Evaluation of patient/client satisfaction with pharmacy services as a crucial part of the health services through appropriate studies is important. This will help identify specific areas of the service which need improvement in realizing high quality pharmacy services in general and enhance the positive changes in the current pharmaceutical services provision in Ethiopia. The current study aimed at assessing the level of client satisfaction with the services of the outpatient pharmacy of Gondar University Referral Hospital (GURH) in northwestern Ethiopia.An institution-based cross-sectional study was conducted involving 400 clients who had prescriptions/orders filled at the outpatient pharmacy of the hospital during the period of 5th to 25th of November 2013. The data on the level of satisfaction of clients with the services of the outpatient pharmacy in the hospital was collected using a structured interview guide adopted from an instrument translated into Amharic and validated. The data collected was entered into and analyzed using Statistical Packages for Social Sciences (SPSS) version 16.The overall mean score the respondents gave to satisfaction with the pharmaceutical services was 2.48 out of a maximum of 5.00 score. The mean scores for all the individual parameters rated were less than 3.00. Maximum mean scores were given for parameters asking about the promptness of prescription medication service (2.99), and professionalism of the pharmacy staff (2.96) with the lowest being scored for information given to clients about the storage of medication (1.25), and explanations of possible side effects (1.27). Clients who were served free of fee recorded significantly higher level of satisfaction than those who paid. Higher levels of satisfaction were also reported among illiterates, older adults and those with no job compared to those with higher education, merchants and government employees.This study showed that the overall mean satisfaction level of clients of the outpatient pharmacy was low and it differed among different socio-demographic characteristics. Further research in to the reasons behind the low satisfaction should be done to provide appropriate solutions to improve the service. Good pharmacy practice (GPP) was defined by joint International Pharmaceutical Federation (FIP)/World Health Organization (WHO) guidelines on GPP as the practice of pharmacy that responds to the needs of the people who use the pharmacists’ services by providing optimal, evidence-based care. According to the guidelines it required that a pharmacist’s priority be the welfare of patients; helping patients make the best use of medicines as a main activity; contributing to rational and economic prescribing and dispensing; and that pharmacy services objectives should be relevant and properly communicated to patients .American society of hospital pharmacists defined the mission of the pharmacist, with some modification on the definition by Hepler and Strand, 1990 as the provision of pharmaceutical care which in turn was defined as the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patient’s quality of life , 3.In order to ensure the implementation of GPP with the current philosophy of pharmaceutical care, its quality should be assessed. In this process quality could be seen from three aspects including structure, process and outcome of the services provided . StructuPatient satisfaction has been described to improve other treatment outcomes in addition to being a goal of treatment by itself . So, evaIn the measurement of the level of satisfaction of patients/clients with the services of pharmacies different instruments have been used –10. DiffAnother study done in Botswana reported satisfaction of clients with quality of a primary health care facility which contained pharmacy services as one part . StudiesPharmacy practice in Ethiopia has traditionally involved product oriented approach majorly. The different practice areas in the country include health institution pharmacy, community medicine retail outlets, the pharmaceuticals supply system, manufacturing establishments, medicines regulatory body and academic areas among others. In recent times there have been moves toward a major shift in the direction of patient oriented pharmacy services. In line with this a change in the curriculum, which was previously product focused, to a five years clinically oriented pharmacy education curriculum has been instituted. In the year 2013, through this curriculum 426 pharmacists graduated and in relation to this there are efforts in different hospitals of the nation especially in university hospitals toward provision of clinical pharmacy services through involvement in patient care in wards, other hospital pharmacy sections –22.In Ethiopia, few studies on the satisfaction of clients/patients with the general health care services in different health institutions have been conducted which did not emphasize pharmacy services –26. One An institution-based cross-sectional study was conducted at GURH, located in the northwestern Ethiopian town of Gondar. The institution is a referral and teaching hospital with a catchment population of 5 million. GURH has more than 400 beds capacity and provides its services in various departments including internal medicine, surgery, pediatrics, gynecology and obstetrics, dermatology, dentistry, ophthalmology, pharmacy , medical laboratory and others .1 ‐ α)2 × σ2/SE2] considering the standard deviation (σ) of mean satisfaction level to be 0.5 based on the finding from the pretest done on 41 interview encounters. The margin of error (standard error (SE)) was set to be 0.05 with 95 % confidence interval (CI) [The sample size of participants to be included in this study was determined using single mean formula: [N =  . With anIn selecting participants of the study, adult clients (18 years or older) who were willing and had their prescript/orders filled at the outpatient pharmacy of the hospital were included in the study. The study was conducted during the period of 5th to 25th of November 2013. The average daily client flow to the pharmacy was estimated to be about 100 and the number of clients to be interviewed during the 21 days of data collection was 21. By dividing the daily client flow to the pharmacy with the number of clients to be surveyed per day, every fifth client was approached the interview. The first client was selected daily through drawing a number from 1 up to 5 and continuing with every fifth number until the daily sample limit was reached.The data on the level of satisfaction of clients with the services of the outpatient pharmacy in university hospital was collected using a structured interview guide. The guide was adopted from an instrument employed by Eshetu and Gedif, 2011 in a study done in governmental hospitals of Addis Ababa to assess the level of satisfaction of clients with the services of the pharmacies in the hospitals. The instrument was assessed for its reliability in the cited study and had Cronbach’s alpha of 0.9 .The instrument contained two sections, one section which focused on the socio-demographic profile of respondents and another on the level of satisfaction of the clients with the services provided in the pharmacy. The section focused on the level of satisfaction of clients contained twenty one five-point Likert scale items. On the scale “1” stood for a rating of the item as “very low” while “2”, “3”, “4” and “5” stood for “low”, “moderate”, “High” and “Very high” in that order. Based on this, the mean level of satisfaction of clients was calculated by averaging their ratings for the 21 parameters of measuring satisfaction. The resulting mean was interpreted by considering the closest Lickert scale to it.The data collection instrument was pretested on 41 clients, which were excluded from the final analysis, before the commencement of actual data collection process.The data was collected by four of the principal investigators through interviewing clients after they had their prescriptions/orders filled in the pharmacy. The investigators who collected the data were properly trained on the instrument and ways of approaching clients and securing their permission for interview prior the data collection process.t test was employed to assess the difference in satisfaction of clients between sex, payment and patronage. On the other hand one way ANOVA was used to check the difference among age groups and educational status of the clients with regard to level of satisfaction with the services provided in the pharmacy. In doing the different analyses 95 % CI and p value of 0.05 were used for deciding statistical significance of differences observed [The data collected was entered into and analyzed using Statistical Packages for Social Sciences (SPSS) version 16. In the study socio-demographic and satisfaction level of the clients were described using frequencies, percentage, mean and standard deviation. Independent observed .This study was approved by the ethical review committee of the school of pharmacy, University of Gondar. In addition permission was secured from the hospital and the pharmacy administrators to proceed with the study. Each of the clients were provided with explanations on the purpose of the study and asked for their consent to participate in the study. Only when they were willing to proceed with the interview were they involved in the study. In addition, patient identifiers were not used in the study and the data collected was used by the investigators only for the purpose of the study.In this study out of the total questionnaires/interview guides of sample of 405 clients who were interviewed 400 were included in the analysis, and five encounters were excluded due to incompleteness making the response rate 98.8 %. Most of the respondents were male (60.2 %), married (68.2 %) and Orthodox Christians (79.2 %). Among the respondents, those in the age group of 30 to 39 years old constituted the highest proportion (35.5 %) followed by those in the age group of 18 to 29 years of age (31.5 %) (Table Respondents who were from Gondar town (73.0 %), those taking medications for themselves (66.0 %) and those who paid for the medications (79.2 %) constituted the highest proportion in their respective categories Table .As regards to the educational status of respondents the most frequent had a status of higher education (44.2 %) followed by those completing secondary education (25.8 %). Among the respondents employees of government institutions (27.0 %) and those with no job (26.2 %) constituted majority of the respondents Table .In the present study of the satisfaction level of pharmacy clients towards the pharmaceutical services, all the 400 respondents gave their responses to all the twenty-one parameters they were asked to rate. The overall mean score the respondents gave to satisfaction with the pharmaceutical services was 2.48 out of a maximum of 5.00 score , and “the professionalism of all the pharmacy staff” (2.96). On the other hand, the parameters rated lowest included “the information the pharmacist gives you about the proper storage of your medication” (1.25), and “how well the pharmacist explains possible side effects” (1.27) ’ level of satisfaction only by less than 1 % of the total respondents. In addition, in nearly half 42.9 %) the parameters none of the respondents rated the parameters as ‘very high (5.00)’  and those 60 years or older  had higher mean satisfaction levels compared to those in the age group of 18 to 29 years of age.In the one way ANOVA test performed on different socio-demographic characteristics of clients in the study; age, educational status and occupational status were found to have statistically significant differences. The Post Hoc test (Tukey HSD) revealed that, the age groups 50 to 59 years of age . With regard to occupational status, farmers showed higher level of mean satisfaction compared to government employees  and merchants  based on the Post Hoc test. In the same group clients with no job were found to be more satisfied with the services they received compared to government employees  (Table On the other hand a similar Post Hoc test on educational status uncovered that clients in the group with higher education had a statistically significant lower mean satisfaction level compared to illiterate clients (In the present study the mean level of satisfaction was found to be low as it fell below the “moderate” level in the five point Likert scale. The reported mean level of satisfaction was lower compared to findings in Spain and in Portugal on community pharmacies which reported high level of satisfaction among clients , 30. ThiThe low level of satisfaction on the side of clients in this study was comparable to the finding from a study done in Addis Ababa, on pharmacies of governmental hospitals which reported a mean level of