Objectives: The aim of this systematic review is to evaluate and compare the risks and benefits of germectomy and delayed removal of third molars and develop a patient management algorithm for second molar eruption in syndrome/incompliant patients. Materials and Methods: A literature search was performed in the following databases; the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Scopus, and Web of Science. Last search was done on July 2nd, 2018 including articles published from the last 18 years. The search aimed to identify all relevant studies written in English language. Gray literature was excluded. Risk of bias was evaluated with specific predetermined criteria. This systematic literature review was reported according to the PRISMA-P statement and was registered in the PROSPERO database with the following protocol ID: 104261. Results: Literature search war performed on July 2018 and updated on February 2019. A total of 1610 articles were screened. After abstract screening and discarding duplicates, 86 full-text articles were obtained and subjected to additional evaluation. Four articles were included in the review. Three studies were considered as having a medium risk of bias and one was assessed as at high risk. Due to the heterogeneity of presenting results and a very low number of included studies a quantitative analysis was not possible. Only qualitative analysis was made. Considering the limited number of studies included and the level of risk of bias there is no sufficient evidence to state the benefits of preventive removal of impacted third molars, especially in patients with poor oral hygiene due to intellectual disability. Early germectomy represents an elective approach of pathologic alteration of tooth germ; orthodontic issues meet appropriate indication for a delayed removal. Conclusions: Given the best evidence-based information regarding patients’ medical condition, we highlight the need to provide an ethical-based comprehensive approach in the diagnostic workflow and the assessment of treatment outcome. Tooth impaction is a pathological situation where a tooth fails to attain its normal functional position. A relationship between the presence and the role of the mandibular third molar as a physical obstacle of the eruption path of the mandibular second molar has been hypothesized, even if the most recent evidences seem to confirm the results of Kaplan, who suggested that the impaction of the mandibular second molar can be related primarily to an arch length deficiency ,2. When Among the reasons why some clinicians do not consider the preventive extraction of the germ of the third mandibular molars there is the possibility of postoperative complications. Furthermore, an additional source of debate is represented by the evidence that third molar germectomy seems to be connected to less morbidity than extraction of third molars with formed roots. So, some authors underline the necessity of carrying out a very careful assessing of cost–benefit ratio for evaluating the indications of third molar early or delayed extraction .Unfortunately, incompliant/syndrome patients often require general anesthesia to remove wisdom teeth; dental practitioners and oral surgeons have a wide variation of judgments regarding the indication of early or delayed extraction of third molar gems ,8.This lack of global consensus on all the aspects described above leads to the concept that early extraction of the third molar gems is decided on an empirical basis.The aim of this systematic review is to evaluate the rate of surgical complications associated to germectomy  and the benefits in terms of duration of therapy for correction of the second molar inclination after the removal of third molar germs.The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) checklist  was usedThe following focused question, formulated in the Patient, Intervention, Comparison and Outcome (PICO) format was developed: “Does early extraction of third molar germs produce a benefit in terms of duration of therapy for correction of second molar inclination or in terms of surgical complications? Is it possible to draw some recommendations from the literature reports, especially for syndrome/incompliant patients?”Studies were conducted on participants who were suggested to extract third molar germs at the age of 18 years or under.Any intervention or combination of surgical techniques given for the extraction of third molar germs, including early or delayed germectomy.Any clinical outcome, including (but not restricted to) complications of germectomy and duration of therapy for correction of second molar inclination between treated and untreated subjects.Studies were included if they were case–control or cohort study with prospective or retrospective design or if they dealt with recommendations regarding the management of third molar germs. Studies were selected if they were published in the last 18 years in English, French, German, Spanish, or Italian.Publications in languages other than English, French, German, Spanish, or Italian.Case reports, case series, review articles, abstracts, and discussions.Studies that evaluated less than five patients.Excluded articles:The literature search war performed on July 2018 and updated on February 2019. The following electronic databases were systematically searched; MEDLINE-PubMed and all evidence-based medicine reviews via Web of Science, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL).#1 OR ((“third molar *” OR “wisdom tooth” OR “wisdom teeth” OR “3rd molar *” OR third-molar).mp.)#2 OR ((tooth impact *) OR (teeth impact *).mp.)) OR Tooth, unerupted/)#3third molar * germ OR wisdom tooth germ OR wisdom teeth germ OR 3rd molar* germ OR third.molar germ.mp.#4#1 AND (#2 OR #3)#5(((Tooth extraction/indications) OR ((extract * OR remov *)/indications)) OR Tooth extraction/early) OR Tooth extraction/early#6#4 AND #5#7third molar * germectomy OR wisdom tooth germectomy OR wisdom teeth germectomy OR 3rd molar * germectomy OR third-molar germectomy#8#6 OR #7.The combination of MeSH terms and free text words used for MEDLINE-Pubmed database are as follows.The MeSH terms “Syndromes” or “Patient Compliance”, or other variations related to the keywords, were not included in order to make the list of searches more concise; therefore, we included those search terms in the selection criteria to focus the search results.This search strategy was firstly designed for Medline and then adapted for the other databases.A supplementary manual search was performed of the following peer-reviewed journals for articles published between January 2000 and December 2018: European Journal of Orthodontics, American Journal of Orthodontics and Dentofacial Orthopedics, Angle Orthodontist, Progress in Orthodontics, International Journal of Pediatric Dentistry, Journal of Oral & Maxillofacial Surgery, International Journal of Oral and Maxillofacial Surgery, British Journal of Oral & Maxillofacial Surgery, and Journal of Cranio-maxillofacial Surgery. In addition, the bibliographies of all selected articles were checked and all corresponding authors of included articles were contacted by e-mail in order to recover unpublished articles or raw data and to include as many relevant studies as possible in the analysis.Screening process was conducted independently and in duplicate, two reviewers (FG and AC) evaluated the titles and abstracts of the retrieved studies from the database searches using the inclusion criteria. Subsequently, the same reviewers performed the assessment of the full-text articles. Any disagreements were solved through discussion until consensus.The data were first extracted independently and in duplicate by the same reviewers (FG and AC) using specially designed data extraction forms. For studies matching with the inclusion criteria, or for which information in the title and abstract was insufficient to make a clear decision, the reviewers obtained and screened the full report.The variables extracted from each selected article included: study type, sample size, population details (including age and gender), complications, and follow-up.The outcomes were the complications rate of germectomy as well as the benefit in terms of duration of therapy for correction of second molar inclination between treated and untreated subjects and the factors associated with the recommendations to extract third molar germs.The reviewers independently evaluated the outcomes through a structured form.Methodological quality scores were given according to predetermined custom-built criteria and the quality of evidence was assessed as high, moderate, or low for each study.The initial electronic search resulted in a total of 1610 titles . After the independent elimination of duplicate articles, a total of 1379 titles were considered for possible inclusion. A total of 1293 articles were removed based on their title and abstract; therefore, 86 full-text articles were selected. Among these studies, four were included in the review ,12. AfteIn conclusion, only four studies were identified as potentially eligible for inclusion in this review .After full-text evaluation, twelve articles were excluded because their design did not fit the inclusion criteria. Fifteen studies were excluded because they were case reports or case series with less than five patients treated, thirty-four studies were excluded because they did not evaluate indications to germectomy procedure, and twenty-one studies were excluded because they were only narrative reviews about the topic.Two studies were carried out in USA ,12, one Three studies were conducted at University dental clinics ,10,12 anCharacteristics of all the included studies are summarized in Overall the included studies were very heterogeneous because they did not always report data regarding the outcomes of this systematic review. Furthermore, in some cases authors presented the data graphically preventing the authors of this article from retrieving them accurately. For these reasons, a quantitative analysis of the results was not possible; only a qualitative analysis was made.The selected studies included adolescents (age range: 12–18 years) and adult patients (older than 21 years) candidate or subjected to third molar surgical extraction according to a retrospective or prospective design; one study reported data drawn from questionnaires mailed to department chairpersons regarding recommendations about early third molar extraction [Patients were excluded if they matched at least one of the following exclusion criteria: active caries lesions, orthodontic appliances, previous extraction of one third molar, and any systemic disease or syndrome.Data regarding the sample site, population details, eventual complications, and follow-up periods are summarized in Only one article evaluates the rate of surgical complications associated to germectomy , and anoThe risk of bias is summarized in p = 0.033). No statistically significant differences were found regarding the association between complications and the third molar calcification stage or the degree of impaction in upper third molars. This contrasted with the situation in the case of the