relatively common among physicians in dengue endemic countries Although these findings contribute to our understanding of the knowledge and management of dengue in Puerto Rico, our study has several limitations. First, non-response might have biased the results In summary, our survey suggests that despite dengue being endemic in Puerto Rico for more than 40 years, physicians' diagnosis and clinical management of dengue in Puerto Rico are not optimal. As other dengue endemic countries have reported similar findings, a sustained continuing medical education training initiative may be necessary to improve case detection and clinical management even in countries where the disease is common


This Editorial introduces a special issue from the 20th International Symposium on Alcohol Fuels (ISAF 2013) on alcohol fuels enabling sustainable future development. Climate change is real and its consequences are ominous. The international level of awareness and the intensity of response have so far not measured up to the threat.’ With these sober words, Sergio C Trindade, co-laureate of the 2007 Nobel Peace Prize as a member of the Intergovernmental Panel on Climate Change (IPCC) and one of the founding members of the International Symposium on Alcohol Fuels (ISAF), opened the 20th International Symposium on Alcohol Fuels (ISAF 2013) held from 25 to 27 March 2013 at Stellenbosch, South Africa. Alcohol fuels have a significant role to play in the future of mobility fuel mixes, particularly for heavy duty and long distance transport. Conventional technologies for the production of alcohol fuels, particularly bioethanol, are established, significant, and competitive with fossil fuels (as proven in Brazil). At the same time, advanced technologies are coming to fruition that will enable sustainable production of biofuels from non-food crops and agricultural residues.‘alcohol fuels enabling sustainable future development’ with a focus on its potential role in Africa. A selection of papers presented at the meeting that capture the most recent advances in alcohol technologies are published in this special issue of Biotechnology for Biofuels. Conversion technologies for a variety of feedstocks, ranging from spruce slurries, wheat straw, rice straw, and sweet sorghum stalks to bamboo, palm oil, empty fruit bunch (EFB), and grape pomace are discussed. The secretome hydrolases produced by unique fungal strains are reported; the development of unique yeast strains for raw starch conversion is discussed; and tracking the cellulolytic activity of Clostridium thermocellum is demonstrated. Many of these technologies could have applications in developing sustainable biofuel options for the future.Against this background, the ISAF 2013 meeting reported on the status of conventional and advanced alcohol technologies and their applications, but participants also deliberated on the theme of the meeting, ‘During the ISAF 2013 meeting, Carlos Henrique de Brito Cruz, Scientific Director of the São Paulo Research Foundation (FAPESP), briefly highlighted the history of ethanol production in Brazil since the start of the Proálcool national alcohol program in 1975 to present where Brazil is the second largest ethanol producer in the world with gasoline being the alternative and subsidized fuel. Today, 95% of cars sold in Brazil have flex-fuel engines, and Brazilians can choose on a daily basis if they wish to fill their tanks with gasoline or bioethanol. Only 1.5% of Brazil’s arable land  is used to replace more than 30% of the gasoline without affecting pasture land, protected areas (such as the Amazon), and native vegetation. In many ways, Brazil offers lessons and an example of how to establish a sustainable biofuels industry that does not only ensure economic growth, but also contributes towards the social development of employees and their families participating in the bioeconomy. Applying some of these lessons to developing countries, such as in Sub-Saharan Africa, was one of the key recommendations from the ISAF 2013 meeting.The Chief Executive Officer of the New Partnership for Africa’s Development (NEPAD) Planning and Coordination Agency of the African Union, Ibrahim Assane Mayaki, highlighted the contrast in Africa with its huge hydropower, solar irradiation, and biomass potential, but with on average 70% of the population not having access to clean energy. More than 80% of the rural African population use biomass for firewood, leading to deforestation and desertification with associated health problems and land degradation. Africa is confronted with many challenges, including a lack of institutional capacity to design bankable energy projects, low cross-border energy trade, and underdeveloped regional energy markets. Public monopolies and national projects rather than regional projects enjoy priority. Policies and regulations are inadequate for allowing private sector participation while also serving public interests. Africa needs a different perspective on energy, in particular bioenergy. The issue Africa faces is not whether bioenergy should be adopted, but rather how it can be used in a sustainable and efficient way. Ideally, it should ensure agricultural transformation, creating a bioeconomy through integrating bioenergy into local livelihood systems. However, it should also benefit rural producers located off the electricity grid and, in general, ensure environmental preservation.In order for biofuels to address more strategic challenges, such as sustainable production that supports food security, industrial application of lignocellulosic ethanol technologies have to come to fruition. Jim McMillan from the National Renewable Energy Laboratory (NREL) in Denver, CO, USA, eloquently showed how advanced cellulosic ethanol technologies are coming online with significant reductions in the process costs and examples