To prevent postnatal transmission of HIV in settings where safe alternatives to breastfeeding are unavailable, the World Health Organization (WHO) recommends exclusive breastfeeding followed by early, rapid cessation of breastfeeding. Only limited data are available on the attitudes of health workers toward this recommendation and the impact of these attitudes on infant feeding counselling messages given to mothers.As part of the Breastfeeding, Antiretroviral, and Nutrition (BAN) clinical trial, we carried out an in-depth qualitative study of the attitudes, beliefs, and counselling messages of 19 health workers in Lilongwe, Malawi.Although none of the workers had received formal training, several reported having counseled HIV-positive mothers about infant feeding. Health workers with counselling experience believed that HIV-infected mothers should breastfeed exclusively, rather than infant formula feed, citing poverty as the primary reason. Because of high levels of malnutrition, all the workers had concerns about early cessation of breastfeeding.Important differences were observed between the WHO recommendations and the attitudes and practices of the health workers. Understanding these differences is important for designing effective interventions. In 2004, approximately 640,000 worldwide children became infected with HIV, primarily through mother-to-child (MTCT) transmission of the virus . TransmiInternational guidance currently states that when replacement feeding is acceptable, feasible, affordable, sustainable, and safe, avoidance of all breastfeeding by HIV-infected mothers is recommended to prevent postnatal transmission of HIV  see Tab. OtherwiExclusive breastfeeding is recommended for HIV-infected mothers who breastfeed because it protects against diarrhoea and other infections -7. In adMalawi is experiencing one of the worst HIV/AIDS epidemics in the world. Out of a total population of 12 million inhabitants, approximately 460,000 women and 83,000 children under age 15 are infected with HIV . GeneralInfant feeding practices in Malawi are far from optimal, and implementing recommendations for infant feeding among HIV-infected mothers in light of these patterns poses a challenge. For example, prolonged breastfeeding is common but a long duration of exclusive breastfeeding is not. The Malawi 2000 Demographic and Health Survey reported that more than half of all infants were continuing to breastfeed at 24 months, but the median duration of exclusive breastfeeding was just 2 months . Thirty-In many sub-Saharan Africa countries, communities often take the recommendations of health providers as the final word ,14. In sAs key gatekeepers in influencing mothers' decisions on infant feeding ,23, healData were collected as part of a formative research study to inform the design of the Breastfeeding, Antiretroviral, and Nutrition (BAN) study, a clinical trial in Lilongwe, Malawi. The objectives of the BAN study are to investigate (a) the benefit of nutritional supplementation given to HIV-infected women during breastfeeding, (b) the benefit and safety of antiretroviral medications given either to infants or their HIV-infected mothers to prevent transmission during breastfeeding, and (c) the feasibility of exclusive breastfeeding followed by rapid cessation of breastfeeding at 6 months -28.The formative study included in-depth individual interviews with HIV-infected mothers, health workers, community leaders and traditional birth attendants; observations of home environments with mothers of unknown HIV status; and focus group discussions with pregnant women, grandmothers, and fathers . In thisAll interviews were conducted in June and July 2002 by Malawian field investigators with prior training in nutrition or public health research. Before data collection, the field investigators participated in a 2-week training course on qualitative research methods and interviewing techniques . They weData were analyzed using methods described in Miles& Huberman . First, The institutional review boards at the U.S. Centers for Disease Control and Prevention, the University of North Carolina at Chapel Hill, and the National Health Science Research Committee in Malawi approved the formative research, and each participant provided written informed consent.Slightly more than half of the 19 health workers were aged 30–39 years and 16 were women Table . About tAlmost all of the health workers (n = 18) knew and understood the correct definition of exclusive breastfeeding and reported believing that breast milk alone was sufficient for an infant during the first 6 months of life. One nurse midwife defined exclusive breastfeeding in this way, "It's the process whereby the child is only breastfeeding without giving him or her any food or water but breast milk only." Another nurse midwife explained why she thought breast milk was sufficient for the infant's first 6 months of life: "Because the child needs not much food and their body demands are still minimal. Breast milk contains all the food nutrients the baby needs."Although the concept was understood, only 11 health workers believed that mothers in the community could practice exclusive breastfeeding for 6 months. Introduction of solid foods before 4 months was reported as the cultural norm and a major barrier to exclusive breastfeeding by seven health workers. One nurse's response illustrated this cultural phenomenon when she said, "They are used to introducing other foods to the baby very early, so they can't change." A nurse midwife also shared how culture hindered exclusive breastfeeding practices in her community: "Women do not understand. They say nowadays children are too hungry. Thus, many start supplementary food at less than 3 months. Some give infant formula to their child."Health workers' attitudes are another barrier to exclusive breastfeeding. Although most had reported a belief that breast milk was sufficient for the infant's first 6 months of life, some did not appear to firmly believe this recommendation. For example, one nurse midwife illustrated how her professional practices conflicted with her personal beliefs when she said, "It [breast milk] is nutritious and contains all the nutrients. Ideally it is supposed to be adequate until the child is 6 months old...but sometimes it [breast milk] is not sufficient."In terms of facilitators of exclusive breastfeeding, several health workers identified unemployment, as mothers who did not work had more time than employed mothers and were more likely to be with their infants. As noted by one nurse, "Most women are unemployed...so they have ample time to breastfeed." Another said, "Because you always have the child with you so milk is readily available."Seventeen health workers reported direct experience counselling mothers on infant feeding, but the advice they provided was sometimes not consistent with WHO and national recommendations. One nurse midwife explained, "I tell mothers to practice exclusive breastfeeding up to 4 months without giving any supplementary feeds or water. From 4 months, I tell them to introduce supplementary feeds containing all the three food groups, so that when the baby is 6 months, it will not have problems digesting these foods since breast milk alone won't be enough." Another nurse advised mothers to "exclusively breastfeed for the whole year. Then I advise mothers to introduce nutritious foods to their babies."Our analysis of the attitudes and counselling messages of the health workers relative to HIV-infected mothers focused on three major themes: (a) perceived risk to the infant of contracting HIV from breastfeeding, (b) differences in attitudes and counselling messages between health workers who had experience in HIV and infant feeding and those who did not, and (c) issues related to the early cessation of breastfeeding.all or most HIV-infected mothers would transmit the virus during breastfeeding, while ten correctly believed that only some mothers would transmit the virus.Almost all of the health workers interviewed (n = 18) were aware that breastfeeding was a mode of transmitting HIV from an infected mother to her infant Table , but theNone of the health workers interviewed indicated having received any formal training in counselling HIV-infected mothers about feeding their infants. Nonetheless, six reported that they had experience in counselling such mothers on options for infant feeding. Most nurses with this experience believed that HIV-infected mothers should breastfeed exclusively, citing poverty as the primary reason why this was the most feasible option in their community. This sentiment was illustrated by a medical assistant who said, "Yes, HIV-infected mothers should breastfeed because they cannot buy infant formula." A nurse also shared this perspective: "Women with HIV should breastfeed because resources are scarce to buy infant formula in this community."In addition to advising HIV-infected mothers to exclusively breastfeed, they also delivered messages of breast health to infected mothers who wanted to avoid transmitting the virus to their infants during breastfeeding. One nurse midwife counselled mothers to check their breasts and their infant's mouth for infections: "I advise them to make sure that the baby is kept away from [breast] infections and mouth sores." Similarly, another nurse midwife counselled HIV-infected mothers to use breast-milk substitutes when experiencing problems with breast health: "She should make sure that if she has breast sores, she should avoid breastfeeding her baby. Instead, bottle feed the baby if she can manage."always contains HIV, so it will infect the baby." This perceived certainty of HIV transmission to an infant through breastfeeding most likely explained the statement of another nurse: "HIV-infected mothers should not breastfeed. They should use formula from the shops, even thin phala (porridge)."In contrast with the views of health workers with experience in counselling HIV-infected mothers, the 11 health workers reporting no direct experience were divided as to whether women with HIV should breastfeed at all. Seven believed that HIV-infected women should not breastfeed because of the risk involved in transmitting the virus to the infant. One nurse said: "Breast milk The WHO recommendation for early, rapid cessation of breastfeeding was discussed. Health workers noted, however, that rather than counselling rapid cessation, they advised HIV-infected mothers to gradually introduce complementary foods after 6 months of exclusive breastfeeding. One nurse midwife said, "She should stop breastfeeding gradually. She should try giving the baby food and once it accepts it she can then stop the baby from latching." Agreeing, another nurse expressed her concern with programs recommending rapid or abrupt breastfeeding cessation: "With an HIV-positive mother it is difficult [to advise them] because it [breastfeeding cessation] is supposed to be done abruptly. But I think it should be done gradual while introducing supplementary feeds."The recommendation for early cessation of breastfeeding for HIV-infected mothers conflicts with the cultural norm of breastfeeding for up to 2 years. Health workers were divided when asked whether it was possible for mothers in their community to stop breastfeeding at 6 months, as recommended in the BAN protocol, with seven responding "yes," six "no," four "possibly," and the remaining two with no answer. Explanations for early cessation of breastfeeding included pregnancy and maternal employment. One nurse midwife explained: "Some women become pregnant early [when the nursing baby is still young], so they feel it is not safe to continue breastfeeding the baby." As for stopping at 6 months because of employment status, a clinical officer stated: "Working mothers are more likely to stop breastfeeding their baby early."Health workers identified concerns about the infant's nutritional status and food insecurity as barriers towards early cessation. This was illustrated by a nurse midwife who said, "The child is very young so it is difficult to stop breastfeeding because the baby develops malnutrition and has a lack of bonding with the mother. Food availability might also affect her from stopping breastfeeding because there is a shortage of food in this community."The four health workers who indicated it was possible for women to stop breastfeeding at 6 months based their responses on the mother's HIV status and her concern for her infant's health. One nurse said, "If the [HIV-positive] mothers are told good reasons for stopping, they will listen and follow what they are advised." Similar to this response, a medical assistant mentioned that fear may influence HIV-infected mothers' infant-feeding behaviour when he stated, "HIV-positive