lower third molars, where the teeth presenting impaction Classes III, II, and I accounted for 27.8%, 17.6% and 3.7% of the complications, respectively (p = 0.028). In relation to angulation, distally angled molars posed most complications (41.7%), followed by mesially inclined teeth (19.1%) and vertical molars (9.5%) (p = 0.048). Regarding the reasons for extraction, the group of patients in whom extraction was indicated for early reasons accounted for 11.7% of the complications, while extraction due to clinical symptoms and orthodontic reasons accounted for 17.9% and 18.4% of the complications, respectively. Nevertheless, no statistically significant differences were observed between the reasons for extraction and the incidence of postoperative complications (p = 0.221).Chaparro-Avendaño et al. analyzed the incidence of complications following third molar surgical extraction in patients between 12 and 18 years of age, with an evaluation of the association between such complications and patient age and sex, the reason for extraction, the degree of dental development, and third molar position, angle, and impaction . The posThe position paper regarding recommendations of the US dental school departments published by Jasinevicius et al. in 2008 confirmed the same recommendations derived from the previous department chairpersons’ questionnaires results of 1998/99 . Over 75The cohort study designed by Cunha-Cruz et al. gave information regarding recommendations for third molar removal among private practice dentists belonging to the network named PRECEDENT (Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry) . Dentistp = 0.440).Cassetta and Altieri designed a prospective pilot study in which they evaluated the benefit of germectomy in terms of duration of therapy for the correction of second molar inclination respect to the luxation and positioning of a brass wire . The secThe analysis of the results of the studies published in the last 18 years and included in this systematic review has revealed that there is no evidence to sustain the hypothesis that the third molar germectomy can reduce the treatment time for the correction of second molar inclination. This result gives more strength to the evidence already present in the literature that states that the correction of ectopic eruption of the permanent molars can be achieved even utilizing the brass wire technique alone . Despitemorphostructural alterations or ectopic impactions;eruption not allowed by dysplastic alterations of the tooth germ or pathologic processes of the bone;necessity of distalization of first or second molar; orexcessive anteroposterior growth or severe dentoalveolar discrepancy.On the one hand, scientific literature has already required for many years clinicians a decision-making approach strongly based on the cost–benefit regarding the early extraction of third molars . In factOn the other hand, controversy exists over the extraction of third molars which have caused no pathology at all and this element has been extensively studied by some authors with the aim of defining the indication to germectomy ,18,19.Regarding the risk of postoperative complications following germectomy, this systematic review confirms the evidences already found in the previous reports: female patients are more susceptible to develop postoperative complications, and distally angled third molars or molars presenting Class III impaction are more prone to cause such complications ,21. No oAccording to the evidences found in the present review, the dental school departments’ and general dentists’ recommendations regarding the early removal of third molar germs remain high both in the presence and in the absence of pathology associated with the tooth. Because of the general lack of strong evidences from a methodological point of view regarding this topic it is believed that the decisions taken by the clinicians are often based on personal values and habitual practices ,26,27,28An important limitation of this review is that all results were drawn from only four studies due to the lack of reports that matched with the inclusion criteria. Moreover, some studies included patients belonging to a wide range of age and divided them by age groups. The authors of the present review included results taken from the group closest to the age in which the third molar is present at the stage of germ; this assumption could not be valid in all cases.Only studies conducted in the USA reported recommendations of the dental school departments and general dentists about the early removal of third molar germs, for this reason the indications derived from those reports should not be considered as shared all over the world.Lastly, the general risk of bias judged as medium/high imposes a very cautious interpretation of the results.Lower third molar extraction in syndrome/incompliant patients is a case-based therapeutic treatment; clinical approach is aimed to maximize risk–benefit ratio, basing on four considerations: risk of nonintervention, risk of intervention, benefit of nonintervention and benefit of intervention .Toothache may trigger organic self-mutilation. Syndromes, mental retardation, and autism are often associated with organic self-injuries, defined as unconscious compulsive mutilation behavior not related to specific intent. Self-injuries may involve perioral region  or other anatomical districts .Consequences—wounds pain and tooth sensitivity—provoked by self-mutilation might induce themselves the onset of a negative loop characterized by persistence or even increase of the compulsive self-injuring behavior.Moreover, the removal of the environmental clue is highly recommended in patients with Lesch–Nyhan syndrome, a heterogeneous group of neurological disorders, congenital insensitivity to pain with anhidrosis, and mental retardation.Some antiepileptic drugs  may induce gingival hypertrophy, thus increasing the risk of periodontal complications of lower third molars. Among patients with recurrent epilepsy, the pain elicited by toothache makes the patient uncomfortable and triggers the onset of seizures .Surgical technique for germectomies is highly predictable; as above mentioned, tooth extraction is associated with mild and reversible surgical complications if root development is not completed. Swelling, discomfort, and reduced mouth opening are common sequels that gradually resolve over the next two weeks. Lower incidence of morbidity means less economic hardships from time off work for patient and caregivers .Anesthesiologic side effects are often associated with the drug administration and the difficulty in safely managing syndrome patients  ; howeverAvoidance of risk related to anesthesiologic procedures; syndrome or incompliant patients are eligible for third molar removal under general anesthesia. Respect to regional anesthesia, general anesthesia allows treating incompliant or phobic patients and extract multiple teeth. However, if syndrome/incompliant subjects are meeting criteria for tooth extraction and need to be treated in general anesthesia for many reasons, they should undergo all the procedures at the same time .Furthermore, before planning a germectomy, it is also mandatory to evaluate the absence of pathologies of the young age that may cause premature loss of dental elements . In patiUnder general anesthesia it is possible to remove third molars altogether. Based on our experience, the concomitant removal of all the third molars is needful in patients with a higher incidence of airway management problems; patients who had multiple anesthesiologic procedures or an ASA score of III need a careful examination of the reasons for the extraction of the lower third molars and, once required, they must solve all the dental issues in the same intervention.On the other hand, a longer surgical procedure implies a higher dose of anesthesia and is more often associated with delayed onset infections on mandibular third molar sites. However, to avoid these complications, methods of drug premedication and telephone monitoring of patients have recently been proposed ,40.We set the necessity of undergoing an intervention in general anesthesia as “minimum requirement” to hypothesize the removal of third molars in incompliant/syndrome patients.Early removal meets appropriate indication in case of impaction, delayed or ectopic eruption of the neighboring teeth and in pathological situations such as follicular cyst formation.Lower third molars presenting partial soft tissue impaction have a relatively hopeless long-term prognosis, because the lack of ability in performing daily oral health care may result in severe pericoronitis and extensive decay.Furthermore, mesially impacted lower third molars might elicit grossly decay, frequent periodontal problems, and root resorption on the distal aspect of the second molars.Cellulitis, abscess, temporary local swelling, pain, and mouth opening require prompt intervention as evidences of pathology.Spatial limitations represent a major indication for third molar extraction only if tooth interferes with the eruption of the adjacent teeth ; crowdinConsidering the limited number of studies included and the level of risk of bias there is no sufficient evidence to define absolute indications or contraindications for preventive removal of impacted third molars. Pros and cons of such intervention must be verified by further studies that are encouraged to be conducted with a prospective design, following appropriate scientific guidelines.In agreement with NICE  guidelines, third molars cannot be considered “functionless teeth”, especially in patients with mental disability, when they often replace missing teeth.First of the NICE guidelines is “the practice of prophylactic removal of pathology-free impacted third molars should be discontinued”; specific attention must be drawn in patients with no compliance, who are therefore being exposed to the risk of undertaking general anesthesia unnecessarily.Effective patient management is discussed in the context of the problem-oriented approach; indeed, early diagnosis, proper evaluation, and appropriate treatment are essential for developing an action plan.A systematic approach to diagnosis and treatment planning involves clinical and radiographic examination that encompasses information regarding patients’ health status, age, and compliance.Syndrome patients often present third molars with different crown shapes and sizes, root morphology, position and inclination, eruption paths, development periods, and relationships with contiguous anatomical structures.Young patients revealed high incidence for caries and infection due to poor oral health education at home, high sugar consumption, and no strict compliance for daily brushing; this factor may lead to the premature loss of teeth . The ratSurgical or nonsurgical treatment of third molars in syndrome/incompliant patients should be viewed with the perspective of the “daughter theory”. Considering the quality of life as the main goal of our job, is important to discuss with parents/caregivers about surgical and nonsurgical treatments alternatives, considering patients’ conditions and preferences.