overall satisfaction of 2.7 . SimilarThe parameters “the promptness of prescription medication service”, and “the professionalism of all the pharmacy staff” were among those rated highest in the current study. Different to this pharmacist’s skills and confidentiality, and assistance to patients were rated highest as reported by a study at an outpatient pharmacy in Spain .On the other hand the lowest rated parameters in the present study were “the information the pharmacist gives you about the proper storage of your medication”, and “how well the pharmacist explains possible side effects” which showed similar finding to the study in Addis Ababa . This int test showed that clients who paid for the services in the pharmacy had a statistically significant lower level of satisfaction compared to those served with no payment. A similar finding was reported in the study done in Addis Ababa [In this study the results of independent samples is Ababa . In EthiOne way ANOVA performed also on socio-demographic characteristics showed statistically significant differences among different age groups, educational levels and occupational status of clients in the study. The higher level of satisfaction reported among elderly clients compared to the young ones and the higher level of satisfaction among illiterate clients than in those having higher education were interrelated. This was evident in the chi square test performed which revealed that level of education was different in a statistically significant manner among different age groups, with younger clients being more educated. The higher level of satisfaction among the illiterate and elderly clients could be associated to lesser awareness on the importance of details of the functions in the pharmacy and the services they deserved to get, so overrating it.Differences in satisfaction among different age groups was also reported by the study done in Portugal . In contSatisfaction levels were also found to be statistically different among different occupational groups. Among these, farmers and those without job tended to be more satisfied compared to merchants and government employees. The occupational groups were also different depending on educational status in a statistically significant manner based on the chi square tests done. This showed, similarly to the case of satisfaction level with age groups above, those with no job and farmers were of lower educational status. The higher level of satisfaction could be similar to the above mentioned ones. Unlike this, government employees and merchants who were relatively more educated and with better awareness of what to expect from the services rated their satisfaction lower.In this study an important limitation is the fact that the specific services clients got in the pharmacy were not assessed. This hindered the study’s ability to assess the level of satisfaction of clients in relation to the kind of services received. This would have helped suggest specific services to focus on for future studies.This study showed that the overall mean satisfaction level of clients of the outpatient pharmacy was low. Mean satisfaction level was found to be different in a statistically significant manner between/among different groups including age, educational status, occupational status and payment status. The low satisfaction levels reported should be further studied through qualitative studies to find appropriate solutions in solving the problems. The hospital should institute better service provision system in relation to availing medicines, continuing professional development to professionals to improve the satisfaction of clients with the services provided in the pharmacy.


A metasurface can manipulate light in a desirable manner by imparting local and space-variant abrupt phase change. Benefiting from such an unprecedented capability, the conventional concept of what constitutes an optical lens continues to evolve. Ultrathin optical metasurface lenses have been demonstrated based on various nanoantennas such as V-shape structures, nanorods and nanoslits. A single device that can integrate two different types of lenses and polarities is desirable for system integration and device miniaturization. We experimentally demonstrate such an ultrathin metasurface lens that can function either as a spherical lens or a cylindrical lens, depending on the helicity of the incident light. Helicity-controllable focal line and focal point in the real focal plane, as well as imaging and 1D/2D Fourier transforms, are observed on the same lens. Our work provides a unique tool for polarization imaging, image processing and particle trapping. The reshaping of the light wavefront in traditional optical elements relies on gradual phase change, which is realized by light propagation through media of given refractive indices that can be engineered to control the optical path of light beams. Therefore, the deterministic functionality of an element is usually dictated by the surface topography. For example, a cylindrical lens can perform one-dimensional 1D) optical transformation while a spherical lens can perform two-dimensional 2D) transformation. Driven by device miniaturization and system integration, there is a huge interest in obtaining a lens with multiple functionalities, which can dramatically increase the functionality density of the optical system. The multi-focal lensD opticalD transfoMetasurface, as a new type of artificially structured surface, has provided a new design methodology for ultrathin optical devices, allowing manipulation of light propagation to an unprecedented level by imparting local and space-variant abrupt phase change45678910111213141516171821232425Based on the unique design methodology presented in our recent work17293031323334φ, where φ represents the orientation of the nanorod and the sign ‘+’ or ‘−’ corresponds to the incident LCP or RCP light, respectively. By utilizing the geometric phase, it is very convenient to encode a sampled phase function onto an array of nanorods with the same geometry but varying orientations.In order to reduce the thickness of the traditional lens, Fresnel lens was invented by replacing a standard lens with a set of separate surfaces, with stepwise discontinuities between them. Metasurfaces can further reduce the thickness of the lenses due to their capability in abruptly changing the optical wavefront properties within a deep subwavelength range . In thisIn order to create the multifunctional lens, two independent designs regarding the positive cylindrical lens and the negative spherical lens are firstly carried out. The phase function for the positive cylindrical lens isand that for the negative spherical lens isλ is the incident wavelength and f is the focal length. where On the transmission side of the multifunctional lens, the divergent light from the negative spherical lens acts as a subtle background in comparison with the converging light from the positive cylindrical lens. On the contrary, the negative spherical lens “converges” and the positive cylindrical lens “diverges” the virtual light beams on the incident side. Due to the intrinsic properties of the geometric phase, the sign of the phase profile is flipped if the helicity of the incident circularly polarized light is reversed. The multifunctional lens turns into the combination of a negative cylindrical lens and a positive spherical lens if the incident light is changed from RCP to LCP.The scanning electron microscopy image of the fabricated metasurface is shown in f = 198 μm at the wavelength of 640 nm. When the incident/detected light is RCP/LCP, a clear focal line is observed at z = f on the transmission side [z = −f [z = f and −f, respectively. The experiment clearly verifies that the metasurface is the combination of a positive cylindrical lens and a negative spherical lens for RCP incident light. The polarities of both lenses are reversed when the helicity of the incident light is changed.The spherical and cylindrical lens both have a focal length of ion side . By furt [z = −f . If the  [z = −f  and a vi [z = −f  are obtaUpon the illumination of RCP light, it is transformed both by the positive cylindrical lens and the negative spherical lens simultaneously. Although the real focal line on the incident side is affected by the light emitting from the negative spherical lens, the intensity of the focal line is much higher than the background noise . Similarx direction is obtained due to the 1D transform of the cylindrical lens [As a lens, the imaging properties of the metasurface lens are our main concern. The object to be imaged is the T-shaped aperture array fabricated on a 40 nm thick chromium film. Each T-aperture has a size of 50 μm × 50 μm and the distance between the neighboring apertures is 100 μm along both directions in a square array. The scanning electron microscope image of the T-apertures is shown in the upper panel of cal lens . The uppf but less than 2f. Since only the positive lens can form real images on the transmission side, the images formed by the positive spherical lens are shown in Apart from the virtual images formed by the multifunctional lens, the magnified real images of the object are also obtained by increasing the thickness of the air gap to be larger than the focal length Apart from imaging, Fourier transform is another important functionality of the lens. The 1D and 2D optical Fourier transform can be carried out using the cylindrical lensx axis1z axis) can be integrated onto the same metasurface. If the incident light is linearly polarized and only the cross polarized scattered light is detected, the real images located at different positions corresponding to RCP and LCP light can be formed simultaneously.The uniqueness of the multifunction lens lies in the combination of a spherical lens and a cylindrical lens in a thin device. The unusual performance of such a brand new device has potential application in particle trapping, imaging and information processing. For example, the multifunctional optical tweezers can be realized with individually defined structures of each trap, which is switchable via the incident polarization state. Imaging systems that can be used to detect and analyze circularly polarized light have remarkable capabilities in biological applicationsIout to that of the input light Iin. The helicity-unchanged light is filtered out by using a quarter waveplate and a polarizer. The conversion efficiency in the range of 640 nm ~1080 nm with a step size of 40 nm is measured and the peak efficiency is about 5% at 880 nm in these experiments. Although the geometric phase is independent of the incident wavelengths, the conversion efficiency of the metasurface is closely related to the incident wavelengths since the nanorods are intrinsically dispersive. The useful bandwidth of the metasurface is hence limited by the wavelengths where the efficiency is low.The conversion efficiency is a very important parameter which affects the performance of the metasurface and it is defined as the ratio of the power of the helicity-changed light tuu + tvv = tuv − tvu = 0 should be satisfied for the transmission-type metasurfaces. Here, tuv − tvu = 0 and tuu + tvv ≠ 0, which yields an unavoidable zero-order. To satisfy the above general relationship, a transmission-type dielectric metasurfaceAlthough the efficiency can be greatly improved using the reflective type metasurfaceThe multifunctional metasurface lens in this paper is a combination of two different types of lenses with a real  focal point and a virtual  focal line located on different sides of the metasurface under the illumination of left (right) circularly polarized incident light. The combination design causes background noise, which decreases the signal-to-noise ratio of the image formed by the metasurface lens. However, the background noise can be dramatically deceased by utilizing the angle-multiplexing methodIn summary, we have experimentally demonstrated a multifunction metasurface lens consisting of nanorods with spatially variant orientation and operating at visible frequencies. The design is based on the abrupt phase change that occurs for the circularly polarized light. The observed focal line and focal point in the focal plane are interchangeable, depending on the helicity of the incident light. The unique properties of the metasurface lens in imaging and image processing in Fourier transform agree well with the theoretical prediction. This lens features the combination of two types of lenses operating with opposite incident helicities on the same metasurface, opening a new avenue to achieve a high density of functionality and effectively scaling down the size of photonic systems.How to cite this article: Wen, D. et al. Multifunctional metasurface lens for imaging and Fourier transform. Sci. Rep.6, 27628; doi: 10.1038/srep27628 (2016).


