Often described as an extremely rare zoonosis, cowpox virus (CPXV) infections are on the increase in Germany. CPXV is rodent-borne with a broad host range and contains the largest and most complete genome of all poxviruses, including parts with high homology to variola virus . So far, most CPXV cases have occurred individually in unvaccinated animals and humans and were caused by genetically distinguishable virus strains.Mungos mungo) and jaguarundis (Herpailurus yagouaroundi) at a Zoological Garden were observed with a prevalence of the affected animal group of 100% and a mortality of 30%. A subsequent serological investigation of other exotic animal species provided evidence of subclinical cases before the onset of the outbreak. Moreover, a time-delayed human cowpox virus infection caused by the identical virus strain occurred in a different geographical area indicating that handling/feeding food rats might be the common source of infection.Generalized CPXV infections in banded mongooses (Reports on the increased zoonotic transmission of orthopoxviruses have renewed interest in understanding interactions between these viruses and their hosts. The list of animals known to be susceptible to CPXV is still growing. Thus, the likely existence of unknown CPXV hosts and their distribution may present a risk for other exotic animals but also for the general public, as was shown in this outbreak. Animal breeders and suppliers of food rats represent potential multipliers and distributors of CPXV, in the context of increasingly pan-European trading. Taking the cessation of vaccination against smallpox into account, this situation contributes to the increased incidence of CPXV infections in man, particularly in younger age groups, with more complicated courses of clinical infections. Orthopoxvirus (OPV) of the family Poxviridae. Virions are brick-shaped with a size of around 200 nm in diameter and 350 nm in length and carries its genome of approx. 230 kbp in a single, linear, double-stranded segment of DNA Attention was first drawn to poxviruses infecting exotic zoo animals in 1960, when, still in the era of smallpox vaccination, two captive Asian elephants died at the Zoological Garden in Leipzig/Germany FelidaeRattus norvegicus). Experiments performed by Maiboroda demonstrated that Norwegian rats could be productively infected with CPXV and could shed significant amounts of virus, especially if under stress The most dramatic outbreaks in exotic animals known so far occurred in the Moscow Zoo in 1973 and 1974, causing serious illness in six different species of the family Clethrionomys glareolus), field voles (Microtus agrestis) and wood mice (Apodemus sylvaticus) CPXV occurs naturally in several species of rodents in Europe and Western parts of Russia In this respect, the role of rats has not yet been elucidated. Wild rats could be either a primary reservoir or an amplifying host. Little is also known about the origin of CPXV outbreaks. In very few cases of outbreaks occurring among exotic animals only rats could be identified as a potential origin Direct human-to-human transmission of CPXV has not been reported so far. Among other highly susceptible hosts like exotic animals an intra-species transmission could be observed repeatedly with similar clinical symptoms, indicating different virus susceptibilities among vertebrates that possibly depend on the CPXV strain. Nevertheless, despite the wide host range of CPXV, the same CPXV strain rarely infects different animal species. Likewise, conclusive evidence for the co-circulation of different CPXV strains within the same geographic region has rarely been provided but was rather assumed Mungos mungo) and jaguarundis (Herpailurus yagouaroundi) which occurred at the Zoological Garden in Krefeld in the spring of 2008. A subsequent serological investigation of other exotic animal species living in this zoo provides evidence for subclinical infection before the onset of clinical cases in the mongoose colony. Moreover, this is the first report of a time-delayed CPXV infection with an identical virus strain occurring in different geographical areas, indicating a common source of infection.This is the first description of a generalized CPXV infection in banded mongooses  was found dead with a large number of ulcerated skin lesions distributed mainly on head, extremities and genitals  and cared for by other keepers who had not been in contact with other carnivores. The female jaguarundi showed a reduced general condition but started to recover after February 26, with visible bald patches on the body. Simultaneously, the male cat's condition deteriorated. It became apathetic and lethargic and died on March 6. At the time of death the animal had an anti-orthopoxvirus (OPV) titer of 1∶10.000. Numerous round, “punched-out” erosions were discovered at the mucosal surface of nose , lips anThe first four mongooses (#1–4) revealed large numbers of ulcerated skin lesions distributed over the body  and bactAdditional analysis of organ specimens from the remaining animals (# 5–#13) by quantitative real-time PCR revealed CPXV DNA in several organs of all but two mongooses, indicating infection in three out of five mongooses which were histopathologically unremarkable . FinallyA CPXV strain was also isolated from a skin lesion of the female jaguarundi (CPXV JagKre08/1). Although the female jaguarundi showed clinical signs and revealed a very high orthopoxvirus-specific antibody titer at the beginning of the CPXV infection, she was able to recover. In contrast, the male jaguarundi which revealed only a low antibody titer at the same sampling time died after 15 days. Interestingly, all 9 organ samples of the male cat contained large amounts of CPXV DNA. In comparison to all other animal organs investigated, additional specimens from the male jaguarundi were found to be positive, for example, feces, lymph nodes, larynx and colon.During early spring of 2008 four human CPXV infections occurred in the city of Krefeld and in the surrounding area (not published). Virus was isolated from all human cases and due to their sequence identity was named CPXV HumKre08/1. The source of infection was traced to CPXV-infected pet rats which all had died after purchase from local pet shops. In September 2008 another case of CPXV infection was diagnosed in an employee  of a priThe HA-gene sequences obtained from the four CPXV isolates of the outbreak in the Krefeld Zoo  were all 921 bp in length and 100% identical to each other . BLAST sAfter the death of the male jaguarundi and as a preventative measure to counter the apparently unrestricted transmission of CPXV, all felids and several other carnivores were vaccinated with MVA. To monitor an increase of OPV-specific antibody titers by IFAT, serum samples were collected and tested before and after vaccination . Sera co(Camelus bactrianus), tapir (Tapirus terrestris), kudu (Tragelaphus strepsicornis), duiker , muskox (Ovibos moschatus), springbok  and barashinga (Cervus duvauceli). None of these animals revealed significant antibody titers (data not shown).Other non-carnivorous animal species housed in the same area of the zoo were also tested for orthopoxvirus-specific antibodies, including camel CPXV infections are increasing in Germany despite being described as an extremely rare zoonotic infection. During the two years before the current outbreak (2006/07), 22 human cases have been diagnosed, in addition to numerous cases in pet cats and exotic zoo animals including elephants. While it cannot be excluded that this is due to a reporting bias, this increase may reflect the fact that a smaller proportion of people have immunity against CPXV following the cessation of smallpox vaccinations. Although the lack of significant evidence for increasing case numbers due to the cessation of smallpox vaccination has been discussed Elephants are, by far, the most frequently infected with CPXV. Over 60 cases of elephant infections have been reported from Germany. These days, most elephants are regularly vaccinated with MVA. Hence, only sporadic cases still occur in unvaccinated elephants. The second most commonly infected group are exotic felids with CPXV outbreaks being reported from the UK, continental Europe and Russia. Although felids are highly susceptible to CPXV, very few cases have been reported so far. Exotic zoo animals that are housed in close proximity to other zoo animals and who come into contact with wild rodents and animal keepers are likely to be more susceptible to CPXV infections. Similar epidemics involving animals of different species have been reported only from Moscow in 1973/74, Berlin in 1997 and Almere, the Netherlands, in 2003 Only occasionally is a definite source of infection identified. Either food rodents in a breeding facility are infected from wild rodents The appearance of well-developed clinical symptoms in the first four mongooses during a seven-day period suggests a single common source of infection about 1–2 weeks earlier from the same food source. The remaining nine mongooses revealed high levels of antibodies and healed skin lesions about two weeks after the first mongoose had died, indicating a similar time course of infection as the four previous cases and also that no interspecies transmission among mongooses had occurred. Transmission of the identical CPXV strain to the female jaguarundi occurred at a later time as indicated by the delayed appearance of clinical symptoms. Since no direct contact between mongooses and jaguarundis was possible, an indirect and accidental transmission by one of their keepers seems to be the most probable source of infection despite the applied safety measures. The fact that the appearance of clinical signs in the male jaguarundi was delayed by one week suggests an interspecies transmission by direct or indirect contact with contaminated saliva, urine or feces.In contrast to previous reports where hemorrhagic pneumonia was the main post-mortem finding in infected felids, in both the mongooses and the jaguarundis a prolonged, exclusively dermal type of CPXV infection was observed with lesions distributed over the whole body. Among the group of mongooses the first four infected animals displayed an acute systemic CPXV infection, whereas the latter nine animals were already in the process of healing. The mortality rate was about 30% and no correlation between disease outcome and age or sex could be found. High antibody titers detected in serological analyses indicated a 100% susceptibility of CPXV for mongooses and jaguarundis. Although housed in separate buildings and in different areas of the zoo, several other felids and carnivores including cheetah “Kasai”, snow leopard “Odette” and the bush dog also revealed high antibody titers, pointing towards a high CPXV infection rate during the recent outbreak or previous exposure to CPXV. In other extensive studies no evidence of CPXV antibodies was found in 93 captive exotic animals including cheetahs, lions and tigers As recognized in the female jaguarundi, a significant orthopoxvirus-specific antibody titer early during a CPXV infection seems crucial for survival. This case highlights the need for further extended vaccination studies leading to increased efforts toward the general vaccination of potentially susceptible and rare exotic animals. In contrast to previous reports about the absence of an immunological response after being vaccinated with a smallpox