mothers with a fear of transmitting HIV to their child could stop breastfeeding at 6 months."Cultural norms affect health workers' attitudes and how they counsel mothers about complex behaviours. We undertook this study because existing data suggested that WHO and Malawian recommendations for infant feeding by HIV-positive mothers were in contradiction with local feeding norms and practices, and additional qualitative data were needed to better understand the challenges health workers face when counselling mothers about these recommendations. We observed that even without formal training, some experienced health workers were giving appropriate advice to HIV-infected mothers. However, misperceptions about breastfeeding and HIV were common, and attitudes and cultural beliefs influenced the counselling messages given on this subject, underscoring the importance of locally adapted messages and training on HIV and infant feeding.Based on our findings, we developed a comprehensive training course for health workers in the BAN study, adapting existing training material -37 to loImportant changes to the BAN study protocol were also made , includiThere are many factors influencing mothers' feeding decisions and, in this population, our larger formative study revealed that mothers place a high level of importance on the advice of health workers. Mothers trust the information they receive from these workers and believe it is accurate and beneficial for their infant's health. This creates a challenging situation for counselling on infant feeding because there are several aspects of HIV transmission through breastfeeding that are not yet well understood scientifically. This includes issues such as the mechanisms through which breastfeeding-related transmission occurs, how and when to stop breastfeeding to balance the competing risks of HIV transmission and mortality from other infectious diseases and malnutrition, and the safest way to feed infants who are no longer breastfeeding using locally available foods.At present, in many countries health workers are expected to counsel HIV-positive mothers on infant feeding with little or no training, as reported in a recent evaluation in Malawi, Uganda, Kenya, and South Africa . Thus, we encourage further research on how to counsel HIV-positive mothers about infant feeding, local adaptation of counselling messages, and rapid implementation of locally adapted training so that health workers have the skills needed to counsel mothers effectively about safe infant feeding. Failure to provide this training may compromise the health of infants if counselling is based on personal attitudes or otherwise subject to bias.Regarding possible limitations of the present study, we note that this was a primarily a qualitative examination of the knowledge, attitudes, and counselling messages of Malawian health workers that was based on a small number of purposively selected respondents. Although informative for our purposes, the results cannot be generalized to the large population of nurses and other health workers working in Lilongwe. On the other hand, through our qualitative approach we were able to identify cultural norms on infant feeding, the attitudes of health workers toward existing recommendations, and deficits in the counselling messages of workers relative to infant feeding that may not have been captured through other methods.There are often important discrepancies between the attitudes of health workers, cultural beliefs and counselling messages, and existing recommendations on HIV and infant feeding. Qualitative research is useful for understanding these differences and for adapting counselling messages to the local context. Competency-based training on HIV and infant feeding is necessary in Malawi, and elsewhere, to strengthen health worker counselling and to ensure safe infant feeding practices. Additional data on the impact of this counselling on infant feeding practices and health outcomes are needed.The author(s) declare that they have no competing interest.EP contributed to designing the study protocol, data analysis and drafted the manuscriptYOF contributed to the data analysis and drafted the manuscriptMEB contributed to designing the study protocol and data analysisALC contributed to designing the study protocol, data analysis and supervised the data collection of the studyAM contributed to designing the study protocol and data collectionJN participated in data collection and critiqued drafts of the manuscriptBCT contributed to designing the study protocol and data analysisBMM contributed to designing the study protocol and data collectionYA contributed to designing the study protocol and critiqued drafts of the manuscriptDJJ contributed to designing the study protocol and critiqued drafts of the manuscriptCvdH contributed to designing the study protocol, data analysis and critiqued drafts of the manuscriptPK contributed to designing the study protocol and critiqued drafts of the manuscriptAll authors read and approved the final manuscript


The survival experience of 582 women with premenopausal breast cancer was examined to determine whether prognosis was related to body size or to demographic and reproductive factors. During the follow-up period 228 patients died and 18 emigrated or were lost to follow-up. Usual body weight, reported at the time of diagnosis, was a strong predictor of survival, with a statistically significant trend towards lower survival with increasing weight. Height and obesity (Quetelet index) were not significantly related to survival, although the tallest women and the most obese women appeared to fare worst. Other characteristics of prognostic importance were disease stage and reproductive history (women who were older when their first child was born fared better). Women aged 46-50 when diagnosed also appeared more likely to survive but no clear trend with age was evident. Other characteristics of the women including social class, cigarette use and oral contraceptive use were not significantly related to survival probability.


Previous research on informed consent for research in psychiatric patients has centered on disorders that affect comprehension and appreciation of risks. Little has been written about consent to research in those subjects with Borderline Personality Disorder, a prevalent and disabling condition.Despite apparently intact cognition and comprehension of risks, a borderline subject may deliberately choose self-harm in order to fulfill abnormal psychological needs, or due to suicidality. Alternatively, such a subject may refuse enrollment due to transference or the desire to harm him or herself. Such phenomena could be precipitated or prevented by the interpersonal dynamics of the informed consent encounter.Caution should be exercised in obtaining informed consent for research from subjects with Borderline Personality Disorder. A literature review and recommendations for future research are discussed. Decision-making capacity in psychiatric patients has been the topic of past research . HoweverHowever, what about people that persistently and intentionally harm themselves? A large subpopulation of psychiatric patients suffer pathology which centers around a lifelong tendency to make what appear to others to be bad decisions. They may persistently seek out victim roles and manipulate others to harm them. They may make repeated suicide attempts, or compulsively cut themselves. Can it be considered ethical to draw blood from someone who consented because she has a psychological need to see herself bleed?  Borderline personality disorder (BPD) is a prevalent, chronic, disabling, and treatment-resistant condition. It affects approximately 2% of community dwellers and 20% of psychiatric inpatients . AlthougDSM-IV-TR diagnostic criteria for borderline personality disorder stipulates that a patient display five of the following nine features :1) frantic efforts to avoid real or imagined abandonment2) a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation3) identity disturbance: markedly and persistently unstable self-image or sense of self4) impulsivity in at least two areas that are potentially self-damaging 5) recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior6) affective instability due to a marked reactivity of mood7) chronic feelings of emptiness8) inappropriate, intense anger or difficulty controlling anger9) transient, stress-related paranoid ideation or severe dissociative symptomsCommon clinical features include frequent intense mood swings, the inability to be alone nor to tolerate intimacy, extreme dependency on others alternating with sudden hostility, perceiving others as all good or all bad ("splitting"), chronic self-mutilation , and chronic suicidality. BPD is frequently comorbid with substance abuse, depression, anxiety, and eating disorders . Any of The Belmont Report, the Nurembug Code, and the Declaration of Helsinki all discuss the need for informed, voluntary consent from research subjects.  Possible issues concerning the validity of informed consent in borderline subjects center on the voluntariness of consent. Most borderline patients, except if in a brief psychotic episode when under severe stress, have normal cognitive function, and will be able to comprehend and speak about the risks and benefits of a study.However, long-term health benefits or more abstract service to society may not be as important to them as their immediate psychological needs. Such needs may include recapitulations of childhood abuse. For example, they may involve a need to feel the study doctor is hurting them or putting them in danger, and the subject may consent to research in order to gain this position. BPD subjects may have an immediate need to use the idealizing side of the splitting defense; they may feel special because they were selected for the study, and consent in order to have more contact with the idealized doctor. Alternatively, a borderline subject's actions may be motivated by the abrupt devaluing tendency seen in their interpersonal relationships: they may refuse to consent to a study that could significantly benefit them based on unwarranted anger toward the study staff. Finally, a borderline patient may enter a study because she is suicidal, and hopes he or she will die as part of the study.Just as financial compensation may be in fact coercive to some populations, these perceived benefits may in fact be considered coercive for the borderline subject. The Freudian concept of psychic determinism, which states that all decisions are predestined by the interplay of intrapsychic forces and therefore always necessarily subjective, might in the extreme lead us to conclude that no consent is purely voluntary. However, the concern that decisions are not made based on logical consideration but rather on psychological needs applies especially to borderline subjects, for whom rational decision making is a clear weakness.Carl Elliott raised somewhat similar concerns regarding informed consent for research with the severely depressed . RecogniIn light of these concerns, should borderlines be excluded from research studies? Obviously not. First of all, this would not be practically possible with current standards. There are many more patients with BPD than those who have it documented in their medical records. Even if a study involves formal psychiatric evaluation, practitioners often mistake BPD for other conditions  . This maEven if borderlines could be more reliably identified prior to informed consent, they cannot be ethically excluded from research because this condition desperately needs better treatments ,5. WhileIf borderline subjects' chronic problems with transference, splitting, impulsivity, paranoia, self-injury, and suicidality complicate the informed consent process, but if this process is none the less imperative, how are we to proceed?  As very little research has been done in this area, hard guidelines for informed consent are premature. But future research should seek to address such questions about informed consent. It may be that borderlines should undergo the consent process with people who are used to working with this disorder. This could include experienced mental health nursing staff, or, more likely, someone with psychotherapy training. Experience and training in psychotherapy enables one to monitor transference and counter-transference throughout the encounter with the borderline subject, lending insight into the subject's current motivational state and helping keep her or his affect from spinning out of control. These skills may also minimize unconscious acting out by the study team. For example, someone inexperienced with borderlines may not recognize that he or she is being idealized and may think "we really will be able to do great things for this person; I must get her into the trial." Or an inexperienced clinician may encounter a hostile subject and unconsciously adjust entry criteria such that she does not qualify, or over-emphasize risks in a way that leads her to decline enrollment. Future studies should aim to determine whether psychotherapeutic knowledge and experience affects the informed consent process with BPD subjects. Experiments could potentially involve having researchers with varying levels of psychotherapeutic experience consent the same subjects for similar studies, comparing the resultant interpersonal interactions.Another relevant question is whether the person obtaining consent can ethically be the subject's therapist or psychiatrist. One of the criteria for the diagnosis of BPD is "frantic efforts to avoid real or imagined abandonment."  