The aim of the study was to provide detailed herd level cost information about an outbreak of interdigital phlegmon (IP), which has been an emerging problem with enlarged loose house barns in Finland in recent years. During enlargement, the farmer’s financial situation is sensitive because of the large investments to the farm business and unexpected costs can risk the farm’s survival.The University of Helsinki research herd and three commercial herds having outbreaks of IP in 2012 or 2013 were visited to collect detailed information about the costs and economic impact of the outbreaks. The majority of the costs came from the discarded milk due to the antibiotic treatments. In Finland IP is usually treated with parental benzylpenicillin for 5 days which result in discarded milk for a total of 11 days. Third generation cephalosporins, widely used in other countries, have no milk withdrawal time. However, the use of these antibiotics is not recommended in Finland since these antimicrobials are critically important for human health. Herd-level costs varied between 4560 and 28,386 € depending on the herd size, the frequency of the infected cows, the antibiotics used and other costs involved. The average cost per infected cow was 489 €.The outbreaks of IP cause severe economic losses to dairy farms and the costs are lower if cows are treated with antibiotics with no withdrawal time. However, other costs, such as involuntary culling, reduced production and fertility also produce substantial costs to the farms. Early detection of sick animals, rapid treatment and control measures to limit the outbreak of IP can lower the costs. Because of the high costs farms should concentrate on preventing the disease. Fusobacterium necrophorum (which is believed to be the primary pathogen), Dichelobacter nodus, Porphyromonas levii, P. asaccharolytica, Prevotella intermedia, and P. melaninogenica [F. necrophorum is commonly found in the soil and can be isolated on the feet, rumen and feces of healthy cows [Interdigital phlegmon (IP) or foot rot is a necrotizing soft tissue inflammation in the interdigital region of the foot –3. IP isnogenica . Howeverthy cows . In receIn Finland IP is usually treated with parenteral benzylpenicillin for 5 days (20 mg/kg) with a milk withdrawal time of 6 days, which results in discarded milk of a total of 11 days. Additionally, cows are usually treated with non-steroidal anti-inflammatory drugs and in some cases foot baths for the healthy cows are recommended for controlling the infection in the herd. If IP is diagnosed and treated early the antibiotic treatment is usually successful and most cases respond rapidly . AccordiThe aim of this study was to provide detailed cost information about an outbreak of IP at the herd level. Such information is not possible to obtain from the standard Finland health or economic recording and no previous studies have been undertaken to compile the economic costs associated with an IP outbreak.my) in the previous test day recording before the clinical case of IP was diagnosed, the wait time (wt) due to antibiotic use and the milk price (mp) at that time.vf) and medicines (m).ts) on the clinical case and the hourly wage claim (wc) of the dairy farmer in 2013 in Finland (14.90 €) [rt).tc), the price of the culled cows (pc) which varied between 500 and 1250 € depending on the parity, milk yield and fertility status and the price of the lost calves (plc) which was 100 €/calf.The costs presented in this study do not include taxes (VAT 0 %). In the University research farm the accurate daily discarded milk yields were available. In the other farms losses due to the discarded milk were calculated based on the number of the clinical cases of IP, the milk yield (14.90 €) . The estOther costs, such as the increased use of copper sulfate in the foot baths, were also included. IP can also lower the milk production, prolong the calving interval and predispose cows to other diseases . A decreUniversity of Helsinki research herd (A) and three commercial loose-housed herds (B–D) having outbreaks of IP in 2012 or 2013 were visited to collect detailed information about the costs and economic impact of the outbreak. These farms had not had IP outbreaks before and the previous status of other infectious claw disorders was comparable to other farms in Finland. The commercial farms had already participated in the “Infectious hoof diseases in dairy cows in new loose housing system” project funded by the Ministry of Agriculture and Forestry. The researcher visited the farms at the beginning of the outbreaks and diagnosed IP based on clinical signs  and bacteriology. Later IP cases at the farm were diagnosed by the local veterinarian. Farm location, number of cows, number of cows treated and antimicrobials used are described in Table The costs varied between the farms Table , herd-leIP epidemics cause economic losses to dairy industry and the majority of the costs come from the discarded milk due to the treatments with antibiotics. Also, other costs involved  are substantial. However, rapid treatment and control measures to limit the outbreak of IP will greatly reduce the total herd cost. Based on this study the average cost per infected cow can be assumed to be 600–700 € when the cow is treated with benzylpenicillin. Because of high costs of IP it would be more efficient on the economic point of view to focus on the prevention of the disease.


Currently available perimeters have limited capabilities of performing measurements of the visual field in children. In addition, they do not allow for fully automatic measurement even in adults. The patient in each case (in any type of perimeter) has at his disposal a button which he uses to indicate that he has seen a light stimulus. Such restrictions have been offset in the presented new perimeter ZERK 1.The paper describes a new type of automated, computerized perimeter designed to test the visual field in children and adults. The new perimeter and proprietary software enable to carry out tests automatically (without the need to press any button). The presented full version of the perimeter has been tested on a head phantom. The next steps will involve clinical trials and a comparison with measurements obtained using other types of perimeters.o (95 LEDs on each arm) at a typical position of the patient’s head. The measurement can be carried out in two modes: default/typical (lasting about 1 min), and accurate (lasting about 10 min). Compared with available and known types of perimeters, it has an open canopy, proprietary software and cameras tracking the eye movement, automatic control of fixation points, light stimuli with automatically preset light stimulus intensity in the following ranges: 550–700 mcd (red 620–630 nm), 1100–1400 mcd (green 515–530 nm), 200–400 mcd (blue 465–475 nm).The perimeter ZERK 1 enables automatic measurement of the visual field in two axes (with a span of 870 mm and a depth of 525 mm) with an accuracy of not less than 1The paper presents a new approach to the construction of perimeters based on automatic tracking of the eye movements in response to stimuli. The unique construction of the perimeter and the software allow for its mobile use in the examination of children and bedridden patients. Perimetry is a basic test associated with the quantitative evaluation of the visual field –3. This Fully automatic measurement –31—underLimited use in young children;Deliberate introduction of erroneous results by the patient (by pressing the button routinely when the frequency of stimuli is constant).Therefore, there are three problems in perimetry that have not been solved so far:The perimeter ZERK 1 described in this paper is devoid of the above-mentioned problems.® Core i7 computer-3770 CPU 3.4 GHz, 10 GB of RAM. The eye movements were monitored by a system of EyeTribe and Genius Eye trackers. For instance, the EyeTribe tracker system is a Danish company producing modules for tracking the position of eyeballs. Tracking the eye movement involved a typical measurement consistent with the Declaration of Helsinki, and was performed in 20 healthy volunteers as part of routine applications of the EyeTribe tracker. On this basis, two perimeters were constructed. The first one, designed to test adults, had a chin rest and a forehead rest, and the other one, intended for measurements in young children, was movable and without the rest. The construction of the perimeter is described in detail in the following sections. Currently, the authors are at the stage of submitting an application to the ethics committee to get permission to test the entire system. Moreover, a utility model application has been filed at the European Patent Office. No research was carried out on humans as part of this work. All the results were obtained from routine tests performed with the EyeTribe tracker and (in the case of the full perimeter) tests on a phantom head —in the case of testing the perimeter intended for children and adults.The developed software of the perimeter ZERK 1 was tested on the IntelThe perimeter ZERK 1 was created based on the two premises mentioned in the Introduction. The first one is the ability to perform measurement of the visual field in young children. Accordingly, the presented perimeter cannot have a closed canopy. The child needs to see the carer/parent, which reduces the fear of examination and prevents movements during the test. The second premise is the total automation of the examination. Owing to the built-in eye trackers, the patient’s reaction to the light stimulus is recorded. As a result, the patient does not press any button to signal that he sees the stimulus.Vertical and horizontal arms containing RGB LEDs  placed at a linear distance from each other every 10 mm. The arms have a span of 870 mm (from the outermost left–right or up–down points) and a depth of 525 mm. The horizontal arm has a total of 190 LEDs, 95 LEDs arranged every 1° on each side. The vertical arm has 135 LEDs attached every 1°. In this way, the arms cover the full visual field;The fixation point placed in the main axis of the perimeter containing a colour marker. In the case of children, it is a colourful contour of a favourite character from a fairy tale or an animal. The size of the fixation point is about 20 × 20 mm;A system of EyeTribe trackers;A PC with windows operating system and developed software that enables to track the movement (location) of the eye in response to a light stimulus.The perimeter ZERK 1 is made up of four basic elements—Fig. Simplified, fast mode—allowing for a 1-minute rough assessment of the visual field.Accurate, full mode—allowing for a 10-minute accurate assessment of the visual field.The task of the perimeter ZERK 1 is to preset light stimuli covering the full range of the visual field both vertically and horizontally. The analysis of the patient’s response to the light stimulus was carried out on the basis of the EyeTribe tracker which tracks the eyeball reaction. ZERK 1 can be removed from the base and placed directly next to a bedridden patient (child). The individual LEDs are controlled via USB as well as a microcontroller 89c2051 and USB converter. The test is carried out with the dedicated software in 2 modes:LGRAY is calibrated to the image LC (the head movement and uneven illumination are deleted). Next, the image is subjected to median filtering [LMED) to detect the eye movement (LE) (after earlier covering of the left or right eye). The second block is responsible for controlling LED strips. It includes a microprocessor which controls the LEDs and brightness at random (pulse-width modulation—PWM). The merger of these two blocks results in a map  created in an application developed in C++. Communication with the