Handgrip strength, a measure of muscular fitness, is associated with cardiovascular (CV) events and CV mortality but its association with cardiac structure and function is unknown. The goal of this study was to determine if handgrip strength is associated with changes in cardiac structure and function in UK adults.Left ventricular (LV) ejection fraction (EF), end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), mass (M), and mass-to-volume ratio (MVR) were measured in a sample of 4,654 participants of the UK Biobank Study 6.3 ± 1 years after baseline using cardiovascular magnetic resonance (CMR). Handgrip strength was measured at baseline and at the imaging follow-up examination. We determined the association between handgrip strength at baseline as well as its change over time and each of the cardiac outcome parameters. After adjustment, higher level of handgrip strength at baseline was associated with higher LVEDV , higher LVSV , lower LVM , and lower LVMVR . The association between handgrip strength and LVEDV and LVSV was strongest among younger individuals, while the association with LVM and LVMVR was strongest among older individuals.Better handgrip strength was associated with cardiac structure and function in a pattern indicative of less cardiac hypertrophy and remodeling. These characteristics are known to be associated with a lower risk of cardiovascular events. Cardiovascular disease (CVD) accounts for 17.3 million deaths per year worldwide and is expected to account for 23.6 million by 2030 [The association between handgrip strength and CVD has been demonstrated in various settings. Sasaki et al  showed tRecently, several pathways have been proposed through which sarcopenia, a cause of low handgrip strength, could contribute to heart failure with preserved ejection fraction . Among tThe goal of this study is to investigate the association between muscular fitness as repeatedly assessed by handgrip strength and cardiac structure and function as measured by CMR in a large sample of UK adults.http://www.ukbiobank.ac.uk) is a prospective cohort study of more than 500,000 men and women aged 40–69 at the time of recruitment between 2006 and 2010 in 22 centers across the UK. The baseline assessment of study participants included an extensive questionnaire, a physical assessment including height, weight, body fat, blood pressure, pulse rate, and handgrip strength, and collection of biological samples. Follow-up of participants was conducted via linkage to health record systems and re-contact with the participants. The study complies with the Declaration of Helsinki. All participants provided written consent and UK Biobank’s scientific protocol and operational procedures were reviewed and approved by the North West Research Ethics Committee in the UK.The UK Biobank  Handgrip strength at baseline and (ii) change in handgrip strength between baseline and the imaging visit. Even though handgrip strength was measured in both hands, we limited the analysis to the highest measurement at each visit because of very high correlations between handgrip strength measurements.The outcomes of interest were derived from the manually verified CMR results  and inclIn all statistical models, we adjusted for: (i) baseline demographics, (ii) cardiac risk factors, (iii) drivers of muscle mass, and (iv) physical activity level, measured in metabolic equivalent of task (MET) minutes , mean ceWe used separate multivariable linear regression models to investigate the relationship between baseline handgrip strength and change in handgrip strength and each of the cardiac outcome parameters and expressed the results per standard deviation (SD) increase in handgrip strength / change in handgrip strength (mean centered). To evaluate whether the observed associations differed by age, sex and physical activity level (MET minutes), we included product terms between handgrip strength and each of these potential modifiers.Although missingness was generally low, we used multiple imputation by chained equations (MICE) to generate 10 complete datasets   an analysis with the restricted-cubic-spline-transformed exposures, investigating the relationship between handgrip strength and the cardiac outcome parameters We used restricted cubic spline transformations with five knots and knot locations as recommended by Harrell  if a nonBy April 2017, cardiac parameters had been measured in 5,065 individuals. Of those, the left ventricular function was analyzed in 4,874 participants. After exclusion of 220 individuals with prior cardiovascular disorders, 4,654 individuals  were included in our study . Mean baThere was evidence that the association between baseline handgrip strength and LVEDV, LVSV, LVM, and LVMVR varied by age, but not between men and women or across levels of physical activity. The association with LVEDV and LVSV was strongest among younger individuals, while the association with LVM and LVMVR was strongest among older individuals. Among 40 year olds, higher levels of handgrip strength at baseline were associated with higher LVEDV  and LVSV . These associations decreased with age. There was no clear association between baseline handgrip strength and LVM or LVMVR among 40 year olds. However, these associations increased with age. Among 69 year olds, higher levels of handgrip strength at baseline were associated with lower LVM  and LVMVR  .There was no consistent evidence that the observed associations between handgrip strength and the CMR-based measures of cardiac structure and function were non-linear . NeitherThe association between handgrip strength, a measure of muscular fitness, and measures of cardiac structure and function was not previously known. This is the first study to show that higher levels of handgrip strength are associated with higher LVEDV and LVSV, and lower LVM and LVMVR. The association with LVEDV and LVSV decreased with age while the association with LVM and LVMVR increased with age. These findings advance our understanding of the pathophysiologic processes that may mediate the association between handgrip strength and cardiovascular incidence and mortality.Two large Swedish studies , 7 showeLower handgrip strength among younger individuals was associated with a pattern resembling concentric remodeling, a process characterized by a lower LVEDV, no difference in LVM, and higher LVMVR . Among oOur results were not materially altered in models that did not adjust for other cardiac risk factors such as hypertension and diabetes mellitus suggesting that these risk factors do not strongly mediate the association between muscular fitness as assessed by handgrip strength and the CMR-based measures of structure and function. This is in line with the PURE study  that shoThe absence of an association between change in handgrip strength and any cardiac outcome parameter was unexpected. However, several features of the study design preclude a strong interpretation of those results: CMR was performed only once at the end of the study, but not at baseline. The associations found for baseline handgrip strength therefore likely represent the relationship between handgrip strength and the CMR-based measures over a time period that far exceeds the study period.Our study has several notable strengths including a large population-based study sample; standardized data collection protocols as part of the UK Biobank prospective cohort study; CMR-based measures of cardiac structure and function measured with a consistent research protocol; and robust results across a wide range of sensitivity analyses.Like all observational studies, our study also had some limitations. Even though we adjusted for many potential confounders, residual confounding cannot be excluded. Furthermore, CMR was performed only once at the end of the study and therefore reverse causation cannot be excluded. However, it seems unlikely given the consistency of the results with previous studies investigating clinical outcomes. Finally, as a population based study the UK Biobank was planned without administration of contrast agents and therefore gadolinium / relaxometry imaging was not available.In conclusion, better handgrip strength was associated with the CMR-based measures of cardiac structure and function that are indicative of less cardiac hypertrophy and remodeling. Those characteristics are known to be negatively associated with CVD incidence. Handgrip grip strength might, thus, allow early identification of individuals at risk for development of CVD. Focused surveillance and intervention may improve outcomes, but further research is necessary to assess whether fitness training can reduce cardiac remodeling and prevent cardiovascular events.S1 Methods(DOC)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S1 Fig(DOCX)Click here for additional data file.