Whatever the consent form says about lack of consent not affecting provision of medical care, borderlines live in a world where desertion is always seconds away. Thus, they may be easily coerced to participate based on the fear of loss of love; they also might refuse a trial that could benefit them, in order to test the loyalty of those seeking their participation. This question could be tested by comparing a consent experience using a BPD's own therapist with another using an unknown researcher.In addition, given the chronic impulsivity BPD subjects display, it may be that informed consent processes that take place over more than one visit could increase the validity of the consent (as well as help retention rates). Letting the subject consider the study away from the interpersonal context of the clinic may help him to be more objective about his desires and less interpersonally reactive.  Multiple consents could be fairly easily added to a research protocol with follow-up subject satisfaction surveys and comparisons of retention rates.Whether proxy decision-makers apply to this situation is another question.  Severely-ill borderlines may have court-appointed guardians that will be enlisted in the consent process; however, in some cases in which the patient is his or her own guardian but seems incapable of making a rational decision, surrogate decision-makers could be considered.Clinical research on borderline personality disorder is alarmingly underdeveloped considering the prevalence and costliness of this disease ,5.  ThisThe author(s) declare that they have no competing interests.All work on this manuscript was performed by RD.The pre-publication history for this paper can be accessed here:


Pediatric Allergy and Immunology. Exposure to certain fungal spores can make children more susceptible to developing allergies to mold, pollen, dust mites, pet dander, or foods, the study revealed. On the other hand, exposure to other types of fungal spores may be protective.When it comes to allergies, not all fungi are created equal, according to a study by University of Cincinnati researchers published in the September 2006 issue of Fungal samples were collected in 2003 and 2004 from the homes of 144 infants under age 10 months as part of the five-year Cincinnati Childhood Allergy and Air Pollution Study, supported by the NIEHS. Fungal measurement included long-term air sampling—48 hours, compared to the 5–10 minutes typical of such studies—which improved exposure assessment. The team then analyzed the spore samples, comparing the breakout with allergy symptoms exhibited by the infants (such as sneezing and runny nose) and skin-prick tests for 17 allergens with specific fungal spore counts.Basidiomycota (club fungi) and Penicillium/Aspergillus (whose spores are very similar) were more likely to develop multiple allergies, says coauthor Tiina Reponen, a professor in the University of Cincinnati Department of Environmental Health. Those exposed to Basidiomycota were more likely to exhibit allergy symptoms; those exposed to Penicillium/Aspergillus and Alternaria (one of the most common fungi in outdoor air) were more likely to have a positive skin-prick test.Children who were exposed to higher levels of spores from Cladosporium (a black mold) had the opposite association, with exposed children testing positive for sensitivity to fewer allergens. This contrasts with the experience of adults, in whom Cladosporium has been associated with greater allergic sensitization.Meanwhile, exposure to The researchers did not find any correlation between the total fungi count and allergies. “The [observed] associations would have been missed if the exposure was assessed by using the total [fungal spore] count only,” Reponen says. The study indicates that the relationship between exposure to airborne fungal spores and health effects is more complicated than researchers believed.total concentration may have on these outcomes,” the researchers write.The indoor environment is indeed complicated. According to the authors, allergens can mix with pollutants and toxicants in synergistic ways, effects that were not addressed in this study. “We believe that contrasting relationships among the various fungal genera to the health outcomes investigated in this study might actually cancel the effect that Although researchers still know little about how infants develop allergies to environmental agents, the new study offers new insights into the health effects of fungi, according to Zalman Agus, associate dean of continuing medical education at the University of Pennsylvania. The study lends credence to the so-called hygiene hypothesis, which posits that an ultraclean environment may wipe out innocuous organisms and collaterally alter some parts of children’s developing immune systems.Cladosporium exposure may inhibit the response of Th2 lymphocytes, white blood cells that block dangerous microbes or foreign organisms from invading the body’s cells.Yet researchers don’t know how some microbes might induce a protective effect. One hypothesis is that Longer-term follow-up of this cohort will better elucidate the clinical implication of the findings, Reponen says. In the meantime, the researchers advise in the paper that “clinicians and researchers should be attentive to the composition of the fungal spore profile and the respective concentrations of the fungal genera present rather than the total or culturable spore count alone.”


In order to examine the production of marker proteins, a reproducible method has been established for culturing purified epithelial cells from normal and malignant endometrium. We have examined the differential expression of secretory proteins using immunohistochemistry in frozen tissue sections, immunocytochemistry in cell cultures derived from the same specimens and protein assays on the culture supernatants. Placental protein 14 (PP14) was produced by normal premenopausal epithelium but not by the post-menopausal or malignant endometrial epithelium. In contrast, placental alkaline phosphatase (PLAP) was produced by endometrial cancers and the endometrial adenocarcinoma-derived cell line Ishikawa, but not by the normal endometrial epithelium. Other markers such as CA-125, which was produced by both normal and malignant endometrium but not by the cell line, and human chorionic gonadotrophin (beta-hCG), which was produced by Ishikawa cells but not by any of the fresh tissues, were less cancer specific. Placental alkaline phosphatase is a direct product of endometrial cancers that can be readily assayed in serum using this two-site assay to test its clinical usefulness in monitoring patients at risk for endometrial cancer.


Both flies and vertebrates express these genes in three adjacent stripes that span the length of their nascent nerve cords. But stripe patterns in fruit flies depend on the nuclear protein Dorsal and in vertebrates on the signaling molecule Hedgehog; both factors are produced in ventral regions of the nerve cord. Since Dorsal and Hedgehog belong to unrelated signaling pathways, vertebrates and fruit flies seem to have independently evolved distinct means of expressing vnd, ind, and msh in the same striped pattern. But in a recent study, Claudia Mieko Mizutani, Ethan Bier, and colleagues demonstrate that both flies and vertebrates similarly rely on a third dorsally produced signal, the bone morphogenetic proteins (BMPs), to paint stripes along their nerve cords. They propose that BMPs are the ancestral patterning signal that the precursors of flies and vertebrates originally shared and that later were reinforced by recruiting either Dorsal or Hedgehog in neural development.During evolution, organisms seem to maintain the function of certain key genes but vary the mechanisms that call these genes into action. For instance, fruit flies and vertebrates share three genes—BMPs are extracellular proteins that function early in embryonic development to stem neural differentiation and promote epidermal cell fates. As a result, the nervous system of flies and vertebrates arises only where other extracellular proteins known as Chordin or Sog stave off the influence of BMPs. But in many developmental processes, BMPs act as morphogens: they diffuse away from their source and create patterns in neighboring tissues by regulating gene expression in a dose-dependent manner. As development proceeds, Chordin and Sog subside while the BMPs continue bathing the epidermis. Mizutani thought that the BMPs might also act as morphogens in the developing nerve cord, but that their role would be masked by the more prominent effect of Dorsal or Hedgehog. Thus, to unmask any possible effect, the researchers erased all trace of Dorsal or Hedgehog pattern.vnd in two ventro-lateral stripes (one on each side of the embryo), while intermediate Dorsal doses turn on ind at a middle location. The dorsal msh stripes lie next to the source of Dpp, the fly BMP, which emanates from the embryo’s dorsal half. By manipulating the genetic control of Dorsal distribution, Mizutani and her colleagues created embryos with a uniform, intermediate level of Dorsal protein, and no Dpp. In these lateralized embryos, all patterning by Dorsal is erased: ind is expressed around the whole embryo’s circumference, and vnd and msh remain silent.In flies, the Dorsal protein has a graded distribution that peaks at the embryo’s ventral midline and tapers off midway around the embryo’s circumference. High Dorsal concentrations elicit expression of ind was repressed locally and made room for msh expression close to the Dpp source. This relative pattern of msh and ind expression is similar to that in normal embryos and indicates that Dpp represses expression of ind more effectively than msh. While this experiment shows that Dpp can act as a morphogen in the fly nervous system, it doesn’t demonstrate that Dpp is actually required to do the same thing during normal development. To address this question, the researchers created local disruptions of Dpp signaling in normal embryos by expressing Brinker—a nuclear protein that blocks Dpp signaling—in a narrow stripe perpendicular to the vnd, ind, and msh stripes: all three stripes swerved dorsal-ward when they crossed Brinker. This result confirms that Dpp normally patterns the fly’s nervous system by limiting the dorsal expansion of the vnd, ind, and msh stripes.When the researchers genetically introduced a local source of Dpp in lateralized fly embryos, part of the stripe pattern was recreated: Nkx2.2, vnd’s vertebrate homolog. But when cultured next to a tissue fragment releasing BMPs, the fragments activated the intermediate and dorsal neural genes Pax6 and Msx in concentric rings, recapitulating the expression pattern seen in normal neural tubes. Hence, in vertebrates as well, BMPs alone can recreate most of the dorso-ventral pattern of neural gene expression. This suggests a conserved role for BMP function during early and late patterning of the neuroectoderm. This unified view in which BMPs repress neural genes in a dose-dependent fashion runs contrary to the prevailing view of vertebrate neural patterning, since BMPs have been proposed to turn on genes in dorsal regions of the neural tube.To test whether BMPs function analogously in patterning of the nervous system in vertebrates, co-authors Henk Roelink and Néva Meyer ventralized fragments of chick neural tubes by soaking them in a Hedgehog solution. The fragments originally expressed only A morphogen shared by flies and vertebrates is likely to come from their common ancestor, which was small, according to fossil data. The researchers speculate that a BMP gradient may have been sufficient to pattern the nerve cord of a small organism. But as organisms grew larger, the need arose for additional patterning mechanisms to complement the BMPs, which eventually lost their preeminence in nervous system patterning.


