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This paper is a contribution to the EUMETNET AutoPollen Programme, which is developing a prototype automatic pollen monitoring network in Europe covering all aspects of the information chain from measurements through to communicating information to the public., Background: Information about airborne pollen concentrations is required by a range of end users, particularly from the health sector who use both observations and forecasts to diagnose and treat allergic patients. Manual methods are the standard for such measurements but, despite the range of pollen taxa that can be identified, these techniques suffer from a range of drawbacks. This includes being available at low temporal resolution (usually daily averages) and with a delay (usually 3–9 days from the measurement). Recent technological developments have made possible automatic pollen measurements, which are available at high temporal resolution and in real time, although currently only scattered in a few locations across Europe. Materials & Methods: To promote the development of an extensive network across Europe and to ensure that this network will respond to end user needs, a stakeholder workshop was organised under the auspices of the EUMETNET AutoPollen Programme. Participants discussed requirements for the groups they represented, ranging from the need for information at various spatial scales, at high temporal resolution, and for targeted services to be developed. Results: The provision of real-time information is likely to lead to a notable decrease in the direct and indirect health costs associated with allergy in Europe, currently estimated between €50–150 billion/year.. Discussion & Conclusion: A European measurement network to meet end user requirements would thus more than pay for itself in terms of potential annual savings and provide significant impetus to research across a range of disciplines from climate science and public health to agriculture and environmental management.

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Purpose:To evaluate the effect of a mobile digital intervention on voiding patterns, we performed 24-h voided volume monitoring in individuals with metabolic disorders.\nMethods:Participants with metabolic disorders were grouped into either the intervention group (n = 17), who had access to a smartphone app (CARADA), or the non-intervention group (n = 11), who did not. Urine monitoring was conducted for 24 h using a novel digital self-health monitoring system for urine excretion (s-HMSU). Body weight, abdominal circumference, blood pressure, and biomarkers were measured.\nResults:Physical findings and blood test results at baseline and 6 months indicated no significant between-group differences. Night-time frequency did not change between baseline and 6 months in the intervention group but significantly worsened at 6 months in the non-intervention group, as compared to baseline (1.0 ± 0.7 vs. 1.5 ± 0.5, p, 論文

This study aimed to characterize the clinical profile of patients with brief psychotic disorders (BPD) triggered by the psychosocial distress derived from the COVID-19 crisis. A multicenter study was conducted from March 14 to May 14, 2020 (the peak weeks of the pandemic in Europe). All consecutive patients presenting non-affective psychotic episodes with a duration of untreated psychosis of less than 1 month and whose onset was related to the COVID-19 crisis were recruited, but only those patients meeting Diagnostic Statistical Manual 5th edition (DSM-5) criteria for "BPD with marked stressors" (DSM-5 code: 298.8) during follow-up were finally included. Patients' sociodemographic and clinical characteristics were collected at baseline and summarized with descriptive statistics. During the study period, 57 individuals with short-lived psychotic episodes related to the emotional stress of the COVID-19 pandemic were identified, of whom 33 met DSM-5 criteria for "BPD with marked stressors". The mean age was 42.33 ± 14.04 years, the gender distribution was almost the same, and the majority were rated as having good premorbid adjustment. About a quarter of the patients exhibited suicidal symptoms and almost half presented first-rank schizophrenia symptoms. None of them were COVID-19 positive, but in more than half of the cases, the topic of their psychotic features was COVID-19-related. The coronavirus pandemic is triggering a significant number of BPD cases. Their risk of suicidal behavior, their high relapse rate, and their low temporal stability make it necessary to closely monitor these patients over time.

Purpose Knife carrying has caused considerable public concern in the UK. But little is known of the epidemiology and characteristics of men who carry knives. We investigated associations with socioeconomic deprivation, area-level factors, and psychiatric morbidity. Methods Cross-sectional surveys of 5005 British men, 18–34 years, oversampling Black and Minority Ethnic (BME) men, lower social grades, and in London Borough of Hackney and Glasgow East. Participants completed questionnaires covering violent behaviour and psychiatric morbidity using standardised self-report instruments. Socioeconomic deprivation measured at small area level. Results Prevalence of knife carrying was 5.5% (4.8–6.9) and similar among white and BME subgroups. However, prevalence was twice the national rate in Glasgow East, and four times higher among Black men in Hackney, both areas with high levels of background violence and gang activity. Knife carrying was associated with multiple social problems, attitudes encouraging violence, and psychiatric morbidity, including antisocial personality disorder (AOR 9.94 95% CI 7.28–13.56), drug dependence (AOR 2.96 95% CI 1.90–4.66), and paranoid ideation (AOR 6.05 95% CI 4.47–8.19). There was no evidence of a linear relationship with socioeconomic deprivation. Conclusion Men who carry knives represent an important public health problem with high levels of health service use. It is not solely a criminal justice issue. Rates are increased in areas where street gangs are active. Contact with the criminal justice system provides opportunity for targeted violence prevention interventions involving engagement with integrated psychiatric, substance misuse, and criminal justice agencies.

Background Very little is known about self-harm in children. We describe the characteristics and outcomes of children under 13 years who presented following self-harm to five hospitals in England. Methods We included children under 13 years who presented after self-harm to hospitals in the Multicentre Study of Self-harm in England. Information on patients’ characteristics and method of self-harm was available through monitoring of self-harm in the hospitals. Area level of socioeconomic deprivation was based on the English Index of Multiple Deprivation (IMD). Results 387 children aged 5–12 years presented to the study hospitals in 2000–2016, 39% of whom were 5–11 years. Boys outnumbered girls 2:1 at 5–10 years. The numbers of boys and girls were similar at age 11, while at 12 years there were 3.8 girls to every boy. The proportion of study children living in neighbourhoods ranked most deprived (43.4%) was twice the national average. 61.5% of children self-poisoned, 50.6% of them by ingesting analgesics. Of children who self-injured, 45.0% self-cut/stabbed, while 28.9% used hanging/asphyxiation. 32% of the children had a repeat hospital presentation for self-harm, 13.5% re-presented within a year. Conclusions Gender patterns of self-harm until age 11 years are different to those of adolescents, with a male preponderance, especially in 5–10 years, and hanging/suffocation being more common. The frequent use of self-poisoning in this age group highlights the need for public health messages to encourage safer household storage of medicines. Self-harm in children is strongly associated with socioeconomic deprivation; understanding the mechanisms involved could be important in effective prevention.

European archives of psychiatry and clinical neuroscience 271(1), 61-67 (2021). doi:10.1007/s00406-020-01160-9, Published by Steinkopff, Darmstadt

Purpose This study investigates the effects of the all-inside repair of posterosuperior popliteomeniscal fascicle (PMF) on lateral meniscus stabilization using a posterior arthroscopic approach. Methods Between 2015 and 2018, 17 patients with hypermobile lateral meniscus (HLM) underwent posterior knee arthroscopy for PMF repair. The all-inside repair was performed through posteromedial transseptal and posterolateral portals using a suture hook technique. Patients were clinically assessed based on IKDC and Lysholm scores. Results Both IKDC and Lysholm scores improved significantly after an average follow-up of 3.5 years (P Conclusion The all-inside suture hook technique using posterolateral and posteromedial transseptal portals fixes HLM with excellent IKDC and Lysholm scores. Level of evidence Level IV.