As a model of human pregnancy, research studies in catheterized fetal sheep have made significant contributions to our understanding of both normal and abnormal fetal development.Owing to the invasive nature of catheterization surgery, effective postoperative analgesia is required.Decisions regarding appropriate analgesia should consider effectiveness in reducing maternal pain and fetal well-being as well as potential impacts upon fetal physiological parameters under investigation.The reporting of analgesic regimes in all research studies should comply with the ARRIVE guidelines.Studies in sheep have made significant contributions to our understanding of normal and abnormal fetal development, and have enabled scientists and clinicians to answer questions about the etiology and treatment of poor maternal, placental, and fetal health . One funWhile pregnant ewes appear tolerant of abdominal/intrauterine surgery to access the fetus, effective postoperative analgesia is required both from an animal welfare perspective and to reduce the potential confounding effects of pain on the physiological variables under investigation. The effectiveness of postoperative analgesic regimens largely focus on maternal recovery. Whether or not the fetus is sensate, and therefore capable of experiencing pain as we understand it, is difficult to quantify and requires consideration of the physical, emotional, and cognitive aspects of pain perception. The fetus itself may be relatively less perceptive of postsurgical pain than its mother due to the physiological suppression of central nervous system activity by allopregnalone, a metabolite of progesterone, which maintains the fetus in sleeping behavioral states . AlthougIn this review, we summarize the most commonly reported analgesics in sheep fetal vascular catheterization surgery , discussXylazine has been widely used in veterinary medicine and preclinical research studies to induce sedation or as an adjunct to injectable and inhalational anesthetics . Xylazin+ and closing Ca2+ channels, thus providing antinociceptive effects for thermal stimuli for up to three and a half hours  are also routinely used for postoperative pain management in veterinary medicine . NSAIDs Paracetamol administration has been given postoperatively to sheep recovering from fetal catheterization surgery . AlthougAnalgesic administration to pregnant ewes may have significant direct and indirect consequences for the fetus and may threaten the integrity and/or reproducibility of research outcomes. It is, therefore, important to consider both maternal and fetal effects of analgesia when deciding upon an analgesic regime .2)  , althoug2) .Despite their widespread use and well-documented tolerability in nonpregnant animals, there are major concerns around the use of NSAIDs during pregnancy. Patency of the fetal ductus arteriosus  is maintained by circulating prostaglandins derived from the placenta and by the low oxygen tension normally present in the fetus . In humaDecisions about postoperative analgesic regimen must consider effectiveness, duration of pain relief, potential side effects, and fetal impacts. Owing to concerns around sustained effectiveness, we transitioned from the use of xylazine analgesia to a regime of subcutaneous administration of meloxicam on the day prior to and following surgery, for all maternal/fetal indwelling catheter procedures conducted in our laboratory from 2017 onwards. Here we retrospectively compare the behavioral impact of meloxicam with xylazine, as assessed by prospective documentation of postoperative clinical condition, including feed intake. Studies using xylazine analgesia (2013–2016) and those using meloxicam analgesia (2017–2018) were all conducted at the South Australian Health and Medical Research Institute (SAHMRI) Preclinical Imaging Research Facility (PIRL), in accordance with the Australian Code of Practice for the Care and Use of Animals for Scientific Purposes , and with approval from appropriate local Animal Ethics Committees.−1) supplemented with pellets containing straw, cereal, hay, clover, barley, oats, lupins, almond shells, oat husks, and limestone . Anesthesia was induced with diazepam  followed by ketamine , then maintained with 1.5% to 2.5% isoflurane in oxygen. Vascular catheters were implanted into the maternal jugular vein, fetal femoral artery and vein as well as the amniotic cavity as described previously  and fetus . Antibiotics were administered intramuscularly to each ewe for 3 days after surgery and intra-amniotically (5 mL of 100 mg mL−1 ampicillin) for 4 days after surgery.Merino ewes between 105 and 125 days of gestation (term = 150 ± 3 days of gestation) were housed individually in a 12:12 (light:dark) hr photoperiod with ad libitum access to water. Animals were daily fed 1 kg lucerne chaff  upon recovery from anesthesia, or meloxicam  at 1600 hr on both the day prior to and day of surgery. Daily food consumption was determined by weighing daily food offered and residual feed. Routine clinical records were collected for 3 d prior and up to 6 d following surgery by trained animal technicians who were not members of the research group. Ewes were assessed each morning and scored on a scale of 0 to 3 for appetite, drinking, defecation, urination, alertness, and surgical site, where 0 is normal and 3 is severely affected . In singleton-bearing ewes administered xylazine, surgery increased total score at day 1 , day 2 , and day 3  postsurgery (P = 0.001) and day 2  postsurgery .The effect of surgery on total clinical scores in singleton- and twin-bearing ewes depended on the type of analgesia used . In singleton-bearing ewes administered xylazine, surgery reduced food consumption at day 1 , day 2 , and day 3  postsurgery (P = 0.034) postsurgery (P = 0.008) and only in singleton-bearing ewes.Similarly, the effect of surgery on food consumption in singleton- and twin-bearing ewes depended on the type of analgesia  taken at a point in time that may not be representative or relevant. Nevertheless, considerations such as route of administration, transport across the placenta, and placenta drug metabolism may influence decisions.Specific analgesic drugs or drug classes may be more or less appropriate depending on the main outcomes of interest. Fetal catheterization studies cannot be ethically or scientifically justified if the analgesic regimen compromises scientific outcomes. Furthermore, the choice of an appropriate analgesic regimen for specific studies will need to consider issues such as comparability with previous work and the need to maintain consistency throughout an experimental series, to avoid the ethical impact of additional animals needed to repeat previous work. Ideally, factors influencing analgesic choice will be considered and changes implemented at the start of a new series of studies. In addition, restrictions on access to, or the personnel allowed to administer, some classes of licensed drugs, may restrict available options.Finally, critical to any studies involving maternal and fetal surgery is the need to report the analgesic regimen including dose, route of administration and regimen, as prescribed by the ARRIVE guidelines  and requJLM was funded by a National Health and Medical Research Council (NHMRC) Career Development Fellowship  and an Australian Research Council Future Fellowship . The animal component of the study was funded over several years and thus grants including National Health and Medical Research Council , Canadian Institute of Health Research , National Heart Foundation  and University of South Australia Research Themes Investment Scheme (2016).


Healthcare systems in Africa suffer from neglect and underfunding, leading to severe challenges across the six World Health Organization (WHO) pillars of healthcare delivery. We conducted this study to identify the principal challenges in the health sector in Africa and their solutions for evidence-based decisions, policy development and program prioritization.The study was conducted as part of a recent African Epidemiological Association Meeting in Maputo, Mozambique with participants drawn from 11 African countries, Cuba, Portugal and the United Kingdom. Participants were divided into 10 groups, consisting of 7 to 10 persons each. Brainstorming approaches were used in a structured, modified nominal group process exercise to identify key challenges and strategies to mitigate healthcare service challenges in Africa. Identified challenges and solutions were prioritised by ranking 1–5, with 1 most important and 5 being least important.The first three challenges identified were inadequate human resources (34.29%), inadequate budgetary allocation to health (30%) and poor leadership and management (8.45%). The leading solutions suggested included training and capacity building for health workers (29.69%), increase budgetary allocation to health (20.31%) and advocacy for political support and commitment (12.31%).The underdeveloped healthcare systems in Africa need radical solutions with innovative thought to break the current impasse in service delivery. For example, public-private initiatives should be sought, where multinational companies extracting resources from Africa might be encouraged to plough some of the profits back into healthcare for the communities providing the workforce for their commercial activities. Most problems and their solutions lie within human resources, budget allocation and management. These should be accorded the highest priority for better health outcomes. Globally, countries are faced with health system problems which vary from one to the next. While health service delivery challenges are more often seen in countries with a very high Human Development Index (HDI), human resources challenges attract more attention within those with a low HDI.5Dilapidated healthcare systems have facilitated medical tourism, for example, leading to over 5000 people leaving Nigeria every month for various forms of treatment abroad and about 1.2 billion US dollars lost from the Nigerian economy to medical tourism yearly.15As part of efforts to remedy the lack of financial risk protection mechanisms in Africa, some countries, such as Nigeria, Ghana, Tanzania, Kenya, Rwanda and Ethiopia have started implementing social health insurance schemes.11Several studies have documented key healthcare system challenges globally with recommended solutions. However, challenges that healthcare systems in Africa face require in-depth exploration to identify, generate and implement contextual solutions that make significant population-level health gains with efficient use of resources.The study was conducted as part of the African Epidemiological Association (AfEA) Annual Scientific and General Meeting in Maputo, Mozambique, between April 14 and 17th, 2019.The conference, with the theme, “Epidemiology for Sustainable Development in Africa” had epidemiology, policy development and community health; data and the science of evidence; disease surveillance and response; environmental epidemiology; epidemiological transition; new tools and horizons in epidemiology; and delivery science and implementation research as subthemes. Participants focused on how to improve epidemiology practice and policies in Africa in