This project investigates the effectiveness and feasibility of scaling-up an eco-bio-social approach for implementing an integrated community-based approach for dengue prevention in comparison with existing insecticide-based and emerging biolarvicide-based programs in an endemic setting in Machala, Ecuador.An integrated intervention strategy (IIS) for dengue prevention  was implemented in 10 intervention clusters from November 2012 to November 2013 using a randomized controlled cluster trial design . Current existing dengue prevention programs served as the control treatment in comparison clusters. Pupa per person index (PPI) is used as the main outcome measure. Particular attention was paid to social mobilization and empowerment with IIS.Overall, IIS was successful in reducing PPI levels in intervention communities versus control clusters, with intervention clusters in the six paired clusters that followed the study design experiencing a greater reduction of PPI compared to controls . Analysis of individual cases demonstrates that consideration for contexualizing programs and strategies to local neighborhoods can be very effective in reducing PPI for dengue transmission risk reduction.In the rapidly evolving political climate for dengue control in Ecuador, integration of successful social mobilization and empowerment strategies with existing and emerging biolarvicide-based government dengue prevention and control programs is promising in reducing PPI and dengue transmission risk in southern coastal communities like Machala. However, more profound analysis of social determination of health is called for to assess sustainability prospects. Ecuador has identified all four dengue serotypes within its borders and the vector, Aedes aegypti, is distributed throughout the tropical, subtropical regions of the country as well as all of its islands.4 Moreover, there has been poor integration of approaches to dengue prevention; especially with regard to primary education, social mobilization, poverty and deficiency of basic public services as determinants for dengue transmission.5 Dengue control programs in Ecuador, as with many countries in the Americas, rely on government application of temephos larvicide, deltamethrine adulticide and Bacillus thuringiensis israelensis (bti)-based biolarvicide.8 Present vector control strategies have not succeeded in maintaining vector populations below the levels required to eliminate dengue transmission in endemic regions; however, emerging collaborative work in Machala has developed new integrated approaches to dengue management that focus on community empowerment and determinants of health as well as vector source reduction.Dengue is a major public health problem in Ecuador,12 The relation of this trend to current ‘global change’ factors  has drawn further attention to the need to address this growing health threat. With 50–100 million worldwide cases of dengue fever occurring annually and an estimated 2.5 billion people living in areas endemic for dengue virus transmission,15 the development of effective control and prevention strategies based on the best science and context-specific knowledge is urgently required. Both ecological and social system challenges must be addressed; it is essential that ‘bridges’ to effective control and prevention be built by facilitating participatory, community-based and transdisciplinary approaches16 to overcome institutional barriers.It has been consistently documented that the incidence of dengue fever/severe dengue has increased at an alarming rate in the Latin America and Caribbean region, with epidemics becoming larger and more frequent.9 The ecosystems approach to human health  has been a successful eco-bio-social model used in vector control programs at a local level.21 Communities in Machala have been vocal about the need for alternative vector control and dengue prevention strategies,12 prompting research by epidemiologists, public health officials, vector control officials and university researchers to explore and pilot new prevention efforts based on the eco-bio-social paradigm or the ecohealth, which views human health as a product of and determining force on the ecosystems that people live and work in. While Ecuador reports implementing the Integrated Management Strategy for the Prevention and Control of Dengue  in 2010,4 common challenges remain in ensuring sustainability of social mobilization and social communication elements, as well as operational challenges in assuring adequate coverage of vector source reduction campaigns and reducing dependence on insecticides.8 The work presented here seeks to provide applicable, locally contextualized operational research on these fronts.There is a growing movement and evidence base to support the fundamental change in vector control and dengue prevention, both in practice and in policy, to a community-based participatory model centered around an eco-bio-social approach.11 that established the feasibility and efficacy of conducting community-based interventions to promote the prevention and control of dengue applying an ecosystem approach to human health. The first study11 applied a comprehensive dengue elementary school education program (DESE), including classroom knowledge, practical skill development and application . The second study11 evaluated a 6-week participatory ‘Clean Patio and Safe Container’ (CPSC) strategy focusing on removing discarded or unused containers/materials from patios, and brushing out and covering ground-level tanks to prevent Ae. aegypti breeding sites within the peri-domestic area . Both small-scale pilot studies documented improvements to house index  and Breteau index  measures at the household level, as well as the interest of diverse stakeholders for active involvement in addressing the complex community health challenge of dengue. Integrating these two locally successful approaches and applying them to serve a larger population at risk may provide insights into sustainability and operational challenges experienced with IMS-Dengue in Machala. Further, this study provides the timely opportunity to explore the potential use of the pupa per person index (PPI) as a vector control outcome measure to complement the current use of HI and BI outcome measures by the Ministry of Health National Vector Borne Disease Control Service (SNEM).This collaboration's overarching objective was to better understand the effectiveness and feasibility of applying an integrated ecohealth approach to dengue prevention and control in endemic urban and peri-urban settings marked by infrastructural weaknesses. It builds on two separate participatory action research pilot studies based in MachalaHere we examine the effectiveness of applying an integrated community-based approach to prevent and control dengue in a vulnerable endemic setting and analyze its implementation in comparison with current government programs, and we investigate the effectiveness and feasibility of scaling up an ecosystem approach to dengue prevention and control amid the resurgence of dengue in southern Ecuador.Ae. aegypti are present year-round with high vector indices . Essentially, Machala exists in a perpetual state of risk for outbreaks and epidemic transmission of dengue with frequent outbreaks and an average incidence of 28.5 cases per 10 000 popluation.5Aedes indices historically peak between February and April, following the precipitation trend of the rainy season (October to March) and reported cases of dengue routinely closely follow this trend. Recurrent outbreaks and epidemics are becoming more frequent in Machala due to local climatic variation manifesting in lengthened and less predictable rainy seasons.12Machala is the capital of El Oro , the southernmost province on Ecuador's Pacific coast where 41.4% of the population lives at or below the poverty line. Machala's many peri-urban and semi-rural neighborhoods are characterized by unplanned urbanization, basic infrastructure and provision of basic services, and low housing quality. 6) to select and include 20 clusters of 100 households in a randomized controlled cluster trial (RCCT). Using a satellite image map of Machala generated by Google Earth23, we generated a base map of city blocks, residential areas, roadways, public buildings and green spaces within municipal jurisdictional boundaries upon which to build the study design. Using the PPI as the outcome measure,6 and assuming a PPI value of 0.4 and an expected reduction of 75% after intervention, the power of estimation at a 5% level with this sample size is larger than 90%, comfortably covering possible non-responses.We used a two-stage sampling design  socio-economic indicators and baseline PPI, with random selection of the intervention site.Comparative analyses for the RCCT were based on data collected through the use of both entomological and household surveys informed by the Theory of Planned Behaviour.Within the overall objective of comparatively analyzing effectiveness and sustainability of an eco-bio-social ecohealth-style approach to dengue prevention and control with conventional government-mandated programs, 10 clusters were randomly assigned for the intervention and 10 for the control. The integrated intervention strategy (IIS) was introduced in each intervention site to promote acculturation to the eco-bio-social approach and included a DESE  coupled with a CPSC  program incorporating social mobilization strategies:Ae. aegypti and laboratory observation of the different life stages of the vector. This was followed by a practical learning session in a neighborhood location providing practical education enabling children to practically apply their knowledge in their own context. Classroom sessions were repeated every 6 months, with once-monthly follow-up practical pupal collection ‘homework’ assignments where children collected mosquito pupae specimens from their own homes and submitted to DESE personnel for identification at the SNEM vector entomology lab. Classroom and follow-up assignments were administered by health educators, public health practitioners and frontline vector control personnel, and results were returned to the community within 10 days. The expected outcome of the practical sessions is that children are able to identify, record and control  mosquito-breeding sites in their immediate environment. This program is designed with specific elements for child empowerment and social mobilization for children as emerging health leaders in their own communities.From October 2012 to November 2013, DESE was rolled out in a step-wise way in schools and community centers for children aged 8–12 years in participant households. Four 30-minute classes over 2 weeks taught modules about the symptoms of dengue, the dengue transmission cycle, the lifecycle of the mosquito Ae. aegypti breeding sites in peri-domestic areas, community volunteer CPSC activators  were recruited from within each cluster. SNEM health promoters supported CPSC activators by coordinating house inspection dates and collecting datasheets for project databases; SNEM employees did not accompany activators on their house visits once training was complete. Once-monthly community-directed visits to participant homes cataloged the state of the patio based on three criteria: (1) cleanliness , (2) weed and plant removal (elimination of mosquito sanctuary in wild plants) and (3) orderliness . CPSC data collection recorded condition of the patio, identified and enumerated breeding sites positive for water, larva and/or pupae, and numbers of pupae present in each participant home; monthly visit forms were processed by SNEM health promoters. Households repeatedly showing poor indices over a 3-month period were flagged by community inspectors for