Objectives To compare the outcomes after surgical (SAVR) and transcatheter aortic valve replacement (TAVR) for severe stenosis of bicuspid aortic valve (BAV). Methods We evaluated the early and mid-term outcome of patients with stenotic BAV who underwent SAVR or TAVR for aortic stenosis from the nationwide FinnValve registry. Results The FinnValve registry included 6463 AS patients and 1023 (15.8%) of them had BAV. SAVR was performed in 920 patients and TAVR in 103 patients with BAV. In the overall series, device success after TAVR was comparable to SAVR (94.2% vs. 97.1%, p = 0.115). TAVR was associated with increased rate of mild-to-severe paravalvular regurgitation (PVR) (19.4% vs. 7.9%, p p = 0.053). When newer-generation TAVR devices were evaluated, mild-to-severe PVR (11.9% vs. 7.9%, p = 0.223) and moderate-to-severe PVR (0% vs. 0.7%, p = 1.000) were comparable to SAVR. Type 1 N-L and type 2 L-R/R-N were the BAV morphologies with higher incidence of mild-to-severe PVR (37.5% and 100%, adjusted for new-generation prostheses p = 0.025) compared to other types of BAVs. Among 75 propensity score-matched cohorts, 30-day mortality was 1.3% after TAVR and 5.3% after SAVR (p = 0.375), and 2-year mortality was 9.7% after TAVR and 18.7% after SAVR (p = 0.268) Conclusions In patients with stenotic BAV, TAVR seems to achieve early and mid-term results comparable to SAVR. Type 1 N-L and type 2 L-R/R-N BAV morphologies had higher incidence of PVR. Larger studies evaluating different phenotypes of BAV are needed to confirm these findings. Clinical trial registration ClinicalTrials.gov Identifier: NCT03385915. Graphic abstract

PurposeCurrent RCT and meta-analyses have not found any effect of community treatment orders (CTOs) on hospital or social outcomes. Assumed positive impacts of CTOs on quality-of-life outcomes and reduced hospital costs are potentially in conflict with patient autonomy. Therefore, an analysis of the cost and quality-of-life consequences of CTOs was conducted within the OCTET trial.MethodsThe economic evaluation was carried out comparing patients (n = 328) with psychosis discharged from involuntary hospitalisation either to treatment under a CTO (CTO group) or voluntary status via Section 17 leave (non-CTO group) from the health and social care and broader societal perspectives (including cost implication of informal family care and legal procedures). Differences in costs and outcomes defined as quality-adjusted life years (QALYs) based on the EQ-5D-3L or capability-weighted life years (CWLYs) based on the OxCAP-MH were assessed over 12 months (£, 2012/13 tariffs).ResultsMean total costs from the health and social care perspective [CTO: £35,595 (SD: £44,886); non-CTO: £36,003 (SD: £41,406)] were not statistically significantly different in any of the analyses or cost categories. Mental health hospitalisation costs contributed to more than 85% of annual health and social care costs. Informal care costs were significantly higher in the CTO group, in which there were also significantly more manager hearings and tribunals. No difference in health-related quality of life or capability wellbeing was found between the groups.ConclusionCTOs are unlikely to be cost-effective. No evidence supports the hypothesis that CTOs decrease hospitalisation costs or improve quality of life. Future decisions should consider impacts outside the healthcare sector such as higher informal care costs and legal procedure burden of CTOs.

Background and purpose In the group of severe mental disorders, psychotic depression (PD) is essentially under-researched. Knowledge about the risk factors is scarce and this applies especially to early risk factors. Our aim was to study early childhood and adolescent risk factors of PD in a representative birth cohort sample with a follow-up of up to 50 years. Methods The study was carried out using the Northern Finland Birth Cohort 1966 (NFBC 1966). We used non-psychotic depression (NPD) (n = 746), schizophrenia (SZ) (n = 195), psychotic bipolar disorder (PBD) (n = 27), other psychoses (PNOS) (n = 136) and healthy controls (HC) (n = 8200) as comparison groups for PD (n = 58). We analysed several potential early risk factors from time of birth until the age of 16 years. Results The main finding was that parents’ psychiatric illness [HR 3.59 (1.84–7.04)] was a risk factor and a high sports grade in school was a protective factor [HR 0.29 (0.11–0.73)] for PD also after adjusting for covariates in the multivariate Cox regression model. Parental psychotic illness was an especially strong risk factor for PD. The PD subjects had a parent with psychiatric illness significantly more often (p Conclusions A low sports grade in school may be a risk factor for PD. Psychiatric illnesses, especially psychoses, are common in the parents of PD subjects. A surprisingly low number of statistically significant risk factors may have resulted from the size of the PD sample and the underlying heterogeneity of the etiology of PD.

The wrist is the most frequently injured body region among snowboarders. Studies have shown that the risk of sustaining a wrist injury can be reduced by wearing wrist protection. Currently, there are a wide variety of wrist protection products for snowboarding on the market that offer a range of protective features. However, there are no minimum performance standards for snowboarding wrist protectors worldwide. The International Society for Skiing Safety convened a task force to develop a White Paper to evaluate the importance and necessity of a minimum performance for all wrist protectors used in snowboarding. The White Paper outlines the need for a general framework for a harmonized international standard and reviews the existing evidence. Therefore, this White Paper may serve as a common base for future discussions. The broader goal of developing and implementing such a standard is to reduce the incidence and the severity of wrist injuries in snowboarding without increasing the risk of adverse events, such as upper arm or shoulder injury. The European standard for inline skating wrist protectors (EN 14120) can serve as a starting point for efforts related to a standard for snowboard wrist protectors, but certain modifications to the standard would be required. It is hypothesized that implementation of a snowboarding wrist protector standard would result in fewer and less severe wrist injuries in the sport and could translate into more riding days for healthy snowboarders and significant health-care costs savings., Sports Engineering, 16 (4), ISSN:1369-7072, ISSN:1460-2687

For a hardcopy of this article, printed in the Netherlands, an estimated 100 l of water have been used. Most of the water is required in the forestry stage, due to evapotranspiration (green and blue water). In addition, the water footprint during the industrial stage, as accounted for in this study, consists of evaporation from water obtained from ground water and surface water (blue water). In this study estimates are made of water requirements for producing paper using different types of wood and in different parts of the world. The water footprint of printing and writing paper is estimated to be between 300 and 2600 m3/t (~2-13 l for an A4 sheet). These estimates account for paper recovery rates in different countries. This study indicates that by using recovered paper for the production of paper the global average water footprint of paper is only 60% of what it would be if no recovered paper would be used at all. Further savings may be achieved by increasing the recovery percentages worldwide. In addition, the global water footprint of paper can be reduced by choosing production sites and wood types that are more water-efficient. The results of this study suggest that the use of recovered paper may be particularly effective in reducing water footprints. This study is a first step towards a better understanding of the significance of the water footprint of paper and the effect of using recovered paper.

In this paper two procedures are developed for the identification of the parameters contained in an orthotropic elastic-plastic-hardening model for free standing foils, particularly of paper and paperboard. The experimental data considered are provided by cruciform tests and digital image correlation. A simplified version of the constitutive model proposed by Xia et al. (Int J Solids Struct 39:4053---4071, 2002) is adopted. The inverse analysis is comparatively performed by the following alternative computational methodologies: (a) mathematical programming by a trust-region algorithm; (b) proper orthogonal decomposition and artificial neural network. The second procedure rests on preparatory once-for-all computations and turns out to be applicable economically and routinely in industrial environments.

There are large differences between paper mills in, e.g. feedstock use and grades produced, but typical processes are similar in all mills. The aim of this study is to benchmark the specific energy consumption (SEC) of similar processes within different paper mills in order to identify energy improvement potentials at process level. We have defined improvement potentials as measures that can be taken at mill/ process level under assumed fixed inputs and outputs. We were able to use industrial data on detailed process level, and we conducted energy benchmarking comparisons in 23 Dutch paper mills. We calculated average SECs per process step for different paper grades, and we were able to identify ranges in SECs between mills producing the same grade. We found significant opportunities for energy efficiency improvement in the wire and press section as well as in the drying section. The total energy improvement potential based on identified best practices in these sections was estimated at 5.4 PJ (or 15 % of the total primary energy use in the selected mills). Energy use in the other processes was found to be too dependent on quality and product specifications to be able to quantify improvement potentials. Our results emphasise that even a benchmark on detailed process level does not lead to clear estimations of energy improvement potentials without accounting for structural effects and without having a decent understanding of the process.

Objectives: Previous attempts at meta-analysis and systematic review have not provided clear recommendations for the clinical application of thermal ablation in metastatic colorectal cancer. Many authors believe that the probability of gathering randomised controlled trial (RCT) data is low. Our aim is to provide a consensus document making recommendations on the appropriate application of thermal ablation in patients with colorectal liver metastases. Methods: This consensus paper was discussed by an expert panel at The Interventional Oncology Sans Frontières 2013. A literature review was presented. Tumour characteristics, ablation technique and different clinical applications were considered and the level of consensus was documented. Results: Specific recommendations are made with regard to metastasis size, number, and location and ablation technique. Mean 31 % 5-year survival post-ablation in selected patients has resulted in acceptance of this therapy for those with technically inoperable but limited liver disease and those with limited liver reserve or co-morbidities that render them inoperable. Conclusions: In the absence of RCT data, it is our aim that this consensus document will facilitate judicious selection of the patients most likely to benefit from thermal ablation and provide a unified interventional oncological perspective for the use of this technology. Key Points: • Best results require due consideration of tumour size, number, volume and location. • Ablation technology, imaging guidance and intra-procedural imaging assessment must be optimised. • Accepted applications include inoperable disease due to tumour distribution or inadequate liver reserve. • Other current indications include concurrent co-morbidity, patient choice and the test-of-time approach. • Future applications may include resectable disease, e.g. for small solitary tumours.