This paper describes the development of a graphene-based dry flexible electrocardiography (ECG) electrode and a portable wireless ECG measurement system. First, graphene films on polyethylene terephthalate (PET) substrates and graphene paper were used to construct the ECG electrode. Then, a graphene textile was synthesized for the fabrication of a wearable ECG monitoring system. The structure and the electrical properties of the graphene electrodes were evaluated using Raman spectroscopy, scanning electron microscopy (SEM), and alternating current impedance spectroscopy. ECG signals were then collected from healthy subjects using the developed graphene electrode and portable measurement system. The results show that the graphene electrode was able to acquire the typical characteristics and features of human ECG signals with a high signal-to-noise (SNR) ratio in different states of motion. A week-long continuous wearability test showed no degradation in the ECG signal quality over time. The graphene-based flexible electrode demonstrates comfortability, good biocompatibility, and high electrophysiological detection sensitivity. The graphene electrode also combines the potential for use in long-term wearable dynamic cardiac activity monitoring systems with convenience and comfort for use in home health care of elderly and high-risk adults. Cardiovascular disease, which includes both coronary heart disease and stroke, is one of the most prevalent causes of death worldwide. In addition to these fatal cases, at least 20 million people experience nonfatal heart attacks and strokes every year; many of these people subsequently require prolonged and costly medical care ,2. ElectFollowing the development of flexible and stretchable electronics, alternative electrodes that do not require electrolytic gel (referred to as active dry electrodes) have been reported by many groups ,14,15,16In this study, flexible graphene textile was synthesised by the reduction of graphene oxide with the help of vacuum filtration to improve the amount and degree of adsorption, and then the graphene textile was used to construct electrodes for long-term wearable ECG monitoring applications. The structural properties of graphene were first characterized by Raman spectroscopy and scanning electron microscopy (SEM), and then the electrical properties of the designed electrode were evaluated by diverse testing based on alternating current (AC) impedance spectroscopy and connect impedance with skin, according to frequency changes. Subsequently, we measured ECG signals in different states of human body motion and studied the feasibility of long-term monitoring through continuous measurements. The experimental result and statistical comparative study demonstrates the potential usefulness of the proposed graphene electrodes for routine electrophysiological activity monitoring of the heart and other vital organs.Numerous methods can be used to fabricate graphene, including chemical vapor deposition (CVD) , organicRaman spectroscopy and SEM are widely used characterization methods for examination of the microstructures of materials. Raman spectroscopy provides information about the characteristic vibrational states, while SEM gives surface profile information. In this paper, the Raman spectra of graphene electrodes were measured using a Horiba Jobin Yvon confocal LabRAM HR800 spectrometer with an excitation wavelength of 532 nm, and the SEM was performed using a Hitachi TM3030 electron microscope with an accelerating voltage range of 3–15 kV. The electrical properties of the ECG electrodes were characterized via electrochemical impedance spectroscopy (EIS) measurements that were performed using a CS350 electrochemical workstation , which worked with a sweeping frequency range from 50 mHz to 10 Hz and an AC perturbation of 10 mV. Skin–electrode contact impedance measurement has always been of interest due to the desire to prove the reliability of the collected biopotential . Here, tFor performance evaluation of the graphene electrode, ECG signals were measured in different human body motion states in 24-year-old male volunteers. Two electrodes were fixed on the left and right sides of the ribcage of each test subject, and the reference ground was located in their lower right abdomen. To ensure similar test conditions for comparison, these electrodes were positioned in the same locations for every measurement. The resting-state ECG signals were measured first, and then the motion artifacts that result from walking and swinging of the subject’s arms were investigated. To study the effects of moisture on the quality of the ECG signals, measurements were also taken after exercise. Finally, the ECG signals were measured using the graphene textile electrodes over a period of one week to evaluate their long-term monitoring capabilities.The Raman spectra of graphene for various thicknesses are shown in hickness ,29, and In the graphene textile and the graphene paper, the Raman spectra show two main peaks, the G- and D-peaks, which lie at approximately 1580 cmc G band . CompareThe morphological studies of the graphene samples performed using SEM are shown in Bode plots of the graphene electrodes and of commercial Ag/AgCl electrodes within the 0.05 to 10 Hz frequency range are presented in To estimate the ECG detection performances of the different kinds of graphene electrode, typical ECG signals are collected, as shown in When compared with graphene–PET and graphene paper, the graphene textile electrode shows the best flexibility and assembly characteristics, and thus it was selected for further study in terms of its performance in daily ECG monitoring applications. Skin–electrode contact impedance directly influenced the reliability of collected signals, low contact impedance resulting in less noise and a higher quality ECG signal. Here, we measured the skin–electrode contact impedance of graphene textile with different contact force, and compared that to standard Ag/AgCl electrode. Four examples of motion artifacts are shown in Furthermore, we compared the performance of graphene textile electrode with commercial Ag/AgCl electrode at different motion states, the peak-to-peak amplitude (P–P), heart rate, SNRs, and standard deviation (SD) of collected ECG signals are summarized in In order to assess the performance in long-term measurement, the ECG signal was collected over seven days of continuous wear of the graphene textile electrode. The waveforms of ECG signals in days 1, 3, 5, and 7 are displayed in Mobile health care systems have increased in popularity because of their noninvasive features and convenience for use in daily life. In this study, we aimed to develop wearable flexible electrodes for daily ECG monitoring, which would be very helpful in the detection of sudden onset heart disease, especially in elderly patients. Electrodes that are highly sensitive, comfortable, and offer biological compatibility and persistence are essential components for daily ECG monitoring systems. The results presented here have demonstrated that the proposed graphene-based electrode offers sensitivity comparable to that of commercial Ag/AgCl electrodes; this research also indicates opportunities to transfer graphene for use in other biological applications, such as electroencephalography (EEG) and electromyography (EMG) detection.However, one challenge that remains for the use of graphene materials in daily ECG monitoring is their intrinsically high hydrophobicity, which might lead to a weak binding force to the substrate and high impedance between the graphene and electrolyte surfaces. In our early study of graphene electrodes on a soft elastic PDMS substrate, the graphene films were found to fall off easily, and they showed much higher resistance due to broken parts of the graphene structure. In this study, graphene was adsorbed on polyester fibers using a vacuum suction filter; the intrinsic internal resistance of the graphene textile reached several megaohms, indicating that the adsorption amount and the combination degree must be further improved to enhance the detection sensitivity and the frictional resistance. We will apply our efforts to the selection of a more suitable substrate, and will increase the binding force between the graphene films and the substrate by introducing molecules with grafting chains. With regard to toxicity, carbon is commonplace and has a stable structure; previous studies have demonstrated the biological compatibility of carbon group elements, including carbon nanotubes and graphene , and thuIn this paper, we have fabricated graphene-based electrodes and a corresponding wireless ECG collection system. The results demonstrated that ECG signal recording can be carried out using a flexible graphene electrode with high SNR. The graphene electrode provides effective electrical performance, high flexibility, satisfactory biocompatibility and wearability, and offers detection capabilities in various states of motion. The design presented here provides a potential electrode structure for long-term wearable monitoring, and offers convenience and comfort for home health care management of the elderly population, with collection and computer display of the results performed via wireless communication using the developed graphene electrode.


Measles is a highly transmissible infectious disease that causes serious illness and death worldwide. Efforts to eliminate measles through achieving high immunization coverage, well-performing surveillance systems, and rapid and effective outbreak response mechanisms while strategically engaging and strengthening health systems have been termed a diagonal approach. In March 2015, a large nationwide measles epidemic occurred in Mongolia, 1 year after verification of measles elimination in this country. A multidisciplinary team conducted an outbreak investigation that included a broad health system assessment, organized around the Global Health Security Agenda framework of Prevent-Detect-Respond, to provide recommendations for evidence-based interventions to interrupt the epidemic and strengthen the overall health system to prevent future outbreaks of measles and other epidemic-prone infectious threats. This investigation demonstrated the value of evaluating elements of the broader health system in investigating measles outbreaks and the need for using a diagonal approach to achieving sustainable measles elimination. Measles, a highly transmissible infectious disease that causes serious illness and death worldwide, is often referred to as a public health “canary in the coalmine” because it can be used as both a signal of weak health systems and a driver for strategies and policies to strengthen health systems , approved by the World Health Assembly in 2012, set targets for vaccination coverage and a goal to achieve measles and rubella elimination in 5 of the 6 World Health Organization (WHO) regions by 2020 , participates in the GHSA  measles surveillance data for cases with onset during December 1, 2015–June 27, 2016, during which period-specific healthcare exposures were collected for case-patients. We defined healthcare-associated cases as laboratory-confirmed measles virus infection in a patient who was a healthcare worker (HCW) or who was hospitalized (non-HCW) during the 7–21 days (measles incubation period) preceding onset of signs or symptoms and who had an epidemiologic link to a hospitalized case-patient or lacked a known community source.To better describe the epidemiology of healthcare-associated measles and to identify and recommend prevention measures, we reviewed data from case-based surveillance for March 1, 2015–June 26, 2016. Confirmed cases were either laboratory confirmed by positive test result for measles-specific IgM ELISA or PCR or clinically confirmed by meeting criteria of rash plus fever and We assessed IPC practices at 3 hospitals in Ulaanbaatar with a large number of reported outbreak cases in surveillance data: 2 national referral tertiary care hospitals  and 1 district hospital. We also assessed 1 primary care facility. At the 4 selected HCFs, we conducted structured interviews of facility staff and directly observed IPC practices and compliance with MOHS guidance and recommendations from previously published IPC documents  staff to formulate specific recommendations on the basis of evidence from the investigation findings.