The elicitation of expert judgment is an important tool for assessment of risks and impacts in environmental management contexts, and especially important as decision-makers face novel challenges where prior empirical research is lacking or insufficient. Evidence-driven elicitation approaches typically involve techniques to derive more accurate probability distributions under fairly specific contexts. Experts are, however, prone to overconfidence in their judgements. Group elicitations with diverse experts can reduce expert overconfidence by allowing cross-examination and reassessment of prior judgements, but groups are also prone to uncritical “groupthink” errors. When the problem context is underspecified the probability that experts commit groupthink errors may increase. This study addresses how structured workshops affect expert variability among and certainty within responses in a New Zealand case study. We find that experts’ risk estimates before and after a workshop differ, and that group elicitations provided greater consistency of estimates, yet also greater uncertainty among experts, when addressing prominent impacts to four different ecosystem services in coastal New Zealand. After group workshops, experts provided more consistent ranking of risks and more consistent best estimates of impact through increased clarity in terminology and dampening of extreme positions, yet probability distributions for impacts widened. The results from this case study suggest that group elicitations have favorable consequences for the quality and uncertainty of risk judgments within and across experts, making group elicitation techniques invaluable tools in contexts of limited data. Policy and management concerns on issues as diverse as health, technology, and the environment require scientific input to understand the mechanisms, magnitudes and characteristics of emerging risks , 2. A raa priori undetermined variables in an under-specified context, we do not know how techniques designed to question confidence then affect expert judgement.In order to increase the quality of information derived from experts, researchers relying on expert judgement require knowledge about effective elicitation strategies , 7, 9. EThis problem is thus: humans are imperfect intuitive statisticians, relying on cognitive heuristics to make judgements when confronting uncertainty , 15–17. a priori [This group-discussion effect has been tested and understood under contexts where experts are asked to provide quantitative estimates under conditions where context is fully specified thereby enabling parameterization . Howevera priori . ExpertsIf and when group processes do lead to unreliable judgements because the elicitation context is difficult, for example, understanding highly uncertain problems such as cumulative impacts, elicitation processes using individuals may be more useful provided other biases can be adequately managed. In light of these dilemmas, we imagine four possible outcomes for how group processes will affect expert estimates in these two-phased problems. The first outcome is that experts will suffer from groupthink, and both individual and group estimates will be more certain after a group process because groupthink minimizes conflict and decreases critical evaluation in experts while increasing confidence . With thThis study seeks to address these questions in a case where experts are asked to specify the most important risks and then score the impact from them, in the context of eliciting judgments about cumulative impacts on Tasman and Golden Bays in New Zealand. Specifically, we address these questions through an expert elicitation study designed to understand prominent risks to ecosystem services in coastal New Zealand. In this case, to understand how group deliberation affected expert consistency/variation and subjective uncertainty (an expert’s uncertainty in estimating risk), we asked experts to provide individual responses before and after a workshop with a diverse group of experts.Our case study in Golden Bay and Tasman Bay  included four major methodological steps. First, we identified local experts and solicited their expertise about major risks to four ecosystem services via an online survey. Second, we interviewed all of these experts individually, wherein we asked additional questions about mechanisms and magnitude of impacts. Third, we held a Delphi-like group workshop involving most interviewed experts, which involved a group deliberation and then individual re-scoring of impacts. Our design was focused on training and guiding experts through the problem context and data collection exercises. The opportunity to enable expert learning about and training for tasks is a major advantage of expert elicitation , 9. FourTasman and Golden Bays are situated at the northern end of the South Island of New Zealand. We focus on impacts to fisheries, shellfish aquaculture, marine recreation, and existence values of biodiversity because these are all important uses/benefits in the bays.Tasman and Golden Bays have a history of human alteration. Trawl fisheries have historically contributed to the transformation of the benthic habitat from a structurally complex environment with thick mussel beds and oyster reefs to a flat silty bottom . RemovalWe recruited experts through recommendation by a leading research organization in the area (the Cawthron Institute). Experts were not just scientists; they were people who worked and recreated in, studied, or advocated for the area, which was important given the site specificity of both the ecosystem services and the anthropogenic impacts that occur there , 9, 32. First, each expert was asked to complete an online survey consisting of one question, which asked them to provide a ranked list of up to five risks they regarded as threatening a given ecosystem service. They were given a list of risks to choose from, with the option of adding others not indicated . The preAll 20 experts who took part in the online survey were then interviewed (step 2). Experts were first asked to confirm their ranking, then asked why they ranked the way they did. As the study focus was on impacts to ecosystem services–encompassing biophysical and socioeconomic domains—experts were reminded that humans can cause impact through biophysical as well as socioeconomic means. The interviewer asked each respondent to explain the processes by which risks cause impact, and what aspects of risk they emphasized in their ranking . Experts were then asked to provide estimates of impact of their ranked risks to the bays under current levels of activity for the immediate future (0–5 years). Experts were asked to provide an interval of values (i.e. a minimum and a maximum) they believe includes the level of impact to their specific ecosystem service, between scores of 0–1. A score of 0 indicates that the ecosystem service is unimpacted, while a score of 1 indicates that the ecosystem service is rendered unavailable for human enjoyment. They were also asked to provide a best estimate of impact. After completing these steps, experts were asked to indicate how confident they were in their judgement (from 0–100%) that their estimated interval included the true value, and asked to make sure they were at least 50% confident. This step forces experts to reevaluate the interval they provided, and often forces them to expand their interval . Then exFinally, we convened an expert workshop adapted from Burgman , FischhoThe workshop had four sessions, each dedicated to one ecosystem service. Each session was based on a Delphi method approach with facilitators prompting experts to defend their views to each other about the most important risks. All ecosystem service experts were invited to partake in each discussion; this was designed to reduce disciplinary bias and expand the scope of the problem being considered . Though Only data from experts who provided both pre-workshop and post-workshop estimates  were analyzed, and only on those risks that they scored both before and after the workshop. Expert consistency was analyzed in two ways. First, importance of risks within each expert domain was modeled to predict how the experts as a group would rank risks to particular ecosystem services using the Insertion Sorting Rank (ISR) algorithm for analyzing ranking data , 37. We To assess between-expert consistency (vs variability) in responses, we analyzed the best estimates (modes of the elicited expert distribution) of impact from all experts before and after the workshop, and compared the consistency in scores. To do this, for each specific type of risk for each ecosystem service, we calculated the absolute value of the difference of individual scores from the mean score to generate a measure of difference among experts. We then compared the difference scores post-workshop from the difference scores pre-workshop. According to the impact scale experts used to judge activities and stressors, differences from the mean on the order of 0.1 represent a view that is 10% different from the mean expert judgement. Because our samples before and after the workshop were not independent and were shared with experts, we conducted a mixed-effect paired t-test of these differences for estimates before the workshop and after . The paiSubjective uncertainty in individual expert judgement was analyzed by comparing the intervals of impact for a given risk on a given ecosystem service by a given expert. Similar to the analysis on best estimates, we only include results from the 14 experts shared between the interview and workshop stages. We compared the range of intervals before and after the workshop by subtracting the interval of each post-workshop estimate from the interval of the corresponding pre-workshop estimate and using a mixed-effect paired t-test. We treated the before-after pair nested within an expert as a random effect and interval range as a fixed effect. In contrast to the analysis of best estimates, which compared individual estimates against a group mean, we could include intervals for activities and stressors that were not considered by multiple experts, meaning that our samples sizes were larger than for the previous analyses of best estimates. Sample sizes for analyses on intervals are 14 comparisons for aquaculture, 7 comparisons for fisheries, 11 comparisons for marine recreation, and 20 comparisons for biodiversity. Mixed-effect paired t-tests were conducted using the nlme package in R  and the −4–2.0×10−3).Following the expert workshop, experts displayed a more homogenous ranking of risks across all four ecosystem services compared to rankings by experts interviewed alone . The larAfter the workshop, experts were more likely to rank specific stressors highly, such as sedimentation and pollution, whereas before the workshop most experts pointed to activities that contribute to these stressors, providing a diverse list of activities such as agriculture, forestry, and land clearing. During interviews, one expert highlighted sedimentation as an