In the last few years, a lot of publications suggested that disabling cerebellar ataxias may develop through immune-mediated mechanisms. In this consensus paper, we discuss the clinical features of the main described immune-mediated cerebellar ataxias and address their presumed pathogenesis. Immune-mediated cerebellar ataxias include cerebellar ataxia associated with anti-GAD antibodies, the cerebellar type of Hashimoto's encephalopathy, primary autoimmune cerebellar ataxia, gluten ataxia, Miller Fisher syndrome, ataxia associated with systemic lupus erythematosus, and paraneoplastic cerebellar degeneration. Humoral mechanisms, cell-mediated immunity, inflammation, and vascular injuries contribute to the cerebellar deficits in immune-mediated cerebellar ataxias., SCOPUS: re.j, info:eu-repo/semantics/published

No abstract available.

A fundamental question about the complexity of corvid social cognition is whether behaviours exhibited when caching in front of potential pilferers represent specific attempts to prevent cache loss (cache protection hypothesis) or whether they are by-products of other behaviours (by-product hypothesis). Here, we demonstrate that Eurasian jays preferentially cache at a distance when observed by conspecifics. This preference for a ‘far’ location could be either a by-product of a general preference for caching at that specific location regardless of the risk of cache loss or a by-product of a general preference to be far away from conspecifics due to low intra-species tolerance. Critically, we found that neither by-product account explains the jays’ behaviour: the preference for the ‘far’ location was not shown when caching in private or when eating in front of a conspecific. In line with the cache protection hypothesis we found that jays preferred the distant location only when caching in front of a conspecific. Thus, it seems likely that for Eurasian jays, caching at a distance from an observer is a specific cache protection strategy. Electronic supplementary material The online version of this article (doi:10.1007/s10071-016-0972-7) contains supplementary material, which is available to authorized users.

Tradition has it that first anniversaries are celebrated with gifts of paper. Thus, it is fitting that on this first anniversary of our start as co-Editors in Chief of the Journal of General Internal Medicine, we should look back on the 12 paper issues we’ve published in 2010. The paper journal is sent to every member of the Society of General Internal Medicine and to a diminishing number of libraries who still choose to display the bound journal instead of relying solely on electronic access. As editors, we take the print journal seriously, striving to craft each issue to be a self-contained and coherent whole. This year has seen the addition of several new features that we hope add value to each issue. From the Editor's Desk directs readers’ attention to articles and themes of special interest. Exercises in Clinical Reasoning examines the diagnostic process as highly skilled clinicians work through a tough clinical case. Innovations and Improvement explores the process of quality improvement and enlivens the journal through interviews and first person narratives, and Healing Arts sounds the lived experience of general internal medicine in essays, poems, and criticism. Although we choose the articles appearing in each issue of the print journal with care, most consumers of medical journals never touch the paper of each monthly issue and instead prefer to access JGIM and other journal content as if it were on iTunes, searching through titles and abstracts and downloading individual articles. They find JGIM content through on-line sources such as Google Scholar, PubMed Central, and others. In fact, over the past year, while Springer, our publisher, mailed just over 2,000 copies of the paper journal to subscribers or members each month, there have been more than 1 million JGIM articles downloaded by readers since the publication of our inaugural issue last January. This, of course, is the present and future of medical journals; the increasing ‘webification’ of journal content and the growing irrelevance of the print journal. We are well aware of these trends and will work over the remaining 4 years of our editorship to prepare JGIM for the inevitable demise of the print journal and the predominance of the web-based journal. With the help of Associate Editor Malathi Srinivasan and others, work on eJGIM has already begun. In addition, the next 12 months will see the reinvigoration of Innovations in Medical Education, a stunning series of articles on Health Policy, and new collaborations with AHRQ, the VA, and the Annals of Internal Medicine. JGIM depends on the generosity of a committed and outstanding group of reviewers. In 2009–2010, JGIM reviewers volunteered their time and expertise to review about half of the more than 1,000 manuscripts that JGIM receives each year. During this period, 986 reviewers provided a total of 1,294 reviews with a mean quality score of 2.98 on a scale of 1–6 (as judged by JGIM Deputy Editors). Of these, 276 provided at least two reviews, and 29 provided three or more. We are indebted to them for their service. Among this group of dedicated peer reviewers, there is a cohort that stands out. Reviewers included in this prestigious group performed at least two reviews between July 2009 and June 2010, returned all reviews within 30 days, and received no quality score on any review lower than 4 on our 1–6 scale. An asterisk identifies the 131 reviewers meeting these criteria. We thank them for their efforts on behalf of the Journal. In our first “From the Editor’s Desk” in January 2010 we wrote: “In steering the journal forward over the next 5 years, we will be guided by the principle that JGIM is a journal for generalists committed to improving the world in which they practice and teach. Thus, we will seek to publish data derived from settings where real patients live and real doctors practice, as well as reviews and tools that clinicians and educators can use to do their jobs more effectively, efficiently, and humanely.” We remain committed to this vision over the next 4 years and hope that you, our readers, will join us by continuing to submit to, review for, read, and respond to JGIM. Whether in print or on-line, JGIM is your journal, and we need to hear from you. Send us an e-mail (or a paper letter!) and share your thoughts for the future of medical journalism and the future of medicine. The Editors

Purpose To compare (1) fluid, food and nutrient intake obtained with a paper versus an online version of a 7-day food record and (2) user’s acceptability of both versions of the food record. Methods A cross-over study was carried out in 2010 in France. A total of 246 participants aged 18–60 years reported their food and fluid intake using both versions of the 7-day food record, separated by a 7- to 14-day washout period. To help participants in estimating consumed portions, both versions of the food record were supported by a photographic booklet of standard portions and containers. At the end of the study protocol, participants completed a questionnaire designed to assess the acceptability of the two questionnaires. Results The reported water intake of fluids was significantly higher with the online version compared with the paper version (respectively 1348 ± 36 and 1219 ± 34 mL/day, p

This report was prepared in late 1965 at the request of the U.S. House-Senate Joint Committee on Atomic Energy (JCAE) to review its program on controlled thermonuclear research (CTR), now called just “fusion energy research.” It was transmitted to them on June 11, 1966 by then chairman of the U.S. Atomic Energy Commission (AEC) Glenn T. Seaborg. The AEC is the predecessor agency of the current U.S. Department of Energy (DOE). The report has previously only been available as AEC report TID-23277. This version of the report is complete except for the omission of lengthy discussions of the then current fusion research activities at various AEC sites. This paper includes, as does the original report, a copy of Seaborg’s June 11, 1966 transmittal letter and, as appendices, copies of a 1962 review of the fusion program by the AEC’s General Advisory Committee (GAC), a review of the Policy Paper by a special 1965 AEC committee, prior to its submittal to the JCAE, comments on the report by the GAC and the President’s Science Advisory Committee, and the charter for then newly established CTR Standing Committee.

Refereed conferences require every submission to be reviewed by members of a program committee (PC) in charge of selecting the conference program. There are many software packages available to manage the review process. Typically, in a bidding phase PC members express their personal preferences by ranking the submissions. This information is used by the system to compute an assignment of the papers to referees (PC members). We study the problem of assigning papers to referees. We propose to optimize a number of criteria that aim at achieving fairness among referees/papers. Some of these variants can be solved optimally in polynomial time, while others are NP-hard, in which case we design approximation algorithms. Experimental results strongly suggest that the assignments computed by our algorithms are considerably better than those computed by popular conference management software.