vaccine The time-delayed appearance of the clinical signs in both jaguarundis followed by the death of the animal infected later indicated one of the management problems during a CPXV outbreak. When animals known to be or suspected to be susceptible to CPXV reveal typical signs of an infection, they should immediately be separated from other animals by applying strict quarantine measures, treated with antibiotics against secondary bacterial infections and observed closely for at least three weeks. Nevertheless, prompt segregation of potentially infected animals may not be possible due to lack of separate pens available at the crucial time. Further, it is impossible to permanently segregate zoo animals from wild rodents. A continuous control of food animals might be hard or impossible to accomplish, especially when purchased from different wholesale dealers or animal husbandries. Since no effective and approved treatment for animals in case of CPXV infections is available, e.g. previous trials with γ-globulin were not successful Mungos mungo and Herpailurus yagouaroundi) are susceptible to CPXV infection and this was unknown previously. We also observed high orthopoxvirus-specific antibody titers in unvaccinated zoo animals that did not show symptoms of infection, suggesting that there are a far higher number of CPXV infections than is generally hypothesized. The probable existence of additional unknown CPXV hosts may present a risk to other exotic animals but also to the general public, as was shown in this outbreak. With the cessation of the smallpox vaccination, younger humans are susceptible to CPXV infection and we expect to see an increased incidence of infection in humans in the future.Our study has revealed that two species  or had been taken previously during routine examinations. All samples were kept frozen at −20°C until further use. For the human patient, for diagnostic evaluation a swap sample was taken directly from the lesion and processed further for routine PCR and sequence analysis Tissue samples were fixed in 10% buffered formalin, processed routinely, embedded in liquid paraffin and sectioned at 3 µm. Slides were stained with hematoxylin and eosin (HE).Homogenized skin lesions were centrifuged at low speed to remove debris and processed for negative staining electron microscopy as described elsewhere The titer of orthopoxvirus-specific antibodies in animal sera were determined by immunofluorescence staining of CPXV-infected human cells that was performed according to standard procedures DNA from skin lesions and other organs was prepared using a Qiagen Blood kit according to the manufacturer's instructions . Quantitative real-time PCR amplification was applied to detect orthopoxvirus DNA www.megasoftware.net) using the neighbor-joining method Phylogenetic analysis of sequences of the entire open reading frame (ORF) of the HA gene of virus isolates described here and orthopoxvirus reference strains  were perAs a protective measure against CPXV infections various zoo animals were vaccinated twice intramuscularly with an interval of 5 weeks by blowpipe with 2 ml of modified vaccinia virus Ankara (MVA) obtained from the University of Munich, Institute for Medical Microbiology, Infectious and Epidemic Diseases, Germany (Dr. Werner Eichhorn).


Worldwide there is growing attention paid to the reproductive decisions faced by HIV-infected individuals. Studies in both developed and developing countries have suggested that many HIV-infected women continue to desire children despite knowledge of their HIV status. Despite the increasing attention to the health care needs of HIV-infected individuals in low resource settings, little attention has been given to reproductive choice and intentions. Health care providers play a crucial role in determining access to reproductive health services and their influence is likely to be heightened in delivering services to HIV-infected women. We examined the attitudes of health care policy makers and providers towards reproductive decision-making among HIV-infected individuals.In-depth interviews were conducted with 14 health care providers at two public sector health care facilities located in Cape Town, South Africa. In addition, 12 in-depth interviews with public sector policy makers and managers, and managers within HIV/AIDS and reproductive health NGOs were conducted. Data were analyzed using a grounded theory approach.Providers and policy makers approached the issues related to being HIV-infected and child bearing differently. Biomedical considerations were paramount in providers' approaches to HIV infection and reproductive decision-making, whereas, policy makers approached the issues more broadly recognizing the structural constraints that inform the provision of reproductive health care services and the possibility of "choice" for HIV-infected individuals.The findings highlight the diversity of perspectives among policy makers and providers regarding the reproductive decisions taken by HIV-infected people. There is a clear need for more explicit policies recognizing the reproductive rights and choices of HIV-infected individuals. Worldwide there is growing recognition of the reproductive decisions faced by HIV-infected individuals. Studies in both developed and developing countries have suggested that many HIV-infected women continue to desire children despite knowledge of their HIV status -4. DespiThe HIV/AIDS epidemic has far reaching consequences for women's reproductive health care services. South Africa is currently experiencing one of the worst HIV/AIDS epidemics in the world with a national HIV prevalence rate of 30% . Here anProviders play a crucial role in determining access to, and quality of, reproductive health services  and theiResearch in South Africa and elsewhere has demonstrated the important roles that health service providers play in determining women's access to reproductive health services generally, and it is likely that their influence may be particularly important in the case of HIV-infected women ,9-11. ReThis article reports on qualitative research that explored health care providers, public sector health policy makers and representatives of non-governmental organizations (NGOs) attitudes towards HIV-infected individuals' fertility intentions and reproductive choices. The research formed part of a broader study in which HIV-infected women and men were interviewed about their reproductive intentions and is reported elsewhere . UnderstThe study was conducted between May 2004 and January 2005 at two public sector primary health care clinics in Cape Town, South Africa. Both health care facilities are located in predominantly black urban working class communities, with a high HIV prevalence and are broadly representative of the types of services available for HIV-infected individuals in this setting.In-depth interviews were conducted with 14 health care providers delivering HIV care or anti-retroviral (ARV) treatment at two study sites. Health care providers consisted of 3 public health doctors, 7 registered professional nurses and 4 HIV adherence counselors. An additional 12 in-depth interviews were conducted with public sector policy makers and managers, and managers within HIV/AIDS and reproductive health NGOs. Policy makers included high-level managers and directors working in reproductive and sexual health, and HIV/AIDS directorates in Provincial level (Western Cape) Departments of Health. Key influential people from the NGO sector included local and international advocacy and service delivery organizations involved in HIV/AIDS and reproductive and sexual health. In South Africa, the NGO sector has over the past ten years assisted the government in the treatment, support and care of HIV-infected individuals.Respondents were recruited using purposive sampling. All providers who worked at the two health care facilities, from which we recruited HIV-infected women for the larger study, were contacted and invited to participate in the study. All in-depth interviews were conducted in English by fieldworkers trained in qualitative research methods. All interviews were audio tape-recorded and transcribed verbatim. Informed consent was obtained from all participants prior to recording. Interviews lasted approximately 45 minutes and were conducted in a private space within the respondents' place of work. Interview guides were semi-structured, open-ended and probing. Areas explored in the interview guide included: policy makers and providers attitudes towards HIV-infected women's reproductive intentions and the role of male partners in the process; health service delivery factors influencing reproductive choice including the impact of availability of ART on reproductive choice and the management of pregnancy and contraceptive provision for HIV-infected women.Data were analysed using a grounded theory approach, based on a process that helps researchers to "discover" categories, themes and patterns that emerge from the data . InitialAll participants provided written informed consent. Confidentiality and anonymity was ensured by removing all identifiers including participants' names and places of work from the data. Permission was obtained from the local health authority to interview providers at their facilities. The University of Cape Town's Research Ethics Committee and the Population Council's Institutional Review Board granted approval to conduct the research. Individual data has been kept confidential.Fourteen health care providers and twelve policy makers were interviewed. The mean age of providers was 38 years (range 22 – 69 years), 79% (n = 11) were women and 21% (n = 3) were men. The mean age of policy makers was 47.8 years (range 40 – 60 years), 67% (n = 8) were women and 33% (n = 4) were men.Health care providers and policy makers approached the issues related to being HIV-infected and child bearing differently. Biomedical considerations were paramount in providers approach to HIV infection and reproductive decision-making, whereas, policy makers tended to approach the issues more broadly recognizing the structural constraints that inform the provision of reproductive health care services and the possibility of "choice" particularly with regards to HIV-infected individuals.Health care providers' attitudes towards HIV-infected women's fertility intentions were largely shaped by their experiences in individual patient care. Providers tended to see the issues in terms of medical concerns, particularly in terms of the potential impact of a pregnancy on HIV disease progression. Many providers felt that deciding to have a child required careful planning and consideration, with a "right time" to fall pregnant, which included an adequately high CD4 count, access to ART and PMTCT programmes, and whether the individual was physically healthy. Explained by a doctor:We never tell people they can't have children ... a lot of people say "if you have HIV what are you doing having a baby?" But you have to recognize that people are entitled to have children and that is their choice, but we would prefer them to have their own health sorted out first. (Doctor)However, providers also considered a woman's socio-economic circumstances and strong desire to experience motherhood when making recommendations. A nurse explored the complex circumstances faced by some women:Looking at the patient, one considers, can you afford to have this baby? Are you well? Are