>9 months of age who were eligible for routine measles vaccination; and 448 (74%) occurred in infants >6 months of age who were therefore eligible for postexposure or outbreak response measles vaccination.Of 33,947 confirmed case-patients with rash onset during March 1, 2015–June 27, 2016, a total of 14,407 (42%) were hospitalized and 2,222 (7%) reported visiting an HCF during the incubation period before rash onset, particularly during the initial phase of each of the 2 waves of intense transmission in 2015 and 2016, when ≈25% of cases had HCF exposure . During Some IPC policies were available, but lack of corresponding infrastructure limited proper infection control to prevent measles virus transmission in hospitals. For example, we found inconsistent implementation of appropriate procedures for isolation or cohorting of confirmed measles cases; in addition, no negative pressure isolation rooms existed in any of the HCFs visited, and only 1 airborne isolation room existed in the country.Policies and SOPs for measles contact tracing and postexposure prophylaxis (PEP) in HCFs existed; however, these recommendations were generally not practiced during the outbreak. The National Standard on Measles Surveillance Guidelines from 2003 recommended routine contact tracing of measles cases and, where appropriate, administration of measles-containing vaccine (MCV) or immunoglobulin as PEP  or SOPs outlining airborne disease outbreak response activities.The NCCD EOP was formally activated in December 2015 to lead the measles outbreak response. The NCCD EOP used a draft IMS proposal, and although the draft covered basic sections required in a public health emergency response (logistics and finance sections), the structure , panel AResponse demands exceeded the capacity of available NCCD EOP staff and resources, especially at the outbreak peak. No staff roster or surge capacity were available to mobilize staff from other national agencies that had applicable skill sets  to address this deficit.As a result of our investigation, we developed several recommendations. These recommendations addressed the gaps in policy, practice, and infrastructure identified as likely contributing causes of the outbreak and sustained virus transmission.Recommendations for long-term systems strengthening included improving physical building infrastructure necessary for proper IPC of measles and other contagious respiratory diseases. In the short term, measles contact tracing and PEP in HCFs should be implemented according to existing national guidelines. MCV and immunoglobulin for PEP should be stockpiled and mechanisms developed for rapid mobilization and delivery once a measles outbreak is confirmed. To limit healthcare-acquired transmission during measles outbreaks, only staff who have 2 documented MCV doses or evidence of immunity through serologic testing should be allowed to interact with patients (A comprehensive surveillance review should be conducted to identify gaps in surveillance performance and improve data flow to decision makers for prompt, effective action. One of our key recommendations was to establish coordination mechanisms to align EWARN and case-based VPD surveillance systems so that cases are adequately and promptly investigated and so that trends in one surveillance system trigger enhanced surveillance mechanisms in the other surveillance system. In addition, we recommended improved linkage between epidemiologic investigation and laboratory testing, appropriate use of a unique identifier variable, and case classification including epidemiologic linkage for case confirmation.We recommended that a national outbreak preparedness and response plan for measles and other airborne infectious diseases be established and agreed upon by all relevant stakeholders. Emergency response SOPs should be finalized as an urgent preparedness activity to map out the organizational structure per WHO recommendations, define the interaction of the EOC and EOPs, delineate procedures for activation and deactivation, define roles and responsibilities of positions in the IMS structure, and outline data flow and communication mechanisms with national and subnational staff and partner agencies , panel BUntil measles is eradicated worldwide, the risk for measles virus importations and subsequent outbreaks will remain in countries such as Mongolia that have achieved measles elimination. Prevention of large measles outbreaks that may occur after virus importations can be achieved by implementing measles elimination strategies, maintaining high 2-dose measles vaccination coverage, and developing robust capacity for rapid response. Measles outbreaks in postelimination settings can provide valuable lessons on how to prevent and overcome hurdles on the road to eradication and can reveal weaknesses in health systems that might undermine control efforts for other infectious diseases.Preventing and controlling measles outbreaks require established policies and procedures that pay special attention to specific settings where measles virus introduction and sustained transmission may occur. For example, HCFs can serve as amplification points for outbreaks of measles and other infectious diseases (Rapid detection and response to measles outbreaks is essential for elimination efforts and can prevent infections and reduce the number of deaths (Achieving successful control of measles outbreaks requires a multifaceted strategy involving surveillance, laboratory capacity, contact tracing, vaccination, and hospital IPC measures; thus, maintaining a capacity for coordination of activities is critical for an effective, cohesive outbreak response (The broad health systems assessment we conducted, following the Prevent-Detect-Respond framework of the GHSA, is an example of one tactical element of a comprehensive diagonal approach to link measles elimination with immunization program and health system strengthening. Other proposed tactical elements included reaching the chronically unreached by using measles risk assessments and campaigns to identify and target underserved populations and geographies; introducing routine use of a second dose of measles vaccine to create new opportunities to receive vaccines and other child health interventions in the second year of life and beyond; and advocating for measles elimination to support institutions, policies, and practices needed to sustain high-quality immunization programs (When measles outbreaks occur because of gaps in the confluence of multiple sectors of health systems that include immunization, IPC, surveillance, and emergency response, the GHSA framework provides useful tools to leverage outbreak investigations to strengthen the overall health system and prevent future outbreaks of measles and other infectious disease threats. In this way, GHSA investments to Prevent-Detect-Respond reduce rates of illness and death. Even relatively small measles outbreaks can have substantial cost implications (


Evaluating health systems and policy (HSP) change and implementation is critical in understanding reproductive, maternal, newborn and child health (RMNCH) progress within and across countries. Whilst data for health outcomes, coverage and equity have advanced in the last decade, comparable analyses of HSP changes are lacking. We present a set of novel tools developed by Countdown to 2015 (Countdown) to systematically analyse and describe HSP change for RMNCH indicators, enabling multi-country comparisons.Policy and Programme Timeline Tool (depicting change according to level of policy); (ii) Health Policy Tracer Indicators Dashboard (showing 11 selected RMNCH policies over time); (iii) Health Systems Tracer Indicators Dashboard (showing four selected systems indicators over time); and (iv) Programme implementation assessment. To illustrate these tools, we present results from Tanzania and Peru, two of eight Countdown case studies.International experts worked with eight country teams to develop HSP tools via mixed methods. These tools assess RMNCH change over time (e.g. 1990–2015) and include: (i) The Policy and Programme Timeline tool shows that Tanzania’s RMNCH environment is complex, with increased funding and programmes for child survival, particularly primary-care implementation. Maternal health was prioritised since mid-1990s, yet with variable programme implementation, mainly targeting facilities. Newborn health only received attention since 2005, yet is rapidly scaling-up interventions at facility- and community-levels. Reproductive health lost momentum, with re-investment since 2010. Contrastingly, Peru moved from standalone to integrated RMNCH programme implementation, combined with multi-sectoral, anti-poverty strategies.The HSP Tracer Indicators Dashboards show that Peru has adopted nine of 11 policy tracer indicators and Tanzania has adopted seven. Peru costed national RMNCH plans pre-2000, whereas Tanzania developed a national RMNCH plan in 2006 but only costed the reproductive health component. Both countries included all lifesaving RMNCH commodities on their essential medicines lists. Peru has twice the health worker density of Tanzania , although both are below the 22.8 WHO minimum threshold.These are the first HSP tools using mixed methods to systematically analyse and describe RMNCH changes within and across countries, important in informing accelerated progress for ending preventable maternal, newborn and child mortality in the post-2015 era.The online version of this article (doi:10.1186/s12889-016-3402-5) contains supplementary material, which is available to authorised users. The Millennium Development Goals (MDGs) ended in 2015, when the 189 signatory countries assessed progress made in the past 15 years. At the heart of the MDGs are MDG4, which called for a reduction of child mortality by two-thirds, and MDG5, which focused on improvement of maternal health through a reduction of maternal mortality by three-quarters and universal access to reproductive health care [Established in 2005, Countdown to 2015 for Maternal, Newborn and Child Survival (Countdown) uses country-specific data to stimulate and support country progress towards achieving MDG4 and MDG5 in the 75 countries where more than 95 % of all maternal, newborn and child deaths occur. Although maternal and child mortality have dropped nearly 50 % since the 1990s . AccordiThe past decade has seen an encouraging increase in the availability of data and development of methods for evaluating influence coverage levels including patterns of equity, and contextual variables impact on RMNCH. Measuring changes in policy and systems environments, including strength of policy to programme implementation, is also key to understanding which interventions have the greatest impact and to be able to anticipate future health gains –12. ImplPolicy and Programme Timeline Tool to identify what policies and major systems changes were introduced for RMNCH over time or the lack thereof from 1990 to present;Health Policy Tracer Indicators Dashboard to track a set of key tracer RMNCH policy indicators as tracked on Countdown country profiles;Health Systems Tracer Indicators Dashboard to assess key tracer health systems indicators as per Countdown country profiles; andProgramme implementation assessment using geographical mapping with implementation readiness barometers to assess health system readiness to implement RMNCH interventions.With increasing availability of HSP data, especially at national level, from health management information systems (HMIS) and other routine data collections systems being put into place, there is an opportunity to routinely track RMNCH policy formulation to implementation including health systems strengthening activities within and across countries and to