In the present school-based study, a convenience sample of 477 students in grades 6–9 and second year in high school from a city and a smaller town recorded daily occurrence and intensity of headaches in a standard paper diary during a 3-week period. Total headache activity (headache sum), number of headache days, intensity level and duration for weekly headaches were estimated. Approximately 85% of the adolescents had experienced headache of any intensity level during the 3-week recording period. On the average, they reported 2.5 headache days per week and a mean intensity level for headache episodes of 1.7. Our estimates for headache of any intensity level (1–5) occurring at least once a week was surprisingly high (73.8%). For the highest intensity level across the whole 3-week period, almost identical proportions of mild and moderate headaches were reported by students (22.3–22.5%), while about twice as many (40.7%) had experienced severe headaches. Girls consistently reported more headaches than boys, in particular of the moderate and severe intensity types. Students in the city also reported more frequent and intense headaches than those in the town. Peak headache activity was observed at noon and in the afternoon and in the days from the middle of the week until weekend. The use of prospective recordings in diaries will further advance our knowledge on the prevalence and characteristics of recurrent headaches among children and adolescents in community samples. Ó The Author(s) 2011. This article is published with open access at Springerlink.com

Background Response rates to surveys are declining and this threatens the validity and generalisability of their findings. We wanted to determine whether paper quality influences the response rate to postal surveys Methods A postal questionnaire was sent to all members of the British Society of Gynaecological Endoscopy (BSGE). Recipients were randomised to receiving the questionnaire printed on standard quality paper or high quality paper. Results The response rate for the recipients of high quality paper was 43/195 (22%) and 57/194 (29%) for standard quality paper (relative rate of response 0.75, 95% CI 0.33–1.05, p = 0.1 Conclusion The use of high quality paper did not increase response rates to a questionnaire survey of gynaecologists affiliated to an endoscopic society.

Objective To conduct a systematic review and meta-analysis of the equivalence between electronic and paper administration of patient reported outcome measures (PROMs) in studies conducted subsequent to those included in Gwaltney et al’s 2008 review. Methods A systematic literature review of PROM equivalence studies conducted between 2007 and 2013 identified 1,997 records from which 72 studies met pre-defined inclusion/exclusion criteria. PRO data from each study were extracted, in terms of both correlation coefficients (ICCs, Spearman and Pearson correlations, Kappa statistics) and mean differences (standardized by the standard deviation, SD, and the response scale range). Pooled estimates of correlation and mean difference were estimated. The modifying effects of mode of administration, year of publication, study design, time interval between administrations, mean age of participants and publication type were examined. Results Four hundred thirty-five individual correlations were extracted, these correlations being highly variable (I2 = 93.8) but showing generally good equivalence, with ICCs ranging from 0.65 to 0.99 and the pooled correlation coefficient being 0.88 (95 % CI 0.87 to 0.88). Standardised mean differences for 307 studies were small and less variable (I2 = 33.5) with a pooled standardised mean difference of 0.037 (95 % CI 0.031 to 0.042). Average administration mode/platform-specific correlations from 56 studies (61 estimates) had a pooled estimate of 0.88 (95 % CI 0.86 to 0.90) and were still highly variable (I2 = 92.1). Similarly, average platform-specific ICCs from 39 studies (42 estimates) had a pooled estimate of 0.90 (95 % CI 0.88 to 0.92) with an I2 of 91.5. After excluding 20 studies with outlying correlation coefficients (≥3SD from the mean), the I2 was 54.4, with the equivalence still high, the overall pooled correlation coefficient being 0.88 (95 % CI 0.87 to 0.88). Agreement was found to be greater in more recent studies (p p p p p Conclusion The present study supports the conclusion of Gwaltney’s previous meta-analysis showing that PROMs administered on paper are quantitatively comparable with measures administered on an electronic device. It also confirms the ISPOR Taskforce´s conclusion that quantitative equivalence studies are not required for migrations with minor change only. This finding should be reassuring to investigators, regulators and sponsors using questionnaires on electronic devicesafter migration using best practices. Although there is data indicating that migrations with moderate changes produce equivalent instrument versions, hence do not require quantitative equivalence studies, additional work is necessary to establish this. Furthermore, there is the need to standardize migration practices and reporting practices (i.e. include copies of tested instrument versions and screenshots) so that clear recommendations regarding equivalence testing can be made in the future.raising questions about the necessity of conducting equivalence testing moving forward.

This proposed method is a promising way, which can be implemented in pulp and paper industries by effective removal of the color and chemical oxygen demand (COD) and the resulting treated water may surely reuse to the other streams. Fourier Transformer Infra Red spectra confirmed the presence of the respective functional groups in the removed pollutants from the wastewater. The efficiency of Non-ferric Alum (NF Alum) and cationic polyacrylamide (C-PAM) with and without power boiler fly ash was also studied. The reduction efficiency of color and chemical oxygen demand (COD) is evaluated at the optimum dosage of NF Alum, fly ash, and C-PAM. At the optimized pH attained from these coagulants using to treat the wastewater, the flocs formation/settling and the pollutant removal efficiency are encouraging and the resulting color of the wastewater is to 40 PtCo units from 330 PtCo units and COD to 66 mg/L from 218 mg/L. While using NF Alum alone with C-PAM for the treatment of wastewater, the highest reduction efficiency of COD is 97 mg/L from 218 mg/L and the color is 60 from 330 PtCo units at pH 4.8 was noted. From these observations, NF Alum and power boiler fly ash with C-PAM can effectively remove the pollutants from the pulp and paper mill wastewater and the water can be reused for other streams.

Anal fissure is one of the most common and painful proctologic diseases. Its treatment has long been discussed and several different therapeutic options have been proposed. In the last decades, the understanding of its pathophysiology has led to a progressive reduction of invasive and potentially invalidating treatments in favor of conservative treatment based on anal sphincter muscle relaxation. Despite some systematic reviews and an American position statement, there is ongoing debate about the best treatment for anal fissure. This review is aimed at identifying the best treatment option drawing on evidence-based medicine and on the expert advice of 6 colorectal surgeons with extensive experience in this field in order to produce an Italian position statement for anal fissures. While there is little chance of a cure with conservative behavioral therapy, medical treatment with calcium channel blockers, diltiazem and nifepidine or glyceryl trinitrate, had a considerable success rate ranging from 50 to 90%. Use of 0.4% glyceryl trinitrate in standardized fashion seems to have the best results despite a higher percentage of headache, while the use of botulinum toxin had inconsistent results. Nonresponding patients should undergo lateral internal sphincterotomy. The risk of incontinence after this procedure seems to have been overemphasized in the past. Only a carefully selected group of patients, without anal hypertonia, could benefit from anoplasty.

Research collaboration is the way forward in order to improve quality and impact of its research findings. International research collaboration has resulted in international co-authorship in scientific communications and publications. This study highlights the collaborating research and authorship trend in clinical medicine in Malaysia from 2001 to 2010. Malaysian-based author affiliation in the Web of Science (Science Citation Index Expanded) and clinical medicine journals (n = 999) and articles (n = 3951) as of 30th Oct 2011 were downloaded. Types of document analyzed were articles and reviews, and impact factors (IF) in the 2010 Journal Citation Report Science Edition were taken to access the quality of the articles. The number of publications in clinical medicine increased from 4.5 % (n = 178) in 2001 to 23.9 % (n = 944) in 2010. The top three contributors in the subject categories are Pharmacology and Pharmacy (13.9 %), General and Internal Medicine (13.6 %) and Tropical Medicine (7.3 %). By journal tier system: Tier 1 (18.7 %, n = 738), Tier 2 (22.5 %, n = 888), Tier 3 (29.6 %, n = 1170), Tier 4 (27.2 %, n = 1074), and journals without IF (2.1 %, n = 81). University of Malaya was the most productive. Local collaborators accounted for 60.3 % and international collaborations 39.7 %. Articles with international collaborations appeared in journals with higher journal IFs than those without international collaboration. They were also cited more significantly than articles without international collaborations. Citations, impact factor and journal tiers were significantly associated with international collaboration in Malaysia's clinical medicine publications. Malaysia has achieved a significant number of ISI publications in clinical medicine participation in international collaboration.