particular, and the world at large. Plenary discussions, group work and scientific sessions were used to fully explore the various topics and a communiqué addressing the participants’ submissions, fears and solutions were delivered at the end of the conference.A total of 77 participants, composed of programme implementing partners (n=40), policy-makers (n=5) and health researchers (n=13) were drawn from 11 African countries, Cuba, Portugal and the United Kingdom. Some participants were identified as belonging to multiple categories, either as both implementing partner and researcher (n = 24), researcher and policy-maker (n = 5), implementing partner and policy-maker (n = 1), or implementing partner, researcher and policy-maker (n = 6). The participants were divided into 10 groups with each group consisting of 7–10 persons. A brainstorming approach in a structured-modified nominal group process (NGP) exercise was used.The NGP was conducted in two phases designed to maximise participant focus and engagement. During the first phase, each group member identified key challenges facing healthcare services and strategies to mitigate them in the African context. The groups then discussed and elaborated on these issues in the next NGP phase. Each of these sessions included three distinct activities, namely 1) generating key challenges, 2) generating key strategies/solutions, and 3) ranking the challenges and strategies.We used “brainstorming” first as it is an effective and low-cost method of identifying key challenges and possible solutions to identified challenges.The principal investigator, a public health physician, recruited 2 research assistants who acted as the facilitators of this study. The facilitators created the 10 groups, shared the study instrument and timed the whole exercise. Approval for the study was obtained from the AfEA Council and Executive and each participant provided consent to participate in the study.We delinked data, entered findings into SPSS v23  and MS Excel Sheet , analysed, and reported aggregated results. Four questionnaires were completed in Portuguese. These were translated and analysed by one of the authors who speaks Portuguese. Two of the authors analysed the results and developed themes base on similar entries. Results were further summarized along the line of the WHO health system pillars (building blocks)Respondents came from 11 African countries, Cuba and Portugal with close to half of the respondents from Nigeria (44.2%), followed by Mozambique (31.2%), which was the host country for the conference. The majority of the respondents had an MPH or MSc (36.4%); this was followed by those who had a Medical College Fellowship (23.4%) or a PhD (14.3%). Over a half of the respondents were programme officers (54.6%), while about one-fifth of the respondents were academics .Table 1SThe top four problems of the health sector in African countries identified by individual participants were inadequate human resources , poor resource allocation to health , poor maintenance of healthcare system infrastructure  and lack of political will . The rest includes lack of access to healthcare, weak healthcare systems, high disease burden, healthcare system corruption, poor leadership and administration, non-use of evidence-based intervention, poor quality of healthcare services, lack of good resource management, weak training and education of healthcare workers, weak healthcare management information systems (HMIS), non-prioritization of healthcare activities, and professional rivalry, as shown in According to the groups, the top four challenges were inadequate budgetary allocation , inadequate human resources for health , ineffective leadership and management , poor data quality with poor use of data for audit  and lack of political will . The rest included limited access to healthcare, inadequate healthcare infrastructure, weak healthcare systems, poor integration of healthcare programmes and professional rivalry.When these problems were regrouped, based on the six building blocks of the health system proposed by WHO, the leading problems clustered around leadership and governance (26.18%), healthcare workforce (25.45%) and healthcare service delivery (22.91%) .Figure 1Participants also individually and collectively identified some solutions to these challenges. The leading solutions suggested to the outlined challenges in the healthcare sector by individuals included training and capacity building of healthcare workers , adequate health insurance schemes , advocacy and increase political engagement , increased budgetary allocation to healthcare  and improved healthcare infrastructure . Other factors included increase collaboration among stakeholders to address healthcare issues, improved capacity to prevent and control disease, leadership and management training, improved monitoring and evaluation of healthcare services and better remuneration of healthcare workers, as shown in Groups identified investment in capacity building/training of healthcare workers , advocacy for political support , increased budgetary allocation , and adequate health insurance schemes . The rest included improved data management and use of data for action, upgrading of healthcare infrastructure, improve leadership and management and active recruitment of healthcare workers.Further analysis of the suggested solutions based on the six WHO health system building blocks showed that the solutions proffered were majorly changes in leadership and governance (31.8%), healthcare workforce (31.8%) and healthcare financing (21.50%). These were followed by service delivery, healthcare information systems and access to medicines and technologies .Figure 2Solutions ranked first by the groups include training and capacity building of health workers , increased budgetary allocation to health , and advocacy for political support and commitment . The rest is shown in Healthcare systems in Africa are mostly in unworkable conditions with very poor health outcomes. There have been several studies that looked at the challenges of the healthcare system in Africa, and our major findings were to a large extent similar to previous studies.At individual level, our study showed that inadequate human resource is the foremost leading challenge in the health sector in Africa. This is both overt and covert which reflects the complexity of this challenge. It is overt in the sense of inadequate number, mix and distribution resulting from inadequate output from training institutions; brain drain to Europe, America and Asia; and unfavourable governmental policies mitigating employment into the civil services. Covert reasons include poor availability of engaged healthcare workers to deliver services, resulting from healthcare worker strikes, attendance at private practice , internal migration to big cities, and poor attitude to work.25Also, healthcare systems may not be able to respond to public health emergencies such as outbreak of diseases leading to increase mortality and morbidity in these countries. The major solution proffered to this key challenge centered on capacity building of healthcare workers, which may itself address this challenge to some extent. Other issues which influence the retention of healthcare workers also need to be investigated.Inadequate financing of healthcare in Africa is another major challenge identified. This is in tandem with several other previous studies.28For instance, Musango and colleagues in their studies found that in the majority of African countries, scarcity of funds for healthcare is a chronic problem with even the richest countries finding it increasingly difficult to keep up with rising healthcare costs, especially in the face of the ongoing economic downturn.28Although we identified low budgetary allocation to the healthcare sector and poverty as the key financial challenges faced by the healthcare systems, these are in contrast to those outlined by Roncarolo and colleagues which included increasing healthcare costs, financial unsustainability and lack of financial autonomy.The third leading challenge identified in this study is poor leadership and management. This finding is in line with that noted by Dye and Garman, who stated that one of the biggest challenges in the coming decades will be the selection and development of leaders who are trained and prepared for leadership in increasingly complex healthcare systems.In summary, the solutions proffered by the respondents which mostly addressed the issues outlined as the major challenges include training and capacity building for health workers, increase budgetary allocation to health, advocacy for political support and commitment, health insurance for all and improved leadership and management. Categorization of these solutions into the six WHO pillars of the healthcare system further showed that the major solutions outlined grouped into leadership and governance, healthcare workforce, and healthcare financing, accounting for over two-third of the suggested solutions. These imply that the solution to the key challenges in the healthcare system lies mainly in these three building blocks. These must be prioritized for action by policy makers and implementers if we desire to see better, healthier and more functional healthcare systems in Africa, translating into better healthcare outcomes and health indices.The strength of this study is the variety of subjects drawn from across Africa and beyond, who are lettered and well versed in healthcare services and systems in Africa. The study also used self-administered questioner to avoid interviewer bias. The study has not been done anywhere before and thus provides a fresh perspective to the issues of healthcare systems in Africa, and results and recommendations are designed to improve healthcare systems in Africa.The limitations include the sample size which was small and the fact that majority of the responders are epidemiologists at different career levels. There is therefore the need for a broader study involving not only epidemiologists, but also professionals and healthcare customers from other fields. However, the findings are very important and should both inform policy decisions in health, and development of strategies to improve healthcare outcomes in Africa.33Inadequate human resource and healthcare financing and poor leadership and management are the major challenges of healthcare systems in Africa. The major solutions outlined by the participants grouped into leadership and governance, healthcare workforce and healthcare financing. It is important for public health policy makers in Africa to adopt national guidelines for healthcare system development, based on the WHO framework with buy-in from healthcare workers and most importantly from governments across the region. Creative solutions are required and lack of resources may mean that public–private partnerships may need to be adopted with companies using corporate social responsibility schemes to provide a portion of profits to offset health insurance schemes for employees, their families and the communities in which they work. Legislation may be required to encourage large multinationals to participate in such schemes as the price for extracting raw resources from the African continent.