develop methodologies to link HSP to RMNCH outcomes on a regular basis. This paper’s objectives are to describe a standardised set of tools developed by Countdown to systematically analyse national policy formulation for RMNCH and progress to implementation, assessing similarities and differences between countries and programmes across the continuum of care. These tools assess whether HSP change is happening, supporting analyses which can then be used to ask whether and why or why not it is occurring. Results from two Countdown country case studies, Tanzania and Peru, are described to illustrate outputs from the HSP tools, as these two country teams were integral in piloting and refining the tools. The HSP tools include:Agenda setting, the first phase, is the stage where a handful of the hundreds of problems that exist gain the attention of social actors and national decision-makers. Policy formulation, the second phase, refers to deliberation surrounding policy alternatives, and the enactment of authoritative decisions concerning which of these to adopt. Policy implementation, the third phase, involves the execution of policy. Finally, the evaluation phase assesses policy impact. These tools do not assess the cross-cutting dimension of policy change related to the decision-making phase of the heuristic, i.e. governance, power and partnerships, key to assessing the “how” and “why” of policy change.Countdown used the four phases of the ‘stages heuristic’ of the public policy process  to guideCountdown developed HSP tools to standardise the type of data collected (inputs), methods for assessing (process) and presenting these data (outputs) for each of the countries included in the portfolio of the country case studies, to assess and describe HSP factors that have contributed to change, or lack thereof, in RMNCH in a country, and to enable cross-country comparison of policy and systems changes.The Policy and Programme Timeline Tool  are presented in Figs.  are presIn contrast, Fig. The Health Policy Tracer Indicators Dashboard  Maternal, Newborn, Child and Adolescent (MNCAH) Systems and Policy Survey, and specific sources e.g. the WHO abortion database and International Labour Organisation (ILO) maternity protection legislation database.- Family planning for adolescents- Legal status of abortion- Midwives authorised for specific tasks- Maternity protection (Convention 183)- Maternal deaths notification- Postnatal home visits in the first week after birth- Kangaroo Mother Care for low birth weight newborns- Antenatal corticosteroids as part of management of preterm labour- International code of marketing of breastmilk substitutes- Community treatment of pneumonia with antibiotics- Low osmolality oral rehydration salts (ORS) and zinc for management of diarrhoeaThe Health Policy Tracer Indicators Dashboard  surveys by WHO, United Nations Population Fund (UNFPA) and the Averting Maternal Death and Disability Programme (AMDD), and WHO Global Health Observatory for health workforce.- National strategy/plans of action to improve RMNCH- Integration of selected lifesaving commodities in essential medicines and supplies list- Density of health professionals- National availability of EmOC servicesThe Health Systems Tracer Indicators Dashboard  commodities: availability of tracer drugs at health facilities; (iii) financing: per capita recurrent expenditure; and (iv) infrastructure: number of health facilities per 10,000 population.Implementation readiness barometers can be constructed at the district, regional or zonal level of a country depending on availability of subnational data. As an example, we used Arc GIS 10.3 software to construct district-level maps in Tanzania with implementation readiness barometers to show variations in reproductive and child health outcome using DTP3 coverage and demand satisfied by modern methods of contraception as proxy indicators. The barometer was constructed using data from Tanzania’s Health Management Information System (HMIS) from Quarter 4 of 2014 , 26, theData for the barometer were categorised based on data for each health systems indicator achieving a proportion of its respective benchmark, which were categorised as follows: (i) green: ≥ 75 %; (ii) yellow: 50 - <75 %; (iii) orange: 25 - <50 %; (iv) red: <25 %. For health workforce, the WHO minimum density threshold of 22.8 skilled health workers per 10,000 population was used as a benchmark (i.e. 100 %) in the construction of the barometer  was usedThe barometers show mixed implementation readiness by region in Tanzania Fig. . None ofThis paper addresses the “black box” of HSP assessment by presenting a comprehensive set of standardised tools to use mixed methods to systematically analyse and describe progress of policy formulation to implementation to discuss how and why RMNCH changes took place within and across countries. Although these tools do not address the cross-cutting governance, power and partnerships dimension component of policy change; they focus on assessing if there are signs that RMNCH issues are being prioritised for consideration in policy agendas, being considered in policy formulation, and being moved towards implementation – to prompt discussion with a view to making further progress. This evidence is important in informing accelerated progress for ending preventable maternal, newborn and child mortality in the post-2015 era. The study represents a step forward in relation to previous efforts to document the role of health policy and systems on the evolution of RMNCH at country and sub-national levels, which used qualitative and quantitative approaches , 35, butThe Policy and Programme Timeline tool uses a chronological timeline to document and analyse what policies, programmes, and implementation strategies, and pivotal moments have changed for RMNCH in a country. This tool builds on the Policy and Programme Timeline tool developed by Saving Newborn Lives to capture changes in key policy, programme and research achievements influencing newborn survival at national level . The polThe Health Policy and Systems Tracer Indicators Dashboards are a standardised assessment of 11 RMNCH policy tracer indicators and four health systems tracer indicators reported on the Countdown country profiles and defined by the Countdown HSP Technical Working Group , 37. TheThe implementation readiness barometer is a novel way of visualising subnational variations in RMNCH outcomes with health service readiness and availability using the WHO health system building blocks. A recent review shows that geographical mapping is increasingly being used to visualise national and subnational data for women and children’s health , for exaThe Lancet Every Newborn Series [In addition to geographical mapping, bottleneck analysis using qualitative methods is another method that has been used to measure implementation strength. Dickson et al. built on analyses and evidence published previously in n Series , to adapn Series . This toImplementation strength has also been measured previously using quantitative methods such as scores or rating systems based on mixed method data collection using interviews or focus groups. Bergh et al. developed and tested a monitoring model with quantitative indicators or progress markers to measure the progress of individual hospitals in the implementation of Kangaroo Mother Care in South Africa , and havBenchmarks of health system readiness to implement integrated community case management of childhood illness (iCCM) have also been widely used . These bAdditional approaches to HSP analysis include Systems Thinking and Realist Review, which rely heavily on qualitative information , 48, takThese are the first HSP tools developed for application across a range of lower and middle-income countries in Africa, Asia and Latin America, and can be used in other settings to analyse and describe HSP dynamics and changes in a country as related to implementation of RMNCH interventions, enabling cross-country comparisons. However, limited data availability both at national and subnational level remain a barrier to analysing HSP changes and implementation. These tools make progress in linking changes in impact indicators to changes in policies and programmes; however, there is a need to build on these tools to further develop mixed methods to identify key HSP factors and also attributable fractions of mortality decline for individual RMNCH policies and related programmes.These HSP tools can also be used to prompt national policy dialogue. For example, the HSP tools were used as part of the Countdown Tanzania case study analysis, with results used to inform accelerated focused action towards the end of the MDGs and contributing to ending preventable maternal, newborn, and child deaths by the end of the Sustainable Development Goals in 2030 . A policThe policy heuristic is the theoretical framework used to underpin these HSP tools. However, they are limited in assessing the implementation stage of the heuristic, signalling the need for the development of standardised metrics for strength of programme implementation. Additionally, these HSP tools do not capture information on power, partnerships, leadership and champions and the important role they play in influencing all stages of the policy heuristic, i.e. agenda setting, policy formulation, implementation and evaluation, to understand why and how policy change took place –54.when, but not why changes in policies and programmes took place within and across countries, which raises the question of whether a linear approach to understanding policy adoption is appropriate, or if it should be combined with a political economy approach that recommends that policy adoption and decision making involves more than just evaluation of scientific evidence. Nevertheless, Walt et al. defend the heuristic as it offers a useful and simple way of thinking about the entire public policy process, and helps researchers situate their research within a wider framework [Furthermore, the policy heuristic framework has been critiqued by Sabatier et al. for presuming a linearity to the public policy process that does not exist in reality, for postulating neat demarcations between stages that are blurred in practice, and for offering no propositions on causality . For exaramework .When developing tools and metrics for HSP analysis, we also need to consider context-specific issues when setting-up reference standards, e.g. when considering facility-based versus community-based RMNCH interventions. For example, the latter may be privileged by some countries while the former may be considered a priority in health systems like in Peru.There is a need for the development and validation of globally-agreed standards for WHO health systems building blocks to inform evidence-based benchmarking. We constructed benchmarks for health financing and commodities indicators due to lack of international standards. Varying benchmarks exist for health workforce and facilities, with little agreement on global standards, e.g. WHO’s minimum density threshold is 23 skilled health professionals per 10,000 population(34), whereas the International Labour Organisation recommendations vary from 35  to 41 heNone of the approaches used to date to assess RMNCH intervention implementation have been assessed comparatively or synthesised to perform an in-depth assessment of policy formulation to programme implementation pathways. However, with national and subnational-level data becoming increasingly available via establishment of routine data collections systems, there is a need to develop analysis methods to address this “black box” of HSP science. At the subnational level, data analysis methods need to be developed and applied to identify “stronger” and “weaker” performing districts on RMNCH outcomes and health systems indicators, and to evaluate subnational variation in implementation of the RMNCH interventions, with a focus on service availability and readiness. These novel subnational data analysis methods should link implementation strength to health outcomes, and be complemented with analyses of governance, power and partnerships to fully understand how and why policy change took place; thus allowing for assessment of national policy formulation to implementation within and across countries.The Countdown HSP tools are the first mixed method assessment to analyse when changes in policies and programmes took place within and across countries. Further work is needed in developing standardised approaches to measure the implementation strength of programmes, which is critical to attribute health outcomes to interventions, and to anticipate outcomes of future interventions. This evidence base is key to understanding how countries are able to make progress in ending preventable maternal, newborn and child deaths, and can provide important lessons to guide countries in their efforts to reach the Sustainable Development Goals Table .Table 2KAMDD, Averting death and disability programme; EmOC, emergency obstetric care; HMIS, health management information system; HSP, health systems and policy; ILO, International Labour Organisation; MBB, marginal budgeting for bottlenecks; ORS, oral rehydration salts; RMNCH, reproductive, maternal, newborn and child health; SARA, service availability and readiness assessment; SPA, service provision assessment; UNCoLSC, United Nations commission for life saving commodities for women and children; UNFPA, United Nations population fund; UNICEF, United Nations children’s fund; WHO, World Health Organisation