Contains fulltext : 171307.pdf (Publisher’s version ) (Open Access) PURPOSE: The Cervical Spine Research Society Europe (CSRS-E) actively promotes scientific activities, the annual meeting being the most evident of them. The publication rate of oral and poster presentations at the annual meeting could be a measure for the success of the promotional activities. The publication rates of abstracts presented at the annual European meetings of the CSRS are unknown. The quality of the abstracts presented at a conference is reflected by the publication rate. A high publication rate is usually interpreted as representative of high scientific value of the conference. METHODS: Poster and podium presentations from the 2007 to 2012 annual meetings were identified. Pubmed was used to search for the abstract title and/or the combination of authors to verify whether the data were published in a peer-reviewed journal. Abstracts were considered published if the data presented at the meeting were identical to that in the publication. The journals in which the data were published were identified, as well as the origin of the research centre. RESULTS: From 2007 to 2012 826 abstracts were featured at the CSRS Europe annual meetings. There were 236 podium presentations and 590 poster presentations. 42 % of the podium presentations resulted in a publication, and 28 % of the poster presentations led to a publication. Overall, 32 % of accepted abstracts effectuated a publication in a peer-reviewed scientific journal. Abstracts from European research groups had a publication rate of 29 % compared to 34 % for abstracts from non-European research groups. Spine, European Spine Journal, Journal of Spinal Disorders and Techniques and J Neurosurgery Spine were the most common publication journals for the abstracts. The mean impact factor of the journals in which was published was 2.2. CONCLUSION: 42 % of the abstracts that were accepted for podium presentation at the CSRS Europe resulted in a publication in peer-reviewed MEDLINE indexed journals. Publication rates are at the high end of the publication rate spectrum of abstracts accepted for European scientific meetings.

A recent study published by the Manhattan Institute “Why Has Longevity Increased More in Some States than in Others? The Role of Medical Innovation and Other Factors,” purported to show that the more rapid adoption of new drugs has substantial benefits in the form of increased life expectancy, higher productivity and lower non-drug health care expenditures. This study has been cited as evidence supporting the more rapid acceptance of new drugs in Medicaid, Medicare, and other public programs and has helped to shape public debate on the value of new drugs. This analysis questions the key conclusions of the study. It points out that the key statistical regressions appear to be misspecified, since they show anomalies such as a negative correlation between income growth and life expectancy and find no relationship between education and productivity growth. Methodological flaws addressed include lack of adjustment for infant mortality rates; inadequate proxy measures of health status; lack of adjustment for ages of individuals and other sociodemographic factors; inherent problems with the definition of drug age, or ‘vintage;’ and the failure to consider reverse causation as an obvious explanation for several findings. The Manhattan Institute study does not provide reliable evidence for favoring adoption of newer drugs in either public or private health care programs.

Background The paper hand-held record (PHR) has been widely used as a tool to facilitate communication between health care providers and a pregnant woman. Since its inception in the 1950s, it has been described as a successful initiative, evolving to meet the needs of communities and their providers. Increasingly, the electronic health record (EHR) has dominated the healthcare arena and the maternity general practice shared-care arrangement seems to have adopted this initiative. A systematic review was conducted to determine perspectives of the PHR and the EHR with regards to data completeness; experiences of users and integration of care between women and health care providers. Method A literature search was conducted that included papers from 1985 to 2012. Studies were chosen if they fulfilled the inclusion criteria, reporting on: data completeness; experiences of users and integration of care between women and health care providers. Papers were extracted by one reviewer in consultation with two reviewers with expertise in maternity e-health and independently assessed for quality. Results A total of 43 papers were identified for the review, from an initial 6,816 potentially relevant publications. No papers were found that reported on data completeness in a maternity PHR or a maternity EHR, in a shared-care setting. Women described the PHR as important to their antenatal care and had a generally positive perception of using an EHR. Hospital clinicians reported generally positive experiences using a PHR, while both positive and negative impressions were found using an EHR. The few papers describing the use of the PHR and EHR by community clinicians were also divergent and inconclusive with regards to their experiences. In a general practice shared-care model, the PHR is a valuable tool for integration between the woman and the health care provider. While the EHR is an ideal initiative in the maternity setting, facilitating referrals and communication, there are issues of fragmentation and continued paper use. Conclusions There was a surprising gap in knowledge surrounding data completeness on maternity PHRs or EHRs. There is also a paucity of available impressions from community clinicians using both forms of the records.

In April 2007, the American College of Radiology released the "White Paper on Radiation Dose in Medicine". The Blue Ribbon panel members included private practice and academic diagnostic radiologists, medical physicists, representatives of industry and regulatory groups, and a patient advocate. The panel concluded that the expanding use of imaging modalities using ionizing radiations such as CT and nuclear medicine may result in an increased incidence of radiation-related cancer in the exposed population in the not-too-distant future, and this problem can likely be minimized by preventing the inappropriate use of such imaging and by optimizing studies that are performed to obtain the best image quality with the lowest radiation dose. The White Paper set forth practical suggestions to minimize radiation risk, including education for all stakeholders in the principles of radiation safety and preferential use of alternative (non-ionizing) imaging techniques, such as MRI and ultrasound. These recommendations are especially relevant for cardiologists, who prescribe and/or practice medical imaging examinations accounting for at least 50% of the total effective dose by radiation medicine, which amounts to an equivalent of about 160 chest x-rays per head per year in US. Were they be enacted, these simple recommendations would determine a revolution in the contemporary way of teaching, learning and practising cardiology.

Background Most hospitals keep and update their paper-based medical records after introducing an electronic medical record or a hospital information system (HIS). This case report describes a HIS in a hospital where the paper-based medical records are scanned and eliminated. To evaluate the HIS comprehensively, the perspectives of medical secretaries and nurses are described as well as that of physicians. Methods We have used questionnaires and interviews to assess and compare frequency of use of the HIS for essential tasks, task performance and user satisfaction among medical secretaries, nurses and physicians. Results The medical secretaries use the HIS much more than the nurses and the physicians, and they consider that the electronic HIS greatly has simplified their work. The work of nurses and physicians has also become simplified, but they find less satisfaction with the system, particularly with the use of scanned document images. Conclusions Although the basis for reference is limited, the results support the assertion that replacing the paper-based medical record primarily benefits the medical secretaries, and to a lesser degree the nurses and the physicians. The varying results in the different employee groups emphasize the need for a multidisciplinary approach when evaluating a HIS.

The EUROFUNG network is a virtual centre of multidisciplinary expertise in the field of fungal biotechnology. The first academic-industry Think Tank was hosted by EUROFUNG to summarise the state of the art and future challenges in fungal biology and biotechnology in the coming decade. Currently, fungal cell factories are important for bulk manufacturing of organic acids, proteins, enzymes, secondary metabolites and active pharmaceutical ingredients in white and red biotechnology. In contrast, fungal pathogens of humans kill more people than malaria or tuberculosis. Fungi are significantly impacting on global food security, damaging global crop production, causing disease in domesticated animals, and spoiling an estimated 10 % of harvested crops. A number of challenges now need to be addressed to improve our strategies to control fungal pathogenicity and to optimise the use of fungi as sources for novel compounds and as cell factories for large scale manufacture of bio-based products. This white paper reports on the discussions of the Think Tank meeting and the suggestions made for moving fungal bio(techno)logy forward.

Background Historically, the paper hand-held record (PHR) has been used for sharing information between hospital clinicians, general practitioners and pregnant women in a maternity shared-care environment. Recently in alignment with a National e-health agenda, an electronic health record (EHR) was introduced at an Australian tertiary maternity service to replace the PHR for collection and transfer of data. The aim of this study was to examine and compare the completeness of clinical data collected in a PHR and an EHR. Methods We undertook a comparative cohort design study to determine differences in completeness between data collected from maternity records in two phases. Phase 1 data were collected from the PHR and Phase 2 data from the EHR. Records were compared for completeness of best practice variables collected The primary outcome was the presence of best practice variables and the secondary outcomes were the differences in individual variables between the records. Results Ninety-four percent of paper medical charts were available in Phase 1 and 100% of records from an obstetric database in Phase 2. No PHR or EHR had a complete dataset of best practice variables. The variables with significant improvement in completeness of data documented in the EHR, compared with the PHR, were urine culture, glucose tolerance test, nuchal screening, morphology scans, folic acid advice, tobacco smoking, illicit drug assessment and domestic violence assessment (p = 0.001). Additionally the documentation of immunisations (pertussis, hepatitis B, varicella, fluvax) were markedly improved in the EHR (p = 0.001). The variables of blood pressure, proteinuria, blood group, antibody, rubella and syphilis status, showed no significant differences in completeness of recording. Conclusion This is the first paper to report on the comparison of clinical data collected on a PHR and EHR in a maternity shared-care setting. The use of an EHR demonstrated significant improvements to the collection of best practice variables. Additionally, the data in an EHR were more available to relevant clinical staff with the appropriate log-in and more easily retrieved than from the PHR. This study contributes to an under-researched area of determining data quality collected in patient records. Electronic supplementary material The online version of this article (doi:10.1186/s12913-014-0650-x) contains supplementary material, which is available to authorized users.