PC was realized via USB 2.0. It is two-way communication. The information about the eyeball movements is obtained from the eye tracker, whereas the information which LED, with what intensity, and where exactly on the perimeter is to shine, is returned. The methods of image analysis and processing shown in Fig. In each test mode, the brightness (in the range of 550–700 mcd) and the order of stimuli are random. The interval between stimuli is also random and ranges from 0.5 to 5 s. The random position of the next stimulus and different length of the interval between stimuli prevents the patient from getting used to a scheme, prevents his weariness during the test, and thus reduces the number of false positive results . Figure iltering –34  owing to a random change of the stimulus location, a random change in its brightness and the analysis of the eyeball movements which do not result from the stimulus.The full system of ZERK1 has been compared with the Heidelberg edge perimeter , 8, 22 aMeasurement in only two axes—horizontally and vertically;The impact of the perimeter position on the results obtained ;The need for fixation of the patient in the central position of the perimeter—and difficulty in staying focused on this point;The dependence on external illumination due to the open construction of the perimeter.The limitations of ZERK1 should be also mentioned here:An example of a report (phantom) from tests performed with ZERK1 is shown in Fig. At the current stage, the authors plan thorough clinical trials in adults and children with various diseases, both those involving various types of defects in the visual field and those directly related to extra ocular muscle dysfunctions. They can reduce the possibility of carrying out measurements or exclude the patient from the test.The paper presents a new approach to the construction of a perimeter based on automatic tracking of eye movements in response to stimuli. Owing to this unique solution, the patient does not have to press any button to signal seeing the stimulus. The unique construction of the perimeter allows for its mobile use for the examination of children and bedridden patients. Currently, the authors intend to carry out detailed clinical trials of the created perimeter and compare the results with the results obtained using other perimeters. It is already known, on the basis of the presented preliminary results, that the new type of the perimeter will work perfectly in basic diagnostics of visual field  in adults as well as in screening tests in children. The scope of diagnostic procedures will comprise monitoring the speed of the eyeball response and the assessment of sensitivity to a light stimulus. To conclude, the presented perimeter does not constitute competition for the known types of perimeters, it only completes the market in the area of fully automatic measurement, examination of bedridden patients and additional analysis of movement parameters (speed of response) of the eyeball.


Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT) is officially released in English and Spanish. In the Basque Autonomous Community two languages, Spanish and Basque, are official. The first attempt to semi-automatically translate the SNOMED CT terminology content to Basque, a less resourced language is presented in this paper.The A translation algorithm that has its basis in Natural Language Processing methods has been designed and partially implemented. The algorithm comprises four phases from which the first two have been implemented and quantitatively evaluated.Results are promising as we obtained the equivalents in Basque of 21.41% of the disorder terms of the English SNOMED CT release. As the methods developed are focused on that hierarchy, the results in other hierarchies are lower .We are in the way to reach two of our objectives when translating SNOMED CT to Basque: to use our language to access rich multilingual resources and to strengthen the use of the Basque language in the biomedical area. SNOMED Clinical Terms (SNOMED CT)  is widelBasque Scheme to normalize the use of the Basque language in Osakidetza for the period 2005-2012. In the evaluation of this plan  + allergy'', that is, a pharmacological product or a substance followed by "allergy", like "urokinase allergy", "cortisone allergy" or "phentolamine allergy". Our hypothesis is based on the evidence that we have already the translations of some chunks within the complex term. In this step the translation application should generate the Basque equivalences using the already translated components and some generation rules.Regarding the third phase which aim is the translation of complex terms, we are analyzing their nature in the English version of SNOMED CT and we found out that many different terms share a specific structure. In Table Matxin  (o 0:+)]* SUFF] ;In order to reduce the overproduction of the transducer, we fixed the criteria to pick the output with less identified parts. For instance, for the term "photodermatitis" four possible outputs are generated:• photo+dermat+itis: 3• photo+derm+at+itis: 4• phot+o+dermat+itis: 4• phot+o+derm+at+itis: 5In this case, the first identification is given to the translation transducer as it contains only three parts."kolezist" in Basque) is the same as the combination of "kole" and "zist" so the translation transducer will output the same string. That is to say, in most cases the overproduction is reduced once the translation and the composition FSTs are applied as the output equivalent term will be the same.Following this criterion, even though we can reduce the overproduction we cannot always avoid it. In fact, if we analyze the lexicon of the prefixes we obtain that 93% of the translation pairs are equal to the ones obtained from transcription rules that will be described in the First approach. In Example 1 we can observe how the equivalence given to "cholecyst" , and then 28 rules for morphotactics are applied (simplified in the rule numbered 5). Some of these rules were determined empirically by analyzing examples from dictionaries, and others have as a basis the orthographic rules set by the Royal Academy of the Basque Language . The traListing 2 Rules for the affix translation1 read lexc prefixes.lex2 define TRANSPRE3 read lexc suffixes.lex4 define TRANSSUF5 define MORPHO ...6 define TRANS (ˆ) [[[TRANSPRE +] (o:o +)]* TRANSSUF] ;7 regex TRANS .o. MORPH ;We decided to make the suffix compulsory as we discovered that the equivalences of the suffixes are more complex than the equivalences of the prefixes. That is, only 22% of the suffixes follows the transcription rules mentioned before, and what is more, we have not been able to find a pattern based on morphotactics for those endings. Thus, we consider that for this stage of the development the suffix must be compulsory to guarantee a higher precision of the translation. Besides, this condition seems to exclude terms that do not follow a "prefix, root and/or suffix" structure which is the structure this method has been designed for. Example 2 shows the whole process with an example. First, we identify the prefixes and suffixes of the English input term by means of the transducer that marks those affixes . Then, we obtain the corresponding Basque equivalent for each part and we form the term .Example 2 Basque simple term generation.Input term: schizencephalyIdentified affixes: schiz+encephal+yTranslated affixes: eskiz+entzefal+iaOutput. Basque term: eskizentzefalia"radio" needs of the mentioned rule, obtaining "erradio".As we said before, in order to obtain a well formed Basque term, we apply different morphotactic rules. For example, in Basque, there are not words that start with "r" and an "e" is needed at the beginning. Example 3 shows a case where the translated prefix Example 3 Morphotactic rule application.Input term: radionecrosisIdentified affixes: radio+necr+osisTranslated affixes: radio+nekr+osiOutput. Basque term: erradionekrosiIn order to identify the English medical suffixes and prefixes we have joined two lists: the "Medical Prefixes, Suffixes, and Combining Forms" from Stedman's Medical Dictionary  and the Zientzia eta Teknologiaren Hiztegi Entziklopedikoa (Dictionary of Science and Technology)  (o 0:+)]* SUFF] ;3 define IDEN2 [(? + 0:# +) [PREF 0:+]]* (? + 0:# +) SUFF ;4. regex IDEN1 .P. IDEN2 ;We had to adapt the criterion to choose among the possible identifications. In this case, whenever a term has non-identified parts, we add to the number of parts the number of characters in the non-identified part. Thus, we choose the term with less non-identified characters, but also with the more robust identification. For example, for the term "diverticulitis" four possible identifications are given :• diverticul#+itis: 10 + 2 = 12• divertic#+ul+itis: 8 + 3 = 11• di+verticul#+itis: 8 + 3 = 11• di+vertic#+ul+itis: 6 + 4 = 10In this case, even if the last option has more parts, it contains less non-identified characters and the addition of the two lengths results in the smallest number. Thus, it will be the one chosen.Listing 4 shows three of the rules defined for the transcription of the parts. Lines 2 and 3 describe the rule that converts "c" into "k" or "z" depending on the following character and line 4 corresponds to the transcription of "v" into "b". Lines from 5 to 10 show the rule about the palatalization of the sibilants "z", "s" and "x". In Basque, sibilants whenever are followed by a vowel and preceded by "n", "l", "r" or "m", are palatalized by adding a "t" before them.Listing 4 A few rules for the transcription1 ...2 define C c −> k | | [ noC ] [ a | o | u | noHC | #] , ,3           c −> z | | [ noC ] [ e | i | y ] ;4 define V v −> b ;5 define Vow [ a | e | i | o | u | y ] ;6 define Sib [ s | z | x ] ;7 define PAL n −> n t | | Sib Vow , ,8             l −> l t | | Sib Vow , ,9             r −> r t | | Sib Vow , ,10             m −> n t | | Sib Vow ;11 ...By means of these improvements, we are able to translate all the simple terms that contain just a suffix from the suffix lexicon. That is, we still keep the suffix compulsory as mentioned in the Baseline approach. We check whether the term contains any prefix from the translation pair list in order to identify the parts. After the identification, we translate the prefixes and the suffix from the translation pair list and the rest of the parts by means of transcription rules. We finally apply the morphotactic rules from the baseline system to join the translated or transliterated parts and thus create the equivalent Basque term.Example 4 shows step by step the work carried out. In the first step we take the input term "hypophosphatemia" and we split it into the possible affix combination (in this case "hypo+phos+phat#+emia" or "hypo+phos+phat#+em+ia"). In the second step, we get the Basque equivalences of the affixes ("hipo+fos+fat+emia" or "hipo+fos+fat+em+ia"). Finally, we apply the morphotactic rules to compose the well-formed Basque term (in both cases "hipofosfatemia" is generated).Example 4 Term translated by means of affix equivalences.Input term: hypophosphatemiaIdentified affixes: hypo+phos+phat+emia, hypo+phos+phat+em+iaTranslation of the affixes: hipo+fos+fat+emia, hipo+fos+fat+em+iaMorphotactics output term: hipofosfatemiaWith this improvement the recall of the system increases to 0.826. However, as it is often the case, the precision decreases to 0.813 as shown in the Results section. This loss in the precision led us to analyze the mistakes made by the system with several experts specialized in Basque terminology from the medical domain.Following the advice provided by the experts we restricted the criteria used to choose the terms to be eligible for translation. On the one hand, we reduced the lexicon of the