you on ARV's? ...What is this baby going to do to your life? Is it going to make it better, is it going to make it worse? ... That's the way I look at it forgetting about their positive status. They want to prove they can have children. (Nurse)Providers acknowledged that their counselling of patients about their reproductive options depended, in part, on the patient's health status. Despite this, almost all providers were familiar with the principles of reproductive rights and acknowledged the importance of "a woman's right to choose". However, some providers acknowledged that choice was often a more complex issue, alluding to the importance of remaining "objective and non-judgmental", and allowing women to make "informed choices" even though [it] might not be the "right choice".Similarly, policy makers focused on issues of reproductive choice and felt that HIV-infected women's fertility intentions could be a politically sensitive issue. Concern was raised that suggesting women curtail or delay having children could be interpreted as infringing on women's reproductive rights and choice as enshrined in the South African constitution. Notwithstanding this, many acknowledged the difficulties of offering reproductive choice in an environment of limited health care resources and a burgeoning HIV/AIDS epidemic. As a policy maker explained:South Africa is different to first world countries where they are able to offer women various services during a pregnancy such as delivery with an elective Caesar ... and sperm washing which is kind of irrelevant in our setting. (NGO policy maker)Some public health care sector policy makers also expressed concerns about the feasibility of reproductive choice in a context in which there were an increasing number of AIDS orphans and overstretched treatment services for HIV-infected people.Some providers and public sector policy makers acknowledged societal expectations regarding childbearing and that some women faced pressure from boyfriends or husbands to have children, fearing abandonment if they did not.Nurse providers cited numerous reasons why HIV-infected women may want to have a baby. These included: wanting to have "something of their own", pressures from partners, in-laws and family to have children, a woman's age and whether they already had children. A nurse provider suggested that younger women or those who had no children often wanted at least one child, whereas women who already had children might not have the same desires. Furthermore, women who were economically dependent on their male partners often felt pressured into having a baby so as to remain in the relationship.Providers grappled with the complexities involved in providing unbiased advice to HIV-infected women around childbearing. Nevertheless, some providers displayed insight into the emotional difficulties faced by women who were diagnosed HIV positive and what this in turn could mean for future fertility intentions. A nurse described the dilemmas faced by a young HIV-infected woman of seventeen who she had counselled. Whilst on the one hand she could empathise with the client's reproductive intentions, on another level, she felt it was inappropriate to have a child due to the perceived difficulties associated with both an adolescent pregnancy and being HIV-infected." I am going mad ...I must have a baby" I could empathize with her... for some reason in my experience this urge just comes up and there is very little you can do about it...So I said to her, " look, exclude the fact that you are HIV [positive], at 17 do you need a baby right now?" I still told her the choices, but she was saying to me, "I know it's not right but I can't help this". (Nurse)Another nurse provider acknowledged that there was little she could do to prevent HIV-infected women from wanting children despite the perceived health risks, asserting she was "at peace with decisions that people make and that one can't make decisions for people, nor should one try to change things beyond one's control". Similarly, providers and policy makers spoke of the importance of motherhood in many of the communities in which women lived. Having a child in this context was frequently a defining feature of womanhood.Both providers and policy makers alluded to the difficulties associated with including men in reproductive health care services including fertility-related counselling and contraception. Some providers stated that men's involvement in contraceptive decision making processes was minimal, contraception and more general reproductive matters were viewed by men as part of a "woman's responsibility".A public health policy maker felt that reproductive health services were not "gender sensitive", as they focused more on women's needs and in the process left men "on the outside". In relation to contraceptive services and dual protection he had this to say:I think the contraceptive services have always been geared more towards women than men of course,... men are not taking their equal share of responsibility for fertility regulation. And I think maybe the staff are also not so good at handling men and their feelings about contraception and so on. (Policy maker)Indeed, several providers were open about their limited knowledge of HIV-infected men's reproductive intentions and their relative inexperience with male clients given the relatively small number of men who sought treatment for HIV/AIDS at their health care clinics.Discussion of reproductive health services for HIV-infected individuals led many policy makers and providers to speak more generally about the structural constraints endemic to the healthcare system as a whole. Several providers identified systemic problems that inhibited the public healthcare system from providing services to all patients, regardless of HIV status. These included the general organization of existing health services, including a lack of integration between HIV and reproductive healthcare services. A policy maker referred to the current system as "vertical protocol-driven silos" that inhibited referral systems between different services. Furthermore, overall staff shortages and associated low morale inevitably influenced the quality of HIV-related services provided. A policy maker explained:There is the philosophy and then there's reality...sometimes I sit in ante-natal clinics and I hear some of the exchanges that go on between staff and patients and they fall very short of the ideal. They [healthcare staff] are tired, discouraged, depressed, and overwhelmed. Related to this, providers identified difficulties with the delivery of health care services, including ART, the management of HIV and pregnancy and appropriate contraceptive provision and counselling.Several providers acknowledged that the availability of ARV treatment made possible an extended lifespan and may cause some HIV-infected women and men to rethink their reproductive options. A doctor explained that after several months on medication patients began to feel well and that they were "not going to die, but live, and part of living is about reproducing and having kids".Providers recognized the importance of encouraging greater openness in discussing reproductive choices, particularly amongst pregnant women. Some doctors feared that if providers did not acknowledge patients' pregnancy intentions and counsel them accordingly, they may cease seeking ARV treatment. A doctor explained:Of course there definitely is a time and a place for avoiding getting pregnant with ARV's...But it shouldn't come across in patients' minds that being on ARV's, that you can never have children. I think that will stop people from coming for treatment.(Doctor)Providers also described the possible difficulties in managing a pregnancy in a woman taking ARV treatment. This was further underscored by a lack of specific clear guidelines available to providers on reproductive health counselling for both pregnant women and those wanting to become pregnant. Several providers emphasised the need for women to be open about their fertility intentions in order to limit the risk to both the woman and her infant. Given the possible teratogenic effects of the antiretroviral therapy Efavirenz, providers were particularly concerned about the risk of an unplanned pregnancy for women currently undergoing ART.Both policy makers and providers identified a lack of clear policy guidelines and training around contraceptive counselling for HIV-infected individuals as a shortcoming in current reproductive health care services. Providers felt that they had insufficient knowledge of the possible interactions between different ARV treatment regimens and hormonal contraceptives. In the absence of specific contraceptive guidelines, providers developed their "own" guidelines which were often not based on clinical evidence. Contraceptive options suggested for HIV-infected women included injectable contraceptives and to a lesser extent, combined oral contraceptive pills, intra-uterine devices and male condoms. Sterilization was considered suitable for women who already had a child or in the post partum period. Yet some policy makers alerted to the possible dangers of "forced sterilization" of HIV-infected women. Policy makers also voiced concern around continued "vertical family planning services" with a high reliance on injectable contraceptives as this had implications for reproductive counselling and contraceptive choice. A lack of integration between reproductive health care services and HIV care and treatment services was of concern to both policy makers and providers.Policy makers recognized providers' concerns about a general lack of reproductive health guidelines for HIV-infected individuals. Most policy makers felt that developing counselling guidelines on reproductive options for HIV-infected individuals would be valuable. Without these guidelines providers would continue "bumbling along" and make decisions in an "ad hoc" manner. However, a few expressed reservations about designing reproductive health guidelines specifically targeting HIV-infected individuals, as a large number of peoples' HIV status was unknown and favoured focusing on improving reproductive health services for all.This study presents valuable new insights into providers' and policy makers' views towards HIV-infected individuals' fertility intentions in South Africa and is the first known study in South Africa to explore these issues. Policy makers and providers reflected on a number of issues that would influence their approach to HIV-infected individuals' fertility intentions and desires. While most participants were aware of the broader social issues that made reproductive decision-making complex for HIV-infected women, their own attitudes towards childbearing in the context of HIV were strongly mediated by biomedical and health service related factors. These included HIV-infected patients' health status, possible health risks associated with pregnancy and access to ART and contraceptive services and an overall lack of clear reproductive health policy guidelines for HIV-infected individuals.Whilst discourse around reproductive rights and choice emerged spontaneously in both the providers and policy makers discussions, there was little consideration of how it would translate into every day practice. Moreover, "reproductive choice" was not fully interrogated by providers in terms of what choice really means for women in situations of