Background Screening and determining the immune status of individuals for hepatitis B is usually done by detecting hepatitis B surface antigen (HBsAg) and hepatitis B surface antigen-specific antibodies (HBsAb). In some countries with the highest viral burden, performing these assays is currently impractical. This paper explores the use of filter paper as a blood specimen transport medium. Methods Samples, chosen from routine clinical laboratory pool, were applied and dried onto filter paper. Eluates, from the paper samples, were analyzed as routine clinical specimens on ADVIA Centaur 5634® immunoassay analyzers using the standard HBsAg and HBsAb kits. Dried blood samples were subjected to a range of environmental conditions in order to assess stability. Results After drying and elution the assays showed linearity and precision comparable to clinical assays performed on fresh serum. Elutions at various times during a 149 day incubation period showed very little variability in the Index numbers. All analytes were temperature stable except for a decrease in the HBsAg signal at 42°C. Conclusions Filter paper is an acceptable storage and transport medium for serum to be used in the detection of hepatitis B markers if atmospheric variability can be controlled. HBsAg, HBsAb and HBcAb are all stable for at least five months under storage conditions below room temperature. Drying specimens, particularly serum, on filter paper at remote locations, offers a reasonable solution to the problem of hepatitis surveillance in underdeveloped regions, although some attempt at temperature control might be desirable.

Trauma, both blunt and penetrating, is extremely common worldwide, as trauma to major vessels. The management of these patients requires specialized surgical skills and techniques of the trauma surgeon. Furthermore few other surgical emergencies require immediate diagnosis and treatment like a ruptured abdominal aortic aneurysm (rAAA). Mortality of patients with a rAAA reaches 85 %, with more than half dying before reaching the hospital. These are acute events demanding immediate intervention to save life and limb and precluding any attempt at transfer or referral. It is the purpose of this position paper to discuss neck, chest, extremities and abdominal trauma, bringing to light recent evidence based data as well as expert opinions; besides, in this paper we present a review of the recent literature on rAAA and we discuss the rationale for transfer to referral center, the role of preoperative imaging and the pros and cons of Endoluminal repair of rAAA (REVAR) versus Open Repair (OR).

Background Assessment of pain in children is an important aspect of pain management and can be performed by observational methods or by self-assessment. The Faces Pain Scale-Revised (FPS-R) is a self-report tool which has strong positive correlations with other well established self-report pain intensity measures. It has been recommended for measuring pain intensity in school-aged children (4 years and older). The objective of this study is to compare the concordance and the preference for two versions, electronic and paper, of the FPS-R, and to determine whether an electronic version of the FPS-R can be used by children aged 4 and older. Methods The study is an observational, multicenter, randomized, cross-over, controlled, open trial. Medical and surgical patients in two pediatric hospitals (N = 202, age 4-12 years, mean age 8.3 years, 58% male) provided self-reports of their present pain using the FPS-R on a personal digital assistant (PDA) and on a paper version. Paper and electronic versions of the FPS-R were administered by a nurse in a randomized order: half the patients were given the PDA version first and the other half the paper version first. The time between the administrations was planned to be less than 30 minutes but not simultaneous. Two hundred and thirty-seven patients were enrolled; 35 were excluded from analysis because of misunderstanding of instructions or abnormal time between the two assessments. Results Final population for analysis comprised 202 children. The overall weighted Kappa was 0.846 (95%CI: 0.795; 0.896) and the Spearman correlation between scores on the two versions was rs = 0.911 (p < 0.0001). The mean difference of pain scores was less than 0.1 out of 10, which was neither statistically nor clinically significant; 83.2% of children chose the same face on both versions of the FPS-R. Preference was not modified by order, sex, age, hospitalization unit (medical or surgical units), or previous analgesics. The PDA was preferred by 87.4% of the children who expressed a preference. Conclusion The electronic version of the FPS-R can be recommended for use with children aged 4 to 12, either in clinical trials or in hospitals to monitor pain intensity.

The present document is the result of a consensus reached by a panel of experts from European and non-European countries on Occupational Rhinitis (OR), a disease of emerging relevance which has received little attention in comparison to occupational asthma. The document covers the main items of OR including epidemiology, diagnosis, management, socio-economic impact, preventive strategies and medicolegal issues. An operational definition and classification of OR tailored on that of occupational asthma, as well as a diagnostic algorithm based on steps allowing for different levels of diagnostic evidence are proposed. The needs for future research are pointed out. Key messages are issued for each item.

Background This study sought to ascertain whether there might be excess lung cancer mortality among the population residing in the vicinity of Spanish paper and board industries which report their emissions to the European Pollutant Emission Register (EPER). Methods This was an ecological study that modelled the Standardised Mortality Ratio (SMR) for lung cancer in 8073 Spanish towns over the period 1994–2003. Population exposure to industrial pollution was estimated on the basis of distance from town of residence to pollution source. An exploratory, near-versus-far analysis was conducted, using mixed Poisson regression models and an analysis of the effect of municipal proximity within a 50-kilometre radius of each of the 18 installations. Results Results varied for the different facilities. In two instances there was an increasing mortality gradient with proximity to the installation, though this was exclusively observed among men. Conclusion The study of cancer mortality in areas surrounding pollutant foci is a useful tool for environmental surveillance, and serves to highlight areas of interest susceptible to being investigated by ad hoc studies. Despite present limitations, recognition is therefore due to the advance represented by publication of the EPER and the study of pollutant foci.

Background The aim of this study was to determine the potential of produced compost from the sludge of wastewater treatment plant using earthworms and compare it with the vermicompost produced from household solid waste. Methods In the current study, three treatments with the same conditions in terms of organic wastes type were prepared to produce vermicompost from household solid waste and sewage sludges using earthworms. The standard methods were used to determine the physical and chemical parameters in the different produced vermicomposts. Results The mean of C/N in the household solid waste, raw biological and chemical sludges was 32, 22.5, and 26.5, respectively. These levels were 16.5, 14.5, and 15 in the vermicomposts. The mean of nitrogen and phosphorus percentages in the vermicompost of solid waste, biological and chemical sludges was 2.2%, 2.6%, 2.3% and 0.72%, 0.54%, and 0.56%, respectively. The mean percentages of organic matters in the initial substrates and vermicomposts of solid waste, biological and chemical sludges were 97.2%, 90%, 80.5% and 65.8%, 67.8% and 63% respectively. The concentrations of heavy metals decreased in all vermicomposts. The EC levels in solid waste, biological and chemical sludges were 1459, 1041, and 1487 μs/cm, respectively. These levels were 544, 385 and 635 μs/cm in the produced compost. Conclusion Eisenia fetida can convert household solid waste, and biological and chemical sludges produced from wastewater treatment plant into a high-quality and acceptable compost.

Biochemical oxygen demand (BOD) is a widely used index of water-quality assessment. Since bioelectrochemical BOD biosensors require anaerobic conditions for anodic reactions, they are not directly used in aerobic environments such as aeration tanks. Normally, the BOD biosensors are closed-type, where the anode is packed inside a closed chamber to avoid exposure to oxygen. In this study, a novel bioelectrochemical open-type biosensor was designed for in-situ monitoring of BOD during intermittent aeration. The open-type anode, without any protection against exposure to oxygen, was directly inserted into an intermittently aerated tank filled with livestock wastewater. Anodic potential was controlled using a potentiostat. Interestingly, this novel biosensor generated similar levels of current under both aerating and non-aerating conditions, and showed a logarithmic correlation (R2 > 0.9) of current with BOD concentrations up to 250 mg/L. Suspended solids in the wastewater attached to and covered the whole anode, presumably leading to the production of anaerobic conditions inside the covered anode via biological oxygen removal. Exoelectrogenic anaerobes (Geobacter spp.) were detected inside the covered anode using the 16S-rRNA gene. This biosensor will have various practical applications, such as the automatic control of aeration intensity and the in-situ monitoring of natural water environments.