Healthy People 2020 objectives  and basal and squamous cell skin cancers. Data on new cases of invasive cancer diagnosed during 2011 were obtained from population-based cancer registries affiliated with the NPCR and/or SEER programs in each state, the District of Columbia (DC), and Puerto Rico . For comPopulation denominators for incidence rates are race-, ethnicity-, and sex-specific county population estimates from the 2010 U.S. Census, as modified by SEER and aggregated to the state and national level.For the first time, a subset of the USCS dataset includes the 5-year relative survival rate, defined as the proportion of persons surviving ≥5 years after cancer diagnosis compared with the proportion of survivors expected in a set of comparable cancer-free persons. These estimates are based on data from NPCR-funded states that met USCS publication criteria and conducted active case follow-up or linkage with CDC’s National Center for Health Statistics National Death Index . For thiIn 2011, a total of 1,532,066 invasive cancers were diagnosed and reported to central cancer registries in the United States (excluding Nevada), including 786,102 among males and 745,964 among females . The ageBy cancer site, rates were highest for cancers of the prostate , female breast , lung and bronchus , and colon and rectum  . These fHealthy People 2020 targets were reached in 37 states for incidence of colorectal cancer and in 28 states for incidence of cervical cancer. Compared with the states and DC, cancer incidence rates in Puerto Rico in 2011 were lower for all-sites cancer , lung cancer , and breast cancer , but higher for prostate cancer , colorectal cancer , and cervical cancer .By state in 2011, all-sites cancer incidence rates ranged from 374 to 509 per 100,000 persons . State sAmong persons with cancer diagnosed during 2003–2010, the 5-year relative survival rate was 65% . This peHealthy People 2020 targets were achieved in 37 states for reduced colorectal cancer incidence and 28 states for reduced cervical cancer incidence. For the first time, cancer incidence rates in Puerto Rico are included with the state-specific cancer incidence rates. Cancer incidence rates in Puerto Rico reflect screening practices and risk factors that might differ from those in the U.S. states.This report provides estimates of cancer incidence for 2011 in the United States and shows that Also for the first time, data on survival are included. In the United States, about two of three persons diagnosed with cancer survive ≥5 years after diagnosis. This depends on the type of cancer and age at diagnosis, and was lower among black persons compared with white persons. Differences in survival after cancer diagnosis might be attributable to differences in type of cancer, stage at diagnosis, timeliness of follow-up after diagnosis, appropriate treatment after diagnosis, or having a chronic condition . CDC str**Cancer incidence and survival data can guide the planning and evaluation of cancer prevention and control programs. In Vermont, for example, cancer registry data were used to identify two counties with high melanoma incidence rates in which to pilot a new program for skin cancer prevention . These d††The findings in this report are subject to at least three limitations. First, analyses based on race and ethnicity might be biased if race and ethnicity were systematically misclassified; ongoing efforts are made to ensure that this information is as accurate as possible.Healthy People 2020.National cancer surveillance data are essential for public health officials to monitor cancer incidence, mortality, and survival in the United States; identify populations that might benefit most from targeted cancer prevention and control efforts; help guide the planning of health care allocation and support services; and track progress toward the national cancer objectives set forth in What is already known on this topic?Cancer is a leading cause of illness in the United States. Because of earlier detection of cancers with effective treatments, improved cancer treatments, and better general medical care, the percentage of persons living after a cancer diagnosis has increased over the past decades.What is added by this report?Healthy People 2020 targets were reached in 37 states for reduced incidence of colorectal cancer and in 28 states for reduced incidence of cervical cancer. About two of three persons diagnosed with cancer survived ≥5 years after diagnosis.National cancer surveillance data indicate that 1,532,066 new cases of invasive cancer were diagnosed in the United States (excluding Nevada) in 2011, an annual incidence rate of 508 cases per 100,000 among males and 410 among females. All-sites cancer incidence rates ranged by state from 374 to 509 per 100,000 persons and was 339 per 100,000 persons in Puerto Rico. What are the implications for public health practice?Public health officials can use cancer incidence and survival data to identify population groups with high cancer incidence rates and low cancer survival rates who might benefit most from targeted cancer prevention and control efforts. Using these data to effectively develop comprehensive cancer control programs, including supporting the needs of cancer survivors, can help reduce cancer incidence and improve survival.


The use of Facebook groups by health care researchers and professionals for chronic disease management, namely type 2 diabetes mellitus and coronary heart disease, is in its early stages and challenges are emerging. While Facebook groups offer great potential to deliver health support, research of Facebook groups for chronic disease management remains in its infancy, with robust evidence not yet available. Designing Facebook groups that are acceptable to users, health care researchers as well as health care professionals is a challenge, and there is a poor fit with traditional research and evaluation methods. Key recommendations for future research of Facebook groups for chronic disease management include: (1) iterative content development with input from the target patient population; (2) further understanding of the potential role of group “champions”; (3) ensuring the social media policies of health care institutions allow for real time online communication; and (4) utilizing comprehensive evaluation strategies, including the use of process evaluations. Patient education is a core component of chronic disease self-management, and is particularly important for type 2 diabetes mellitus (T2DM)  and coroOnline, real-time social media platforms, such as Facebook, may offer solutions to existing problems with accessing traditional group-based programs for chronic disease management. In mid-2017, Facebook’s community reached two billion people . The conSocial media interactions enable individuals to read and post material at any time, and from any location, as a part of their usual routine, substantially eliminating obstacles to participation compared to in-person interactions. While expert health care staff are still required, costs may be reduced through more convenient and effective scheduling. However, the potential for Facebook groups to provide novel methods for delivering group-based health care, and enabling support from health care professionals and peers, is yet to be fully harnessed .At this present stage, systematic reviews and meta-analyses are not warranted as previous research has only investigated existing publicly available Facebook groups for general chronic disease management , and speThere is emerging evidence that chronic disease self-management programs delivered by alternative means, such as telehealth and electronic health  delivery, have comparable outcomes to in-person programs ,19. HoweFacebook groups may offer a mutual platform of support for the management of chronic diseases. Facebook defines their group feature as “a space to communicate about shared interests with certain people” . The FacFacebook groups can enable health care professionals to give both individuals and groups support, advice, and encouragement to foster self-management and behavior change ,27. FurtDeveloping Facebook groups that are acceptable to and effective for people with chronic disease, as well as health care professionals and researchers, is a challenge requiring engagement of multidisciplinary teams . While tContent for in-person chronic disease management peer support groups cannot be directly converted to group-based interventions on Facebook, due to the difference in communication mechanisms. Pagoto et al  developeFormative research on older adults with chronic diseases is lacking, with only two studies investigating cardiac patients’ frequency of social media use , and expModerators of Facebook groups need to be aware of the use and communication preference of older adults living with chronic diseases, as well as being experienced Facebook users themselves . ConsideModerators may also be required to provide initial education and reminders to inform group members about the privacy settings of the group, as well as their personal account. All posts within a closed or private Facebook group are only visible to moderators and group members. However, issues such as data security and privacy of data management on commercial platforms, like Facebook, requires further attention.Health care institutions’ policies on the use of social media by health care staff need to be flexible to account for the real-time nature of conversations on Facebook . This isAnalysis of publicly available Facebook groups on chronic disease showed that the majority of groups identified were focused on awareness creation ,15. HoweThe additional challenge of evaluating Facebook groups is that many types of data, including both quantitative and qualitative, must be collected to assess engagement and effectiveness. If the Facebook group is a component of a multicomponent program, process evaluations can potentially provide insight into the causal mechanisms of such interventions and enable fine-grained understanding of the individual components ,58. ProcNo robust evidence presently exists to showcase the advantages and/or disadvantages of using chronic disease peer support groups on Facebook. This is partly because only publicly accessible, peer-led groups have been evaluated or groups have only been evaluated as part of larger multicomponent mHealth programs. While Facebook groups can reduce the participant burden of engaging in in-person group support programs, further research is required to understand their potential future role in chronic disease management.