inequitable gender relations and societal norms which view reproduction as an integral part of women's lives and underscores the difficulty in translating rhetoric into practice. Recognition by many policy makers and providers towards the central role of childbearing on women's social identities was superseded by concerns of an overburdened health care system.For many providers and policy makers an overriding concern was an overextended health care system with limited capacity to provide adequate reproductive health care services to a general population of women and men using public sector services, let alone to HIV-infected individuals. This is not surprising considering the flux in the health care system in South Africa and controversy surrounding the relatively slow introduction of ARV treatment programmes, with confusing and contradictory messages to both providers and the public regarding the efficacy and safety of ARV treatment . Within Policy makers and some providers acknowledged that choice was often not possible, particularly in a climate of judgmental and negative attitudes displayed by healthcare providers, making opportunities for non-judgemental counselling around reproductive choice difficult. Quality of care is not an unexpected issue to emerge and has been reported elsewhere in South Africa within the context of abortion and family planning services ,11,16. TBoth policy makers and providers were mindful of the dearth of policy and guidelines for dealing with reproductive choice among HIV-infected individuals. World Health Organization guidelines on contraception for HIV-infected individuals exist and appropriate guidelines need to be developed and adapted for reproductive counselling of HIV-infected individuals in South Africa.A possible limitation to this study is that it was specific to one setting in South Africa and although is broadly representative of prevailing attitudes in South Africa, further research is needed in both South Africa and other resource limited settings.Moreover, the findings reflect the views of a particular group of health care providers, i.e., providers located within a well resourced urban area with better health care infrastructure in terms of HIV treatment and care than health care facilities located within rural areas of South Africa.The results of this study underscores the need for creating linkages between HIV care and treatment and reproductive health care services for HIV-infected individuals in South Africa. Ideas for further research and interventions should include explicit policies that recognise reproductive choice in HIV-infected individuals including improved access to contraception and other reproductive health care services. Training of health care providers to deal sensitively with the reproductive health care needs of HIV-infected individuals from both a psychosocial and biomedical perspective should be initiated. The latter should include potential interactions between ART and hormonal contraceptives and the impact of HIV and ART on pregnancy. The need for integration of all aspects of reproductive health care services with other HIV care and treatment in South Africa needs to be explored.The author(s) declare that they have no competing interests.JH assisted in designing the study, data collection and data analysis and drafted the manuscript.DC conceptualized and assisted in designing the study, data collection and analysis and critically reviewed the manuscript.LM and HB conceptualized and assisted in designing the study and data analysis and critically reviewed the manuscript.VZ conceptualized and assisted in designing the study, data collection and analysis and reviewed the manuscript.PO assisted in data collection and analysis and reviewed the manuscript.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


The guidelines for cardiopulmonary resuscitation (CPR) have been in place for decades; but despite their international scope and periodic updates, there has been little improvement in survival rates in out-of-hospital cardiac arrest for patients who did not receive early defibrillation. Instituting the new cardio cerebral resuscitation protocol for managing prehospital cardiac arrest improved survival of adult patients with witnessed cardiac arrest and an initially shockable rhythm. Cardiac arrest highlights one of the critical interactions between the heart and the brain, and it remains a leading cause of death. The concept of cardio cerebral resuscitation as an alternative to traditional cardiopulmonary respiration (CPR) for out-of-hospital cardiac arrest is fast evolving into a reality. Because cardio cerebral resuscitation results in improved survival and cerebral function in patients with witnessed cardiac arrest with a shockable rhythm, it should replace CPR for out-of-hospital cardiac arrest and CPR should be reserved for respiratory arrest.1Despite the development and periodic updating of guidelines for CPR and emergency cardiovascular care from the American Heart Association (AHA) survival rates for victims of out-of-hospital cardiac arrest are dismal and have remained essentially unchanged in the recent past.23The traditional CPR approach has three major drawbacks:Most bystanders to a person who unexpectedly collapses are willing to activate emergency medical services (EMS) but are not willing to initiate rescue efforts because they do not want to perform mouth-to mouth assisted ventilation. Bystanders are more willing to perform chest-compression-only resuscitation for a person who unexpectedly collapses an approach that all agree is dramatically better than doing nothing.Interrupting chest compressions for ventilation during cardiac arrest decreases survival.Positive pressure ventilation during CPR for cardiac arrest increases intrathoracic pressures, which decreases venous return to the thorax and subsequent perfusion of the heart and the brain.45In contrast to CPR, cardio cerebral resuscitation eliminates mouth-to-mouth ventilation for bystanderinitiated resuscitation efforts, dramatically decreases the role of positive pressure ventilation by EMS responders, and emphasizes chest compressions prior to and immediately after a single shock for cardiac arrests not witnessed by EMS personnel.In a human study, investigators from Japan found that among witnessed victims of out-of-hospital cardiac arrest who had a shockable rhythm upon the arrival of EMS personnel, chest-compression-only resuscitation resulted in better survival than did chest compressions plus mouth-to-mouth ventilation.6The message that needs to be promulgated is twofold but nevertheless simple: firstly-cardio cerebral resuscitation is for cardiac arrest, and secondly CPR with ventilation is recommended for respiratory arrest. The lay public should be taught that an unexpected collapse in an adult is, in all likelihood, a cardiac arrest, to be differentiated from obvious respiratory arrest, such as choking or drowning, where assisted ventilations may be appropriate.4In the absence of early defibrillation, survival beyond the first 5 minutes of ventricular fibrillation (VF) arrest is predominantly dependent on adequate coronary and cerebral perfusion pressures, both of which are generated by chest compressions. It is well established that in the absence of early defibrillation or bystander-initiated resuscitation efforts, survival is rare.The decades-old recommendation of two ventilations before each 15 chest compressions has recently been acknowledged not to be optimal, as this ratio was changed from 2:15 to 2:30 in the 2005 AHA guidelines to increase the recommended number of chest compressions. However, this change did not address the major problem, which is bystanders’ reluctance to initiate resuscitation if ventilation is involved, regardless of the ventilations-to-compressions ratio. The greatest impediment to the initiation of bystander resuscitation is the public's aversion to and/or the complicated nature of performing mouth-to-mouth resuscitation.56When a person collapses with VF, or if VF is induced in an animal model, gasping is present in a significant number of individuals and animals. This abnormal breathing, which varies in duration, can be either fortunate or unfortunate. When chest compressions are promptly initiated, gasping is fortunate in that the subject is likely to continue to gasp and provide self ventilation (negative intrathoracic pressure)However, gasping also may be unfortunate in that most laypersons interpret it as an indication that the subject is still breathing, causing them not to initiate bystander resuscitation or call for EMS personnel as soon as they should. Education will be essential to ensure prompt initiation of bystander chest compressions in patients who gasp with cardiac arrest, as well as to ensure that chest compressions are not stopped because of continued gasping.In emergency medical service protocols, laypersons are to be taught to “be a lifesaver.” They are to be instructed to call emergency as soon as possible and then to begin chest compressions alone. If an automated external defibrillator (AED) is available, they should obtain it and follow its directions. Rescue breathing is not recommended. The technique for chest compressions is ideally taught with emphasis on a metronomeguided rate of 100 per minute. Additionally, full chest recoil after each compression is specifically emphasized.8Adoption of the cardio cerebral resuscitation technique will prompt some changes in EMS protocols; these are best understood in the context of the three phases of cardiac arrest due to VF. The three-phase time-dependent conception of cardiac arrest due to VF was articulated by Weisfeldt and Becker.11The electrical phase is the first phase, lasting about 5 minutes. The most important intervention during this phase is defibrillation. This is why the availability of AEDs and programs to encourage their use have saved lives in a wide variety of settings, including airplanes airports, casinos, and the communityThe circulatory phase is next. It varies in duration but runs approximately from minute 5 to minute 15 of VF arrest. During this time, generation of adequate cerebral and coronary perfusion pressure before and after defibrillation is critical to neurologically normal survival. Ironically, if anAED is the first intervention applied during this phase, the subject is much less likely to survive. If preshock chest compressions are not provided, defibrillation during the circulatory phase almost always results in a pulseless rhythm, asystole, or pulseless electrical activity. The previous stacked-shock protocol for the use ofAEDs resulted in prolonged interruption of essential chest compressions, not only for rhythm analysis before shocks but also for rhythm analysis after shocks during this circulatory phase of cardiac arrest.Successful resuscitation from these pulseless rhythms requires not only preshock chest compressions but also prompt, effective post shock resumption of chest compressions.The metabolic phase occurs late (sometime after15 minutes) in cardiac arrest due to VF. This is when resuscitative efforts are least successful and is the phase for which new innovative concepts are needed.One reason why survival of out-of-hospital cardiac arrest has been so poor is that paramedics, who almost always arrive after the electrical phase of cardiac arrest due to VF, spend only half their time doing chest compressions.1314Defibrillator