Despite major progress in defining the genetic basis of Mendelian disorders, the molecular etiology of many cases remains unknown. Patients with these undiagnosed disorders often have complex presentations and require treatment by multiple health care specialists. Here, we describe an integrated clinical diagnostic and research program using whole-exome and whole-genome sequencing (WES/WGS) for Mendelian disease gene discovery. This program employs specific case ascertainment parameters, a WES/WGS computational analysis pipeline that is optimized for Mendelian disease gene discovery with variant callers tuned to specific inheritance modes, an interdisciplinary crowdsourcing strategy for genomic sequence analysis, matchmaking for additional cases, and integration of the findings regarding gene causality with the clinical management plan. The interdisciplinary gene discovery team includes clinical, computational, and experimental biomedical specialists who interact to identify the genetic etiology of the disease, and when so warranted, to devise improved or novel treatments for affected patients. This program effectively integrates the clinical and research missions of an academic medical center and affords both diagnostic and therapeutic options for patients suffering from genetic disease. It may therefore be germane to other academic medical institutions engaged in implementing genomic medicine programs. There are approximately 7,000 clinically described rare Mendelian diseases, and only about half of these have a clearly described genetic cause.2 The total number of Mendelian diseases may be substantially higher,3 leaving many new conditions to be clinically described. In addition, the benefits of genomic sequencing in Mendelian diseases extend beyond individuals with rare disorders. Genes responsible for large effects in Mendelian disorders may contribute moderate effects to more common forms of the same or related disease phenotypes.6Although rare as unique disease entities, Mendelian disorders are altogether more frequent than previously thought and collectively affect millions of patients worldwide.We describe a multidisciplinary integrated clinical diagnostic program situated in an academic medical center whose goal is to identify the genetic basis of presumptive undiagnosed Mendelian conditions. This differs from typical clinical diagnostic services, which primarily test for genetic variants whose association with clinical disorders is often supported by substantial prior evidence. The central premise that informs this multidisciplinary integrated model is that a particular subset of clinical genetics cases that are encountered in the hospital and outpatient setting offer unique opportunities for gene discovery and disease pathway elucidation and, in some cases, for the re-purposing of existing therapeutics or the advent of novel therapeutic and clinical management options Fig. .Fig. 1Wohttps://allofus.nih.gov), the Million Veterans Program (MVP) (https://www.research.va.gov/mvp/), the UK 100,000 Genomes Project (https://www.genomicsengland.co.uk), The Genome of the Netherlands,7 and Korean Genome and Epidemiology Study (KoGES).8 In addition, several smaller programs with a more precise focus on monogenic diseases, such as the National Institutes of Health (NIH) Undiagnosed Diseases Network (UDN),9 the Idiopathic Diseases of Man (IDIOM) study,10 the Centers for Mendelian Genomics (CMG),12 and the UK Deciphering Developmental Disorders (DDD),13 feature the application of genome sequencing integrated with clinical assessment and multidisciplinary gene discovery.At the present, several national sequencing projects aim to establish platforms for genomic epidemiology that include a health database and biobank. Most notably, these include the US “All of Us” Research Program  for patients presenting with a wide range of phenotypic traits and family history consistent with a Mendelian pattern of inheritance. A distinctive feature of BGM is its focus on undiagnosed monogenic disease cases that are refractory to standard diagnostic approaches. In addition, the program provides an integrated and continuous pathway from case ascertainment to treatment. Whenever reasonable, a new or improved management strategy is initiated for the patients based on novel genomic findings.The main objectives of the program described here are to: (1) use state-of-the-art clinical and research methods to discover the genetic causes of undiagnosed Mendelian cases; (2) provide new diagnostic and treatment options for these patients; and (3) promote the clinical implementation of genomic medicine by educating physicians and researchers to recognize possible genetic disorders. An important feature of this program and its accompanying team is its interdisciplinary nature. For example, in addition to academic physicians from different clinical specialties and subspecialties, the program includes clinical molecular geneticists, genetic counselors, and scientists with expertise in statistical genetics, genomic analysis, bioinformatics, molecular genetics, and experimental disease modeling. The interdisciplinary team is therefore well-equipped to tackle analytical and diagnostic challenges as they arise.The program team routinely includes about 25 members who meet weekly to review 1–3 cases. Meetings are typically structured around new case presentations or discussion of ongoing analyses for existing cases. New cases are presented by referring physicians with the goal of discussing the medical appropriateness of the case, and the a priori likelihood of a tractable solution via whole-exome and whole-genome sequencing (WES/WGS); a decision is then made about each case’s acceptance to the program. Decisions require a quorum of at least three clinicians and three biomedical scientists. If a case is accepted for WES/WGS, the patient and relevant family members are consented to BGM research protocol, samples are sent to a commercial sequencing provider, and the resulting BAM sequence files are analyzed further in-house using a genomic sequence analysis pipeline, as described below. The results of the in-house analysis pipeline are then curated and compared to the “clinical genomic sequencing” report, when available.Once the variant list has been generated, the referring physician and program team reconvene to discuss and refine the results. These meetings are typically preceded by a distribution of the case synopsis and variant list via a crowdsourcing portal, also described below. To accommodate busy clinical work schedules, referring physicians may participate either in person or via conference call. To encourage the participation of clinical faculty and physicians, the weekly case conference provides continuing medical education (CME) credit to clinical participants.To optimize the probability of solving a case, specific criteria are used to select cases and to determine their suitability for WES or WGS. These selection criteria include: (1) the likelihood of solving the case, which in turn is a function of the likelihood that a phenotype has an underlying monogenic etiology, the predicted inheritance mode, and the availability of the family members needed to solve the case; (2) the disease morbidity that might be alleviated if the case were solved; (3) the potential for scientific discovery ; and (4) the potential relevance of the case to more common diseases with similar phenotypes.16Clinicians from all clinical departments are encouraged to refer Mendelian cases that could have broad impact on patient care if the causal gene were identified. To date, physician champions in the departments of genetics, pediatrics newborn medicine, gastroenterology, cardiology, rheumatology, endocrinology, nephrology, dermatology, and hematology as well as the NIH UDN, and the National Institute of Dental and Craniofacial Research (NIDCR) FaceBase Consortium have referred most of the cases to the program. However, since the ultimate impact of solving a case cannot be determined in advance, all cases involving medically significant disease are potentially eligible for consideration. A genetic counselor and a clinical geneticist examine the referred patients and review all available medical records and the family history. Patients who appear to be good candidates for WES or WGS have their cases presented by their referring physician to the program, as described above, to determine whether they meet the inclusion criteria and to define the optimal testing strategy; for example, whether to use WES, WGS, or some intermediate approach such as chromosomal microarray. WES is ordinarily the default sequencing strategy, primarily for cost considerations, but factors favoring WGS include: (1) cases in which a chromosomal rearrangement, insertion or deletion, or copy number variation is suspected; (2) cases in which uniform genome coverage is preferred; and (3) cases in which a regulatory variant is assumed due to high suspicion of a specific monogenic etiology despite a negative WES. The cases selected for WES/WGS are described using Human Phenotype Ontology (HPO), which provides a structured, comprehensive set of terms for the phenotypic abnormalities characterizing human disease.Unlike many other similar programs that may accept undiagnosed cases at large, the cases selected for WES/WGS analysis via this program are unique in that in general they are not routinely solvable by conventional WES of the proband alone or by application of conventional clinical or commercial WES analytical pipelines. Thus, patients and family members undergo an informed consent process to participate in a research study and to have their data shared for a crowdsourcing analysis in accordance with an institutional review board (IRB)-approved protocol. To protect privacy, each patient is assigned an anonymous identification number at admission.Blood is drawn and DNA is extracted for WGS, or a combination of WES (to detect coding variants) and single-nucleotide polymorphism chromosomal microarrays to detect structural and copy number variants, and to conduct genome-wide linkage analysis if necessary. Sequencing is performed in a CLIA -certified laboratory when clinical indications for sequencing exist and once reimbursement by insurers is approved; otherwise, sequencing is conducted in a research laboratory.most remote affected available relative, most commonly a cousin, to reduce the number of candidate variants to the smallest number possible, ideally less than 10. Finally, individual cases without available relatives or cases where the phenotype requires both a discrete environmental stimulus and a genetic susceptibility variant can occasionally be solved from a single genome sequence.Our preferred sequencing and analytical approach utilizes specific inheritance models for each case in addition to the following assumptions to identify a small list of candidate variants without bias from known biological or phenotypic gene associations: (1) rare, severe, monogenic disease is typically caused by coding variants that are absent or extremely rare in the general population; (2) rare, severe monogenic diseases are caused by highly penetrant genetic variants. For example, in cases with only a single affected family member for which dominant de novo and recessive inheritance modes are each possible, our preferred approach is to sequence the trio consisting of proband and both parents and to analyze the proband’s variants with respect to the parental genotypes. In such a case, we expect to identify 1–2 de novo variants, 0–1 homozygous variants, and 2–5 compound