support by vector control personnel to collaboratively seek solutions to address underlying dynamics of identified dengue risks. Community CPSC activators were recruited in October 2012, with program rollout unfolding in eight of the ten intervention clusters from an initial fully supported month-long program launch and scaled-up ‘pilot’ in November 2012. This initial intensive capacity-building and human resource investment ensured communities were trained, willing and able to run CPSC efforts without continued intensive support from vector control and Ministry of Health staff; it was also used to assess levels of community capacity in this respect. The majority of communities independently carried forward the CPSC program using built capacity. Continued capacity building and human resource investments for the duration of the implementation window were offered to communities with higher risk factors and special considerations from November 2012 to November 2013.Using community empowerment and social mobilization to eliminate Ae. aegypti control in response to suspected and confirmed dengue cases) intradomiciliary deltamethrine fogging using backpack sprayers, and neighborhood vehicle-mounted malathion fogging. Once or twice yearly household visits by vector control workers are conducted to monitor entomological indices. However, from April 2013 SNEM dengue control strategies were significantly altered in Machala by the rollout of a new federally mandated bti-biolarvicide-based control program characterized by a huge increase in government vector control worker presence, educational and technical intervention in individual homes and communities. In this revised monitoring and control strategy, a vector control technician/frontline worker visits each home in Machala twice per month to educate household members on mosquito-breeding source reduction, to apply biolarvicide, educate around biolarvicide application, leave a small quantity of biolarvicide for domestic use until the next visit, and inspect/record/educate/eliminate mosquito-breeding source containers. Although the new strategy does incorporate eco-bio-social elements, it is currently in the pilot stage and full integration of these elements has not been achieved, nor has full coverage of Machala to date. The biolarvicide-based program was incrementally rolled-out and implemented during the intervention period resulting in a temporally and geographically varied mix of baseline control programs in control clusters. This called for a more sophisticated analysis than had been originally planned, to ensure that the intervention's effect would focus on those cluster pairings that remained faithful to the study design.Conventional SNEM dengue prevention and control strategies included the use of temephos larvicide (Abate) as a preventive breeding-source control measure, coupled with routine (blanket mosquito control) and reactive  as the independent variable, our model is:The effect of the intervention compared to the control is expressed as the difference in the log (pupa rate) between the two models where ‘b’ is the additive difference on a log scale.26 To compare observed versus expected pupal distributions within each cluster pairing, we also applied a χ2 test. Due to the complexities of IIS implementation introduced by the concurrent rollout of new Ministry of Health biolarvicide mosquito control programs, we organized our analysis to highlight those clusters where the original study design was successfully applied and where there were no confounding municipal interventions, while considering the effects of the biolarviciding program as a confounder in those sites where it had been introduced. This effectively excluded clusters where not all the interventions had been introduced as planned as a result of implementation personnel being overextended with the biolarviciding program , and pair 7  where effects were observed due to substantially improved infrastructure and basic services being introduced during the study period.We then applied a generalized estimating equations (GEE) analysis that is appropriate for a randomized cluster design study.Informed consent was obtained for each household and child participant recruited to the study prior to their participation. This collaborative work partnered communities, researchers and governmental decision-makers to validate and approve the integrated intervention strategy: Ministry of Education, Ministry of Health, Ministry of Health National Vector Borne Disease Control Service (SNEM), Provincial Government of El Oro, Municipal Government of Machala, Parish Councils and Community Councils.A total of 1986 households participated within the 20 cluster RCCT, with 4014 residents in intervention households and 3886 in control households  increases generalizability and improves the evaluation of efficacy of the programs through a more accurate estimation of adult vector abundance.30 Our multifactorial approach, integrating social mobilization, addressing proximal environmental determinants of dengue transmission risk (peri-domestic vector breeding site reduction) and engagement in intersectoral collaboration, has shown a significant reduction in PPI at the scaled-up level .The eco-bio-social approach is particularly promising for dengue prevention and control as the presence of the vector and its density depends on the human population, human behavior and how these affect the surrounding environment.bti-biolarvicide dengue prevention program in the study area and adjacent areas.Each cluster had its own unique context and dynamics that affected IIS implementation resulting in varying degrees of eco-bio-social intervention success. Community-driven implementation of the CPSC in two cluster communities required continuing capacity-building support and human resource investment: Sauces #1 (cluster 14), a neighborhood frequently flooding, poor infrastructure and solid waste collection, and significant public insecurity; and Mario Minuche (cluster 19), a peri-urban neighborhood characterized by inadequate housing, poor solid waste collection bordering on an uncovered canal. Implementation of IIS following original experimental design was not achieved in pairs 1, 2 or 4 due to saturation of skilled human resources for vector control and the incremental rollout of the SNEM Further, the significant reduction of PPI in control cluster 2  is a direct result of long-standing and ongoing community-based political action by the neighborhood council and neighborhood president that saw the realization of a full neighborhood revitalization project in collaboration with the Municipal Government of Machala during the intervention period. Prior to revitalization, Simon Bolívar's dengue transmission risk indicators were high (PPI 1.123), with many residents lacking potable water in their homes, significant gang activity and social insecurity in the neighborhood, poor and sometimes lacking roadway infrastructure and garbage collection, and inadequate housing. The revitalization included basic infrastructure such as installation and improvement of sewers and storm sewers, roads, sidewalks, lighting in public spaces, a children's playground, increased police presence, improved garbage collection, and improvements to private residences and properties. As a result, and without the implementation of the IIS in their neighborhood, PPI was reduced to very low or minimal risk. This empowered intersectoral collaboration between the community of Simón Bolívar and the Municipal Government of Machala vividly illustrates the crucial role that provision of basic services, basic infrastructure, and considerations for human and community security, play in establishing healthy communities and reducing the incidence of diseases of poverty like dengue fever and severe dengue. The increase in PPI for cluster 9 is a result of localized flooding during November 2013 in the neighborhood.Ae. aegypti breeding sites), and an infrastructure project partnered with the Municipal Department of Public Works to fill in the lagoon in their neighborhood square to reduce standing water.IIS implementation was very successful in cluster 14 (Sauces #1) with high community enthusiasm and sustained involvement. This, along with the effects of localized flooding in 2012 and a very dry season in 2013, resulted in a significant reduction of PPI. Also interesting in this cluster pair is the dramatic reduction of PPI in control cluster 17 (24 de Septiembre). This highly organized and motivated community capitalized on project presence to leverage support for other ongoing efforts to improve well-being and human security in their neighborhood. Community leaders routinely assemble and coordinate efforts to address community issues and garner support from the Municipal Government of Machala as well as the Ministries of Health, Environment and Education; there were a number of these efforts that coincided with interests of the IIS in reducing dengue transmission risk. Two particular efforts were of interest in this respect: an improved community-driven solid waste removal campaign partnered with the Municipal Department of Environment to reduce the presence of containers  affected the CPSC empowerment strategy and original scale-up recommendations in three ways: (1) shifts in Ministry of Health vector control programs and services increased governmental intervention in communities that do not depend on community-driven empowerment strategies; (2) they introduce a more ecologically sensitive model of dengue prevention with the reduction of insecticides (addressing a major community concern); and (3) offer a parallel stream for community involvement, time, enthusiasm and good-will toward dengue prevention and control. While a complication, this experience introduced a novel opportunity to consider the interface of alternative strategies.The success of our proposed IIS dengue prevention program during biolarvicide program rollout indicates a complementarity of efforts: both programs respond to community concerns of reducing insecticide use in domestic and peri-domestic environments, increasing skilled Ministry of Health human resource investment to reduce dengue incidence in affected communities, and improving health education and dengue prevention through positive behavior change in homes, neighborhoods and schools. However, it is the IIS strategy that is observed the more effective approach for reducing PPI levels. Nevertheless, integrating community-driven empowerment strategies like DESE and CPSC within the robust structure and function of the biolarvicide program could enhance synergy between parallel streams and capitalize on emerging momentum and progress in dengue prevention and control in southern Ecuador.An integrated eco-bio-social approach to reducing PPI as a useful outcome measure of dengue transmission risk has been successful in Machala, Ecuador, although difficulties encountered in smoothly implementing this study as it was designed suggest that it would still be valuable to conduct further implementation trials as part of scaling-up activity. Additionally, our results suggest that local successes in ecosystems approaches to dengue prevention can be successful if that process is pursued in partnership with communities, incorporates an element of social mobilization and empowerment, and emphasizes intersectoral collaboration. Examples outlined in this paper of intersectoral collaboration between communities, control programs and municipal governments underscore the importance of integrating efforts, resources, momentum and empowerment from all actors involved with and concerned with dengue prevention and control in individual communities and over larger municipal and regional endemic zones.