The mammalian external ear houses extrinsic and intrinsic auricular muscles. There are three extrinsic auricular muscles—the posterior, superior, and anterior auricular muscles—and six intrinsic muscles—the helicis major and minor, tragicus, anti-tragicus, transverse and oblique muscles. These muscles have been considered vestigial in humans. However, numerous therapeutic and diagnostic wearable devices are designed to monitor and alleviate the symptoms of neurological disorders, brainstem injuries, emotional states, and auditory functions, by making use of the neural networks of the auricular muscles and their locations, which are easily accessible for ergonomic wearable biomedical devices. They can also serve as a bio-controller of human neuroprosthetics. The functionality of these auricular muscles remains elusive and requires further experimentation for a more in-depth understanding of their anatomy. The aims of this review are (1) to provide a detailed account of the neural networks of the extrinsic and intrinsic auricular muscles, (2) to describe diagnostic and therapeutic functions of these muscles as demonstrated in the current literature, and (3) to outline existing and potential neuroprosthetic applications making use of the auricular muscles and their neural networks. The auricle of humans and other mammals contains three extrinsic and six intrinsic muscles , 2. The The aims of this review are (1) to provide a detailed account of the neural networks controlling the extrinsic and intrinsic auricular muscles, (2) to summarize the diagnostic and therapeutic functions of these muscles as described in the current literature, and (3) to outline existing and potential future neuroprosthetic applications based on the auricular muscles and their neural networks.In humans, three extrinsic auricular muscles—the SAM, AAM, and PAM—arise from the temporal aspect of the cranium and insert into the auricular cartilage Figure A. They hThe intrinsic auricular muscles have origins and insertions within the cartilaginous auricle . They plThe auricular muscles have direct or indirect neural connections with a network that comprises brainstem structures and multiple cortical zones. At the brainstem level, the motor nucleus of the facial nerve contains motor neurons that directly control all the auricular muscles. In 1948, Szentágothai demonstrated that when the entire facial nucleus was lesioned, all three extrinsic auricular muscles showed 100% degeneration . In 1978Auditory stimuli such as clicks or tone-bursts can induce an electrical potential in the PAM in awake humans, which is referred to as the postauricular reflex (PAMR) –40. The via the pedunculopontine nucleus (PPN). The reticular nucleus also receives the second pathway from the cochlear nucleus via the lateral lemniscus  and lateral lemniscus Figure B. The pas Figure B. In thes Figure B  and abducens motor nuclei in the midbrain and pons, respectively . The PAMR can be potentiated by pleasant pictures and inhibited by aversive pictures, particularly pictures that have high emotional intensity . Generalvia the SC and thalamus , but may also apply to vertical gaze. In 1978, Schmidt and Thoden reported that the TAM was coactivated (43%) with vertical eye movements; however, it is worth noting that this response was not confirmed by others , 23. VerMonitoring the TAM also has potential value for assessing stroke-related motor dysfunctions. Although it is innervated by the facial nerve, activation of the glossopharyngeal and vagal nerves during coughing, swallowing, and inspiration also results in activation of the TAM  Figure A. The TARecently, Cakmak et al.  stimulatThe upper part of the facial muscles shows bilateral hemispheric control by the facial nerve . It has A recent fMRI study demonstrated that stimulation of the anti-tragicus muscle zone can activate the nucleus cuneatus, which receives proprioceptive input from the neck muscles . The nucThe extrinsic and intrinsic auricular muscles have extensive and intact neural connections within the brainstem, deep brain structures, and the cortex, including motor and limbic neural structures. Although the neural networks of the auricular muscles are not fully understood, this review provides an insight of their connections with neural networks to underline their existing and potential future use for the diagnostic and therapeutic devices.Developed the concepts: YC; performed literature review: ML; performed advanced literature review: YC and MZ; data collection: YC and ML; analyzing the literature: YC, MZ and ML; neuronal network diagrams: YC; wrote the draft: ML; edit the draft: YC; wrote the main paper: YC, ML, and MZ.YC has one granted and three pending patents for wearable neuroprosthetics based on auricular muscles. The other authors declare no conflicts of interest. The reviewer ES and handling editor declared their shared affiliation.


International Journal of Environmental Research and Public Health (IJERPH) incorporates 19 articles that broaden EJ research by considering emerging topics such as energy, food, drinking water, flooding, sustainability, and gender dynamics, including issues in Canada, the UK, and Eastern Europe. Additionally, the articles contribute to three research themes: (1) documenting connections between unjust environmental exposures and health impacts by examining unsafe infrastructure, substance use, and children’s obesity and academic performance; (2) promoting and achieving EJ by implementing interventions to improve environmental knowledge and health, identifying avenues for sustainable community change, and incorporating EJ metrics in government programs; and (3) clarifying stakeholder perceptions of EJ issues to extend research beyond the documentation of unjust conditions and processes. Collectively, the articles highlight potentially compounding injustices and an array of approaches being employed to achieve EJ.Environmental justice (EJ) research seeks to document and redress the disproportionate environmental burdens and benefits associated with social inequalities. Although its initial focus was on disparities in exposure to anthropogenic pollution, the scope of EJ research has expanded. In the context of intensifying social inequalities and environmental problems, there is a need to further strengthen the EJ research framework and diversify its application. This Special Issue of the  International Journal of Environmental Research and Public Health (IJERPH) incorporates 19 articles that collectively advance EJ scholarship in conceptual, methodological, and empirical terms.Environmental justice (EJ) research seeks to document and redress the disproportionate environmental burdens and benefits associated with social inequalities. Although its initial focus was on anthropogenic pollution, the scope of EJ research has expanded significantly in recent years to encompass other phenomena—for example, access to healthful food and climate change—with disparate negative impacts on particular social groups. Dimensions of social inequality examined have expanded beyond race and socioeconomic status to focus to some degree on ethnicity, immigration status, gender, sexual orientation, age, as well as intersections between dimensions of inequality. In the context of intensifying social inequalities and environmental problems, there is a need to further strengthen the EJ research framework and diversify its application. This Special Issue of the These articles demonstrate how the scope and purpose of EJ research have broadened significantly in recent years and continue to expand in new directions, both topically and geographically. Several articles in this Special Issue break new ground by extending the EJ research framework to consider emerging issues such as energy ,2, food In addition to broadening the scope of EJ scholarship by exploring these new frontiers, our Special Issue contributes to three specific research themes: (a) documenting connections between unjust environmental exposures and health impacts; (b) promoting and achieving EJ; and (c) clarifying stakeholder perceptions of EJ issues. These themes and related articles are described below.Documenting connections between unjust environmental exposures and health impacts: As the EJ framework has expanded in new directions, recent research has emphasized the need to examine health outcomes and health disparities associated with exposure to environmental hazards, thus extending EJ to environmental health justice. Several articles in this Special Issue advance environmental health justice scholarship by documenting linkages between unequal environmental exposure and adverse health impacts associated with unsafe infrastructure and homes [nd homes ,14, subsnd homes , and chind homes . Campbelnd homes  provide nd homes  review and homes  focus onPromoting and achieving EJ: While EJ scholars often focus on describing the injustices experienced by socially disadvantaged communities, several articles in this Special Issue direct attention toward efforts to achieve EJ through implementation of interventions to improve environmental knowledge and health [d health ,17, idend health ,9,13, and health . In the d health  was summd health  argue thd health  trace thClarifying stakeholder perceptions of EJ issues: The EJ research framework has focused on objectively documenting conditions and processes that constitute environmental injustices. Based on this materialist foundation, less emphasis in EJ research has been placed on people’s subjectivities. Several articles in this Special Issue advance EJ research by examining and clarifying stakeholder subjectivities regarding EJ issues [J issues ,11,18,19The wide array of environmental health hazards, communities, and countries represented in this Special Issue reflect the expanding scope and purpose of EJ research, which has broadened and transformed significantly in recent years. The articles cover topics ranging from energy, food, water, obesogenic chemicals, landfills, and greenspace. They document connections between unjust environmental exposures and health impacts; provide ideas for how to promote and achieve EJ; and clarify stakeholder perceptions of EJ issues. In doing so, the Special Issue illustrates the existence of multiple and compounding marginalities, but also the wide variety of approaches being employed to achieve EJ, in its many diverse forms.