heterozygous variants at allele frequencies lower than 0.1% in the population. In consanguineous recessive cases and/or recessive cases with available affected siblings, the DNA of the proband can be sequenced along with that of an affected sibling, and the shared recessive variants can then be further tested for appropriate segregation among unaffected siblings by simple PCR analysis or Sanger sequencing. In dominant cases with multiple affected family members, we prefer to sequence the proband in parallel with the Z score, and the probability of being loss-of-function intolerant (pLI)17  UDN9 and from the NIDCR FaceBase Consortium.21The two major components of the analytical pipeline include: (1) alignment and calling of sequence variants from WES/WGS data, and (2) interpretation of the functional consequences of the identified sequence variants Fig. . This pi)17 Fig. . In addiPutative causal variants must fulfill the following criteria: (1) co-segregation with the disease based on the inheritance mode; (2) rare with a minor allele frequency of 0.1% or less in all populations from unaffected consortia  and (3) predicted functional impact on the gene product.22 and (2) empiric functional experiments. For the latter, we use a wide range of experimental systems for biological validation of the top 1–3 identified candidate genes, including: (a) in vitro protein and biochemical assays to study the interactive and enzymatic effects of specific variants on protein function; (b) use of cellular models, including human induced pluripotent stem cells and CRISPR  to investigate the effects of gene inactivation or specific variants on cellular function; and (c) use of engineered zebrafish and mouse models to recapitulate human phenotypes.To establish the causality of variants identified by WES/WGS for a given case, appropriate follow-up studies are tailored to address the relevance of the gene and genetic variant to the disease phenotype in question, in collaboration with faculty across the academic medical center. This approach makes use of a flexible two-part strategy: (1) identifying additional cases  with a similar phenotype bearing presumptive functional variants in the same gene, typically via Matchmaker Exchange;23 One of the patients presented to our emergency department in acute respiratory distress during flu season. Electrophysiological studies performed with a collaborator demonstrated that the identified PIEZO2 variants affect biophysical properties related to channel inactivation and caused PIEZO2-dependent, mechanically activated currents to recover faster from inactivation, resulting in increased channel activity in response to a mechanical stimulus. These findings indicated that DA5 is caused by gain-of-function variants in PIEZO2.As an example Table , case 7,In sum, we pursue biological validation through collaboration with investigators with expertise in functional assays relevant to the discovered genes. Thus, whenever required, we seek to establish collaborations with scientists external or internal to our institution, whose expertise focuses on the gene or disease of interest.Solving undiagnosed and complex cases requires diverse knowledge and expertise. While many cases benefit from analysis via a “case champion” model in which one individual, usually with special knowledge of the disease or of a primary candidate gene, drives the analysis, this strategy is not always available or successful. To further help solve challenging cases we have implemented an innovative crowdsourcing strategy among faculty and staff to utilize specialized expertise across the entire academic medical center. Our crowdsourcing system is restricted to physicians, clinical staff, and research faculty of the parent institution. All cases are fully de-identified, allowing useful information to be shared without violating HIPAA  regulations or patient privacy. The HIPAA-compliant portal is securely installed behind a firewall and integrated with the institution’s authentication system  to provide controlled access.The patient data shared for crowdsourcing include de-identified clinical and laboratory details as well as a list of variants identified by WES/WGS Fig. . TogetheOur first 30 solved cases span a wide range of disorders presenting in children and adults and were drawn from multiple referral sources Table . CriteriSeventeen of the cases were solved using the crowdsourcing mechanism among ~50 participating faculty, scientists, physicians, genetic counselors, and fellows in our institution, while the remaining cases employed a case champion model. For example, one illustrative case that was resolved via the crowdsourcing mechanism involved a male infant with symptoms consistent with very early-onset inflammatory bowel disease (VEO-IBD) and hearing loss . The patient’s clinical and genomic data were posted on the program portal. A genetic counselor annotated the potential relevance of a novel gene variant with the comment that: “Variants in a homologous gene are associated with variable clinical presentations in patients with familial hemophagocytic lymphohistiocytosis (HLH) type 5 - sensorineural hearing deficit, abnormal bleeding, and, most frequently, severe diarrhea only present in early-onset disease infantile IBD and hearing loss.” In this instance, the annotation for the homologous gene provided an important clue that the variant was likely to be causal in the VEO-IBD case. The significance of this variant was subsequently confirmed by the identification of seven additional VEO-IBD cases that involve loss-of-function variants in the same gene, and by accompanying functional studies .23 To ascertain additional cases, we make extensive use of Matchmaker Exchange,21 as well as of ad hoc inquiries to other investigators who are actively working on phenotypically related conditions. In the case of the patient with VEO-IBD and bilateral hearing loss described above, additional unrelated cases with deleterious variants in the same gene were identified using Matchmaker Exchange and inquiries to external investigators including the VEO-IBD consortium (www.veoibd.org). Indeed, in this specific case, engagement across multiple institutions resulted in a fruitful collaboration with BGM. This work ultimately led to a novel disease gene discovery and diagnosis for multiple families .The identification of additional unrelated patients with overlapping phenotypes and deleterious intragenic variants in the same gene constitutes a powerful strategy to establish the causality of a given candidate disease gene of uncertain clinical significance.In a second illustrative example Table , case 5,PIEZO2 gene in an independent case, thus establishing causality. This led to a multi-institutional discovery of PIEZO2 as the cause of DA5.23In some cases, collaborators may also serve as matchmakers, by introducing additional related but independent cases. For example, in our investigation of the case of DA5 that involved musculoskeletal contractures and severe restrictive lung disease, an experimental collaborator whom we had contacted connected us with Norwegian clinicians who had identified a second intragenic variant in the When sufficient evidence supports a causal relationship between a genetic variant and a disease phenotype, our group discusses the results with the patient’s referring physician and other pertinent clinical consultants in the context of the regular weekly meeting. For cases in which empiric management previously provided little benefit, additional therapeutic interventions may also be discussed. A comprehensive written report of the findings and potential treatments suggested by the genetic mechanism is submitted to the referring physician. Variants identified in research-based analyses are independently confirmed in a CLIA laboratory in accordance with return of results process defined in our IRB-approved protocol. The referring physician invites the patient and other relevant family members to visit the clinic for an on-site discussion of the results and for counseling, typically with a medical geneticist and/or a genetic counselor. This formal return of results provides a satisfying culmination to the genomic evaluation process, which is important since the overall process for each case often takes many months. The turnaround time for cases with novel gene discovery is 6 to 18 months, where the rate limiting steps are (1) the experimental work required to elucidate the function of the candidate gene (when it is unknown), and the functional impact of the candidate variant; and (2) the identification of independent cases with similar phenotypes caused by variants in the same gene.The main distinction between BGM and other programs aimed at clinical diagnosis of suspected monogenic disease is that our main focus is on discovering novel disease–gene associations, most typically in undiagnosed disease states. For this reason, cases with recognizable or known phenotypes are either directed elsewhere or are initially screened for the extant disease-causing variants linked to those phenotypes. Therefore, the majority of cases that come to the attention of the program described here are non-routine, high-complexity cases, and often referred from other programs, where they were deemed intractable.28To date, we have enrolled 244 families, sequenced DNA from 122 patients, along with additional samples from informative family members, analyzed 106 of these cases ,23LOX ,29WISP3 (precocious arthritis),30CHST11 ,31 complement factor C3 gene , several cases of undiagnosed craniofacial dysmorphoses, and a gene that causes a rare form of lung cancer  among others.Additional examples of significant disease-associated gene identifications, summarized in Table CAPZB  case  safety guidelines, might augment the Cu2+-dependent enzymatic function of LOX and therefore help protect against aortic disease in individuals carrying this variant. This hypothesis is now directly testable in a murine model where the specific genetic variant has been knocked-in to the endogenous Lox locus. In addition, family members carrying the p.Met298Arg variant are now being serially monitored by echocardiography and by magnetic resonance angiography for aortic dilatation, which may prevent significant morbidity and mortality when identified early in the course of disease rather than at the time of rupture.Other successful case analyses illustrate the potential of a modern genomic medicine service to provide insight into disease-causing pathways of direct therapeutic importance. For example, a 35-year-old Caucasian male presented to the hospital for evaluation of a personal and family history of thoracic aortic aneurysm and dissection (TAAD). He had undergone surgical repair of pectus excavatum at 2 years of age and was diagnosed with a large ascending aortic aneurysm at age 19. Based on these anomalies and other physical features including tall stature, high arched palate, and dental crowding, as well as a family history consistent with an autosomal dominant mode of inheritance, he was diagnosed of Marfan syndrome. However, genetic testing identified no variants in Despite the successes mentioned above, programs for integrated genomic medicine, such as that described here, face a number of challenges. These include the time required to accumulate evidence for disease causality of candidate genes and variants, the development of a standardized clinical classification guideline for variants of uncertain significance, gaining acceptance of clinical reimbursement standards among third-party payers, and assessing and reporting incidental