important risk not included on the original list, indicating that many activities are primarily a risk through sedimentation. Indeed, many experts who raised concerns of agriculture, forestry, land clearing, and even dredge-based fisheries identified sedimentation as the primary reason they ranked these risks highly, with some suggesting runoff-based pollution and nutrient input are major considerations for the inclusion of land based activities. Through facilitated discussion, terminology was agreed and experts were able to clarify their meaning and focus their ranking on more specific stressors . As a reIn some cases, experts included entirely different risks in their rankings after deliberation. For example, in interviews marine recreation experts did not consider land-based drivers important (compared to their other top five activities and stressors), but when confronted with expertise in fisheries and biodiversity (who ranked sedimentation as the chief concern), recreation experts included sedimentation as one of the top 5 risks to marine recreation.Experts’ best-estimate impact scores were more consistent (with other experts) after the workshop than before . This waThe mean size of interval that experts believe captures the true impact score of specific risks was larger post-workshop than in individual interviews, a statistically significant finding for all four ecosystem services . The sizThe findings of our case study support the well-documented effect of group settings to reduce expert over-confidence and non-overlapping estimates among experts , 6, 19. Some authors have proposed group processes as a mechanism to make expert responses more consistent, but such processes have sometimes been shown to yield consistency at the expense of accuracy via a phenomenon with the Orwellian title “groupthink” –24. GrouThe design of our workshop was specifically tailored to counteract groupthink. First, allowing experts to provide their estimates individually reduces the chance for pressure from dominant voices to sway their reporting . Second,The potential list of human impacts on coastal environments is immense and diverse, without an established nomenclature, and made up of generic activities, each of which includes many types of activities  and specific stressors . Experts tasked with identifying the more important risks must wade through this list, and individual experts may have different ways of describing and identifying risks even when describing the same phenomena . To expeOur finding of increased numerical consistency among experts suggests that the workshop also helped experts reassess their individual judgements about specific risks. More extreme views about the severity (or lack of severity) of impact from risks were moderated when confronted with challenges from other experts in our workshop, a finding found in other cases . Though Whether the findings of our case study that increased numerical consistency among experts after a workshop is generalizable to other workshop settings will likely depend on the skill of the facilitator, makeup of experts involved, including whether experts with pre-existing animosity are included, and whether contrasting advocates are involved in the workshop . Any facOne of the most prevalent problems with eliciting expert advice is contending with over-confidence , 19. ExpSome specific interventions applied to individual experts, such as asking experts to provide confidence intervals that meet a confidence cutoff, which we applied here, can force experts to reassess their intervals and provide larger intervals . SimilarWe used a before-after design to understand the influence of group elicitation on expert responses. Though this provides evidence of influence, a before-after-control-impact (BACI) design would provide stronger evidence . By compExpert elicitation is a valuable tool in situations where data is sparse and decisions urgent, and has the promise to be more valuable to tackle problems where a problem is not fully characterized beforehand. Where experts are needed both to provide context and estimates, evidence-based designs are needed to ensure that high quality expert judgements are captured. Through our case study, we show that in understanding cumulative impacts on ecosystem services, where prominent risks are not known beforehand, individual expert assessment followed by group deliberation can both increase consistency in experts’ identification of risks and decrease overconfidence in estimate intervals of impact. We argue that given their favorable effects on expert uncertainty, any study involving expert elicitation to deal with highly uncertain problems should strongly consider the use of expert workshops to improve expert risk estimates.


Escherichia coli Nissle 1917 are two probiotics that are commonly used in children to treat various medical conditions including human rotavirus diarrhea and inflammatory bowel disease. Although the health benefits of probiotics have been confirmed, the specific effects of these established Gram-positive (G+) and Gram-negative (G−) probiotics in modulating immunity against pathogens and disease are largely undefined. In this review, we discuss the differences between G+ and G− probiotics/commensals in modulating the dynamics of selected infectious diseases and host immunity. These probiotics modulate the pathogenesis of infectious diseases and protective immunity against pathogens in a species- and strain-specific manner. Collectively, it appears that the selected G− probiotic is more effective than the various tested G+ probiotics in enhancing protective immunity against rotavirus in the gnotobiotic piglet model.The role of intestinal microbiota and probiotics in prevention and treatment of infectious diseases, including diarrheal diseases in children and animal models, is increasingly recognized. Intestinal commensals play a major role in development of the immune system in neonates and in shaping host immune responses to pathogens. Lactobacilli spp. and  Escherichia coli and other enterobacteria colonize the intestinal tract early after birth, followed by the subsequent establishment of anaerobes  immune system and protection of the host from pathogens . Coloniznaerobes . The intnaerobes . Perturbnaerobes  and alsonaerobes . Probiotnaerobes –10 and tDiarrheal disease is one of the leading cause of deaths in children and it accounts for the death an estimated of 700,000 children annually worldwide . SpecifiLactobacillus spp. were widely used to treat or prevent RV diarrhea in children. Specifically, prophylactic supplementation of Lactobacillus rhamnosus GG (LGG) to children significantly reduced the incidence of HRV disease  due to its proven effects in attenuating inflammatory disorders and modulating immunity in humans  was observed in some G− intestinal commensal bacteria (Direct interactions between viruses and bacteria are being increasingly investigated in recent studies –75. Spec and HRV . Also, ibacteria  and certbacteria  enteric in vivo Gn piglet model system, it appears that the induced beneficial effects of G− EcN against HRV disease may be accomplished by the integrated interaction of DCs, NK cells, and immunoglobulins as well as direct binding of EcN to virus (Figure Comparison of the beneficial effects of G+ and G− probiotics and intestinal commensals indicated that the selected G− probiotic had higher beneficial effects in inducing protective immunity against enteric pathogens such as HRV as compared with the selected G+ probiotics in humans and animal models. In our simplified s Figure . Most ofAll authors listed have made substantial direct contribution to the work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Wild animals often engage in intense physical activity while performing tasks vital for their survival and reproduction associated with foraging, avoiding predators, fighting, providing parental care, and migrating. In this theme issue we consider how viewing these tasks as “exercise”—analogous to that performed by human athletes—may help provide insight into the mechanisms underlying individual variation in these types of behaviors and the importance of physical activity in an ecological context. In this article and throughout this issue, we focus on four key questions relevant to the study of behavioral ecology that may be addressed by studying wild animal behavior from the perspective of exercise physiology: (1) How hard do individual animals work in response to ecological (or evolutionary) demands?; (2) Do lab-based studies of activity provide good models for understanding activity in free-living animals and individual variation in traits?; (3) Can animals work too hard during “routine” activities?; and (4) Can paradigms of “exercise” and “training” be applied to free-living animals? Attempts to address these issues are currently being facilitated by rapid technological developments associated with physiological measurements and the remote tracking of wild animals, to provide mechanistic insights into the behavior of free-ranging animals at spatial and temporal scales that were previously impossible. We further suggest that viewing the behaviors of non-human animals in terms of the physical exercise performed will allow us to fully take advantage of these technological advances, draw from knowledge and conceptual frameworks already in use by human exercise physiologists, and identify key traits that constrain performance and generate variation in performance among individuals. It is our hope that, by highlighting mechanisms of behavior and performance, the articles in this issue will spur on further synergies between physiologists and ecologists, to take advantage of emerging cross-disciplinary perspectives and technologies. The past decade has seen a steep rise in research focussing on individual trait variability within animal species . AlthougOver time, however, research has shifted toward being more holistic with proposed links between animal personality and metabolic demand, and an accompanying focus on quantifying individual variation in physiological traits . It is bAs is demonstrated repeatedly throughout this issue, the current integration of physiological and behavioral research is being facilitated by technological advances in bio-logging, telemetry, and the tracking of animal movements in natural environments . These tIn this theme issue, we examine the mechanistic underpinnings of individual variation in behavior and, specifically, how the physiological capacity for physical activity or “exercise” may directly enhance individual fitness. Aside from the direct biological implications of how activity is relevant in ecology, we also consider whether traditional methodological approaches and paradigms are appropriate for answering these questions. Though exercise is traditionally viewed as a strictly human endeavor , we arguSome activities of free-living animals are widely considered to be energetically-demanding “hard work,” such as long-distance migration . HoweverAs a result, we