Primary Care Health organizations, operating under universal coverage and a regulated package of benefits, compete mainly over quality of care. Monitoring, primary care clinical performance, has been repeatedly proven effective in improving the quality of care. In 2004, Maccabi Healthcare Services (MHS), the second largest Israeli HMO, launched its Performance Measurement System (PMS) based on clinical quality indicators. A unique module was built in the PMS to adjust for case mix while tailoring targets to the local units.This article presents the concept and formulas developed to adjust targets to the units’ current performance, and analyze change in clinical indicators over a six year period, between sub-population groups.Six process and intermediate outcome indicators, representing screening for breast and colorectal cancer and care for patients with diabetes and cardiovascular disease, were selected and analyzed for change over time (2003–2009) in overall performance, as well as the difference between the lowest and the highest socio-economic ranks (SERs) and Arab and non-Arab members.MHS demonstrated a significant improvement in the selected indicators over the years. Performance of members from low SERs and Arabs improved to a greater extent, as compared to members from high ranks and non-Arabs, respectively.The performance measurement system, with its module for tailoring of units' targets, served as a managerial vehicle for bridging existing gaps by allocating more resources to lower performing units. This concept was proven effective in improving performance while reducing disparities between diverse population groups. Healthcare organizations operating under universal coverage, regulated prices and package of benefits compete mainly over quality of care and patient satisfaction , 2.Monitoring clinical performance measures by large healthcare organizations has been repeatedly proven effective in improving the quality of care –6. HowevAchieving equity in health care is an important goal of most primary health care systems and reforms. Although primary health care plays an important role in improving health equity , internaThe VA has questioned the adequacy of their monitoring system using a "treat to target" method, which focuses on attainment of specific risk factor thresholds, in achieving control, in a diverse population. This concern has led the VA to develop a system that is based on “tightly linked” clinical action measures, in which the process specified by the measure is strongly tied to the evidence. Specifically, clinical action measures focus not only on the risk factor level but also give credit to the process . In otheResearch usually distinguishes between equality and equity in the provision of care and health outcomes: health equity is defined as the absence of systematic and potentially remediable differences in one or more characteristics of health across populations or population groups which are socially, economically, demographically or geographically defined ; whereasThe Israeli population is highly diverse. Twenty percent are Israeli Arabs who live mainly in rural settlements and mixed cities, and like all Israeli citizens, they are fully insured by the National Health Insurance Law under a universal care system. Eighteen percent of the Israeli population are considered "poor" with a 0.363 Gini Index for inequality in household income for 2013 . TherefoThis article has two objectives: 1) to describe the concept and implementation of a unique module, which adjusts performance targets for current achievements, in order to compensate for different case mixes and population diversion; and 2) to present an analysis of the effect of this concept on care quality and equity.This study was initiated by Maccabi Healthcare Services (MHS), the second largest Israeli health plan (HMO), that provides primary and secondary community-based services to two million beneficiaries. These services are provided to diverse population groups country-wide, through five regions, divided into 150 branches (the basic administrative unit). Services are based on a core staff of 8,000 physicians, including 2,000 primary care physicians, 1,200 nurses and other health professionals. Physicians are normally self-employed who work in MHS' clinics or in their private clinics with seventeen million encounters (in 2013). In-patient care is purchased by the MHS from local medical centers.Nine percent of MHS members are categorized in the lowest quartile of socioeconomic status, while 25.6% are in the upper quartile. Seven percent of MHS members are Israeli Arabs who are entitle for a full healthcare coverage.In 2004 MHS launched a Performance Measurement System (PMS), aiming to improve quality of care by monitoring and internally reporting on clinical performance. Twenty-five process and intermediate outcome indicators represented six clinical domains: early detection of cancer (colon and breast); influenza and pneumococcal vaccination; early detection of risk factors and treatment for cardio-vascular diseases; diabetes care; diagnosis and treatment of depression; and appropriate use of antibiotics.Each indicator definition was based on the National Program for Quality Indicators in Community Healthcare's definitions , which iThe core of the PMS is a unique module, built into the system, which allows setting tailor-made benchmarks for each of MHS' administrative units (regions and branches). The system produces monthly reports, which are distributed in a transparent manner to local managers. The reports reflect each unit's gaps between achieved and desired targets.MHS is a fully computerized healthcare organization: all diagnoses, prescriptions, diagnostic tests and billings are stored in a central data warehouse, from which the PMS retrieves information. A Microsoft Performance Point Server acts as a mediating platform supporting the integration of data, reports and explanatory documents.The main objective of setting tailor-made targets, was to continually support and encourage the successful units but also to help and push, for better achievements, the weaker units.For each clinical indicator, MHS has defined an upper benchmark , which is the level of performance MHS aims to achieve within a 3–5 year period. For every given year, an organizational target is set, based on prior progress towards the upper benchmark and an estimation of resources and capabilities. A unique mechanism helps to adjust a tailor-made unit target, taking into account the unit’s diverse member populations and their socio-economic; personal and social characteristics. Weighted unit's grades (UGs) for all indicators are calculated and contribute to the unit's "overall grade" for the purpose of recognition and modest reward. This was done as follows:Step 1. Formulating an indicator factor (IF): Since each indicator demonstrates a different range of performance, we formulated a factor for each indicator (i), calculated yearly as follows:Step 2. Calculating the unit target, using the following formula for each clinical indicator:† performance) + the unit's last year† performance († December 31).UTi = IFi *UGi = (0.3 *% of achieving the upper benchmark) + (0.7 *% of achieving the tailor-made target). These rates (30% and 70%) were assigned based on the idea to encourage excellence beyond the tailored targets.For example: MHS's upper benchmark (for the next 3–5 years) for mammography screening was 80%; MHS' target for the upcoming year is assigned to 70%; MHS' end of last year performance was 60%.The unit's last year performance in Mammography screening was 50%Performance data at the branch (unit), region and organization levels were distributed monthly to all managers and caregivers. Quarterly and yearly reports analyzed temporal trends and gaps in performance between units serving different sub-populations. These same reports were used to identify the need for process redesign, and to encourage the design of tailor-made local interventions .Rewards were mainly based on organizational acknowledgements to managers who achieved higher scores. Every year, in an organizational managerial conference, these managers were publicly announced. There were no sanctions on those branches who did not meet the desired scores, however, there was a managerial pressure to improve performance.In order to evaluate changes in performance over time, six indicators, for which definitions were not changed over time stable and each patient's data was fully recorded, were selected: 1) mammography; 2) colorectal cancer screening; 3) HbA1C performance; 4) diabetes adequate control; and 5) diabetes poor control , we estimated linear regression models for curve fit for each of the selected indicators.The Curve Estimation procedure generates a time variable in which the period of time between cases is uniform. If Time is selected, the dependent variable should be a time-series measure. Time-series analysis requires a data file structure, in which each case (row) represents a set of observations at different times, and the period of time between cases is uniform .Dependent variable: each indicator’s rate.Independent Variable: Socio-Economic Rank (SER) and ethnicity: Israeli Arabs vs. non-Israeli ArabsSocio-Economic Rank (SER) was defined by the rank  of members' area of residence (based on Israeli Census Bureau data), and then categorized into the lowest (1–5) and highest (16–20) categories [tegories .Ethnicity: Since Israeli HMOs do not have access to personal ethnicity data, Israeli Arabs were identified by the ethnicity of their residence as recorded in the National Census [l Census .The study population (2009) ranged between 153,785 mammography eligible women and 54,095 adults diagnosed with cardiovascular disease (CVD) who were targeted for decreasing LDL cholesterol  improvement, the message to regional managers was a demand to allocate more resources to the weaker branches, in order to gradually close the gap. This in turn was transmitted to front-line caregivers. A request to provide special attention to less achieving units pushed the formulation of local solutions to overcome barriers that potentially prevented weaker populations from achieving optimal health outcomes. An example of such a productive local activity, supported by organizational infrastructures, is the case of increasing breast cancer screening among Arab women . The manThe second objective of this article was to present analysis of the effect of the above described concept, on care quality and equity. From the year 2003 to 2009, most of the selected quality indicators demonstrated a significant and steady improvement. Of special value is the finding that members who lived in low socioeconomic neighborhoods or in Arab settlements/local authorities achieved a relatively larger improvement, in comparison with members of higher socioeconomic groups or non-Arabs.Over the years, MHS has paid attention to and invested resources in care quality improvement. This was done by sending a clear managerial message, distributed by the target-based measurement system. Transparency of performance, frequent internal reporting and competition over recognition and modest rewards , all contributed to a clear unequivocal organizational "voice".This message was facilitated by MHS' Quality Infrastructure, consisting of a central quality body, as well as multidisciplinary "quality teams" at the regional and branch levels. Teams were provided with training, tools and a framework for organizational learning from across units while implementing quality improvement initiatives such as breast cancer prevention program among Arab women .It should be noted that tailoring of targets is only one, and definitely not the sole mechanism, for improving equity of health care and health outcomes. Experiencing success in some reduction of disparities indeed created organizational discourse on equity and equality issues, and raised top managerial concern and belief that this might be feasible. From a long-term perspective, implementation of the measurement system has made "quality" integral to the MHS organizational discourse. This dialogue, supported by a set of validated data, has contributed a new "language". Terms like quality gap, data analysis, prioritization of domains for intervention, effective methods for improvement and reduction of health disparities have all helped create a new organizational culture within MHS. Medical directors, as well as nonmedical administrators, all perceived quality improvement as a crucial element in their role definitions. Quality issues have consequently captured an increasing portion of the managerial dialogue conducted with primary care physicians and other health professionals.Performance measuring systems are used in many health organizations around the world. To illustrate, the American Veterans Affairs (VA) healthcare system, has undergone various transformations in an attempt to improve quality of care, including implementation of performance measurement, focusing on high-priority conditions such as diabetes and coronary artery disease. In earlier published studies, the VA reported a steady and significant increase in all the selected measures –27, inclOur positive statistical findings should take several limitations into consideration:First: the lack of a control group. The PMS was initiated as an organizational system which covers all units. As a result, there are no units that can serve as a control group. What we can see, are the differences between units and subpopulation groups, in performance and intermediate outcomes, for which the tailored targets try to compensate and adjust.Second, due to technical barriers such as the insufficient timely flow of hospital data on health outcomes, we were limited to the use of process and intermediate outcomes to evaluate the quality of care provided to MHS members. The use of long-term outcome measures, such as rate of amputations among diabetics or disease-related mortality, was precluded.Third, most quality indicators are sensitive to patient characteristics for their validity . IsraeliFourth: we analyzed six indicators, for which the definitions has not been changed over time and the patient's information was fully recorded. These indicators do not necessary represent the other indicators.The Performance Measurement System described in this article, with its unique built in formulas, adjusting for the relative level of performance, has a potential of serving as a locomotive, pulling the quality system toward its goals. The concept of management by assigning tailor-made targets to healthcare services units and rewards for achieving those targets, proved effective in improving care, while reducing disparities.