Dear Sir:Haemaphysalis longicornis that is known as a vector of SFTSV and has been collected from birds in Korea, 2) high-prevalence regions of SFTSV concur with geographic ranges of migratory birds in east Asia, 3) patients had no history of international travel, and 4) terrestrial mammals cannot cross the sea.We read with interest the article by Yun and others entitled “Phylogenetic Analysis of Severe Fever with Thrombocytopenia Syndrome Virus in South Korea and Migratory Bird Routes between China, South Korea, and Japan” recently published.Migratory birds can obviously carry parasitic arthropods and associated pathogens,First, SFTSV has a very confined distribution in the context of the spatial scale of bird migration. Migrations of birds are generally “latitudinal” movements in a predictable manner in terms of spatial and temporal scales.H. longicornis.Haemaphysalis flava that was a dominant tick collected from migratory birdsH. longicornis was an accidental tick on birds even in H. longicornis-dominated landscapes, suggesting that ticks on birds can be very different from those on mammals.6Second, there are clear differences between ticks infesting mammals and birds in terms of species and their life cycles. Positive SFTSVs were mainly detected in adult female ticks, especially, Finally, the occurrence of SFTS in patients without international travel history is consistent with infection and transmission largely caused by local mammals. Although terrestrial wild and domestic mammals carrying SFTSV cannot cross the sea in a natural condition, we cannot ignore anthropogenic factors in animal movements: increasing international trade of agricultural products and domestic and exotic animals. We may pretend that customs and quarantine services completely regulate introduction of ticks, but there are still large volumes of undetected movements of animals through illegal wildlife smuggling from China to Korea and Japan.7We respect the conclusion of Yun and others


The use of online technologies in health professionals’ education, including physiotherapy, has been advocated as effective and well-accepted tools for enhancing student learning. The aim of this study was to critically review the effectiveness, and user perceptions of online technology for physiotherapy teaching and learning.st of August 2013 for articles describing implementation of online technologies into physiotherapy teaching and learning: ERIC, CINAHL, Web of Science, Academic search complete, ProQuest Nursing and Allied Health Source, Medline, Embase, and Scopus. No language, design or publishing date restrictions were imposed. Risk of bias was assessed using the 2011 Mixed Methods Appraisal Tool checklist (MMAT).Following databases were systematically searched on the 31A total of 4133 articles were retrieved; 22 articles met the inclusion criteria and were accepted for final analysis: 15 on the effectiveness of technology, and 14 on users’ perceptions. Included studies used three designs: case study (14 articles), controlled trial (3), and randomized controlled trial (5). Studies investigated both pre-registration physiotherapy students (1523) and physiotherapy professionals (171). The quality of studies ranged from 67 to 100 % on the MMAT checklist which can be considered moderate to excellent. More than half of the studies (68 %) received scores greater than 80 %. Studies typically investigated websites and discussion boards. The websites are effective in enhancing practical skills performance, and discussion boards in knowledge acquisition, as well as in development of critical and reflective thinking. Students’ perceptions of the use of websites were mostly positive, providing students with entertaining, easy accessible resources. Perceived barriers to the use of websites included difficulties with internet connection, insufficiently interactive material, or personal preference for paper-based materials. Discussion boards were perceived as deepening students’ thinking and facilitating reflection, allowing for learning from multiple perspectives, and providing easy communication and support.The results of this review suggest that online technologies  have many benefits to offer for physiotherapy teaching and learning;There was minimal evidence of barriers for the use of online technologies, however, addressing the identified ones could enhance adherence to use of online technologies in health professionals’ education. Online technologies can be defined as any service and communication tools available on or utilising the internet including social networks, web-based resources and discussion boards. Online technologies have become an indispensable part of students and academics’ life in higher education, influencing strategies for learning –3. StudeThe broader incorporation of online technology into health professionals’ education is increasingly advocated, with claimed benefits including incorporation of quality content, support of life-long learning, flexibility of access, enrichment and personalisation of learner experience, and improved communication networks –11. HoweThe aim of this study was twofold. First, we aimed to assess current evidence for the effectiveness of technology in physiotherapy teaching and learning in enhancing students’ skills and knowledge. Second, we aimed to summarize perceptions of physiotherapy students  on the use of online technology.What is the effectiveness of technology on teaching and learning in physiotherapy in respect to student learning outcomes ?What are the users’ perceptions  of benefits and barriers for use of technology in physiotherapy teaching and learning?The research questions were:PRISMA guidelines were used to design and report this systematic review .Articles published in peer-reviewed journals describing implementation of any online technology for teaching and learning in physiotherapy  were included in this review. Articles could present designs such as case study (CS), controlled trial (CT), or randomised controlled trial (RCT). No restrictions on publication date or language were imposed.Articles were excluded if: in studies with wide professional focus, results of the physiotherapy sample were impossible to separate from those for other allied health professions; at least one of effectiveness of, or perceptions of, online technologies were not investigated in the study; or if articles were of a review type.For the purpose of this review, we adopted a pragmatic approach, and used effectiveness in a broad sense. Studies could investigate the effect of any online technology on knowledge or skills acquisition, engagement and participation, critical thinking and similar. Perceptions of online technologies were defined as mainly qualitative comments provided by physiotherapy students and practitioners in the studies.st of August 2013 in the following databases: ERIC, CINAHL, Web of Science, Academic search complete, ProQuest Nursing and Allied Health Source, Medline, Embase, and Scopus. A combination of key words related to the ‘technology’ and ‘physiotherapy’ was used. An example of the search strategy is presented in Table To capture maximum data and reduce bias in this review, a systematic search methodology was used to identify relevant articles. The systematic searches were performed on the 31The process of study selection is presented in Fig. Risk of bias was assessed using the 2011 Mixed Methods Appraisal Tool checklist (MMAT) , which aRisk of bias in individual studies was independently assessed by two reviewers  and all discrepancies resolved by discussion to reach consensus. Inter-rater agreement on the risk of bias assessment was calculated by means of Cohen’s Kappa  using SPStudies were classified based on each of the two research questions of this review. One focused on the effectiveness of online technology to enhance learning and teaching in physiotherapy, and the other on the perceptions of learners on the use of technology. Study characteristics such as design, sample size and type, technology implemented, physiotherapy course, type of outcome measures and main findings, were extracted to a (pre-agreed) tabular form by one review author (AKM) and checked by the second review author (DCR). Disagreements were resolved by discussion between the two reviewers. Risk of bias was then assessed and added to the tables. The main findings from both groups of studies were analysed and narratively summarized.Findings of the studies, designs and risk of bias were taken into account to draw the recommendations for some of the technologies.The flow and number of the studies screened through each stage of this review are presented in Fig. All articles were published in English, but original studies were conducted in seven countries . In general, studies used three designs: case study (14 articles), controlled trial (3), and randomized controlled trial (5). In total, included studies investigated 1694 participants, both pre-registration physiotherapy students , doctor of physical therapy (341), postgraduate (148)) and physiotherapy professionals (23). Studies investigated the use of online technologies, principally including websites and discussion boards across basic sciences , physiotherapy disciplines , to physiotherapy research . Eight studies investigated the effectiveness of technology in teaching and learning in physiotherapy, seven studies explored perceptions of physiotherapy students or professionals related to the use of such technology, and a further seven studies investigated both aspects. The map of technologies used in physiotherapy teaching and learning is presented in Fig. , doctor The quality of studies ranged from 67 to 100 % on the MMAT checklist, which can be considered moderate to excellent. More than half of the studies (68 %) received scores greater than 80 %. Cohen’s Kappa for inter-rater agreement was 0.75, indicating “substantial agreement” between raters (range 0.61–0.80) . None ofReview results are presented in two domains related to the research questions: the effectiveness of online technology, and perceptions of online technology.A summary of individual studies investigating the effectiveness of technologies in physiotherapy teaching and learning is presented in Table Effects of websites on practical skills performance was investigated in five studies: four RCTs –26, 27 aSeven studies explored the effect of discussion boards on knowledge acquisition, as well as on development of critical and reflective thinking. Two case studies , 29 founCase studies have shown no improvement in grades using collaborative wikis , but thaA summary of individual studies investigating perceptions related to online technology use in physiotherapy teaching and learning is presented in Table Seven studies investigated users’ perceptions of websites focusing mostly on positive feedback , 38–40. Three studies investigated feedback related to the use of discussion boards , 39, 41;Users’ perceptions of other online technologies were investigated in eight studies, which investigated chat , video lThis study is the first to systematically review the effectiveness of, and users’ perceptions of, online technology in physiotherapy teaching and learning. This review included a total of 22 articles . Articles included in this review used different methods , study designs , and outcome measures. Therefore, it was not possible to conduct meta-analysis. Despite the heterogeneity of study designs, interventions, and outcome measures, all included studies were considered as of low risk of bias.The effectiveness of interventions varied according to the technology used Table . WebsiteUsers’ perceptions of the use of technologies for teaching and learning purposes were mostly positive Table . Users aResults from this review are in agreement with previous reviews investigating the use of online and computer-related technologies in medical, dental, and nursing education. Previous reviews have shown equal or superior learning outcomes with the use of online technologies , 15 withFrom the date the searches were commenced for the current review, five additional articles have been published on the topic. These five articles were case studies, four were published in English language and one article was published in French . Two stuResearch on the use of web-based technologies in physiotherapy is at its infancy, which impacted on the present review in several respects. First, the included studies had different study designs, outcome measures, used different technologies (interventions), and explored the use of web-based technologies in different physiotherapy courses and populations. Therefore, it is difficult to identify the optimum approaches and practices for the use of web-based technology on teaching and learning in physiotherapy. It also precluded meta-analysis of results. Second, only five out of 15 studies were RCTs, limiting the classification of the level of evidence regarding the effectiveness of interventions being evaluated. Finally, the definition of online technologies used in this study might not have been exhaustive and this is recognised as limitation. This field of research is rapidly evolving with a paucity of studies and varying definitions. There is a need for clarification of the definitions as the literature expands.Future research should focus on the identification of barriers for the use of online technologies for teaching and learning in physiotherapy. Addressing such barriers may optimize adherence to the use of online technologies, enhancing learning outcomes. Also, physiotherapy education would benefit from studies evaluating individual online technologies in robust methodologically designs , and the adoption of reporting guidelines such as CONSORT  or COREQThe results of this review suggest that online technologies  have many benefits to offer for physiotherapy teaching and learning. These include enhancing practical skills performance and knowledge acquisition, providing students with entertaining, easy accessible resources, enhancing deep learning and encouraging reflection. Such benefits allow for learning to occur from multiple perspectives. Perceived barriers included difficulties with internet connection, insufficiently interactive material, or personal preference for paper-based materials. Although there was minimal evidence of barriers for the use of online technologies, addressing the identified ones could enhance adherence to use of online technologies in health professionals’ education.