still have relatively little understanding of the “currency” by which ecological trade-offs are evaluated from an evolutionary perspective. Do animals actually prioritize the optimization of energy intake, or is this consideration modulated by other direct or indirect costs of physical activity? In addition to measuring the energy expenditure of individual animals while performing physical activity associated with parental care , foraginper se  which are giving biologists an unprecedented ability to track movements and to understand inter-individual variability in the behaviors of free-living animals . One parFor any long-lived animal that is likely to experience more than one annual cycle, life-history theory predicts that individuals should rarely work so hard at any single activity  that they kill themselves, for example, individuals should invest more in self-maintenance, decreasing investment in current reproduction, if this allows them to maintain higher future fecundity and survival . NeverthThe behavioral and physiological mechanisms underpinning costs of activity remain poorly understood , especiaThe obvious experimental approach to examine negative consequences of activity or workload is to make animals work harder and measure effects on fitness in terms of current reproduction, future fecundity, or survival. Laboratory studies of captive animals can achieve this using forced exercise paradigms, and these studies have reported negative physiological effects of intense exercise that would be consistent with “costs” . In the sensuNumerous studies using these direct, experimental manipulations of workload have looked for immediate, short-term effects  but few have comprehensively measured longer-term effects on future fecundity and survival. Furthermore, few experimental studies have insofar been coupled with detailed analysis of animal behavior using advanced bio-tracking technology which is now available. More detailed analysis of activity might therefore reveal complexities of behavior that help rationalize the often contradictory results of studies of “costs.”. As an example, many studies fail to find that wing-clipped birds reduce parental effort based on observed nest visit rates. However, measurement of overall activity sensu using anGiven the potential for routine locomotor costs and constraints on performance to affect individual fitness, it is worth considering how established frameworks for studying exercise physiology in humans may be useful for understanding ecophysiology in non-human animals . In thisEmploying an exercise paradigm to ecological questions may also provide new perspectives on the constraints that animals face and the resources  that they invest to overcome such limitations. For example, it is well known that humans must perform regular physical activity to maintain peak physical performance or capacity for endurance. Given that the consequences of under-performing are a matter of life and death for free-living animals—unlike human athletes at the Olympics, or couch potatoes—do other animals also need to engage in training to maintain their performance level or prepare themselves for demanding activities ; Bidder ? RoutineWe suggest that the study of behavioral ecology and ecophysiology will be enhanced by embracing the concepts of “exercise” and “training” as frameworks for understanding the locomotor constraints faced by animals in their natural environment. This approach will encourage the direct quantification of the energetic costs of behaviors related to fitness and allow us to appreciate how limitations beyond the optimization of energy input may influence individual variation in behaviors and the resulting evolutionary trajectories. Furthermore, viewing the behaviors of non-human animals as exercise will allow ecologists to take advantage of established knowledge and approaches , already


Four cluster randomized controlled trials (cRCTs) conducted in long-term care facilities (LTCFs) have reported reductions in patient risk through increased healthcare worker (HCW) influenza vaccination. This evidence has led to expansive policies of enforcement that include all staff of acute care hospitals and other healthcare settings beyond LTCFs. We critique and quantify the cRCT evidence for indirect patient benefit underpinning policies of mandatory HCW influenza vaccination.Plausibility of the four cRCT findings attributing indirect patient benefits to HCW influenza vaccination was assessed by comparing percentage reductions in patient risk reported by the cRCTs to predicted values. Plausibly predicted values were derived according to the basic mathematical principle of dilution, taking into account HCW influenza vaccine coverage and the specificity of patient outcomes for influenza. Accordingly, predicted values were calculated as a function of relevant compound probabilities including vaccine efficacy (ranging 40–60% in HCWs and favourably assuming the same indirect protection conferred through them to patients) × change in proportionate HCW influenza vaccine coverage (as reported by each cRCT) × percentage of a given patient outcome (e.g. influenza-like illness (ILI) or all-cause mortality) plausibly due to influenza virus. The number needed to vaccinate (NNV) for HCWs to indirectly prevent patient death was recalibrated based on real patient data of hospital-acquired influenza, with adjustment for potential under-detection (5.2-fold), and using favourable assumptions of HCW-attributable risk (ranging 60–80%).In attributing patient benefit to increased HCW influenza vaccine coverage, each cRCT was found to violate the basic mathematical principle of dilution by reporting greater percentage reductions with less influenza-specific patient outcomes  and/or patient mortality reductions exceeding even favourably-derived predicted values by at least 6- to 15-fold. If extrapolated to all LTCF and hospital staff in the United States, the prior cRCT-claimed NNV of 8 would implausibly mean >200,000 and >675,000 patient deaths, respectively, could be prevented annually by HCW influenza vaccination, inconceivably exceeding total US population mortality estimates due to seasonal influenza each year, or during the 1918 pandemic, respectively. More realistic recalibration based on actual patient data instead shows that at least 6000 to 32,000 hospital workers would need to be vaccinated before a single patient death could potentially be averted.The four cRCTs underpinning policies of enforced HCW influenza vaccination attribute implausibly large reductions in patient risk to HCW vaccination, casting serious doubts on their validity. The impression that unvaccinated HCWs place their patients at great influenza peril is exaggerated. Instead, the HCW-attributable risk and vaccine-preventable fraction both remain unknown and the NNV to achieve patient benefit still requires better understanding. Although current scientific data are inadequate to support the ethical implementation of enforced HCW influenza vaccination, they do not refute approaches to support voluntary vaccination or other more broadly protective practices, such as staying home or masking when acutely ill. Annual influenza vaccination for health care workers (HCWs) is widely endorsed –5 and inThe ethical premise for mandatory HCW influenza vaccination critically hinges upon the valid demonstration of patient benefit substantial enough to justify infringement of the personal rights of HCWs who would otherwise choose not to receive influenza vaccine each year. In this re-analysis, we undertake critique and quantification of the evidence for indirect patient benefit, translating methodological considerations in a way not previously made plain or accessible. In particular, our critique evaluates the plausibility of cRCT conclusions by assessing consistency with the natural boundaries for indirect vaccine effects set by the mathematical principle of dilution, taking into account involved compound probabilities. In addition, to gauge the potential impact of enforced HCW vaccination if further extended to all acute care hospitals, we quantify the number needed to vaccinate (NNV) to potentially prevent a single patient death in the hospital setting—a core epidemiological concept that is critical to policy-makers but that has not previously been addressed in the scientific literature.Vaccine efficacy (VE) is the percentage reduction in a particular disease outcome in vaccinated compared to unvaccinated individuals. For example, a VE of 60% means that vaccinated people have a 60% reduction in their risk of a given outcome compared to unvaccinated people.Studies of VE may include a variety of outcomes for which prevention may be desirable. For example, for influenza, preventable outcomes of interest may include laboratory-confirmed influenza infection, or clinical influenza-like illness (ILI), or hospitalization or death. Illness that is laboratory-confirmed for influenza using molecular diagnostic tools (such as polymerase chain reaction (PCR)) is the most specific study outcome and virtually 100% of cases defined this way are actually related to the influenza virus . But it may be challenging to study laboratory-confirmed outcomes and so other surrogate clinical outcomes are sometimes used in VE studies. For example, ILI is typically defined as a clinical syndrome consisting of some constellation of respiratory and systemic symptoms, such as cough and fever, but these are not just features of influenza. ILI can be caused by multiple other non-influenza respiratory pathogens against which influenza vaccine has no effect. When assessing the benefits of influenza vaccine, these other causes of ILI dilute the measured effects. The proportion of seasonal ILI cases actually due to influenza  may vary with defining conditions but is generally <35% . As a moIt may be of public health interest to assess the benefits of vaccine against the sum total of any ILI or mortality, but to be considered valid these claimed benefits must adhere to the basic principle of dilution. The principle of dilution governs the inverse relationship between percentage reduction in a given outcome, and percentage contribution of non-targeted events to that outcome. Because of dilution effects, the more that non-target conditions contribute to an outcome the lower must be the percentage reduction in that outcome brought about by a targeted intervention. This basic mathematical principle of dilution is universal; it applies not only to vaccination but also to other practical considerations involving percentage reductions. For instance, most shoppers intuitively know that the percentage reduction from a discount coupon will always be greatest in relation to the price of the product featured on the coupon, and lower when calculated in relation to their entire shopping bill that includes other non-applicable items. This commonplace example is shown in the Supporting Information to reinforce the general truism of the basic principle of dilution .Influenza vaccination targets