pad electrodes are applied and the patient is given 200 chest compressions and then a single defibrillation shock that is immediately followed by 200 more chest compressions before the rhythm and pulse are analyzed. These additional 200 chest compressions applied after the shock but before rhythm and pulse analysis represent another important aspect of cardio cerebral resuscitation. Therefore, chest compressions were immediately initiated until an arterial pressure was established.9It has been documented that positive pressure ventilation during VF arrest is detrimental, concluding that “there is an inversely proportional relationship between mean Intrathoracic pressure, coronary perfusion pressure, and survival from cardiac arrest. Adverse effects of positive pressure ventilation include an increase in intrathoracic pressure as well as the inability to develop a negative intrathoracic pressure during the release phase of chest compression. Positive pressure ventilation inhibits venous return to the thorax and right heart, resulting in decreased coronary and cerebral pressures. Additionally, hyperventilation and increased intrathoracic pressure have adverse effects on intracranial pressure and cerebral perfusion pressure. These effects are compounded by the fact that ventilation rates by physicians and paramedic rescuers are often much faster than the rate recommended by the guidelines, even after extensive retraining.During cardiac arrest, faster ventilation rates increase the mean intrathoracic pressure and further impede forward blood flow.15Uninterrupted perfusion of the heart and brain prior to defibrillation during prolonged cardiac arrest is essential to neurologically normal survival. It is our conviction that the widespread implementation of cardio cerebral resuscitation for cardiac arrest will dramatically improve survival. This may mandate a paradigm shift away from advanced cardiac life support and basic life support, which emphasize standardization of content and format rather than institution- or agency- specific protocols and training.18


Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. We propose that a list of “Never Events” is created for spinal cord injury patients in order to improve the quality of care. To begin with, following two preventable complications related to management of neuropathic bladder may be included in this list of “Never Events.” (i) Severe ventral erosion of glans penis and penile shaft caused by indwelling urethral catheter; (ii) incorrect placement of a Foley catheter leading to inflation of Foley balloon in urethra. If a Never Event occurs, health professionals should report the incident through hospital risk management system to National Patient Safety Agency's Reporting and Learning System, communicate with the patient, family, and their carer as soon as possible about the incident, undertake a comprehensive root cause analysis of what went wrong, how, and why, and implement the changes that have been identified and agreed following the root cause analysis. Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. A policy on Never Events was introduced in the National Health Service in England from April 2009, following its proposal in High Quality Care for All . The polWrong site surgery: a surgical intervention performed on the wrong site .Retained instrument postoperation: one or more instruments or swabs, or a throat pack, are unintentionally retained following an operative procedure, and an operation or other invasive procedure is needed to remove this, and/or there are complications to the patient arising from its continued presence.Wrong route administration of chemotherapy: intravenous or other chemotherapy  that is correctly but administered via the wrong route .Misplaced nasogastric or orogastric tube not detected prior to use: naso or orogastric tube placed in the respiratory tract rather than the gastrointestinal tract and not detected prior to commencing feeding or other use.Inpatient suicide using noncollapsible rails.In-hospital maternal death from postpartum haemorrhage after elective caesarean section: in-hospital death of a mother as a result of a haemorrhage following elective caesarean section, excluding cases where imaging has identified placenta accreta.Intravenous administration of wrongly selected concentrated potassium chloride.Escape from within the secure perimeter of medium or high secure mental health services by patients who are transferred prisoners.We propose that a list of “Never Events” is created for spinal cord injury patients in order to improve the quality of care. To begin with, following two preventable complications related to management of neuropathic bladder may be included in this list of “Never Events.”Severe ventral erosion of glans penis and shaft of penis caused by indwelling urethral catheter. Incorrect placement of a Foley catheter leading to inflation of Foley balloon in urethra.Severe ventral erosion of penis relates only to those cases where the urethral catheter has cut through glans penis and shaft of penis as well. Patients with minor erosion of urethra, which is limited to glans penis such as wide-open urethra or fish mouth appearance, will not fall under the category of “Never Events.” Incorrect positioning of Foley catheter with balloon inflated in the urethra in a tetraplegic patient can lead to life-threatening autonomic dysreflexia, apart from causing bleeding from urethra and retention of urine in bladder. We present two cases to illustrate these complications, which should not have occurred if good care had been provided to spinal injury patients.A twenty-three-year-old male sustained C-5 incomplete tetraplegia in a road traffic accident in 1982. He underwent implantation of sacral anterior root stimulator in 1986. The receiver block was removed in 2007. He developed a 5 cm left trochanteric sore due to friction as he transferred himself from bed to chair. Considering this patient's condition, he was advised to have indwelling urethral catheter on 26 February 2009 in the community. In December 2009, this patient was admitted to spinal unit for management of pressure sore. Clinical examination revealed severe degree of erosion of urethra. Ventral erosion of penis was quite extensive and included glans penis and almost the entire penile urethra . Erosion of urethra by an indwelling catheter is preventable. This patient was advised to manage his bladder by intermittent catheterisation. But intermittent catheterisations were not possible in the community. Therefore, this patient was left with long-term indwelling catheter, which resulted in erosion of urethra. Ventral erosion of penis by indwelling catheter can lead to bleeding from raw edges of split urethra, and increased chances of urine infection because of shorter urethra. Patients with urethral damage and erosion related to prolonged catheter present a formidable challenge in surgical reconstruction. Most have serious comorbidities and a single operation does not usually solve all the problems . Casey aThe need for urinary diversion can be averted if spinal cord injury patients are not allowed to develop ventral erosion of penis by indwelling catheter. Anchoring the drainage tube of leg bag to thigh with a strap will allow free movement of catheter and avoid any pull on the catheter and penis. When the urethral catheter is fixed taut and the patient develops erection of penis, the indwelling catheter acts as a bowstring and cuts through the penis. Leaving the catheter slack prevents catheter-induced erosion of urethra especially when patient develops erection of penis. Of course, discarding indwelling urethral catheter is the best way to prevent erosion of urethra. Intermittent catheterisation is preferable to indwelling urinary catheter drainage. Suprapubic cystostomy would have prevented catheter-induced erosion of urethra. A 56-year-old male with tetraplegia (C-5 incomplete) attended spinal unit in May 2009 with history of sweating. He started sweating after indwelling urethral catheter was changed by a community health professional. On examination, a long segment of Foley catheter was lying outside penis. The balloon of Foley catheter was palpable in the perineum. Clinical impression was that Foley catheter had been placed incorrectly with the balloon inflated in urethra. Five mL of water was aspirated from the balloon channel of Foley catheter. Then two mL of contrast (Optiray 300) was injected into the balloon channel of Foley catheter and X-rays were taken as per the radiological technique described for demonstration of incorrect positioning of Foley catheter [Insertion of urinary catheter in a tetraplegic patient requires expert knowledge, skills and judgement. Spasm of urethral sphincter may hinder insertion of urethral catheter in a spinal cord injury patient. False passages in urethra if present, pose additional difficulties in urethral catheterisation. Even when a catheter is inserted into the bladder, sudden bladder spasm may push the catheter out before Foley balloon is inflated. In such a situation, an inexperienced health professional may not realise what has happened and unknowingly might inject water in to the balloon channel. This will lead to inflation of the balloon of Foley catheter in urethra, as indeed happened in this patient. If excessive length of Foley catheter lies outside penis, this indicates that “Long catheter sign” is positive and denotes incorrect placement of Foley catheter . An astuKashefi and associates from Division of Urology, University of California-San Diego School of Medicine, San Diego, California  recognisSevere ventral erosion of glans penis and shaft of penis caused by indwelling urethral catheter, and incorrect placement of Foley catheter in urethra are preventable complications. In a good spinal injuries centre these adverse events should never occur. Therefore, we wish to create a “Never Event List” for spinal cord injury patients. To begin with, following two preventable complications related to management of neuropathic bladder may be included in this list of “Never Events.” Severe ventral erosion of glans penis and penile shaft caused by indwelling urethral catheter. Incorrect placement of a Foley catheter leading to inflation of Foley balloon in urethra.After spinal cord injury physicians have become familiar with the concept of “Never events”, and what to do when a never event occurs, this list should be expanded to include other adverse clinical incidents such as incorrect dosing of a pump implanted for intrathecal administration of baclofen in spinal cord injury patients.We believe that spinal cord injury physicians should observe following protocol if a Never Event occurs.Report the incident through hospital risk management system to National Reporting and Learning Service, National Patient Safety Agency. http://www.npsa.nhs.uk/nrls/improvingpatientsafety/patient-safety-tools-and-guidance/beingopen/.Communicate with the patient or service user, family or their carer as soon as possible about the incident in line with the policy: Undertake a comprehensive root cause analysis of went wrong, how and why . National Patient Safety Agency's Incident Decision Tree may be used to decide what initial action to take with the staff involved in the incident . This enImplement the changes that have been identified and agreed following the root cause analysis or significant event audit.Discuss the learning and corrective/preventative actions following the occurrence of the Never Event with all health professionals in spinal unit and in the community.Following preliminary feedback from the National Health Service, initial data from the Reporting and Learning System of the National Patient Safety Agency, and recommendations in “The operating framework for the National Health Service in England 2010/11”, the Never Events framework outlines was updated with new aspects for 2010/11 [Ensure that patient safety incidents which are Never Events are reported to the National Patient Safety Agency.Publish the numbers and types of events on an annual basis.By applying this policy to spinal cord injury patients, it is likely that the quality of care will be is improved. Steps have already been taken by National Patient Safety Agency to decrease the risks of suprapubic catheter insertion , reduce