suffixes, excluding the suffixes that are used in common words. That is, suffixes like "-tion" or "-able" have been excluded as they are not exclusive from the biomedical domain, and only suffixes closely related to this specialized terminology were used to conform the lexicon of suffixes. In addition, short prefixes with three characters or less were excluded from the lexicon of prefixes to eliminate prefixes that could be found within terms. For instance, the prefixes "an-" or "col-" were taken off.In the following enumeration we list the criteria to identify the components of a term. If we cannot separate the components with the first criterion the second one is tried. If it is not applicable, the last one is attempted.1 The whole term is identified by means of the extended lexicons (line 8 in Listing 5).2 The term has the suffix that appears in the reduced lexicon of suffixes (line 9 in Listing 5).3 The term has the suffix that appears in the extended lexicon of suffixes and contains at least one prefix from the reduced lexicon of prefixes (line 10 in Listing 5).Listing 5 Rules for the affix identification second approach1 ...2 read lexc prefixes Reduced.lex3 define PREFREDUCED4 define PREFRED PREFREDUCED.u ;5 read lexc suffixes Reduced.lex6 define SUFFREDUCED7 define SUFFRED SUFFREDUCED.u ;8 define IDEN1 [[[PREF 0:\%+] (o 0:+)]* SUFF] ;9 define IDEN2 [(? + 0:# +) [PREF 0:+ ]]* (+ 0:# +) SUFFRED ;10 define IDEN3 [(? + 0:# +) [PREFRED 0:+ ]] + (? + 0:\ # +) SUFF ;11 regex IDEN1 .P. IDEN2 .P. IDEN3 ;"haurtzaro" ("childhood") and "-tasun" in "gizontasun" ("manhood"). We are aware that the manual procedure may be prone to errors, however, we have reviewed the suffixes appearing in the general suffixes list, and so, the most common ones were excluded.The selection of the suffixes to be excluded has been made by consulting the suffixes in a general dictionary of English suffixes in the Wiktionary . We manuIn this process we had to make certain decisions as in the case of the suffix "-on". Even if its three senses are related to biology or chemistry, it is the ending of many general suffixes as "-tion" or "-isation", being "-tion" the most popular one. As those suffixes have been excluded from the lexicon, we decided to exclude the suffix "-on", as by means of including it we will be identifying the terms with the "-tion" suffix in most of the cases.The exclusion process led us to exclude 71 suffixes and 241 short prefixes, leaving a lexicon of 559 suffixes and 1,462 prefixes.As we will see in the Results section, the new approach did not improve the results. The precision obtained was 0.813 and the recall 0.747. That is, the precision did not improve, and there was a decrease in the recall.Clinical finding/disorder, Procedure and Body Structure hierarchies, as they are the most populated ones. Since the Clinical finding/disorder hierarchy is specially populated we split it according to its semantic tags: disorders and findings.As mentioned before, we divided SNOMED CT into hierarchies to simplify the translation process. We evaluated the quality of the translations, but of quantity. As we used manually generated and checked dictionaries written by lexicographers and domain experts, we assumed the quality of the Basque terms. In any case, Basque is a language in its standardization process and some orthographic rules have been changed, so, the orthographic correctness of the descriptions and its possible disambiguation will be manually checked in the future.We want to remark that Phase 1 could not be evaluated in terms of the Disorder sub-hierarchy we have 3,063 SNOMED CT concepts translated and 3,975 Basque terms for the same concepts.Table "drepanocito" and from the English term "drepanocyte". This equivalence will be counted in both English and Spanish columns, but once in the Total columns.If we consider the Total columns of the table (columns 6 and 7), we can observe that the totals do not match the sum of the previous columns. This is caused by the fact that the same equivalent term may be obtained from the English matching as well as from the Spanish matching, but it is counted only once. For example, the term "drepanozito" is obtained from the source term in Spanish Body Structure and Disorder hierarchies get the best results in terms of concepts translated , but it is remarkable the high amount of synonyms that Body Structure has  which can be put down to the very specialized dictionaries devoted to this hierarchies: the Glossary of Anatomy and the ICD-10.We can highlight the amount of synonyms obtained in this Phase: 1.86 for each concept. Disorder, Finding, Body Structure and Procedure hierarchies. The set of terms from each hierarchy is split into two: i) to define and develop the system and ii) to evaluate it.In this phase, results are given for the simple terms extracted from the The development and test sets comprise the simple terms that have been previously translated in the first phase of the algorithm. That is, we used the correct English-Basque pairs from the dictionaries as Gold Standard. This Gold Standard was manually created by setting a label to each term indicating whether or not the term should be translated by means of this system. That is, the system should not work with terms like "shock" or "dengue" that are not composed of medical roots.Disorder sub-hierarchy, 375 from Finding, 774 from Body Structure and 248 from Procedure. The remaining 3,114 terms from Disorder, 1,446 from Finding, 1,838 from Body Structure and 1,729 from Procedure were used for development.For the evaluation set we took 848 terms from the To measure the results of the experiment True Positives (TP), False Negatives (FN), False Positives (FP) and True Negatives (TN) are defined in the following way:• True Positives: The term should be translated, it is translated and the translation is correct. That is, at least one of the Basque terms generated matches at least one synonym from the Gold Standard.• False Negatives: The term should be translated and it is not translated.• False Positives: The term should not be translated and it is translated, or the term should be translated and the Basque term generated is not correct.• True Negatives: The term should not be translated and it is not translated.Table We must consider that our evaluation does not take into account whether the system overproduces wrong Basque terms if the correct one is also produced. In any case, the overproduction is properly controlled as mentioned in the Methods section, and in average 1.05 Basque equivalents are produced from an English term.Considering the results obtained in the Baseline approach, the changes made to the system in the first and in the second approaches show a huge improvement of the system. Even if we obtain a small decrease in the precision, the improvement in the recall is remarkable: changes from 0.343 in the baseline to 0.826 in the first approach and 0.747 in the second approach.Disorder hierarchy as it is the one with more simple terms composed of Latin and Greek roots and affixes. The bias to this sub-hierarchy is evident as the Disorder sub-hierarchy obtains the best results.We must highlight that we focused the development of the system on the We show the overall results of the translation algorithm in Table Clinical disorder/finding hierarchy and that the disorder semantic tag is the most benefited with 11,224 equivalences. In this case, the mapping does not offer synonyms, but obtains a single term from each mapping.The results labeled as "Phase 0 - ICD-10 mapping" in Table Translated shows the quantity of English terms for which a translation has been obtained. The second row labeled as Total reveals the total amount of English terms, and finally, the last row presents the percentage of the translated terms.Table Disorder and Procedure (85.51% and 87.84% respectively). It is remarkable that 12.94% of the two tokens terms from Body Structure have already been translated from the dictionaries.The mentioned Table In order to give a wider view of the process followed, Table Let us highlight the most promising results for each hierarchy:Disorder sub-hierarchy, we obtained the translation of 21.41% of the terms .• In the Procedure hierarchy the dictionaries are of hardly any use , it is a solid base to implement the following two phases in an incremental strategy.In this paper we presented some steps of an algorithm for the translation of the multilingual terminology content of SNOMED CT. We also described the good results obtained on the morphosemantics phase by means of an experiment, and how this phase and the dictionaries contribute on the translation of SNOMED CT by means of quantities.On the one hand, we take advantage of existing lexical resources, and on the other hand, we use transducers to generate Basque equivalents by means of domain-specific affixes and transcription rules. The implementation can be available on request contacting the authors. It will be publicly accessible once the implementation is concluded.Disorder sub-hierarchy and 87.84% in the Procedure hierarchy.Even if the specialized dictionaries provide Basque simple and complex terms, in this case the transducers are designed to translate simple terms. Thus, we got the translation of 85.51% of the simple terms in the Disorder sub-hierarchy is especially remarkable . The Disorder sub-hierarchy is the largest and here we obtained the equivalents in Basque of 5.21% of the source English terms.Even if in this paper we only show the results obtained in the most populated hierarchies, we applied the translation algorithm to the whole SNOMED CT terminology. The use of lexical resources is promising as seen in the Results section, and the contribution of the ICD-10 mapping in the linguistic correctness of the translation and the fidelity of the translated content are appropriate for this evaluation of the translation quality. In addition, we are working in a platform to help the specialists with the evaluation and correction. If the quality of the terminology generated reaches high and solid results, we will contact the SNOMED CT providers to offer them the result of our work, which at the moment is in the field of academic research.Nevertheless, as we said before, our aim is to check the quality of the Basque SNOMED CT version we are generating. For this evaluation (and correction) we count on the help of specialists of medical terminology such as doctors and terminologists. We consider the In regard to the evaluation of our systems, the first phase does not require a deep evaluation as it extracts English-Basque and Spanish-Basque pairs from dictionaries. In any case, a deeper evaluation of the approaches based on morphosemantics is presented. We implemented and evaluated three systems for the translation of simple terms using morphosemantic characteristics of the terms.In the future, we plan to implement the remainder of the algorithm in two ways: on the one hand, to generate the complex terms by means of syntax rules and on the other hand, to adapt the machine translation tool. The promising results obtained up to the present encouraged us to finish the semi-automatically generated version in Basque of SNOMED CT.SNOMED CT: Systematized Nomenclature of Medicine - Clinical Terms. HIT: Health Information Technology. EHR: Electronic Health Record. FSN: Fully Specified Name. PT: Preferred Term. ICD-10: International Statistical Classification of Diseases and Related Health in its 10th version. True Positive: TP. False Positive: FP. False Negative: FN. True Negative: TN. FST: Finite State Transducer.The authors declare that they have no competing interests.OPV performed the implementation of the algorithm. OPV and MO wrote, read and approved the final manuscript.