of scale-up worldwide. David Chiaramonti from the University of Florence, Italy, reported on the first commercial 50 ML cellulosic ethanol plant constructed in Crescentino  for the Chemtex/Mossi and Ghisolfi (M&G) Group and the associated technology breakthroughs. The time is ripe to support these technologies, integrated with first-generation biofuel technologies, to find sustainable solutions that also promote food security.Developing countries, as found in southern Africa, will soon be major users of transportation fuels and have the greatest potential for future biofuel production. It is thus appropriate for developing countries to explore biofuel production, but in a manner that is socially beneficial for local communities and not threatening to food production. To realize a bioenergy transformation in Africa, we need political will to: 1) develop regional policies that support biofuel industry; 2) introduce incentives that benefit the full value chain from feedstock growers to ethanol producers; 3) promote economic/industrial development initiatives, for example demonstration plants; and 4) enjoy support from complementary industries (for example flex-fuel vehicle manufacturing). To improve sustainability, we also need to develop appropriate technologies to: 1) optimize for specific feedstocks (production/ha) and specific products that are required; 2) improve land management (land ownership) and agricultural practices; 3) ensure there is enough land to grow crops for both the table and tank; and 4) establish sustainable farming practices.Apart from technological improvements, we also need better regional cooperation by improving cross-border cooperation to develop technologies for regional feedstocks and build critical mass to achieve economies of scale. Extension through education and training would also be required as farmers need to understand biofuels (in layman’s terms) and skills to participate in technology development. More pertinent to Africa, but with elements that are also true for other developing countries, public-private partnerships need to be developed to ensure that technologies come to fruition, fostering long-term visions rather than short-turn reactions to current challenges and constraints. Many of these aspects will be further discussed in a commentary paper on the potential role of bioenergy in Africa’s transformation to a more sustainable continent.Biotechnology for Biofuels and Helen Whitaker, Philippa Stevens, and Emma Laycock at BioMed Central for their help in the editorial process. Both James and I would like to thank the many colleagues that offered their time to assist in the peer review process, improving the quality of the manuscripts. Last but not least, thank you to the authors that contributed articles to this special ISAF 2013 issue of Biotechnology for Biofuels.I would like to thank James du Preez for assisting with the peer review process for EFB: Empty fruit bunch; FAPESP: São Paulo Research Foundation; IPCC: Intergovernmental panel on climate change; ISAF: International Symposium on Alcohol Fuels; NEPAD: New partnership for Africa’s development; NREL: National Renewable Energy Laboratory.


Objective: The nutrition of children in kindergartens has a great significance for proper growth and development of children. In order to save time and money, the control of macronutrients content is performed by calculations using food composition tables instead of performing a chemical analysis.Methods: We examined the macronutrients content of 240 whole day meals using food composition tables and performed chemical analysis of meals to determine adequacy and validity of food composition tables in calculation of macronutrient contents in kindergarten meals.Findings: We established no correlation (P>0.05) between the value of proteins, fats and carbohydrates. Significant difference was established between the average content of proteins , and carbohydrates , but not with the content of fats in the meals  .Conclusion: Until we establish new food composition tables, chemical analysis remains the only valid method for assessment of macronutrients content and energy value of a meal in kindergarten. For this reason the kindergarten diet has an important role in the daily intake of energy and nutrients. Proteins from diet are important for growth and development during childhood, and dietary requirements (g/kg of body weight) are significantly increased in this period. Dietary fat and carbohydrates are energy sources, but dietary fats are also source of fat soluble vitamins and some fatty acids important for children[4].  As a consequence of the modern style of life, characterized by long working day of parents, most of children in developing countries spend 8-12 hours during the day in kindergartens[5]. In order to save time and money, chemical analysis of meal (often cooked or prepared food) is increasingly rare and calculations by using food composition tables are applied. In few of the studies, nutrient content in kindergarten meals was calculated by food composition tables - studies from Brazil[6], China[7], Finland[8] or by chemical analysis in Croatia[9] or by both methods as in Poland[10] and in our study. There are different methods for estimation of the composition of food: data from printed food composition tables, electronic databases, food industry data and data from scientific literature The purpose of this article is to compare results of protein, carbohydrate and fat content in daily kindergartens meals obtained from food composition table and by chemical analysis, and to suggest how to ensure the correct calculation of macronutrients contents in kindergarten meals.There are three meals in Niš kindergarten , planned by a nutritionist, a physician and a nurse. Use of food composition tables. It was necessary to calculate the amount of consumed food, and then multiply the food intake by the mean nutrient content obtained from the food composition database. Daily amount of food used for preparation of 240 meals is calculated based on the warehouse supply list. Nutrient contents of meals were calculated by Serbian food composition tables[11]. Chemical analysis: After the collection, the samples of meals in duplicate were transported to the laboratory at 4°C within one hour. They were analyzed for moisture, protein, fat and ash[12] in the laboratory of the Institute for Public Health, Niš (Serbia).  