Results from recent event-related brain potential (ERP) studies investigating brain processes involved in the detection and analysis of emotional facial expression are reviewed. In all experiments, emotional faces were found to trigger an increased ERP positivity relative to neutral faces. The onset of this emotional expression effect was remarkably early, ranging from 120 to 180 ms post-stimulus in different experiments where faces were either presented at fixation or laterally, and with or without non-face distractor stimuli. While broadly distributed positive deflections beyond 250 ms post-stimulus have been found in previous studies for non-face stimuli, the early frontocentrally distributed phase of this emotional positivity is most likely face-specific. Similar emotional expression effects were found for six basic emotions, suggesting that these effects are not primarily generated within neural structures specialised for the automatic detection of specific emotions. Expression effects were eliminated when attention was directed away from the location of peripherally presented emotional faces, indicating that they are not linked to pre-attentive emotional processing. When foveal faces were unattended, expression effects were attenuated, but not completely eliminated. It is suggested that these ERP correlates of emotional face processing reflect activity within a neocortical system where representations of emotional content are generated in a task-dependent fashion for the adaptive intentional control of behaviour. Given the early onset of the emotion-specific effects reviewed here, it is likely that this system is activated in parallel with the ongoing evaluation of emotional content in the amygdala and related subcortical brain circuits. A numbeMany recent studies have investigated the neural network underlying emotional processing by measuring brain responses to emotionally salient stimuli. Differences in brain responses to stimuli that vary in their emotional content have been interpreted as evidence for functional specialisation among neural processes responsible for the processing of emotional information. Such studies have revealed a complex interconnected network of brain structures responsible for the analysis of emotional events. This network includes higher order sensory cortices, where perceptual representations of emotionally relevant stimuli are formed, and the amygdala, orbitofrontal cortex, and ventral striatum, where such sensory representations appear to be classified in terms of their emotional significance. It also includes paralimbic and higher cortical areas such as somatosensory cortex, anterior cingulate, and medial prefrontal cortex, where conscious representations of emotional states are generated, which can be used in the strategic control of behaviour in complex social situations, and in the planning of future goals and actions  are also activated during the processing of facial emotion. The initial perceptual analysis of faces takes place in inferior occipital cortex  or magnetoencephalographic (MEG) measures.This paper reviews a series of recent studies in our lab that have used ERP measures to investigate the processes involved in the detection and analysis of emotional facial expression. In Section 2The basic question addressed in our initial study  was whenThese ERP results suggest that emotional facial expression is analysed rapidly and can affect cortical processing at very short latencies  takes place irrespective of attentional task instructions. In contrast, no ERP evidence for emotional expression processing can be found when peripherally presented faces are unattended. However, and equally importantly, it appears that subsequent stages in emotional face processing are under full strategic control, and are therefore only activated when attentional task instructions require observers to process these faces, irrespective of whether they are presented foveally or in the periphery of the visual field.The ERP studies presented in this section have demonstrated that emotion-specific ERP modulations are strongly dependent on spatial attention. The observation that both short-latency as well as sustained longer latency ERP emotional expression effects are completely eliminated when emotional faces are presented at lateral positions and outside of the current focus of attention is clearly at odds with the hypothesis that emotional facial expression is always fully processed, regardless of other current task demands. It should be noted that our observation that ERP modulations sensitive to emotional facial expression are gated by spatial attention contrasts markedly with fMRI results showing that amygdala responses to fearful faces and other emotionally salient stimuli are unaffected by attention , which wThe striking differences between these results and the ERP findings discussed in this section suggest that frontal neocortical and limbic systems involved in the analysis of emotional events might differ with respect to their functional properties. Rapid amygdala responses may be triggered by attended as well as unattended emotional stimuli , but not high spatial frequency (HSF) representations of fearful faces . This obGiven the assumed preference of amygdala and connected structures for LSF information, driven by magnocellular afferents, we have recently conducted a study  to inves7In the studies reviewed in this paper, ERPs were measured in response to emotional and neutral faces. We investigated the onset, time course, and topographic distribution of brain responses to emotional faces in order to learn more about functional properties of emotional face processing. These studies have revealed robust and replicable differential ERP responses to emotional versus neutral faces. In all experiments reviewed in this paper, emotional faces triggered an increased positivity relative to neutral faces. The onset of this emotional expression effect was remarkably early, ranging from 120 ms post-stimulus when faces were presented at fixation and no competing non-face stimuli were simultaneously present  to 180 mThe initial phase of the emotional expression effects observed in the studies reviewed here showed a frontocentral scalp distribution, while its later phase beyond 250 ms post-stimulus was more broadly distributed see , thus stThe short onset latency of emotional expression effects observed in the ERP studies reviewed in this paper might suggest that the early phase of these effects reflects the rapid pre-attentive automatic assessment of the emotional content of faces, as implemented by structures such as the amygdala. One obvious objection against this hypothesis is that it is highly unlikely that the effects of emotional expression on ERP waveforms reviewed in this paper are generated in the amygdala, given its deep position and its electrically closed nuclear structure of clustered neurons . Of course, even though amygdala activations themselves are unlikely to result in measurable ERP responses at the scalp surface, rapid automatic amygdala activations triggered by emotional faces might still be relayed directly to neocortical areas , where tThe most important evidence against the hypothesis that ERP modulations sensitive to emotional facial expression are generated during the initial automatic classification of emotional content comes from our finding that spatial attention had a strong modulatory effect on these modulations. When faces were presented foveally, early emotional expression effects (but not longer latency effects) were triggered independently of the current focus of attention. However, and most importantly, even these early effects were completely eliminated when attention was directed away from the location of peripheral emotional faces towards another perceptual task . This obIt is conceivable that the absence of early emotional expression effects in response to unattended peripheral emotional faces found in our previous studies  may be dIt should also be stressed that amygdala activations in response to emotional stimuli do not always and exclusively represent a rapid and automatic classification of these stimuli. Attentional modulations of amygdala responses to fearful or happy facial expressions have in fact been observed , and modOverall, our findings that ERP modulations in response to emotional faces were triggered in a very similar fashion for all basic facial expressions, were not selectively driven by low spatial frequency information, but were strongly modulated by attention all suggest that these effects are elicited during stages in the processing of emotional information that are located beyond the initial rapid and automatic classification of emotional content. The outcome of an initial rapid and automatic appraisal of emotional stimuli will be fed into higher necortical stages of emotional processing, where the evaluation of emotional material is likely to continue in parallel with ongoing emotion evaluation in amygdala and related brain circuits. We suggest that emotional expression effects, as reflected by ERP waveforms in response to emotional faces, reflect processes at this later neocortical stage in the processing of emotional information.At present, it would be premature to speculate in more detail about specific cortical regions where the ERP effects reviewed in this paper might be generated, although regions such as anterior cingulate, somatosensory cortex, or medial prefrontal cortical areas seem plausible candidates. For example, The analysis of emotional facial expression is based on a complex neural network, and includes both a rapid, obligatory, and pre-attentive classification of emotional content , and the subsequent in-depth analysis of emotional faces in higher order necortical emotion areas . In spite of the fact that ERP effects of emotional facial expression are triggered at very short latencies, they are likely to reflect processes that form part of the second, higher level and attention-dependent emotional processing system, where representations of emotional content are generated in a strategic and task-dependent fashion for the adaptive intentional control of behaviour. Further studies will have to investigate to what extent effects of emotional facial expression on ERP waveforms, such as reviewed here, might represent the initial stages of higher level emotional processes, which may not just be involved in the analysis of emotionally relevant sensory stimuli, but perhaps also in the representation of subjective emotional states.