Family physicians (FPs) have a central role in the detection and management of child abuse. According to the literature, only 2–5 % of initial reports of child abuse come from the medical profession.The objective of this study was to assess levels of knowledge of risk factors for child abuse by Family Physicians (FPs) and the attention that the physicians pay to these risk factors. We conducted a mixed-method survey based on semi-structured interviews. 50 FPs practicing in the Somme County (northern France) were interviewed with closed and open questions. The FPs’ level of knowledge of risk factors for child abuse and obstacles in the detection of child abuse were assessed.The FPs’ level of knowledge of risk factors for child abuse was similar to that reported in the literature. However, FPs knew little about the significant role of prematurity. Likewise, the FP’s training did not seem to influence their knowledge of risk factors. Fear of an incorrect diagnosis was the main obstacle to reporting a suspected case. The FPs considered that they were often alone in dealing with a difficult situation and considered that the judicial system and the social services were not sufficiently active.Few FPs had actually received specific training in the detection and management of child abuse but many stated their need for this type of training. FPs encounter many obstacles in the detection of child abuse, which sometimes make the FP reluctant to report a suspected or potential case. Medical education need to be improved in this field.The online version of this article (doi:10.1186/s13104-015-1607-9) contains supplementary material, which is available to authorized users. The family physician (FP) has a key role in detecting and caring for abused children or those at risk of being abused. A suspected case of abuse is always difficult to deal with and some physicians will be unsure of how to act .France has well codified systems for dealing with suspected or potential child abuse . We used a hetero-administered questionnaire with open and Likert scale questions questions during interview  and perceived training needs. The interviews were conducted in French and were transcribed and analysed by native French speakers. This study was approved by the Committee of Primary Care of the university. FP were informed and all participants provided their informed consent.A descriptive analysis of these data was performed using SPSS software . Quantitative variables were expressed as the mean ± standard deviation and qualitative variables were expressed as the frequency and percentage.p < 0.05. A multivariate analysis could not be validly applied because of the small sample size.In a second step, a bivariate analysis of the data was performed by using the Chi squared test or the Fisher’s exact test. The threshold for statistical significance was set to ® for content analysis and then coded according to the session headings. After content analysis, the discussions were recoded according to the themes that had emerged. Lastly, the answers were grouped into categories, in order to summarize the opinions.In a third step, answers to open-ended questions were analyzed with a qualitative approach. Answers related to a common concept were then gathered together. Open responses were analyzed qualitatively, in order to identify the concepts developed. The transcripts were entered into TropesTo achieve the target of 50 physicians, we called 173 FPs so the response rate was 28.9 %. The median age was 52 and 38 of the FPs (76 %) were men. All FP are born and graduates in France. The FPs mainly practiced alone  in semirural areas . The others FPs practiced in rural areas  or urban areas .Ninety percent of the FPs considered that there are risk factors for child abuse, whereas 3 (6 %) considered that there are none at all. All the results are summarized in Table Some doctors talked about their desire for screening tools: “I will use it to simplify the screening, I like what we can quantify. A scale is reassuring official” or “Just to have this tool available is relevant. If we have the tool, we think more about screening, thus increasing our experience in this field and we are more vigilant”. Others are more reserved, “it’s not a scale that will tell me if a child is being abused.”Eighty-two percent of the FPs (n = 41) had already suspected a case of child abuse and had identified risk factors beforehand in more than half of these instances. Of these FPs, 31 (62 %) stated that their diagnosis had been strengthened by the presence of risk factors. In most cases, the child’s consultation had been followed by hospitalization. Ten of the FPs had filed an administrative report and 12 (25 %) had contacted the State Prosecutor. Some of the FPs preferred to ask the social services for advice, to discuss the case with a colleague or investigate matters further themselves.p = 0.7).In four cases, the report was not followed by legal proceedings. The child abuse was confirmed in 61 % of cases (n = 25); 64 % (n = 16) in the presence of risk factors and 50 % (n = 6) in the absence (Only nine FPs (18 %) had never encountered a case of suspected or potential child abuse. Fifty-six percent considered that the presence of risk factors would not strengthening their diagnosis. More than half declare to have no barriers in the support of a case of child abuse.The most frequently mentioned problem was the difficulty in establishing a diagnosis of child abuse Fig. . Almost The impact of a procedure for the child and his family are a hindrance, that reporting is done wrongly or rightly, “I may explode the family”; “I’m afraid of losing sight of the child”; “The risk is that the report due to bringing more harm to the child that if I did not report.”Many doctors criticize relations with social services, seeing them as being unresponsive, holding that the monitoring of the child they propose is not always consistent, “they show considerable inertia”, “workers social are useless," “social services? Either they panic for nothing, or they are missing out on real life situations".Most of the FPs  stated that they felt personally involved in caring for children at risk of child abuse. However, once child abuse had been identified, less than about ten of them refer the child and her family, even report.Many of the FPs  did not feel that they were sufficiently involved in the process by the other stakeholders in the field of child abuse . Some of the surveyed FPs  deplored the lack of information about the consequences of reporting suspected child abuse and sometimes went as far as criticizing the action of the social services .Some doctors emphasize their personal and professional conscience, “I will act so as not to be angry with me all my life if I close my eyes to a situation of child abuse.”Only 15 of the FPs (30 %) had received training on detecting and managing child abuse and over half of these had found it useful. Of those who had not received any training, 35 (78 %) wished to receive training in the future; the remainder considered that they did not need any additional training.The FPs stated that the training course should be compact, practice-based, FP-led and up-to-date (to reflect changes in the legislation) and should be delivered in a university-level institution. More than half of the FPs , suggested that a 24/7 medical support line would be useful.vs 33 %, p < 0.05).We did not observe significant differences between FPs having received specific training and those not having specific training in terms of knowledge of risk factors for child abuse. However, there was a statistically significant difference between trained and untrained FPs in terms of their level of knowledge of the reporting procedures (71 Forty-five of the 50 FPs (90 %) in our study considered that there are a number of risk factors for child abuse. The FPs were not greatly aware of the key role of prematurity and psychological and emotional factors; they considered that disadvantaged socioeconomic status was more important. It is probably more difficult, for the practitioners, to detect the child abuse in the favored environments (higher socioeconomic status), especially as they belong to them. The French Social Action Observatory has emphasized that psychological and emotional factors are more important that low socioeconomic status in the risk of child abuse . This waAccording to the literature, there are many risk factors for child abuse  , 7, 13.Even in clear cases of abuse, physicians fear that breaking up the family unit will have even more harmful consequences for the child. This aspect is also related to the widely reported feeling that judicial and social services are not sufficiently active or do not offer adequate solutions. , 13, 21 Training is one possible solution. However, although this is a legal obligation in France, few FPs stated that they had received specific training. An important aspect in line with the literature is the fact that most professionals did not attend training on the thematic of violence against children and adolescents. Other authors highlight the scarce knowledge about the issue as one of the main factors affecting the identification and reporting of maltreatment , 23. An There was a significant difference between FPs having received training and those who had not; the former were more likely to state that that did not understanding the reporting procedure. This may be because training increases the physician’s awareness of the complexity of the situation without helping him/her in practical terms.One can hypothesize that FPs do not have a particular focus child abuse during their medical training because they are rarely confronted with this problem in practice. Even though training on detecting and managing child abuse is a part of the French national curriculum for sixth-year medical students, it is not a greatly studied topic.Other tools mentioned by the FPs included a national hotline for physicians. A French national hotline for reports of suspected abuse (including reports by children themselves) already exists, and county child protection units often offer similar services? However, these hotlines are not specifically targeted at and staffed by physicians  .Recruitment bias was a potential limitation; since participation was voluntary, practitioners who were more interested in and comfortable with the subject were probably more like to agree to participate. A third potential source of bias related to the vocabulary used in the study; before starting the interview, we did not remind the FP of the main definitions in this field .Overall, our findings are in agreement with the literature data on risk factors for child abuse. Nevertheless, they did not know much about the predominant role of prematurity and psychological/emotional factors (as opposed to socioeconomic factors) in the genesis of child abuse. Insisting on this point in specific trainings for FPs might increase the detection of suspected child abuse. With regards to the current legal obligation, it would be advisable to extend this training to all FPs and to make it very practically focused and rich in case studies.In contrast to several larger studies performed outside France, our survey of the obstacles to reporting did not highlight a particular interest in this type of training , 20, 24.One of the major obstacles mentioned by the FPs in our study related to the impact of the report on the child and its family if child abuse was confirmed. We did not assess the FPs’ knowledge of the various types of support available to the child and its family following a report. It may be of value to provide FPs with more information about these measures and to show that the overall outcome of support is beneficial for the families  .Similarly, changing the FP’s view of the social and judicial services appears to be essential if practitioners are to improve their detection and management of suspected child abuse. A Canadian survey of pediatricians suggested informing them more precisely about the roles of the social services and their own difficulties when faced with an at-risk child . It may Along with a well-designed training program, the surveyed FPs suggested that a support hotline would be of great value. Working as part of a network with specialist hospital units may be a source of support for primary care physicians .There are many obstacles in FP’s to perform their role in protecting children from abuse. It is important to offer the FP support (in terms of the availability of training and multidisciplinary networks) so that the physician does not have to deal with these challenging situations alone.