Descriptive statistics  of macronutrient contents (g) was calculated using Microsoft Excel software. Student's t-test and linear correlation was applied to compare the values between two methods.Results for contents of macronutrients in kindergartens meals were similar for fats, but not proteins and carbohydrates when calculated by chemical analysis and food composition tables . SignifiData on macronutrients content of meals in the collective nutrition, obtained from food composition tables are mostly informative. [13-15]. There are several explanations for these results.  Depending on the type of food, nutrient and table or software selected for comparison, there were significant statistical differences between results of laboratory analyses and results calculated though tables and software data[16]. Using food composition databases from different countries may increase errors in calculation of macronutrient intake, and there is tendency to standardize food composition databases all over the world[17]. Firstly, there were differences in macronutrient estimations depending upon the choice of the food composition tables. Some food composition tables are not adequately documented . Results from 18 laboratories in Europe showed statistically different values for macronutrients in the well-homogenized samples of foods[18]. Secondly, there is a variation in food composition depending on environmental, genetic and processing influences such as feed, soil, climate, genetic resources , storage conditions, processing, fortification and market share[19].  Thirdly, the majority of nutrient databases provide information mainly on the composition of raw foods. Cooking methods, times, temperatures and food preparation habits vary widely by countries, and that can influence the macronutrient content Fourthly, we don’t have data about food plate waste in kindergartens.[20]. Many food composition tables, including tables used in our study did not consider yield and retention factors. Camilli et al. found that when yield factor and retention factors were applied, the results of the computed nutrients according to food composition tables showed a satisfactory degree for protein and lipid contents[21]. Contrary to the results of previous studies, Bedogni et al concluded that food composition tables may be used to assess energy, carbohydrate, lipid and protein intake in the military settingsIt is evident that food composition tables must include the nutrient composition of cooked and prepared foods, as well as yield factor and retention factor.  Taking into account the time that preschool children spend in kindergartens and the importance of proper nutrition for child development in that life period, the chemical analysis of foods (dishes) must be applied for situations such as preschool institutional nutrition.


Kawasaki Disease (KD) and Henoch Schönlein Purpura (HSP) are paediatric vasculitides that can lead to significant morbidity. Evidence-based guidelines are sparse and management is mostly based on physician experience. Consequently, treatment regimens differ throughout Europe. In 2012, a European initiative called SHARE (Single Hub and Access point for paediatric Rheumatology in Europe) was launched to optimize and disseminate guidelines for diagnosis and management for children and young adults with paediatric rheumatic diseases (PRD) such as KD and HSP within Europe.To provide evidence-based recommendations for diagnosis and treatment of paediatric vasculitides, specifically KD and HSP.Evidence based recommendations were developed using evidence drawn from systematic reviews of the literature. An expert committee was formed consisting of paediatric rheumatologists from across Europe with expertise in vasculitis. Preliminary statements regarding recommendations on diagnosis and treatment of KD and HSP were developed. These recommendations were evaluated by the expert committee using an online survey. Those with less than 80% agreement in the online survey were reformulated. Subsequently, all recommendations were discussed at a consensus meeting in Genoa  in March 2014 using the nominal group technique [Evidence supporting recommendations for diagnosis and treatment was extracted from the literature. Subsequently, 53 statements on diagnosis and treatment were formulated based on this evidence and expert opinion and were evaluated in an online survey. After discussion of the statements at the consensus meeting, 29 recommendations for KD and 15 recommendations for HSP were accepted with more than 80% agreement during the meeting. Topics covered were criteria for diagnosis, referral of patients, clinical symptoms, useful laboratory investigations, imaging techniques and treatment.The SHARE initiative provides recommendations for diagnosis and treatment of paediatric vasculitides and thereby facilitates improvement and uniformity of care for patients throughout Europe. Currently, similar processes are ongoing to add additional recommendations on diagnosis and treatment where consensus to date has not been reached, as well as recommendations regarding the holistic care of patients. As a final result, SHARE will provide standards of minimal care for different PRDs, including KD and HSP, as well as more rare vasculitides .None declared.