Dear Editor, We wish to thank Professor Raybaud for his valued comments [7] with regards to the embryology of the fourth ventricular outlet and the history of the terminology currently in use for cystic malformations of the posterior fossa [2, 4, 10]. In his original, well-illustrated paper published at the turn of the century, Blake states that “his investigations on the subject were prompted by the contradictory opinions and the lack of absolute knowledge concerning the nature of the communications between the cavity of the fourth ventricle and the subarachnoid space” [2]. Interestingly, to date, there are still “contradictory opinions and a lack of absolute knowledge” with regard to the spectrum of posterior fossa cysts and cyst-like malformations, including the one supposedly related to the embryological entity known as Blake's pouch, which is referred to as Blake's pouch cyst by some, and persisting Blake's pouch by others. Because of our incomplete understanding of normal and abnormal embryological development in the posterior fossa, there are many descriptive terms, eponyms, classifications, and revised classifications [1, 5, 6, 9] that lack uniformity and add to the confusion. A great deal of answers may be in anatomical and embryological studies that may nowadays include such sophisticated techniques as ultra high-field strength MR imaging, or phase-contrast cine MR imaging to evaluate cerebrospinal fluid flow [11]. However, in our opinion, everyday clinical practice requires a more practical approach, which was exactly the purpose of our paper [3]. Modern MR imaging techniques enable us to recognize distinct imaging features that may help identify subgroups in the spectrum of posterior fossa cysts and cyst-like malformations, as suggested by Barkovich et al. as early as 1989 [1]. Moreover and possibly of greater importance to clinicians, these techniques may enable us to identify children who may benefit from a specific surgical intervention (i.e., cyst fenestration, cyst shunting, ventricular shunting, endoscopic third ventriculostomy). In this regard, the most important questions might be (1) whether there is fourth ventricular outflow obstruction and resulting hydrocephalus and (2) whether there are associated (developmental) anomalies. We were inspired by the paper of Tortori-Donati et al. [9] who proposed a practical classification for those cystic malformations of the posterior cranial fossa originating from a defect of the posterior membranous area. According to these authors, in the absence of anomalies of the anterior membranous area (i.e., when vermis, cerebellar hemispheres, and fourth ventricle are roughly normal) a defect of the posterior membranous area may produce two distinct malformations: mega cisterna magna and persisting Blake's pouch. Still according to these authors, a mega cisterna magna should be clinically silent (no symptoms or signs secondary to compression of the nervous and ventricular structures of the posterior fossa), should not produce hydrocephalus, and should never be treated. Differential diagnosis in case of a dilated retrocerebellar subarachnoid space and an associated hydrocephalus should be either an arachnoid cyst (produced by an entirely different mechanism that does not involve the posterior membranous area), an acquired encystment of the fourth ventricle (e.g., posthemorrhagic, postinfectious, or postoperative), or a Blake's pouch cyst. The latter is defined as a failure of regression of Blake's pouch (hence the term “persisting Blake's pouch”) secondary to non-perforation of the foramen of Magendi, resulting in a posterior ballooning of the superior medullary velum into the cisterna magna. As such, according to these authors, a persisting Blake's pouch should communicate freely with the fourth ventricle, and should always be accompanied by hydrocephalus. Moreover, it may (or may not) produce symptoms early or late in life [3] pretty much in the same way as in congenital aqueductal stenosis. Tortori-Donati et al. [9] continue that shunting of either the lateral ventricles or the pouch restores the ventricular system to a normal size and allows re-expansion of the compressed cerebellum, while the pouch diminishes in size or completely collapses. Such practical radiological classifications are appealing and easy to apply in everyday clinical practice. As such, we reported six cases with a retrocerebellar cyst that appeared to communicate freely with the fourth ventricle, an associated hydrocephalus, and a roughly normal vermis, cerebellar hemispheres, and fourth ventricle configuration [3]. We admit we had some discussions about the first child who died and had an autopsy, but decided to include the case for several reasons. First, it did look like an acute bleeding into a pre-existent posterior fossa cyst-like malformation that may have acted as a locus minoris resistentiae when (for unrelated reasons) the child developed a coagulation disorder. Second, to attract the readers' attention underscoring the wide clinical spectrum of Blake's pouch cyst, that may on the other end of the spectrum remain asymptomatic throughout life. Moreover, whereas Tortori-Donati et al.[9] suggested a treatment involving some kind of shunting, we successfully treated three symptomatic cases by means of an endoscopic third ventriculostomy, and suggest this may be regarded the best current treatment option for symptomatic Blake's pouch cyst. Also of interest, some years earlier than Tortori-Donati, Strand et al. [8] proposed a unified embryological theory with regard to posterior fossa cysts and cyst-like malformations. These authors emphasize that it is more important to describe the morphologic findings (using a kind of checklist proposed in their material and methods section) than to label the retrocerebellar cyst with an eponym. They point out that it is of particular importance whether the retrocerebellar cyst is associated with a malformed hindbrain (i.e., true cerebellar hypoplasia), a deformed hindbrain (i.e., merely mass effect on a roughly normal cerebellum), or both, as the two may actually coexist, illustrating every classification in the end is somewhat arbitrary. Moreover, of equal importance is the detection and delineation of other central nervous system anomalies, as well as aqueductal patency in case of an associated hydrocephalus [8]. Finally, we fully agree with Professor Raybaud's comment [7] that an extraventricular hydrocephalus caused by arachnoid encystment after an intraventricular hemorrhage should be included in the differential diagnosis. However, because imaging as well as therapeutic options are pretty much the same for both entities, again from a practical standpoint, distinguishing both entities despite their different etiology (one congenital, the other one acquired) may not be necessary. In conclusion, over the years, the eponyms Blake's pouch cyst and persisting Blake's pouch have been used inconsequently in the literature on posterior fossa cysts and cyst-like malformations. From a practical standpoint, however, as well as for the sake of clarity, we would agree with Tortori-Donati et al. [9] that Blake's pouch cyst should be regarded as a separate entity, involving a retrocerebellar cyst that appears to communicate freely with the fourth ventricle, an associated hydrocephalus that may or may not become symptomatic, and a roughly normal vermis, cerebellar hemispheres, and fourth ventricle configuration. Importantly, not all posterior fossa cysts and cyst-like malformations with an associated hydrocephalus are a Dandy–Walker or a Dandy–Walker variant (defect of the anterior membranous area). They may be a Blake's pouch cyst (defect of the posterior membranous area), or may even be acquired (secondary arachnoidal adhesions causing fourth ventricular outflow obstruction). We suggest that endoscopic third ventriculostomy may be regarded the best current treatment option for symptomatic Blake's pouch cyst.

The advantages of patient-held portable health files (PHF) and personal health records (PHR), paper or electronic, are said to include improved health-care provider continuity-of-care and patient empowerment in maintaining health. Top-down approaches are favored by public sector government and health managers. Bottom-up approaches include systems developed directly by health-care providers, consumers and industry, implemented locally on devices carried by patient-consumers or shared via web-based portals. These allow individuals to access, manage and share their health information, and that of others for whom they are authorized, in a private, secure and confidential environment. Few medical record technologies have been evaluated in randomized trials to determine whether there are important clinical benefits of these interventions. The COMMUNICATE trial will assess the acceptability and long-term clinical outcomes of an electronic and paper patient-held PHF. This is a 48-month, open-label pragmatic, superiority, parallel-group design randomized controlled trial. Subjects (n=792) will be randomized in a 1:1:1 ratio to each of the trial arms: the electronic PHF added to usual care, the paper PHF added to usual care and usual care alone (no PHF). Inclusion criteria include those 60 years or older living independently in the community, but who have two or more chronic medical conditions that require prescription medication and regular care by at least three medical practitioners (general and specialist care). The primary objective is whether use of a PHF compared to usual care reduces a combined endpoint of deaths, overnight hospitalizations and blindly adjudicated serious out-of-hospital events. All primary analyses will be undertaken masked to randomized arm allocation using intention-to-treat principles. Secondary outcomes include quality of life and health literacy improvements. Lack of blinding creates potential for bias in trial conduct and ascertainment of clinical outcomes. Mechanisms are provided to reduce bias, including balanced study contact with all participants, a blinded adjudication committee determining which out-of-hospital events are serious and endpoints that are objective (overnight hospitalizations and mortality). The PRECIS tool provides a summary of the trial’s design on the Pragmatic-Explanatory Continuum. Registered with Clinicaltrials.gov (identifier: NCT01082978 ) on 8 March 2010.