Previous studies on sensorimotor adaptation revealed no awareness of the nature of the perturbation after adaptation to an abrupt 30° rotation of visual feedback or after adaptation to gradually introduced perturbations. Whether the degree of awareness depends on the magnitude of the perturbation, though, has as yet not been tested. Instead of using questionnaires, as was often done in previous work, the present study used a process dissociation procedure to measure awareness and unawareness. A naïve, implicit group and a group of subjects using explicit strategies adapted to 20°, 40° and 60° cursor rotations in different adaptation blocks that were each followed by determination of awareness and unawareness indices. The awareness index differed between groups and increased from 20° to 60° adaptation. In contrast, there was no group difference for the unawareness index, but it also depended on the size of the rotation. Early adaptation varied between groups and correlated with awareness: The more awareness a participant had developed the more the person adapted in the beginning of the adaptation block. In addition, there was a significant group difference for savings but it did not correlate with awareness. Our findings suggest that awareness depends on perturbation size and that aware and strategic processes are differentially involved during adaptation and savings. Moreover, the use of the process dissociation procedure opens the opportunity to determine awareness and unawareness indices in future sensorimotor adaptation research. The involvement of cognitive components such as explicit strategies and explicit knowledge, i.e. awareness, in motor learning has been intensively investigated since their manipulation is thought to lead to beneficial effects on various types of motor learning –3, and cIn the aforementioned studies, sensorimotor perturbations were induced suddenly leading to large movement errors at the beginning of adaptation. When perturbations are introduced gradually in a stepwise fashion, only small movement errors occur. Compared to sudden adaptation, performance in aftereffect tests was improved after gradual prism  and saccThus, there is a contradiction between studies showing enhanced explicit knowledge not effecting recalibration as shown in the first section and others claiming that unawareness, i.e. absent explicit knowledge, results in an increase of recalibration as shown in the second section. One explanation of this inconsistency could be an intermingling effect of explicit strategies, which might have been applied independently by some participants. Explanations of the nature of the perturbation or strategies like deliberate past pointing were shown to lead to a faster reduction of errors –23, 1, bTwo further drawbacks of previous research on awareness or explicit knowledge during motor adaptation can be identified. The first drawback is the irregular use of the term awareness. Some authors refer to awareness of a perturbation, i.e. the notion that something has changed , 21. OthThe domain of cognitive psychology has a strong tradition of analysing awareness and there is an enduring debate about the acquisition of knowledge and whether or not it is available to conscious access –38. QuesThe present project pursued the idea of incorporating the current best methodology for measuring awareness and unawareness into the study of sensorimotor adaptation. We decided to test whether the degree of awareness depends on the magnitude of the perturbation applied to the subjects´ movements and whether it can be manipulated by providing the participants with an explicit strategy before adaptation.Twenty-four right-handed subjects participated in the study in exchange for course credit and were randomly assigned to an implicit  or an explicit group . Participants’ ages ranged from 18 to 32 years, thus all reaching majority in the country of testing. The participants of the first group were told that there would be a perturbation, but remained uninformed about its nature. The participants of the latter group, however, received detailed explanations with the help of a clock face as in Benson et al. (2011). None of the subjects had any experience in visuomotor adaptation research or exhibited overt sensorimotor deficits besides corrected vision. The experimental protocol was pre-approved by the Erasmus MC Medical Ethical committee, was conducted according to the principles expressed in the Declaration of Helsinki and all subjects gave written informed consent.-3 degrees on each joint of the shoulder which translates into a resolution in Cartesian coordinates of less than 0.2 mm. The registered signal was used to display a green cursor (diameter 6 mm) representing the handle position onto the screen with the help of a projector. Furthermore, a black origin and one of three possible red targets were alternately projected. The origin was positioned approximately 45 cm away from the eyes of the participant and the targets were positioned 10 cm away from the origin, either straight ahead or 45° to the left or the right. The origin as well as the targets had a diameter of 14 mm and the cursor one of 6 mm. The subjects were instructed to move the cursor accurately and quickly from the origin to the target and back. To control for the speed of the movements target color changed to green for actual trail times of 850ms ± 100ms and turned to blue or yellow when movements were too slow (>950ms) or too fast (>750ms), respectively. Intertrial intervals lasted for 1500ms.Participants watched a horizontal screen and held the handle of a robot that was placed underneath the screen, while a cloth prevented the sight of their arm . The posfamiliarisation with veridical and baseline without visual feedback, i.e. no cursor visible, all participants conducted six sets, each containing a baseline/washout block with veridical visual feedback, an adaptation block with rotated visual feedback  and an inclusion and exclusion block without feedback. During each adaptation block, six clamp trials were inserted to test for the progression of recalibration . In those trials a perfect movement of the cursor from the starting to the target dot was displayed independent of the subjects´ movement. Each participant performed two consecutive sets for each rotation size with alternating order of inclusion and exclusion blocks. Before inclusion subjects were instructed to ‘use what was learned during adaptation’ and before exclusion subjects were asked to ‘refrain from using what was learned, perform movements as during baseline’. This order as well as rotation size order was randomised between participants. Between the third and fourth set there was a rest break of 5 min. After After completion of the experiment all participants filled out a questionnaire as in Benson et al. (2011). Those participants who characterized the perturbation as a rotation or reported the use of a rotational strategy were considered to be explicitly aware of the distortion.After the conclusion of the experiment, movement direction (MD) was determined as the angle between a line connecting starting and target dot and a line between movement onset and movement position at 150 ms after movement onset. Movement onset was defined as the movement position at which velocity exceeded 0.03 mm/ms for the first time. The trial was omitted if the distance between movement onset and movement position at 150 ms after movement onset was smaller than 10 mm; 4.59% of trials were thus excluded.MDclamp trials and MDadaption trials were calculated as the mean of the MD for the trials in a specific bin of trials. We used bins of 9 trials for adaptation trials and bins of 3 trials for clamp trials. We calculated MDbaseline trials as the mean MD of all baseline trails. Both indices range from -1 to 1 with 1 indicating full adaptation and 0 (or a negative number) indicating no adaptation. If a subject produced an AI of ≤ 0.2 during the last two bins of an adaptation block, data for that set was dropped from further analysis. Thus, for each rotation size the data of three participants was excluded . This resulted in a total amount of 12 implicit and 7 explicit subjects.From the movement directions of each subject and in order to compare the three rotation sizes, we calculated normalized indices for the different parameters. Adaptation index (AI) and the clamp trial index (CI) were determined asDuring the inclusion condition awareness and unawareness both contribute to performance. In the exclusion condition, however, aware and unaware learning are set in opposition. If all knowledge acquired through adaptation is conscious, i.e. a person is fully aware, performance during the exclusion task (E) should not be different from performance during baseline (B). Or, inversely, E > B can be seen as evidence for unaware knowledge. If, in addition, performance during the inclusion task equals that during exclusion, the person is fully unaware . Within of words . Thus, atatistica 7.1.For statistical analysis we submitted the different indices to several analyses of variance (ANOVAs) with the between-factor Group  and the within-factors Rotation Size , Block Order of inclusion and exclusion  and Bin. Type III sums of squares were used in all analyses unless stated otherwise. Normality within each Bin, Rotation Size and Block Order in each group separately was explored by Shapiro-Wilk test and variance stability of the pairs of levels across the factor Group was explored by Levene´s test. In case of violation, a Kruskal-Wallis-Test with the factor Group  was performed with the respective data point. Greenhouse-Geisser-adjustments were applied when necessary to compensate for heterogeneity of variances and significant effects were further explored with Turkeys HSD post-hoc tests for unequal sample sizes. Furthermore, Pearson product-moment correlation coefficients (PCC) between awareness and adaptation indices were calculated in case of normality and variance stability of the respective data. Otherwise Spearman's rank correlation coefficients (SCC) were used. All analyses were done with Scorrected = 32.52; p<0.001)). We further found effects of Block Order  = 4.73; p<0.05), Bin × Group  = 12.81; p<0.001) and Bin × Block Order  = 3.80; p<0.01). Post-hoc decomposition of Bin × Group showed no significant difference of AI between both groups for each respective bin. However, AI of the first bin of the implicit group is different from all following bins of both groups and the second bin is different from the