Acupuncture has been used for thousands of years in treating diseases. Meridians and acupoints, on which acupuncture is practiced, have also attracted many research interests. Moxibustion is often used in conjunction with acupuncture as a thermal stimulation on acupoints. Laser, which generates extremely pure light of single wavelengths, is now used widely to stimulate acupoints, because it is noninvasive and easy to manipulate.This special issue contains 1 human research investigating the electrical characteristics of the acupoints, 2 randomized controlled trials (RCTs) evaluating the effect of traditional moxibustion on patients with knee osteoarthritis and lumber disc herniation, respectively, 3 animal studies exploring the effect and mechanism of the traditional moxibustion and laser moxibustion on irritable bowel syndrome (IBS), cyclophosphamide-induced leucopenia, and knee osteoarthritis (OA), respectively, 1 systematic review reviewing the safety of moxibustion, 1 paper describing the design of an electrical thermal stimulation system comparable to moxibustion, and 2 animal researches studying the effect and mechanism of electroacupuncture on disc degeneration and hepatic blood perfusion respectively.The results of these researches showed that acupoints may have special electrical characteristics at pathological status; moxibustion may relieve back pain and improve quality of life in patients with knee OA. Although the two RCTs did not report severe adverse events related to moxibustion, the systematic review found many factors may affect the safety of the moxibustion. The results of these researches also enhanced our knowledge of how traditional moxibustion, laser acupuncture-moxibustion, and electrical-acupuncture work in treating IBS, knee OA, cyclophosphamide-induced leucopenia, disc degeneration, and hepatic blood perfusion.The encouraging findings in this special issue will promote further investigations in the fields of biophysical and clinical research of acupuncture and moxibustion and may encourage more use of moxibustion in clinic. The electrical thermal moxibustion and laser moxibustion might be good substitutes for traditional moxibustion, because they produce thermal effect but with no chocking smoke and smell, thus being more suitable in modern medical environment. However, in this current special issue, researchers only investigated the effect of laser moxibustion on animal and introduced a design of electrical thermal moxibustion device; further clinical research on both moxibustion devices is needed in the future.


Rapid diagnostic tests (RDTs) largely account for the scale-up of malaria diagnosis in endemic settings. However, diversity in labelling including the instructions for use (IFU) limits their interchangeability and user-friendliness. Uniform, easy to follow and consistent labelling, aligned with international standards and appropriate for the level of the end user’s education and training, is crucial but a consolidated resource of information regarding best practices for IFU and labelling of RDT devices, packaging and accessories is not available.in vitro diagnostics (IVD) (which includes RDTs), complemented with a questionnaire based survey of RDT manufacturers and implementers. A summary of desirable RDT labelling characteristics was compiled, which was reviewed and discussed during a RBM Stakeholder consultation meeting and subsequently amended and refined by a dedicated task force consisting of country programme implementers, experts in RDT implementation, IVD regulatory experts and manufacturers.The Roll Back Malaria Partnership (RBM) commissioned the compilation of international standards and regulatory documents and published literature containing specifications and/or recommendations for RDT design, packaging and labelling of e.g. place of labelling on the box or cassette packaging allowing quick oversight). A generic IFU template was developed, comprising background information, a template for procedure and reading/interpretation, a selection of appropriate references and a symbol key of internationally recognized symbols together with suggestions about appropriate lay-out, style and readability.This process led to the development of consensus documents with a list of suggested terms and abbreviations as well as specifications for labelling of box, device packaging, cassettes, buffer bottle and accessories . Emphasis was placed on durability (permanent printing or water-resistant labels), legibility , comprehension (use of symbols) and ease of reference  contains supplementary material, which is available to authorized users. As the global burden of malaria is decreasing, diagnostic testing for malaria before starting treatment is crucial to avoid overtreatment with anti-malarials and delayed management of non-malaria febrile illnesses. To this end, since 2010, the World Health Organization (WHO) broadened its recommendations for parasitological confirmation of malaria diagnosis before treatment to all age groups.Plasmodium falciparum infections made by well-performing RDTs has been shown to be equal or superior to routine microscopy, and appears to be more cost-effective than microscopy. In. In23]. i.e. a glossary of symbols used) to the IFU is recommended, in line with FDA recommendations[In view of swift and consistent interpretation of communication, the use of graphical symbols is promoted: symbols save space, obviate the need for translations and convey standardized and clear messages at high visual impact and noticeability, 21, 34.ndations.The malaria RDT market currently comprises a plethora of products and manufacturers, with constant revisions made to products in order to improve quality and performance, 14. AltAnother perceived difficulty of RDT use was confirmed by interviews with implementers from the public sector in the present study but also recorded from the private sector: weaknesThe present study assessed the available evidence to identify best practices in labelling and IFUs tailored to malaria RDTs and associated accessories. In the initial phases of the project, identifying a representative group of implementers involved in daily use of RDTs was challenging; however, the consultation on the original working document and subsThe present HarT recommendations offer an opportunity for improving consistency and harmonization of RDT product characteristics and provide a comprehensive resource upon which international recommendations and tender specifications can be based. Various channels may be exploited for diffusion and application to ensure maximum uptake. Furthermore, the recommendations may also guide and orient emerging national IVD regulations and regional initiatives such as the Pan-African Harmonization Working Party on Medical Devices and Diagnostics (PAHWP). SynergiThe present document together with its additional files compiled proposes best practices in labelling and IFU for malaria RDTs. It is expected that compliance with these best practices will increase harmonization among the different malaria RDT products available on the market and improve their user-friendliness.Suggested terms and abbreviations related to malaria RDTs.(PDF 74 KB)Additional file 1:Requirements for the labelling of malaria RDT kit components: box, cassette packaging, cassette, buffer bottle and accessories.(PDF 719 KB)Additional file 2:Generic template for Instructions for Use (IFU).(PDF 402 KB)Additional file 3:


Partners HealthCare Personalized Medicine (PPM) is a center within the Partners HealthCare system  whose mission is to utilize genetics and genomics to improve the care of patients in a cost effective manner. PPM consists of five interconnected components: (1) Laboratory for Molecular Medicine (LMM), a CLIA laboratory performing genetic testing for patients world-wide; (2) Translational Genomics Core (TGC), a core laboratory providing genomic platforms for Partners investigators; (3) Partners Biobank, a biobank of samples  for 50,000 Consented Partners patients; (4) Biobank Portal, an IT infrastructure and viewer to bring together genotypes, samples, phenotypes  from the electronic medical record to Partners investigators. These components are united by (5) a common IT system that brings researchers, clinicians, and patients together for optimal research and patient care. In this article we will describe the resources devoted to Personalized Medicine at Partners HealthCare, how we integrate that set of resources with the existing infrastructure at the two academic medical centers: Massachusetts General Hospital and Brigham and Women’s Hospital and how we advance our mission to better integrate genomic data into clinical practice at Partners in a cost effective way. This article will describe the center and its components and relate each element to our overall vision and mission.Partners HealthCare System (Partners) is a not-for-profit, integrated health care system in Boston, Massachusetts founded by two of the nation’s leading academic medical centers (AMC), Massachusetts General Hospital (MGH) and Brigham and Women’s Hospital (BWH), which have been ranked #1 and #6 respectively in the U.S. News and World Report 2015 Honor Roll of academic medical centers. In addition to the two AMCs, Partners also includes community and specialty hospitals, a physician network, community health centers, home care, and other health related services, cares for four million patients with more than 7000 physicians attending and has 160,000 admissions per year. The composition of the patients in terms of race, gender and age is representative of the population of eastern Massachusetts. In addition, Partners institutions maintain a total research budget of more than $1.4 billion. MGH and BWH are the largest private hospital recipients of National Institutes of Health (NIH) funding in the nation. The mission of the PPM is to utilize genetics and genomics to improve the care of patients through the promotion and implementation of personalized medicine in caring for patients throughout the Partners HealthCare System and in healthcare nationally and globally in a cost effective manner. Harvard Medical School (HMS) and Partners established the Harvard-Partners Center for Genetics and Genomics (HPCGG) in 2001, recently renamed as Partners Personalized Medicine (PPM) to reflect a heightened focus on translational issues related to moving genetics and genomics into clinical practice.i.e., the Dana Farber Cancer Center and MGH Cancer Center. Major areas of expertise include inherited respiratory disorders, cardiomyopathies, hearing loss, connective tissue disorders, RASopathies, and multi-organ genetic syndromes. Annually, the LMM performs about 5000 high complexity genetic and genomics tests of disease-targeted NGS panels for a variety of disorders with genetic and clinical heterogeneity, covering about 400 genes, as well as exome and genome sequencing. The lab consists of six geneticists and 25 staff including genetic counselors and fellows. The LMM continues to develop novel genetic tests in multiple areas, most recently, pulmonary and renal