BACKGROUND: There is continuing interest among practitioners, policymakers and researchers in the evaluation of complex interventions stemming from the need to further develop the evidence base on the effectiveness of healthcare and public health interventions, and an awareness that evaluation becomes more challenging if interventions are complex.We undertook an analysis of published journal articles in order to identify aspects of complexity described by writers, the fields in which complex interventions are being evaluated and the challenges experienced in design, implementation and evaluation. This paper outlines the findings of this documentary analysis. METHODS: The PubMed electronic database was searched for the ten year period, January 2002 to December 2011, using the term "complex intervention*" in the title and/or abstract of a paper. We extracted text from papers to a table and carried out a thematic analysis to identify authors' descriptions of challenges faced in developing, implementing and evaluating complex interventions. RESULTS: The search resulted in a sample of 221 papers of which full text of 216 was obtained and 207 were included in the analysis. The 207 papers broadly cover clinical, public health and methodological topics. Challenges described included the content and standardisation of interventions, the impact of the people involved (staff and patients), the organisational context of implementation, the development of outcome measures, and evaluation. CONCLUSIONS: Our analysis of these papers suggests that more detailed reporting of information on outcomes, context and intervention is required for complex interventions. Future revisions to reporting guidelines for both primary and secondary research may need to take aspects of complexity into account to enhance their value to both researchers and users of research.

INTRODUCTION BACKGROUND TO METABOLOMICS: Metabolomics is the comprehensive study of the metabolome, the repertoire of biochemicals (or small molecules) present in cells, tissues, and body fluids. The study of metabolism at the global or "-omics" level is a rapidly growing field that has the potential to have a profound impact upon medical practice. At the center of metabolomics, is the concept that a person's metabolic state provides a close representation of that individual's overall health status. This metabolic state reflects what has been encoded by the genome, and modified by diet, environmental factors, and the gut microbiome. The metabolic profile provides a quantifiable readout of biochemical state from normal physiology to diverse pathophysiologies in a manner that is often not obvious from gene expression analyses. Today, clinicians capture only a very small part of the information contained in the metabolome, as they routinely measure only a narrow set of blood chemistry analytes to assess health and disease states. Examples include measuring glucose to monitor diabetes, measuring cholesterol and high density lipoprotein/low density lipoprotein ratio to assess cardiovascular health, BUN and creatinine for renal disorders, and measuring a panel of metabolites to diagnose potential inborn errors of metabolism in neonates. OBJECTIVES OF WHITE PAPER-EXPECTED TREATMENT OUTCOMES AND METABOLOMICS ENABLING TOOL FOR PRECISION MEDICINE: We anticipate that the narrow range of chemical analyses in current use by the medical community today will be replaced in the future by analyses that reveal a far more comprehensive metabolic signature. This signature is expected to describe global biochemical aberrations that reflect patterns of variance in states of wellness, more accurately describe specific diseases and their progression, and greatly aid in differential diagnosis. Such future metabolic signatures will: (1) provide predictive, prognostic, diagnostic, and surrogate markers of diverse disease states; (2) inform on underlying molecular mechanisms of diseases; (3) allow for sub-classification of diseases, and stratification of patients based on metabolic pathways impacted; (4) reveal biomarkers for drug response phenotypes, providing an effective means to predict variation in a subject's response to treatment (pharmacometabolomics); (5) define a metabotype for each specific genotype, offering a functional read-out for genetic variants: (6) provide a means to monitor response and recurrence of diseases, such as cancers: (7) describe the molecular landscape in human performance applications and extreme environments. Importantly, sophisticated metabolomic analytical platforms and informatics tools have recently been developed that make it possible to measure thousands of metabolites in blood, other body fluids, and tissues. Such tools also enable more robust analysis of response to treatment. New insights have been gained about mechanisms of diseases, including neuropsychiatric disorders, cardiovascular disease, cancers, diabetes and a range of pathologies. A series of ground breaking studies supported by National Institute of Health (NIH) through the Pharmacometabolomics Research Network and its partnership with the Pharmacogenomics Research Network illustrate how a patient's metabotype at baseline, prior to treatment, during treatment, and post-treatment, can inform about treatment outcomes and variations in responsiveness to drugs (e.g., statins, antidepressants, antihypertensives and antiplatelet therapies). These studies along with several others also exemplify how metabolomics data can complement and inform genetic data in defining ethnic, sex, and gender basis for variation in responses to treatment, which illustrates how pharmacometabolomics and pharmacogenomics are complementary and powerful tools for precision medicine. CONCLUSIONS KEY SCIENTIFIC CONCEPTS AND RECOMMENDATIONS FOR PRECISION MEDICINE: Our metabolomics community believes that inclusion of metabolomics data in precision medicine initiatives is timely and will provide an extremely valuable layer of data that compliments and informs other data obtained by these important initiatives. Our Metabolomics Society, through its "Precision Medicine and Pharmacometabolomics Task Group", with input from our metabolomics community at large, has developed this White Paper where we discuss the value and approaches for including metabolomics data in large precision medicine initiatives. This White Paper offers recommendations for the selection of state of-the-art metabolomics platforms and approaches that offer the widest biochemical coverage, considers critical sample collection and preservation, as well as standardization of measurements, among other important topics. We anticipate that our metabolomics community will have representation in large precision medicine initiatives to provide input with regard to sample acquisition/preservation, selection of optimal omics technologies, and key issues regarding data collection, interpretation, and dissemination. We strongly recommend the collection and biobanking of samples for precision medicine initiatives that will take into consideration needs for large-scale metabolic phenotyping studies.

Background The aim of this paper is to contribute to the discussion on how to approach patients taking new orally administered anticoagulants (NOAs) dabigatran etexilate (a direct thrombin inhibitor), rivaroxaban and apixaban (factor Xa inhibitors), before, during and after dental treatment in light of the more recent knowledges. Discussion In dentistry and oral surgery, the major concerns in treatment of patients taking direct thrombin inhibitors and factor Xa inhibitors is the risk of haemorrhage and the absence of a specific reversal agent. The degree of renal function, the complexity of the surgical procedure and the patient’s risk of bleeding due to other concomitant causes, are the most important factors to consider during surgical dental treatment of patients taking NOAs. For patients requiring simple dental extraction or minor oral surgery procedures, interruption of NOA is not generally necessary, while an higher control of bleeding and discontinuation of the drug (at least 24 h) should be requested before invasive surgical procedures, depending on renal functionality. Summary The clinician has to consider that the number of patients taking NOAs is rapidly increasing. Since available data are not sufficient to establish an evidence-based dental management, the dentist must use caution and attention when treating patients taking dabigatran, rivaroxaban and apixaban.

The number of reports of clinical trials grows by hundreds every week. However, this does not mean that people making decisions about healthcare are finding it easier to obtain reliable knowledge for these decisions. Some of the information is unreliable. Systematic reviews are helping to resolve this by bringing together the research on a topic, appraising and summarising it. But the quality of these reviews depends greatly on the quality of the studies, and this usually means the quality of their reports. If there are fundamental flaws within a study, such as the use of inappropriate 'randomisation' techniques in the context of reviews of the effects of interventions, the reviewers will not be able to fix these. Worse still, if they are not aware of underlying flaws, they might make incorrect judgements about the quality of the research in their review. A study by Wu and colleagues of 'randomised trials' from China provides a reminder of the cautious approach needed by users of scientific articles. They contacted the authors of more than 2000 research articles, which purported to be reports of randomised trials; and concluded that ten of every 11 studies claiming to be a randomised trial probably did not use random allocation. Better education of researchers, peer reviewers and editors about what is, and is not, a properly randomised trial is needed; along with better reporting of the details for how participants were allocated to the different interventions. Systematic reviewers must be cautious in making assumptions about the conduct of trials based on simple phrases about the trial methodology, rather than a full description of the methods actually used. It's not that you can't believe anything that you read in the papers, just that you cannot believe everything.