findings. For example, in addition to the 30 solved cases reported in Table 37 We have begun to prepare to utilize these changes to CPT coding and billing to maximize the clinical reimbursement for WES/WGS. Recognition of the clinical utility of WES/WGS by clinical and translational research programs will hopefully provide payers with a logical framework in which to evaluate evidence for the value of genomic medicine to the health care system.In addition, while the cost of clinical WES/WGS has dramatically declined in recent years, the reimbursement policies of health insurance companies and payers remain heavily biased to single gene tests and gene panels. Though insurance companies are starting to recognize the significant clinical utility of genomic sequencing, initiatives such as ours have been funded by institutional and extramural research sources. Ultimately, we envision that the secondary analysis of genomic sequencing and the integrated clinical practice of genomic medicine will be supported by third-party payers. Currently, the research components of such programs continue to depend upon institutional and some targeted extramural support. Ultimately, the funding of patient-level experimental biology may be reflected in the reimbursement for clinical care, much as therapeutic drug trials are currently cross funded by payers in oncology. To this end, we plan to leverage the billing expertise of the Brigham and Women’s Hospital Departments of Medicine  and Pathology , while implementing the new revenue streams available under the revised coding structure for genetic testing. In January 2015, the American Medical Association (AMA) released revised Current Procedural Terminology (CPT) codes that reflect recent advances in genomic medicine, including WES/WGS and the re-evaluation of existing sequence data for both patients and family members.Recent advances in genomic sequencing have enabled the resolution of undiagnosed cases of human disease and can provide answers to families and clinicians. The model described here is based on well-defined genetic entry points into human biology that lead to disease gene discovery, with both clinical implications and subsequent mechanistic evaluation. This model integrates state-of-the-art genetic research with innovation across multiple domains, including a refined computational analysis pipeline, translatable functional assays, improved clinical phenotyping, and therapeutic intervention. As this program effectively assimilates a multidisciplinary team of clinical and research expertise in the task of diagnosing and treating these debilitating conditions, this integrated monogenic disease gene discovery model can be readily adapted by other academic medical centers. Lastly, by promoting the clinical implementation of genomic medicine, the genomic medicine program described here also affords a unique educational opportunity for trainees and investigators across many disciplines of biomedicine.Additional data supporting the findings of this study are available within the supplementary information files. The genomic datasets generated and/or analyzed during the current study are not publicly available due to data and privacy protection considerations but may be available on justified request.Supplementary Information


Inclusion criteria: researcharticles in full, in Portuguese, English or Spanish without any temporalcut-off. The descriptive analysis was adopted to categorize the instrumentsfound into the three domains of care: evaluative, preventive and curative.an integrative review that selected 32 articles from the PubMed/Medline,LILACS, Scopus and CINAHL databases using the descriptors NationalPressure Ulcer Advisory Panel (NPUAP) and the EuropeanPressure Ulcer Advisory Panel (EPUAP). 25 instruments for the care of pressure injuries in pediatric and hebiatricpatients were found, with an emphasis on the Braden Q Scale being the mostcommonly used to assess pressure injury risk, and the protocols containingpressure injury staging guidelines developed by the the scientific literature has valid and reliable instruments that can be usedin nursing care practice aimed at the evaluative, preventive and curativecare of pressure injuries in pediatric and hebiatric patients. The care for hospitalized children and adolescents requires the nursing team torecognize their needs, taking into account the different stages of developmentAmong these technologies, we can highlight instruments that express systematizedthinking with a specific purpose, which represents a record/registry and promotesand guides the care process. They can be represented as a consultation script, ascale, a functional organization chart, a protocol, a checklist, or a questionnaire,among otherspressure injury” has been used to replace theterminology of pressure ulcer previously used by healthprofessionals, a change that took place in April 2016Indicators have been studied in seeking care quality, benefiting hospitalizedpatientsStudying pressure injuries is important, since prevention and treatment areattributed as a way to reduce patients hospital stay and thus diminish costs,prevent infections and improve patient prognosisData collected regarding the prevalence of pressure injuries in the United States inhospitalized patients aged 0 to 18 years showed prevalence rates of 1.4% andprevalence of hospital-acquired pressure injuries of 1.1%. Rates are even higheramong patients in pediatric intensive care units (3.7%) and pediatric rehabilitation(4.6%), while the general pediatric units had a lower prevalence (0.57%)In this context, nursing professionals use care technologies that include knowledgejustified by scientific principles and proposals of techniques, procedures andknowledge for their care practiceBased on the risk of developing pressure injuries in pediatric and hebiatricpatients, the use of instruments so that specific interventions are incorporatedinto patient care is urgentIn view of the above, we consider it is fundamental to promote the discussion aboutthe instruments used in the care of pressure injuries in pediatric and hebiatricpatients. Considering the importance that instruments which focus on the care of pressureinjuries in this population have for nursing professionals, an integrative reviewwas carried out with the objective to identify existing instruments in thescientific literature about the care of pressure injuries in pediatric and hebiatricpatients.This is an integrative review of literature in the field of pediatrics and hebiatricson instruments for the care of pressure injuries. Six steps were followed for thisreview: identifying the theme and selecting the hypothesis or research question toelaborate the integrative review; establishing criteria for inclusion and exclusionof studies/sampling or search in the literature; defining the information to beextracted from the selected studies/categorization of the studies; evaluating thestudies included in the integrative review; interpreting the results; and presentinga knowledge review/synthesisThe searches were conducted from October to December 2016, guided by the followingquestion: which instruments exist in the scientific literature for the care ofpressure injuries in pediatric and hebiatric patients? Medical SubjectsHeadings (MESH). For this procedure, two independent researcherssimultaneously performed the collection by combining the search terms in eachdatabase. The searches at SCOPUS, PubMed/Medline and CINAHL databases were initiallyperformed in relation to pediatrics, according to the following crosses:pressure ulcer AND pediatrics ANDprotocols; decubitusulcer AND pediatrics ANDprotocols; pressureulcer AND pediatrics; decubitusulcer AND pediatrics; pressureulcer AND protocols; e decubitusulcer AND protocols. Although pediatrics is defined inthe DeCS and MESH as a specialty aimed at maintaining health and providing care tochildren from birth to adolescence, the databases were also searched in relation tohebiatrics using the crosses: pressure ulcer ANDadolescent AND protocols; decubitusulcer AND adolescent ANDprotocols. In addition to the English equations in the LILACSdatabase, variations of the descriptors in Spanish and Portuguese were used. The following databases were used: National Library of Medicine and NationalInstitutes of Health (PubMed/Medline); Latin American and Caribbean Center on HealthSciencies Information (LILACS); SCOPUS and Cumulative Index to Nursing and AlliedHealth Literature (CINAHL), based on the descriptors of the Health SciencesDescriptors (DeCS): pressure ulcer, decubitus ulcer, pediatrics and protocols, andtheir equivalents in English/Portuguese in the We chose the age group between 0 to 19 years according to the World HealthOrganization (WHO) classification, which considers those up to nine years of age aschildren, and those in the chronological limit between 10 and 19 years asadolescentsThe inclusion criteria were: answering the guiding question; constituting a researcharticle available in full in Portuguese, English or Spanish with no temporalcut-off; published in scientific journals and available electronically.The following exclusion criteria were adopted: literature review, editorials,reviews, case reports, case studies, theoretical reflections, dissertations, theses,monographs and abstracts published in event archives. Repeated articles were alsoexcluded, thus only maintaining the first identified version. checklist, questionnaire, computerized system and form), thepopulation and the application environment of the instruments. The study selectionfollowed the recommendations of the Preferred Reporting Items for Systematic Reviewsand Meta-Analyses (PRISMA)An instrument prepared by the authors was used in order to collect the data, in whichthe necessary information to answer the research question such as titles, authors,years, bases, objectives, environments, populations and instruments used wereorganized. In addition to the data characterizing the studies, we sought to extractinformation about the type of instrument  instruments for the care of pressure injuries in pediatrics andhebiatrics were identified from the 32 articles of this review. Of these, 13referred to evaluative care, five to evaluative/preventive care, four to preventivecare, one to curative care, one to preventive/curative care and one toevaluative/preventive/curative care. Braden Scale,Braden Q Scale, Braden Q+P Scale,Glamorgan Scale, Garvin Scale,Pediatric Pressure Ulcer and Evaluation Tool and theStarkid Skin Scale. The articles did not include informationabout the validation process regarding other instruments. The articles highlighted the validity and reliability of seven instruments:The Pediatric Intensive Care Unit (PICU) was highlighted regarding the applicationenvironment of these instruments with 17 articles. Regarding the population, 20articles contemplated hebiatrics. Among the selected articles, most of them were published in 2013 (seven articles),with a decrease in the following years for 2014 (three articles) and 2015 (threearticles), while five articles were identified in 2012. Two articles were publishedin the following years: 2011, 2010, 2009 and 2003. The years with the least numberof publications were: 2007, 2006, 2005, 2002, 1996, 1994, with only one articleidentified each year. No publications on the subject were identified in the years2016, 2008, 2004, 2001, 2000, 1999 and 1995. The main language of dissemination was English (30 articles), followed by thosepublished in Portuguese (two articles). The predominance of English demonstrates itsadoption as the main language of dissemination