panels. An integral component of the mission of the LMM is the incorporation of IT support into the dayto-day operations of the clinical lab, as well as implementing innovative programs to help physicians stay current on genetic information relevant to their patients. The LMM shares the lab instruments with TGC and Biobank see The LMM is a CLIA-certified molecular diagnostic laboratory, operating within the PPM. The LMM was founded 13 years ago with the mission to bridge the gap between research and clinical medicine, by accelerating the adoption of new molecular tests into clinical care. The current focus of the LMM is on germ line mutation testing. Cancer testing is performed through molecular pathology laboratories at each AMC affiliated with the two cancer centers associated with Partners The Translational Genomics core of the PPM  performsPartners HealthCare Biobank is a large research data and sample repository operating within the framework of PPM . It provPPM provides an integrated IT architecture supporting research and clinical activities, which is directly connected to the Partners and Harvard Medical School networks and to the rest of the academic community through the Internet. The PPM clinical IT team is responsible for IT support for LMM and GeneInsight . The PPMThree pieces of software tie the LMM, TGC, and Biobank together: GeneInsight (described below), GIGPAD, and StarLIMS. GIGPAD is the internal LIMS for LMM and TGC and handles samples management for these two labs. StarLIMS handles sample management for the Biobank and can hand these samples off to GIGPAD either in the LMM or in the TGC. StarLIMS is a commercial biobank software while GIGPAD and GeneInsight are home-grown.The bioinformatics team consists of one director, and seven bioinformaticians. The bioinformatics team routinely processes and analyzes DNA sequencing, RNA sequencing, and microarray data, supporting both our CLIA-certified lab and outside investigators via the translational genomics core. This includes a custom automated pipeline for generating sample-specific, demultiplexed fastq files for all Illumina sequencing projects. For DNA-sequencing: (1) Quality Control steps are performed using Picard and SAMtools; (2) alignment and variant calling use BWA and GATK for indels and small SNVs; (3) coverage metrics are generated with a combination of GATK and custom scripts; and (4) CNV calls are generated with a custom tool VisCap. Additionally, an evaluation of CNV calling using XHMM, ExomeDepth, and others is underway. Our RNA-seq pipeline uses (1) FastQC for quality steps and (2) the Tuxedo package for differential expression analysis and visualization, including TopHat, Cufflinks, CuffDiff and CummeRbund. Microarray data is processed via (1) Affymetrix Expression Console; (2) Illumina GenomeStudio; and (3) Heatmap2 package in R and custom scripts for visualization. We are also in the process of implementing Beelin/Autoconvert, plink, and custom software for high-throughput genotyping and annotation of Illumina data.® assets have been developed through close collaboration between LMM laboratory technicians, laboratory managers, geneticists, IT developers and Partners hospitals practicing physicians to address the distinct, yet interrelated, needs of laboratories and providers. GeneInsight delivers the IT infrastructure needed to overcome these challenges , a laboratory tool to assist with genetic variant knowledge management and interpretative report generation, GeneInsight Clinic®, a standalone hosted clinician interface to enable delivery of patient genetic test results and future variant updates to clinicians, and GeneInsight Network, a hub designed to enable high throughput transfer of structured genetic data between and among laboratories and clinicians. The system has been used to generate over 30,000 clinical reports. The GeneInsight Suite is registered with the FDA as a Class I exempt medical device. It is subject to inspection and must comply with quality regulations. Based on a set of IT assets designed to support genetic testing, the PPM IT team has built a solution to provide broad support for the genetic testing processes in clinical settings. At present a strategic alliance has been formed between Sunquest Information Systems and Partners HealthCare around GeneInsight to collaborate on providing seamless genetic testing workflow capabilities to clinical geneticists and pathologist and the goal to provide a wider dissemination of the software and its continued development into the industry standard for delivery of genomic results to clinicians [IT applications include: GeneInsight Labinicians .Partners Research Computing is a Division of Academic Programs of Partners HealthCare. The group occupies about 5000 square feet about 1200 yards from the MGH main campus and is physically separate from the PPM space at 65 Lansdowne Street, Cambridge. This space is connected through Ethernet with the main campus. The space houses offices for about 27 employees and staff members. Dr. Murphy’s computer resources are located in the Needham Data Center of Partners HealthCare. Over 40 powerful Windows 2003/2008 Pentium IV class servers are available on site, including several that host large Oracle and SQL Server databases. These servers host both relational database (Oracle and SQL Server) and Web server (Microsoft IIS and Tomcat/JBoss) software. Database servers include RAID5 disk array capabilities. There are also redundant Pentium IV class Windows 2003 file servers for shared use. In total the group hosts over 20 Terabytes of server disk storage. All servers are backed up nightly to a Tivoli Storage Manager (TSM) system. Development and production servers reside in the Partners corporate datacenter, which is, staffed 24/7. The main enterprise computer systems at Partners are available through the network. All network activity at Partners occurs behind a Cisco Firewall and traffic is constantly monitored. The group has over 50 desktop workstations ranging from high-end Pentium multi-processor systems to moderate Pentiums. They include machines with Microsoft Windows, Macintosh OS, and Linux operation systems. This group has built the Research Patient Data Registry including the Biobank portal and the Phenotype Discovery Center as described below.Developed by the Partners Research Computing group, the RPDR is a data warehouse that gathers data from multiple hospital electronic record systems at Partners HealthCare and stores it in a SQL Server database. The RPDR gathers clinical data from several hospital systems at Partners HealthCare. , Physician Billing System—IDX and EPIC, Longitudinal Medical Record—LMR, Corporate Provider Master—CPM, Clinical Data Repository—CDR, and Partners Personalized Medicine—PPM), and stores the data in one central data warehouse. Researchers are able to query this data by using an online query tool.The query tool returns aggregate totals of patient data that are populated with appropriately obfuscated, de-identified/encrypted data as per HIPPA privacy rules and the HHS Common Rule. With the proper IRB approval, researchers may access the patients’ detailed medical records for their specified cohorts of patients. The detailed medical records are returned to researchers in an encrypted Microsoft Access file and text (.txt) files. Detailed medical records may include the following types of data: transfusion, cardiology, contact information, demographics, diagnoses, discharge notes, endoscopy, laboratory tests, PEAR allergies, LMR health maintenance, LMR medications, LMR notes, LMR problems, LMR vital signs, medications (RxNorm), microbiology, operative notes, pathology reports, procedures (CPT codes), providers, pulmonary, radiology reports, radiology tests and transfusion. Furthermore, images from hospital image repositories can be returned and viewed online. The RPDR is able to obtain patient notes from hospital systems and create a secure database for eMERGE III . Securiti2b2 algorithms, perform automated natural language processing (NLP), and request samples from cases and matched controls. Data in the Biobank Portal database includes narrative data from doctors’ notes and other hospital text reports , as well as coded data such as demographics, diagnoses, procedures, vital signs, lab values and medications. In addition, patient reported data from the health information survey given to all Biobank subjects is included in the Biobank Portal database and contains data on body mass index, occupational exposure, sun exposure, physical activity, alcohol, smoking and sleep behaviors, family history of disease and reproductive history for women.The Partners Phenotype Discovery Center provides support to investigators to link phenotypes with data on consented subjects in the Partners HealthCare Biobank. As part of the PDC, we have created the Biobank Portal see  to combiUsers of the Biobank Portal application can run queries on the aforementioned data to find particular sets of patients and then view the query criteria in a timeline patient-by-patient to visualize when phenomena of interest have occurred. Users can also review sets of patients in a Viewer that allows them to look at each patient’s data to determine whether or not to request specimen data for that patient. Users can then use the application to request the set of patients selected using the Timeline and Viewer from the Biobank. Another set of functions available in the Biobank Portal is designed to help with phenotyping sets of patients. Existing validated phenotypes are available in the user interface for eight diseases , with an additional set of 12 planned to be completed over the next year. In addition, we are creating a Validation Workbench to help users create their own phenotypes, which will require creating a Natural Language Processing pipeline to help extract required features from narrative data, creating further methods to help users annotate the data, providing basic statistical guidelines and educating researchers about the nature of this work. Ultimately, genotyped results for the biobank subjects will be added into the Biobank Portal data mart and made available for further investigation. The Biobank is fully integrated with the Laboratory for Molecular Medicine, and the Translational Genomics Core via the IT connections in the Biobank Portal . All of Although we do not provide a formal analysis of similar programs at other AMCs in this description of the PPM, it is clear that the comprehensive nature of the infrastructure integration is not common in AMCs. Investigators can utilize the PPM to obtain consented samples, have them genotyped or sequenced, and then develop relevant diagnostic and prognostic indicators using the structured IT system across the three labs. We propose this as one model that will facilitate progress in this complex arena. We also note that the approach that we have taken is dynamic. We are moving in the direction of having not just the LMM approved, but also the TGC core and the Biobank CLIA, thus further strengthening the link between research and clinical care.