High-throughput screens comparing growth rates of arrays of distinct micro-organism cultures on solid agar are useful, rapid methods of quantifying genetic interactions. Growth rate is an informative phenotype which can be estimated by measuring cell densities at one or more times after inoculation. Precise estimates can be made by inoculating cultures onto agar and capturing cell density frequently by plate-scanning or photography, especially throughout the exponential growth phase, and summarising growth with a simple dynamic model (e.g. the logistic growth model). In order to parametrize such a model, a robust image analysis tool capable of capturing a wide range of cell densities from plate photographs is required.Colonyzer is a collection of image analysis algorithms for automatic quantification of the size, granularity, colour and location of micro-organism cultures grown on solid agar. Colonyzer is uniquely sensitive to extremely low cell densities photographed after dilute liquid culture inoculation (spotting) due to image segmentation using a mixed Gaussian model for plate-wide thresholding based on pixel intensity. Colonyzer is robust to slight experimental imperfections and corrects for lighting gradients which would otherwise introduce spatial bias to cell density estimates without the need for imaging dummy plates. Colonyzer is general enough to quantify cultures growing in any rectangular array format, either growing after pinning with a dense inoculum or growing with the irregular morphology characteristic of spotted cultures. Colonyzer was developed using the open source packages: Python, RPy and the Python Imaging Library and its source code and documentation are available on SourceForge under GNU General Public License. Colonyzer is adaptable to suit specific requirements: e.g. automatic detection of cultures at irregular locations on streaked plates for robotic picking, or decreasing analysis time by disabling components such as lighting correction or colour measures.Colonyzer can automatically quantify culture growth from large batches of captured images of microbial cultures grown during genome-wide scans over the wide range of cell densities observable after highly dilute liquid spot inoculation, as well as after more concentrated pinning inoculation. Colonyzer is open-source, allowing users to assess it, adapt it to particular research requirements and to contribute to its development. Saccharomyces cerevisiae (brewer's yeast). Growing cultures on solid agar has some advantages over growth in liquid medium including speed and ease of robotic handling. To grow microbe cultures on solid agar, cultures are inoculated by direct pinning onto solid agar plates, or inoculated from liquid after dilution (spotting). Liquid spotted culture inoculum can be of arbitrary cell density. The inoculation method used affects the initial cell density for each culture on the plate, and the resulting final achievable densities  or environment (e.g. temperature or nutrient availability) on organisms of different genotypes using this method. This is particularly true for model organisms such as see Fig. . Cell poIn order to quantify data produced using this technique, we decided to develop Colonyzer, a new tool for generating several measures of culture cell density and morphology including area, integrated optical density (IOD), colour and granularity which emphasises being able to reliably detect cultures with low cell densities. These measures are appropriate for addressing a wide range of research questions and can be disabled or ignored by the user as required. Colonyzer is capable of detecting low cell densities after performing background lighting correction to allow a fair comparison between the densities of all cell cultures on a plate and implementing a Gaussian mixed model image segmentation algorithm which robustly detects the location of cultures barely visible to the human eye.HT Colony Grid Analyzer described by Collins et al.  (Eq. 3) and maximising it with respect to its parameters (Eq. 4).By constraining the number of Gaussian components in the mixed model to exactly two, we insist that all pixels be classified as either culture or agar. Parameter estimation is carried out by constructing a log likelihood estimator for the model The optimum parameters (denoted by *) are estimated as follows using the genetic optimisation package rgenoud . Fig. 5 xthresh and selecting the root which gives the largest value for The most appropriate threshold intensity is then estimated by numerically solving the following for intensity Huang and Chau  segment In an ideal experiment, cultures would remain entirely within the approximately square tiles that they were intended to be inoculated into on the rectangular agar grid. Biological heterogeneity, overgrowth or slight errors in plate location or alignment during image capture necessitate improving on initial location guesses before quantifying cell density. Colonyzer fine-tunes tile location estimates by taking the corrected, thresholded image, and for each tile, minimizing (by brute-force optimization) the number of culture pixels on the tile edge by changing the tile location while keeping its size fixed. Colonyzer performs this search over a 20*20 pixel search area.xdim and ydim, allowing users to access sub-images of individual tiles if required. Then the number of culture pixels in the thresholded image are counted and this is stored as a measure of culture area. Similarly, the number of pixels in the tile's location on the gradient map are counted as a measure of culture morphology (i.e. texture or granularity). The original image is masked with the thresholded tile and the mean colour (RGB triplet) of the culture, and mean background agar colour are calculated and stored. The lighting corrected image is masked with the thresholded tile and the sum of the culture intensities in the masked image (less the median background intensity) is used as a measure of IOD. The sum of all the pixel intensities in the tile (less the median background intensity) is calculated as another measure of cell density. All of these values are written to a tab-delimited text file, together with row and column number for subsequent analysis.Once an exact tile location has been found, Colonyzer stores the coordinates of the top left hand corner of the tile together with its Sacchromyces cerevisiae, Schizosacchromyces pombe and Escherichia coli  are not designed to be able to quantify growing, dilute spotted culture cell densities. From Table CellProfiler matches many of the features of Colonyzer. CellProfiler is a flexible image analysis environment, but its development has not been focussed on capturing growth kinetics of spotted cultures. Fig CellProfiler and Colonyzer density estimates than with simpler tools, but there are nevertheless some inconsistencies between them. The curvature apparent in the CellProfiler intensity profiles demonstrated in Fig CellProfiler test image does not contain cultures of particularly low cell densities, but this degree of uncorrected intensity bias would cause bias in IOD estimates for low densities. CellProfiler also mis-identifies some example culture locations , however CPU time is relatively cheap and accuracy and high sensitivity for this particular image analysis problem were priorities during Colonyzer development.We have compared the features of Colonyzer with those of several other software tools for quantifying culture density on solid agar , and code for summarising timecourse data with the logistic model (Logisticyzer). The latter also depends on our in-house Robot Object Database system (ROD) which will be released in the near future.In future we are interested in improving the speed of analysis, while maintaining its sensitivity (which is its main feature), adapting Colonyzer to utilize some cloud computing services to achieve ever higher throughput, and to improve the ease with which users can install the packages required to run Colonyzer. Others may be interested in adding new functionality or disabling some Colonyzer functions to suit their particular requirements.This paper presents Colonyzer, an image analysis tool which specialises in quantification of cell density in micro-organism cultures growing on solid agar over a wide range of culture densities from plate photographs. Growing cultures on solid agar is often cheaper and less demanding than equivalent growth in liquid medium. Similarly, photographic image capture is cheaper and faster than spectrophotometric analysis of cell density in liquid wells. Colonyzer's particular strength is its sensitivity in detecting cultures with low density. It achieves sensitivity by correcting for any lighting gradients in captured photographs, and by segmenting images, differentiating between agar and culture, using a two-component Gaussian mixed model of pixel intensity. Algorithms underlying Colonyzer quantify densities of pinned cultures and all late-growth cultures well, but we have optimised them to tackle the more difficult problem of quantifying exponential-phase dilute liquid-inoculated culture density on agar. Colonyzer is significantly more accurate when compared to other tools in this regard. Colonyzer's sensitivity opens up the possibility of quantitative modelling of the growth curves of thousands of independent cultures grown on solid agar during high-throughput screens.Project name: ColonyzerProject home page: http://research.ncl.ac.uk/colonyzerOperating system(s): Platform independent.Programming language: Python & ROther requirements: Python Imaging Library, RPy, NumPy, rgenoudLicense: GNU GPLAny restrictions to use by non-academics: No restrictionsCL and DJW designed the algorithms, CL implemented them, wrote the manuscript and captured test images, AY captured test images and developed procedures for fitting the logistic model to Colonyzer output, SGA captured test images, evaluated Colonyzer quantifications, suggested algorithm improvements and contributed to the manuscript. DAL initiated the project, evaluated Colonyzer quantifications and contributed to the manuscript. All authors read and approved the final manuscript.