last three bins, whereas in the explicit group the first bin is only different from the second and third bin of this group. Hence, there was a larger AI during the beginning of adaptation in the explicit group  = 6.20; p<0.05) with a difference of awareness of adaptation to 20° and 60°. The mean awareness index after 20° and 60° adaptation increased from 0.02 to 0.13 in the implicit and from 0.23 to 0.56 in the explicit group. Even though this increase was larger in the explicit group, we found no significant interaction of Group × Rotation Size. The unawareness index did not differ between both groups, but also did depend on the size of the rotation  = 19.30; p<0.001) with post-hoc tests revealing a significant difference between 20° and both 40° and 60° but not between 40° and 60°.The main results of the present study are shown in Effective Hypothesis sums of squares were used in this ANOVA since not all individual groups were included due to missing data. We found no significant effects either of Rotation Size Order or of any interaction including this factor . However, groups were not all normally distributed and group sizes were very small. To increase group sizes, we, thus, omitted the factor Group and calculated another analysis using only the factors Rotation Size and Rotation Size Order. This analysis also did not reveal a significant effect of Rotation Size Order or its interaction with Rotation Size (both p>0.05). Since two data points out of 18 did not show a normal distribution we calculated a Kruskal-Wallis-Test for each rotation size using the factor Rotation Size Order. None of them revealed a significant effect .It is possible that awareness could benefit from previous training with another rotation. Therefore, the analysis of the awareness index was repeated with the additional factor Rotation Size Order . Type VI or To compare the extent of awareness to the amount of adaptation for the different rotation sizes, we first calculated correlations between the awareness index and the mean adaptation and clamp trial index of the first bin of both blocks, respectively . Larger Measuring savings, i.e. faster relearning during a second exposure to the same perturbation, is a tool for determining whether a long-term memory of the adaptation has been established. We calculated savings as the initial learning difference score that is the difference of the adaptation index of the first bin of the first and the second block of adaptation to the same rotation size . For botWe were further interested whether savings also transferred across rotation sizes. Hence, naïve savings was determined using only the first rotation size of the experimental protocol and experienced savings was additionally calculated using the second and third rotation sizes. Note that this differed between participants; the first rotation size was 20°, 40° or 60° for eight participants each. While naïve savings was larger in the explicit than in the implicit group the reverse holds for experienced savings as can be observed in Finally, we compared the present measurement of awareness by the PDP to that of a questionnaire. Therefore, the results of the verbal assessment were used to classify all subjects into aware or unaware according to the approach used by Benson et al. (2011). Within this procedure explicit awareness was attributed to those participants who described the feedback or disturbance as rotated or claimed the application of a rotational strategy. Nine out of 16 subjects in the implicit group were considered not to have awareness, and, interestingly, two out of eight explicitly instructed subjects were also classified as unaware. For the statistical analyses we used the same data as for the correlations, i.e. the first bin of the mean adaptation and clamp trail indices of both blocks and entered them into two ANOVAS with the factors Group  and Rotation Size . Neither the analysis of adaptation index (effect of Group: p = 0.32) nor that of clamp trial index (effect of Group: p = 0.59) yielded any significant effects, showing that awareness measured by means of a questionnaire, in contrast to that measured by PDP, was not related to adaptation.The aim of the present study was to find out whether the degree of awareness of the nature of the perturbation depends on its magnitude. An implicit group and a group of subjects using explicit strategies adapted to 20°, 40° and 60° cursor rotations, and we measured awareness and unawareness indices after each adaptation block with a process dissociation procedure. The analyses revealed a larger awareness index in the explicit than in the implicit group and a larger awareness index after adaptation to 60° than to 20° rotation for both groups. This did not depend on the order in which rotation sizes were presented to the subjects. Adaptation and clamp trial indices were also larger in the explicit than in the implicit group. Furthermore, initial adaptation measures—adaptation and clamp trial indices of the first bin—correlated to the size of awareness indices. Savings did not differ between groups and only showed a trend of being larger for larger rotation sizes. The explicit but not the implicit participants transferred savings from the first to the following rotation sizes. Finally, the analyses revealed that awareness measured by means of a questionnaire, in contrast to that measured by PDP, was not related to adaptation.The degree of awareness of the nature of the perturbation did clearly depend on the perturbations´ magnitude in both groups. Naïve participants developed a negligible awareness index of 0.02 after adaptation to 20° and 40° and an awareness index of 0.13 after 60° rotation of visual feedback. This result is consistent with previous work showing awareness only in three out of 27 participants when a 30° rotation was introduced , 20, 18.Moreover, the outcome of the present study can help explaining the actual disagreement on whether the gradual adaptation paradigm can improve the amount of recalibration  as shownIt can be argued, that the group difference in awareness is due to the group difference of the inclusion index, that is the lack of the implicit group of reproducing what was learned compared to the explicit group. However, underestimation of awareness in the implicit group is unlikely, because those factors that might have contributed to the increased loss between the end of adaptation and inclusion are rather implicit or unaware: the passage of time, reaching without visual feedback or the observed decrease of errors during ongoing reaching during no feedback trials –68.We found no effect of the order of rotation sizes on the amount of awareness. However, we cannot rule out that a possible beneficial effect of previous adaptation to different rotation sizes was cancelled out by a detrimental effect due to fatigue or to forgetting the instructions in the explicit group. Future studies should be conducted with a between-subject design in which each group gets exposed to a single rotation size only.As expected the unawareness index was smaller in the explicit compared to the implicit group but with mean indices of approx. 0.55, 0.4 and 0.3 after adaptation to 20°, 40° and 60°, respectively, unawareness was still surprisingly large in explicitly instructed participants. On the one hand, this large proportion of unawareness might be consistent with the results of a study by Mazzoni and Krakauer (2006) in which participants used an explicit strategy to quickly reduce errors during adaptation to a visual rotation. Later on during learning, reaching errors increased again, representing a simultaneous implicit adaptation process driven by sensory prediction errors. Our unawareness index could reflect this implicit process. On the other hand, we could also be seeing a modulation of strategies over the time course of adaptation with different strategies being differently accessible to consciousness as has been suggested earlier .Comparison of adaptation of both groups revealed a larger initial adaptation index in the explicitly instructed group. The magnitude of early adaptation clearly correlated to awareness across groups and for all rotation sizes, whereas we found no correlation between late adaptation and awareness for 20° and 60° rotations. This pattern of findings is in line with the results of a previous study showing explicit instructions leading to increased early but not late adaptation . Since tEven though we found no significant effects of savings, there was a marked increase from almost no savings in the 20° adaptation to savings in 40° and 60° adaptation. This is in line with previous work showing savings after 45° but not after 30° rotation of visual feedback . In the Multiple learning processes have been suggested to facilitate motor behaviour during adaptation. A distinction has been drawn between slow and fast adaptation , error-bThe possibility to measure awareness as well as unawareness as an index is an evident advantage of using PDP over the use of a questionnaire that only allows the classification of aware or unaware. Moreover, questionnaires may underestimate awareness due to the difference of retrieval contexts or because knowledge is held with low confidence , 37, 39.Heuer and Hegele measured explicit knowledge by providing the participants with a line which they moved through verbally instructing the experimenter until they found it to match the direction of a successful hand movement , 11, 45.In conclusion, the results of this study suggest that the development of awareness of the nature of the perturbation depends on its size and confirm the idea that participants adapting to gradually introduced perturbations are usually not aware. Moreover, our findings can help explain the disagreement regarding the effects of the gradual adaptation paradigm by proposing that some studies chose perturbation sizes which left participants adapting to the suddenly introduced distortion just as unaware as those in the gradual group. Furthermore, the present results emphasize the importance of controlling or monitoring awareness in future studies comparing gradual and sudden adaptation. The awareness index of the current study measured by PDP correlated to the size of early adaptation, whereas the results of a questionnaire were not related to adaptation. To sum up, our results can thus explain the contradiction of previous studies analysing the effect of cognitive components such as explicit strategies and explicit knowledge, i.e. awareness, on sensorimotor adaptation.