influenza virus and is ineffective against non-influenza causes of ILI, hospitalization or death. The mathematical principle of dilution thus requires that the percentage reduction (i.e. VE) must be lower when non-targeted events (i.e. non-influenza etiologies) are included in the study outcome  than when only the targeted condition (i.e. influenza infection) contributes. In other words, the lower the positive predictive value of an outcome for influenza, the lower must be the measured VE for that outcome. Under valid conditions, VE will always be higher for laboratory-confirmed influenza than for ILI, and higher for ILI than for all-cause mortality. Where this pattern is not observed, claimed benefits of a vaccine cannot be accepted at face value; other explanatory factors must exist.In fact, the percentage reduction in a given outcome can never exceed the positive predictive value for influenza of that outcome (even with an influenza VE of 100%), and will be even lower when further taking into account vaccine coverage. When comparing two groups or populations in order to attribute vaccine benefits, the percentage reduction in a given outcome will be proportional to the absolute difference (Δ) in vaccine coverage between the two populations compared.The percentage reduction in a given outcome attributed to change in vaccination coverage can thus be calculated according to the following equation, based upon the principle of dilution:Through Medline search, we confirmed that the US CDC (published 2014 ) and Cocde facto flaw in the exclusive attribution of vaccine effects was understood. To then quantify the potential magnitude of discrepancy in attributing patient outcome reductions to HCW vaccination, we derived the ratio of cRCT-reported versus derived-predicted reductions.Using the principle of dilution to anchor our analyses and interpretations, we assessed the plausibility of the cRCT results in attributing patient disease reductions to HCW influenza vaccination. Where the pattern of highest-to-lowest percentage reduction against most-to-least specific outcomes  was not observed, or the percentage reduction was not proportional to the change in vaccine coverage, a Eq 1. For this analysis, we assumed a VE of 60% as reported in an earlier meta-analysis of RCTs in young adults that used virologically-confirmed influenza outcomes  = 8) and further proposed in their concluding statements that their results were likely to be generalizable to other care homes and acute hospital settings, in particular geriatric and rehabilitation wards .To put this summary value and conclusion into context, if actually generalized to the ~1.7 million HCWs in LTCFs in the US, Hayward’s estimate of the NNV would mean that 212,500 patient deaths in LTCFs could be prevented every year through HCW vaccination (i.e. 1.7 million/8), an estimate that substantially exceeds the total number of influenza deaths estimated annually for the whole US population  ,34. If fTo re-assess the NNV for acute care we therefore drew on two networks that have published estimates of hospital-acquired influenza—one in the US and one in Canada. The US FluSurv-Net reported by Jhung et al was conducted during the 2010–11 season and covers a population under surveillance of 29 million (~10% of the US population) . We estiThe Canadian network reported by Taylor et al consisted of 54 hospitals that conducted surveillance for hospital-acquired influenza across six seasons (2006–2012), with a variable number of participating hospitals each year . The 201Of these 27 US and 7 Canadian deaths in 2010–11, we estimated that 8 and 4 respectively were attributed to unvaccinated HCWs and 5 and 2 respectively could be prevented through HCW vaccination, assuming HCW-attributable risk and vaccine efficacy each of 60% .Based on these data, the number of hospital staff that would need to be vaccinated (NNV) to prevent a single patient death was similar in the Canadian and US settings at 32,688 and 32,819, respectively . The NNVPolicies of enforced HCW influenza vaccination are gaining popularity in North America, bolstered primarily by four cRCTs broadly interpreted to prove substantial patient benefit. Our analyses, however, show that these policies lack a solid empirical underpinning. Although RCTs represent the gold-standard study design for assessing interventions, unblinded cRCTs are at greater risk of bias and where their conclusions appear implausible caution is required in their interpretation, particularly if used to guide policies that abrogate individual rights. In that regard, each of the four cRCTs used to champion compulsory HCW influenza vaccination policies reports patient benefits that are mathematically impossible under any reasonable hypothesis of indirect vaccine effect. Whereas it is assumed on the basis of these studies that unvaccinated HCWs place their patients at great influenza peril, we show through detailed critique and numerical recalibration that these impressions are exaggerated.Eq 1 makes plain the principle of dilution—a relatively simple concept, whose central importance in assessing the reliability of the cRCT evidence seems to have been overlooked by policy analysts to date. We detail it here to expose an obvious incongruity: reported percentage reductions that are greater for less specific outcomes or that exceed increases in vaccine coverage cannot be accepted as valid demonstration of vaccine benefit. To reinforce this understanding, we underscore that other (non-cluster) RCTs that have explicitly reported the effects of dilution have shown its substantial impact. For example, VE against specific laboratory-confirmed influenza vs. non-specific ILI in RCTs involving HIV-negative pregnant mothers was 50% vs. 4% [% vs. 4% ; in HIV-% vs. 4% ; in adul% vs. 4% ; and in % vs. 4% . In eachEq 1 may seem simplistic, they should be understood to have a priori over-estimated potential patient benefit; any other conditional probabilities  included as “chain of event” transmission parameters within a more complex model would serve only to further reduce the patient benefits we have optimistically projected as attributable to HCW vaccination. This is shown in the dynamical simulations of van den Dool et al [Although the derivations we present based on ol et al ,49 incorol et al ,49, assuol et al ,49. In aol et al .The simulations by van den Dool et al are based on small facility settings  and result in average HCW infection rates (absent vaccination) of 50% in the hospital scenario—more than double the highest  estimate measured empirically by Elder et al among unvaccinated hospital workers ,52. It iDespite assumptions designed to substantially over-estimate indirect patient benefit, the four cRCTs reported reductions in all-cause mortality among patients that were 6- to 15-fold greater than predicted . Even alCluster RCTs are at greater risk of bias to explain findings than trials with individual randomization. As highlighted by the Cochrane group, the cRCTs showing patient benefit through increased HCW vaccination in LTCFs suffered multiple methodological issues including failure to conceal group allocation (i.e. blinding), poor performance in increasing HCW vaccine coverage, insufficient power to assess specific influenza outcomes and the possible influence of selection bias . None ofThe effects of these non-vaccine factors may be particularly evident in the chosen analysis periods prior to influenza circulation in at least two of the four cRCTs. HCW influenza vaccination cannot prevent ILI or death in patients for which influenza is not somehow implicated and therefore cannot account for differences between intervention and control groups before the period of influenza virus circulation. It is then likely that the confounding factors or co-interventions driving those pre-existing differences between groups had persistent effects through the rest of the study period. This type of confounding in reporting indirect VE against non-specific patient outcomes is reminiscent of the bias previously identified by Jackson et al in reporting significant VE against all-cause pneumonia and mortality in seniors themselves, not only during the influenza period, but also before and after . To furtSupporters of compulsory policies have cited other studies, including an additional cRCT conducted by Riphagen-Dalhuisen et al in acute care facilities . The maiIt is in generalizing beyond the context of voluntary programs in LTCFs to compulsory vaccination of all acute care staff that incongruities in the cRCT evidence become most apparent. A literal extrapolation of the heretofore unchallenged NNV estimate of 8 to all hospital staff leads to the untenable conclusion that unvaccinated HCWs pose a risk to their patients that is tantamount to a 1918-style influenza pandemic every year . To recalibrate these utterly implausible impressions, we drew upon published hospital-based surveillance networks in the US and Canada, focusing on their real data for patient mortality as the outcome most clinically and ethically relevant to the argument for enforced HCW vaccination. This showed that more than 32,000 hospital staff would need to be vaccinated before a single patient death could potentially be averted—4000-fold greater than estimated by Hayward et al . These hOther personal benefits to HCWs or their families, or to their institutions through possible reductions in worker absenteeism, were not factored into our analyses since these do not constitute the main ethical imperative for enforced vaccination of HCWs compared to other citizens or occupational groups. We did not consider the emerging evidence of negative effects from prior vaccination on subsequent influenza vaccine protection or pandemic risk, or the potential liability to institutions or organizations in the event of vaccine-associated harm under compulsory or coercive policies ,68–77. Osome evidence in support of some patient benefit is insufficient scientific basis to ethically override individual HCW rights. While HCWs have an ethical and professional duty not to place their patients at increased risk, so also have advocates for compulsory vaccination a duty to ensure that the evidence they cite is valid and reliable, particularly in the absence of good scientific estimates of patient impact. The diversion of resources from more evidence-based efforts and other important but less tangible costs related to loss of trust and credibility also need to be considered, including the implications for other immunization programs and workplace policies. Although current data are inadequate to support enforced HCW influenza vaccination, they do not refute approaches to support voluntary vaccination or other more broadly protective practices such as staying home or masking when acutely ill.Through this detailed critique and quantification of the evidence we conclude that policies of enforced influenza vaccination of HCWs to reduce patient risk lack a sound empirical basis . In thatS1 Appendix(PDF)Click here for additional data file.