Fire is widely recognized as a critical ecological and evolutionary driver that needs to be at the forefront of land management actions if conservation targets are to be met. However, the prevailing view is that prescribed fire is riskier than other land management techniques. Perceived risks associated with the application of fire limits its use and reduces agency support for prescribed burning in the private sector. As a result, considerably less cost-share support is given for prescribed fire compared to mechanical techniques. This study tests the general perception that fire is a riskier technique relative to other land management options. Due to the lack of data available to directly test this notion, we use a combination of approaches including 1) a comparison of fatalities resulting from different occupations that are proxies for techniques employed in land management, 2) a comparison of fatalities resulting from wildland fire versus prescribed fire, and 3) an exploration of causal factors responsible for wildland fire-related fatalities. This approach establishes a first approximation of the relative risk of fatality to private citizens using prescribed fire compared to other management techniques that are readily used in ecosystem management. Our data do not support using risks of landowner fatalities as justification for the use of alternative land management techniques, such as mechanical (machine-related) equipment, over prescribed fire. Vehicles and heavy machinery are consistently leading reasons for fatalities within occupations selected as proxies for management techniques employed by ranchers and agricultural producers, and also constitute a large proportion of fatalities among firefighters. Our study provides the foundation for agencies to establish data-driven decisions regarding the degree of support they provide for prescribed burning on private lands. Prescribed fire has long-been touted as a management tool critical for the sustainability of fire-dependent ecosystem services, but with the caveat that it is a dangerous technique that requires considerable planning and careful implementation to ensure safety and control . This noIrrespective of the questionable ecological and economic legitimacy of using mechanical techniques as surrogates to fire, relative measures of risk are needed to provide natural resource agencies with important quantitative information to consider when making decisions that affect landowner use of resource management techniques. To date, decisions have been based largely on perceptions of risk, which can be more reflective of conventional norms or cultural legacies than objective, data-driven information . UnderstIn this paper, we develop first approximations of the relative risk of fatality to private citizens using prescribed fire compared to other management techniques that are readily used in ecosystem management. Due to the complete absence of data capable of answering this question directly , we use professional occupational fatality statistics as proxies to represent the various techniques used by landowners. Landowners use crop production techniques for weed management, animal production techniques for grazing management, components of logging practices for timber harvest and management of woody invaders, wildland fire techniques to implement prescribed fires in order to enhance forage quality, reduce litter, create structural heterogeneity for wildlife habitat, and prevent/reduce woody invaders, and heavy machinery associated with construction for ranch and farm infrastructural development, general operations, and to reduce woody invaders. We then test for differences in fatalities between prescribed fires and wildfires. Risks of using fire for natural resource objectives in the private sector are almost entirely tied to prescribed fire, not wildfire, and this distinction is not necessarily considered in perceptions of prescribed fire risk. We then identified the factors associated with fatalities in the wildland fire profession and the relative number of fatalities from mechanical (machine-related) and non-mechanical sources.Data were compiled for this study from two databases: the National Interagency Fire Center Wild Fire Accidents by Type of Accident  and the The CFOI database is a collection of six different occupation-specific fatality data sets for 2006 to 2013. The database contains three values: 1) total fatality injuries, 2) total hours worked, and 3) fatality rate. Total hours worked is calculated by multiplying the annual average estimates of total at work US civilians by the average hours for civilians, 16 years of age and older, from the United States Census Bureau Current Population Survey (CPS 2006–2013). The fatality rate represents the number of fatal occupational injuries per 100,000 full-time equivalent workers and was calculated as: (N/EH) x 200,000,000, where N = the number of fatal work injuries, EH = total hours worked by all employees during the calendar year, 200,000,000 = base for 100,000 equivalent full-time workers  (CFOI 2006–2013).To develop a first approximation of the relative risk of fatality for different management techniques used by private land managers, we compiled data from each year of the CFOI for occupations that use resource management techniques. Occupational fatality rates served as proxies for relativizing the risks of various land management techniques and included occupations of animal production, operating engineers and other construction equipment operators, crop production, firefighting, and logging workers. Further descriptions of each occupation, including the techniques and practices contributing to hazards in the workplace, are given in The difference in rates of fatal injuries among occupations was determined using repeated measures ANOVA for years 2006–2013. Students t-tests were used to compute individual pairwise comparisons using the pooled standard deviation. We used Bonferroni adjustment to control the familywise error rate. Data for firefighter fatality rates in 2012 were not included because they were not available.To compare numbers of fatalities in prescribed fires to wildfires and the causal factors associated with fatalities in each, data were compiled from the WFA database that directly compared wildfire and prescribed fire deaths. These categories, as stated exactly in the WFA Database, included: burnover, burns, entrapment, and snag for both wildfire and prescribed fire . Data weTo determine relative differences in the causal factors accounting for wildland fire-related deaths, irrespective of whether the fatal injury occurred in a prescribed fire or wildfire, data from the WFA database were broadly categorized and separated into mechanical (machine-related) and non-mechanical components . Fire fighting, construction equipment operation, and animal production were not significantly different, with rates of 5.6, 12.1, and 15.6 respectively  a comparison of fatalities resulting from different occupations that are proxies for techniques employed in land management, 2) a comparison of fatalities resulting from wildland fire versus prescribed fire, and 3) an exploration of causal factors responsible for wildland fire-related fatalities, our data universally suggest that current risk aversion driving the preference for alternative land management techniques over prescribed fire is not supported. We found crop production and logging to have much higher relative risks of fatal injuries than other occupations related to land management on private lands. Firefighting was the least risky of the occupations reviewed herein. Moreover, fatalities from the firefighting profession include wildfire-related injuries as well as prescribed fire-related fatal injuries. In the private sector, risks associated with land management techniques are entirely tied to prescribed fire, not wildfire. This distinction is important when evaluating the risks of using fire in the private sector because wildfire-related fatalities exceed those resulting from prescribed fire by 3,350%.It is important to recognize that farming and ranching is one of the deadliest occupations in the U.S. workforce. Agriculture, forestry, fishing and hunting-related occupations have consistently been the most dangerous jobs of any industry sector, according to occupational fatality rates from the US Bureau of Labor Statistics. Agriculture involving ranching and farming is one of the ten deadliest jobs in the U.S. . Smith eThe wildland firefighting profession is less dangerous in terms of fatalities than ranching and farming, which is perhaps counter to the perception of natural resource agencies involved with land management on private lands. Relative rates of fatality, based on the number of deaths per number of workers, shows animal production and crop production to be considerably higher than fighting fires. Accidents involving mechanized equipment and vehicles are the leading causes of deaths in agriculture . TractorCalkin et al.  describeMedia, imagination and memory, along with social norms and cultural beliefs shape people’s perception of risk and extreme events . For exaOur analysis is meant to move past the rhetoric and “biases” often associated with decisions regarding prescribed fire use on private lands. Common biases present in fire management have the potential to create fundamental divides between public agencies and private land managers, who tend to prioritize profitability and personal values over risk aversion ,28. ThesWe were able to use existing data sources to develop a comparative first approximation of fatality risk for prescribed fire practitioners in the private sector; however, limitations in data availability constrain the power of assessments attempting to determine the risks of using prescribed fire. Here, we provide a list of recommendations that would improve future evaluations. First, monitoring and data on non-fatal injuries and work-related illnesses are generally inadequate to establish rates of injury and illness associated with land management practices in the private sector . PrescriS1 FigLines indicate locally weighted scatterplot smoothing (LOWESS) of the number of fatal injuries in each category over time. Points show number of fatal injuries for each year data are available.(TIFF)Click here for additional data file.


Injectable medicines commonly are used in health-care settings for the prevention, diagnosis, and treatment of various illnesses. Examples include chemotherapy, intravenous antibiotics, vaccinations, and medications used for sedation and anesthesia. Medical injections often are administered in conjunction with surgical procedures, endoscopy, imaging studies, pain control, and cosmetic or complementary and alternative medicine procedures. Safe manufacturing and pharmacy practices are essential because every injection must begin with sterile medication. The appropriate medication must then be safely prepared , then administered in a manner that maintains sterility and minimizes risk for infection. Safe administration depends on adherence to the practices outlined in CDC’s evidence-based Standard Precautions guideline . Health-Traditionally, injection safety has been recognized as a public health issue mainly in low- and middle-income country settings. Estimates of the global burden of disease associated with unsafe injections in the year 2000 included approximately 20 million new hepatitis B virus (HBV) infections, 2 million new hepatitis C virus (HCV) infections, and 250,000 new human immunodeficiency virus (HIV) infections .Unsafe injection practices fall into two overlapping categories: reuse of syringes and mishandling of medications. “Direct” syringe reuse occurs when a single syringe is used for more than one person, as when the same syringe is used to inject via intravenous tubing or only the needle is changed between patients. These unsafe practices are still encountered; recently, several large patient notification events have stemmed from reuse of insulin injection pens for multiple patients ,4. ThereOutbreaks investigated by CDC and state and local health departments have illustrated that the U.S. health-care system is susceptible to the dangers of unsafe injections. The investigation of an HCV outbreak in Nevada in 2008 revealed that reuse of syringes on multiple patients and use of single-use medication vials on multiple patients was the likely mechanism by which HCV infections were transmitted . The ambSeveral states are addressing the public health issue of unsafe injection practices, including New York. Since 2002, the New York State Department of Health (NYSDOH) has conducted 11 investigations of known or potential bloodborne pathogen transmissions that involved notification of nearly 10,000 persons . The predominant modes of exposure or transmission discovered were related to unsafe injection practices similar to those described in the Nevada outbreak. NYSDOH also has implemented policy and educational initiatives as part of a comprehensive public health response to the investigations. These include 1) changes to the public health law in 2008 to strengthen the ability of the health department to investigate and hold physicians accountable for poor infection control practices and to update infection control and barrier precautions training mandated by NYSDOH , and 2) The Centers for Medicaid & Medicare Services (CMS), the single largest purchaser of health care in the United States, seeks to promote innovation and the consistent advancement of safety and quality of health care. Many, but not all, types of facilities that participate in Medicare or Medicaid are subject to unannounced, onsite inspections by state or federal surveyors to be certified under those programs. Examples of such regulated facilities are ASCs, clinical laboratories, dialysis facilities, hospitals, and nursing homes . ASCs arCDC, CMS, and the state of Nevada began an intense collaboration during the 2008 HCV outbreak  investigInjection safety is a complex public health issue that requires a multidimensional approach. The four “E’s” for ensuring safe injections include 1) epidemiologic surveillance, reporting, monitoring, and investigation of outbreaks potentially related to unsafe injections; 2) educational initiatives to promote understanding and use of safe injection and basic infection control practices; 3) enforcement and oversight by federal and state authorities; and 4) engineering of devices, equipment, and processes to reduce or eliminate disease transmission risks.Since 2009, CDC has worked to improve epidemiologic capacities at state health departments by supporting the formation and development of state programs that address health-care–associated infections . To bridUnsafe injection practices put patients at risk for infection and have been associated with various procedures and settings. Unsafe injections also increase the financial and emotional burden borne by patients, health-care providers, and public health and medical-care systems. This harm is entirely preventable. To eliminate the problem of unsafe injections, injection safety interventions need to be implemented in all settings where injections are delivered. Many outpatient facilities, including oncology clinics, pain management clinics, and physician offices, typically do not fall within the purview of federal and state regulatory oversight of health-care facilities, thus making it difficult to monitor injection safety and other infection control practices. Unsafe injection practices have resulted in disease transmission and the need for notification of hundreds of thousands of patients. The risks of unsafe injections practices are unacceptable. The goal of public health and health-care systems should be to eliminate such risks immediately and definitively through comprehensive preventive actions.