IntroductionBrain death (BD) is the irreversible termination of the functioning of the brain. The diagnosis should be first made by clinical criteria and confirmed by using paraclinical confirmatory techniques (ancillary tests). While conventional brain angiography remains the standard method of choice, computed tomography angiography (CTA) has emerged as an alternative method. In this study, we tried to evaluate the accuracy of CTA for the diagnosis of BD.MethodsIn this study, we included nine patients with a clinical diagnosis of BD, confirmed by electroencephalography (EEG). CTA was then performed to compare the results.ResultsThe most frequent cause for BD was multiple trauma (7/9) in our patients, followed by aneurysm rupture and brain infarct. CTA examination in all patients showed opacification of extracranial arteries and major branches of external carotid artery (ECA), including superficial temporal arteries (STAs), while no opacification was observed in the internal carotid arteries (ICA) including and beyond the cavernous segment, middle cerebral arteries (MCAs), anterior cerebral arteries (ACAs), distal vertebral arteries (VAs), and basilar artery (BA). Moreover, no opacification was observed in the internal cerebral veins (ICVs) or great cerebral vein (GCV).ConclusionThe accuracy rate of CTA in the detection of intracranial circulatory arrest was 100%. CTA examinations confirmed BD diagnoses in all patients who had clinical and EEG BD diagnoses, and no confliction between CTA findings and clinical diagnoses was observed. Brain death (BD) is a state of irreversible termination of the functioning of the entire brain. The diagnosis of BD should be first made on the basis of clinical criteria -2. This The protocol to confirm BD in many countries not only requires a clinical diagnosis but also the use of paraclinical confirmatory techniques (ancillary tests), which include electroencephalography (EEG), evoked potentials, transcranial Doppler (TCD), and conventional brain angiography . The objWhile conventional brain angiography with a catheter remains the standard method of choice, computed tomography angiography (CTA) has emerged as an alternative method , 3-4. CTIn the current study, we first confirmed BD in patients by clinical criteria and EEG. We then performed brain CTA in these patients and compared its yield of diagnosis and accuracy to the EEG, trying to advocate a highly accurate and specific CTA finding. The goal of our study was to evaluate the accuracy of cerebral CTA for the diagnosis of BD.Between February 2015 and August 2015, nine patients were enrolled in the study. First, BD was suggested by a nurse with special training for the diagnosis of BD. Repeating the examination after six to 12 hours, the clinical diagnosis was confirmed by both an anesthesiologist and a neurologist, blind to the results of each other’s evaluation. The inclusion criteria were: 1) unresponsive coma with a Glasgow Coma Scale (GCS) of 2/10 ; 2) absence of brainstem reflexes ; 3) absence of central spontaneous respiratory drive assessed by apnea test. The exclusion criteria were: 1) abnormal serum electrolytes or acid-base state; 2) prescription of any kind of central nervous system (CNS) or suppressant drugs . Patients who were diagnosed to have BD by both physicians would then undergo a standard EEG based on accepted guidelines for the diagnosis of BD . After cThe patients’ families gave their written consent to participate in the study. All procedures were performed in accordance with local ethical committee of Medical University.In the study period, nine patients fulfilled both clinical  and EEG criteria (isoelectric line for the entire 30 minutes recording) for the diagnosis of BD (Table The mean patient age was 34.6 years. The most frequent cause for BD was multiple trauma (seven out of nine) in our patients, followed by aneurysm rupture and brain infarct.CTA examination in all patients showed opacification of extracranial arteries and major branches of the external carotid artery (ECA), including superficial temporal arteries (STAs), showing the proper administration of contrast media and reliability of CTA studies. In three patients, no opacification was observed in internal carotid arteries (ICA) after the cervical segment, middle cerebral arteries (MCAs), anterior cerebral arteries (ACAs), basilar artery (BA), or vertebral arteries (VA) in their entire intradural segments  Figures .Although the complete intracranial non-filling was seen, extracranial flow was still observed in some cases Figure .In six patients, there was some remnant unilateral ICA flow until the petrous segments, which abruptly terminated thereafter. There was no opacification in MCAs, ACAs, VAs, and BA, however Figure .Among these six patients, two had also minor unilateral filling in a short length of intradural VA   or great cerebral vein (GCV).The accuracy rate of CTA in the detection of intracranial circulatory arrest was 100%. CTA examinations confirmed BD diagnoses in all patients who had clinical and EEG BD diagnoses, and no conflict between CTA findings and clinical diagnoses was observed.BD is defined as the irreversible cessation of all functions of the entire brain, including the cerebrum and brainstem. Based on medical achievements in organ transplant, the diagnosis of BD is of particular importance . It is pFollowed by clinical diagnosis of BD, lack of brain function  or circulation  should be demonstrated by standard and accepted paraclinical ancillary methods; among them are EEG, TCD, and conventional angiography .Demonstrating cerebral circulatory arrest is a necessity for confirmation of BD. For many years, conventional catheter angiography has been considered the gold-standard method for detection of cerebral circulatory arrest, with blood flow termination at the level of the foramen magnum for posterior circulation and carotid siphon for anterior circulation as the characteristic finding , 9. CTA Most series have shown that CTA has demonstrated high sensitivity, specificity, and validity in detecting intracranial circulatory arrest . DiffereOn the other hand, some studies have suggested that CTA is not a validated confirmatory test for cerebral circulatory arrest in brain death, as it may be associated with false-positive results  and loweIn the current study, we first confirmed BD in nine patients, mostly victims of traumatic brain injury, with clinical criteria (which were performed twice) and EEG. We then performed a 16-slice CTA. The major observed finding in all patients was a circulatory arrest in both the anterior (beyond the level of skull base and the petrous segment of ICAs) and posterior circulations and also venous return, while external cerebral circulation  was preserved. The only remnant flow that was observed in a minority of patients was the filling of a short segment of the proximal intradural VA , which does not exclude BD. This finding is similar to intracranial non-filling observed in some other studies , 5-6, 19Based on these, the results of our study were in complete accordance with previous studies that proposed CTA as a useful ancillary test and an alternative to conventional angiography in the diagnosis of BD. Our study, nevertheless, suffers from limitations; the first limitation is its low patient volume. Second, our study was designed in a single-centric nature; the two need further studies recruiting more patients and more centers. Finally, it is possible that we performed CTA late in the course of BD; therefore, we observed the lack of flow in all intracranial arteries and their segments. Should we have performed the CTA sooner, other findings would also be observed. Of course, an interval of six hours before performing a CTA is recommended to avoid repetitive examinations . HoweverBrain CTA can be considered as a reliable modality in demonstrating cerebral circulatory arrest, and hence, the diagnosis of brain death. Its findings, in particular, intracranial non-filling, are associated with a high specificity and correlate well with the results of an EEG.