The aim of this study was to investigate general practitioners’ (GPs) attitudes, beliefs and behaviours regarding the use of exercise for patients with chronic knee pain (CKP) attributable to osteoarthritis.Primary care GPs in the UK.5000 GPs, randomly selected from Binley’s database, were mailed a cross-sectional questionnaire survey.GPs’ attitudes and beliefs were investigated using attitude statements, and reported behaviours were identified using vignette-based questions. GPs were invited to report barriers experienced when initiating exercise with patients with CKP835 (17%) GPs responded. Overall, GPs were positive about general exercise for CKP. 729 (87%) reported using exercise, of which, 538 (74%) reported that they would use both general and local (lower limb) exercises. However, only 92  GPs reported initiating exercise in ways aligning with best-evidence recommendations. 815 (98%) GPs reported barriers in using exercise for patients with CKP, most commonly, insufficient time in consultations  and insufficient expertise .While GPs’ attitudes and beliefs regarding exercise for CKP were generally positive, initiation of exercise was often poorly aligned with current recommendations, and barriers and uncertainties were reported. GPs’ use of exercise may be improved by addressing the key barriers of time and expertise, by developing a pragmatic approach that supports GPs to initiate individualised exercise, and/or by other professionals taking on this role. This large UK survey is the first known to directly, specifically and concurrently investigate the attitudes, beliefs and behaviours of general practitioners (GPs) regarding exercise for patients with chronic knee pain (CKP). Exercise initiation did not concur with best-evidence recommendations and GPs reported uncertainties and barriers in relation to using exercise.The questionnaire was pretested and piloted before being used in this main study. Use of a vignette to investigate clinical management ensured a consistent patient scenario to all GPs and minimised the confounders inherent in observational research using real patients.Limitations of this study include the likely overestimation of exercise use among GPs given the low response rate (response bias), the self-report nature of the questionnaire , inability to explore underlying reasons for responses and the relatively uncomplicated vignette case. However, as GPs should be using exercise for all patients with CKP, the results of this survey are valuable for indicating an apparent evidence-practice gap in the way in which GPs employ exercise with this patient group.General practitioners (GPs) are the most frequently accessed source of formal medical advice and treatment for patients in the UK with chronic knee pain (CKP).To maximise patient outcomes, GPs should align their management with best-evidence recommendations. As sociocognitive behavioural theories suggest an association between individuals’ attitudes and beliefs and their behaviours,A cross-sectional survey was used to investigate GPs' attitudes, beliefs and behaviours regarding exercise for CKP. The survey tool had previously been developed through pretesting by a local group of GPs and a subsequent pilot study with 172 UK GPs,et al who investigated this among physiotherapistsIn this main study, GPs were mailed an eight-page questionnaire . A further 470 provided MDS. The most common reason for returning MDS, rather than a full response was, having insufficient time . The characteristics of GPs responding with an MDS were similar to those responding with a full questionnaire, except that they had been qualified for longer and were more likely to work in practices in the most deprived areas . When coexercise works just as well for everybody, regardless of the amount of pain they have’, however the greatest proportion of respondents disagreed. GPs recognised the need to tailor exercises to individual patients, acknowledged the importance of adherence with exercise but placed responsibility for adherence on the patient.suggesting general exercise and demonstrating local exercise, and giving the patient a leaflet about both exercise types. Thirty-two (6%) GPs reporting to use both exercise types stated they would achieve this solely by referring the patient to another HCP. Ninety-two GPs  reported to use strategies aligned with evidence-based recommendations;Of the 835 respondents, 729 (87%) reported using exercise of some type for the vignette case. Of the 729 GPs reporting to use of exercise, 494 (68%) stated that they would follow-up the vignette patient to establish ongoing engagement with regular exercise. This was most commonly achieved through opportunistic follow-up  which most GPs  suggested would occur if the vignette patient failed to improve and reconsulted.Most GPs  reported having experienced barriers when using exercises for patients with CKP which included: (1) service-related, (2) GP-related and (3) (perceived) patient-related barriers . The mos‘prescribe’ local and general exercise to all patients with CKP, believed that CKP is improved by local and general exercise, and reported that they would use exercise in the management of the vignette patient, only a tenth of responding GPs reported initiating exercise in a way that matches best-evidence recommendations.This cross-sectional questionnaire survey sought to identify the attitudes, beliefs and behaviours of UK GPs regarding the use of exercise for patients with CKP. While most GPs agreed that they should Variable GP attitudes regarding exercise for CKP were recognised in an earlier systematic reviewGPs’ reported behaviour was consistent with higher estimates from other physician questionnaire studies; between 9%–89% of GPs advising exerciseThis large UK survey is the first known to directly, specifically and concurrently investigate the attitudes, beliefs and behaviours of GPs regarding exercise for patients with CKP. The questionnaire was pretested and piloted before being used in this main study. Employing a vignette provided a consistent patient scenario to all GPsImplementation of current evidence-based recommendations for the management of CKP needs to be improved among GPs in the UK. It is possible that at least part of the problem in implementing the recommendations is the lack of explicit guidance regarding the role of GPs, and other members of the multidisciplinary team who may be involved in managing patients with this condition. This is perhaps reflected by the variable perceptions among GPs regarding their role in managing CKP and the extent to which they believe they should provide exercise advice or prescription. However, given the apparent association between perceived role and behaviour among the GPs who responded to the survey (reported elsewhere)et alTo deliver best practice for patients with CKP, strategies which target both GPs and the wider primary care team are needed. Two key areas should be addressed: (1) development of a pragmatic approach for GPs to initiate individualised local and general exercise and (2) identification of additional methods of initiating exercise and/or supporting patients to continue with exercise that do not solely rely on GPs. Given that theoretical patient behaviour change modelsAlthough the majority of UK GPs who responded to the questionnaire survey were positive about exercise for patients with CKP and used exercise in their clinical management, this survey identified GP uncertainties with respect to the safety and efficacy of exercise and suboptimal approaches to the initiation of exercise with patients. GPs’ use of exercise may be improved by addressing the key barriers of time and expertise, by developing a pragmatic approach that supports GPs to initiate individualised exercise with patients, and/or by other professionals taking on this role.


Isolated ST-segment elevation only in the aVR lead, reflecting an acute myocardial infarction due to a left main coronary artery occlusion, was ignored as part of physicians' training in emergency medicine for a long time. The recognition of aVR lead elevation is becoming more accepted as a mandatory diagnostic tool, in particular for physicians working at emergency departments. We report a typical myocardial infarction with total occlusion of the proximal part of the left anterior coronary artery, presenting with ST-segment elevation in the aVR lead, which was misinterpreted as diffuse ischemia. The lacking mandatory awareness of this entity endangered prompt and correct treatment.


Left ventricular free wall rupture is usually a catastrophic mechanical complication of myocardial infarction. Risk factors include advanced age, female gender and absence of prior infarction. The vast majority of patients succumb rapidly due to cardiac tamponade and electromechanical dissociation. Expedited and accurate diagnosis can improve the chances of survival. Echocardiography has been advocated as the gold standard for diagnosis, but other imaging modalities can provide valuable information in these patients. We present the case of a patient who presented with cardiogenic shock, in which the definitive diagnosis of a left ventricular free wall rupture was accomplished by CT scan with intravenous contrast. Mechanical complications of myocardial infarction continue to challenge physicians in the modern reperfusion era. Amongst these, left ventricular free-wall rupture (LVFWR) can be responsible for as much as 20-30% of all infarct-related deaths ; it carrA 65-year-old female with a history of COPD and tobacco use but no previously documented coronary artery disease was transported to the Emergency Department after a witnessed cardiac arrest. Her husband reported that the patient suddenly clutched her chest in pain and collapsed. She had been complaining of increasing fatigue and malaise for 2 days. The patient was found to have pulseless electrical activity by EMS, but had return of spontaneous circulation after CPR en route. On arrival, she was in shock. Physical examination did not reveal elevated neck veins or rales on auscultation. Initial ECG  showed aMore than 350 years after the first description of a LVFWR by William Harvey , it is sFrom an imaging standpoint, a new pericardial effusion is the most common finding, and can be quickly assessed by an echocardiogram. The absence of an effusion by echocardiography in an individual with an AMI virtually excludes the diagnosis of myocardial rupture , but itsAwareness of the risk factors associated with post-infarction LVFWR is important to maintain a high-degree of suspicion in the appropriate clinical circumstances. These include age over 65, female gender, hypertension without significant left ventricular hypertrophy and late presenters . DiabeteThe most typical ECG sequence described for patients presenting with the acute-type of LVFWR after an AMI is that of anterior ST segment elevation followed by sudden bradyarrhythmia or electromechanical dissociation ; howeverLVFWR continues to be an ominous complication of acute myocardial infarction, that should be strongly suspected in patients presenting with cardiogenic shock, particularly when other risk factors such as advanced age, female gender, absence of prior diabetes, coronary or peripheral vascular disease are noted on initial assessment. Echocardiography remains a key modality in the expedited diagnostic sequence required in these cases, but emergent CT with contrast can be an adjuvant tool in confirming the diagnosis and excluding other causes of hemopericardium. Further studies are needed to compare the sensitivity and specificity of these imaging modalities in patients with LVFWR.


Genome size varies by many orders of magnitude across plants and animals, but resolving the most important evolutionary forces driving this variation remains challenging. Since eukaryotic genome size variation is not associated with complexity, genetic drift of the amount of noncoding DNA could dominate, implicating population and species history as key drivers of shifts in DNA content. Alternatively, directional selection could be acting on DNA content, but if so, it has not been resolved which level of selection is most important. Since the predominant component of many eukaryotic genomes is comprised of selfish genetic elements such as transposable elements (TEs) and regions subject to meiotic drive, factors that influence their differential success across populations and species could account for much of the variation in genome size. However, DNA content can also have important effects on organismal phenotype that could be under directional selection. Genome size may often be an important determinant of cell size and division rate and the subject of selection via its effects on developmental and metabolic phenotypes ,2. SuppoZea mays spp. have been well described, with a number of studies showing evidence of genome reductions, including the loss of knobs and B chromosomes, in regions of high altitude and latitude [Bilinski et al.  capitalilatitude –13. WhilBilinski et al.  add to tUsing this approach to test for local adaptation, the authors are able to reject the predictions of the neutral model, concluding that genome size differences along altitudinal clines are too extreme to be explained solely by drift . When coWith the finding that natural selection shapes genome size variation across multiple parallel altitudinal clines in maize and its wild relatives, Bilinski et al.  searchedThis paper provides important evidence for the organismal-adaptation view of genome size evolution—but what of the coevolutionary struggle with selfish elements? The major evolutionary force driving genome expansion in maize is still likely to reflect selfish evolution through selection on meiotic drivers and self-replicating TEs, since selection pressures on such alleles are typically very strong. Knob elements, for example, have a strong transmission advantage driving their increase . On the Conversely, other selective pressures on selfish genetic elements may provide an additional source of genome size variation in maize populations beyond the effects of flowering time. Since chromosomal knobs are known to have severe fitness costs, the extent of these costs may well depend on the environment , possibl