As part of an initiative to expand diagnostic resources, information, and quality of care for patients with rare diseases in Hungary, a network of specialists dealing with rare diseases was established at our University Clinical Center, and a Rare Disease Working Group was formed within the Pediatric Hospital.We hope to document a selection of diagnoses, which came about through close cooperation between the pediatric rheumatology and clinical genetics services at our Pediatric Hospital, in the context of an initiative to better evaluate and care for patients with rare diseases, or who present a differential diagnostic dilemma.Each of the following cases were seen together by a clinical geneticist and pediatric rheumatology service physician involved in the Rare Disease Working Group. We document here three different cases from among those seen with complaints and presentations representing part of the pediatric rheumatology disease spectrum.Case 1: A 14 year old male presented with painless swelling of PIP joints II-V on both hands which had been consistently present for over one year. The patient was seen in a joint session , and the diagnosis of pachydermodactyly established, sparing the patient further diagnostic interventions and unnecessary treatments.Case 2: A 6 year old boy presented initially at 3 years of age with bilateral coxitis. One month later, significant radiological changes in both hips (including the acetabulum) were noted, with relatively minor physical complaints. He was initially diagnosed with Legg-Calvé-Perthes Disease by an orthopedic surgeon. Through our clinic, urine glycosaminoglycan, enzymatic and genetic testing confirmed the diagnosis of mucopolysaccharidosis II (Hunter Disease). In addition to the initiation of enzyme replacement therapy, the diagnosis allows for planning of specialized care, follow up and intervention with regard to the patient's progressive joint disease.Case 3: An 8 year old girl had been seen by a pediatric neurologist and orthopedic surgeon because of symmetrical painless contractures of her hips, knees, ankles and the small joints of her feet, which were increasingly affecting her everyday activities. She was referred to our clinical geneticist because of suspicion of a lysosomal storage disease. Upon examination the patient had scleroderma-like lesions symmetrically affecting both lower limbs. Findings on laboratory, imaging, and histopathological examination led to the tentative diagnosis of congenital fascial dystrophy, or "Stiff-skin Syndrome". An analysis of the Fibrillin-1 (FBN1) gene, recently found to be mutated in several such patients, found no alterations. We are closely following the patient, and additional extensive genetic analysis will hopefully be initiated in the near future.We hope to encourage the consideration of these diseases  as potential differential diagnoses, and the establishment of such "rare disease working groups" where they may not yet exist.None declared.


Despite the fact that scientific and political consideration for ecosystem services has dramatically increased over the past decade, few studies have focused on marine and coastal ecosystem services for conservation strategies. We used an ecosystem services approach to assess spatial distributions of habitat risks and four ecosystem services , and explored the tradeoffs among them in coastal areas of South Korea. Additionally, we analyzed how the social and ecological characteristics in coastal areas interact with conservation and development policies by using this approach. We found strong negative associations between the habitat risks and ecosystem services  across the coastal counties. Our results showed that the intensity of the habitat risks and the provision of ecosystem services were significantly different between reclamation-dominated and conservation-dominated counties, except for coastal vulnerability. A generalized linear model suggested that reclamation projects were dependent on economic efficiency, whereas demographic pressures and habitat conditions influenced the designation of protected areas at a county level. The ecosystem services approach provided guidelines to achieve both sustainable development and environment conservation. By using the approach, we can select the priority areas for developments while we can minimize the degradation of biodiversity and ecosystem services. As cultural ecosystem services are evenly distributed throughout coastal areas of South Korea, decision makers may employ them to improve the conditions of coastal wetlands outside of protected areas. Ecosystem services are defined as benefits to human well-being that are derived from nature systems , 2. The in situ development such as land reclamation, but also pollutions derived from upland agriculture and industry [As many studies have provided hidden values of coastal wetlands such as habitats for migratory birds, storm protection, erosion control, water treatment, and high biodiversity , the estindustry , 4. TherIn East Asia, the reclamation projects of coastal wetlands in the past few decades have often been performed to expand land areas for increasing human activities such as urbanization and industrial development , 8. WherImplementing reclamation policies often causes conflicts between different groups, which demand either conservation or development . If deveAn ecosystem services approach provides a way to integrate ecosystem services and socioeconomic characteristics into decision-making processes . The staIn this paper, we aimed to reveal determinants behind wetland reclamation projects and the designation of protected areas in coastal zones of South Korea. Additionally, we aimed to propose effective strategies for coastal management using an ecosystem services approach. We followed a scientific assessments tool, InVEST model, to understand the complex interactions between human and natural systems. Then, we performed spatial assessments of natural habitat risks and ecosystem services. Using the results of the spatial assessments, we carried out tradeoff analysis and uncovered the determinants of reclamation projects and the designation of protected areas.2 in area. It also contains 27% of the total population of Korea. The average annual temperatures are between 10 and 15°C, and the annual precipitation varies from 1,200 to 1,500 mm in the central region and from 1,000 to 1,800 mm in the southern region [Study areas consist of the western and southern coastal zones of South Korea, which cover both terrestrial counties and coastal areas . The coan region . The sean region .2 in the 1980s to 1,222 km2 in the 2000s [2 of coastal areas since 1982 [2 of South Korea, which is 10% of the land area and 15% of territorial waters of South Korea [2 of the total coastal wetlands  [Coastal wetlands in South Korea provide multiple ecosystem services such as fish production, coastal protection, and recreation to human society, which contribute to local livelihoods and economies , 24. Abohe 2000s ; large-snce 1982 . The coath Korea  Fig 1)..2 in the487 km2) .The Korean government amended the Coast Management Act in 2009 to achieve effective conservation and sustainable development of coastal areas. In 2011, the Ministry of Land, Transport and Maritime Affairs (the Ministry of Oceans and Fisheries as reconstituted in 2013) established the second integrated coastal management plan for 2011–2021 under the provisions of Article 8 of the Coast Management Act . The objIn South Korea, anthropogenic impacts such as urbanization and industrial complexes have caused the degradation of natural habitats and biodiversity loss in coastal zones. Coastal wetland reclamation projects have dramatically degraded natural habitat and therefore led to biodiversity loss. The biodiversity loss has a negative impact on several ecosystem services . Thus, wConservation strategies, especially for strictly protected areas, benefit regulation and cultural services , whereasThe focus of the spatial assessment was four regulation and cultural ecosystem services  among Marine and Coastal Ecosystem Services (MCES) . First, Additionally, we added the amounts of aquaculture production (in metric tons) as a variable for statistical analyses, because the aquaculture production represents provisioning services in coastal areas, and conservation strategies can directly and indirectly impact provisioning services. Presently, the fishery resources in South Korea have been quite well regulated under several conservation acts. Traditionally, fisheries in South Korea are government-owned, and the local communities have formed cooperatives of fishing villages and gained access by obtaining fishery licenses from the government. The Fisheries Act and Fishing Villages and Fishery Harbor Act have been enacted for increasing the fishery productions and improving the quality of life for fishing workers. The Fishing Ground Management Act and Fish Resources Management Act also designate restricted fishing areas, the period of the non-fishing season, and length limits to avoid overfishing and achieve sustainable fisheries.Previous studies have applied various approaches to assess biodiversity and ecosystem services from statistical analysis to spatial model. According to MA 2005), approaches for ecosystem service studies have largely pursued to assess ‘ecosystem condition and trend’, ‘the value of ecosystem services for human well-being’, and ‘tradeoffs in ecosystem services’ 005, appr. For exaSpecifically, spatial assessment and advanced statistical analysis facilitate to figure out a hidden relation between human and natural systems, because socioeconomics interact with natural systems and thus impact on the status of biodiversity and ecosystem services , 40. RecIn ecosystem services approach, combining spatial assessment and statistical analysis gives new perspectives in the study areas and helps to develop the regional model of both human and nature dimensions . The resThe spatial dataset consisted of geographic, ecological, and social data provided by Korean government agencies and institutes –22, 49. The database for statistical analyses consisted of demographic, socioeconomic, and biophysical data , 21, 49.We calculated total protected areas in South Korea: national parks, cultural properties areas, ecological and scenic conservation areas, wildlife protection areas, and coastal wetlands conservation areas. The reclaimed areas of each county were estimated by the spatial database .We selected InVEST model for the spatial assessments of coastal habitat risks and ecosystem services for two reasons. First, this model is used broadly by lots of research groups in the world such as Indonesia, Colombia, Canada, and China , 28. TheOur ecosystem service approach consisted of four parts. First, we mapped the impact of human activities in both terrestrial and coastal areas and identified where human impacts are high. These proxies show the status of environmental degradation and can be used for terrestrial and coastal biodiversity, because habitat degradation significantly increase the possibility of species extinctions and then lead to biodiversity loss . Second,Spatial assessments used InVEST  version 2.5.6 to assess and quantify habitat risk and ecosystem services in coastal areas . We