established by several journals inthe world. However, this preponderance does not indicate that the selected articleswere produced in countries with that language. Most articles were developed in theUnited States (16 articles), Australia, England, Brazil and Switzerland (twoarticles each), Spain, India, Nigeria, Jordan, Canada, Germany, China and Wales (onearticle each). Three figures were organized according to the types of instruments found in order tofacilitate comprehension. According to Regarding the protocols , apredoAccording to In the search for instruments aimed at the care of pressure injuries in pediatricsand hebiatrics, we have identified predictive scales for evaluating the risk ofdeveloping lesions, and evaluation scales for the characteristics of installedlesions, protocols and other instruments in the three care domains: evaluative,preventive and curative. The risk for pressure injury can be identified by applying the scales. The oldestpublication of this review using the Braden Scale dates back to 2003Braden Q Scale. It was created in 1996, constituting as a toolspecifically for pediatric pressure ulcer risk assessmentBradenScale, in addition to “tissue perfusion and oxygenation” as the seventhsubscale, reflecting that scale modifications reflect unique developmentcharacteristics of pediatric patients. Patients only receive one score per subscale,which is scored from 1 (least favorable) to 4 (most favorable). The total Braden Qscale ranges from 7 (highest risk) to 28 (lower risk), where scores below or equalto 16 identify pediatric patients at risk of developing pressure injuryThe Braden Scale was adapted for the pediatric population and entitled theThe Braden Q Scale has also been modified and adapted, constituting the Braden Q + PScale, which is targeted at pediatric patients undergoing cardiac surgery as part ofa comprehensive pressure injury prevention initiative that guides the planning ofnursing interventionsthpercentile, and Incontinence (inappropriate for age) are classified as 0 or 1. Thescores of the items are summarized in scores resulting between zero and 42. Thehigher the score sum, the higher the risk of pressure injuryOther scales were also found in the review, among them the Glamorgan Scale, designeddirectly for children and adolescents. It consists of nine items: mobility, pressureequipment, anemia, pyrexia, peripheral perfusion, nutrition, serum albumin, weightand incontinence. The mobility item consists of four categories that can beclassified as 0 , 10 ,15 (unable to change position without assistance/cannot control body movement), and20 (child cannot be moved without great difficulty). The equipment/objects/hardsurface pressing or rubbing on skin item can be classified as 0 (no) or 15 (yes)points. The items significant anemia (Hb < 9g/dl), persistent pyrexia(temperature > 38°C for more than 4h), poor peripheral perfusion (coldextremities/ capillary refill > 2 seconds/cool mottled skin), inadequatenutrition, low serum albumin (<35 g/l), weight less than the 10The Glamorgan Scale has been modified (mGS), and even though it is simpler in termsof usability and efficiency, it has been observed that this tool is equallyeffective in categorizing patients as the original Glamorgan Scale, producing thesame categorization of risk in the assessment of pediatric patientsBy using the area under the ROC curve to compare the Braden Q Scale  with the Glamorgan Scale , it was observed that both have the same predictive power sincethe confidence intervals overlapped. Both scales probably have similar validity inthe Pediatric Intensive Care Unit  and in the NeonatalIntensive Care Unit  and for more serious injuries,although the Braden Q has shown better results in pediatric wards In addition to these scales, the Garvin Scale is based on four risk factors:mobility, sensory perception, nutrition and moisture, in which a total score is usedto divide children into categories with increasingly intense interventions as therisk increasesThe comparison between the Glamorgan Scale, the Braden Q Scale, and the Garvin Scaleidentified that the Glamorgan Scale has a greater predictive power than the Braden Q scale  or the Garvin scale Neonatal Skin Risk Assessment Scale - NSRA)Visual Analogue Scale-VAS)Starkid Skin Scale)Other assessment scales were found addressing skin ruptures in neonates(Bates-Jensen Wound Assessment Tool (BWAT)was also found, which differs from the others as it evaluates installed injuries byconsidering the following aspects: wound size, depth, edges, undermining, type ofnecrotic tissue, amount of necrotic tissue, granulation tissue, epithelialization(tissue), type of exudate, amount of exudate, surrounding skin, peripheral edema andhardening of the peripheral tissue. This tool has 13 items that use a modifiedLikert scale in which a score of 1 indicates the healthiest, and 5 the unhealthiestattribute for each trait. The total score of the scale is obtained by adding theindividual scores of each evaluation item, with the total value ranging from 13 to65Bates-Jensen Wound Assessment Tool - Brazilian versionIn addition to these, the Pressure Ulcer Prediction and EvaluationTool (PPUPET) is a scale that evaluates aspects related tomobility, activity, sensory perception, humidity, external medical devices,friction/shear, perfusion and tissue oxygenation, skin condition and nutritionThe In view of the above, nurses could more accurately determine interventions forprevention and treatment of pressure injury by applying a predictive risk scale andperforming a clinical evaluation, then using this data to conduct a care plan forpressure injuriesNationalPressure Ulcer Advisory Panel (NPUAP) and the European PressureUlcer Advisory Panel (EPUAP), which are recommendations based onevidence for evaluating pressure injuries to be used by health professionalsworldwide, helping to choose interventions related to pressure injuryAmerican HealthCare Research and Quality (AHRQ), which has the mission of producingevidence to make health care safer, affordable, equitable and of higher qualityQuality-improvement guideline, which isfocused on reducing the rate of pressure injury in pediatric and neonatal intensivecare unitsPractice guideline and skinbreakdown was created to direct the practice and guide theprofessionals of pediatric cardiac intensive care units about interventions forpossible problems of skin rupture in patientsCare plans can follow existing guidelines and protocols. Some publications haveadopted the guidelines for pressure injury staging developed by the Bundle Pressure Ulcer PreventionProgram (PUPP) was evaluated to determine whether there is anassociation between its implementation and a significant reduction in thedevelopment of pressure injury in a pediatric intensive care unitProtocols for the prevention and/or treatment of pressure injury are also part ofexisting instruments for such purposes. The Skin care pathway was developed for standardizing care aimed atpreventing pressure injury complications arising from orthopedic corrections inchildren and adolescentsThe Another protocol sought to compare the effect on healing when nursing care wasreceived alone by adolescents older than 15 years of age with spinal cord injury whohad pressure injury, with the implication on wound healing in nursing care combinedwith laser treatment or with an ultrasound/ultraviolet C. The results demonstratedthat they can shorten the healing time, which allows a faster return torehabilitation programs, to work and leisure activities for patients with spinalcord injury who have pressure injuryIn this review, we have identified a protocol for preventing pressure injurydeveloped in 1996, which sought to provide nurses with tools to assist them inmaking clinical decisions regarding pediatric patients with potential or actualchanges in their skin integrity. The components of this protocol included a riskassessment tool for the development of pressure injury (Braden Q), a skin carealgorithm to decrease unnecessary variation in preventive care practices and apressure injury algorithm to reduce unnecessary variation in staging and managementof patients with pressure injuryDutch National PrevalenceMeasurement of Care Problems (LPZ), which includes the followingcategories for evaluation: patient characteristics ;assessment of the location and severity of pressure injuries; assessment of the riskof pressure injury according to the Braden Scale; predisposing factors for thedevelopment of pressure injury; preventive interventions and therapeuticinterventionsAnother questionnaire type instrument found was the An instrument developed by Bours et al. was used to assess prevalence, severity, riskfactors, and preventive and therapeutic interventions for pressure injuries. Thisincludes six data categories to be collected: characteristics of the healthfacilities, the ward or the staff, from the patients , an evaluation of the risk of developing pressure injury using the Bradenscale, assessment of the severity of pressure injuries and preventive interventionsimplementedOne of the publications in this reviewKids safe checklist)comprising eight care areas for patients in pediatric intensive care units:developmental needs, infection, prophylaxis of deep venous thrombosis, skinintegrity, sedation, analgesia and enteric needs. This checklist incorporatesimportant priorities for members of the multidisciplinary team and can be easilyadapted to local needsAnother instrument was developed to undertake holistic pediatric care, incorporatingthe physiological and developmental requirements of children and adolescents,focusing on preventable adverse eventsIn general, the instruments were aimed at children and adolescents; however it can bequestioned whether those instruments aimed only at pediatrics could not be adaptedand used for hebiatric/adolescent patients, since both groups are at risk ofdeveloping pressure injuries. As a contribution to clinical practice, this integrative review grouped andsynthesized knowledge on instruments for the care of pressure injuries in pediatricsand hebiatrics with the purpose of making evidence-based practice of healthprofessionals feasible in the care of children and adolescents.As a limitation we can point out the methodological data collection from the studies,considering that many did not explicitly present a description of the study type,making it difficult to identify the levels of evidence. The results obtained in this review show 25 existing instruments in the literaturethat can be used for the care of pressure injuries in pediatric and hebiatricpatients, including scales, protocols, system, forms, checklists and questionnaires.We point out the Braden Q scale was the most used instrument to assess the risk ofpressure injury. With regard to protocols, we can point out adopting the guidelinesfor the staging of pressure injuries developed by the NPUAP and the EPUAP. Although pressure injury is not very common in this population, the results havecontributed to show that the subject has been studied and that the instruments forevaluative care have been most used to provide qualified and safe care in pediatricsand hebiatrics. In view of the above, nurses have instruments available to evaluate, prevent andtreat pressure injuries, which will assist in creating and implementing a specificcare plan based on scientific evidence. Skin care is one of many nurses’ roles, however these professionals must worktogether with the multiprofessional team to assess, prescribe and implementpreventive and curative care of pressure injuries by making use of the technologiesin this process.