Despite great advances in the fields of pain management and palliative care, pain directly or indirectly associated with a cancer diagnosis remains significantly undertreated. The present paper reviews the current standard for cancer pain management and highlights new treatments and targeted interventional techniques. At least 70% of cancer patients will experience pain at some point during the course of their illness Although opioids remain the primary class of medications indicated in the treatment of chronic cancer pain, greater attention has been given to the utility of adjuvant analgesics. Different types of pain vary in the extent to which they respond to various classes of medications, suggesting the need for a clear understanding of pain pathophysiology and an individualized management strategy. The present paper reviews the basics of cancer pain management and addresses some of the more complex clinical pain syndromes, focusing on the medical and interventional therapies currently available.Pain in patients with cancer is a symptom that can be well managed, and yet it is a consistently undertreated problem The crucial initial step in effective pain management is patient identification through inquiry and observation. Identification can be achieved by universal implementation of valid screening tools. Follow-up steps must include a detailed pain assessment and accurate classification, which together will allow the clinician to select the combination of therapies most likely to provide relief.Cancer-related pain can be classified into two main types, nociceptive and neuropathic:Nociceptive pain occurs when tissues surrounding nociceptive fibres are injured or stressed. Nociceptive pain can be further divided into somatic pain  and visceral pain  Neuropathic pain is pain related to damage or dysfunction of the nervous system, and this pain type is described in more detail in its own subsection, later in this article.Patients may simultaneously experience more than one type of pain at more than one location, with each pain being likely to respond in varying degrees to various therapies.In an attempt to simplify pain management for clinicians, the World Health Organization devised a medication algorithm known as the “3-step analgesic ladder” On their own, the strong opioids have no maximum dose. But it is important to note that, although oxycodone is a strong opioid, dosing for combination products containing both short-acting oxycodone and acetaminophen is limited by the maximum allowable daily dose of acetaminophen. Such combination agents are therefore considered appropriate for step 2 of the analgesic ladder.Although meperidine is considered a strong opioid, it is not used in the cancer pain setting, because consistent use leads to the accumulation of normeperidine in the body and a lowering of the seizure threshold If around-the-clock dosing of short-acting opioids is required, the patient should receive a dose every 4 hours “Breakthrough pain” refers to pain experienced despite around-the-clock analgesia. Given the time required to reach maximum concentration, a breakthrough dose should be available to patients once every hour. When initiating an opioid, calculate the breakthrough dose to be at least half of the routine 4-hourly dose, or 10%–20% of the total daily dose of opioid Long-acting or extended-release opioids have a half-life of approximately 12 hours; most patients should therefore receive them twice daily In general, patients should receive the same opioid for routine and breakthrough dosing. The exception is fentanyl, because a breakthrough form is not currently available in Canada. Although on its own fentanyl is a short-acting opioid, it is commonly used in the form of a transdermal patch If pain begins to stabilize on a routine dose of a short-acting opioid, the long-acting equivalent of the same opioid should be substituted. The availability of hourly breakthrough dosing should not change.Whenever possible, opioid side effects should be prevented nsaids) nsaids tends to be limited by side effects and concerns about gastrointestinal and renal toxicity. The utility of these drugs initially improved with the advent of the cyclooxygenase-2 selective inhibitors, which lack significant gastrointestinal and renal toxicity, but recent associations with heart disease may affect availability The effective management of cancer pain related to primary or metastatic bony disease may include classes of analgesic drugs other than opioids—for example, acetaminophen and nonsteroidal anti-inflammatory drugs  receptor, making for a third target.Several mechanisms have been proposed to mediate nerve damage or injury expression Although often used as first-line therapy, opioids may have limited efficacy in the management of neuropathic pain Gabapentin, first licensed in 1994, was designed as a γ-aminobutyric acid analogue intended to reduce seizure activity No randomized trials have examined the efficacy of gabapentin in the setting of cancer pain. In the management of diabetic neuropathy, gabapentin produces greater pain control with fewer side effects than amitriptyline does Structurally similar to gabapentin, pregabalin was designed to have greater bioavailability and a greater affinity for the same calcium channels blocked by gabapentin In the setting of cancer pain management, clinical efficacy comparisons have not been made between gabapentin and pregabalin. If either gabapentin or pregabalin must be discontinued, the drug should be tapered over a 1- to 3-week period to prevent withdrawal syndrome .Clinicians must educate themselves regarding medication reimbursement issues, because many drug benefit plans will not cover gabapentin or pregabalin for neuropathic pain unless documentation of poor response to less-expensive medications is provided.Agents including carbamazepine, phenytoin, valproate, and clonazepam are occasionally used in the setting of cancer pain, but evidence for their benefit is limited tcas) are commonly used in the setting of cancer pain tca has been found to have greater efficacy than any other for neuropathic pain; side effects tend to be the limiting factor in titrating. Nortriptyline tends to have the least anticholinergic properties, and the initiating dose should be 10–25 mg once daily, taken at night.First reported to reduce neuropathic pain in 1977, tricyclic antidepressants (tcas remain the antidepressant of choice The newer selective serotonin (and serotonin–norepinephrine) reuptake inhibitors, have been studied in the setting of diabetic neuropathy and trigeminal neuralgia. There is moderate evidence that these medications can provide can provide relief from neuropathic pain; however, Corticosteroids possess analgesic properties for several cancer pain syndromes, including both neuropathic and bony pain ii, methadone was initially designed for use in pain management; however, for several decades, this synthetic opioid was used preferentially in the clinical setting of opioid addiction Developed in Germany during World War nmda receptor and the pre-synaptic reuptake of both norepinephrine and serotonin Methadone exists as a racemic compound: one isomer is a μ-receptor agonist; the other is responsible for inhibition of the Methadone’s rapid absorption is followed by tissue distribution and a highly variable elimination phase intended to maintain plasma levels. The resulting half-life varies greatly—from 4 hours to 120 hours—among individuals Methadone is metabolized in the liver via the cytochrome P450 system, specifically the CYP3A4 group of enzymes Methadone has no active metabolites, and no adjustments in dosing need be made in the setting of renal insufficiency. The same formulation of methadone is used for both routine and breakthrough dosing. Because of methadone’s complex pharmacodynamics and pharmacokinetics, breakthrough dosing differs from that of other opioids, tending to be offered every 3 hours at maximum. The onset of analgesia with methadone is 20–30 minutes for oral preparations, and routes of administration include rectal, subcutaneous, intravenous, epidural, and intrathecal Several models for rotating to methadone from another opioid have been devised Methadone is available at very low cost, which makes it an attractive medication for pain management in developing countries. One study compared methadone with morphine as a first-line opioid agent and found equal efficacy in the setting of cancer pain for opioid-naïve patients Mike, a 33-year-old man with recurrent metastatic rectal carcinoma presents with severe burning rectal pain. He is unable to sit for more than 30 minutes at a time despite titration of both his long-acting hydromorphone to 84 mg three times daily and gabapentin to 1200 mg three times daily. Opioid rotation to methadone proved somewhat beneficial, because at a dose of 50 mg three times daily, Mike was able to cut back his breakthrough requirement during the day to four 15-mg doses of methadone. He was referred to interventional anesthesia for an impar ganglion block.Despite use of the original World Health Organization three-step analgesic ladder for cancer pain management , up to 25% of people with cancer may continue to experience pain Neurolysis attempts to interrupt the neural pathway thought to be responsible for the pain syndrome. This interruption can be achieved through anesthesia, including chemical (injection of agents), thermal (cryoablation and radiofrequency), and surgical (cordotomy) techniques Continuous epidural, subarachnoid, or intrathecal infusion of an opioid and adjuvants as required is now routinely considered in the management of patients with refractory cancer pain Jim, a 45-year-old man with metastatic renal cell carcinoma to the pelvis, describes severe, deep, stabbing pain in the right buttock that radiates down the right leg. Trials of several opioids in combination with neuropathic adjuvants have not brought his pain below a 5 on a pain scale of 10. Sativex  and oral ketamine were added to his regimen of methadone and pregabalin, and he is being considered for an intraspinal technique.In Canada, the first buccal cannabinoid spray (Sativex) was recently approved for use in cancer pain. The cannabinoid CB1 receptor acts on pathways that partly overlap with those affected by opioids. It is widely distributed throughout the central and peripheral nervous systems nmda receptor antagonist is thought to be responsible for its utility in treating opioid-resistant neuropathic pain Ketamine has been used with some success to reduce the dose of opioid and to improve pain control in the setting of cancer pain Adverse effects that have been reported with ketamine include tachycardia, hypertension, raised intracranial pressure, and nausea, but the ones that raise the most concern are the psychotomimetic effects such as hallucinations, confusion, and sedation. In some patients, these effects can be avoided by administering haloperidol or a benzodiazepine as a prophylactic Tramadol exists as a racemic compound: one isomer is both a weak μ-receptor agonist and a serotonin reuptake inhibitor tcas or selective serotonin reuptake inhibitors is being considered; patients receiving combinations of this kind are at great risk of seizure Tramadol has few drug interactions; a notable exception occurs with antidepressants. Caution must be used if a combination of tramadol and either Tramadol is available in an extended-release form that is given once daily. Maximum doses of tramadol should not exceed 600 mg daily, and for opioid-naïve individuals, the typical starting total daily dose is 150 mg. The side effects of tramadol are similar to those of other opioids , with the exception of constipation, which has been found to be significantly less with tramadol than with other opioids In head-to-head trials, tramadol at high doses has been found to have efficacy equivalent to that of low-dose morphine. The equianalgesic ratio between tramadol and morphine has not been consistently described and falls into the range 4:1–15:1 in the literature Buprenorphine, a synthetic opioid, was developed in the 1960s as a partial μ-receptor agonist Studies in the cancer pain population are limited, but one head-to-head study versus morphine in chronic pain demonstrated significantly greater efficacy and few side effects with buprenorphine Chronic pain syndromes related to treatment  are mostly neuropathic in classification The treatment algorithm for post-treatment neuropathic pain syndromes is different from that for pain directly related to neoplastic disease, in that first-line medications tend to be anticonvulsants or antidepressants Appropriate use of medications and provision of education to dispel the fears and myths surrounding opioids are crucial components of a cancer pain management strategy. Among clinicians, fears regarding side effects, misconceptions about addiction, and negative previous experiences have been shown to greatly influence opioid prescribing habits Given current understandings of the pain pathways in the body and the cadre of medications and interventions available that may provide complete relief, patients living with cancer should not unnecessarily live with pain. Clinicians have a duty to manage this symptom with intensity and aggression equal to that applied to the cancer itself. With increased education, it is to be hoped that health care professionals will develop greater comfort in using opioids, will introduce adjuvant analgesics appropriately, and will refer to palliative care colleagues when pain or related symptoms in their patients are not well controlled.


As hidden Markov models (HMMs) become increasingly more important in theanalysis of biological sequences, so too have databases of HMMs expanded in size,number and importance. While the standard paradigm a short while ago was theanalysis of one or a few sequences at a time, it has now become standard procedureto submit an entire microbial genome. In the future, it will be common to submit largegroups of completed genomes to run simultaneously against a dozen public databasesand any number of internally developed targets. This paper looks at some of thereadily available HMM (or HMM-like) algorithms and several publicly availableHMM databases, and outlines methods by which the reader may develop customHMM targets.