seleei represents the exposure value, ci represents consequence value, di is the data quality rank, and wi is the importance weights for each criterion i. N is the number of criteria for each habitat [j causes risk to habitat i, and Rij is quantified using Euclidean Risk calculation [The Habitat Risk Assessment (HRA) model produces maps of habitat risk and informs how each habitat exposes each threat or stressor in marine and coastal areas . The ris habitat . Second,culation .The third step calculates the sum of risk values for each habitat, and finally the model assesses and maps the habitats’ risk hotspots.r (wr); 2) the distance between habitat and the threat in grid cell x and y (irxy); 3) the level of legal and physical protection from disturbance (Sjx) [xj, the total threat level in each grid cell x, with habitat type js.The habitat quality model in terrestrial areas is similar to the HRA model, except that the habitat quality model employs land use and land cover maps instead of habitat layers. The model produces a habitat quality map by integrating LULC information with threats to biodiversity. The quantification of threats on each habitat in a pixel consists of four factors: 1) the relative impact of each threat t (Sjx) . Then, tThe habitat quality model produces a habitat degradation map of the current landscape. To facilitate understanding where coastal areas are vulnerable to human activities, we simply overlapped coastal and terrestrial habitat risk maps into a single map.The coastal vulnerability model shows the risk of coastal erosion and inundation, which can also threaten human society . WhereasRGeomorphology is the rank of geomorphology for each coastline segment, RRelief is the relief ranking of each coastline segment, RHabitats is a natural habitat ranking for each coastline segment, RSLR is the level of net sea level change within the study site, RWindExposure is the wind exposure ranking of each coastline segment, RWaveExposure is the average depth of adjacent seas, and RSurge is the distance ranking between the coastline and the edge of the continental margin.The variables in The carbon storage model estimates the carbon stocks of four carbon pools: aboveground biomass, belowground biomass, soil organic matter and dead organic matter. Carbon storage data in terrestrial areas collected from national reports in South Korea and IPCC report –55 S3 T. The amoi) using an Important Score (IS):The overlap analysis model allows us to identify the important areas of human use  in marine and coastal areas . The modn is the number of human activities using the analysis,  is the usage of activity j in grid cell i, and j [The variables in tivity j .To verify the accuracy of spatial assessments, we compared the spatial results with existing datasets in coastal areas provided by Korean governments and institutes. They provided the ecological grading system of coastal wetlands (7 grades) , the est2) of the first grade  and protected areas and aggregated the results of the results of terrestrial habitat quality and carbon storage at each county. Then, we compared the total areas with the results of the habitat quality and carbon storage.First, the ecological grading system of coastal wetlands involved habitat diversity, species diversity, and ecological health of coastal wetlands. From 2008 to 2013, researchers evaluated the ecological conditions over the 879 points of coastal wetlands in South Korea using field works and laboratory experiments . We randWe performed correlation analysis between habitat risk assessments and ecosystem services and among services. The analysis was performed on each pair of two habitat risk assessments and four ecosystem services. We determined the relations of their associations and identified potential tradeoffs between habitat risk and ecosystem services using R statistical software .2 to 1006 km2.Firstly, using zonal statistics tools in ArcGIS 10.1, coastal and terrestrial habitat assessments and four ecosystem services were quantified from the spatial assessments at each county . In thisThen, we divided coastal counties into two groups: conservation-dominated and reclamation dominated-counties. As most counties in South Korea have focused on one side of the debate, either conservation or development due to county circumstances, we divided the counties into two groups. Potential differences in the level of habitat risks and the provision of four services were assessed between the two groups using a one-way ANOVA. Also, we used a one-way ANOVA to determine if several factors—including demographic, socioeconomic, and biophysical determinants—are different between the two groups. The ANOVA assumptions  were verified, and log transformations were carried out as needed.βis are the parameters to be estimated by Maximum Likelihood (ML) method. The variables in 1 is protected areas, Y2 is reclaimed areas, X1 is population of coastal counties, X2 is population density, X3 is the number of households, X4 is the average number of household members, X5 is the average age of population, X6 is the appraisal value of land, X7 is Gross Regional Domestic Product, X8 is the number of fishery households, X9 is the number of tourists, and X10 is the median slope within a kilometer radius of coastline  and the ration of the Deviance (or Pearson Chi-square) to DF. If the sub model had the lowest AIC and the ration of the Deviance to DF was close to 1, we stopped. Because AIC is a measure of goodness of model fit, a smaller value of AIC represents a better model fit. In addition, the ratio of the Deviance to DF should be close to 1, when the model is a good fit for the data. To avoid multicollinearity problems, we checked whether the largest Condition Index (CI) in all models is greater than 10. As a result, there was no evidence of multicollinearity in the final models. All statistical analyses were performed using R and SAS 9.2 , 60.The coastal and terrestrial habitat risk assessments in the study area are shown in Maps of recreation and aesthetic represent the number of recreational sites and visual impacts in the study area. The number of recreational sites indicates the intensity of human recreational uses in the coastal areas, and the aesthetic quality map demonstrates the specific areas of aesthetic appreciation. The locations of high recreational sites and aesthetic quality are evenly distributed across the counties. Many counties are generally of high value to multiple services with good habitat conditions . HoweverWe performed correlation analysis to verify the accuracy of the spatial assessments see . CoastalMost of the habitat risks and ecosystem services significantly correlate with one another . We founThe results of the t-test are presented in A comparison of the demographic, socioeconomic, and biophysical predictors between conservation-dominated counties and reclamation-dominated counties is shown in Two generalized linear models revealed a significant association between socioeconomic/biophysical factors and reclaimed or protected areas at a county level . The modIn this study, the ecosystem services approach that combines spatial assessment with statistical analysis provided spatially explicit information on habitat risks and ecosystem services along with synergies and tradeoffs among habitat risks and ecosystem services. Additionally, we determined drivers on the designation of reclamation projects or conservation policies by using a generalized linear model. We showed how demographic, socioeconomic, and biophysical factors associated with the designation of reclamation and conservation areas at the county level. Thus, the approach can provide scientific evidence that previous studies have not treated for a decision-making process in coastal managements. Also, the benefit of the approach is to spend no additional cost, because the necessary data has been established and verified by Korean governments. Indeed, the approach is available to adopt immediately in coastal areas where it need to analysis for development or conservation.Our results indicated that reclamation of coastal wetlands has severely reduced biodiversity and their ecosystem services. The statuses of biodiversity and associated ecosystem services in conservation-dominated counties were quantitatively better than reclamation-dominated counties. Previous studies suggested that coastal wetland reclamation leads to degrade ecological health and biodiversity in coastal areas , 8. FurtWhereas economic factors were highly associated with reclamation areas at a county level, habitat conditions and demographic factors are significantly associated with protected areas. Conventionally, when coastal counties have been urbanized, development pressures on coastal wetlands have been increased for further regional economic growth . Along wSpatially mapped ecosystem services can be used to select possible development sites  that minimize degradation of ecosystem services , 62. In Provisioning services are affected by habitat conditions and regulation services , and alsConsideration of spatial scale differences between an ecological scale and an institutional scale is crucial for implementing conservation strategies . An ecolThe reclamation and conservation policies also influence social and biophysical characteristics at a county level. Our ANOVA results show that local society and natural environments may be of relevance for the designations of the conservation and development policies Tables  and 4. AIf future research confirms a causal relationship between socioeconomic characteristics and the designation of reclamation projects or conservation policies, the coefficient estimates in As seen in Natural habitats and ecosystem services are to change and transform over time with human activities. As such, the construction of scenarios that reflect coastal planning zone systems is necessary to implement effectively conservation policy and predict the impacts of policy by using the ecosystem services approach . This stField works are crucial in elaborating spatial assessments and statistical models at the local and regional levels , 73. UsiSecond, sociological field works based on surveys and interviews help to construct an accurate statistical model . To incrThe ecosystem services approach in this study provided opportunities to constitute guidelines for conservation and sustainable development of biodiversity and ecosystem services. We assessed the relative risk of human activities and regulation and cultural services in coastal areas. The results of the statistical analyses provide synergies and tradeoffs among services and between habitat risks and services. Additionally, social and ecological characteristics in the unified spatial scale correlated with the designation of reclamation and conservation areas. We expect that the findings can help decision makers determine priority areas for conservation outside of protected areas.China and other south-Asia countries have followed similar economic development model to South Korea; import substitution industrialization in heavy industry, governmental control over finance and support for enterprises, dependence on export markets . TherefoS1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 Table(DOCX)Click here for additional data file.